We are not alone: an American perspective on long-term care in Nova Scotia

Nursing Homes, Sept, 1998 by Steven A. Mosher

America's long-term care providers sometimes feel uniquely besieged, but this investigator's journey to the "land of my grandparents" struck some (surprisingly) familiar notes

Long-term care services have been viewed in Nova Scotia in a rather traditional manner. Institution-based care (nursing homes, homes for the aged, special care, etc.) is the cornerstone of the delivery system. There are 70 facilities in the system, serving a provincial population of approximately one million people. Of these facilities, 22 are municipally owned, 21 are private for-profit, 6 are based in hospitals and the remainder are an assortment of private non-profit and charitable organizations. There is a total of 5,883 licensed beds plus 54 respite beds, with the size of the facilities ranging from 8 to 596 beds (Shannex Healthcare Management, Inc., is the largest provider of longterm care with 850 beds). Per diem rates of reimbursement for services rendered range from $69 to $129 (Canadian) per day, the rate depending upon wage differentials, whether the facility is new or old (i.e., principal and interest or principal and depreciation are paid), and facility size. Total budget for 96/97 was $188,000,000, with the provincial Department of Health subsidizing individuals (based on their income level) in the amount of $103,000,000.

Contrary to the view that all medically necessary services are covered in Canada through their social health insurance system, long-term care is not an insured service in Nova Scotia. Perhaps out of tradition, long-term care is not considered to be a "medical service," but rather a "social service." Even though people with dementia accounted for upwards of 65% of the residents in the facilities I visited, and medications were provided and rehabilitation offered, the residents' condition was not deemed to be "medical" for insurance purposes. Instead, the provincial government has a spend-down model - a nursing home requires residents to spend down to their "last dollar" before government subsidies will pay for their care (residents can keep their home and a portion of their assets).

The administrative structure was far "leaner" in nursing homes than in acute hospitals. For instance, at the R.K. MacDonald Nursing Home in Antigonish, 150 employees are managed by seven managers plus one administrator.

The regulations that govern long-term care have been developed primarily as responses to problems. A yearly inspection visit by the province ensures compliance. The Canadian Council on Accreditation also performs on-site surveys, which are gaining more support as a valuable review of a facility's operations. Such visits are more consultative in nature. In my view, though, changes in the provision of services due to technology, educational requirements and cost have resulted in a need for a thorough review by the provincial government of the entire set of rules and regulations that govern long-term care.

Long-term care, although delivered locally, is beginning to see a regional flavor to its operations. Nova Scotia is divided into four regions for health planning purposes. Although not all long-term care providers are participants in the regional councils (most notably missing are home care agencies), this forum does provide an excellent example of an effort at integrating the continuum of care. Nevertheless, delivery of care is quite decentralized, and attempts to remedy this have not gone smoothly. For example, an attempt to integrate the boards of a nursing home (R. K. MacDonald) and a hospital (St. Martha's) in Antigonish has stalled because no provincial law exists to handle such a situation.

Most long-term care providers are located in physical structures that were not originally built for the purposes now served - they were constructed not so much to "deliver care" as to "house people." For example, special care units for Alzheimer's residents are not widely found, in part because of the perceived lack of evidence that segregated units provide better outcomes, and in part because of cost. It is a myth, however, that the Canadian healthcare system puts money into human resources rather than physical resources. Each facility I visited had just been renovated, was being renovated or was about to be. Each facility's leadership was keenly aware of the need to have a clean, safe and healthy environment for residents.

Although these facilities exist to deliver resident care, the type of residents they intend to serve is not clear. Nova Scotia does have a resident classification system, of sorts: Level I Care is personal care (1/2 to 1 hour of care in a 24-hour period) and Level II Care, encompassing nursing supervision and/or nursing care (2 to 2.5 hours of care in a 24-hour period). However, there is no standardized admission assessment process - thus, for example, cognitive impairment is not always documented. Fragmentation of information reigns supreme. Drug utilization data are not available from a centralized data bank (as they are in Alberta). Community health assessments are not well developed, so residents' projected needs are difficult to determine. In short, the classification of residents in longterm facilities is not systematically connected to their needs.