Skip to main content

Home/ CUPE Health Care/ Group items tagged guidelines

Rss Feed Group items tagged

Govind Rao

Long-term care homes not up to minimum standards: report; Staffing levels an issue at 2... - 0 views

  • Vancouver Sun Tue Apr 5 2016
  • The vast majority of governmentfunded long-term care homes for seniors in B.C. do not meet Ministry of Health staffing guidelines. The Residential Care Facilities Quick Facts Directory, a report released by the Office of the Seniors Advocate, compiles staffing, serious incident reports and other qualityof-life measures for all publicly funded seniors homes in B.C. in 2014-15. Of the 292 governmentfunded facilities, 232 did not meet the ministry's staffing guideline, a recommendation of 3.36 hours of care per senior every day. This includes help with tasks such as toileting, feeding and bathing. Just 17 facilities
  • Of the 232 government-funded seniors homes below the staffing guidelines, 74 per cent were owned and operated by private businesses instead of health authorities or by a non-profit group, such as a church. All but two of the 25 care facilities providing the lowest number of staffing hours were in the Vancouver Coastal Health Authority. Isobel Mackenzie, the B.C. Seniors Advocate, and Jennifer Whiteside of the Hospital Employees Union, which represents care aides in long-term facilities, are calling on government to legislate minimum staffing levels instead of leaving it up to facility operators. "We regulate the staffing ratios in child care, why don't we regulate it in senior care?" said Mackenzie. She said she was surprised to learn how many seniors homes fall below provincial guidelines.
  • ...9 more annotations...
  • were meeting the guideline, while 33 facilities were exceeding it. (Information is missing on another 10 for a variety of reasons. For example, some were new.) The directory's data shows that a quarter of seniors in the homes have a diagnosis of depression and nearly one-third are being given anti-psychotic medication without a diagnosis of psychosis.
  • Your questions show we have some work to do here," she said. "I will specifically be writing to each Health Authority and the government on this issue. We have a target of care hours and here's how many of your facilities are at that or under that." Mackenzie said her office will also analyze the Residential Care Facilities Quick Fact directory data to determine whether facilities with low staffing levels may also have more seniors who are depressed or who are prescribed antipsychotics medication. She also wants to study whether these homes offer fewer amenities to boost quality of life such as recreational and occupational therapy. Mackenzie said the Quick Facts Directory, available online, provides numbers to back anecdotal evidence that quality of care has declined in many B.C. seniors homes. The directory will be updated annually, but does not include data on private nursing homes that receive no government funding.
  • "Anecdotally, everyone was saying hours (for staff) were being cut, but now you have quantitive evidence. For policy shifts (in government), they want to know the magnitude of the issue. Let's have a discussion on how we can fix this. Before you can deal with what homes are not providing recreational therapy and OT (occupational therapy), for instance, you have to fix the hours of care first," said Mackenzie. Whiteside said the figures showing the vast majority of government-funded homes are below ministry staffing guidelines prove what HEU members have been saying for years - that they are rushed in trying to care for seniors in nursing homes and concerned that seniors are suffering and workers are placed in dangerous situations when a senior acts out violently.
  • A recent Vancouver Sun series on violence in nursing homes found more than 1,000 physical assaults by seniors in long-term care facilities last year. And in the past four years in B.C., 16 seniors in care have been killed by other seniors suffering from dementia. "There's simply not enough time for them (care aides) to do their job and provide the care seniors need. When we establish what the level of care needed is, it needs to be mandatory. Clearly, there needs to be more strenuous accountability in this system for seniors - many of whom are frail," said Whiteside. Nor was she surprised to find 74 per cent of the privately owned and operated businesses failed to meet ministry guidelines. "The system is set up so Health Authorities are contracting with private providers and some of those private providers are subcontracting out some of the care to other contractors and at each phase there needs to be a profit made. It's not the kind of system to have for frail seniors. It's quite shocking to think this is the system we have for them," said Whiteside.
  • A Vancouver Sun request to interview Health Minister Terry Lake was not granted. However, the ministry sent an email stating there are no plans to introduce mandatory staffing levels. The recommended 3.36 direct care hours is a number used "as a starting point for planning decisions," the email said. "The standard that we want care providers to meet is high quality care at whatever level is most appropriate for an individual patient," the ministry email states. "Direct care hours are dependent on the individual's needs and are determined through a comprehensive assessment process involving the client, their family and staff. Experts all agree that having a legislated or policy requirement for staffing ratios and staffing hours is not appropriate, because of the complexity of patient needs." Daniel Fontaine, the CEO of the B.C. Care Providers Association, whose members represent approximately 60 per cent of the government's contracted-out beds, said home operators would be happy to provide 3.36 direct care hours, but the government funding isn't enough to reach this level.
  • We can only do what we are funded to do," said Fontaine. "While the government and health authorities are trying to bring those on the lower (staffing) levels up, it's been a slow process." One of the solutions could be to take some of the money spent in the acute care system and shift it into continuing care so seniors in long-term care facilities benefit, Fontaine said. Lorri Chmilar, who retired from nursing last year after working mainly for the Interior Health Authority, said the most stressful place she worked during her career was nine months spent in geriatric care. "Anyone who has worked in public care facilities has seen a decrease in staffing, decrease in activities, and decrease in quality of meals. What has increased is the amount of time in recording statistics, and basically CYA (cover your ass)," she said. "Understaffing is also a result of the poor mix of residents. It only takes one or two residents with severe dementia or severe physical impairments to increase the workload significantly to the detriment of the rest. To increase staffat this point, or to transfer a resident to a different care area is a major undertaking that requires much justifying and time. Nurses are derided for asking for extra assistance, if there is any to be had, and roadblocks to transfers are numerous. I fear for my family, and others, and the grey wave of us to come."
  • THE NUMBERS DRUGS WITHOUT DIAGNOSIS In B.C. facilities, an average of 31 per cent of residents were given antipsychotics without a diagnosis of psychosis. 133 facilities were above this average. 11 were at the average.
  • 136 were below the average, but just one reported zero cases of providing antipsychotics without a diagnosis of psychosis. DAILY PHYSICAL RESTRAINTS In B.C. facilities, an average of 11 per cent of residents have daily physical restraints placed upon them. 116 facilities are above the average.
  • 9 are at the average. 155 are below the average, of which 27 made no use of physical restraints. Source: Office of the Seniors Advocate, Province of B.C. © 2016 Postmedia Network Inc. All rights reserved.
Cheryl Stadnichuk

Medical regulators in every province impose safeguards for assisted dying - The Globe a... - 0 views

  • Medical regulators in every province have issued detailed guidelines doctors must follow to help suffering patients end their lives once Canada’s ban on medically assisted dying is formally lifted next month.And most of those guidelines impose safeguards similar to — or even more stringent than — those included in the federal government’s proposed new law on assisted death. The existence of guidelines in every province undercuts federal Justice Minister Jody Wilson-Raybould’s contention that there’ll be a dangerous legal void if the government’s controversial new law on assisted dying isn’t enacted by June 6.
  • Like the proposed federal law, most of the various guidelines produced by provincial colleges of physicians and surgeons require that at least two doctors must agree that a patient meets the eligibility criteria for an assisted death, that a patient must submit a written request signed by witnesses, that there be a waiting period between the request and the provision of an assisted death, that a patient must be competent to give free, informed consent throughout the process, up to the time of dying.Some impose more stringent safeguards, for instance putting the age of consent at 19 rather than the federally proposed 18, and requiring a psychiatric assessment in cases where depression or mental illness might impair a patient’s ability to give consent.The one big difference, said Paterson, is that the provincial guidelines rely on the relatively permissive eligibility criteria spelled out by the Supreme Court whereas the federal government is proposing more restrictive conditions.
  • Yet the federal government has all but ignored the wishes of medical regulators and the guidelines they’ve produced, citing instead approval of its proposed law by the Canadian Medical Association, which lobbies on behalf of doctors but does not regulate, license or discipline them.“I’m not sure that the federal government generally ... has a good understanding about the role of medical regulators and our powers and our authority and our ability to regulate our professions,” said Theman.“So it may be that they see a void (if the legislation isn’t enacted by June 6) because they’re not used to dealing with us and they’re less aware of what we’re capable of.”
Irene Jansen

