Integration within Long-Term Care: A Comparative Analysis of Nova Scotia and British Columbia
Apurva Dixit* BHSc, University of Toronto, Temerty Faculty of Medicine
Praniya Elangainesan* BSc, University of Toronto, Temerty Faculty of Medicine
Dr. Abi Sriharan PhD MSc, University of Toronto, Institute of Health Policy, Management and Evaluation
ABSTRACT: Long-term care (LTC) was heavily impacted by the COVID-19 pandemic and as a result, gaps in this sector garnered substantial media attention. Studies have shown that systems that are more integrated with primary/acute care may provide more effective care than those that do not [5]. The Nova Scotia (NS), Care By Design (CBD) model and British Columbia (BC) Long Term Care Initiative (LTCI) are both relatively new approaches that aim to employ integration into its operation to improve care for LTC residents. The objective of this paper is to assess the benefits and shortcomings of integration in NS and BC. This comparison will enable a better understanding of possible approaches for LTC integration in different contexts. Literature surrounding provincial LTC structure, the CBD and LTCI models were searched to compare consequences of LTC integration. Key themes that were found to be the focus of both models included ED transfers, quality of care, potentially inappropriate prescription/polypharmacy, and response to the COVID-19 pandemic. Overall, adopting integration into LTC models has been shown to improve health outcomes, be cost-effective and ultimately address systems level issues. There is a need for more primary studies and standardized data collection of metrics to allow for further evaluation as well as recommendations to be made to inform other provincial jurisdictions.
SUBMITTED: 25 APR 2022 | PUBLISHED: 19 JUL 2022
DISCLOSURE: No conflicts declared.
ACKNOWLEDGMENTS: *Co-first authors: These authors contributed equally to the work.
CITATION: Dixit, Apurva; Praniya Elangainesan; Abi Sriharan (2022). Integration within Long-Term Care: A Comparative Analysis of Nova Scotia and British Columbia. Canadian Health Policy, JUL 2022. ISSN 2562-9492, https://doi.org/10.54194/OGRE3624, canadianhealthpolicy.com
INTRODUCTION
The LTC sector has been a long neglected de-centralized system with multiple gaps in care. These issues were brought to light during the beginning of the COVID-19 pandemic where many long-term care facilities (LTCF) were faced with coronavirus outbreaks and high resident mortality [1]. Specifically, the lack of coordination between LTC and other sectors of care led to lack of timeliness for transfer, inappropriate transfer, lack of timely communication among other issues [2]. Furthermore, there is a huge strain placed on emergency departments (ED) by LTC because of unnecessary or inappropriate transfers which also places a large financial burden on the already stretched healthcare system. Approximately 60,000 LTCF patient transfers to EDs in 2014 with a quarter of them being preventable [3]. The downstream effect of crowding includes increased wait times for admission, longer hospitalization stays and increased risk of morbidity and mortality. Specific to the LTC patient population, transfers can be harmful as they place residents at an increased risk to iatrogenic exposures and complications. Residents may also face psychological, physical, and economic distress because of a transfer [4]. Ultimately, there is lower quality of care for residents within LTC homes and during their transition to acute care.
However, not all LTC models in the country are performing poorly. Studies have shown that systems that are more integrated with primary/acute care may provide more effective care than those that do not [5]. With an integrated system, unnecessary transfers can be avoided, residents can be treated in the LTC setting and overall quality of care is improved. When examining different LTC structures from east to west coast in Canada, two jurisdictions that have adopted integration include: Nova Scotia (NS) and British Columbia (BC). NS implemented their new integrated LTC model, Care By Design (CBD), in 2010 [4]. This model was developed in response to the Primary Care of the Elderly project that found multiple concerns in NS, including delayed admission into LTC, high rates of transfers to acute care even for those who do not transfer orders, high rates of polypharmacy and low rates of family physician consultation [6]. It aims to improve access to care and continuity of care having designated family physicians per floor and having on-call access to urgent care 24/7.
