Chapter 3: Current State Alberta Needs Assessment · 2018-09-17 · Figure 4 - AHS Access to Continuing Care Delivery Process ... 104 Figure 5 - Factors Impacting Continuing Care

Continuing Care Health Technologies Roadmap

______________________________________________________________________________ Advanced Education and Technology Chapter 3 Page 95

Chapter 3: Current State – Alberta Needs

Assessment



Contents 1. Introduction ............................................................................................................................................ 98

1.1 Objectives ...................................................................................................................... 98

1.2 Background .................................................................................................................... 98

1.2.1 The Grey Wave ...................................................................................................... 98 1.2.2 Alberta Impact ....................................................................................................... 98

1.3 Aging in Place ............................................................................................................... 100

2. Continuing Care in Alberta ................................................................................................................... 101

2.1 Continuing Care System .............................................................................................. 101

2.2 Continuing Care Access ............................................................................................... 102

3. Needs Identification ............................................................................................................................. 105

3.1 Literature Review – Key Challenges ............................................................................ 105

3.2 Needs Identified in Literature Review ......................................................................... 109

3.3 Expert Interviews ......................................................................................................... 111

3.3.1 Interview Process ................................................................................................ 111 3.3.2 Interview Results ................................................................................................. 111 3.3.3 Needs Interconnectedness .................................................................................. 118

4. Identified Needs – Prevalence and Impacts ......................................................................................... 119

4.1 Dementia ..................................................................................................................... 119

4.1.1 Definition ............................................................................................................. 119 4.1.2 Prevalence ........................................................................................................... 120 4.1.3 Economic Impact ................................................................................................. 120 4.1.4 Current Practice ................................................................................................... 120 4.1.5 Risks ..................................................................................................................... 121

4.2 Falls & Fall Related Injury ............................................................................................ 122

4.2.1 Definition ............................................................................................................. 122 4.2.2 Prevalence ........................................................................................................... 122 4.2.3 Economic Impact ................................................................................................. 123 4.2.4 Current Practice ................................................................................................... 123 4.2.5 Risks ..................................................................................................................... 124

4.3 Caregivers, Caregiver Stress and Burnout ................................................................... 124

4.3.1 Definition ............................................................................................................. 124 4.3.2 Prevalence ........................................................................................................... 125 4.3.3 Economic Impact ................................................................................................. 125 4.3.4 Current Practice ................................................................................................... 125 4.3.5 Risks Associated with Caregiving ......................................................................... 126

4.4 Social Isolation ............................................................................................................. 126

4.4.1 Definition ............................................................................................................. 126 4.4.2 Prevalence ........................................................................................................... 127



4.4.3 Current Practice ................................................................................................... 127 4.4.4 Risks ..................................................................................................................... 128

4.5 Activities of Daily Living ............................................................................................... 128

4.5.1 Definition ............................................................................................................. 128 4.5.2 Prevalence ........................................................................................................... 128 4.5.3 Risks ..................................................................................................................... 129

4.6 Medication Compliance ............................................................................................... 129

4.6.1 Definition ............................................................................................................. 129 4.6.2 Prevalence ........................................................................................................... 129 4.6.3 Current Practice ................................................................................................... 130 4.6.4 Risk ....................................................................................................................... 130

5. Use Case Studies................................................................................................................................... 131

5.1 Use Case Study # 1 ....................................................................................................... 131

5.2 Use Case Study #2 ....................................................................................................... 133

6. Care Plan Development through Use Case Studies Examples .............................................................. 135

Figure 1 - Alberta Population Distribution (2035) ......................................................................... 99 Figure 2 - Alberta Population Projections ..................................................................................... 99 Figure 3 - Continuing Care Standards .......................................................................................... 101 Figure 4 - AHS Access to Continuing Care Delivery Process ........................................................ 104 Figure 5 - Factors Impacting Continuing Care ............................................................................. 106 Figure 6 - Effects of Aging - Waterfall .......................................................................................... 110 Figure 7 - Continuing Care Needs / Demands ............................................................................. 112 Figure 8 - Interconnected Needs ................................................................................................. 118 Figure 9 - Needs-driven technology assignment process ............................................................ 135



1. Introduction

1.1 Objectives

The Current State – Alberta Needs Assessment Chapter of the Continuing Care Health Technologies Roadmap report has five objectives:

Confirm the Continuing Care context; identify challenges and issues confronting the delivery of care to the frail elderly and disabled

Identify why Seniors lose their independence and require progressively increased levels of care

Confirm the areas of key needs for Continuing Care clients as expressed by select experts in the Alberta health care system

Determine the prevalence and impact of these needs

Establish opportunities to better support seniors and their caregivers through the use of technology

1.2 Background

1.2.1 The Grey Wave

The health care system in Canada is being confronted by an enormous challenge.

Dramatic changes are required if we are to transition to effectively address and manage the changing demographics of the Canadian population.1 Demographic ageing (“greying” of the population) is proceeding more rapidly than first anticipated, and the proportion of older people is increasing as mortality falls and life expectancy increases.2

The aging of Canada’s population is one of the country’s most widely discussed demographic phenomenon3. Among others, there are huge cost implications to public services and labour market shortages. In Canada and other high income countries, the numbers of seniors will continue to grow, particularly among the oldest old. The provision of financing and other measures to meet the long-term needs of our aging population, including support for their family caregivers, is becoming an increasingly urgent political priority. Government policies and planning foresees an inevitable shift of resource expenditures toward older people.4

1.2.2 Alberta Impact

In terms of Alberta, it is currently forecast that the number of Alberta seniors will increase from approximately 410,000 to 627,200, between the years 2011 and 2021. This represents an increase of the percentage of seniors in the population from approximately 12% to 16% of the total population.5 As illustrated in Figure 16 and



Figure 27 below, by the year 2031 it is projected that there will be more than 888,000 seniors in Alberta, or about one in five Albertans.

Figure 1 - Alberta Population Distribution (2035)

Figure 2 - Alberta Population Projections

As the Alberta population ages, it is clear that the demand for and the cost of delivering health care will continue to rise. The Government of Alberta has recognized that the challenges to providing accessible, high quality care for Albertans in a sustainable manner will increase dramatically. According to the Vision 2020 document8 the government has recognized that ”in the absence of change, a new



300-bed hospital will have to be built in the province every two years to meet the growing demands and population growth, and Alberta will face a shortfall of many health-care providers”9.

Vision 2020 was developed following a provincial health services optimization review, which was conducted to assess Alberta’s health needs and find opportunities to improve health service organization and delivery for the next 10 to 15 years.

1.3 Aging in Place

Seniors are demanding to have more choice with regard to health, wellness and lifestyle in their aging years. The majority of Albertans and Canadians would prefer to age at home independently for as long as possible.10

As identified in the Canadian Senate Report “Special Committee on Aging – Final Report – 2009” 11 most Canadians want to stay in their communities as they grow older. Others want to move closer to family and friends, or to communities that provide the retirement environment they seek. While some choose to stay in their own homes, others want to move into housing that requires less maintenance or provides supports to daily living. The choice available to seniors depends on many factors, including:12

Health status

Where they live in Canada

Urban or rural area

Support of family

Friends in the vicinity; and

Financial situation

While a variety of supports are in place to provide viable choices for seniors, for example: housing and renovation programs; supportive housing options; home care; and palliative care, the report considers that “too many seniors across Canada are not being well served by this continuum of supports to age in places of choice. A health system designed to deal with episodic illness is ill prepared to deal with the rise in chronic illness associated with the aging population.”13

A challenge to the “continuum of supports” is that the needs for care tend to escalate over time. As identified in the World Alzheimer Report14, needs for care escalates from increased support for household, financial and social activities, to personal care, to what for some is almost constant supervision and surveillance. The transitions between these various stages in the continuum of care require a broad range of services and integration - health care, housing, long-term care, supportive housing/assisted living, home care and respite care. From a client’s and the client’s family perspective, the transitions can be difficult.15 16



2. Continuing Care in Alberta

Alberta's Continuing Care system provides Albertans with the health, personal care and accommodation services they need to support their independence and quality of life.

2.1 Continuing Care System

As depicted in Figure 3 below17, a number of options are available based on a person's needs, as determined by a health care professional. The options are available in three streams: home living, supportive living and facility living.18

Figure 3 - Continuing Care Standards

The Alberta Health and Wellness and Alberta Seniors and Community Supports, which publishes and maintains the Continuing Care in Alberta website, (http://www.continuingcare.alberta.ca/) describes the respective options within the streams as follows:19

Home Living: for people who live in their own house, apartment, condominium or in another independent living option. They are responsible for arranging any home care and support services they require.

Supportive Living: combines accommodation services with other supports and care. It meets the needs of a wide range of people, but not those who have highly complex and serious health care needs.

Facility Living: includes long-term care facilities such as nursing homes and auxiliary hospitals. Care is provided for people with complex health needs who are unable to remain at home or in supportive living.

In 2008, 95,000 clients province-wide were Home Care clients, while approximately 20,600 Albertans lived in 400 Supportive Living facilities. There are approximately 14,500 Long-Term Care beds.20

http://www.continuingcare.alberta.ca/



Continuing Care allows clients to receive a wide range of services in one’s familiar surroundings. Home care allows maximum freedom for the individual, in contrast to institutions, which are regulated environments; Home care is personalized – tailored to the specific needs of each individual.