Health ministers look to cut back on pricey diagnostic tests - The Globe and Mail - 0 views

  • Ontario, for instance, is pumping money into providing more home care. Manitoba is looking toward preventive medicine. Saskatchewan is reviewing ways to improve long-term care. Nova Scotia has a system where paramedics treat some ailments in long-term care facilities to avoid tying up hospital beds.
    • Irene Jansen
       
      For truth re. Ontario home care, see: as http://ochuleftwords.blogspot.ca/search/label/homecare Wall's vision of "improving LTC" in Saskatchewan involves expanding retirement homes (largely private for-profit, lesser-regulated).
  • Mr. Ghiz said they could use more help from Ottawa.“Hopefully, some day, the federal government will be at the table with dollars and with ideas – we're open
    • Irene Jansen
       
      "Hopefully, some day, the federal government will be at the table with dollars and with ideas - we're open". This is not a battle cry.
  • finding ways to keep seniors out of hospital. Ontario, for instance, is pumping money into providing more home care. Manitoba is looking toward preventive medicine. Saskatchewan is reviewing ways to improve long-term care. Nova Scotia has a system where paramedics treat some ailments in long-term care facilities to avoid tying up hospital beds.
    • Irene Jansen
       
      For the truth on Ontario home care, see http://ochuleftwords.blogspot.ca/search/label/homecare Wall's vision of "improving LTC" in Saskatchewan involves expanding retirement homes (lesser-regulated, largely for-profit).
  • ...16 more annotations...
  • The provinces will look to expand a collective drug-purchasing plan, set new guidelines to cut the number of unnecessary medical procedures and improve home care for senior citizens. These strategies were on the table Friday as provincial health ministers hunkered down in Toronto for two meetings on overhauling the nation's universal health-care system and wrestling down its cost.
  • The greatest cost pressure on the system, however, may be the demographic shift and the steady rise in the number of senior citizens requiring chronic care.
  • The second, chaired by Ontario Health Minister Deb Matthews, focused on dealing with the nation's aging population.
  • The provinces are also looking at ways to cut back on pricey diagnostic tests and surgeries such as MRIs, knee replacements and cataract removals. After consulting with health-care professionals, they hope to draw up a series of voluntary guidelines, to be presented this summer, on when such procedures are necessary and when they can be skipped.
  • The provinces will look to expand a collective drug-purchasing plan, set new guidelines to cut the number of unnecessary medical procedures and improve home care for senior citizens. These strategies were on the table Friday as provincial health ministers hunkered down in Toronto for two meetings on overhauling the nation's universal health-care system and wrestling down its cost.
  • The first session was part of the Health Care Innovation Working Group
  • The first session was part of the Health Care Innovation Working Group
  • The second, chaired by Ontario Health Minister Deb Matthews, focused on dealing with the nation's aging population.
  • Last year, the working group produced a deal that saw the provinces and territories, with the exception of Quebec, team up to purchase six generic drugs in bulk, which resulted in savings of $100-million annually.They want to take a similar approach to buying name-brand medicines. Mr. Ghiz estimated such a plan could save $25-million to $100-million more.
  • Last year, the working group produced a deal that saw the provinces and territories, with the exception of Quebec, team up to purchase six generic drugs in bulk
  • They want to take a similar approach to buying name-brand medicines. Mr. Ghiz estimated such a plan could save $25-million to $100-million more.
  • The provinces are also looking at ways to cut back on pricey diagnostic tests and surgeries such as MRIs, knee replacements and cataract removals. After consulting with health-care professionals, they hope to draw up a series of voluntary guidelines, to be presented this summer, on when such procedures are necessary and when they can be skipped.
  • The greatest cost pressure on the system, however, may be the demographic shift and the steady rise in the number of senior citizens requiring chronic care.
  • finding ways to keep seniors out of hospital.
  • For all the provinces' innovations, however, Mr. Ghiz said they could use more help from Ottawa.
  • “Hopefully, some day, the federal government will be at the table with dollars and with ideas – we're open
Govind Rao

Three quarters of guideline panellists have ties to the drug industry BMJ 2013; 347 doi... - 0 views

  •  
    Ingrid Torjesen Author Affiliations The majority of health professionals in the United States who sit on guideline panels deciding the definitions or diagnostic criteria for common conditions have financial ties to pharmaceutical and medical device companies, a study has found.1 The researchers identified 16 publications by national and international guideline panels that had been published between 2000 and 2013 on the diagnosis of 14 common conditions. Of these, 10 proposed changes widening diagnostic definitions, one narrowing definitions, and the impact of the other five was unclear. Conditions that had their definitions expanded included high blood pressure, Alzheimer's disease, and rheumatoid arthritis. Panels widened definitions …
Irene Jansen

M. McGregor and D. Martin. 2012. Testing 1, 2, 3. Is overtesting undermining patient an... - 0 views

  • the guideline committees that make recommendations do not appear to consider cost-effectiveness, opportunity costs, and the potential harms of decisions to broaden screening guidelines
  • Not only are we screening with widespread laboratory testing at younger ages, but our definition of disease is also shifting.
  • In BC, there has been a 13.9% increase per year in treatment rates for 8 chronic diseases, beyond what would be expected for the changing demographic characteristics of the population
  • ...8 more annotations...
  • Either British Columbians are rapidly becoming much sicker, or this increase in prevalence is a reflection of what Welch and colleagues describe as “looking harder” and “changing the rules.”
  • about one-third of the increasing cost of testing is related to physician adherence to guidelines
  • patients now often request particular tests
  • Earlier diagnoses and more aggressive treatments appeal to our self-definition as fighters of illness—and we all shudder at the successful lawsuit against the physician who did not screen
  • we use them as therapy of a sort, giving hope to the patient that we will find an explanation for the symptoms instead of admitting that we do not know and might never know the exact cause of the problem
  • At the highest level, there needs to be a broader evaluation of guidelines. Such evaluation needs to have representation from policy thinkers and health economists in addition to family doctors, other specialists, patients, and the public.
  • the opportunity costs of deciding to implement widespread laboratory testing for healthy people, compared with adopting population-based policies, such as 24-hours-a-day, 7-days-a-week access to community recreation facilities and social housing, or free access to smoking cessation supports, should be debated.
  • Tests and repeat tests that are deemed to be of less benefit or not worth the opportunity-cost trade-off should be delisted.
Irene Jansen

MHCC Seniors Guidelines - 0 views

  •  
    New guidelines for seniors' mental health have been released by the Mental Health Commission of Canada. It includes: key factors to consider in planning a comprehensive integrated mental health system for seniors; an integrated model for mental health services in late life; and, facilitators of a comprehensive mental health service system.
Govind Rao

Doctors receive interim guidelines for assisted death - Infomart - 0 views

  • The Globe and Mail Wed Jan 27 2016
  • The guidelines were amended following 30 days of consultations with doctors and Ontario residents. An earlier draft limited physicians to providing the service only to Ontario residents. Other changes include a clarification that conscientious objectors do not have to assess whether a patient is eligible for doctorassisted death before referring them to another physician. The Supreme Court found last year that Canadians with unbearable and irremediable suffering could be eligible to end their lives with a doctor's aid.
  • Ontario doctors will be permitted to provide assistance in dying to eligible patients within Canada who qualify for publicly funded health care as the federal government works to legislate doctorassisted suicide. The College of Physicians and Surgeons of Ontario on Monday approved its interim guidelines for doctors who are approached by patients seeking help in dying before doctor-assisted death becomes legal countrywide on June 6.
  • ...1 more annotation...
  • The decision to strike down the ban on doctor-assisted dying was set to take effect on Feb. 6 but the federal government obtained a four-month extension, during which those seeking the service must get approval from court. "We believe this guidance needs to be in place as patients will have the option over this period to apply to a judge for an exception to the current law," CPSO president Dr. Joel Kirsh said in a statement.
Govind Rao

B.C. Health Minister orders review of staffing guidelines in long-term care homes for s... - 1 views

