NEW ALTERNATIVE HOUSING MODELS IN THE PROVINCE OF

QUEBEC, CANADA: ARE PROVISION AND QUALITY OF CARE BETTER

THAN IN PUBLIC NURSING HOMES?

DUBUC Nicole1,2, DEMERS Louis3, TOUSIGNANT Michel1,2, TOURIGNY André4, DUBOIS Marie-France1,2, DESROSIERS Johanne1,2, CORBIN

Cinthia2, TROTTIER Lise2.

1. Faculty of Medicine and Health Sciences, Université de Sherbrooke, Qc, Canada 2. Research Centre on Aging, Sherbrooke Geriatric University Institute, Qc, Canada

3. École nationale d’administration publique, Quebec Campus, Qc, Canada 4. Centre de recherche FRSQ du CHA universitaire de Québec, Qc, Canada

Demographic Characteristics

Total population: 7.4 million

14 % are adults > 65 years old

Near 30 % in 2040 30% of disabilities and

need for long-term services

Geographical location

Province of Quebec, Canada

The Quebec Health and Social Services System

Free, universal, public health insurance plan

Social services and health care services

Long-term care services:

– In home care

– Intermediate facilities

– LTC institutions (4%)

Background

Decrease in financial resources

Limited access to public nursing homes

In 2004, the MSSS explored strategies that could better support older people with moderate to severe disabilities in the community.

A subsidy program was established for Alternative Housing Models (AHM) that: – Allows private or community organizations to

offer housing services for the disabled elders – Within the framework of a partnership with public

services that provide professional services (nursing, social services, occupational therapy).

The Program

The Program

Alternative Housing Models (AHM) where elders:

– may benefit from the same services (quantity and quality) as in nursing homes (NH), but in a more homelike environment.

– permitting “aging in place”

– have possibilities of cohabitation with a family member

– promoting partnership with family caregivers

Study Objectives

To find out if this program allows the health and social services network to meet the needs of elders and their families in a comparable or superior way to nursing homes (NH).

Evaluation

Guided by an adaptation of the logic model

– Which depicts the input, activities, processes and outcomes.

– A cross-sectional comparative design (45 facilities, 238 elders)

– A multiple case study ( 8 AHMs and 30 family caregivers)

– This presentation will compare provision and quality of care both in AHMs and NHs.

Methodology

Settings and Sampling – The comparative design : Residents chosen according

to a 2-stage sampling – All AHMs available at the moment of the study (23

AHMs located in metropolitan, urban and rural areas) and NHs located in the same territory were invited to participate.

– Five residents aged over 65 and living in the residence for at least three months were randomly selected in each AHM.

– Five residents from each NH matched by gender, age and disability profiles were chosen for the comparison group.

Sociodemographic Data: Age, gender, level of education, type of housing, living alone, living in an

urban or rural environment, etc.

Level of Disability Functional Autonomy Measurement System (SMAF). (score /87) • Five areas: Activities of Daily Living (ADL)(7 items), Mobility (6 items),

Communication (3 items), Mental functions (5 items) and Instrumental Activities of Daily Living (IADL) (8 items).

Cognitive Functions:

Mini-Mental State Examination (MMSE)(score /30) Behavioral Symptoms:

Cohen-Mansfield (frequency of 29 behaviours) Social Functioning:

Social SMAF (6 items) (score /18)

Participants were evaluated on:

Methods

Evaluation of the Quality of Care

Assessed with the Qualcare Scale (Bravo G. & al. 1995)

– A multidimensional instrument (54 items)

– Six key areas: environmental, physical, medical management, psychosocial aspects, human rights and financial aspects

– Each item is scored on a 5-point scale from 1 (best possible care) to 5 (worst possible care)

– Item ratings are assigned after spending time in the facility, directly observing and interacting with the residents and their care providers

Statistical Analysis

Descriptive data:

– Summarized using the mean (SD) and percentages.

Comparisons:

– Paired Student's t-test

– All analyses took into account the intra-setting correlation.

Results

AHM Characteristics

Heterogeneous Settings Status:

– 10 for-profit organizations , 6 low-income housings, and 7 non-profit private organizations.

Type: – 10 projects with room only; 6 with apartments only (HLM) and

7 mixed.

