The COVID-19 pandemic, and its devastating impact on long-term care residents, has brought much needed attention to one of Canada’s most vulnerable populations. By failing to include extended care under the provisions of the Health Canada Act, which would have provided necessary government oversight, these facilities have long been operating outside of the public eye. This has resulted in environments ripe with under-trained staff, inadequate staff to resident ratios, over-crowding, aging facilities in poor condition, and sorely lacking infection control policies (Webster, 2011). None of this is new: we have been failing this population for decades. Rather than delve into COVID-19, I want to focus on another aspect of LTC inequality that I have never seen mentioned in the media. Something that has always troubled me, but even more so since learning about health inequalities and social determinants of health in MHST601, is the ways in which long term care residents are denied access to publicly funded therapy for treatable/"rehab-able" conditions.
Figure 1. Canada's seniors population outlook: Uncharted territory.
(Canadian Institute for Health Information, 2017)
In my first assignment for this course I wrote about how, in North America, the elderly are often considered to be a financial and resource "burden" to society (Lovell, 2006). I mentioned that the same stigma exists among a substantial proportion of health professions (Happell & Brooker, 2001). I work in hospitalist medicine, a department in which our average patient age likely hovers around 90-years-old. I love this population, but I can see that this is not the norm. Our department is a revolving door of new graduates who take a position on our units to "get their foot in the door". I have heard therapists and managers speak of how these physios, after working for a short time with my population of interest are ready to move on "to something better”. It is this attitude- that older patients are less desirable to work with-that allows the healthcare system to continue to deny access to rehabilitation to patients residing in long-term care.
Hip fractures in elderly populations are common and have devastating consequences. According to the Public Health Agency of Canada (2014) over one third of all fall-related hospitalizations are a result of hip fractures. Likely resulting from their increased general frailty, residents of long-term care are at least two times as likely as seniors living in the community to experience a hip fracture (Papaioannou et al., 2016). However, once they are admitted to hospital post fracture, LTC residents are not given the same access to rehabilitation services as their community dwelling counterparts.
Figure 2. Osteoporosis is more than just a number.
(American Bone Health, 2019)
In their study, Burleigh et al. (2011) compared hospitalization data for patients admitted with hip fractures from LTC and from the community. Patients admitted from care facilities had shorter hospital length of stay and were unlikely to be discharged to a rehabilitation facility (Burleigh et al., 2011). A cohort study by Beaupre et al., (2007) echoed this and found that, compared to seniors admitted from their own home, residents of LTC had a much higher risk of not returning to their pre-fracture function even after controlling for age, baseline mobility, comorbidities and cognitive status. They attributed this to the shorter acute care stay (four days less on average) and decreased rate of admission to inpatient rehab which they found to be less than 10% for LTC residents versus nearly 80% for patients admitted from the community (Beaupre et al., 2007). This is consistent with my observations working in acute care in Alberta and British Columbia. Inpatient rehabilitation facilities in both provinces exclude LTC residents from admittance (this is not on any documents, but it is common knowledge among staff). Patients admitted from LTC are seen by physiotherapists in the hospital, but as soon as the patient is medically stable, they are sent back to their facility. The logic behind this is that, theoretically, they are able to continue to rehabilitate within their facility.
It is the same situation for patients who are admitted to hospital with an acute stroke. In the settings that I have worked, if you are from LTC you are excluded from inpatient stroke rehabilitation, even if you might have good rehab potential. This is even though stroke rehabilitation has been demonstrated to be beneficial to LTC residents, with as few as three monthly visits resulting in improved independence in appropriate patients (Walker et al., 2013). In fact, the Canadian Stroke Best Practice recommendations for 2020 state that patients with ongoing rehabilitation goals should have access to specialized stroke services following their admission to LTC, and that residents demonstrating improvement in functional status post stroke should be offered a trial of active inpatient rehabilitation (Mountain et al., 2020). In my experience this does not happen unless a resident’s family is willing (and able) to pay for private therapy, essentially making access to rehab a function of one’s socioeconomic status and interpersonal factors such as a having a supportive family.
Figure 3. What to expect from stroke rehabilitation.
