Speaking up for seniors
By Leslie Campbell, July 2016
BC’s Seniors Advocate Isobel Mackenzie makes the case for more government intervention on behalf of seniors.
I MEET WITH BC SENIORS ADVOCATE Isobel Mackenzie weighed down by personal experience of aging parents and relations, and complaints about “the system” from friends and fed-up professionals in the health and homecare fields. Much of my baggage points to at least some systemic dysfunction and an apparent disconnect between what is claimed about the government’s respect for seniors and what’s happening on the ground.
After reading through most of the eight reports produced by Mackenzie’s office over the past two years, I discover the data largely dovetails with my experiences. It certainly makes clear that we are not doing enough for a significant number of seniors, particularly those with lower incomes or who reside in rural and northern areas of the province.
Mackenzie was appointed BC’s Seniors Advocate—the first such in Canada—in 2014 after an 18-year career with Victoria-based Beacon Community Services. As Beacon’s executive director, she led the implementation of a new model of dementia care that has become a national best practice.
In her office on the main floor of the Blanshard Street Ministry of Health building, Mackenzie is keen to talk about anything and everything related to seniors.
We get right into her recent response—in no uncertain terms—to a June 7 column by Globe & Mail writer Margaret Wente. In “Time to Soak the Seniors,” Wente suggested the federal government is throwing too much money at seniors. Mackenzie described the column as a “generationally divisive and stunningly inaccurate generalization of a group of people based on their age.” Contrary to the image painted by Wente of seniors who use their Old Age Security (OAS) “to pay the air-conditioning bill for the winter place in Florida,” Mackenzie points out that “fully half of single Canadian seniors are living on less than $26,000 a year.”
She tells me she does not disagree with Wente’s questioning of OAS payments made to those who do enjoy a high income: “People with $100,000 in income don’t need…OAS. I agree with that.” And in fact, she says, many BC seniors are doing just fine. “But offices like this don’t exist for the majority,” she comments.
And she certainly takes issue with Wente including seniors’ health care costs in her calculations of government largesse towards them: “Before we go blaming seniors for the fact they need a new hip or bypass surgery, we should first thank them for the billions, yes billions of dollars they save the health care system by taking care of each other.”
BC seniors, she tells me, “have the lowest median income of any age cohort. Median is a much more meaningful number than average, because average is skewed if there are some high income earners, and conversely if there are some low income earners. So we know that half of the seniors in this province live on less than $26,000 a year. We know that they disproportionately live alone, relative to the rest of the population, so it’s one income for the household.”
Mackenzie’s research shows that it’s income that largely influences other determinants of health. A low income can play out in many ways, from not being able to afford hearing aids, which in turn cuts one off from others, which leads to depression, to forcing a senior out of a beloved home when maintenance costs mount.
BC has a host of programs aimed at helping low income seniors—programs like the Shelter Aid for Elderly Renters (SAFER), Medical Service Plan Premium Assistance, Fair Pharmacare, Property Tax Deferment Program, and Home Adaptations for Independence. Ironically, Mackenzie’s research indicates, it is exactly the people most in need who are least aware of them.
Hurdles with home support
The Seniors Advocate’s 2015 Seniors’ Housing in BC report provided a snapshot of the places seniors call home: A rather surprising 93 percent of seniors live independently. Twenty-six percent live alone. Twenty percent rent. Eighty percent are homeowners, four-fifths of them mortgage-free. Only three percent live in assisted living facilities and four percent in “residential” or long-term care (LTC). Among those over 85, 15 percent live in LTC.
BC seniors who are living independently constitute by far the largest group of seniors. Some need and receive subsidized support services to be able to remain independent. They’re charged a reduced rate based on income. This might mean a care worker dropping by daily for an hour or two to help a senior get up and dressed, do regular meal preparation, medication checks, weekly showers and other personal care. Housework is generally not provided.
Despite the rising population, such assistance, Mackenzie tells me, is decreasing. The number of hours of home support went down in three out of five health authorities (Island Health was one of them), while the number of clients increased in four out of five.
Yet she acknowledges that all the research shows that helping people stay in their own homes not only keeps them happy, but helps save taxpayer dollars. And, she says, “I believe the government is genuine when it says ‘We want to keep people in their homes.’”
So why the apparent disconnect? Why are home care hours being cut back or limited when a bit more might, in the end, save the government money?
The delivery of services, she notes, is driven by funding decisions and human resources. “I think what happens is there are so many layers and people involved, and different perspectives, and different values…” Case managers are people, after all, and each applies their own values at least to some degree; the evaluation process for care, making a judgement about what is safe, is not an exact science, she says.
And clients are living longer, with complex needs and evolving expectations. To illustrate, Mackenzie says, “I looked at the assessments of our home support clients and found 53 percent meet the clinical complexity of people in residential care. When I started 20 years ago, that number was about 10 percent.” Additionally, she points out, we’ve “fragmented the system.” Even something as simple as approving the installation of a raised toilet seat for a client can now mean home visits by two professionals with attendant communications—and delays.
