# Presentation: 276672

## Alberta’s Continuing Care System

- Nagoya, Japan - April 2007
- Vivien Lai, Senior Policy Advisor
- Alberta Health and Wellness

## Presentation Outline

- The Province of Alberta
- Demographics
- Alberta’s Continuing Care System
- Challenges and Directions

**Notes:**
Good morning, I am pleased to share with you information on the possible impact of the entry of baby boomers to the Alberta continuing care system and the steps we have taken to address this challenge.

To start with, I would like to thank our Japanese hosts for organizing this symposium.   The aging of the population is an issue that will face us all.  It is very valuable for us to exchange information on how we intend to address the needs of the baby boomers.

## Canada and the Province of Alberta

**As of July 1, 2006, Canada’s population was 32,623,500.  Alberta’s population was 3,375,800,** **or 10.3% of the country’s total population**** **

**Notes:**
To begin, I would like to give a bit of background about Canada and Alberta.  Canada has a population of $32 million, and Alberta has a population of $3.4 million (approximately ten per cent of Canada’s total population)

## Alberta’s Aging Population

**Notes:**
Currently, 10% of Alberta’s population is over 65 years.  This will increase to 21% in 2030. (In Alberta, there are currently about 350,000 seniors over the age of 65 and 160,000 over the age of 75.)  Like many countries around the world, the aging of the baby boomers presents a significant challenge for the health system.

## Ministry of Alberta Health and Wellness 

**Ministry of Alberta Health and Wellness **

- Budget (2006/07): $10.5 billion or 37 per cent of total provincial budget
- Continuing care budget: Approximately
- 	12 per cent of the Ministry’s total budget
- The population over 65 years uses over
- 	50 per cent of total health expenditures

**Notes:**
Alberta is a growing and booming province. The Alberta government's per capita health spending is one of the highest in the country.  37% of provincial budget is spent in health care.
Alberta provides medically necessary, insured services under the Canada Health Act, such as physician services, hospital services as well as other services such as drugs, long-term care, home care and mental health services.
Alberta spent roughly $456 million on home and community based care and $581 million on long-term facility-based care services in 2004/2005.
The, the population over 65 years represents only about 10 per cent of the Alberta population but consumes over 50 per cent of provincial health expenditures.
In light of an aging population, Alberta’s health system faces many challenges in terms of its future sustainability. 

## Historical Review

- Long-Term Care Review: Final Report of the Policy Advisory Committee (1999)
- Auditor General’s Report on Seniors’ Care (2005)
- MLA Task Force on Continuing Care Health Service and Accommodation Standards (2005)

- “The status quo is not an option for a number of reasons – most importantly, because it will not meet the needs of a new
- generation of aging Albertans”

**Notes:**
During the last ten years, there has been a number of reports in Alberta addressing health reform in long-term care.
Long Term Care Review 1999:
In 1999, the Minister of AHW appointed a Long Term Care Review Committee to assess changes that are required from the continuing care system to address the future needs of the baby boomers.  
The Committee talked to more than 5000 baby boomers, and concluded that the “status quo is not an option”: baby boomers desire a long-term care system different from what we have now.
The Committee develops a new policy concept for delivery of services called “unbundling of services”.  Traditionally,  someone is admitted to a nursing home because he/she requires the services delivered in a nursing home, such as nursing, therapy, medication and room and board services. If we unbundle the health services from the room and board services delivered in a nursing home building, these high levels of services can be delivered in a variety of other sites outside of nursing homes where it is cheaper and government construction costs may not he required.
This is strategy we are implementing is called the “aging in place strategy”. We are expanding other sites of delivery of services such as assisted living, groups homes, lodges and home care instead of building more long-term care beds. Our slogan for delivery of services is “Bring service to the people, instead of bring people to the service”.
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## Historical Review

- Long-Term Care Review: Final Report of the Policy Advisory Committee (1999)
- Auditor General’s Report on Seniors’ Care (2005)
- MLA Task Force on Continuing Care Health Service and Accommodation Standards (2005)

- “The status quo is not an option for a number of reasons – most importantly, because it will not meet the needs of a new
- generation of aging Albertans”