(American Stroke Association, nd)
Publicly subsidized care facilities technically include rehabilitative services, but in reality access to this service is very limited. The Ministry of Health (2017) target staffing ratio for direct patient care hours in LTC is 3.36 hours per resident day. Of this, 0.36 hours per resident day is meant to be direct care time provided by allied health, a group which includes social work, physiotherapy, occupational therapy, dieticians, and recreational therapists (Ministry of Health, 2017). It should be noted that 81% of the LTC facilities in the province were found to be operating below this target (Ministry of Health, 2017). This 22 minutes per resident day is far from adequate to rehabilitate any injury or stroke. That was the conclusion of a survey completed by Buddingh et al. (2013) in which physiotherapists working in LTC identified low staffing levels and in adequate time as barriers to providing rehabilitative care.
In their retrospective analysis of Canadian LTC facilities, McArthur et al. (2015) concluded that while access to rehabilitation professionals was sparse overall, intrapersonal factors such as increasing age and greater cognitive impairments were associated with a much lower likelihood of receiving physiotherapy treatment. This seems to imply an assumption that cognitively impaired patients cannot improve, which is not supported by the evidence (McArthur et al., 2015). A systematic review completed by Crocker et al., (2013) for the Cochrane Collaboration found good evidence that physical rehabilitation in LTC settings is associated with significant improvements in physical and mental functioning, even for patients with cognitive impairment.
Patients who do not have the opportunity to receive active physical therapy treatment after a stroke, fracture or other acute illness are not given the chance to recover any level of independence. For example, in the Burleigh et al. (2011) study referred to above, LTC residents that were previously mobile prior to hip fracture were much less likely to return to their baseline function 120 days post fracture compared to patients living in their homes. This results in a greater level of dependency: needing more help from nurses and care aides in a setting that is already stretched too thin. As well as increasing their care needs, this loss of independence also has an inverse effect on quality of life. In a 2011 study, Kane found that being engaged in meaningful activities, having a sense of autonomy and some level of functional independence is crucial for LTC residents to report a good quality of life. These opportunities are denied for individuals who are essentially being forced into a state of greater vulnerability while in LTC as a result public policy.
Figure 4. Activities of daily living.
(VetAssist, 2020)
So why should we be thinking of this now (or rather, why should we have been thinking about this years ago?). Putting aside the fact that all Canadians should be entitled to equal access to quality health care, we need to acknowledge our aging population. Thirty percent of Canadians aged 85 and older currently reside in care (Statistics Canada, 2018) and the growth of this segment of the population far outpaces the rate of increase in long-term care beds. If we continue to treat these vulnerable citizens by shuttling them into poorly staffed facilities, confining them to wheelchairs and gradually taking away their functional abilities and independence by not providing them with access to proven therapies, we are creating a population so dependent that their most basic care needs will never be met in 3.36 hours/day. And that is assuming we can even reach this target to begin with. As health care professionals, we need to harness the fact that COVID-19 has shone a light onto this long-neglected population and advocate for better standards, better staffing levels, and equal opportunity to quality of life. Access to any therapy that improves a person's ability to participate in meaningful tasks, whether by improving their ability to speak to their family, feed themselves, or being able to move around their environment is worthwhile and not only contributes to well-being of residents but could also decrease workload for staff. We need to stop treating long-term care as a place to store the elderly, and think of it as a place where people can truly live their last years.
Figure 5. Quality of life in older age.