  • April 6, 2016
  • Health Minister Terry Lake has ordered a review of staffing guidelines in government-funded long-term care homes for seniors after a report from the province’s seniors advocate.
Cheryl Stadnichuk

Parliament has fumbled assisted death from the beginning: Tim Harper | Toronto Star - 0 views

  • OTTAWA—This country’s highest court ultimately gave Parliamentarians 16 months to craft legislation on assisted dying. That apparently wasn’t enough.Missing the court-imposed June 6 deadline will not plunge this nation into some type of chaotic constitutional abyss, but the past 16 months leading to that deadline have taught us a lot about our political system and the men and women who represent us.
  • It fell to Liberal leader Justin Trudeau, then at the helm of the third party, to call for an all-party committee to begin work on the issue. Trudeau, prophetically, said a year did not seem adequate to write legislation when Quebec took more than four years, but warned, “if we do nothing, . . . Canada will find itself without any laws governing physician-assisted death. That kind of legislative vacuum serves no one—not people who are suffering, not their anxious family members, not the compassionate physicians who offer them care.’’
  • But the work of a joint Commons-Senate committee was done in warp speed, its work was largely ignored and the Liberal push to meet the deadline meant a parliamentary committee unwilling to accept substantial amendments. A bill which comes down the middle on the question, without fully responding to the court decision, led to parliamentary skirmishes over time limits on debate, opposition obstruction, a physical skirmish in the House and a deadline drifting away.
  • ...2 more annotations...
  • This Senate has already sent a report back to the Commons, saying the Liberal bill should be amended to allow advance directives from those who wish assistance in dying and are still able to let their wishes be known.When the bill comes back to the Senate, independent Liberal James Cowan will push for an amendment broadening restrictions on eligibility.
  • The B.C. Civil Liberties Association says every provincial medical regulator has issued “detailed, comprehensive” guidelines for doctors under the high court ruling. Doctors’ conscientious objection rights are protected and, under provincial guidelines, two doctors are required to confirm the patient’s eligibility and consent.The real danger may lie in future court challenges — if assisted deaths are allowed under the Supreme Court wording that would be denied under the federal legislation, the government will have a problem.We shouldn’t be here after 16 months. Canadians deserved better. They deserve a better law.
Irene Jansen

Minimum safe staffing levels may be set for emergency departments and elderly care ward... - 0 views

  • The public inquiry into the high number of deaths at Mid Staffordshire NHS Foundation Trust is expected to recommend that minimum staffing ratios be set for total numbers and the skills mix of doctors and nurses in accident and emergency and elderly care wards in England to ensure the safety of care.
  • counsel to the inquiry, Tom Kark QC, said “that consideration should be given to the production of model staffing guidelines for certain types of wards and departments against which the Care Quality Commission should assess the acceptability of staffing.”
  • Mr Kark pointed out that the real danger in accident and emergency services at Mid Staffordshire was understaffing, inadequate training, and poor governance.
  • ...5 more annotations...
  • Brian Jarman, director of the Dr Foster Unit at Imperial College London, told the inquiry that hospitals with poor staff ratios had higher hospital standardised mortality ratios.
  • more doctors per bed
  • the Care Quality Commission made it clear that it does not want to see minimum staffing ratios
  • Mr Kark said that although he recognised that the number of patients on some wards often changed, making the setting of minimum staffing ratios a complex business, certain wards were less susceptible to such change and would benefit from some guidance, particularly elderly care wards and accident and emergency departments.
  • guidelines are merely that and one-off failure to comply would be unlikely to attract disproportionate attention from the regulator
Irene Jansen

Managing Conflicts of Interest in Research - 0 views

  • A recent study found that 52% of the experts involved in developing clinical practice guidelines for the management of diabetes in the United States and Canada had a financial conflict of interest. 
  •   A recent study found that over half of the members of guideline committees declared a conflict of interest, while a clear conflict of interest was not declared by 11%.
  • In Canada, some argue that disclosure does not  appropriately minimize conflicts of interest. Gordon Guyatt, a Professor in the Faculty of Medicine at McMaster University says that “people have accepted that they must declare that they took money – and then it is ignored – making disclosing financial conflicts of interest extremely ineffective”.  
  • ...1 more annotation...
  • Guyatt also suggests that “intellectual conflicts of interest are completely ubiquitous” and have generally been ignored.
Govind Rao

'We have the evidence ... Why aren't we providing evidence-based care?'; Mental illness... - 0 views