The continuing care system is a shared responsibility between Alberta Seniors and Community Supports and Alberta Health and Wellness. Provincial standards for health services and accommodations are designed to ensure home care, supportive living and long-term care operators provide quality health and accommodation services to the Albertans they serve.21

2.2 Continuing Care Access

Although Alberta will remain one of the youngest provinces from a population demographic perspective, the number and percentage of seniors in Alberta has began to increase. To meet this changing need, senior-based services, in both the health and social systems, are also beginning to evolve. New generations of seniors, including the aging Baby Boomers, have their own ideas with regard to aging. Most want to age in place and stay in their own homes living independently for as long as possible. If they begin to require help, they want the system to be as responsive and collaborative as possible. Tomorrow’s seniors will demand to be involved in determining their aging and associated care, and many are already involved in planning with spouses and families long before the care is required to ensure their wishes are respected. Of great importance is that seniors want choice and options available to them to allow them to age in a desirable and dignified manner.22

Changes to Alberta’s Continuing Care System

Alberta has a continuing care system that offers more choice to seniors than most other provincial systems in Canada. With the evolution of Alberta Health Services into one service delivery entity, additional optimizations and efficiencies are being sought to enable the system to continue to sustain the expected growth in demand for service while maintaining their high level of quality of care.

According to Alberta’s Continuing Care Strategy (2008), Alberta's continuing care system will continue to provide Albertans with the health, personal care and accommodation services they need to support their independence and quality of life, while offering more choices and living options.23

A number of options are available based on a person's needs, as evaluated by a health care professional. The options are available in three streams: home living, supportive living and facility living.

What is new is the introduction of the one point of access, or Coordinated Access Intake. By streamlining the access point all Albertans will encounter a consistent process and will be assured that the needs of seniors will be assessed and met in accordance with current best practices.24

Figure 4 describes process of delivering Continuing Care services to Alberta Seniors. It is based on Alberta’s new Continuing Care Strategy: Aging in the Right Place25, and is designed to offer greater choice and enable senior and individuals with disabilities to



remain in their own homes and communities as long as possible. The new goal of AHS Continuing Care is to ensure that this care delivery model is standardized across the province, which will include:

A Coordinated Access process, where all clients will be assessed for access to the most appropriate level of care and identified program.

All clients being provided with information regarding the range of available services and options to meet their assessed needs including access to affordable accommodation.

Access criteria for each level of care serve as general guidelines. Each client will be individually assessed. Temporary changes in status may occur with acute episodes of illness, falls and post hospitalization and reassessment may be required.

Efforts to support individuals to stay in their choice of living option to enable “aging in the right place”.

This AHS Coordinated Access to Continuing Care process, which describes delivery of Continuing Care services to Alberta Seniors, is very similar to the typical Referral to Response (R2R) process established in Chapter 2. Technology interventions resulting from the Continuing Care Technology Initiative (CCTI) will provide AHS with additional interventions during the care planning phase of the process.

Critical Success Factor 3-1: As AHS revises processes for

accessing Continuing Care, they must include R2R process

elements to ensure consistency in the access and delivery of

Telecare services throughout Alberta.



COMMUNITY REFERRALS• Self• Family• Family MD• Seniors Health• Community Services

ACUTE CARE REFERRALS• Acute Units• Sub-Acute Units

AHS CORDINATED ACCESS INTAKE

Assigned to a Case Manager

Professional Care Plan Developed

Care Plan Implemented

Evaluation of Care Plan & Re-assessment

Figure 4 - AHS Access to Continuing Care Delivery Process

The R2R process mirrors a typical clinical care process. It is central to Telecare program planning and the application of technology to individual clients as part of the care planning process. Section 1.9.2.1 (Technology in the R2R Process) in Chapter 4 details the process of identifying and assigning appropriate technology to a client. The AHS Access to Continuing Care Process outlined above is compatible with the R2R process, which is central to this report and thinking on the planning and integration of Telecare in the Alberta context.



3. Needs Identification

InnoTraction undertook a needs identification and assessment process in order to discover:

Why seniors lose their independence?

What causes them to require increasing levels of care?

Why caregivers have difficulty coping?

By determining the root causes, it is anticipated that opportunities for applying technologies to address specific needs can be identified, which will enable seniors to remain more safely and securely in their home environment – “aging in the right place”. This is consistent with the Ministry of Health and Wellness’s recognition that technologies and innovation is particularly relevant for Continuing Care26. This view and approach is also expressed in the Continuing Care Strategy and supported by Initiative #7 22 (dedicated health technology funding), which is based on the belief that proven and innovative technologies could allow seniors and those with disabilities more freedom and independence. The technologies aren’t limited to medical needs; and can play a big role in safety, social and informational needs. They may provide a substitute for some professional healthcare resources, and better link caregivers to clients to allow them to participate more effectively, at various levels, in the caregiving process.27

Our approach consisted of a literature review, followed by a series of interviews with select individuals within the health care community and other service organizations, and a number of focus groups with front-line Home Care professionals, rural seniors and a provincial group of seniors, caregivers and volunteers (see below). While we attempted to obtain statistical data from key health care and the social services sectors personnel to review why Albertans were referred to Home Care and why they required increasing levels of continuing care (leading to institutionalization), we were largely unsuccessful in this effort.

Due to transition within the organization (AHS centralization) and limited resource availability within Alberta Health Services to perform additional work, current primary statistics were not made available at this time to quantify the continuing care clinical priorities in Alberta. Statistics used in this report have been gathered from previous documentation, both published and unpublished, from Alberta Health Services, Alberta Health and Wellness, Canadian Institute of Health Information, Health Canada, and Statistics Canada and other health and social agencies.

3.1 Literature Review – Key Challenges

InnoTraction completed a literature review to identify some of the key challenges confronting Continuing Care in Alberta. The review included clinical and social resources on Seniors Health, Continuing Care, Home Care, Supported Living, Aging in Place, and Independent Living. Current international, national and Albertan key online and paper resources were also reviewed and synthesized. These sources included, among others:



Alzheimer’s Disease International, World Alzheimer’s Report. 2009

Carstairs and Keon, Canada’s Aging Population: Seizing the Opportunity.

Special Senate Committee on Aging Final Report. Govt of Canada, 2009

Government of Alberta. A Profile of Alberta Seniors, 2009

Alberta Health and Wellness. Alberta Continuing Care Strategy. 2008.

Calgary Health Region. Bringing the Pieces Together – Home Care Service Plan and Logic Model 2007-2012, May 2007

Alberta Health & Wellness, Continuing Care Health Service Standards, July 200

Alberta Continuing Care Strategy Plan

Calgary Health Region, Framework for the Prevention of Falls and Fall Relation Injuries in Older Adults, 2003.

Canadian Institute for Health Information

Statistics Canada

Canadian Study on Health and Aging

Canadian Home Care Association

This literature review resulted in the identification of a list of key challenges illustrated below in Figure 5, which impact the current and future Continuing Care in Alberta. These challenges have been categorized under Demographic, Health System, and Clinical factors.

Impacts on Continuing

Care

Increasing prevalence

chronic disease

Increasing prevalence cognitive

impairment

FallsChildren with

complex needs

Increasing cancer

prevalence

Individuals with disabilitiesWorkforce

shortage

Expanding Geographic

Coverage

Risks of institutionalization

Fragmented services

Shift to Community

Health

Dispersion of Families

Rural Health

Consumerism in Healthcare

Aging Population

Increasing population

Demographic

Factors

System

Factors

Clinical

Factors

Figure 5 - Factors Impacting Continuing Care



Clinical Factors:

Rise in Chronic Disease: Currently, chronic diseases such as diabetes and cardiovascular disease represent a significant strain on the healthcare system. They are now the leading cause of avoidable illness, healthcare system utilization and premature death in Alberta and the cause of death and disability worldwide.28

Increase in Cognitive Impairment: With the aging population comes a higher incidence of cognitive impairment. Statistics indicate that around 18% of all persons over the age of 65 suffer from some form of cognitive impairment, with 8% suffering from a degenerative brain disease such as dementia.29 Two out of three Canadians over the age of 80 suffer from cognitive impairment. The Institute of Aging estimated in 2002 that, due to our aging population, the prevalence of cognitive impairment would double over the next 30 year. 30

Falls Related Hospital Admissions: According to Albertan injury statistics, individuals over 65 represent 78.3% of all injury related hospitalizations and 59% of all injury related emergency room visits, with individuals over the age of 85 being at particular risk. Falls account for 85% of all injury related admissions. One third of all emergency room visits due to falls are made by existing Home Care clients.31

Children with complex needs: There are complex challenges faced by children and families. It is difficult to deliver consistent and coordinated services to these clients across the health-care continuum and in other sectors. The well being of these children/youth needs to be optimized at home and in the community.

Rising Prevalence of Cancer: According to a 2006 study done by the Alberta Cancer Board, the prevalence of cancer in the province will rise by the year 2025 to more than 25000 new cases annually.32

Individuals with disabilities: In order to be healthy, secure, mobile and actively involved in their communities, individuals require support. Current services are fragmented and available adaptive technology and assistive devices are often difficult to obtain.

