Submission to the

ROYAL COMMISSION ON HEALTH CARE AND COSTS

Submitted byThe British Columbia Seniors’ Advisory Council

November 16, 1990

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Submitted by: The B.C. Seniors’ Advisory Councilc/o Office for SeniorsMinistry of Health6th Floor, 1515 Blanshard StreetVictoria, B.C. V8W 3C8(604) 387—2292

The British Columbia Seniors’ Advisory Council wasestablished according to the terms of the Seniors’Advisory Council Act (1989). Council is mandatedto advise and guide the Government of BritishColumbia on issues of concern to seniors byproviding advice to the Minister of Health andMinister Responsible for Seniors.

Council members are from all regions of BritishColumbia and the majority are seniors.

TABLE OF CONTENTS

EXECUTIVE SUMMARY 1

INTRODUCTION 1

THE TABA AND NACA REPORTS 3Principles 3Recommendations 4

ADDRESSING THE HEALTH CARE NEEDS OF SENIORS: THREEFUNDAMENTAL CONSIDERATIONS 5

The Aging Process 5The Complexity of Seniors’ Health Conditions 6The Impact of Socioeconomic Circumstances 6

TRAINING OF HEALTH CARE WORKERS/PROFESSIONALS 7

DELIVERY NODE OF HEALTH SERVICES TO SENIORS 8

ACCESS TO INFORMATION AND SERVICES 9

SPECIAL NEEDS’ SENIORS 9

Native Seniors 9Older Women 10EthnoculturalSeniors 10Disabled Seniors 11Seniors With Low Literacy Levels 11

CONCLUSION 12

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EXECUTIVE SUMMARY

The British Columbia Seniors’ Advisory Councilwould like to bring to the attention of the RoyalCommission on Health Care and Costs the special healthneeds and requirements of senior citizens. The Councilbelieves that the health care system must be sensitiveto the special needs of all vulnerable populations,among which the elderly form a significant and growinggroup.

The Council’s submission to the Commissionhighlights two recent reports, Towards A Better Age:Report of the British Columbia Task Force on Issues ofConcern to Seniors and The National Advisory Council onAging Position On Community Services in Health Care ForSeniors, and reviews their guiding principles andrecommendations in terms of the health care needs ofseniors.

This submission summarizes three fundamentalconsiderations which are crucial in understanding thehealth needs of the elderly: 1) the natural process ofaging and its accompanying characteristics; 2) thecomplexity and chronicity to which the health of theelderly is prone, and; 3) the significant impact ofsocioeconomic circumstances on the overall health ofseniors. Based on these three important determinants,the submission emphasizes the importance of theeducation and training of all those, professional andnon—professional alike, who care for the elderly.Similarly, the Council believes that the present modeof delivery of health services to seniors could beimproved to better accommodate and address the healthneeds of seniors.

Although the provision of appropriate andsensitive health services is vital, it is alsoimportant to ensure that seniors are aware of suchservices and able to use them. This submission pointsout the importance of ensuring access to servicesthrough providing seniors with information about healthand health services and assistance with obtainingappropriate services.

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While the problems highlighted by this submissionare common to seniors as a group, there are seniors forwhom these difficulties are intensified. Thesubmission looks at seniors who may need specialconsideration and emphasizes the importance of ensuringthat native seniors, older women, ethnoculturalseniors, disabled seniors, and seniors with lowliteracy levels, have equal access to the health caresystem.

The British Columbia Seniors’ Advisory Councilbelieves that health and weliness for seniors involvemore than the traditional medical model of care allows;health and weilness involve assessing and ministeringto the whole person, taking into account personalhistory, special circumstance, age, and uniquevulnerability.

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INTRODUCTION:

The most important reason for examining the healthcare needs of the elderly in the context of BritishColumbia’s health care system as a whole is the factthat we live in a rapidly aging society. BritishColumbia, with the rest of North America, is currentlyundergoing dramatic demographic change. The number ofelderly citizens of the province has been steadilyincreasing for some time. At present, approximately13% of the population of British Columbia is over theage of 65, compared with 11.3% of the Canadianpopulation. It is estimated that by the year 2000,there will be 526,000 British Columbians in this agegroup or 14.5% of the population. Moreover, the numberof people over the age of 80 is growing even morerapidly than the general seniors’ population. Thus, atthe beginning of the new century, there will be moreelderly people and more of the oldest elderly than everbefore. This trend is expected to continue well intothe twenty-first century.

