While COVID-19 has focused attention on problems in long-term care, a new study raises concerns about assisted living and concludes it’s time for BC’s Seniors Advocate to review the sector.
On Wednesday, June 17, 2020, the BC Health Coalition released The Place of Assisted Living in BC’s Seniors Care System: Assessing the Promise, Reality and Challenges report with the Canadian Centre for Policy Alternatives and the Hospital Employees’ Union.
As many people age and face choices about where and how to grow older, or have senior relatives facing those choices, this report may help to inform decisions – and suggest what questions to ask before deciding.
Assisted living was introduced in 2002 as a less institutional environment for seniors with less complex needs than long-term care. It offered the promise of greater independence and being able to live in a more home-like environment -- which are important and highly valued by seniors.
Drawing on interviews in different parts of the province with 28 care aides, Licensed Practical Nurses (LPNs), front-line managers, residents and family members, the study offers a preliminary assessment of the quality and appropriateness of assisted living services, the conditions for both residents and workers, and the legislative and regulatory frameworks that govern assisted living.
The key findings portray symptoms of a crisis in our fragmented, under-regulated, and largely privatized system of home- and community-based health care:
- Many seniors have care needs that are not met due to affordability challenges, particularly in private-pay units (where the senior or their family pay the full cost and are charged for each additional service beyond the basic minimum required). For example, LPNs and care aides reported residents using towels as adult diapers or for wound care, skipping meals not included in basic food packages, or wearing dirty clothing because laundry detergent was too expensive or residents could not afford to buy new clothes.
- A significant number of seniors in assisted living residences do not appear to qualify for assisted living under provincial legislation, which requires that residents are able to direct their own care and independently respond in case of an emergency. LPNs and care aides overwhelmingly reported struggling to meet the needs of residents with moderate to advanced dementia or significant mobility limitations – but who were nevertheless living on their own in both publicly-subsidized and private-pay assisted living.
- The assisted living model allows residents to make the choice to “live at risk” in order to remain independent, but it can easily become a way for operators to cope with or justify low staffing levels, and too often leaves residents in situations that border on neglect.
- In subsidized and especially private-pay assisted living, front-line staff reported being unable to do what they ethically know they should as a result of institutional constraints like low staffing levels, a lack of resources and the philosophy of allowing residents to “live at risk.”
- Front-line staff participating in this study reported a high rate of ER visits and hospital admissions of residents in assisted living, particularly due to falls.
The comments quoted and the incidents related by LPNs, residents, family members and managers are poignant, and clearly point to a need for changes. The report recommends a shift to “relational care” – meaning, care with more personal interaction with residents, and better lines of communication between levels of staff, and removing some restrictions on actions by staff who are qualified to perform them.
“We know seniors want to live in the more home-like environment that assisted living can provide,” says report author Dr. Karen-Marie Elah Perry. “But I am concerned many seniors and front-line workers are instead dealing with a poorly coordinated sector that increasingly resembles under-resourced and more lightly regulated long-term care.”
In long-term care, operators are responsible for the overall care of residents and provide 24-hour nursing care and personal supports. Assisted living, in contrast, is considered a housing model, and the assisted living unit is seen as the individual’s home, with operators providing any number of non-medical services (e.g. assistance with dressing, bathing, medication administration, etc.) but are not responsible for providing traditional medical care (e.g. nursing, physician or rehab services) or mobility aides, as would be found in long-term care.
“COVID-19 has exposed serious problems in long-term care resulting from two decades of underfunding, privatization and precarious working conditions. But these problems are not isolated to long-term care,” says Jennifer Whiteside, Secretary-Business Manager with the Hospital Employees’ Union (HEU). “Care aides in assisted living are overworked and undervalued. They experience serious distress when they can’t provide the level of care seniors deserve and need.”
“Working as an LPN in assisted living can be heartbreaking. We routinely encounter situations where residents are clearly suffering because they aren’t getting the level of care they need, but we are told not to interfere because they have the right to live at risk. This violates our Code of Ethics and Standards of Practice to provide safe and compassionate ethical care,” says Anita Dickson, President of the Licensed Practical Nurses Association of BC.
“We see changes in the level of care, more dementia patients. They are not moved right away, they are left there, but our employer doesn’t provide more staff. We want to give the care that’s needed but we don’t have the time or staff,” says a care aide who is commenting anonymously due to concerns about speaking out publicly. “We have to make decisions as to whether or not we’re sending residents to hospital, especially during the night shift. We send residents to hospital often.”
“This is important research on many fronts, including health care ethics,” says Patricia Rodney, Associate Professor in UBC’s Faculty of Nursing and a member of the study’s advisory group. “The research points to the moral distress that health care providers experience when they are unable to practice according to their professional standards. Further, it points to the need for more systematic attention to the dignity and autonomy of residents.”
“The majority of assisted living units in BC are owned and operated by for-profit companies,” says Andrew Longhurst, a CCPA-BC research associate and author of a companion study looking at trends in access, affordability and ownership in the province’s assisted living sector. “We also know that for-profit companies are more likely to build and own private-pay units which many lower- and middle-income seniors cannot afford.”
“More than two decades have passed without a comprehensive assessment of seniors’ care services in BC,” said Marcy Cohen, CCPA-BC research associate and member of the advisory group for the research project. “The recommendations in this report provide a road map to the Seniors Advocate and the provincial government for a more comprehensive assessment of assisted living, driven by the experiences and voices of seniors, their families and the front-line workers who provide care amid frequently impossible circumstances.”
For those who can look forward to getting old, this report is enlightening, and provides another opportunity for citizens to call for better conditions, better regulation, better staffing, better design, and better treatment -- wherever those need improvement.