(PEW Research Centre, 2013)
References
American Bone Health (2019). Osteoporosis is more than just a number [Figure]. American Bone Health website. https://americanbonehealth.org/osteoporosis/osteoporosis-is-more-than-just-a-number/
American Stroke Association (nd). What to expect from stroke rehabilitation [Figure]. American Stroke Association website. https://www.stroke.org/en/professionals/stroke-resource-library/post-stroke-care/patient-focused-rehab-resources/what-to-expect-at-rehab
Beaupre, L. A., Cinats, J. G., Jones, C. A., Scharfenberger, A. v., William C. Johnston, D., Senthilselvan, A., & Saunders, L. D. (2007). Does Functional Recovery in Elderly Hip Fracture Patients Differ Between Patients Admitted From Long-Term Care and the Community? The Journals of Gerontology Series A: Biological Sciences and Medical Sciences, 62 (10). https://doi.org/10.1093/gerona/62.10.1127
Buddingh, S., Liang, J., Allen, J., Koziak, A., Buckingham, J., & Beaupre, L. A. (2013). Rehabilitation for Long-term Care Residents Following Hip Fracture. Journal of Geriatric Physical Therapy, 36(1). https://doi.org/10.1519/JPT.0b013e3182569b4f
Burleigh, E., Smith, R., Duncan, K., Lennox, I., & Reid, D. (2011). Does place of residence influence hospital rehabilitation and assessment of falls and osteoporosis risk following admission with hip fracture? Age and Ageing, 40(1). https://doi.org/10.1093/ageing/afq139
Canadian Institute for Health Information (2017). Canada’s seniors population outlook: Uncharted territory. CIHI website. https://www.cihi.ca/en/seniors-in-transition-exploring-pathways-across-the-care-continuum
Crocker, T., Forster, A., Young, J., Brown, L., Ozer, S., Smith, J., Green, J., Hardy, J., Burns, E., Glidewell, E., & Greenwood, D. C. (2013). Physical rehabilitation for older people in long-term care. Cochrane Database of Systematic Reviews. https://doi.org/10.1002/14651858.CD004294.pub3
Happell, B., & Brooker, J. (2001). Who Will Look After my Grandmother? Journal of Gerontological Nursing, 27(12). https://doi.org/10.3928/0098-9134-20011201-07
Kane, R. A. (2001). Long-Term Care and a Good Quality of Life. The Gerontologist, 41(3). https://doi.org/10.1093/geront/41.3.293
Lovell, M. (2006). Caring for the elderly: Changing perceptions and attitudes. Journal of Vascular Nursing, 24(1), 22–26. https://doi.org/10.1016/j.jvn.2005.11.001
McArthur, C., Hirdes, J., Berg, K., & Giangregorio, L. (2015). Who Receives Rehabilitation in Canadian Long-Term Care Facilities? A Cross-Sectional Study. Physiotherapy Canada, 67(2). https://doi.org/10.3138/ptc.2014-27
Ministry of Health (2017). Residential care staffing review. Government of British Columbia website. https://www.health.gov.bc.ca/library/publications/year/2017/residential-care-staffing-review.pdf
Mountain, A., Patrice Lindsay, M., Teasell, R., Salbach, N. M., de Jong, A., Foley, N., Bhogal, S., Bains, N., Bowes, R., Cheung, D., Corriveau, H., Joseph, L., Lesko, D., Millar, A., Parappilly, B., Pikula, A., Scarfone, D., Rochette, A., Taylor, T., … Cameron, J. I. (2020). Canadian Stroke Best Practice Recommendations: Rehabilitation, Recovery, and Community Participation following Stroke. Part Two: Transitions and Community Participation Following Stroke. International Journal of Stroke, 15(7). https://doi.org/10.1177/1747493019897847
Papaioannou, A., Kennedy, C. C., Ioannidis, G., Cameron, C., Croxford, R., Adachi, J. D., Mursleen, S., & Jaglal, S. (2016). Comparative trends in incident fracture rates for all long-term care and community-dwelling seniors in Ontario, Canada, 2002–2012. Osteoporosis International, 27(3). https://doi.org/10.1007/s00198-015-3477-3
PEW Research Center (2013). Quality of life in older age [Figure]. PEW website. https://www.pewforum.org/2013/11/21/chapter-6-aging-and-quality-of-life/
Public Health Agency of Canada. (2014). Senior’s falls in Canada- Second report. .
Statistics Canada. (2018). Transitions to long-term and residential care among older Canadians. Health Reports, Statistics Canada Website. https://www150.statcan.gc.ca/n1/pub/82-003-x/2018005/article/54966-eng.htm
VetAssist (2020). Activites of daily living. Veterans Homecare website. https://veteranshomecare.com/adls-and-iadls-according-to-the-va/
Walker, M. F., Sunnerhagen, K. S., & Fisher, R. J. (2013). Evidence-Based Community Stroke Rehabilitation. Stroke, 44(1). https://doi.org/10.1161/STROKEAHA.111.639914
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