**Notes:**
AG Report:  
In 2005, the Auditor General of Alberta conducted an audit of Alberta seniors’ programs and services.  The audit report recommended that AHW place higher priority in developing and updating standards, improving quality and ensuring compliance. 
MLA Task Force:  
In response to the Auditor General report, a MLA Task Force was appointed by the Minister of AHW. The report recommended new continuing care standards emphasizing client-centered care, enhanced care planning and case management, improved protocols for service delivery , and requirement of core competencies for unregulated workers.  The standards also require that all continuing care providers must have quality improvement program to strive at excellence in the delivery of services.  It also recommended the development of a compliance framework and monitoring mechanisms.

## Continuing Care in Alberta

-   Federal
-   Provincial
-   Local

**Notes:**
Now, I want to describe the Alberta Continuing Care System.
In Albert's, we have a regionalized system of delivery for health services. AHW is responsible for setting policy direction, overall goals and standards for the system.  Regional Health Authorities are responsible for the delivery of services across the province of Alberta.
In Alberta, there is a single entry to all continuing care services.  All RHAs are expected to have a toll-free line operating 7 days a week to respond to clients request for services. Standardized assessment instruments are used to determine the appropriate services which the clients should be referred to. The single-entry system called co-ordinated access ensures that only appropriate services are delivered to the clients.  Admission to long-term care facilities would only be done if the individuals cannot be look after in the community. Our system is a “needs based system”, not an entitlement system.

## Challenges

- Increasing Volume of Service Needs
- Changing Expectations of baby boomers
- Emphasis on Quality
- Issue of Sustainability
- Public  Accountability
- Workforce Issues
- Technological Advances

**Notes:**
With an increase in the number of baby boomers, Alberta will face many challenges:
Firstly: because of the increase in numbers, there will be a need for increase volume of services. The second challenge is the higher expectation by baby boomers. They are different from the current generation of elderly.  They are more educated, expect choice and have higher expectations of the health system. They are not shy to tell us if they are unhappy with the services they receive.  Consumer relationships will be a very important aspect in the future management of long-term care services. The third challenge is the emphasis on quality.  The public has higher expectations and expect quality health services. The fourth challenge is the issue of sustainability.  With the demographic change, many projections have shown that we cannot afford the health system as we know now, without significant policy change. The fifth challenge is public accountability.  The public demands accountable and transparency in the delivery of health services. Sixth, workforce will be an important issue for the next ten years.  We need to find more people and human resources to deliver services.  We need to make good use of technology to make delivery of services more efficient.  

## Increasing Volume

**Direction - Deliver services in a different way: **
- Primary health care
- New approaches to acute care: North-East Community Health Centre (Edmonton)
- Prevention of admission to hospitals and LTC facilities: CHOICE program

**Notes:**
Our first response to the challenge is to deliver services in a different way. We have developed many strategies to address the problem of an increasing demand in the volume of services. 
Primary Health Care:
Alberta has allocated $100 million through an agreement with the Alberta Medical Association to implement primary health care throughout Alberta.  In primary health care, primary care physicians are expected to work with a team of health professionals to address the needs of the clients. Home care workers are located in offices of primary care physicians to review their cases, provide home care services, healthy life style programs, thus freeing up the scare resources of physicians to address clients with complex medical needs. 
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## Increasing Volume

**Direction - Deliver services in a different way: **
- Primary health care
- New approaches to acute care: North-East Community Health Centre (Edmonton)
- Prevention of admission to hospitals and LTC facilities: CHOICE program

**Notes:**
North-East Community Health Centre:
An innovative model of primary health care: under one roof, the centre combines community-based services with a 24-hour emergency department. There are no inpatient beds.  Multidisciplinary teams not only provide care to people who use the centre, but also link them with needed services outside the centre. )
CHOICE program
The CHOICE program is a community based day program aimed at reducing the use of long-term care beds and acute care hospital beds.  Clients that would normally require long-term care placement.  
The program is a day program, providing physician, nursing therapy and medication management services.  Transportation buses usually pick up clients from their homes to go to the programs which are located at long-term care facilities.
Home care services will be provided if the client requires home based services.  The program has two to three acute services beds to provide services to clients who experience an acute care episode.  This reduces the need for acute care admission.
Implementation of the CHOICE program in Alberta has shown very impressive results.  Since implementation:
Inpatient days have decreased 70%’
Emergency room visits have decreased 63%
Ambulance trips have decreased 51%

