We’ve all heard it, and in the figure below, you can see it: the proportion of seniors in Canada is burgeoning. Over the next 20 years, the senior population in Canada will have increased 68%.
Figure 1. Canada’s seniors population outlook: Uncharted territory. Reprinted from https://www.cihi.ca/en/infographic-canadas-seniors-population-outlook-uncharted-territory by Canadian Institute for Health Information retrieved November 1, 2018 from URL. Copyright 2017 Canadian Institute for Health Information. Reprinted with permission.
Home Care is a cost-effective way to provide support for individuals throughout the functional changes that can occur with disease processes or disabling and chronic conditions. While progression to another level of care – a long-term care (LTC) facility, for example – should not be considered a failure, Home Care’s goal is to provide home support with the intent of keeping that client home for as long as it is safe to do so (“Home Care” n.d.). Surveys of seniors indicate more than 83% prefer to remain in their homes, and families echo that sentiment (CBC News, “Seniors Age Friendly”). What factors positively influence a senior’s remaining at home or, conversely, their being placed in a care facility? Is it simply that their needs become too high, their disease process too advanced? While these may be relevant, considering only the individual would be an incomplete review of the subject yielding limited avenues for intervention. There are other considerations that may uncover ways to intervene that would enhance service improvement.
So, what makes home care work? Applying the Social Ecological Model (SEM) to this question enables us to consider the factors at play, and how they influence and interact. The SEM provides a framework for thoughtful review of considerations by examining how an issue is affected by influences at five levels, each nested within the next; each interacting in ways either resonant or discordant. We will use the SEM to evaluate what is involved in a senior with a disabling condition remaining in their home at the levels of the individual, their interpersonal interactions, their community, the organizations that support them and the public policy that affects them (Kilanowski, 2017; Unicef, n.d.).
The Individual Level of the SEM looks at those characteristics unique to the individual user of the system. The home care client’s own attributes may influence their ability to remain home. The individual factors that have been found to be likely to contribute to institutionalization include the presence of verbally or physically abusive behaviors, having need for physical assistance, cognitive decline, and a tendency to wander. Features of the individual that may correlate with institutionalization demonstrate the social determinants of health in action, like access to financial resources, physical fitness, absence of chronic conditions, and good mental health (Mikkonen, J. & Raphael, 2010; Friedman, Parikh, Giunta, Fahs, & Gallo, 2012).
Who does the client have in their immediate circle of support? The Interpersonal Level of the SEM includes family, friends and social network. The availability and capability of a primary caregiver is a key determinant of whether a client is able to remain at home (Nuernberger, et al., 2018; Tew, Tan, Luo, Ng, Yap, 2011). Individuals who live alone, or situations where caregivers indicate they are no longer able to continue providing care are more likely to result in LTC placement. Those who have a family caregiver able and willing to provide support tend to remain at home. When that primary caregiver experiences high caregiver burden, the client’s risk of placement escalates. When care hours required of the caregiver increase to 20 hours/week, institutionalization risk similarly rise. It is also noted that caregivers of clients with verbally or physically abusive behaviors were four times more likely to experience distress than caregivers of clients without these behaviors (Nuernberger, et al., 2018; Tew, et al., 2011). If the caregiver has a strong sense of confidence and comfort in managing a client with a disabling condition, this has a mitigating effect (Tew, et al., 2011).
Community is the cultural, physical and communications environment in which we live. The house, the home care client and their family are part of a community. There can be a cultural imperative for families to maintain a senior in the home regardless of their disability (Tew, et al., 2011). Calgary has a very culturally diverse population and I have observed this cultural phenomenon at play, at times to the detriment of the family caregiver.