For some time now, researchers, policy makers, andgovernments throughout the world have been aware ofthis anticipated growth in the absolute numbers ofseniors and have been directing their energies towardsplanning for appropriate and affordable responses tothe needs of an aging population. In order to plan forthe future of the health care system, it is importantto consider this predicted increase in both the numbersand proportion of senior citizens. This phenomenon ispredicted to put increasing pressure on health carebudgets. Currently, approximately 50% of B.C. annualhealth care budget is directed towards the seniors’population; the 1990-91 health care budget is estimatedto be about $5 billion. In addition to budgetaryconsiderations, there will be an increased demand forparticular services and programs to meet the uniquehealth care needs of this segment of the population.

This submission concentrates on identifying andelucidating some of the unique health care needs ofseniors. Nevertheless, the Council recognizes that thefollowing observations apply to a number of vulnerablegroups and that many of the suggested adjustments tothe health care system would be of benefit to all.

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The British Columbia Seniors’ Advisory Councilwould like to bring to the attention of the RoyalCommission On Health Care and Costs two recentdocuments which discuss issues of health and aging --

Towards A Better Age: Report of the British ColumbiaTask Force on Issues of Concern to Seniors (1990) andThe National Advisory Council on Aging Position OnCommunity Services in Health Care For Seniors (1990).Council believes that these reports discuss some of themost important issues of health care and the elderly.Council trusts that the Commission will review thesereports in detail and thus only briefly summarizestheir guiding principles and major recommendations.

In addition, the Council would like to bring tothe Commission’s attention the following issues whichalso concern the health care of the elderly:

• the aging process;• the complexity of seniors’ health conditions;• the impact of socioeconomic conditions;• training of health care workers;• delivery mode of health services to seniors;• access to information and services;• special needs’ seniors.

The Council believes that these issues particularlybear further exploration and discussion.

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THE TABA ~D NACA REPORTS:

The British Columbia Seniors’ Advisory Councilrecommends to the Royal Commission on Health Care andCosts the following two reports:

1. Towards A Better Age: Report of the BritishColumbia Task Force on Issues of Concern toSeniors (1990) (hereafter called the TABA Report)

2. The National Advisory Council on Aging Position OnCommunity Services in Health Care For Seniors(1990) (hereafter called the NACA Report)

These documents were produced after extensivedeliberation and consultation with senior citizens;their recommendations are thoughtful and informed andemerge from a comprehensive understanding of theelderly and aging.

Principles

First, Council would like to bring to theCommission’s attention the principles which are thefoundation of these reports and emphasize both theirimportance and Council’s concurrence with them.

The foundation of the TABA report is the followingseven guiding principles:

1. Preserving the personal independence of seniors;2. Fostering informal helping networks for seniors;3. Favouring community—based services for seniors;4. Respecting the productive capacities of seniors;5. Ensuring that seniors have easy access to programs

and services;6. Accommodating the needs of seniors within general

programs;7. Providing consultation with seniors.

These principles underlie the report’s discussions ofhealth issues and determine a broad-based view ofhealth care services which moves outside the bounds ofclinical, curative care.

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Similarly, the NACA position paper emerges from abelief in the necessity of adopting a globalperspective of health: “This means recognizing thathealth is a resource for living that includes manydimensions of the quality of life, in addition tophysical well-being” (NACA: 1). The NACA position isfounded on the belief that in order to effectivelyaddress the health care needs of the elderly, there isa major shift required in the emphasis of the healthcare system, a shift away from an acute, curativemedical model to a community-based model which isbetter suited to the long-term chronic conditions oftenassociated with the aging process.