This model has already been able to make large strides based on its outcome data such as reductions in ED transfers and improved quality of care [4]. Similarly, BC also has a public health system that has been more integrated with LTC recently. The Long-Term Care Initiative (LTCI) was initiated by the Ministry of Health in 2011. It is a model of care that aims to standardize medical care while adopting best practices and targeting three system outcomes “reduced unnecessary or inappropriate hospital transfers, improved patient/provider experience, [and] reduced cost/patient as a result of higher quality of care” [7]. This was to address delayed admission due to difficulty finding family physicians to care for patients at LTC homes and to accommodate the growing LTC needs and the reduced physician numbers in the population [8]. Initially, this model was piloted at five locations and after witnessing its success, was expanded across the province in 2015 to 90 communities [9]. Now, the LTCI is operating in some capacity in 99.4% of eligible LTC beds and each region’s implementation plan of solutions can be varied [7].
With the CBD model in NS and LTCI introduction in BC, in 2010 and 2011 respectively, there is an opportunity to compare differences in the structure and outcomes as they pertain to LTC homes. Furthermore, in a report released by the BC Care Provider’s Association in 2017, it is mentioned that while BC has expanded in the LTCI, it could be worthwhile to explore alternative models like the CBD in NS [10]. Now in 2021, with both approaches gaining maturity since being implemented for over 10 years, there is value in comparing the trajectories of development, expansion, and outcomes. This paper will compare the CBD and LTCI models and their outcomes between NS and BC. The objective is to assess the benefits and shortcomings of integration and how they can be used to inform LTC models in other provincial jurisdictions.
METHODS
Data Collection
Google, Google Scholar, PubMed, and Health Systems Evidence database were searched for English language articles focused on the LTC sectors in NS and BC. Relevant literature included scientific papers and documents such as reviews, government websites, and quality-improvement reports. Search strategies included the name of the province combined with words such as “long term care”, “nursing home”, “residential care” or the names of the new care models implemented. In addition, citation mining was done where the references of relevant articles were also examined.
Data Analysis
The goals outlined by the new models of LTC and any additional literature on the systems in NS and BC was evaluated. In examining the literature, key emerging themes were identified and compared to help outline the consequences of these novel initiatives on the patient population. These themes were then critically analyzed to determine the utility of the different strategies in addressing healthcare integration gaps in LTC.
RESULTS
Governance of LTC Delivery
The responsibility of governance and LTC structure lies with each provincial jurisdiction. The demographic breakdown shows that in both NS and BC, most LTC residents are over the age of 85 years with approximately 43% [11] and 59% [12] respectively. In statistics, from NS in 2007, it was found that 71% of nursing home residents were women [11]. In BC as of 2018, approximately 65% of residents are female and “73% of residents reside in single-occupancy rooms”, though there is variation in this proportion between publicly owned and privately owned facilities [12]. In BC, according to 2016/2017 statistics, residents in LTC homes stayed for an average of 871 days [12]. In NS, the average length of stay in a study evaluating 93 nursing homes to be 1059 days [13].
In NS, LTC is broken up into two types of continuing care homes: residential care facilities, and nursing homes. LTC is delivered by the Nova Scotia Department of Health’s Continuing Care Branch under the Homes for Special Care Act [11]. NS has 93 LTC homes of which “24% are publicly owned, 44% are owned by private for-profit organizations and 42% are owned by private not-for-profit organizations” [14]. The NS Health Authority coordinates LTC for residents who wish to enter a licensed public/private LTC home [14]. LTC is covered by both the provincial government and the residents themselves with the government paying for healthcare costs for those who enter through the single-entry access system while residents pay for their accommodations and personal expenses [11]]. The single-entry access system involves residents across Nova Scotia being able to call a number to access Continuing Care Services. In BC LTC is governed by the health authorities (HA) through the Community Care and Assisted Living Act or the Hospital Act [15]. As of March 31st 2021, there are 308 LTC homes across the province of which 35% fall under the public sector, 37% are private for profit organizations and 28% are private not-for-profit organizations [14]. In publicly funded LTC homes where fees are subsidized where rates are typically calculated based on 80% of after-tax income rate per month [16]. However, there are various additional deductions based on being in lower income brackets. Often, the limited number of publicly subsidized LTC homes means that there are longer wait times [16]. The HAs will be responsible for ensuring these homes are annually inspected and meeting government standards [16].
