Long Term Care: Understanding the Past, and Looking to the Future
Working through the Philosophical Foundations of Health Systems course has provided an invaluable opportunity to learn the basics of a multilevel health care system. To fully understand how to deliver effective health care at the resident level, it is important to gain a thorough understanding of how each level of the health care system interacts and how those interactions affect care. Through this course, we have reviewed the determinants of health, levels of influence, chronic disease prevention and management, health of Indigenous people, vulnerable populations, and the future of health care. These concepts will be applied to our senior population and more specifically, to those seniors living in long term care homes.
Determinants of Health
The determinants of health can vary slightly depending on the organization presenting them, but they do have a common theme. They can include the following processes: the social gradient, stress, early life, social exclusion, work, unemployment, social support, addiction, food, and transport (Wilkinson & Marmot, 2003). The social gradient and stress levels are evident in long-term care settings where residents who are in a lower income group, suffer more complex disease processes and a higher incidence of chronic diseases (Salazar & Beaton, 2000). A resident’s early life experiences can dictate how the rest of their life will unfold (Mikkonen & Raphael, 2010). Were they well supported by their parents, did they reach higher levels of education, and were they encouraged through positive development. We need to ensure our seniors who are living in a long-term care (LTC) homes are not socially excluded from the joys of everyday life as this will cause undue hardship, stress, resentment, depression, and hostility (Wilkinson & Marmot, 2003). Unemployment indirectly affects the residents by a potential lack of qualified staff to meet their needs (Government of Canada, 2011). Social supports in the nursing home are very important to keep our residents from feeling isolated (Wilkinson & Marmot, 2003). These can include one-on-one visiting, family visits, interaction with staff, and games and activities with activation staff. Addiction issues in LTC can include tobacco, alcohol, and pain killers (Wilkinson & Marmot, 2003). If residents can no longer safely manage their addiction, they are placed on a cessation program. Food is one of the enjoyments and control elements seniors have in LTC (Mikkonen & Raphael, 2010). It is included in the Resident Bill of Rights that each resident has a choice in menu options. Using a social ecological model (SEM), multiple factors that affect healthy eating can be addressed and a plan implemented to focus on healthy eating, obesity and the factors and barriers that will affect dietary behaviours (Townsend & Foster, 2013). It is very important for residents to maintain their mobility for as long as possible as mobility can stimulate independence and bolster self-confidence for those with decreased mobility issues (Mikkonen & Raphael, 2010).
Levels of Influence
There are four main levels of influence that affect resident care and include: personal, community, industry, and global influences (Levy, 2017). In a LTC home, personal influences would include personal support workers (PSW’s), activation staff, or dietary staff caring for them and their families. Community influences would include pastoral care, hairdresser, podiatrist, or wound care specialist. Management at the LTC facility would be included under industry influences. This group is highly motivated, focused, and can motivate others toward a common goal – optimal care for residents. The global influencers would include provincial and federal governments, and provincial agencies whose goal is improving senior care. This group’s influence is high-level and must be interpreted at the facility level to meet the needs of the residents.
Chronic Disease Prevention and Management
Chronic diseases are something that develops over time, progresses in severity, can often be controlled, but rarely cured. In Ontario, chronic diseases account for the top four leading causes of death, and over 80% of residents in LTC homes have multiple chronic diseases (Ministry of Health and Long Term Care, 2007). New challenges include obesity, diabetes, and uncontrolled hypertension (Thornburg, 2015). Multiple chronic diseases increase the complexity of resident care (Chu, 2015).
The Health of Indigenous People
Indigenous people function under a different value system where their elderly people are cared for in the homes of their children (Smylie, & Firestone, 2015). Initially, when Europe colonized this land, they brought with it many infectious diseases that were foreign to indigenous people. Since they do not have the same access to health care as their non-indigenous counterparts - they do not have the opportunity to take part in screening programs during a treatable stage of the disease (Ahmed, Shahid, & Episkenew, 2015). There should be equal access to health care for all Canadians, regardless of age, race, or ethnic origins.