  • The Globe and Mail Sat May 23 2015
  • It's 4:30 on a Friday afternoon at her Sherbrooke, Que., clinic and Marie Hayes takes a deep breath before opening the door to her final patient of the day, who has arrived without an appointment. The 32-year-old mother immediately lists her complaints: She feels dizzy. She has abdominal pain. "It is always physical and always catastrophic," Dr. Hayes will later tell me. In the exam room, she runs through the standard checkup, pressing on the patient's abdomen, recording her symptoms, just as she has done almost every week for months. "There's something wrong with me," the patient says, with a look of panic. Dr. Hayes tries to reassure her, to no avail. In any case, the doctor has already reached her diagnosis: severe anxiety. Dr. Hayes prescribed medication during a previous visit, but the woman stopped taking it after two days because it made her nauseated and dizzy. She needs structured psychotherapy - a licensed therapist trained to bring her anxiety under control. But the wait list for public care is about a year, says Dr. Hayes, and the patient can't afford the cost of private sessions.
  • Meanwhile, the woman is paying a steep personal price: At home, she says, she spends most days in bed. She is managing to care for her two young children - for now - but her husband also suffers from anxiety, and the situation is far from ideal. Dr. Hayes does her best, spending a full hour trying to calm her down, and the woman is less agitated when she leaves. But the doctor knows she will be back next week. And that their meeting will go much the same as it did today. In its broad strokes, this is a scene that repeats itself in thousands of doctors' offices every day, right across the country. It is part and parcel of a system that denies patients the best scientific-based care, and comes with a massive price tag, to the economy, families and the health care system. Canadian physicians bill provincial governments $1-billion a year for "counselling and psychotherapy" - one third of which goes to family doctors - a service many of them acknowledge they are not best suited to provide, and that doesn't come close to covering patient need. Meanwhile, psychologists and social workers are largely left out of the publicly funded health-care system, their expertise available only to Canadians with the resources to pay for them.
  • ...42 more annotations...
  • Imagine if a Canadian diagnosed with cancer were told she could receive chemotherapy paid for by the health-care system, but would have to cough up the cash herself if she needed radiation. Or that she could have a few weeks of treatment, and then be sent home even if she needed more. That would never fly. If doctors, say, find a tumour in a patient's colon, the government kicks in and offers the mainstream treatment that is most effective. But for many Canadians diagnosed with a mental illness, the prescription is very different. The treatment they receive, and how much of it they get, will largely be decided not on evidence-based best practices but on their employment benefits and income level: Those who can afford it pay for it privately. Those who cannot are stuck on long wait lists, or have to fall back on prescription medications. Or get no help at all. But according to a large and growing body of research, psychotherapy is not simply a nice-to-have option; it should be a front-line treatment, particularly for the two most costly mental illnesses in Canada: anxiety and depression - which also constitute more than 80 per cent of all psychiatric diagnoses.
  • Why aren't we providing evidence-based care?" .. The case for psychotherapy Research has found that psychotherapy is as effective as medication - and in some cases works better. It also often does a better job of preventing or forestalling relapse, reducing doctor's appointments and emergency-room visits, and making it more cost-effective in the long run.
  • Therapy works, researchers say, because it engages the mind of the patient, requires active participation in treatment, and specifically targets the social and stress-related factors that contribute to poor mental health. There are a variety of therapies, but the evidence is strongest for cognitive behavioural therapy - an approach that focuses on changing negative thinking - in large part because CBT, which is timelimited and very structured, lends itself to clinical trials. (Similar support exists for interpersonal therapy, and it is emerging for mindfulness, with researchers trying to find out what works best for which disorders.) Research into the efficacy of therapy is increasing, but there is less of it overall than for drugs - as therapy doesn't have the advantage of well-heeled Big Pharma benefactors. In 2013, a team of European researchers collated the results of 67 studies comparing drugs to therapy; after adjusting for dropouts, there was no significant difference between the most often-used drugs - selective serotonin reuptake inhibitors (SSRIs) - and psychotherapy.
  • The issue is not one against the other," says Montreal psychiatrist Alain Lesage, director of research at the Douglas Mental Health University Institute. "I am a physician; whatever works, I am good. We know that when patients prefer one to another, they do better if they have choice." Several studies have backed up that notion. Many patients are reluctant to take medication for fear of side effects and the possibility of difficult withdrawal; research shows that more than half of patients receiving medication stop taking it after six months. A small collection of recent studies has found that therapy can cause changes in the brain similar to those brought about by medication. In people with depression, for instance, the amygdala (located deep within the brain, it processes basic memories and controls our instinctive fight-or-flight reaction) works in overdrive, while the prefrontal cortex (which regulates rational thought) is sluggish. Research shows that antidepressants calm the amygdala; therapy does the same, though to a lesser extent.
  • But psychotherapy also appears to tune up the prefrontal cortex more than does medication. This is why, researchers believe, therapy works especially well in preventing relapse - an important benefit, since extending the time between acute episodes of illnesses prevents them from becoming chronic and more debilitating. The theory, then, is that psychotherapy does a better job of helping patients consciously cope with their unconscious responses to stress.
  • According to treatment guidelines by leading international professional and scientific organizations - including Canada's own expert panel, the Canadian Network for Mood and Anxiety Treatments - psychotherapy should be considered as a first option in treatment, alone or in combination with medication. And it is "highly recommended" in maintaining recovery in the long term. Britain's independent, research-guided scientific body, the National Institute for Health and Care Excellence, has concluded that therapy should be tried before drugs in mild to moderate cases of depression and anxiety - a finding that led to the creation of a $760million public system, which now handles therapy referrals for nearly one million people a year.
  • In 2012, Canada's Mental Health Commission estimated that only about one in three adults and one in four children are receiving support and treatment when they need it. Ironically, anti-stigma campaigns designed to help people understand mental illness may only make those statistics worse. In Toronto, for instance, putting up posters in subway stations in 2010 had the unexpected effect of spiking the volume of walk-ins at nearby emergency rooms by as much as 45 per cent in 12 months. Dr. Kurdyak treated many of them at CAMH. The system, he says, "has been conveniently ignoring this unmet need. It functions as if two-thirds of the people suffering won't get help." What would happen if the healthcare system outright "ignored" two-third of tumour diagnoses?
  • Essentially, argues Dr. Lesage, adding therapy into the health-care system is like putting a new, highly effective drug on the table for doctors. "Think about it," he says. "We have a new antidepressant. It works as well as many others, and it may even have some advantages - it works better for remission - with fewer side effects. The patients may prefer it. And [in the long run] it doesn't cost more than what we have. How can it not be covered?" ..
  • A heavy price This isn't just a medical issue; it's an economic one. Mental illness accounts for roughly 50 per cent of family doctors' time, and more hospital-bed days than cancer. Nearly four million Canadians have a mood disorder: more than all cases of diabetes (2.2 million) and heart disease (1.4 million) combined.
  • Mental illness - and depression, in particular - is the leading cause of disability, accounting for 30 per cent of workplace-insurance claims, and 70 per cent of total compensation costs. In 2012, an Ontario study calculated that the burden of mental illness and addiction was 1.5 times that of all cancers, and more than seven times the cost of all infectious diseases. Mental illness is so debilitating because, unlike physical ailments, it often takes root in adolescence and peaks among Canadians in their 20s and 30s, just as they are heading into higher education, or building careers and families. Untreated, symptoms reverberate through all aspects of life, routinely trapping people in poverty and homelessness. More than one-third of Ontario residents receiving social assistance have a mental illness. The cost to society is clearly immense.
  • Yet, when family doctors were asked why they didn't refer more patients to therapy in a 2008 Canadian survey, the main reason they gave was cost. For many Canadians, private therapy is a luxury, especially if families are already wrestling with the economic fallout from mental illness. Costs vary across provinces, but psychologists in private practice may charge more than $200 an hour in major centres. And it's not just the uninsured who are affected.
  • Although about 60 per cent of Canadians have some form of private insurance, the amount available for therapy may cover only a handful of sessions. Those with the best benefits are more likely to be higherincome workers with stable employment. Federal public servants, notably, have one of the best plans in the country - their benefits were doubled in 2014 to $2,000 annually for psychotherapy. Many of those who can pay for therapy are doing so: A 2013 consultant's study commissioned by the Canadian Psychological Association found that $950-million is spent annually on private-practice psychologists by Canadians, insurance companies and workers compensation boards. The CPA estimates t
  • These are the patients that family doctors juggle, the ones who eat up appointment time, and never seem to get better, the ones caught on waiting lists. Sometimes, they have already been bounced in and out of the system, received little help, and have become wary of trying again. A 40-something mother recovering from breast cancer, suffering from chronic depression post-treatment, debilitated by fear her cancer will return. A university student, struggling with anxiety, who hasn't been to class for three weeks and may soon be kicked out of school. A teenager with bulimia removed from an eatingdisorder program because she couldn't follow the rules. They are the ones dangling on waiting lists in the public system for what often amounts to a handful of talk-therapy sessions, who don't have the money to pay for private therapy, or have too little coverage to get the full course of appointments they need.
  • Canada's investment does not match that burden. Only about 7 per cent of health-care spending goes to mental health. Even recent increases pale when compared to other countries: According to a study by the Canadian Mental Health Association, Canada increased per-capita funding by $5.22 in 2011. The British government, meanwhile, kicked in an extra 12 times that amount per citizen, and Australia added nearly 20 times as much as we did. Falling off a cliff, again and again
  • In Winnipeg, Dr. Stanley Szajkowski watched for months as his patient, a woman in her 80s, slowly declined. Her husband had died and she was spiralling into a severe depression. At every appointment, she looked thinner, more dishevelled. She wasn't sleeping, she admitted, often through tears. Sometimes she thought of suicide. She lived alone, with no family nearby, and no resources of her own to pay for therapy. "You do what you can," says Dr. Szajkowksi. "You provide some support and encouragement." He did his best, but he always had other patients waiting.
  • hat 30 per cent of private patients pay out-ofpocket themselves. When the afflicted don't seek help, the cost isn't restricted to their own pocketbook. People with mental-health problems are significantly more likely to abuse drugs and alcohol, and to become physically sick, further increasing health-care costs. A 2014 study by Oxford University researchers found that having a mental illness reduced life expectancy by 10 to 20 years, roughly the same as did smoking and obesity. A 2008 Statistics Canada study linked depression to new-onset heart disease in the general population. A 2014 U.S. study found that women under the age of 55 are twice as likely to suffer or die from a heart attack, or require heart surgery, if they have moderate to severe depression. The result: clogged-up doctors' offices, ERs, and operating rooms. And an inexorable burden for the patients' families forced to fill the gaps in caregiving - or carry on when they lose a loved one.
  • Patients refer to it as falling repeatedly off a cliff. And they can only manage the climb back up so many times. Family doctors interviewed for this story admitted that they are often "handholding" patients with nowhere else to go. "I am making them feel cared for, I am providing a supportive ear that they may not get anywhere else," says Dr. Batya Grundland, a physician who has been in family practice at Toronto's Women's College Hospital for almost a decade. "But do I think I am moving them forward with regard to their illness, and helping them cope better? I am going to say rarely." More senior doctors have told her that once in a while "a light bulb goes off" for the patients, but often only after many years. That's not an efficient use of health dollars, she points out - not when there are trained therapists who could do the job better. However, she says, "in some cases, I may be the only person they have."
  • Family doctors aren't the only ones struggling to find therapy for their patients. "I do a hundred consultations a year," says clinical psychiatrist Joel Paris, a professor at McGill University and research associate at the Montreal Jewish General, "and one of the most common situations is that the patient has tried a few anti-depressants, they have not responded very well, and from their story it is obvious they would benefit from psychotherapy. But where do they go? We have community clinics here in Montreal with six-to-12-month waiting lists even for brief therapy." A fractured, inefficient system
  • "You fall into the role that is handed to you," says Antoine Gagnon, a family doctor in Osgoode, on the outskirts of Ottawa. He tries to set aside 20-minute appointments before lunch or at the end of the day to provide "active listening" to his patients with anxiety and depression. Many of them are farmers or self-employed, without any private coverage for therapy. "Five of those minutes are spent talking about the weather," he says, "and then maybe you get into the meat of the problem, but the reality is we don't have the appropriate amount of time to give to therapy, even to listen, really." Often, he watches his patients' symptoms worsen over several months, until they meet the threshold of a clinical diagnosis. "The whole system could save on productivity and money if people were actually able to get the treatment they needed."
