Service cuts mean seniors lose the support they need

The Report: January / February 2004 vol.25 num.1


ike many health professionals these days, Maureen Ashfield has been juggling shrinking resources, struggling to care for clients with less.

Maureen Ashfield
Home health services coordinator
Central Community Health Centre:
North Shore / Garibaldi

In her work as a home health services care coordinator (formerly called a long term care case manager) in North Vancouver, she helps allocate resources to clients needing care in the community.

-I visit clients in their home to determine what their needs are. I assess whether their status has changed from the last time we saw them, and whether the care plan is working," she said.

-I also talk to family members of clients, their doctors, home support supervisors and other health professionals like occupational therapists, physiotherapists, home care nurses and the discharge coordinators of the hospital. All these people may be involved with the client and I need to get a sense of what's going on - the kind of service they're providing, and sometimes to make referrals to them.

"These activities are to ensure the care plan is being carried out, appropriate home support is provided and community services are accessed.

"Care coordinators also assess whether a person meets the criteria to go into a long term care facility and send the paperwork off to the person who manages the wait list for admission."

She said that part of the reason her job has recently become more complex is that the criteria for admission to services and to care facilities are stricter. And increasingly, Ashfield finds her time being eaten up by paper work and administrative issues.

"We're being asked to provide more justification for the services we're allocating," she said.

"As much as our clinical judgment is respected, there is an incredible amount of documentation to be done. It's time consuming to complete the assessment form, write out referrals, and create a care plan. And it drains time away from direct client contact."

Some of Ashfields work is driven by emergencies. -Were not an emergency service, but clients might have a change in status or care needs. We put a plan in place and then they might have a medical crisis, which means a redesign of their care plan as quickly as possible," she said.

-I dont feel like I have a typical day. Its constant telephone calls, e-mails, reports to respond to and visits to complete," she said.

-My caseload is about 90 clients, and their acuity is increasing. I honestly do not know what might come each day."

-In many cases, there are advantages to making efforts to keep someone at home as opposed to moving them to a care facility. Some clients want to be at home no matter what, so for those clients to try and make it consistent we try a lot of things. If the client is willing to work with us, we can help them stay home and they are happier. And it can be more cost-effective.

-For somebody who needs medication, their meals prepared, a bath assist, and maybe some help dressing, its more cost-effective to have two hours of home support a day than to be in a care facility," she said.

-But there are some clients who do better in a care facility. Sometimes, we go through everything we can to try to help a client stay at home, but then we eventually have to move them into care where we find that theyre blossoming. Thats what they needed."

Ashfield said that although her caseload numbers have gone down since the implementation of more stringent criteria, her workload remains heavy.

-The low-needs clients who required house cleaning or shopping visits have now been removed from the service ... but they didnt take a lot of time in the first place.

-The proportion of clients with high care needs has gone up. The number of people I have with Alzheimers disease or other dementia is high, for example. And they are extremely high-needs, requiring lots of time, especially if there is not family involvement.

-It feels like theres always more you could do to try to be more supportive, but many times I feel we respond to the immediate crisis and then move on. I try to do what I can, try to do as much long-term planning as possible, but it always feels there is more I could do. Theres always another client on the phone, or there are 10 voice mails.

-Last night when I left I had four voice mails, this morning I had 16: nurses want to know what home support is doing, the occupational therapist gives a report - all kinds of issues and all this has to be written down and documented. It never seems like there is enough time to sink your teeth into a long-term response."

Despite the frustrations, Ashfield is enthusiastic about her work. -What I really like about my job is that there are resources ... in spite of the fact that some things have been cut and community volunteer programs are stretched. Nevertheless there are resources and I have access to mobilizing those resources for seniors," she said.

-Whether its the authority or the power to actually put services into place, to make referrals to programs, or to refer to specialist programs that we have for seniors, I am able to do things that will actually make a difference for people.

-For example, the hardest clients to work with are the ones with dementia, because they dont believe theres a problem. So when I first see them, they might have been losing weight, not clean, confused, getting lost, not taking their pills," she said.

-And now, with the services, in spite of increasing dementia, I can still maintain them in their home ... and for them, thats where they want to be. And thats satisfying.

And while she has the ability to match resources with clients, she is frustrated by the shortage of those resources ... like adult day care.

-If I visit somebody who is clearly dementing, and the family is burnt out because they havent called us until theyve reached the point of not being able to cope, a service that might be most useful to them is adult daycare," she explained.

-But theres an eight-month waiting list, and I cant jump the list because everybody else is in exactly the same position. Other case managers want their clients in as quickly as possible for the same reasons.

"When they get to the top of the list, clients can only attend two days a week. Adult day care staff often ask us if we can increase people to three or four days a week and we can't unless there is a major exception. If someone goes for four days, then someone else can't go at all."

Ashfield brings a formidable array of academic and professional experience to her job: she has a gerontology diploma from Simon Fraser University, as well as a Masters degree in arts and sociology, with a specialty in aging. In addition, she has worked with seniors since her very first job at the age of 16.

She also serves as the unions chief steward for her facility. -My approach to union work is very similar to the way I approach my own job: Im a methodical person," she said.

-Im also tenacious. I dont give up. I approach my client cases the same way. Whats the best way to advocate for my client? I hate when things are unfair, and I have an inclination to get involved. I am that kind of person."