The built environment of the home or community has an effect on a client’s ability to manage their needs within it. Homes have not historically been built with considerations for aging-in-place (Eisenberg, 2015). Home Care Occupational Therapists invest efforts to keep seniors safe in their home with adaptive equipment or home modifications, although research suggest this intervention may not do as much as anticipated to enhance home-living outcomes (Boland et al., 2017). Our Canadian climate complicates community access and support significantly, and creates another variable that affects care. Walkability and safety of a community contribute to the sense of well-being of its residents (Friedman et al., 2012). In Calgary, the winter of 2017-2018 was characterized by heavy, repeated snowfalls, and this adversely affected both safety and walkability in our city. Many clients were effectively homebound by the not-so-temporary barrier of snow, and others experienced weather-related falls and subsequent injuries (CBC News, 2017; Fletcher, 2017).
Clients and families exist in systems of work, service delivery, education, infrastructure and economy. These make up the Organizational Level of support. Home Care is an organization that supports a client within their home. Home care involvement and provision of caregivers have been shown to be successful in helping clients remain in their homes. Community centers, accessible transportation and adult day programs may also have a positive effect on seniors remaining at home and the degree of caregiver stress experienced (Friedman et al., 2012; Tew, et al.,2011). Training and counseling of family caregivers may serve to delay or avoid placement (Tew, et al., 2011). When transitions through the community care continuum were examined in Canada, a surprising organizational factor was observed. If clients were assessed in hospital, rather than in the community, they were 3.5 to 8.7 times more likely to be placed (“Seniors needs and care”, 2017). This effect existed outside of differences in complexity or acuity. This is an area where education and improved communication between acute care and home care could make a significant impact (Tew, et al., 2011 & Nuernberger, et al., 2018).
Figure 3. Seniors’ needs and care settings: Improving alignment. Retrieved from https://www.cihi.ca/en/infographic-seniors-needs-and-care-settings-improving-alignment Canadian Institute for Health Information retrieved October 30, 2018 from URL. Copyright 2017 Canadian Institute for Health Information. Reprinted with permission.
The final level of influence institutionalization risk is Public Policy and includes laws like the Canada Health Act, as well as more local policy decisions. Organizations like CIHI influence social policy through publications providing data to help inform policy direction. The data provided suggest that home living is a desirable option for seniors (Nuernberger, et al., 2017). The World Health Organization’s Global age-friendly cities – a guide (2007) provides a framework to make communities more accessible. The City of Calgary has adopted many principles included in the WHO document in the Seniors Age Friendly Strategy (2015). Ontario’s strategy to address limited LTC beds by increasing availability of home care support seems like a positive policy decision. Unfortunately, it has also resulted in some unintended pressures and distress for family caregivers due to the extended wait to access residential options for care (“Ontario’s long-term care”, 2016). The Alberta government’s recent changes to minimum wage may present a financial hurdle to hiring assistance in the home. The presence or absence of programs providing financial support with equipment or home modification; specifications of building codes and laws that govern conduct of renovation companies can all affect an individual’s ability to modify their home to meet their needs. Access to knowledge resources can support a client or family in their efforts to remain at home, but a lack of connectivity may render such education inaccessible. It cannot be assumed that all of those requiring information will be able to access electronic resources. Policy steps must be taken to ensure information can be accessed in whatever form the end user requires (Ruimy, 2018; “Seniors age-friendly”, 2015).
Figure 4. Hypothetical vs. Evidence-based Contributing Factors to Institutionalization using the SEM. Adapted from Unicef. (n.d.). Module 1: Understanding the social ecological model (SEM) and communication for development (C4D) [Word document]. Retrieved October 21, 2018 from www.unicef.org
Conclusion
Clients and families have made it clear that for them, there’s no place like home. Home Care is a key part of the supports and solutions that enable this goal to be realized. The vision of supporting seniors in their homes to live well includes steps on every level within the SEM. For the individual, investing effort to manage their health and chronic conditions yields improved results. For families, access to knowledge and seeking help to offset their burden is key. For organizations including Home Care, providing services targeted to meet clients’ and families support needs is an effective and sustainable method that has measureable positive impact. Laws and communities provide the legislative and physical environments for seniors to maintain their function and value. As we join together, each level’s efforts are multiplied which, given the anticipated exponential growth in the number of seniors in Canada, is exactly what is needed.
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