Both reports are based on a broad understanding ofhealth which recognizes the importance of individualindependence and responsibility for health and stressesthe profound effect of the complete life experience onoverall health status.

Recommendations

The report of the TABA Task Force makes specificrecommendations stemming from the major health issuesidentified by the Task Force. Submissions to the TaskForce confirmed that health and wellness are primaryconcerns for seniors. The report’s recommendationssupport community health care options which enhance anindividual’s independence and allow seniors to remainin their own communities; they also emphasize theimportance of informal caregivers and the need toprovide supports for them. The report raises the issueof seniors “at risk,” who are lonely, isolated, andvulnerable to abuse and neglect. The report alsofocuses on health promotion and recommends the furtherdevelopment of initiatives which encourage weilness,good nutrition, and appropriate medication use amongseniors.

As the NACA Report concerns the role of communitybased services in caring for the elderly, itsrecommendations are focused on community services. Thereport recommends the continued development andenhancement of community health care services guided bycommunity needs and planning. Accessibility to theseservices by all seniors must be assured through

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effective outreach, information, coordination,referral, and convenient location of services. NACAemphasizes that the three service sectors -- informal,community—based, and institutional —— must berecognized as complementary to one another and of equalimportance in caring for the elderly. Other centralrecommendations include enhanced training for communityhealth care professionals and an increased emphasis oncomprehensive multidisciplinary geriatric assessmentand treatment to ensure that the frail elderly areassessed and treated in the most appropriate manner.

Both the TABA and NACA Reports discuss health andseniors with an awareness of health that goes beyond aclinical definition. Therefore, their recommendationsand discussions encompass a broad range of services andprograms which minister to the whole person. Thesereports emphasize the community-based health care modelwhich is believed to most effectively address the broadspectrum of the health care needs of the elderly.

ADDRESSING THE HEALTH CARE NEEDS OF SENIORS: THREEFUNDAMENTAL CONS IDERAT IONS

In addition to the substance of the TABA and theNACA reports, Council would like to emphasize threebasic and important points which are fundamental inaddressing the health care needs of the elderly.

The Aging Process

By virtue of their age, seniors tend to havehealth needs which arise, in part, from the naturalaging process. The health care system must be aware ofthe fundamental conditions of aging, such as decreasedvisual acuity, hearing loss, mobility impairment, etc.in order to appropriately care for the elderly. Thesefactors are important in both the kinds of health careservices and the mode of delivery of these services.For example, an elderly person with poor eyesight mayneed to be told in detail how a prescription is to beused and provided with clearly-written instructions inbold type to supplement those appearing in small print.

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The Complexity of Seniors’ Health Conditions

Beyond the natural result of aging, some seniorstend to have multiple health problems resulting fromcomplex and/or chronic pathologies. The standard modelof diagnosis and treatment may not always adequatelyaccommodate those older adults with multiple andchronic health conditions.

Elderly persons’ presenting symptoms are oftendifferent from those in younger age groups; symptomsmay be the result of a variety of conditions actingupon each other and interacting with a variety ofprescription medications. (It is well known that theincidence of adverse drug reactions among this group isvery high.) The multiple and complex health problemsof elderly persons are thus often very difficult todiagnose and even more difficult to treat.

The Impact of Socioeconomic Conditions

One important factor affecting the overall healthstatus of senior citizens is the profound impact ofsocioeconomic conditions.

As is the case in the rest of Canada, the incomesof persons over the age of 65 tend to be lower thanthose of younger people in British Columbia. Accordingto the 1986 census data, the median income for femaleBritish Columbians over 65 years of age was $7,882 andthe median income for males over 65 was $11,809. Thesestatistics also show that 52.3% of women and 21.3% ofmen over 65 years had incomes of less than $8,000.

It has been well documented that social and healthproblems such as inadequate housing, isolation,depression, medication misuse, alcoholism, dentalproblems and, generally, poor physical health, areoften directly correlated with low income.

The aging process, the characteristic complexityof seniors’ health problems, and their socioeconomicsituation are factors which have a profound effect onthe nature of their health care needs and are importantconsiderations in determining how these needs may bestbe met.