  • But these issues aren't insurmountable, as other countries have demonstrated. Britain, for instance, has trained thousands of university graduates to become therapists in its new public program, following research showing that, as long they have the proper skills, people don't need PhDs to be effective therapists. Australia, which has created a pay-for-service system, also makes wide use of online support to cost-effectively reach remote communities.
  • Except for a small fraction of GPs who specialize in psychotherapy, few family doctors have the training - or the time - to provide structured therapy. Saadia Hameed, a GP in a family-health team in London, Ont., has been researching access to psychotherapy for an advanced degree. Many of the doctors she has interviewed had trouble even producing a clear definition of therapy. One told her, "If a patient cries, than it's psychotherapy." Another described it as "listening to their woes." A 2007 survey of 163 family doctors in Ontario found that almost four out of five had not received training in cognitive behavioural therapy, and knew little about it. "Do family doctors really need to do that much psychotherapy," Dr. Hameed asks, "when there are other people trained - and better trained - to do it?"
  • What further frustrates treatment for physicians and patients is lack of access to specialists within the system. Across the country, family doctors describe the difficulty of reaching a psychiatrist to consult on a diagnosis or followup with their patients. In a telling 2011 study, published in the Canadian Journal of Psychiatry, researchers conducted a real-world experiment to see how easily a GP could locate a psychiatrist willing to see a patient with depression. Researchers called 297 psychiatrists in Vancouver, and reached 230. Of the 70 who said they would consider taking referrals, 64 required extensive written documentation, and could not give a wait-time estimate. Only six were willing to take the patient "immediately," but even then, their wait times ranged from four to 55 days. Psychiatrists are in increasingly short supply in Canada, and there's strong evidence that we're not making the best use of these highly trained specialists. They can - and often do - provide fee-for-service psychotherapy in a private setting, which limits their ability to meet the huge demand to consult with family doctors and treat the most severe cases.
  • A recent Ontario study by a team at CAMH found that while waiting lists exist in both urban and rural centres, the practices of psychiatrists in those locations tend to look very different. Among full-time psychiatrists in Toronto, 10 per cent saw fewer than 40 patients, and 40 per cent saw fewer than 100 - on average, their practices were half the size of psychiatrists in smaller centres. The patients for those urban psychiatrists with the smallest practices were also more likely to fall in the highest income bracket, and less likely to have been previously hospitalized for a mental illness than those in the smaller centres.
  • And those therapy sessions are being billed with no monitoring from a health-care system already scrimping on dollars, yet spending a lot on this care: On average, psychiatrists earn $216,000 a year. There is nothing to stop psychiatrists from seeing the same patients for years, and no system to ensure the patients with the greatest need get priority. In Australia, Britain and the United States, by contrast, billing for psychiatrists has been adjusted to encourage them to reduce psychotherapy sessions and serve more as consultants, particularly for the most severe cases, as other specialists do.
  • As the Canadian system exists now, says Benoit Mulsant, the physician-in-chief at CAMH and also a psychiatrist, the doctors in his specialty "can do whatever they please. If I wanted, I could have a roster of actor patients who tell me entertaining stories, and I would be paid the same as someone who is treating homeless people. ... By treating the rich and famous, there is zero risk of being punched in the face by a patient." Left out in all this, by and large, are other professionals who can provide therapy. It doesn't help that the rules are often murky around who can call themselves psychotherapists. While psychologists and social workers are licensed under their professional associations, in some provinces a person can call himself a marriage counsellor or music therapist with no one demanding they be certified. In 2007, Ontario passed a law to regulate psychotherapists, requiring them to register with a provincial college that would set standards and handle complaints. Currently, however, the law is in limbo, although the government has said it will finally bring it into force by December. The brain keeps many secrets
  • Science, however, has yet to find depression's equivalent of insulin. Despite being scanned, poked and stimulated over and over and over again, the brain keeps its secrets. The "chemical imbalance" theory is now viewed as simplistic at best. It may not do much for patients, either: A 2014 study published in the journal Behaviour Research and Therapy suggested that, rather than reassuring them, focusing on the biological explanation for depression actually made patients feel more pessimistic and lacking in control. SSRIs work by increasing the amount of serotonin, a chemical that helps deliver messages within the brain and is known to influence mood. But researchers aren't sure why the drugs help some patients and fail with others. "Basically, it's like we have a bucket of water and we pour it over the patient's head," says Dr. Georg Northoff, the University of Ottawa's Michael Smith chair of Neurosciences and Mental Health. "But you want a drug that injects the water in a very specific brain regions or brain system, which we don't have."
  • Critics of therapy have argued that it's basically "good listening" - comparable to having a sympathetic friend across the kitchen table - and that in the real world of mercurial patients and practitioners of varying abilities, a pill just works better. That's true in many cases, especially when the symptoms are severe and the patients is suicidal: a fast-acting medication is safer, and may even be necessary before starting talk therapy. The staunchest advocates of therapy do not suggest it should be the first course of treatment for psychosis, or debilitating chronic depression, or mania - although, in those cases, there is evidence that psychotherapy and medication work well in tandem. (A 2011 meta-analysis found that patients with severe depression who received a combination approach had higher recovery rates and were less likely to drop out of treatment.) But drugs also don't work as well as the manufacturers would like us to think. Roughly one-third of patients given a drug will see no benefit (although they often respond to a second or third medication). In randomly controlled trials, drugs often perform only marginally better than sugar pills.
  • Yet it's talk therapy that the public often views most skeptically. "Until you go to a therapist, or a member of your family has a serious psychological problem, people are unsympathetic [about therapy]," says Dr. Paris, the Montreal psychiatrist. "They are very skeptical, and they don't believe the research. It's amazing, because pharmaceutical trials will get approval for a drug on the basis of two clinical trials that they paid for. And we have 100 clinical trials and no one believes us."
  • Dr. Ajantha Jayabarathan, an assistant professor at Dalhousie University's medical school, spent her early years as a family doctor in Spryfield, N.S., trying to manage an overload of mental-health cases. Most of her patients had little insurance; there was one reduced-cost counselling service in town, but the waiting lists were long. In 2000, her group practice became a test site for a shared-care project, which gave the doctors access to a mental-health team, including weekly in-person consultations with a psychiatrist. "It was transformative," she says. "We looked after everything in-house.
  • Over time, Dr. Jayabarathan says, she learned how to properly assess mental illness in patients, and how to use medication more effectively. "I just made it my business to teach myself what to do." It's the kind of workaround GPs are increasingly experimenting with, waiting for the system to catch up. Who would pay - and how?
  • The case for expanding publicly funded access to therapy is gaining traction in Canada. In 2012, the health commissioner of Quebec recommended therapy be covered by the province; it is now being studied by Quebec's science-based health body (INESSS), which is expected to report back next year. A new Quebec-based organization of doctors, researchers and mental-health advocates called the Coalition for Access to Psychotherapy (CAP) is lobbying the government.
  • In Manitoba, the Liberal Party - albeit well behind in the polls - has made the public funding of psychologists one of its campaign platforms for the province's spring 2016 election. In Saskatchewan, the government commissioned, and has since endorsed, a mental-health action plan that includes providing online therapy - though politicians have given themselves 10 years to accomplish it. Michael Kirby, the former head of the Canadian Mental Health Commission, has been advocating for eight annual sessions of therapy to be covered for children and youth in need.
  • There are significant hurdles: Which practitioners would provide therapy, and how would they be paid? What therapies would be covered, and for how long? Complicating every aspect of major mentalhealth change in Canada is the question of who should shoulder the cost: the provinces or Ottawa. In a written statement in response to questions from The Globe and Mail, federal Health Minister Rona Ambrose lobbed the issue back at her provincial counterparts, pointing out that the Canada Health Act does not "preclude provinces and territories from extending public coverage to other services or providers such as psychologists."
  • One result can be overloaded family doctors minimizing mental-health problems. "If you have nothing to offer someone," asks Dr. Anderson, "how much are you going to dig around to find out what is going on?" Some doctors also admit that the lack of resources can lead to physicians cherry-picking patients who don't have mental illness. And yet family physicians alone bill about $361million a year for counselling or psychotherapy in Canada - 5.6 million visits of roughly 30 minutes each. This is a broad category, and not always specifically related to mental health (some of it includes drug counselling, and a certain amount of coaching is a necessary part of the patient-doctor relationship). When it is psychotherapy, however, doctors admit it's often more supportive listening than actual therapy.
  • So how would Canada pay for access to such therapy? It wouldn't be cheap, in the short term. The savings would come from what Canadians would not have to spend in the long term: in additional medical and drug costs, emergency-room visits and hospital stays, and in unnecessary disability payments, to say nothing of better long-term health outcomes for patients given good care earlier. Some of the figures being tossed around sound staggering. Rolling out a version of Britain's centre-based program across Canada would cost $950-million. Michael Kirby's plan would amount to $1,000 annually per patient. A 2013 report commissioned by the Canadian Psychological Association calculated that, based on predicted need, and assuming no coverage from private health-care plans, providing an average of six sessions of therapy a year would cost an estimated $2.8-billion annually.
  • But any of those figures would still be a fraction of the roughly $210-billion that Canada spends annually on health care. Figuring out how to make the system most costeffective is, according to sources, currently delaying the INESSS report to the Quebec government. "You need to facilitate the government," says Helen- Maria Vasiliadis, a professor of community health at the University of Sherbrooke. "You can't be going to policymakers and showing them billions and billions of dollars. People start having heart attacks. With evidence in hand, we have to present possible solutions."
  • An insurance-based plan is the proposal that has emerged from the Quebec-based CAP group, which sent its proposal to Quebec's health minister last month. In its design, the system would work much like Quebec's public drug plan - Quebeckers not covered through work plans would contribute to a provincial insurance program for therapy. That would be similar to the system that Germany has used for decades. One step forward, one step back
  • Last year, the Sherbrooke clinic where Marie Hayes works received provincial funding for a part-time psychologist and a full-time social worker. With a roster of 25,000 patients, the clinic team laid out clear guidelines for the psychologist, who would consult on cases and screen patients, and be limited to a mere four sessions of actual counselling with any one patient. "We wanted to be careful she didn't become a waiting list - like everything in the system," says Dr. Hayes. The social worker helps guide patients into services such as housing and addiction counselling. They have also offered group sessions for depression management at the clinic. As stretched as those new professionals are in such a large practice, Dr. Hayes says the addition of that mental-health team is improving the care she can provide patients. Recently, for instance, the 32- year-old mother with anxiety attended sessions with the psychologist. "She is making progress," says Dr. Hayes, "slowly."
  • At Women's College Hospital in Toronto, Dr. Grundland is not so lucky. Asked to describe a difficult case, the family-practice physician mentions a patient suffering from depression after a lifechanging accident. Every month, doctor and patient would repeat the same conversation they'd already had more than a dozen times - and make little real headway. Her patient, says Dr. Grundland, needs a trained therapist: someone she can see regularly, to help her move past her frustration, counsel her about addiction, and ease the burden on her family.
  • But there's no extra money in the patient's budget for a psychologist. "I do my best," Dr. Grundland says, "but it's not my area of expertise." Meanwhile, the patient isn't getting better, and in the time that it takes to make it through one appointment with her, Dr. Grundland could see three other people with problems she was actually trained to treat. "But," says Dr. Grundland, "she has nowhere else to go." Erin Anderssen is a feature writer at The Globe and Mail. OPEN MINDS How to build a better mental health care system
  • The Centre for Addiction and Mental Health has purchased advertisements to accompany this series. While CAMH professionals are quoted in this story, the organization had no involvement in the creation or production of this, or any other story in the series. $20.7-billion The cost, according to a 2012 Conference Board of Canada report, of lost productivity each year due to mental illness. What else does $20-billion represent?
  • $20B: Canadian spending on national defence, 2012-13 $20B: Market valuation of Airbnb, 2015 $21B: Kitchener-CambridgeWaterloo region's GDP, 2009 $21B: Amount food manufacturing contributed to the economy, 2012
Govind Rao

