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Facility Based Continuing Care Review

The Government of Alberta recently released the findings of their comprehensive Facility Based Continuing Care review, and we at ExquisiCare applaud this review! In fact, a number of the recommendations are already part of the standards of practice at ExquisiCare.

I reviewed the report, and have highlighted below how we at ExquisiCare are already meeting the recommendations, or how our model could be easily adapted to meet the recommendations. As well, I offer feedback and thoughts on some of the recommendations relating to their implementation.

Policy Direction #1: Establish Quality of Life as the number one priority goal for Alberta’s Continuing Care system.

At ExquisiCare, we couldn’t agree more, that quality of life needs to be THE priority for residents in continuing care. Our Core Values of Love, Reverence, and Family reflect our commitment to Quality of Life. Our Vision, to Transform the Culture of Long Term Care, is also supported by these recommendations.

Other recommendations under this policy include a more resident model center of care where residents age in place. Our staffing model allows our residents to age in place starting at support living, through long term care and the palliative phase, all in the comfort of our homes.

ExquisiCare does not follow the antiquated model of care or clinical task-based model, instead, our model of care focuses on the relationship with our client and their family. Families are seen as partners in care and are regularly contacted to devise the care plan. Families (pre-COVID) regularly and openly visit with their loved one and their other co-residents. Residents are regularly involved in the meaningful contribution of the operations of their own home. Where they have ability and desire, our residents can help with meal preparation. The ExquisiCare staffing model decreases the number of different staff that care for the residents. Our ratio of a minimum of 2 staff for 10 clients far exceeds the recommended hours in the FBCC report. Because our staff continually provide care to only 10 clients, they get to know the clients and can anticipate their wants and needs. Our small staff groups at each location are empowered to make decisions for their 10 clients. Decisions are made in collaboration with the staff, residents, and families. The FBCC in fact referenced the Greenhouse Project and the Butterfly Household Model of Care. ExquisiCare homes organically follow both of these models but have created our own model right here in Edmonton. ExquisiCare homes are designed to look, feel, and act like a true residential home.

Our Recreation program includes meaningful 1:1 programming and group programs which includes music, gardening in the home gardens, and pets.

As team members at Exquisicare we are here to fit into the resident’s world. This is their home. They are not living in a care ‘facility’ and having to adhere to staff or work schedules. If they want to sleep until 11, they sleep until 11. Couples or singles can be accommodated in their own private room with an attached ensuite bath. Meals are made in accordance with the residents’ wishes; sometimes they even cook! In fact, I credit one of our very first residents, Anne-Marie, with teaching us all how to make a roux! And Marion, the pie-lady, taught all her care givers the best apple pie recipe. At ExquisiCare, the team benefits from those we provide care to, just as much as they do from receiving our care. It is a reciprocal and respectful relationship between the team and the elders they serve.

Policy Direction #2: Enhance overall quality of care with residents living with dementia

ExquisiCare homes specifically geared to people with dementia result in less wandering, less exit seeking and less aggression. We know that approach and staff trained to work with people with dementia is important. Staff know that when a resident does not want to get up and walk to come back 5 minutes later.

Policy Direction #3: Improve the provision of culturally appropriate continuing care services.

10-bedroom ExquisiCare homes are ideally designed to provide care for distinct cultural groups. For example, homes can be easily designed to include cultural design features, meals prepared that meet their cultural needs, and activities to honor their cultural norms, as well as staff that speak their language.

Exquisicare homes could easily be on First Nations lands with adjustments to meet resident choice.

Policy Direction #4: Improve coordination in the continuing care system, making it easier to navigate for the client and better integrated with other health, community, and social services.

As the report notes, it is extremely difficult to navigate the complex system of continuing care. What is missing in the report is the integration of non-funded care options. On many occasions clients have come to us saying that they would have gladly looked at the ExquisiCare care model but that they didn’t know we existed. Private sites need to be listed as options and included in the navigation to seniors’ choice. Furthermore, self-managed care or having the funding follow the patient will enable seniors to access the care where they want it.

Policy Direction #5: Increase staffing hours and consistency of staffing to improve quality of care.

The ExquisiCare staffing model employs a consistent group of direct care staff with expanded work responsibilities which leads to greater team-work and better health outcomes for the residents. The report recommends increasing direct care hours in LTC to 4.5 hours/resident /day. At ExquisiCare, we already exceed that recommendation with 5 hours/resident.

The unique role of the Elder Guide at ExquisiCare means that the Elder Guide (LPN or RN) provides direct care and overall case management for a maximum of 10 residents. Not only is this a very manageable caseload, but the design of the position results in better work life balance and job satisfaction. The consistent staff model utilized at ExquisiCare is key to the quality of life and clinical outcomes for our residents.

Policy Direction #6: Develop a Workplace Improvement Action Plan to enhance working conditions for staff working in both FBCC and home care.

This is another admirable recommendation, and an area where ExquisiCare already excels. Throughout the pandemic, ExquisiCare had no cases of COVID in our residents and only a few in our staff. The teams at ExquisiCare homes regularly engage in group problem solving. All members of the team contribute and are empowered to make a difference in the lives of our residents.

Policy Direction #7: Expand the choices available to Albertans who require continuing care services.

We wholeheartedly agree in the principle to provide more choice to Albertans in where they want to receive the care.

We also agree that there needs to be a greater focus on again in place such as having smaller more personal living environments. Smaller congregate care settings can easily provide greater choice with regards to food, mealtime, bedtimes, bathing, clothing, décor, activities, and communication. We agree that private providers need to be licensed and subject to inspections. Having the funding follow the patient creates an equitable system whereby having the ability to pay does not dictate the services that are eligible for.