Integration Model Design
The Care by Design model was a new model of care introduced that currently only exists in NS among the Canadian provinces to provide more coordinated care between primary and acute care in LTCF using specialized family physicians [4]. It involves having family physicians with an interest in geriatrics cover each floor of the LTCF in addition to regular on-site visits. There is also 24/7 call coverage and various protocols. There is also the addition of a specialized paramedic program called the extended care paramedic program that can facilitate transfers and provide acute care on site. This is in addition to interdisciplinary education, using a standardized geriatric assessment tool and measuring performance at regular intervals [6]. The aim of this model was really to address the previous challenges in NS which were uncoordinated resident care, onus on the resident to find a family physician for entry into LTC and preventing unnecessary ED transfers. It was specifically designed to increase continuity, access and quality of care while optimizing healthcare costs and reducing staff burden [2].
In BC, following the success of prototype divisions, the LTCI model was expanded in 2015 [7]. It is currently overseen, operated and evaluated by the General Practice Services Committee (GPSI), an entity that is composed of members from the Doctors of BC, BC Family Doctors, Ministry of Health, and Regional Health Authorities [17]. The LTCI model works to improve relationships between the patients and providers by better supporting family doctors to work more closely with LTC homes and to develop solutions to issues in their communities. The three systems-level goals of the LTCI are “reduced unnecessary or inappropriate hospital transfers, improved patient/provider experience, [and] reduced cost/patient as a result of higher quality of care” [7]. These were to be accomplished by maintaining the following best-practice expectations’ including, “24/7 availability and on-site attendance when required, proactive visits to residents, meaningful medication reviews, completed documentation, [and] attendance at case conferences” [7]. This demonstrates better integration between primary care and LTC. However, although the best-practice expectations remain consistent, guidelines surrounding the expectations vary between different divisions of family practice. For example, in considering “proactive visits to residents’ ‘, Nanaimo Division of Family Practice recommends each patient be visited at least once every 3 months [18] while the Victoria and South Island Division recommend proactive visits once every 4 to 6 weeks [19]. In terms of funding model, physicians who are eligible and operate via fee-for-service are eligible for the Community Longitudinal Family Physician Payment which in 2020, distributed “$20.7M to 3,300 family doctors’ ‘ [20].
Outcomes of Integration
Emergency Department Transfers
Emergency department overcrowding is a major health system challenge within Canada and globally, with one contributor being unnecessary transfers from LTC. Reducing preventable transfers is essential in reducing human resources and economic burden in EDs as well as preventing the ensuing consequences to the LTC residents.
In NS, the CBD model aimed to address this problem by incorporating an Extended Care Paramedic program [21]. This allows paramedics to facilitate onsite physicians with transfers as well as provide certain acute care services at the LTC home. Some of these services include oxygen administration, blood samples, urinalysis, 12-lead ECG, suturing slab splinting and steroid therapy [4, 21]. The CBD model was able to reduce the number of monthly transports of LTCF residents to EDs by 36% and reduce the number of overall 911 calls by 34% after implementation 4]. On the other hand, the LTCI chose a different approach by implementing best-practice expectations and protocol in regions which have led to reductions in ED admissions. Since the start of the initiative, ED transfers have decreased in the Fraser Health Authority by as much as 28% [8]. In other individual regions that have implemented LTCI practices, similar trends are being seen and cost savings are also being reported [22]. In the Fraser Northwest division, emergency transfers have been reduced by 5% and in approximately 2 years this has led to over $1.5 million saved [22].
Quality of Care
In general, studies show that patients with long-term relationships with their family doctor tend to have better health outcomes [20]. In NS, the Care by Design model is intended to improve quality of care through increased continuity [2]. This is done by reducing the number of providers that residents have to see, ensuring that therapeutic relationships are formed with the same provider and that there is improved communication in times of transfer. A study by Marshall et al., 2016 found that overall, there was improved relational continuity of care when comparing LTC homes prior to and post CBD implementation [4]. In particular, the number of family physicians providing care decreased by 84% from 214 to 33 in 8 facilities [4]. The fewer family physicians were able to provide care for a larger number of residents thus, allowing for a reduced provider to patient ratio, strengthening the therapeutic relationship. In BC, the LTCI sought to address concerns surrounding fewer family physicians working in LTC settings. This resulted in barriers in access to family physicians. In 2015, LTC homes in BC were shown to have access to a family doctor after hours 64% of the time [8]. Following the LTCI initiative expansion, this was reported as 87% access in 2021 [8]. In addition, in a survey of facility residents, 90% of respondents reported the quality of care they received by a nurse practitioner/family doctor as good or very good during the pandemic [8].