HOW TO FIX CANADA'S MENTAL HEALTH SYSTEM; Too many patients seeking mental health diagn... - 0 views

  • The Globe and Mail Tue Jun 2 2015
  • OPEN MINDS How to build a better mental health care system A weary-looking single mother brought her son into the London, Ont., walk-in clinic where Christina Cookson works on a weekday evening. Her son, who recently attempted suicide in another city, was sent home from hospital with no follow-up. Now, with a doctor they had never met before, they were trying to get help. Dr. Cookson asked a few questions about his current treatment, learned of a new antidepressant that his mother said seemed to be working.
  • With no history of care, Dr. Cookson had no way to know for sure. She advised him to make sure he told his mom if he had suicidal thoughts again and wrote a referral to see a psychiatrist, though even an urgent request would take weeks. Other than that, she had little to offer. They had no coverage for psychotherapy, which ideally, she would have prescribed. Since the young man was a walk-in patient, there is no guarantee she will see him again. "I want to be able to give them the care they deserve, and I know will benefit him, and I have no way of arranging that," she says. "It's a pretty helpless feeling."
  • ...9 more annotations...
  • And one to which many family doctors, struggling to help mentally ill patients, can attest. After months of research, and as detailed in our Open Minds series, The Globe and Mail identified some of the top evidence-based approaches to building a mental health system that will work for Canadians. These are changes that would move the country beyond its patchwork, fragmented mental health system in which the care patients receive is too often determined by what they can afford, or where they live or what they are savvy enough to cobble together on their own. These initiatives abide by the principals of Medicare and good science, and treat the disorders of the mind as diligently as the diseases of the body.
  • Expanding access to publicly funded therapy One in five Canadians will be affected by mental illness in their lifetimes. The cost to the country's economy is staggering: $50billion a year in health care and social services, lost productivity and decreased quality of life, estimates the Mental Health Commission of Canada. The personal costs are more devastating - unemployment, family breakup, suicide. Canadians who seek help for a mental illness will most often be prescribed medication, even though research shows that psychotherapy works just as well, if not better, for the most common illnesses (depression and anxiety) and does a better job at preventing relapse. According to a 2012 Statistics Canada study, while 91 per cent of Canadians were prescribed the medication they sought, only 65 per cent received the therapy they felt they needed. Access to evidencebased psychotherapy, which experts say should be the front-line medical treatment, is limited and wait-lists are long.
  • No provinces cover therapy delivered in private practice by a psychologist, social worker or psychotherapist, creating a twotier system, which means families without coverage through work - those more likely to be low-income - often either pay out of pocket or go without or, if they are lucky, rely on a non-profit group working to fill a gaping hole in a flawed health-care system. Even Canadians with coverage rarely have enough for a proper dose that meets treatment guidelines. This kind of inconsistent, unequal and scientifically flawed approach to care would be untenable for diabetes, cancer or heart disease. Yet it persists for some of the most debilitating illnesses suffered by Canadians. "Clearly this is the biggest gap we have, and the one that most needs to be fixed," says psychiatrist Elliot Goldner, director of the Centre for Applied Research in Mental Health and Addiction. Psychotherapy is a medically necessary treatment, he argues, that should be publicly funded. The question is not whether Canadians need it, but how to deliver it.
  • A system that responds nimbly to patients' needs would have clear treatment guidelines, appropriate screening and good data collection to ensure that therapies are working for patients. There should be a role, for instance, for non-profit groups on the ground to be woven into a comprehensive system to provide additional supports, particularly in areas such as housing, employment and mental health promotion - without expecting them to patch up shortfalls in services the system should provide. That should include, says Dr. Goldner, non-physicians with training in psychotherapy who are integrated into the mental health system, so that access to care is based on sound science and the best treatment plans for individual patients, rather than what happens to be available. Canada doesn't have to start from scratch. As Dr. Goldner points out, Britain and Australia have both made huge investments to expand public access for all citizens to psychotherapy, recognizing both its clinical value and cost-effectiveness over the long run. Britain's system, especially, has been designed to be accountable, to track outcomes with extensive data and to be flexible enough to incorporate changes to the system to improve results.
  • Using technology to deliver therapy into the homes of Canadians It can be hard enough to get timely treatment if you only have to drive a few blocks to find it. But what if access to care for, say, an anxiety disorder requires traversing a sprawling wilderness, for hours by car, sometimes through a blizzard? These were the stories that Fern Stockdale Winder heard often from Saskatchewan patients, as the psychologist charged with developing the province's new mental health strategy. Even when mental health care was available, reaching treatment was often one more layer of stress. It doesn't have to be this way. Chief among the strategy's recommendations: a provincewide online therapy system. The evidence for tech-delivered therapy, with support over the phone, is strong - for many patients with depression and anxiety, it can be just as effective as face-to-face sessions. It allows patients to manage care around their work and school schedules, to maintain privacy and to take control of their own recovery in a way less likely to happen with medication.
  • And it's cost-effective, says Dr. Stockdale Winder, potentially reducing appointment no-shows and cutting down on travel time for patients and therapists to and from remote communities. Canadians have ready access to medication for mental illness not because it's the best option, but because it's the easiest - even though psychotherapy works as an effective early intervention, a standalone treatment or in combination with drugs, and to prevent relapse. This front-line treatment can also be delivered in a modern and increasingly convenient way that gives patients more choice in how they receive their care.
  • It's very much about how people like to learn. Whether for reasons of stigma or personal preference, many people like to work on life challenges by themselves," says Chris Williams, a psychiatrist at the University of Glasgow, whose self-guided program is used as a first-stage treatment in Britain's publicly funded psychotherapy system. It has also been adapted in British Columbia and is being piloted in other provinces by the Canadian Mental Health Association. Self-guided therapies vary - some use DVDs or booklets, others are delivered online - but the evidence is strongest for ones that also link patients to therapists, either by e-mail or with brief phone calls.
  • A separate online program at the University of Regina has already had promising results. (Even so, the government is taking a wait-and-see attitude: Health Minister Dustin Duncan said last week that the government is keeping an eye on the project and will consider whether to expand the service after the pilot concludes next year.) What Dr. Stockdale Winder envisions is a system in which family doctors could use depression and anxiety screening to easily steer appropriate patients away from medication and toward accessible, online therapy.
  • "She clicks a button, and the patient is in," she says. Such a system would also monitor the progress of participants and direct them into more intensive care if their conditions worsened. The need for early intervention is pressing, and the evidence for online therapy is already convincing. In a country of wide open spaces, with remote communities difficult to reach even in the best weather, it's necessary. What are policy-makers waiting for? Teaching the next generation about mental health
Govind Rao