Policy Direction #8: Consolidate monitoring processes and improve the coordination of inspections, while enhancing accountability and public reporting.

We agree with the panel recommendations which state monitoring and accountability should focus on outcome measures rather than task-based measures (inputs). This is terrific as it will also encourage innovative models of care. Current audit requirements mandate certain inputs such as certain number of hours per professional supports. Many of these mandated inputs do not necessarily result in quality-of-life outputs for the residents and need to be re-evaluated.

Funding should be tied to quality-of-life outcomes so that sites that do well should be rewarded.

Policy Direction #9: Optimize the use of technology, research, and innovation in transforming FBCC.

ExquisiCare uses electronic health systems and electronic safety monitoring. Another benefit to the smaller home model is that we can easily and quickly integrate new technologies as they emerge.

Policy Direction #10: Ensure sustainability and affordability for the future of continuing care.

A key comment in this section of the report, and one that requires further investigation, is the admission that the current PCFB Funding model has a lack of flexibility in the accountability measures. Also, the current funding system has a lack of responsiveness to the needs of smaller facilities. ExquisiCare is 100% private and that is because the current funding system can not work for smaller facilities to deliver Long Term Care. Admittedly, we do not meet all of the accountabilities, yet our residents enjoy better quality of life and better outcomes. Current LTC sites generally need about 28 beds/site to fit in the current funded model. Our homes have only 10.

I was struck by the capital development costs between AHS/Public facility versus a private facility – AHS facilities are constructed at double the cost!

The shift towards enhancing continuing care options in the community to allow individuals to remain in their home/community longer is admirable. AHS is to be commended for their innovative programs like “Self-Managed Care” and the “Invoicing Model” which allow seniors to choose who will provide their care, where they choose to live. However, there is currently an inequity in the deliverance of these programs in that seniors living in congregate independent living sites are being forced to accept care from an agency and provider that they don’t choose. This needs to change. Another limitation of the Self-Managed Care program is that it does create a heavy burden of care management for families as they continue to be very involved in the day-to-day care and operations of the homes being lived in by the senior receiving community based care. The burden can be so cumbersome that some have forgone the self-managed care and begrudgingly placed their loved one into Long Term Care.

Again, we see in this section of the report a recommendation for smaller congregate living facilities, and we applaud this, but again note, the current funding model will not work for small home sites. And another small note – let’s quit calling them small ‘facilities’ and call them homes. These are places where our elders will live out their lives. Don’t we want them living in a home, not a facility? “Personal Care Homes” is an appropriate term and one that AHS and AB Health can adopt to define the ExquisiCare Model, and determine funding.

Linking payment to quality and efficiency in ‘pay for performance’ will result in improvements in resident satisfaction and employee retention rates. Furthermore, providing users with choice over the care giver they prefer will stimulate competition and encourage providers to provide better care. Over time, this will naturally result in the elimination of the old, antiquated buildings and substandard quality of life. We are particularly encouraged by Recommendation # 34: Examine methods for funding the operation of smaller homes to facilitate their implementation!!

Policy Direction #11: Learn from the COVID-19 experience to prevent the spread of infectious diseases in FBCC sites and improve quality of life and care.

The COVID 19 Pandemic is one of the most impactful events that has happened in LTC in Canada and reports show that Canada has one of the highest proportions of death from COVID in LTC. But not at ExquisiCare! None of the residents at any of our locations contracted COVID. Our dedicated teams of front-line staff and engaged management consistently implemented measures, ahead of government regulations to do so, which kept our residents safe and loved in their own homes.

Detailed Recommendations

The future vision for FBCC and detailed recommendations in this report, provide hope for seniors living in care and operators alike. As a nurse, I certainly appreciate the layering of services to show the importance of primary care and prevention at the top of the Policy Change, as it should be. But it is the second layer, for policies related to complex care provided at home and in the community, where we are most excited for the changes and eager to contribute. The repeated inferences to the development of new models of supportive housing such as small or cottage like homes, or homes designed specifically for delivering dementia care services are very encouraging.

Of the detailed recommendations, there are several areas where ExquisiCare can add significant value. First, I am formally offering our 3 ExquisiCare locations, built right here in Edmonton, to act as demonstration sites for evaluation of the small home model. We naturally and organically have all the essential elements of Green House and Butterfly homes and our exemplary results are proof of it.

Refocusing Capital Grants to allow for the funding of Smaller Homes will need to be married with a change to the Accountability Framework for FBCC. This is achievable by modifying the funding models to fund and reward for outcomes, not inputs. The lofty goal to create 1600 small home FBCC spaces by 2030 will meet the needs of culturally specific communities and rural communities alike. Our Small Home model also organically achieves the recommendation to assign consistent staffing who are engaged and accountable for their care.

Throughout the Pandemic, and even prior to it, there have been calls to implement more full-time positions at FBCC. While I understand and applaud the sentiment behind this, as a nurse and manager who has been scheduling staff for 20+ years, this will be tough. The nature of the work (24/7) coupled with labour law and union agreements will make this very difficult. I’m also not convinced it is across the board supported. Throughout my years as a nurse, I have found there is a large contingent of people who want part-time positions.

At ExquisiCare, we have always believed, and it has been a tenant of our philosophy of care – to take great care of our team, so they can take great care of our elders. I again offer ExquisiCare as a demonstration project to show the smaller homes enjoy a better work culture with team planning and empowered team members.

We know the ExquisiCare model is a highly effective and sought after alternative to FBCC, and we look forward to a day when many more seniors across Alberta can also benefit from it.