Health Systems Factors:

Workforce shortage: Like most sectors in Alberta, the provision of Continuing Care services is threatened by high wages and a shortage of qualified workers. While admissions and graduates from nursing schools have increased in recent years, Alberta remains below the national average in the attraction and retention of qualified health care professionals.

Expanding Geographic Coverage: Alberta has seen significant population growth and resultant urban sprawl in recent years. This has come without the concomitant infrastructure needed to deliver quality community health care.

Risks of institutionalization: Another significant risk factor for institutionalization is incontinence. Approximately 50% of Home Care clients



have urinary incontinence, while 40% present with bowel related problems. These types of problems create much increased risk of hospitalization and greatly increase the likelihood of admission to long-term care. 33

Fragmented services: The current fragmentation of services throughout the healthcare system creates a terrain that is very difficult for clients to navigate. Clients, staff and partners all complain of a system plagued with poor integration, transitions and communication. As the population ages and issues such as chronic disease management become increasingly important, this fragmentation will have serious impacts upon care delivery.

Shift to Community Health: Despite the important role that Continuing Care plays in the sustainability of the HealthCare system, funding and policy barriers continue to hinder the shift from institutional to community based solutions and services. Funding for Continuing Care amounts to only 4-5% of the health care budget and along with other continuing care services is considered to Extended Health Care under the Canada Health Act. The non-insured nature of these services means that there is ongoing uncertainty and continued discussions about issues such as user fees.34

Demographic Factors:

Dispersion of Families: The traditional family network is not longer in place for the majority of Albertans. Children move away for educational and economic opportunities, leaving their parents to continue to age at home independently. Many go to great lengths to provide care from a distance, however much of the burden of delivery of care to seniors who live alone falls onto the health care system.

Rural Health: Challenges in providing effective homecare are magnified in rural and remote settings, where there is less access to health care resources and limited community supports. Rural staffing shortages are generally more severe and staff members who do deliver service in these areas must cover large geographic areas with limited resources. Working over long distances makes teamwork and communication difficult among interdisciplinary teams, resulting in unmet needs, service gaps and inconsistent access.

Consumerism in Healthcare: With ever increasing access to information, healthcare consumers are more sophisticated and informed than ever before. As such, they are far more likely to use new technology to assess healthcare options and have become much more involved in making treatment decisions.

Aging Population: As is the discussion for much of this section, the aging population will significantly impact the Healthcare system over the coming decade and beyond. Between 2010 and 2020 Baby Boomers will begin to reach 65. The proportion of Albertans between 65 and 75 will rise from 5.1% to 8.3% by 2020, while the proportion of the population over 75 will rise from 4.2% to 4.7%; a number that will increase significantly after 2020, as the Baby Boomers begin to reach 75.35



Increasing population: Over the past several decades Alberta’s population has skyrocketed, with growth expected to continue over many years. In 2007 it was estimated that Home Care in Calgary alone would see an increase of approximately 4000 unique clients by the year 2012, over a 17% rise. This kind of growth is certain to have significant impact upon Home Care services across the client spectrum including seniors, disabled adults, palliative care and pediatrics.36

3.2 Needs Identified in Literature Review

The majority of the literature indicated that the main contributing factors to Seniors evolving from living independently in their own homes to requiring assistance from Home Care, and often increasing levels of care through supportive living and/or admission to Long-Term Care facilities is due to the aging process. Physical and Cognitive deterioration have long been accepted as a normal part of the life cycle. 37 38

Physical deterioration resulting in decreased muscle tone, strength and balance often leads to falls. The consequences of falls can be devastating to the former independent senior.

Cognitive deterioration is not uncommon in senior years, often beginning with simple forgetfulness, but in many cases escalating into dementia. Activities of daily living (ADL) become increasingly difficult and overall safety becomes a concern for the senior, their family and their care givers.

Figure 6 demonstrates that the various risks and impacts from aging are interconnected and compounding. These contribute to loss of independence and the need for Continuing Care services. The decline contributes to falls, dementia, decreasing ability to perform activities of daily living, and medication challenges. In addition to physical and cognitive challenges, social isolation is also identified in the literature as a significant contributing factor as to why seniors are institutionalized or are unable to continue coping on their own. The demands of seniors undergoing these effects can readily lead to caregiver burnout, which is in itself a risk for increasing utilization of the Continuing Care system.

Critical Success Factor 3-2: Case managers completing

assessment and care planning tasks must understand the risks

associated with aging including risks to caregivers.



Figure 6 - Effects of Aging - Waterfall



3.3 Expert Interviews

3.3.1 Interview Process

During the project, interviews were conducted with individual health and social care professionals (See Appendix B) who each had a specific area of expertise in Continuing Care. The professionals, for the most part were located in Alberta, and significant effort was made to ensure that each geographical area in the province was represented, as well as an equitable urban/rural split. In addition balance was also sought to ensure that the different perspectives of the service delivery spectrum were represented. Input was solicited from frontline, management and executive levels within various organizations. In addition, input was also sought from social care organizations and deliverers of service external to the health care system.

The proposed list of interviewees was reviewed with the CCTI Working Committee for feedback and additions. During the process, the list was modified due to availability issues (summer vacation period) and/or AHS organization transition factors.

An Interview questionnaire was developed for use during the interview process. This was to ensure adequate focus on the key questions to enable later meaningful data collection and analysis, however non-structured follow-up questions were asked to probe further and to ensure a free-flowing, comfortable format for the participants. While questions #1 and #2 were specific, question #3 was intended as a catch-all question to encourage the interviewee to consider any other comments not previously made. In addition a data collection tool was developed to summarize findings, analyze results and identify common themes.

The interviews were conducted over the telephone, via e-mail or in-person. The majority of participants selected to be interviewed via the telephone. Each interview took approximately 1 hour, and the results of the interviews were documented for further analysis by InnoTraction.

In addition to one-on-one interviews, InnoTraction also scheduled and conducted three (3) focus group sessions covering Professionals (8 participants), Rural Seniors (4 participants) and a Provincial Group consisting of 22 seniors, caregivers and volunteer community visitors. Total combined interview participants for this project then approach close to 80 participants. Details are provided in section 3.3.2.2 below.

As the following sections illustrates, the results from the Interviews were overwhelmingly supportive of the literature findings.

3.3.2 Interview Results

The results of the interview process are summarized below by question. Additional insights and interesting comments captured during the interview are also provided at the end of this section:



3.3.2.1 Questionnaire Responses

Question 1: From your experience can you describe one or more situations or challenges faced by senior Albertans, their family care givers and the health system that creates a lot of demand for Continuing Care services?

Summarized Response: The Interview findings could be categorized into 6 main themes:

Dementia: 80 % indicated that Dementia was a key clinical priority for senior Albertans living in the community

Falls and Falls Related Injuries: 70 % mentioned Falls as being a main priority

Social Connectedness: 67 % stated Social Connectedness was a concern

Medication Compliance: 40 % indicated that Medication Compliance was important.

Activities of Daily Living: 50 % stated that a client’s ability to perform Activities of Daily Living was essential to ensure continued independent living. In fact ADL were considered to be a key driver for the increased utilization of Continuing Care resources

Care Giver Stress: 83 % of the participants mentioned Care Giver Stress/Burnout as a priority that needed to be addressed

Figure 7 below, presents the results graphically.

0

10

20

30

40

50

60

70

80

90

Dementia Falls Medication ADL Social

Isolation

Caregiver

Stress

Pe

rce

nt

of

Pro

fess

ion

als

Figure 7 - Continuing Care Needs / Demands



Question 2: Are you aware of any attempts to use technology in this scenario in the Continuing Care context in Alberta or elsewhere?

The majority of participants were unaware of technology being currently used in Continuing Care scenarios in Alberta or in the rest of Canada:

The use of Lifeline or PERS was mentioned often.

A few mentioned Medication Dispensers however were not aware of any specific examples of usage; they had either read about it or heard via media.

Two participants mentioned that they believed the Good Samaritan Society had looked into using Medication Dispensers however were not aware of details or level of success.

Approximately 50% mentioned either having knowledge about or participated in the previous Provincial Home Telehealth Initiative funded in 2008-09 but which remains currently on hold. The focus was on remote monitoring devices in the home setting for Chronic Disease management.

Question 3: Can you provide us with additional information such as referrals, statistical data or resources? Do you have any additional comments?

Question # 3 was designed as a closing, catch-all question to encourage the interviewee to consider any other relevant information not already provided. Most of the participants had been talking for approximately 45 minutes and had already discussed most of the points in this question. The question and answers become repetitive and the question was usually not formally responded to. It became useful as a ‘recap’ to ensure no points had been missed. Those who did respond usually stated that all of the identified needs were important and needed to be addressed. Caregiver support was often commented. The experts interviewed stressed the importance of supporting family caregivers in order to prevent caregiver stress and burn-out. This was considered to be a big issue.

In terms of data, approximately half the participants stated they were unaware of statistics that could quantify the problem in Alberta. While those who thought some facts and data were available, few could provide details or contact information for follow-up.