A 'well-managed' conflict is still a conflict; Partnerships BC: Larry Blain's tenure as... - 0 views

  • Vancouver Sun Fri May 15 2015
  • An internal report from the Finance Ministry last year raised significant concerns about Partnerships BC, the government corporation that has overseen billions of dollars worth of public-private partnerships under the B.C. Liberals. Among the eyebrow-raising details was the disclosure that longtime Partnerships boss Larry Blain had been doing double duty as board chair and a paid consultant on a number of projects. The unusual arrangement was put in place in October 2010, when Blain stepped down after almost a decade as president and CEO of the Crown corporation and took up the appointment as chair of the overseer board of directors.
  • "A contract was approved by the board to enable him to provide professional services to Partnerships BC," said the report from the internal audit and advisory services branch in the Ministry of Finance. "Services included serving as a project board director on several projects that PBC was supporting and conducting special project work as requested by the CEO and approved by the board." Blain, an economist and investment banker who served on the transition team when the Liberals took office, was the founding CEO of Partnerships and helped steer some $17 billion worth of P3s, including the Canada Line, Sea to Sky Highway and Abbotsford Hospital.
  • ...6 more annotations...
  • Thus the board's justification for putting him on contract to provide advice on projects: "The former CEO has specialized knowledge and experience with partnerships solutions." Still, the Partnerships brass were not oblivious to the conflicts that might arise if Blain were retained as a consultant on a project that was also being vetted by the board.
  • "In order to mitigate the risks of any conflict of interest arising from this arrangement," the review reported, "the board chair was required to recuse himself from any meetings where his projects or his contract were being discussed." Instead, another member of the board was designated to serve as temporary chair. The designated lead director also oversaw the authorization of Blain's consulting contract. "While this conflict of interest issue appears to have been generally well managed," the finance report went on to say, "there could be the perception by some stakeholders that the contractor role still conflicts with the board chair's role of providing independent oversight." Any such perceptions were history by the time the report was completed in July 2014. Blain had already departed as board chair earlier in the year, replaced by Dana Hayden, a former deputy minister turned private consultant.
  • The internal auditors didn't let Partnerships entirely off the hook for tolerating the unorthodox arrangement in the first place. "The government should consider reinforcing the conflict of interest guidelines for board members of crown corporations and government agencies and ensure that those guidelines are appropriately followed." In other words, "not guilty, but don't let us catch you doing it again." The audit findings, including recommendations to rectify other questionable procedures at Partnerships BC, were forwarded to a steering committee of government and industry representatives, chaired by deputy finance minister Peter Milburn. The committee reported back to Finance Minister Mike de Jong on Oct. 23 with further recommendations for tightening up procedures at Partnerships.
  • De Jong released both reports and accepted both sets of recommendations in the course of announcing the change of direction for Partnerships BC on Dec. 16 of last year. That was the same day the Liberals chose to announce they were greenlighting construction of a hydroelectric dam at Site C on the Peace River. Just one of those amazing coincidences, but it goes some way to explaining why there was relatively little reporting of the findings regarding Partnerships BC.
  • There matters stood until this week, when the New Democrats, drawing on a wealth of material gathered by their research department, challenged the Liberals over Partnerships' dealings with Larry (Two Hats) Blain. The highlights package: The contract with Blain's delightfully named consulting firm, Aardvark Insights, was worth $219,000. During that same four-year span he also collected $188,836 in fees and expenses as chair of the board. All this atop the $264,000 he was paid to serve as a director of three other government-owned corporations, and the almost $4 million he was paid for his eight-year service as CEO.
  • "There's plenty of Blain to go around," quipped one press gallery wag as the New Democrats built their case against the Liberals during question period Wednesday. Another joke making the rounds rebranded P3s as B3s, for "Blain, Blain and Blain" Responding for the government, de Jong paid tribute to Blain's well documented contributions to the agency and cited the audit findings that "the conflict issue appears to have been generally well managed." But he also said this: "Whilst one can suggest that by recusing and taking (other) steps ... the procurement process is properly followed, the standard that we set and expect of agencies, the leadership within those agencies, goes beyond that. There must not only not be a conflict; there must be no appearance of a conflict." Which is as close as the finance minister came to admitting his sense of relief that when the audit branch blew the whistle on this arrangement, Blain had already left the building at Partnerships BC.
Govind Rao

Seniors cry out for help as home care aide hours cut; But health authority says it's fo... - 0 views