In the CBD model in NS, another key improvement recognized was the improved informational continuity. A critical component to good quality of care is timely and accurate information transfer. This can be evaluated by ensuring there is adequate documentation, that the documentation is used during transfers in care and that patient wishes are followed. There was an increase in documentation during primary care visits with the median number of chart notes increasing and number of charts with >10 physicians notes also increasing [4]. A trend was also seen with LTCF physicians being contacted prior to 911 calls and onsite assessments conducted prior to these calls also increased [4]. Overall, these trends show that this integrated model helped form better therapeutic relationships, better continuity in terms of information transfer and prevented unnecessary transfers, overall improving quality of care. However, this model is not perfect. A study found that although there was significant reduction in the number of residents transferred to hospital after CBD implementation, paramedics were still called for 80.5% of residents and 73.6% of them were transferred to hospital [23]. Among these residents, 51.3% had explicit advanced directives which were contrary to their transfer [23]. It was found that these transfer decisions were influenced by unclear care plans, team communication, inability to control symptoms and the need for additional investigations that could not be performed on site [23].
Potentially Inappropriate Prescription and Polypharmacy
Polypharmacy, defined as the use of multiple medications or drugs concurrently, is a common challenge within the LTC sector. It involves using more medications than are needed for the patient. It is particularly dangerous for this specialized frail adult population as it can lead to functional decline, falls, nonadherence, increased risk of hospitalization, and mortality amongst residents [24]. It is important to recognize methodological limitations that make it difficult to ascertain inappropriate prescriptions which should be considered when interpreting the statistics presented. CIHI mentions that demographic differences among provincial populations with public coverage plans and exceptions in cases where certain drugs are appropriate regardless of safer alternative may factor into misrepresentation of statistics [25]. Based on the most recent CIHI report in 2016, it was found that 31.2% of LTC residents in BC were potentially inappropriately prescribed antipsychotic medications [26]. This value was much higher than the Canadian average which sits at 27.5%. Similarly, potentially inappropriate medication (PIM) use was found in 86.2% of residents in a study evaluating 10 LTCFs in NS prior to CBD implementation [27]. Both new integration models, CBD and LTCI, have outlined that one of their aims is to reduce the burden of polypharmacy and inappropriate prescriptions through regular medication reviews and new prescribing guidelines.
When comparing the literature, there was an inconsistent definition of polypharmacy. Polypharmacy in the BC was defined as using >9 medications whereas in NS, it was referred to >10 medications. These province-specific definitions will be used to describe the following results. Post CBD implementation, there was a significant decrease, although small, in residents who were taking more than 10 medications from 86.6% to 79.5% [27]. It was specifically found to be driven by a decrease in polypharmacy among residents with dementia [27]. There was no difference found in PIM use pre- and post-CBD in residents overall [27]. However, there was a decrease observed in PIM use for specific classes of medications including anticholinergics, metoclopramide and antiarrhythmics after the new model was implemented [27]. On the other hand, the LTCI has seen a reduction in polypharmacy by 18% in Mission division and Kootenay Boundary in BC [22]. Furthermore, there was a 12% reduction in the number of patients on antipsychotics who are not clinically diagnosed with psychosis, highlighting a decrease in PIM prescribing [22].