## Changing Expectations of baby boomers

- Aging in place options
- Campus concept for elderly care
- Resident-focused care
- Involvement of family members

**Direction - Provide choice and quality of life options to clients:**

**Notes:**
The second direction is to provide choice and quality of life options to baby boomers.
Aging in place strategy:
The “aging in place” strategy enables individuals with high health needs to receive services at home. In the aging in place strategy, service providers have provided continuing care services  at homes, in apartments, group homes, duplexes and assisted living to received services. Many providers in Alberta have built “aging in place” campuses in which private condominiums, supportive housing and long-term care beds are all located in one single complex. As individuals age, they have to move as little as possible. 
Our forecasting model shows that this “aging in place strategy” will save 22.5% operating cost in the system. Since 1999, we have established targets for lowering the ratio of long-term care beds, and increased the expenditures in home care.  Home care expenditures have increased an annual average of 12.0 % a year since 1997/98.
We have created a Rural Affordable Supportive Living program to provide financial assistance to assist housing operators to build affordable supportive housing spaces in rural settings for the elderly.  From 2005-2006, a total of $101 million in targeted one-time capital funding was allocated towards the construction of 1,872 units.  

## Emphasis on Quality 

- Emphasis on Quality

- Implementation of the new Continuing Care Health Service and Accommodation Standards (May 2006)
- Improve staffing
- Enhance Case Management
- Medication Management
- Enhance clinical expertise
- End-of-life care
- Develop compliance framework

**Direction - Provide restricted funding to implement standards and improve quality:**

**Notes:**
The third direction is to enhance quality of care by providing restricted funding targeted at increase funding for the long-term care system. To address the need for expanded long-term care services for seniors, Minister of Health and Wellness has allocated $42 million in targeted funding to increase quality in long-term care. To ensure that funding is used for this purpose, a “targeted funding” approach is used.  
The funding includes: implementation of enhanced standards, improvement of staffing, case management, medication assistance, clinical expertise and end-of-life care.

## Issue of Sustainability 

- Issue of Sustainability

**Direction - Explore alternative funding approaches:**
- Unique funding approaches
- Client responsibility
- Assessment of unmet needs
- 	Health Status - Informal Supports = Services Provided

**Notes:**
The major issue of the aging of the population is sustainability.  Can we afford to provide services in the manner we have been doing? To address this, the fourth direction is to explore alternative funding approaches.
New funding approaches:
Alberta has hired a consulting firm to develop different scenarios for funding the health services.  This included insurance programs for long-term care, drugs and non-urgent acute care cases.  Although there is no decision made to proceed with any of the different funding approaches at this time, the consult’s study provides in-depth knowledge to us on the projected costs of the health system and options for addressing them. Mr. Kataoka has visited Alberta many times, and provided information on the Japanese long-term care insurance program which is most helpful to us.
Current initiatives:
Alberta has in place a number of policy statements which address the sustainability issue:
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## Issue of Sustainability 

- Issue of Sustainability

**Direction - Explore alternative funding approaches:**
- Unique funding approaches
- Client responsibility
- Assessment of unmet needs
- 	Health Status - Informal Supports = Services Provided

**Notes:**
1. Implementation of aging in place strategy to lower the demand for long-term care beds, which is expensive in operating costs and capital cost. Our projection shows that without a chance, Alberta required 14,000 new beds to meet the needs of the baby boomers.  With the implementation of the “aging in place” strategy, only 7000 new beds will be required.
2. Unbundling of health and housing services:
In the implementation of the “aging in place” strategies, health and housing services are unbundled.  The policy states that government only provides for publicly funded health services. Individuals are responsible for paying fully their room and board costs in long-term care facilities.  Since 2003, accommodation charge in nursing homes have been increased to reflect the actual costs of room and board so that those that can afford it have to pay the full cost of room and board. For those who cannot afford it, government subsidy is available. We have a very good income support program for low income clients called Alberta Seniors Benefits program delivered by our department of Alberta Seniors and Community Supports Department.  