In keeping with Mackenzie’s penchant for fact-based decision-making, a survey was recently completed by her office of the 22,000 people receiving subsidized home support 9000 surveys came back. Results will be reported on later this summer, but she gives me some hints about what it shows.
“I think about 79 percent say that the program is usually or always meeting their needs. When it’s not meeting their needs, the number one thing that people want is housekeeping, followed by meal preparation.”
She was surprised that while the survey results point to some frustration with the multiple workers sent out to provide care, it wasn’t “to the degree we expected to find.”
“The other thing it shows is about medications. Some of the good news is most people knew the medications they were taking and why they were taking them, but they didn’t know the side effects. And so, we have to remember that part of the job is to say, ‘Okay, Leslie, this is your statin pill, this is your blood pressure pill. This is why you’re taking them.’ The other half is to say, ‘Now, some potential side effects from these drugs could include…mental confusion, or dry mouth, or lethargy…” This is particularly important with seniors as many drug side effects could be mistaken as just another challenge of aging.
Mackenzie has now visited communities all over the province and thinks those of us in Victoria and the lower mainland have it pretty good on the home support front—at least compared to rural areas where just finding people to do the work is a big problem. It was, she tells me “an unbelievably eye-opening experience when I started to go to other parts of the province.”
Home support programs are supposedly province-wide, but she’s found stark differences across BC. She tells me one part of the province has cut meal preparation from care plans whereas others include it. Even between South Island and North Island there are “different approval processes for maximum hours.” She explains, while there’s no formal maximum hours, the general rule of thumb was always 120 hours a month, or 4 four hours a day, of subsidized care for lower income seniors.
But some health authorities aren’t doing that, she says. “In some health authorities, the discharge nurse will come in and say, ‘Well, you need four hours of home support a day. We can provide two. How are you going to provide the other two?’”
Which leads to the matter of affordability.
Tapping into home equity
As mentioned, 80 percent of BC seniors are homeowners. For low income senior homeowners, Mackenzie is advocating the BC government come up with a plan—two plans actually—that would allow them to access the equity in their homes.
Together they would give such seniors needed funds to fix the furnace or roof, and afford more care services. The Office of the Seniors Advocate has already calculated that the average monthly cost of homeowning, without a mortgage, is $1000. Some seniors, especially when single or widowed, are being forced to move simply for lack of funds—while their home could easily be worth $500,000 or a million, at least in the hot markets of Victoria and Vancouver.
To force someone to sell such a home for want of the cash to pay for a new furnace or to keep up with utility and insurance payments seems absurd. Where could they go in such low vacancy times and pay less than their mortgage-free home? Some could well be forced into subsidized assisted living or residential care facilities.
To address such realities, Mackenzie has asked the government to establish a “Homeowner Expense Deferral Account” which would allow seniors to tap into the equity in their homes to pay for housing costs such as hydro, home insurance and major repairs. The government is thinking about it.
Meanwhile, she’s thinking about a broader application of the concept of tapping into home equity. “The question is, in my mind, does government have an interest in allowing seniors to access as much equity as possible to support their independence? I think they do. Any of that equity that they’re paying to commercial interest charges [with reverse mortgages], is money they can’t spend on themselves. And so, if we had a provincial program, under similar financial rules as property tax deferral, it doesn’t make the Province money, but it doesn’t cost the Province money, either.”
Regarding the broader program, she notes, “By the time you need full-time live-in care, you’re not talking 20 years of life, right? You’re not talking about 20 years of financing. You might be talking about 5, maybe 10.”
This type of program, she feels, would allow a more sustainable way for seniors to access their equity than do commercial reverse mortgages.
Both the Expense Deferral and this broader program could be offered at no cost or risk to taxpayers. And given the cost of subsidized care—for example, LTC costs are $7000/month, with clients charged a maximum of only $3157—the plans should ultimately save the government money.
Mackenzie believes the government is receptive, but cautious. “The government’s concern is, number one, they want to make sure that there’s enough equity left in the house to pay off what’s owed when the house is sold. Fair enough. Certainly you shouldn’t allow it at 55, like we have started to allow property tax deferral, but you may want to say these are the triggers for accessing it.” She says the government tends to like simplicity and prefers to not interfere with the market. “So it’s my job to remind government that [it could put] an income test on accessing this money. These are folks you’re going to be taking care of one way or another, and it’s convenient, it’s serendipitous that what people want actually happens to be what will cost the government less.”