COVID-19 Pandemic Response
With the onset of the Covid-19 pandemic in Canada, long-term care has been highlighted as one of the hardest hit sectors. During the first (March-August) and second waves (September-February) of the pandemic, NS and BC were among the lower half of Canadian provinces in COVID-19 related deaths per 100,000 in LTC homes [28]. However, NS and BC have been both criticized and commended for their LTC pandemic response in different ways. During the first wave of the pandemic, LTC homes represented 88% of COVID-19 related deaths in NS, while the Canadian average was 66% [28]. In a Quality-Improvement Committee report for Northwood, the LTC in NS with the largest Covid-19 outbreak, inadequate staffing, inconsistent cleaning techniques, and structural concerns like shared rooms were listed among the contributing factors for severe outbreak [29]. However, the report also mentioned that Northwood’s CBD model allowed “good goal-directed clinical care on-site, decreased transfers to other facilities and therefore potentially reduced the risk of spread of infection” [29]. In a review of the impact of Covid-19 in Canada by the CIHI, NS was listed as one of the provinces that was able to reduce the number of deaths in LTC homes in the second wave as compared to the first wave [28]. Similar to NS, one of the criticisms of BC LTC homes was that there was already inadequate staffing that was further exacerbated by the pandemic [30]. BC also was said to have inconsistent messaging on policy and guidelines around PPE between different health authorities that resulted in confusion for LTC home operators [31]. However, BC has also been commended for quick mobilization of infection prevention and control and “actions to address public health support” [31]. In an article by Liu et al that evaluated the differences between Ontario and BC during the first wave of the pandemic, BC was cited as having “more coordination between LTC, hospitals and public health” [31]. BC was also reported to experience the least increase in excess LTC deaths in the first wave peak [28] when compared to the average deaths during the same time period in the past 5 years.
DISCUSSION
The Canada Health Act mandates that provinces have a health insurance program that covers specific health services in order to be eligible for the Canada Health Transfer. Unfortunately, LTC is not included in the list of services. As a result, there is more variation in the governance and delivery of LTC between provinces. In looking at the governance of LTC in NS and BC, both systems are coordinated by the Health Authority. NS has the NS Health Authority and BC has 5 Regional Health Authority and 1 Indigenous Health Authority that are involved. Both provinces have LTC homes that are owned by a combination of public, for-profit private, and not-for-profit private homes. Unfortunately, many studies have found that for-profit homes often have significantly lower quality of care and lower quality staffing. [32]. As a result, advocacy groups like the Office of Seniors Advocate in BC have pushed for the government to reconsider the LTC model. In considering the importance of integration of LTC with healthcare, it may also be worthwhile for provinces to look into differences in continuity of care between privately owned and publicly owned LTC homes.
In comparing the CBD model in NS and LTCI in BC, there are some similarities and differences that can be evaluated in approach. Both models address the importance of increased integration with primary care through improved access to family physicians. Furthermore, a goal that both provinces set as part of their model was reducing ED transfers from LTC homes. Thus, it was likely recognized in both regions that preventative primary care is essential and that unnecessary ED transfers mean worse outcomes for patients and increased burden on the healthcare system. However, a key addition in the CBD model was the involvement of extended care paramedics in assisting with transfers to acute care. In general, the NS tends to have very clear guidelines of implementation of integrated care that are standardized across the province. For example, ensuring that a standardized geriatric assessment tool is used to help with the transition of care to another healthcare provider. On the other hand, the LTCI offers broad best-practice protocols which different divisions of family practice across the province can determine how to implement. This has meant that even within the same regional health authority, guidelines vary across LTC homes. One important factor to consider is the larger population and greater number of LTC homes in BC that could be less conducive to a standardized approach across all regions. As a result, the context in which the model is applied is important to consider before determining one approach as superior.
Having access to acute care is crucial to providing quality care for LTC residents. However, unnecessary, or avoidable transfers place many risks. Both models of integration have made attempts to address reductions in emergency department transfers in their protocols through different approaches. NS’s approach involved adding a branching layer between the acute care services and LTC services through the extended care paramedic service. This has led to significant reductions by 36% in transfers and 34% in 911 calls post-CBD [4]. Conversely, BC took more of a bottom-up approach, where they are using decision making trees and protocols prior to transferring patients. This led to a decrease in transfers by 28% [8]. When comparing the utility of both models, NS’s approach may help save healthcare costs in the long-term compared to BC’s approach, however we have yet to see the cost-effectiveness data. Given the success of both models, it may be useful to combine forces and apply aspects of each other’s model into their own jurisdictions for further reductions. Further research into cost-effectiveness would allow for better means of comparison.