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TRAINING OF HEALTH CARE WORKERS/PROFESSIONALS:

The TABA Report refers to the need for adequatetraining for health care providers in the area ofpsychogeriatrics, but does not comment adequately onthe larger issue of education for all professionals whoserve the elderly. The Council would like to emphasizethe importance of appropriate education and trainingand the need to ensure that there is an adequate supplyand distribution of qualified workers, professional andnon-professional alike, to meet the needs of presentand future generations of senior citizens.

It is important for all health workers who servethe elderly to understand the process of aging and howtheir caregiving may be adapted to the special needs ofpersons who are experiencing memory loss, hearing loss,decreased visual acuity, and mobility impairment.

Some seniors tend to have complex, chronic healthconditions. While it is important to ensure that thereis an adequate supply of geriatricians, this does notmean that the elderly should be treated exclusively bygeriatricians. It does mean that family physicians andspecialists who provide the majority of medical care tothe elderly should be adequately prepared to meet theirspecial needs. The present medical education systemtends to concentrate on specialized, technologically—oriented procedures and has not yet recognized the needto move towards a more holistic model of care which ismore appropriate to the complex and chronic conditionsto which the elderly are prone.

The Council would like to emphasize that continuedgrowth in the seniors’ population and increasinglongevity mean that we must ensure that there is anadequate supply of qualified professionals and nonprofessionals who are knowledgeable and skilled inaddressing the special health needs of the elderly.

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DELIVERY MODE OF HEALTH SERVICES FOR SENIORS:

Our traditional health care system is focused onthe institution, high technology, and cure. However,many of the chronic and long-term health conditions ofthe elderly are better approached through holistic careand multidisciplinary support. Health care to theelderly should be provided, as much as possible, bycommunity-based organizations through the cooperativeefforts of informal and institutional sectors.

Although physicians are a major source ofcommunity health care of the elderly, their generalmode of practice does not lend itself well to meetingthe needs of the elderly. Most physicians practiceepisodic rather than continuing care. Many do notappear to be connected to the broader spectrum ofcommunity health care or use the full range ofresources which are required for a multi-disciplinaryfunctional assessment.

Furthermore, the majority of physicians practiceon a fee—for—service basis. Fee—for-service isessentially similar to piecework, which encourages arelatively high volume of patient throughput.Unfortunately, this approach is not suited to caringfor many elderly persons. Aside from the fact thatmost physicians have no formal training in geriatrics,the complex conditions of the elderly may require verycareful and time-consuming diagnosis and treatment,which is not compatible with a practice which mustmaximize its volume.

Alternative systems to fee—for—service paymentwhich could be more compatible with the health careneeds of the elderly are salary, session, andcapitation through, for example, the development ofcomprehensive health organizations. Unlike fee—for-service payment, these alternative methods do not tiephysician income to utilization. Specifically, acapitation system relates income to patient caseload,while sessional and salary payments are based on hoursof work. Clearly, such payment methods would providethe incentive to accommodate the added time and carewhich some elderly patients require.

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ACCESS TO INFORMATION AND SERVICES:

Council would like to emphasize that it is vitallyimportant to ensure that information about health andhealth services is readily available to seniors andtheir caregivers and that the services themselves areaccessible. It is a well-known fact that themultiplicity of programs available can appear as a massof confusing detail which may prevent seniors fromgetting the assistance they need to remain healthy andindependent. It is also important for some seniors toreceive more direct assistance in gaining access to theservices they need; after the initial contact andreferral, such assistance may involve transportation,counselling, and follow—up

This difficulty with access to health-relatedinformation and services is magnified many times forseniors who experience further barriers such aslanguage, culture, social isolation, poverty, ordisability.

SPECIAL NEEDS’ SENIORS:

Native Seniors

There are significant issues involved in providinghealth care to native seniors. Generally, there isinconsistency and lack of clarity about what health-related services are available through differentjurisdictions (federal and provincial) to reserve andnon—reserve native seniors.