## Public Accountability

**Direction - Measure performance of the system:**
- Health Plans
- Auditor General’s Report
- Health Quality Council of Alberta
- Standardized assessment tools

**Notes:**
The fourth direction is to address the challenges is to measure the performance of the system.  Measurement is important as it provides transparency and ensures that the government and providers are accountable to the public.  
Health Plans: 
AHW uses a health plan process to make health regions accountable for the delivery of services.  Every year, the Minister of Health and Wellness issues guidelines for the direction for development of a three year health plan by the health regions.  The guidelines contain factors and measures.  
Auditor General (AG) Report:
The AG report recommends a compliance and enforcement system to be used in continuing care in Alberta.  AHW is exploring options for implementing this recommendation. 
The Health Quality Council of Alberta: 
An independent body, the HQCA was established to identify best practices, to review and monitor health quality and patient safety, and to report to the public on its findings.

## Workforce Issues

- Media campaign for recruitment
- Incentives for students
- Alberta Rural Physician Action Plan
- Core Competencies for Health Care Aides

**Direction - Focus on recruitment and retention strategies:**

**Notes:**
The six direction is to address workforce issues and focus on recruitment and retention strategies.  With the increasing number of baby boomers needing services in future, there is strong concern that we do not have the health human resources in future to provide this.  Alberta has initiated some activities to address this need.
We have underway Media Campaign strategies for recruitment; subsidy, student loan for students and Rural Physician Program to attract physicians to work in rural.
Alberta Health and Wellness, in conjunction with other government departments, has developed a Workforce Strategic Plan aiming to address the workforce problem.

## Technological Advances

**Direction - Use technology to monitor care:**
- Health Link
- Self Managed Care Monitoring System
- Wireless Technology
- Wound Management System
- Alberta Electronic Health Record

**Notes:**
The seventh direction is to use technology to monitor care. With the high number of baby boomers entering the system, we will not have enough human manpower to provide this service.  In future, technology will have substitute some of the human resources requirements.
Health Link:
A 24 hour a day, 7 day a week nurse telephone advice and health information service has been implemented in Alberta province wide.  Public can phone in to this phone line to address issues of health care concern to them.  With the advice, many individuals have chosen to wait for other service options instead of going to emergency departments of hospitals.   
Self Managed Care Monitoring System:
Alberta is pilot testing self-managed care monitoring equipments to lower the demand of the time of the health professions.  This includes: wearable pulse sensor, glucose monitor and diabetes monitoring machines.
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## Technological Advances

**Direction - Use technology to monitor care:**
- Health Link
- Self Managed Care Monitoring System
- Wireless Technology
- Wound Management System
- Alberta Electronic Health Record

**Notes:**
Wireless Technology:
Wireless technology is used for remote monitoring of complex wounds and provides.  The wound picture of clients at home or in long-term care facilities are transferred to a central station where advance specialist consultation are being provided.  This saves the traveling time for the specialist as well as address the shortage of trained staff. 
Alberta Electronic Health Record: 
Alberta is developing the electronic health record that links physicians, pharmacists, hospitals, home care and other providers across the province. The Electronic Health Record stores pertinent patient information on-line to allow health care providers to access a patient’s prescription history, allergies and laboratory test results immediately by computer. The result is more accurate diagnosis and treatment for better, safer patient care. 

**Change doesn't strike like a bolt of lightning out of the blue.  If you know where to look, you can see it coming for miles**

**If you always do what you have always done, you will always get **
**what you have always gotten****	**
- - Nuela Beck

**Notes:**
I would like to conclude by quoting two quotes from the book “Shifting years”.
First quote:
“Change does not strike like a bolt of lightning out of the blue.  If you know where to look, you can see it coming for miles”.
We have known for a long time that baby boomers will be aging, and needing services.  We need to plan for this.
Second quote:
“If you always do what you have always done, you will always get what you have always gotten”.
Baby boomers told us that they do not like the current way we provide services. We need to design a new system for them.
I would like to thank our Japanese hosts again for organizing this very important symposium and I look forward to discussing strategies to address the needs of baby boomers with experts from different countries.