3.3.2.2 Focus Groups

In addition to one-on-one interviews, InnoTraction also scheduled and conducted three (3) focus group sessions covering:

Front-line Home Care Professionals - AHS Calgary Seniors South Team (8 participants – Calgary South Centre))



Rural Seniors (4 participants – Three Hills Alberta), and

A Provincial-wide group of seniors, caregivers and volunteer community visitors (22 participants – Bethany Care Corporate Office)

Similar questions as those in the individual interview questionnaire were used for these focus group sessions, but the emphasis shifted towards the group profile, interest and experience.

In summary form, the responses to the questions were as follows:

Question 1: From your experience can you describe one or more situations or challenges faced by senior Albertans, their family care givers and the health system that creates a lot of demand for Continuing Care services?

Client Challenges Participants were asked to identify the main reasons clients lose their independence and require institutionalization. Overall, Dementia and Falls were still identified as being high priorities, however social isolation was also very much emphasized, particularly by the non-professional groups. Although responses were generally very similar from all three groups, the following differences were noted:

Seniors Seniors who participated often didn’t consider themselves belonging to the target group, but rather being a volunteer who assists other seniors. Most were well connected with family or community and lived active and fulfilling lives. However they provided great insight into the concerns of more vulnerable seniors that they may encounter; namely financial concerns, ability to take care of the day to day activities and social isolation.

Financial concerns were mentioned frequently by senior participants and identified as being a concern for many seniors when trying to stay healthy and independent. The rural residents talked about having a community volunteer driving service that would drive them to the city for medical appointments, but many found it difficult to pay the $100 required to compensate for the gas. Rural seniors were also more likely to stay connected with family and community members, however often struggled with being able to physically continue with household, yard or even farm work. There were often neighbours willing to assist, but many were too proud to request or even accept offers of assistance. In addition, the social isolation experienced by elderly spouses who take care of frail spouses, especially when the clients have dementia, was mentioned as an increasing concern. This is particularly true when the caregiver was male, while it was believed that female caregivers would seek out company and support. Caregivers and Volunteer visitors Caregivers and volunteer visitors identified that lack of family support, aging at a distance from family and social isolation were the main concerns for Albertans aging in place. Many voiced the personal satisfaction they gained by being the one person who visited the senior that day and knowing how much ‘just having someone to talk



to’ meant to the senior and their wellbeing. There was a consensus that some seniors may agree to participate in community programs designed to increase social connectedness, while others just wanted to be left alone, however enjoyed being visited in their home. Professionals The professionals responded understandably from a more clinical perspective. When asked to identify the main reasons seniors lose their independence and require continuing care services, the following percentages of participants identified these themes: Dementia-88% Falls-50% Medication-12% Isolation-38% Care giver Stress-25% ADL-25%

However Lack of Family involvement was also mentioned by 38%. Chronic Disease, Complex Health Issues and Fear of the Health Care System were each mentioned by 25% of participants.

During the original questioning period, only a few mentioned Medication as a priority. It was re-asked at the end of the session, with the large majority stating it was a main concern, one of the main reasons people are admitted to LTC and also very resource intensive to manage.

Question 2: Are you aware of any attempts to use technology in this scenario in the Continuing Care context in Alberta or elsewhere?

The majority of focus group participants believed that Lifeline was the most dominant and most important technology utilized to keep seniors independent.

It was estimated by professionals that approximately 25% of their client roster has lifeline, with rural seniors also estimating 25% of seniors in their rural region having PERS. Comments included:

For those that wear them, it really works

Who pays – (patients can’t afford) should go under government funding.

A watch like Lifeline but goes to children’s cell phones

People won’t pay for it, but it pays off.

Some lifelines give voice messages. For social isolation this is a big thing. Having a voice message like “good morning” when starting up; “did you have breakfast yet?”, “Did you take your pills?” etc. But again, issue with dementia

Falls are huge – lifeline a great solution Wii games sound like a great idea. It is a big hit in the lodges. Big screens – keeps people active.

Medications Dispensers: Would really cut down on staff if medication dispensers had prompts.

Professionals Comments on System

Request Telehealth



o Would be nice to send a picture of a wound site or area of concern for a consultation real-time with a physician

o Virtual home visits

Data Integration: Everyone needs to be on the same system for improved communications.

Improved monitoring leads to earlier intervention, therefore saves hospital time

Sensors might be interesting

“Auto lights is a nice idea – would help prevent falls going to the bathroom

“Who would pay for this” (lights, pendant)

PERS is good for frail elderly

GPS/locator is a good idea

Tax incentives are a great idea.

Question 3: Can you provide us with additional information such as referrals, statistical data or resources? Do you have any additional comments?

Concern regarding need to improve communication within health care system a priority for Professionals:

Communication is a key problem, it is not good.

Need a different medical system for dealing with seniors; current design is for episodic, need for chronic

Need more nurse practitioners – not enough doctors, therefore need to get more nurses involved

Patients tend to go into crisis; need to maintain their health but nurses being pulled back – reduced home visits, told to use telephone instead.

Need better control over contracted Personal Care Aids. They need better training so they can deal with Chronic Disease. These are supposed to be professional caregivers. They get paid by the visit and are supposed to stay 1 hr but often don’t.

3.3.2.3 Additional Insights

Valuable insights were provided by the interview participants during the interview process that shed more light on some of the issues/challenges confronting the health care system in the delivery of Continuing Care, and from the clients’ (and caregiver) perspective regarding their desire to delay institutionalization and enable “aging in place” as long as possible.

These insights are captured in the table below from three (3) perspectives:

Client

Caregiver, and

The Health Care System



CLIENT

Technology in the home needs to be funded like AADL

Exercise is Medicine! There isn’t a chronic disease it doesn’t improve.

Night is the worse time, so is the weekend. The world shuts down on weekends.

They are “scared stiff” of Long-Term Care – would rather stay at home

Bad ER experience – absolutely refuse to go to ER

Live at home, yes. Live in fear, no. They need to know the system will be responsive.

CAREGIVER

We can’t offload to families. They need education, support & respite to cope.

It’s difficult for caregivers to get clients to MD appt. Office hours vs Work hours

Need better control over professional caregivers – some are short-changing the system Not spending the amount of time with clients as they should..

HEALTH CARE SYSTEM

‘Health’ can’t do everything! We need to use our community resources more.

We need to start virtual home visits. Not all, but 1 in every 3 would make a difference.

Need better communications with physicians; Nurse to physician. Could use something like HealthLink but just between nurses and physicians – directly connected to a team of physicians to provide advice to nurses

Paper work is burdensome and takes away from time with clients. Need to streamline simplify and automate.



Social Connectedness

Caregiver Support

ADL

Falls

Dementia

As mentioned previously these insightful comments, and the responses to the interview questions above, strongly corroborate the findings from the literature review and other research activities undertaken by InnoTraction in this domain, as well as the Global and Technology review sections.

3.3.3 Needs Interconnectedness

The literature reviews highlight the fact that there is inter-connectedness between the various needs and client issues. This was described in section 3.1: Literature Review – Key Challenges, and especially in Section 3.2: Needs Identified in Literature Review. Figure 6 - Effects of Aging - Waterfall illustrates this well.

The interview results above further corroborate these findings in terms of the inter-related impacts of physical and cognitive declines – the aging process. This inter-connectedness is further displayed in Figure 8, and described below. These become important considerations when assigning priority to needs and identifying possible technology solutions that can facilitate “aging at home”.

Dementia: A main cause of loss of independence in seniors

Falls: Is also a main cause of loss of independence, and has an increased prevalence in seniors with dementia

ADL: Activities of Daily Living, such as toileting, hygiene, nutrition, and mobility and medication compliance are impacted by dementia & falls. The management of ADL is also a main factor to maintaining independence

Caregiver Support: Is required when seniors are unable to self manage ADL, due to dementia, falls or other physical and cognitive challenges. Caregiver Stress and Burnout is also a main contributing factor to seniors leaving their homes

Social Connectedness: Is crucial to healthy aging. A connection to community is important to self-worth in seniors, reducing isolation and their ability to remain independent. Social networks are also vitally important to the caregivers to reduce isolation and secure the necessary support.

Figure 8 - Interconnected Needs



4. Identified Needs – Prevalence and Impacts

This section explores the key areas of needs identified above to provide additional context and understanding of the individual needs, their prevalence and impact. Due to time constraints and scope focus, the information below is more indicative and “fit for purpose” rather than final authoritative content.

It is intended that this information be used by the CCTI Working Committee to help establish priorities and identify which needs to address with pilot projects. An understanding of client needs better supports the technology assignment activity in the R2R process described above in Section 2.2: Continuing Care Access, and as applied in the Chapter 5. Ultimately, managing the risks will provide the greatest return to seniors, caregivers and the health care system.