Vulnerable Populations
Since the senior population is expected to double by the year 2025, the Canadian government has developed programs aimed at the health of seniors (Government of Canada, 2014). In LTC, seniors have access to dental care, dieticians, physiotherapists, smoking cessation programs, incontinence programs, fall prevention, and end of life care. Each of these programs improves their quality of life, promotes independence, and gives them a sense of control over their life at a time when they need more help then ever. Despite the availability of programs, inaccessibility of some programs, such as dental services for those with lower income and education levels is still evident. Education needs to be focused on those in the lower income, and lower levels of education as this would increase compliance with good dental hygiene practices (Estrada, et al, 2018).
The United Way has developed a strategic plan to address health care accessibility for vulnerable seniors. Their vision involves community partners creating supportive communities for seniors. They would address social, economic insecurity, inadequate and unaffordable housing, poor mental and physical health, inaccessible transportation, inaccessible buildings/offices, mobility limitations, marginalized identities, linguistic barriers, and cultural and environmental conditions (United Way, 2011). In 2004, an estimated 300,000 seniors who were eligible for allowances and supplements had not applied, and elderly single women were more likely not to apply for eligible benefits. Therefore, more effort needs to be invested into informing seniors about these benefits.
The Future of Health Care
The number of seniors in Canada is growing, and we are challenged with providing and paying for long-term care. With populations ageing and the need for long-term care growing rapidly, the government needs to focus on the physical and cognitive decline of seniors and highlight the key policies and strategies that can help address the future demand on long-term care homes (Columbo, et al, 2011).
Dementia is a cognitive impairment that affects millions of people every year globally and includes Alzheimer's disease, vascular dementia, dementia with Lewy bodies, and fronto-temporal dementia. There is rarely a singular dementia present, and these are often diagnosed based on symptoms (World Health Organization, 2012). The future of dementia care involves advocacy and awareness raising actions, the development of dementia policies and plans, and health and social system strengthening (Kraft, 2011).
Conclusion
Long Term Care is a highly regulated and complex health care system. When working with and caring for residents, we must always keep in mind the Resident Bill of Rights and the Ministry of Health and Long Term Care Homes Act. These documents provide the guiding principles of resident care and how that care is graded. To provide residents living in LTC homes with optimal care, we need to understand the history of how care was provided, what our current practices are, and where LTC is heading in the future.
References
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Chu, P. (2015, June 10). Seniors' care at NYGH: Chronic disease management. Retrieved from You Tube: https://www.youtube.com/watch?time_continue=142&v=fP0RTxtjvsM
Colombo, F., Llena-Nozal, a., Mercier, J., & Tjadens, F. (2011). Help Wanted? Providing and paying for long-term care. OECD Publishing. Retrieved March 31, 2018, from https://books.google.ca/books?hl=en&lr=&id=EI-GMlqq7TAC&oi=fnd&pg=PA3&dq=the+future+of+long+term+care+in+canada&ots=6hs7oy1f07&sig=NufXXATwVP0NUWUszOps-A-KQWw&redir_esc=y#v=onepage&q=the%20future%20of%20long%20term%20care%20in%20canada&f=false
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Mikkonen, J., & Raphael, D. (2010). Social Determinants of Health: The Canadian Facts. Toronto: York University School of Health Policy and Management. Retrieved from: http://thecanadianfacts.org/the_canadian_facts.pdf
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Thornburg, K. (2015, July 28). The epidemic of chronic disease and understanding epigenetics. Retrieved from You Tube: https://www.youtube.com/watch?time_continue=259&v=ReCvreRPdeY
Townsend, N., & Foster, C. (2013). Developing and applying a socio-ecological model to the promotion of healthy eating in the school. Public Health Nutrition, 16(6), 1101-8. Retrieved from: https://0-search-proquest-com.aupac.lib.athabascau.ca/nahs/docview/1353372703/fulltext/E8DD32896D06454APQ/10?accountid=8408
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Wilkinson R, Marmot M, editors. Social determinants of health: The solid facts [Internet]. 2nd ed. Copenhagen: World Health Organization; 2003. Retrieved from: http://www.euro.who.int/__data/assets/pdf_file/0005/98438/e81384.pdf
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