  • Vancouver Sun Fri May 22 2015
  • Isabell Mayer takes the bus wearing her slippers because her feet are often too swollen to fit into shoes. The 81-year-old has a tough time getting to her favourite cut-rate grocery store because it takes more than an hour using her walker - including all the rest stops. These are the downsides of aging in ill health that she's taking in stride, but losing half of the home support hours she used to receive from the Vancouver Coastal Health authority sent her looking for help from her MLA. "I haven't been able to vacuum for 15 years," she says in her tiny living room in a subsidized seniors' apartment in east Vancouver.
  • "I can't wash the floor. The back and forth makes me dizzy." These are tasks that home support workers, paid by the health authority, used to do for her. But Vancouver Coastal has revisited the files of some seniors - the actual number was not available by deadline Thursday - to trim hours back. Only medically required assistance and personal care, typically a shower, are allowed.
  • ...4 more annotations...
  • Seniors must find help for house cleaning, shopping or errands elsewhere, either by paying privately, relying on family and friends or turning to a replacement program funded by the United Way called Better at Home, which has received $22 million from the province. Vancouver-Mt. Pleasant NDP MLA Jenny Kwan says Mayer's story is similar to those she's heard from other seniors in her riding during the last month. At least five couples and individuals - most of them Chinese-speaking - contacted her about having their weekly home care hours cut in half. Most have gone from two hours to one, just enough time for a bath. "The government wants seniors to live longer at home, but if you don't provide the supports for them to live successfully and safely, how are they going to manage? That will only mean they are going to need hospitalization, residential care or assisted living," Kwan said. "It's pay now or pay later and pay more," she added, noting that a day in an acute care hospital bed costs taxpayers about $1,500, enough to pay for plenty of routine in-home care. The change in home support hours from Vancouver Coastal Health is part of a move to follow provincial rules more closely, said Bonnie Wilson, director of home and community care for the health authority.
  • Home support is supposed to help clients with daily needs including bathing, dressing, using the toilet, taking medication or setting up a meal. These are considered medical services. Home support workers are paid only to do those tasks and not a wider range of duties that were covered before policy changes about 10 years ago: visiting, transportation, light yard work, minor home repairs, light housekeeping and grocery shopping. "VCH's home support guidelines are consistent with the Ministry of Health and other health authorities. Historically the mandate for home support services used to be broader, but this was sometime before 2004 (the guidelines that preceded our current ones)," Wilson explained in an email. "This was at a time when there was no distinction between medical and non-medical support services, and when clients went to residential care much sooner than they are now."
  • The complex medical problems experienced by some of Canada's oldest residents reflect a growing trend: people are living much longer, but not necessarily in good health. They can often stay at home - and avoid the high cost of either private or publicly funded nursing in residential care - but home support workers are being called upon to deliver some services that formerly fell to nurses. Doing laundry or picking up groceries are long gone from their to-do list. Exceptions to that, says Wilson, are allowed if it's unsafe for workers or the client to be in the home because of the mess, or if a client risks eviction or has been refused other government-subsidized services such as HandyDart because of a lack of cleanliness.
  • In British Columbia, home care is typically provided and subsidized - depending on income - by a local health authority that contracts the duty to a handful of accredited private companies. Clients with higher incomes often hire their own help. In 2013-14, B.C's health authorities spent $1.1 billion on home support for about 39,000 clients. That compares to $1.8 billion spent on residential care for 27,308 seniors. In 2012-13, the province funded 7.37 million hours of home support, according to the Ministry of Health, 23 per cent more than three years earlier. B.C.'s Office of the Seniors Advocate is planning to survey all recipients of publicly funded home support in the province about their experiences for an upcoming report. The Minister of Health was unavailable for comment by press time.
Govind Rao

Home care visits should be at least 30 minutes long, NICE says | The BMJ - 0 views

  • BMJ 2015; 351 doi: http://dx.doi.org/10.1136/bmj.h5057 (Published 23 September 2015) Cite this as: BMJ 2015;351:h5057
  • Ingrid Torjesen
  • Most home care visits should be at least half an hour long to enable carers to provide the personalised and dignified care that elderly patients need when being supported to stay in their own home, says a guideline on social care services from the National Institute for Health and Care Excellence (NICE).1Shorter visits would be appropriate only rarely, said the finalised guideline on home care, published on 23 September. This might be when the visit is part of a wider package of support, made by a carer who is known to the patient, or made to complete a specific time limited task, such as checking that a medicine has been taken or that a person is safe and well.
Cheryl Stadnichuk

Legislate B.C. care home staffing, advocates demand - 0 views

  •  
    When Pamela Hollington placed her 80-year-mother into a nursing home she was shocked to learn there would be as few as two care aides at times overseeing 50 residents on a specialized ward for people suffering from dementia. To ensure her mother's needs are met, Hollington now pays for a companion to visit her mother daily to "augment staffing levels." Daycare has mandated staffing levels for children in care but that isn't the case for seniors in nursing homes. Instead, administrators of B.C.'s 331 long-term care facilities can decide their own staffing needs and can choose or not choose to follow Ministry of Health guidelines. Vancouver Coastal Health, for instance, follows the industry standard of one care aide at night for every 25 residents. The Hospital Employees Union, which represents 15,000 care aides in British Columbia, said the standard being used in the industry is not enough, and chronic understaffing has reached dangerous proportions. "We hear from our members routinely that they are not backfilled when they are on vacation or sick. Our members are literally rushed off their feet to the point where safety is compromised - both their safety and the safety of residents," said the HEU's Jennifer Whiteside. The union is among many advocates for seniors in B.C. who are calling for staffing levels to be put into law for long term care facilities, and at a higher staff ratio than the current guidelines. She said this would also ensure consistency in staffing levels for nursing homes across the province. A HEU study of care aides in late 2014 found more than 70 per cent of its members felt they did not have enough time to comfort, reassure or calm residents they were caring for when residents were feeling confused, agitated or fearful. And nearly 75 per cent said they felt they had to rush through basic care for the elderly. Another 83.1 per cent reported they have been "struck, scratched, spit on or subjected to
Govind Rao

Court allows Quebec law on assisted dying to go ahead - Infomart - 0 views

  • The Globe and Mail Thu Dec 10 2015
  • Controversial Quebec legislation on assisted dying will become law on Thursday, says the province's Health Minister. Gaetan Barrette made the announcement Wednesday after Quebec's top tribunal gave the provincial government permission to appeal a lower-court decision that granted an injunction aimed at blocking adoption of the law. "That [Quebec Court of Appeal] ruling means that, as of tomorrow [Thursday], Bill 2 will be implemented fully," he told a news conference. "The ruling does not state anything for or against Bill 2 in any way. What it says is that, as of tomorrow, Bill 2 can be implemented until there is a definitive hearing and definitive decision on the actual grounds of the appeal."
  • Lawyers will be in court for that appeal on Dec. 18. Quebec Justice Minister Stephanie Vallee issued a statement later Wednesday and said the government will send guidelines to the Crown prosecutors' office in Quebec in a bid to reassure people in the medical community who may be worried about criminal proceedings. She said the guideline is aimed at "allowing people at the end of their lives to receive care that respects their dignity and their autonomy." The legislation, which was adopted by the National Assembly in June, 2014, outlines how terminally ill patients can end their lives with medical help.
  • ...1 more annotation...
  • Quebec is the first province to pass such legislation, arguing it is an extension of end-of-life care and thus a health issue, which falls under provincial jurisdiction. The injunction sought by the Quebec-based Coalition of Physicians for Social Justice and Lisa D'Amico, a handicapped woman, was related to a Supreme Court ruling last February that struck down the prohibition on physician-assisted dying.
Govind Rao

Antibiotics overused with elderly: study; Nursing homes in U.S. advised to do more to p... - 0 views

  • Times Colonist (Victoria) Thu Oct 22 2015
  • Antibiotics are prescribed incorrectly to ailing nursing home residents up to 75 per cent of the time, a U.S. public-health watchdog says. The reasons vary - wrong drug, wrong dose, wrong duration or just unnecessarily - but the consequences are scary, warns the Centers for Disease Control and Prevention. Overused antibiotics over time lose their effectiveness against the infections they were designed to treat. Some already have. And some antibiotics actually cause life-threatening illnesses on their own.
  • The CDC last month advised all nursing homes to do more - immediately - to protect residents from hard-to-treat superbugs that are growing in number and resist antibiotics. Antibiotic-resistant infections threaten everyone, but elderly people in nursing homes are especially at risk because their bodies don't fight infections as well. The CDC counts 18 top antibioticresistant infections that sicken more than two million people a year and kill 23,000. