‘Don’t open another bed’: How to keep NL seniors out of long-term care

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Dr. Roger Butler believes NL could have one of the best senior care systems in the world in 10 years.

That’s if NL Health Services and the government stick to implementing suggestions by the Aging Population Committee in Health Accord NL.

Building this system doesn’t require opening any more nursing home beds; it requires proper intervention and training.

“Don’t open another bed until the people that are working there have the proper training to care for them and that we have a system that looks at frail people and how we keep them in the best place to manage them, instead of just saying, ‘OK, you’ve got dementia and you wandered yesterday so now you got to go into a protective care unit’, and they don’t even need it,” Butler said.

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Butler is a physician in St. John’s who specializes in dementia. He’s been outspoken on topics around, Alzheimer’s disease, geriatric and seniors’ care.

While NL has an aging population, Butler said two main factors are driving long-term care admissions: frailty and dementia. 

Frailty is a multi-complex situation, Butler said. Usually, the person has multiple issues, like diabetes, hypertension, and chronic obstructive lung disease.

Dementia also falls into the frail category.

“Dementia, by definition, is frailty because your brain is not working right, your body is not able to function properly,” said Butler. 

“As dementia advances, you become very frail, quickly. So you need support systems in place to keep you independent.”

7,000 not in the system

NL has one of the fastest-growing 85-plus populations due to aging baby boomers. One in three people over 85, Butler said, has dementia. 

There are 3,000 people with dementia in nursing homes today with dementia, but it’s believed that there are 10,000 people with dementia in NL. 

“Which means 7,000 are not in the nursing home system yet,” said Butler. 

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Butler added that 55 per cent of the beds in hospitals are occupied by frail people and most long-term care referrals come through hospitals. 

“So, if our hospitals are being inundated with frail elderly people, doesn’t it make sense that you would look at those frail populations and try to make them less frail? And do that before they get into the hospital,” said Butler. 

Preventing the issues at home

To do this, he said, we need to find people with dementia and put support structures around them so that they don’t end up in the nursing home system until it’s necessary. 

Butler believes that once a senior goes to the emergency room, it’s a one-way ticket to get them admitted. There are two main reasons seniors end up in emergency rooms: falls and delirium. If we can prevent these issues at home, he added, fewer seniors will need nursing homes.

Butler runs the Home Dementia program, providing comprehensive geriatric assessments and ongoing follow-ups to stabilize frail seniors before they need hospital care. For those participating in the program, he said, it has reduced ER visits by 35 per cent.

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Keeping a person out of long-term care will save the health-care system $120,000 a year, he added. 

How do we keep NL seniors out of long-term care?

Butler said there are options to keep seniors at home longer by modifying them so seniors can age in place, as well as having shared housing or dementia villages.

Currently, the default system is if you’re sick you go into a home. He thinks the focus should instead be on fixing the problem if someone is sick to minimize the risk of having to leave their home. 

“Even if it means redesigning your home inside, putting safety bars in, preventing falls,” said Butler. “Modifying your bathroom, or moving it downstairs because you had a stroke.”

There’s also the shared living model, where two people with dementia living together with a home support person with training to support them. 

What are dementia villages?

A dementia village is a small community that provides housing, care, and support for people with dementia.

In Denmark, he said, they have done away with nursing homes because they don’t feel they work. Their health care costs for looking after seniors are two-thirds that of Canada’s. 

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“Newfoundland is perfect for villages, because we’ve got all these fishing villages out there, and we could have specified villages for dementia care. That way, we could have all the people that are unemployed working as home support workers to look after the people with dementia,” said Butler

“Their job is to follow them around the community and make sure they’re integrated because they need socialization, they need exercise and they need good nutrition. Those are the three things that keep your brain healthy.” 

According to Butler, due to the lack of early interventions for frail seniors, 30 per cent of long-term care residents don’t actually need to be there. 

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‘Lacking staff and training’

But what happens when they do need to be there, because some seniors do require that level of care?

Butler said that nursing home staff are undertrained in geriatrics — he can understand that, because when he began training in the ’70s, it was rare to see a patient over 70, whereas today it’s the norm — but it’s something that needs to be fixed. 

“We got LPNs in there that are trained, but they were trained at a time when there was no geriatric training,” said Butler. “If you keep building nursing homes and putting untrained people in, it just adds more pressure.”

There are some resource issues when it comes to training. While there are 20,000 home support workers in NL, 13,000 lack proper training and only 7,000 have completed dementia training.

NL, he said, is lacking geriatricians — 12 are needed and NL only has six. The province also needs 30 family doctors with extra geriatrics training and 60 nurse practitioners specializing in elder care. 

“With this workforce, we can do upstream work on about 36,000 Newfoundlanders who are frail,” said Butler.

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NLHS perspective

NL Health Services (NLHS) CEO Pat Parfrey agrees with Butler that community-based care should be prioritized. 

If community supports are strengthened, he added, seniors can enter long-term care later and stay for a shorter duration. 

The recommendations laid out by the Aging Population Committee in Health Accord NL are in line with the long-term and personal care report, he said, which was released on Jan. 5. 

According to Parfrey, oversight of implementation is handled by a deputy minister, with a support group in cabinet secretariat, and progress has been made on key recommendations. 

That includes increased wages and expanded financial eligibility for home support workers, as well as the establishment of geriatric units in St. John’s and Corner Brook. St. Clare’s is also set to have an Acute Care of the Elderly unit.

“There’s been a dementia strategy that has been released that involves providing people who can help communities act upon the management of dementia, and there have been regional coordinators hired to do that,” said Parfrey.

One thing that has not been actionable yet is enshrining the rights of seniors in legislation.

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“But work has started in that area,” added Parfrey.

There have been challenges around implementation, however, that are all related to workforce shortages, including those six geriatricians and elderly-trained family doctors and outreach programs Butler wants to see.

Memorial now has a Royal College geriatrics training program in development stages to address this, Parfrey said.

“We’ve already recruited several geriatricians since the health accord came out, and we’re in the marketplace to be able to recruit more geriatricians,” said Parfrey. 

“Funding is not the issue. Finding the people is the issue, and that was the reason that we created the training program for geriatrics.”

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