Susan Brown

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What is your current role?

I am a Clinical Nurse Specialist (CNS) currently focusing on residential care and assisted living. I have practiced in home care for over two decades, and recently transitioned to residential care and assisted living to lead a palliative care strategy, with a focus on integrating palliative approaches within residential care. Specific areas of this strategy include using frailty as a predictor of disease trajectory, using goals of care conversations to guide care, targeting interventions based upon emerging best practices, ensuring family/resident involvement & engagement, enabling the circle of care (care aide to physician), and aligning with the Canadian Hospice Palliative Care Association and Ministry of Health recommendations.

Can you speak about the population that you generally work with?

I generally work with the older adult population. In my years in home health, I have learned that this is a complex population with many seniors living alone and at risk due to mild cognitive impairment, progressive dementia, lack of social supports, and abuse and neglect. The lack of recognition for palliative approaches to care in older adults with chronic life limiting illnesses, and the inability to fully integrate chronic disease management strategies within palliative approaches to care adds to the complexity.

Seniors living in residential care generally have greater needs due to functional decline (both cognitively and/or physically), lack of a support system to safely manage in environments that require greater independence (e.g.: at home or in assisted living), and have greater medical, functional and physical complexity. The focus of care is on the biopsychosocial model of care and personhood. Assisted living clients must be able to direct their own care, as the level of care and resources is less than in residential care.

Which healthcare providers are involved in the care of seniors in assisted living and residential care? Are these healthcare providers being utilized to their full scope?

There are several healthcare providers that provide care to seniors within these environments. Within residential care, Care Aides, Licensed Practical Nurses (LPNs), Registered Nurses (RNs), Registered Psychiatric Nurses (RPN's) and other members of the interprofessional team such as Occupational Therapists, Physiotherapists, Social Workers, Dieticians, and Pharmacists are involved in the care of seniors. However, the accessibility of these providers can vary across facilities.

Within assisted living, care providers generally consist of LPNs and Care Aides.

Full scope needs to be defined more clearly for LPNs and RNs within the context of assisted living and residential care. Care Aides are currently not regulated, and as result, there is no defined scope. However, because Care Aides spend the most time with residents, there is much work being done in residential care to enhance integrated education approaches to care for these care providers.

What is currently working well within residential care and assisted living?

Some things that are currently working well include:

• An intentional focus on quality of life, complexity of care, and ensuring eligibility criteria are renewed and refreshed so that we are enabling seniors to live at home safely for as long as possible.
• Home First and integrated care approaches with the Divisions of Family Practice are well underway.
• Quality improvement initiatives focused on reducing acute care and emergency room encounters such as BreatheWELL.
• A focus on reducing polypharmacy.
• Embedding goals of care conversations proactively (e.g.: advance care planning).
• Enhancing competencies along with the palliative strategy.

Within residential care and assisted living, I have seen greater focus on equipping teams to manage changes in conditions and disease trajectory, enhancing competency of care teams, integrating palliative approaches to care, building partnerships with physicians, and creating structures to support quality of life, optimizing resident function & engagement in alignment with goals of care.

What system level issues currently impact seniors in assisted living?

There are a number of system level issues that are impacting B.C. seniors who are currently in assisted living situations.

First, it is hard for seniors in assisted living to get timely access to General Practitioners who are skilled with caring for the complex health needs of the frail elderly. I think there is a need to explore how nursing can bridge these gaps, specifically with the use of nurse practitioners.

Staffing Models also vary widely from privately and publicly funded assisted living facilities, as well as within different Regional Health Authorities. For example: In some instances, the only overnight staff may be a security guard or a care aide. The staffing coverage by an onsite LPN varies with respect to time of day and day of week, and some sites have care aides with minimal LPN support. The minimal level of professional nursing services may present barriers and limitations.

Another issue that has created barriers to care is the prescribed services model. Prescribed services include assistance with activities of daily living, medication management, therapeutic diets, financial management, intensive rehabilitation therapy and behavioural management. Historically, assisted living facilities have been limited to offering 2 of 6 prescribed services, and some assisted living sites may also choose to limit the extent to which they provide a prescribed service. For example, full support for activities of daily living (i.e.: feeding clients, or transferring with mechanical lift) may not be available, which can lead to premature placement to residential care.

While legislative changes to remove the limit on prescribed services was announced in March 2016, it is unclear what new regulations will look like. As it stands, I think the current prescribed service of structured behavioural management might be a challenge to implement in publicly funded assisted living. The expectation would be to carry out individualized therapeutic programs developed and supervised by a professional for the purpose of changing behaviour. This is rather vague, and leans towards mental health support which has always been difficult to access with limited existing community support.

Assisted living providers are accountable for ensuring staffs have the competency to support their client population. However, with increasing client complexity, the need for clinical support to develop enhanced staff skill sets will need to be addressed.

What system level issues currently impact seniors living in residential care?

Currently, patients waiting for a bed in residential care are required to accept the first available bed that meets their needs. While access teams do their very best to ensure the best match, this does not always fit with the best care environment or meet the unique needs of the resident. As a result, sometimes seniors may have to accept beds that are further away from loved ones than anticipated.

Similar to assisted living, staff mix and competency continue to be challenges. With an evolving population and increasing complexity, focused care for specific population needs is a challenge. However, this has been a focus in residential care, and redesign efforts are underway at this time.

Another issue impacting seniors in residential care is the high utilization of emergency rooms and acute care. It is suspected that this is due to unintended transfers to manage changes in condition and at times, in part due to families' concern, understanding and expectations of care. Often family members or caregivers believe that the more intervention or treatment, the better the care. More engagement with families is needed to establish conversations around goals of care (i.e.: what can happen in the emergency room or acute care versus in residential care, and quality of life and optimal symptom management versus acute treatment with chronic life limiting illnesses).

Some solutions to these issues include early days of integration with family physicians responding to resident needs, participating in care conferences and meaningful medication reviews. Quality metrics are also being used to hold facilities accountable for care quality and delivery.

What are the top three policy issues related to seniors health within the context of assisted living and residential care that ARNBC can further explore, research and study?

There is a need for stronger public education with families and seniors. Specifically, greater emphasis around healthy living, self- management support, as well as the meaning of palliative approaches to care. Education should move towards focusing on symptom burden, optimization of function and quality of life. Nurses play a key role in addressing this gap across the system from public health to end of life care by engaging in health education and capacity building with seniors and their families.

In order to ensure that the prescribed services for assisted living are provided optimally, enhanced partnerships with primary care and mental health, as well as structure to support clinical practice needs are needed. Nursing plays a key role in enhancing collaboration between assisted living, primary care and mental health, as well as advocating for the voice of seniors and families to inform policy development.

Last, there must be more work done to prevent premature placement into residential care. This can be coordinated with increased response by home health. Not only does nursing play a role in improving the collaboration between home health and residential care, nurses are well positioned to assess caregiver burden and provide support for timely proactive mobilization of services. Nurses want to support clients and families to live at home as long and safe as possible, and a key role for nursing is to articulate the importance of caring for the caregiver in the realm of community health nursing practice.