Where appropriate, each need is developed using the following categories:

Definition

Prevalence

Economic Impact

Current Practice, and

Risks

4.1 Dementia

4.1.1 Definition

Alzheimer’s disease is the most common form of dementia. It is a progressive, degenerative disease of the brain, which causes thinking and memory to become seriously impaired. The Alzheimer Society of Canada (2009) defines dementia as:

…a syndrome consisting of a number of symptoms that include loss of memory, judgment and reasoning, and changes in mood, behavior and communication abilities. 39

Dementia can range from very mild to severely debilitating. The most common symptoms include one or more of the following:40

Confusion

Forgetfulness

Agitation

Sitting doing nothing

Repeating themselves

Stubbornness

Sleep disturbance

Suspicious of people



4.1.2 Prevalence

More than 35 million people worldwide will have dementia in 2010, according to the newly released 2009 World Alzheimer’s Report from Alzheimer’s Disease International (ADI). Alzheimer's disease and related dementias has also for the past decade been the subject of increasing focus around the globe. Australia, Scotland, United Kingdom, France, United States and the European Parliament have all taken steps to study dementia and its impact, both social and economic. Many have chosen to make Alzheimer's disease a national priority.41

In Canada, an estimated 500,000 Canadians have Alzheimer's disease or a related dementia. Over 70,000 of them are under 65 and approximately 50,000 are under the age of 60.42

1 in 11 Canadians over the age of 65 has Alzheimer's disease or a related dementia.

Women make up almost three-quarters of Canadians with Alzheimer's disease.

In just 5 years, as much as 50% more Canadians and their families could be facing Alzheimer's disease or a related dementia. Within a generation, the number of Canadians with Alzheimer's disease or a related dementia will more than double, ranging between 1 and 1.3 million people.43

In Alberta, based on the 2008 population, it is estimated that 34,000 Albertans aged 65 years and older have dementia. In Alberta the incidence of dementia significantly increases after the age of 70 and it is estimated that one in ten Albertans over the age of 80 are affected by dementia.44

4.1.3 Economic Impact

Based on a study by Ostbye in 1994, the annual cost of dementia was estimated to be around $3,901,500,000 in Canada. This includes hospitals, institutions, community care, and medication. In 1998, Hux et al. showed that costs rise with the severity of Alzheimer’s disease, from $9,451 per year for mild disease, to $36,794 for severe disease. 45

Based on these findings it can be estimated that in Alberta it costs approximately $10,000 per client to care for a person with mild Alzheimer’s disease annually. A client with severe Alzheimer’s disease would cost approximately $37,000 per client for annual care. Based on 2008 statistics, one can estimate the annual cost to care for Albertan’s with Alzheimer’s disease to range between $322 million and $1.3 billion annually.

4.1.4 Current Practice

Current practice for clinicians is to focus on assessment and monitoring of memory and cognitive impairment and loss of independent living skills. The main focus of caring for a person with Dementia, for care providers, is the management of behavioural and psychological symptoms. These typically occur later in the course of



the disease, but they certainly impact on the quality of life of both the clients and the caregivers. Behavioural and psychological symptoms are an important cause of strain on care providers, and a common reason for institutionalization as the family’s coping reserves become exhausted.46

Clients with dementia eventually require some form of caregiving. The level of care required is very dependent upon the severity of the dementia. It has been demonstrated through experience that the type and level of care required is also dependent upon the client and their social network’s ability to provide the required social care to support the client’s independence.

While some community support from visiting dementia specialists or Home Care specialists occurs, it is generally recognized that not enough resources are available to adequately monitor and introduce effective preventative interventions. The dementia client in the community usually reaches a crisis or their caregiver becomes exhausted.

The community support programs often require a referral from a physician, Home Care, or family member. This is a barrier as many Albertans, especially older couples struggle on their own, either not comfortable asking for help or unaware of the availability. Again often the self-referral comes too late when they are already in crisis.

Adult Day Programs are proving a great resource for dementia patients and their caregivers. The programs provide therapeutic supervised day time activities with an emphasis on socialization. However, most do not utilize this and many continue until crisis and cannot cope, or until they become sick themselves and then both the caregiver and the client require admission.

Respite care is offered, however only a couple of hours a week to enable caregiver to have a small break and enable them to run errands or have a coffee. What most request is overnight respite, as many caregivers require a full night of uninterrupted sleep to enable them to continue caregiving while maintaining self health.

4.1.5 Risks

Risks associated with clients with dementia are often related to Safety and Caregiver stress.

Safety: Due to the cognitive nature of dementia and the associated forgetfulness, safety is a primary risk for clients with dementia, and also a major concern for their family and loved ones. Even a client’s ability to perform simple Activities of Daily living becomes an environmental safety concern - such as a stove not been turned off etc. Outdoor environmental safety is also a concern due to wandering often related to insomnia and frequently occurs during the night. Dementia clients who wander are at high risk of becoming lost and confused. Elderly dementia clients in Alberta who wander outside during winter months, especially at night are of course at the most gravest of risk.

Caregiver Stress: Due to the constant physical, mental and emotional demands related to providing care to a dementia client, caregiver stress and



burnout is a main risk with dementia. Often the primary caregiver lives with the client and is alone providing the majority of care. The nature of the disease results in the caregiver being constantly exposed to a stressful environment of repetitive questioning, confusion, fearfulness, and dependency. Caregivers are often required to provide care 24 hours a day due to insomnia and wandering that is often associated with dementia. Caregivers become tired, exhausted and social isolated. Unless properly monitored caregivers are at greatest risk of burnout. This is particularly true of caregivers who live in the home with the client.

4.2 Falls & Fall Related Injury

4.2.1 Definition

A fall is an early indicator of functional decline. A fall increases older adults’ risk of secondary falls and is the most common reason why older adults lose their independence and have to move out of their homes. 47

Falls and resulting conditions are the most common reason for admission to a care facility - a fall that breaks a bone, especially the hip, results not only in decreased mobility and independence but typically begins a downward spiral of events toward death.48

It is a common misperception that falling is a normal part of aging, and unfortunately is readily accepted as an inevitable occurrence for most seniors, whereas evidence indicates that Falls are indeed preventable.

4.2.2 Prevalence

In Canada, falls are the leading cause of injury-related mortality and morbidity and the most common of all injuries seen in the emergency departments amongst those aged 65 years and older.49

Each year approximately 30% of older Albertans living in the community report experiencing at least one fall within a 6 month period; it is speculated that most falls go unreported.

50% of seniors who do fall, do so repeatedly

In Alberta, falls accounted for nearly 50% of all injury related emergency department visits for older adults and approximately 75% of all injury related hospitalizations for older adults

Each year in Calgary approximately 30% of older adults report experiencing at least one fall within a six month period and it is speculated that close to 60,000 falls go unreported

From 1998 to 2006 there has been a 44% increase in the number of seniors seen in an Albertan emergency department due to a fall

From 1997 to 2006 there has been a 35% increase in the number of seniors admitted to Albertan hospitals due to a fall




Falls negatively affect functional abilities, quality of life and increase use of health care services amongst older adults who have experienced an injurious fall. A 2002 study on the economic burden of unintentional injury in Alberta reported that of the $329 million in direct care costs related to falls, $118 million or 36% was required for the treatment of falls among the elderly.50

Families are often unable to provide care, and 40% of all nursing home admissions occur as a result of falls by older people.

A 20% reduction in falls would translate to an estimated 7,500 fewer hospitalizations and 1,800 fewer permanently disabled seniors. The overall national savings could amount to $138 million annually.

Of all the injury related hospitalizations for Canadian seniors 62% result from falls. Falls cause more than 90% of all hip fractures in seniors and 20% die within a year of the fracture


A reduction in falls and fall injuries will not only decrease the overall societal impact and cost of the problem, but will maintain and enhance the quality of life and independence of many older individuals.51

There is considerable Level I and Llevel II research evidence from randomized controlled trials among community dwelling older people indicating the effectiveness of falls prevention programs targeting single falls risk factors. Current best practice for fall prevention in the community setting includes:52

Targeting home exercise programs incorporating balance and strengthening exercises, developed by a physiotherapist following an assessment

Group exercise programs incorporating Tai Chi Quan. American Geriatric Society/British Geriatric Society (AGS/BGS) notes that exercise programs alone could be beneficial and produce positive spin-off effects, although exercise is more beneficial if combined with assessment and targeted treatments

Vitamin D and calcium supplementation (mixed community/residential aged care sample)

Trained volunteers providing in-home health promotion, health screening and falls prevention information. Volunteers to use reliable risk assessment questionnaires and provide referrals to appropriate health or social service providers

Psychotropic medication review and graduated withdrawal

Home visits by an occupational therapist incorporating home modifications and advice regarding behavioural change to minimize fall risks (effective in sub-group of older people with recent history of falling). Nurses trained in fall risk assessment and prevention are appropriate health care providers for this role. Successful home modification programs include those with financial



and/or manual assistance in completing the modifications, programs that enlist seniors as volunteers and those that target older adults ready for change.

4.2.5 Risks

Even without an injury, a fall can cause a loss in confidence and a curtailment of activities, which can lead to a decline in health and function and contribute to future falls with more serious outcomes.

The following personal risk factors are frequently associated with falling and fall prevention.53

Increasing age

Gender

Low levels of exercise and related values/beliefs

Pre-existing medical conditions

Medications

Visual Impairment

Prior history of falling

Alcohol Use

4.3 Caregivers, Caregiver Stress and Burnout

4.3.1 Definition

Caregiving can be defined as:

“…the provision of extraordinary care, exceeding the bounds of what is normative or usual in family relationships. Caregiving typically involves a significant expenditure of time, energy and money over potentially long periods of time; it involves tasks that may be unpleasant and uncomfortable and are psychologically stressful and physically exhausting.” 54

Caregivers look after family partners, friends or neighbours in need of help because they are ill, frail or have a disability; the care they provide is unpaid. Providing care in the home is necessarily a labour-intensive activity that relies on a variety of providers to deliver an array of both formal and informal clinical and social services in the home setting. These care providers include a mix of both professional and non-professional personnel, as well as paid and unpaid. The care team or network may include nurses, therapists (physical, occupational and speech), personal care aids, social workers, physicians, dieticians, homemakers, companions, volunteers and others. The professionals tend to deliver health care service, while the unpaid care providers tend to deliver the social and personal aspects of care.55

Caregivers typically undertake a large variety of activities, these tend to focus principally around personal activities of daily living as well as some supervision such



as: personnel care and maintenance (may include bathing, grooming, dressing, toileting and eating); everyday household chores or activities required for independent living such as cooking, housekeeping, shopping, laundry, and assistance with finances such as banking. The provision of general supervision is usually required to ensure a clients safety or wellbeing, such as clients with cognitive impairment or mental illness.

4.3.2 Prevalence

According to the Canadian Caregiving Coalition, one-in-five Canadians age 45 and over are providing some form of care to seniors who have long-term health problems. Of these caregivers in Canada, 43% are between the ages of 45 and 54 years old and many therefore are balancing this role with job and family responsibilities. Interestingly 25% of all Canadian caregivers are seniors themselves with one-third of them or over 200,000 people being over the age of 75.56

In Alberta, based upon 2008 population numbers, it is estimated that approximately 658,070 Albertans over the age of 45 years provide some form of unpaid care to other Albertans who are senior, frail, chronically ill or disabled in some manner. These Alberta clients are reliant upon these volunteer care providers to enable them to maintain their independent lifestyle and remain out of institutions or at least be less dependent upon the publicly funded health care system for provision of care in the home. 57


Family caregivers have been referred to as the invisible and hidden backbone of the health and long-term care system in Canada contributing over $5 billion dollars of unpaid care.58

Without these unpaid care givers the number of Albertans reliant on paid providers to remain in their homes would dramatically increase as would the rate of institutionalization and loss of independence in seniors. Without the work of the unpaid caregivers, home care would be totally unsustainable, as would the health care system as a whole. Under the current health care allocation funding structure, the majority of funding is directed to the acute care sector, with community care receiving less than 5% of the overall funding for health care expenditures in Canada. 59


Caregiver burnout is identified by Alberta experts more than any other single factor as the reason they believe that seniors living in the community lose their independence and require institutionalization.60

Currently there is no formal registrar, database or centralized system that registers or monitors care givers and their initial or ongoing need for support. Identification, monitoring and supporting caregivers is done so in an informal, inconsistent and uncoordinated approach, usually requiring the caregiver to seek out assistance by self referral or a referral is submitted by an affiliated professional who identifies the need.



The fortunate ones are identified early on as a caregiver who is managing a dependent client often on their own, and who is at risk for burnout. The identification is usually done by the professionals involved:- physicians, nurses, social workers etc. If resources are available, dementia community outreach workers or Home Care specialists may visit on a regular basis, offering support and monitoring for potential burnout. The visiting professionals are often the one who assists with access to respite care, which is identified in the literature and by experts as being crucial to maintaining caregiver wellbeing.

4.3.5 Risks Associated with Caregiving

The risks associated with caregiving are well documented. In the USA, more than 40% of family and other unpaid care providers of people with dementia rate the emotional stress of caregiving as high or very high. 61

The needs of family and informal care providers should be taken into consideration early in the assessment of client and family. Assessment of direct supportive services to help care providers facing problems they encounter should target the following areas:62

Quality of information allowing informed choice in endorsing a caregiver role

Supportive action to prevent and treat a caregiver’s physical problems, mental and emotional challenges, including easy access to respite care and to professional care and

Education and training in practical caring and skill in coping emotionally with caring.

Professionals should acknowledge that caregivers need emotional support, technical advice and professional support to help them to deliver good services. Little attention is paid to the fact that the mental, physical and emotional burden of caregivers coupled with anxiety and stress of the service users may sometimes lead to conflict, while one of the most important role of formal services in supporting caregivers is to help them to continue providing hands-on care.63

However it is also important to remember that most family and friends who are involved in providing care to loved ones perceive gaining many positive benefits from their care provider roles. In Canada, the longitudinal Study on Aging reported that of those sampled 80% of Canadian care providers who provided care to clients with dementia were able to identify positive aspects of being a care provider. These included companionship (23%), fulfillment (13%), enjoyment (13%), providing quality of life (6%) and meaningfulness (6%). 64

4.4 Social Isolation

4.4.1 Definition

Social isolation is recognized as a high priority area for intervention among older adults. A variety of physical and cognitive health issues in older adults are associated



with social isolation. Social Isolation can be defined as physical separation from other people or as perceived social isolation, even if others are present.

It is a main concern of seniors living independently at home, their families and the health and social service system.65

4.4.2 Prevalence

With prevalence estimates reaching as high as 20% of the senior population, social isolation places a growing number of older adults worldwide at increased risk for hypertension, coronary disease, stroke, elder abuse, depression, and suicide. Older adults who have lost spouses, friends and key social roles such as employment, those caring for an older spouse or parent, the disabled, and the poor are at higher risk or social isolation. In addition, members of the Baby Boomer generation may be at increased risk for social isolation as they age because of a high rate of divorce, declining rate of remarriage, and smaller family units. 66


The current best practice model to address social isolation is one of community outreach. The challenge with this type of social care model is that it requires seniors to contact the system with an identified need. Often seniors self-isolate and therefore will not seek out community activities or outings. Despite this community outreach model to enhance socialization is currently considered best practice, there is in fact little evidence to suggest positive outcomes.

Present day families differ from families in the past in that they are the ‘sandwich’ generation responsible for caring for children and now aging parents or other seniors. Families today are also different in that the majority of women work outside of the home, thereby eliminating the previous option of volunteer or unpaid work taking care of seniors and other community supportive roles. Families often lead very hectic complex lives with children participating in more extracurricular activities, which require more parental time or commitment due to societal safety issues that perhaps were not present in previous generations. When working mothers do make time for volunteerism, it is often related to activities for their children whether at school or through sports. Changes to the Education system also contribute to the absorption of adult volunteer time, now often requiring fundraising obligations to maintain previous standards.67

A challenge for families of seniors is that seniors often do not identify as being lonely, however family members report receiving frequent calls during the work day often for reasons that perhaps are considered important by the senior but not necessarily shared by the adult children or family. Adult children feel guilty about being torn between finding the time to spend with aging parents and those personal and professional obligations to their own families.

There are numerous older adult programs aimed to decrease isolation by increasing socializing with peers or activities. However these often require referral or at least need to be sought out by seniors or family members. Through experience, it is noted that seniors will not seek out social programs, so optimally the programs will come to



the seniors. Another barrier is that many of these programs require some sort of financial reimbursement. Although social services report that families are often willing to pay for the senior to participate, there is a general belief held by the seniors themselves that one should not have to pay for companionship.

4.4.4 Risks

Families are concerned because they see their loved ones having no one to interact with on a daily or regular basis and choosing, either consciously or unconsciously to self isolate thereby decreasing both physical and mental fitness.

Seniors although lonely do not self identify as such, and try their best to cope on their own. This often evolves into self-induced physical and cognitive isolation and often results in physical and cognitive weakness, leading to falls, depression and dementia.

4.5 Activities of Daily Living

4.5.1 Definition

Activities of Daily Living (ADLs) are "the things we normally do in daily living, including any daily activity we perform for self-care (such as feeding ourselves, bathing, dressing, grooming), work, homemaking, and leisure." The term used in medicine and nursing, especially in the care of the elderly.68

While some of the activities of daily living are not necessary for fundamental functioning, they do let an individual live independently in a community.69

4.5.2 Prevalence

When seniors live independently within their own homes in the communities, they often require increasing levels of care as their ability to maintain their activities of daily living (ADL) diminishes. A significant percentage of service delivery in the home is related to personal care. Many seniors can continue to live independently in their homes for much longer, if they receive a little assistance to meet ADL. Typical examples of ADL’s include:70

Doing light housework

Preparing meals

Taking medications

Shopping for groceries or clothes

Using the telephone

Managing money

http://en.wikipedia.org/wiki/Housework

http://en.wikipedia.org/wiki/Shopping



4.5.3 Risks

The risks can be considered classified in two categories:

Safety:

o Stove or other appliances not turned off

o Clutter increase chance of falls

Health & Wellness:

o Decrease in nutritional status

o Increased incontinency

o Decreased skin integrity

4.6 Medication Compliance

4.6.1 Definition

Medications are a critical component of the management of health for older adults. Compliance simply means following the treatment and taking the appropriate medications as prescribed.71

4.6.2 Prevalence

During the past 10 years researchers in Canada and the United States have determined that medication errors are near the top of the list of adverse events occurring in health care.

Home Care professionals in Alberta estimate that the majority of their clients require assistance with medication. Agencies who provide paid caregivers service to Albertans estimate that the majority of personal care service provided to seniors in their home is related to Medication needs.

In 2007, a US study indicated that:72

40% of seniors over 75 yrs experienced adverse events because they did not adhere to their medication regime over the past 12 months.

52% of all seniors with 3 or more chronic conditions were non-adherent with their medication

54% receives prescriptions from 2 or more MDs

30% did not talk to their MD over the past 12 months regarding all their different medications

40% stopped taking their medication due to high costs over the previous year and had never informed their MD




Medication challenges currently fall into several categories:

Clients forgetting to take their medications and needing reminders or prompts to take their medication as scheduled and prescribed

Clients unable to retrieve medications physically out of containers due to dexterity or physical impairment issues

Clients unable to administer their own medications via the prescribed necessary route, either through physical or cognitive impairment

Clients who are reluctant to take medications or keep on regime as prescribed, however require them to maintain independence (ie: Antipsychotic medications)

Clients who are reluctant to take medication due to:73

o Cost

o Side effects

o Perception that they are taking ‘too many”

The large majority of Continuing Care clients fall into the first category of seniors who are absent minded and perhaps require prompts or reminders. All the medication challenges currently require a paid caregiver or family caregiver to visit in person to ensure medication compliance.

This is both a costly management intervention and high demand and stress on the caregiver.

4.6.4 Risk

The risk of not providing service to ensure medications are accurately taken is that the patient is not able to independently maintain their medication regime and their physical or cognitive state deteriorates. The patients will most likely spiral into a physical or psychological crisis and admittance to an acute care facility usually results. The client will remain in an acute care bed until their condition is stabilized. If proper supports are put into place to ensure a similar crisis does not reoccur, then the senior may be able to return home, however often the senior is instead admitted to a long term care facility due to the fear of the senior no longer able to self manage independently in their home.



5. Use Case Studies

InnoTraction has taken a needs-driven approach to the Roadmap, meaning that technology will be assigned based on client needs versus recommending technologies for technologies sake. This process for creating Technology Packages aligned with needs is developed in Chapter 4.

The R2R process introduced in Chapter 2 is central to this report and thinking on the planning and integration of Telecare in the Alberta context. The R2R Process is used to assign Technology Packages to specific clients. Utilizing Use Case studies to present client care management scenarios, allows the reader to assume the role of case manager/care coordinator while looking at client risks and needs. To facilitate this process, InnoTraction has developed a two Use Case Studies that describe the context, risks, challenges/needs and goals that a case manager can use to develop the client’s care plan and determine what technology is appropriate to support the client.

The two Use Case Studies are provided below and will be referenced in Chapter 5 where we develop the technology recommendations to address some of the goals of the Care Plans within each Case Study. The cases are hypothetical and the characters fictional, but should be typical enough for an experienced case manager or care coordinator to recognize the risks and establish care plan goals.

5.1 Use Case Study # 1

Client: Edna is an 84 years old widow, who lives alone in rural Alberta. She has Type 2 Diabetes, vision loss one eye, non injury falls and neighbours have spotted her wandering in yard at night.

Primary Caregiver and Network:

Carol is Edna’s daughter and primary care provider. She lives on the same street as Edna and works full time.

Dennis is Edna’s son who lives in Edmonton and works full time

Risk Assessment for Edna: The following risks have been identified for Edna

Biological/medical risks: advanced age, female, poor vision, diabetes

Environmental risks: Poor lighting, narrow steep stairs to the basement

Behavioral risks: medications for diabetes, irregular eating / hydration habits, very little exercise and does not use her cane, previous falls, prolonged periods of inactivity, night wandering

Social / economic risks: Lives alone, very few visitors, does not engage socially with neighbors

Caregiver challenges and needs: In order to continue supporting Edna as she ages, Carol as the primary care provider needs the following;

Know if Edna checked her blood sugar and what the reading was



Know if Edna took her diabetes medications and if she took them at the correct time

Know when Edna is eating and drinking

Know what Edna should eat to help her control her blood sugar

Explain to Edna how to use her cane properly and know if she ever used it in the house or when she goes outdoors

Get Dennis involved in Edna’s care

Share some of the information about Edna with Dennis so he did not call her all time

Understand when and where Edna is moving around and when she is falling or bumping into things

Understand if Edna is going to the bathroom frequently at night and what she can do to make sure she does not fall or that she can summon help if Edna falls.

To have peace of mind about Edna’s safety when she wanders

Care Plan Goals:

1. Edna can improve the control of her SMBG (Self Managed Blood Glucose) with a little coaching from her children. Her children only need to follow-up with Edna during their workday on an exception basis. They have peace of mind that Edna is managing well, is maintaining normal BG levels and that her risk of falling is decreased. When Edna forgets to take her medication or is not eating properly, her children can follow-up before things are out of control.

2. Carol should access the Alberta Caregiver website to learn more about the foods that Edna should be eating and other tips on controlling blood sugar through proper diet. She also emailed the link to Dennis so he was more prepared to assist Edna and coach her on proper eating.

3. Edna wants to live in her own home, and is concerned that her children may be questioning her ability to live independently now that she has admitted to falling on occasion. Her children are worried that if she falls and injures herself in the house that she won’t be able to summon help. They are also concerned that Edna is now known to leave the house in the middle of the night. This fear is escalating as winter approaches. Carol is willing to help on a moment’s notice but is becoming increasingly stressed trying to monitor from a distance without being intrusive, being on-call 24 hrs a day, while balancing her own wellbeing and other family commitments.

4. Edna normally gets up to go to the bathroom once or twice a night. She knows her house well and was able to navigate safely to the bathroom down the hall by guiding herself using touch and by ‘surfing the furniture’. However, her home is becoming cluttered and less tidy resulting in clothing on the floor and the bathroom door being left open at night. These obstacles increase the risk of falls and falls related injuries. Edna is fearful that if she gets injured she may not be able to remain living in her own home.



5. Carol is concerned about Edna’s overall wellness and her ability to function safely in her own home. When Carol visits, Edna says everything is fine but Carol notices that Edna seems tired and has been asleep in her easy chair frequently. Carol also wonders when Edna is eating and suspects she is having sleep difficulties. Carol called Home Care to find out if they could help or provide some assistance to Edna.

6. Edna enjoys her independence and wants to manage her medications. Edna needs to take one anti-hyperglycemic tablet daily with her evening meal, but forgets while she watches TV during her evening meal.

7. Edna would like to communicate regularly with her son Dennis and his college

age children in Edmonton, but she is never sure when she should call and the

grandchildren forget to call. Dennis calls regularly on the weekends.

5.2 Use Case Study #2

Client & Caregiver: Ann is a 74 years old female with a history of dementia and now associated wandering. She is also a smoker. Her primary care provider is her husband Walter, who is 82 years old and suffers from Arthritis. They have been married 53 years, live in small rural town and are active at their church.

Support Network: Mike is Walter and Ann’s son. He is a busy executive who just moved from Edmonton to Vancouver.

Assessment of Risks: The following risks have been identified for Ann and Walter:

Biological/medical risks: advanced age, female, cognitive impairment; Disabled primary caregiver

Environmental risks: likes to shop in town independently

Behavioral risks: wanderer, smoker, refuses medications from husband, night wandering

Social / economic risks: Son lives at a distance, increased caregiver stress related to spousal caregiver

Caregiver challenges supporting Walter/Ann: In order to continue supporting hios parents, Mike needs the following;

Know if Ann is safe at night while wandering

Allow Walter to get enough sleep

Ensure that Ann takes her medications and at the correct time

Know if both Walter & Ann are eating and drinking

Encourage Walter to keep active and to use his cane properly

Get Community/Church involved in Ann’s care

Ensure Walter has enough information about Ann to increase his confidence

Worrying about Ann’s safety when she goes shopping in town independent



Worry about Ann starting a fire when smoking

Monitor Walter for burnout to ensure he gets support when needed

Care Plan Goals:

1. A sensor at front door to ensure Walter is aware when Ann tries to leave during the night. Walter needs to get more sleep at night so this will let him rest more easily knowing he will be alerted if Ann wanders,

2. Walter and Mike should access the Alberta Caregiver website to learn more about Dementia and caregiver burnout.

3. Installation of a PERS (personal emergency response system) that would send a signal to a central monitoring system anytime in the event that either Walter or Ann needed assistance. (Fall, intrusion, etc.)

4. To enhance Ann and Walter’s safety further, installation of some smart home technologies to assist with daily activities. For example, if the stove is left on or turned on during the night, there is an automatic shut off. If smoke is detected due to Ann’s smoking and alarm / sprinkler system will initiate.

5. Ann likes to walk to the shops in their small town, but Walter, her husband, cannot always accompany her or keep up with her, due to his arthritis. She also likes to attend events at their church that is also within walking distance. Her son Mike who lives in Vancouver and Walter both want to encourage her to maintain social contacts and her independence by going to the shops and church.

6. Medication reminders so that both Ann and Walter takes their medication at the correct time each day.

7. Mike can encourage Ann to take her medications with Home Videoconferencing. Online social networking /video chats with Mike through their television. Attend church by video conference to maintain community ties.

Critical Success Factor 3-3: The case studies (or a typical

assessment) highlight many opportunities for technology to

support seniors and their caregivers. This is not a “one size fits

all” program. Care planners will require a catalogue of

technologies that can be matched to an individual’s needs at any

given point in time or as their needs evolve. A strong working

knowledge of available (approved) technologies is critical to

successful care planning.



6. Care Plan Development through Use Case Studies Examples

To reduce the escalating burden of Continuing Care there is a desire to assist families with the care of their loved ones and delay/prevent institutionalization by enabling them to age in their home and community environment. Most Albertans who enter Continuing Care do so at the request of their families. The families who often live at a distance are concerned and worried about the safety of their loved one. By examining the risk factors to seniors in the home and addressing the issue with appropriate, simple, inexpensive and reliable technology it is hoped that the technology may enable some of Alberta’s seniors to remain at home for as long as possible and age in their own healthy, safe and familiar environment. While Telecare technology can be an enabler, care must still be coordinated between the health care system, the client’s network of caregivers and the client themselves to drive successful outcomes.

Technology provides an additional intervention or enables a new best practice that caregivers and professionals may include in the design of care plans as illustrated in Figure 9.

Utilizing Use Case studies to present client care management scenarios, allows the reader to assume the role of case manager while looking at client risks and the needs of the family. The application of best practice elements leads to optimal care plan development and this is further enhanced through the integration of possible Technology Package interventions.

Chapter 4 will demonstrate how Technology Packages can be created from a wide array of available technologies to deal with:

Safety

Health and Wellness

Social Connectedness (isolation)

Chapter 5 will bridge available technologies that are market ready to the Care Plan Goals identified above.

Chapter 6 will demonstrate how the use of technology within the Care Planning process may contribute to the achievement of the CCTI stakeholder’s goals.

1 Stats Canada; www.statcan.gc.ca/pub/89-519-x/89-519-x2006001-eng.htm

Figure 9 - Needs-driven technology assignment process

http://www.statcan.gc.ca/pub/89-519-x/89-519-x2006001-eng.htm



2 Alzheimer’s Disease International World Alzheimer’s Report. 2009; pg26

3 Ibid 51

4 Carstairs and Keon, Canada’s Aging Population: Seizing the Opportunity. Special Senate Committee on

Aging Final Report. Government of Canada 2009 5 www.seniors.gov.ab.ca/policy_planning/factsheet_seniors/aging_population/how_fast

6 www.health.alberta.ca/documents/Trends-2007-demographics.pdf

7 Statistics Canada, Population Projections for Canada, Provincial and Territories 2005-2031

8 Vision 2020 – The Future of Health Care in Alberta (Phase One) December 2008:

www.health.alberta.ca/documents/Vision-2020-Phase-1-2008.pdf), 9 ibid

10 Carstairs and Keon, Canada’s Aging Population: Seizing the Opportunity. Special Senate Committee on

Aging Final Report. Government of Canada 2009 11

Special Committee on Aging – Final Report “Canada’s Aging Population-Seizing the Opportunity. www.parl.gc.ca/40/2/parlbus/commbus/senate/com-e/agei-e/rep-e/AgingFinalReport-e.pdf 12

ibid 13

Ibid, page 33 14

www.med.upenn.edu/aging/documents/WorldAlzheimerReportdesignedvers9-2-09.pdf 15 Pollock BG, et al. in American Journal of Psychiatry. March 2002;159(3);460-5 16 Finkel SI, et al. in International Journal of Geriatric Psychiatry. January 2004;19(1);9-18. 17 Government of Alberta Seniors and Community Supports, Continuing Care Health Service Standards,

July 2008 p4 18 Alberta Health & Wellness, Continuing Care, www.continuingcare.alberta.ca 19

www.continuingcare.alberta.ca/ 20 Alberta Health and Wellness. Alberta Continuing Care Strategy. 2008. 21

ibid 22

Continuing Care Strategy Aging in the Right Place: 23

ibid 24

Alberta Health Services Draft Guidelines for Living Options (July 6, 2009) 25

Continuing Care Strategy Aging in the Right Place: www.health.alberta.ca/documents/Continuing-Care-Strategy-2008.pdf 26

Vision 2020 – The Future of Health Care in Alberta (Phase One) December 2008: www.health.alberta.ca/documents/Vision-2020-Phase-1-2008.pdf) 27

Continuing Care Strategy Aging in the Right Place: www.health.alberta.ca/documents/Continuing-Care-Strategy-2008.pdf 28 Hollander, M. Unfinished business: The case for chronic home care services, a policy paper. Victoria, BC,

Hollander Analytical Services, 2004. 29 Calgary Health Region. Bringing the Pieces Together – Home Care Service Plan and Logic Model 2007-

2012, May 2007; p 6 30 Institute of Aging. Its time for research on aging! Strategic Action Plan. Canadian Institute of Health

Research, 2002. 31 Calgary Health Region, Framework for the Prevention of Falls and Fall Related Injuries in Older Adults,

2003. 32 Alberta Cancer Board, Cancer in Alberta: A Regional Picture, 2006 33 Calgary Health Region. Bringing the Pieces Together – Home Care Service Plan and Logic Model 2007-

2012, May 2007; p 8 34 Canadian Home Care Association www.cdnhomecare.ca/ 35 Government of Alberta. A Profile of Alberta Seniors, 2009 36 Calgary Health Region. Bringing the Pieces Together – Home Care Service Plan and Logic Model 2007-

2012, May 2007; p 4

http://www.seniors.gov.ab.ca/policy_planning/factsheet_seniors/aging_population/how_fast

http://www.health.alberta.ca/documents/Trends-2007-demographics.pdf

http://www.health.alberta.ca/documents/Vision-2020-Phase-1-2008.pdf

http://www.parl.gc.ca/40/2/parlbus/commbus/senate/com-e/agei-e/rep-e/AgingFinalReport-e.pdf

http://www.med.upenn.edu/aging/documents/WorldAlzheimerReportdesignedvers9-2-09.pdf



http://www.health.alberta.ca/documents/Continuing-Care-Strategy-2008.pdf


http://www.health.alberta.ca/documents/Vision-2020-Phase-1-2008.pdf



../../../../../../../Local%20Settings/Temporary%20Internet%20Files/Content.Outlook/N87VU6YU/www.cdnhomecare.ca



37 Rowe, J., & Kahn, R.L. Successful Aging. The Gerontologist, 37(4), 443-40, 1997. 38 Chapman, S.A., Theorizing about Aging, Canadian Journal on Aging, 24(1) p 9 -13 39 Alzheimers Society of Canada www.alzheimer.ca/ 40

ibid 41

ibid 42

ibid 43 ibid 44

Prodniuk T. et al. Health Trends in Alberta: A Working Document. for Alberta Health and Wellness 2008 45

Canadian Study on Health and Aging. www.csha.ca 46 Alzheimer’s Disease International World Alzheimer’s Report. 2009 47 Calgary Health Region, Framework for the Prevention of Falls and Fall Related Injuries in Older Adults,

2003. 48

ibid 49 Alberta Centre for Injury Control & Research www.acic.ualberta.ca/ 50 SMARTRISK, The Economic Burden of Unintentional Injury in Alberta, 2002 51 Public Health Agency of Canada, Report on Seniors’ Falls in Canada, 2005 52 Calgary Health Region, Framework for the Prevention of Falls and Fall Related Injuries in Older Adults,

2003. 53

ibid 54 Schulz R, Martire LM. Family caregiving of persons with dementia; prevalence, health effects, and

support strategies. Am J Geriatr Psychiatry 2004 May; 12(3); 240 -9 55

Canadian Home Care Association www.cdnhomecare.ca/ 56 Canadian Caregiving Coalition, www.ccc-ccan.ca 57 Government of Alberta. A Profile of Alberta Seniors, 2009 58

Canadian Caregiving Coalition, www.ccc-ccan.ca 59

Canadian Home Care Association www.cdnhomecare.ca/ 60

Government of Alberta. A Profile of Alberta Seniors, 2009 61 Canadian Study of Health and Aging. Canadian study of health and aging; study methods and

prevalence of dementia. Canadian Medical Association Journal 1994 March 15; 150(6): 899-913 62

Canadian Home Care Association www.cdnhomecare.ca/ 63

ibid 64 Canadian Study of Health and Aging. Canadian study of health and aging; study methods and

prevalence of dementia. Canadian Medical Association Journal 1994 March 15; 150(6): 899-913 65 Sabir, M et al. A Community-Based Participatory Critique of Social Isolation Intervention Research for

Community-Dwelling Older Adults, Journal of Applied Gerontology, 28(2) April 2009, 218-34 66

ibid 67 Alzheimer’s Disease International World Alzheimer’s Report. 2009 68

Activities of Daily Living, www.Medicinenet.com 69

ibid 70

ibid 71 Sherman, F.T. , Medication non-adherence; A national epidemic among America’s seniors, Geriatrics,

April 2007 p5 -6 72 Wilson, IB et al, Physician-patient communication about prescription medication non-adherence: a 50-

state study of America’s seniors. J Gen Int Med. 2007; 22; p6 73 Sherman, F.T. Medication non-adherence; A national epidemic among America’s seniors, Geriatrics,

April 2007 p5 -6

http://www.alzheimer.ca/

http://www.csha.ca/

http://www.acic.ualberta.ca/


http://www.ccc-ccan.ca/

http://www.ccc-ccan.ca/



http://www.medicinenet.com/

Documents

Chapter 3: Current State Alberta Needs Assessment · 2018-09-17 · Figure 4 - AHS Access to Continuing Care Delivery Process ... 104 Figure 5 - Factors Impacting Continuing Care