In both the CBD and LTCI models, access to care providers was a crucial component in looking at the quality of care delivered to patients. In NS, this meant improving continuity of care so LTC residents would not have to find their own family physicians. In addition, the number of family physicians providing care to the same LTC home decreased by 84% which enabled residents to be seen by the same physician and develop a longer-term relationship [4]. In BC, the primary goal of the LTCI model was to ensure that residents had appropriate access to primary care doctors in the first place and metrics used to evaluate this indicated an increase from 64% to 85% in after-hours access to family physicians [8]. Surveys also suggested that residents were quite satisfied with the care from their family doctors. In addition to primary care, both the LTCI and CBD systems aimed to improve documentation by physicians so there would be some level of improved information transfer. Although statistics on this measure was limited in BC, studies on NS found that notes by physicians were more detailed with more charts that had greater than 10 notes with the implementation of CBD [4]. However, some studies did indicate concern with miscommunication in the explicit advanced directives of certain patients that impacted care [23]. This suggests that although the integration initiatives have allowed for improvement in access to care, improved communication and information transfer may need to be better implemented and evaluated.
Polypharmacy is a prevalent issue within the frail elderly adult population across Canada. Seniors that live in LTC facilities were found to be prescribed more drugs than those that were living in the community [26]. However, it should be noted that this could be explained by one population being healthier than another. Polypharmacy is particularly difficult to manage when considering seniors with complex medical needs. However, there is a huge risk of neglecting this issue as it can impact quality of life. Seniors that are taking 10-14 different drug classes were more likely to be hospitalized for an adverse drug reaction than a senior taking 1-4 different drug classes [26]. Therefore, the need to reduce the burden of polypharmacy and PIM usage has been growing amongst organizations, practitioners, and new initiatives such as the LTCI and CBD. When comparing the measures taken to address the issue between both provinces, they are comparable with the focus being medication reviews and guidelines. Although BC seems to have had better success at reducing polypharmacy with a 18% decrease as compared to NS with a 7% decrease, this data from BC was from 2 specific divisions [22, 27]. The difference in effect on polypharmacy reduction could also be attributed to the length of time over which the measures were taken. Furthermore, the lack of consistency in the definition of polypharmacy makes it difficult to directly compare outcome data. However, not enough reductions have been made, and polypharmacy continues to be a burden in the LTC setting.
Although both provinces were heavily impacted by the pandemic, some elements of the integrated systems in both may have contributed to some outbreak control. For example, in NS, despite the LTC sector being heavily hit during the first wave, aspects of the CBD model could have prevented further spread to other communities. In BC, there were many issues surrounding inconsistent messaging of guidelines across regions that may have contributed to a worse virus outbreak. Yet, BC was mentioned in having a more integrated system relative to other heavily hit provinces like Ontario which allowed for a better and more efficient response.
Regarding limitations and assumptions of this paper, it is important to mention that comparisons drawn between provinces were often made on statistics that were collected by different sources. As a result, any methodological variability in data collection would have to be considered. In the future, it would be valuable to have more primary data on these provinces in which the same outcomes are reported in both regions. In addition, for the LTCI model, a large portion of the data was gathered by the GPCS, the coalition that oversees the initiative. As a result, there may be bias in the reporting data. This paper highlights the need for more consistent collection of data by neutral parties to allow for a better understanding of limitations and benefits of certain models. This would enable evidence-based decision making in other regions that may be looking to improve their LTC system. In addition, this paper was a literature review wherein themes based on available data were retrospectively pulled. A more systematic prospective approach should be done to draw conclusive comparisons between the CBD and LTC models.
CONCLUSION
Overall, NS and BC have taken different approaches to adopt integration into their LTC models. The CBD design has used family physicians to increase continuity, access and quality of care in LTC settings. On the other hand, the LTCI design was developed to address the difficulty for LTC residents to access primary care and used five general best practice expectations to help achieve system level change. Both models in NS and BC emphasize the benefits of integration in quality and health outcomes for residents, including a reduction in unnecessary emergency department transfers and improved quality of care. However, polypharmacy, although targeted by the respective models, has not yet been adequately addressed. Although the LTC sectors in NS and BC were both highly impacted, integrated care models may have helped prevent further disease transmission and efficiently respond to the crisis. The results of this analysis demonstrate how integration can be used to address the gaps in our LTC sector such that it can be applied in similar settings in other jurisdictions. Further studies with comprehensive and standardized data collection are needed to best inform the optimal model of integration of LTC.
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