Mackenzie is also concerned about appropriate housing in rural areas. Think of a widow, she suggests, who wants to move from a farm into the nearby town—or just wants to downsize to a more manageable home. “There are no condos. There are no patio homes. There’s no assisted living,” she says. “Because the private sector isn’t going in there and building these kinds of things because there aren’t enough people. So, for those folks, the government’s going to have to look at its role in the supply of suitable independent housing.”
The “FAB” system not so fab
Once an elder is deemed, through a formal assessment process, to have needs that make it impossible for that person to be safely cared for in the community or assisted living, his or her name goes on a waitlist for one of BC’s 300 publicly subsidized LTC facilities. They are told to choose a facility—referred to as “Preferred Bed” (PB)—but are also informed they must take the “First Appropriate Bed” (FAB) in their chosen geographical area. They are warned to be ready to move within 48 hours of approval for a bed.
Time spent on the waitlist seems to vary wildly among regions, and Mackenzie’s numbers appear rosier than the present day realities that have come to my attention. Those statistics, for 2013-14, show Island Health seniors spent an average of 41 days on the waitlist before getting a bed. Caseworkers have told me it’s now averaging six months in Victoria.
Mackenzie believes that 5 to 15 percent of BC seniors living in residential care may be incorrectly housed—they are more suited for assisted living or being back in the community with supports. She has called for a reassessment of certain residents, allowing them—if desired—to move elsewhere. This could free up needed LTC beds as assisted living facilities have a 10 percent vacancy rate.
This May, a 600-page downloadable Residential Care Facilities Quick Facts Directory was published on the Seniors Advocate website. It provides standardized, easy to read, comparative information on each long-term care facility in BC—definitely not a marketing brochure, says Mackenzie. For each facility it indicates the number of beds, shared rooms, percentage of the residents on antidepressants and antipsychotics, the number of reported “incidents” (falls, aggression, etc), when it was last inspected, and what percentage of the residents get recreation and other therapies.
Given my own experience with elders on LTC waitlists, this knowledge is a mixed blessing. Stated preferences seem to count for nothing. Mackenzie’s own data is a little less grim. During 2013/14, clients got their “Preferred Bed” 23 to 45 percent of the time, depending on health authority. Even after they accepted the “First Appropriate Bed” (FAB) and applied for a transfer, only 4 to 22 percent of the time—depending on health authority—did they get to move to their desired facility.
Mackenzie says her office hears from many frustrated seniors and their families about this. “Some seniors in more rural and remote regions of the province can find their spouse placed hundreds of kilometres away under the FAB policy.” The FAB system was to be used in tandem with “a fair, equitable and transparent transfer process that would ensure seniors got to their preferred facility as soon as possible.” But that, says Mackenzie, is not happening.
She has recommended health authorities “be diligent” in filling available beds first from the preferred facility transfer list. She knows this is a bit more work for everyone, as it can mean multiple domino-like moves, but if it’s “implemented, monitored and enforced in all health authorities, then seniors and their family members will have greater certainty. They will know exactly how many people are ahead of them on the transfer list and there will be a general idea of how often a bed becomes available in a certain facility. The current situation gives no ability to predict because beds are getting filled first by people on the waiting list, not from the transfer list.”
Mackenzie has also asked the government to ensure that by 2025, 95 percent of all residential care beds in the province will be single room occupancy. Meanwhile she’d like to see those seniors who end up—through no choice of their own—sharing a room, get a rate adjustment.
Mackenzie and her team are currently gearing up to do a massive survey on long term care facilities from the user’s point of view. Her office’s biggest undertaking to date, trained multi-lingual volunteers will interview all 27,000 seniors in care and their most frequent visitor. The survey, says Mackenzie, “[will let us] see if and how the quality of experience is different depending on which care facility, which health authority, which area within the health authority. Are there differences? We’re going to find out.”
But again, I wonder how that knowledge will serve seniors if they cannot choose a facility with much certainty of ending up there. Finding themselves placed in a facility they purposely avoided choosing because of negative reviews might actually be quite worrisome and depressing.
Funding all over the map
Some of BC’s 300 subsidized facilities—two-thirds in fact—are operated by non-profits or private companies on contract to the health authorities. The 27,000 residents in these facilities pay 80 percent of their income towards their care to a maximum of $3157. Asked why there are only 2000 BC elders in totally private beds, Mackenzie notes simply, “Because it costs them eight grand a month.”
The government calculates funding for operators of LTC facilities on the basis of 3.36 hours of care per resident daily for such tasks as toileting, feeding, medication management, and bathing. When compiling information for the Quick Facts Directory, says Mackenzie, “we asked every facility what their funded direct hours of care were, and we found out that 82 percent came up short of the recommended 3.36.”
Yet, she points out, there is no penalty. “Right now, if you run a care facility and you aren’t meeting standards, or you have licensing infractions, [inspectors] come on-site, and it’s embarrassing, and you [generally] fix it, right? But there’s no financial penalty if you don’t. The ultimate penalty is they’ll close you down…But [the government] doesn’t really want to do that because where are they going to put the people who are living there?” She believes there should be a financial incentive for compliance.
The funding, she says, is all over the map. “We’ve done the analysis seven ways to Sunday. We’ve looked at the resident assessment instrument…to see if there is a pattern of higher complexity with higher funding. But there’s nothing.”
Mackenzie says the ministry is looking at it. “I’ve said I believe the 3.36 is what everybody should be funded for, and then you do something called ‘case mix adjust,’ which is you look at the profile, you look at the assessments of the folks, and if there’s higher complexity than norm, you would staff more. If there was lower complexity, you might adjust the staffing downwards. But that’s not happening right now.”
When she hears health authorities making arguments claiming they will look at increasing their staff as funding allows, she says: “Whoa, wait a minute. We’re not talking about when we can afford to upgrade the car…We’re talking about the people in the care facility today who aren’t going to benefit from that tomorrow. They’re the ones who are not getting the [correct level of services].” She cites recreational therapy as an example, noting that BC’s residential care facilities provide less per person than Alberta’s do. Moreover, “We use more antipsychotics and antidepressants in BC for people who don’t need them than they do in Alberta.”
While admitting that, at this point, a causal link isn’t established, she does say, “A population that is more sedated is going to be less likely to engage in recreational therapy [which] does require resources, staffing. And so if you’re lower on the staffing, and you’re higher on the drug use, yes, they could be linked.”
47 percent on antidepressants
The statistics show that the use of antipsychotics has come down from roughly 50 percent of all BC’s LTC residents several years ago to closer to 30 percent—still high considering that they are being used “off label” on a group of frail elders who can experience severe side effects.
“The good news is, it’s coming down,” says Mackenzie. “It’s coming down everywhere. People are becoming aware of this. The not-so-good news is BC is still one of the highest. Alberta, Manitoba, Ontario are all better than we are.”
Asked about the doctors’ role in prescribing these powerful drugs for so many elders, she says she has talked with them and, “depending on the doctor…many will acknowledge that there’s over-prescribing—but they don’t over-prescribe.” She also points out that “within the medical community, there is ageism. Again, I don’t like generalizations, so not all doctors. But a lack of either awareness or understanding of alternatives, a lowered expectation for seniors around life experience, maybe. I think families play a part in this as well: You know, ‘mum’s not happy, or mum’s behaviour is [problematic]. What can we do?’ It’s no different than you and I seeking antibiotics—just give me the pill I can take to feel better, right? We do this at any age. It doesn’t stop when we get older. When we get older, we sometimes have our family members [making requests as well].”
“The antipsychotics are about wanting to regulate their behaviour…On the behavioural front in care facilities, there’s a desire for compliance. It’s communal living, and maybe we need to be more tolerant of different behaviours. Not dangerous behaviours, but different behaviours.”
And on the antidepressant side, she says, “maybe we need to be more tolerant…and recognize that unhappiness and clinical depression are not the same thing.” Still, it’s disconcerting to learn that, on average, 47 percent of residential care clients are being prescribed antidepressant medications—especially when only 24 percent of them have been diagnosed as depressed.
Mackenzie’s staff is examining the data to figure out what medications people were on prior to entering a facility. She wonders if it isn’t a completely “normal” reaction for a person entering a care facility to feel unhappy, even upset. The desire to “fix” the situation, she feels, sometimes overrides accepting that an elder may simply need time to adjust.
Keeping government on the ball
Given the rising tide of the elder demographic, the time seems ripe to adjust “the system” to be more efficient, effective, compassionate and fair at helping seniors navigate the last decade or two of their lives. Seniors already represent 17 percent of Canada’s population, and according to Statistics Canada, by 2031 they will be closer to 24 percent.
Being Seniors Advocate means Mackenzie is in a key place to help us change the system. But is the government listening?
Mackenzie points to at least two areas where the government has taken action: First, it has relaxed the rules that in the past would have forced a senior to move from his or her assisted living unit into a residential care home. For instance, they can now, up to a point, have more assistance with eating, dressing, personal hygiene, medications and rehab therapies without rocking the boat. Secondly, the government has increased the number of seniors who qualify for a subsidy for MSP payments.
But, as her numerous reports attest, there’s much more that can and should be done.
Armed with all the data she’s gleaned over the past two years, Mackenzie will keep at it. She recognizes the need for both patience and persistence when it comes to dealing with the government and existing institutions. “You’ve got to get their attention, you’ve got to keep their attention. I’ve learned that lesson. You may think you’ve got them, but, then there’s a shiny red ball over there and they’ve moved on. So you’ve got to go back and say, okay, we haven’t forgotten about this. We gave you some time. Where is this? And keep harping on about it.”
Leslie Campbell recommends that readers visit www.seniorsadvocatebc.ca for further information on the seniors situation in BC.