Total Number of Residents – Mean of 60 residents – 5 (<20); 15( 20-50); 8 (> 50)

Total Number of Residents Covered by the Program – Mean of 15 – From 3 to 53 residents

The Physical Environment

Less common places and features.

More comfort and privacy

More personal control

More homelike environment

Provision of Care and Services (1)

In AHMs, all types of care were available

Professional services and Nursing care.

– Most provided by the public sector ( home care sector)

Unskilled and basic care in AHMs:

– Some provided by the public sector ( home care sector)

– Some provided by COOP services

– Most provided by the private organization (AHM)

Provision of Care and Services (2)

Meal preparation, house cleaning, and laundry – Provided by the AHM

Supervision during the night – Most of the time carry out by a nursing attendant or

orderly or non-clinical personnel.

Medical services – Most elders have their own physician; 2 AHMs have

formal contract with a physician and 10 AHMs have a physician according to needs

Provision of Care and Services (3)

Admission criteria: 9 AHMs do not accept demented elders with light behavioural symptoms

Most AHMs do not accept or keep (20/23) elders with major behavioural disturbances.

Half of them do not assure a professionnal supervision for the night

8 AHMs do not provided help for eating

In 2 AHMs, they do not admit elders with mobility problems

Sociodemographic Characteristics of Residents

N: 82 pairs of residents

Age: 83 years old

Gender: 69 % of women

Income: 82 % less than CAD $25 000

Marital status: (AHM vs NH) • Married : 27 % vs 21 % • Widowed : 63 % vs 61 % • Others 10 % vs 18 %

Living situation: • Alone: 92 % vs 86 % • With a spouse: 7 % vs 1 % • With an other resident: 0,6 % vs 12 %

Level of education: 53 % (8 years)

Clinical Characteristics of Residents

Heterogeneous

Disability (SMAF): • 15 %: low level of disability

• 60 %: moderate

• 25 %: substantial disabilities

Cognitive functions (MMSE)

– well maintained for approximately 50 % of the residents.

Clinical Characteristics Behaviour Symptoms (Cohen-Mansfield)

– Half had at least one symptom in the previous week:

– Among them:

• 2/3 verbal and physical non agressive symptoms

• 1/3 verbal and physical agressive symptoms

• Small frequency: less than once a week

Social functioning (Social SMAF)

– Not many difficulties

Provision of Care and Services

A mean of 2h/day in AHM versus 2.4h / day in NH (< 1h to > 3h) were required per resident.

They were mainly well fulfilled

A small % of residents had unmet needs (6 residents in AHM vs 15 in NH) (…in the same settings)

In AHM: mainly for bathing, grooming, meals and shopping.

In NH: for bathing, grooming, using toilet, walking outside, behaviour and cleaning the room.

Quality of Care

1 Mean scores [standard error of the mean (SEM)]

•p value associated to the paired t test (* p < 0.05,

•** p < 0.01, *** p< 0.001)

Qualcare

Dimensions AHM

n=82 NH

n=82 p

1. Environmental aspects

1a) Resident space 1,21 (0,03)1 1,30 (0,03) 0,0239*

1b) Overall building 1,34 (0,03) 1,23 (0,04) 0,0201*

2. Physical care 1,37 (0,04) 1,45 (0,03) 0,0826

3. Medical management 1,12 (0,04) 1,24 (0,03) 0,0034**

4. Psychosocial aspects 1,48 (0,04) 1,75 (0,04) < 0,0001***

5. Human rights 1,27 (0,03) 1,40 (0,04) 0,0010**

6. Financial aspects 1,13 (0,03) 1,20 (0,03) 0,0664

Total 1,30 (0,03) 1,42 (0,03) 0,008**

Summary Settings were heterogeneous

– Physical characteristics and organisational attributes.

Homelike environment

Diversity of clientele – Different levels of disability, cognitive status, behavioral

symptoms

– Some AHMs (5) are able to take care of elders with high level of disability as in NHs.

– Have met objectives of the program

AHMs are more similar to intermediate facilities than NHs.

Conclusion Pertinent options AHMs offer the opportunity to certain elders to

have access to a more diversified choice of housing, better geographically distributed, with confidence that they will receive care and services they need…and services of quality better than in NHs.

A limit…Aging in place in AHM may be compromised by lack of professional care providers at night or limited criteria to keep elders with major behaviourial problems.