The more specific problems for non-reserve nativeseniors in urban areas is limited access to servicesand the provision of services that are appropriate totheir needs. Native seniors may not be aware of theservices available to them off—reserve and theavailable services may be seriously restricted bydiscrimination and lack of sensitivity to language,culture, and native health practices. For example, itmay be important for native seniors who need assistanceat home to be attended by trained native home supportworkers; similarly, when it is no longer possible forthem to remain independent, it is important that they

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have access to long-term care facilities that aresensitive to their cultural and spiritual needs. Thelack of access to and inappropriate delivery of healthservices for urban native seniors is made even moreacute by the breakdown of traditional family andcommunity supports for natives in urban areas.

Older Women

Due to their relative longevity, women make up themajority of the population over the age of 65 and inthe over—85 group outnumber males 2 to 1. They are asignificant population in terms of numbers and haveunique health care needs arising, in part, from theirsocioeconomic circumstances.

The socioeconomic problems of older women aresimilar to those of the entire senior cohort andrendered more severe by a number of factors. As theyhave often not been employed in pensionable positions,older women often have to rely on government pensionsand thus form a majority of the poor elderly. Hence,they suffer the problems which accompany poverty --

inadequate housing, isolation, inadequate nutrition,and poor mental and physical health. As primary familycaregivers throughout their lives (for children,spouses, and aged parents), women are subject to theadditional physical and emotional stress of these long-term caregiving responsibilities.

Research has established that Alzheimer’s diseaseaffects twice as many women as men and that chronicdiseases, such as osteoporosis and arthritis are morecommon among women. Women are also more at risk ofdepression and social isolation frequently associatedwith a lack of social identity found among older women.Statistics also reveal that older women are prescribedtwice as many prescription drugs and use more nonprescription drugs than older men.

Ethnocultural Seniors

Throughout the last century, B.C. has experiencedvarious waves of immigration and this trend is expectedto continue into the next century. Immigrationpatterns and family reunification programs have meant

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that there is a significant number of seniors who areaging in a country other than that of their birth.

The primary barriers to appropriate health carefor members of ethnocultural groups are differences inlanguage and culture. Ethnic seniors must have equalaccess to all services, including health care services,by ensuring that they are served in their own languagewhere necessary and that the health services areprovided in a culturally—sensitive manner.

Disabled Seniors

It is also important to recognize the specialneeds of seniors with disabilities. As persons withlife—long disabilities age, their disabilities becomemore pronounced.

Seniors with psychological disabilities haveparticular health needs. For those with life-longmental illnesses, particularly those who have been de—institutionalized late in life or whose parents havedied, it is important to ensure that they are safe andcontinue to receive care. Similarly, care for seniorswho develop age—related dementias, such as Alzheimer’sdisease, require particular care that is sensitive totheir special needs.

Physically disabled seniors must be assured ofaccess to services and to buildings where thoseservices are available. Likewise, seniors withphysical disabilities must have access to barrier-freehousing to allow them to age in place and avoidunnecessary institutionalization. Information onhealth and health services should be available ingraphically clear large print and braille for thoseseniors with visual difficulties and through other nonwritten media for those with other disabilities.

Seniors With Low Literacy Levels

Recent statistics tell us that low literacy levelsin Canada are highest among seniors. It is importantto ensure that all written information for seniors ismade as accessible as possible through the use of plain

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language. Moreover, it is important to ensure thatseniors who have difficulty reading and writing haveequal access to information about health and healthservices through various non-print media.

CONCLUSION:

In summary, the British Columbia Seniors’ AdvisoryCouncil believes that health and wellness for seniorsinvolve more than the traditional medical model of careprovides. For the individual, health and weilness meantaking responsibility for health and practisingpreventive self—care; for the practitioner, health andweliness mean assessing and ministering to the wholeperson, taking into account personal history, specialcircumstance, age, and unique vulnerability.

While the preceding discussion has focused on thehealth and health—related needs of seniors and hasexamined a wide range of factors which may determinethe overall health status of older adults, the issuesraised here also apply to other vulnerable groups.Indeed, corrective adjustments to the health caresystem that would benefit the elderly would be ofbenefit to society as a whole.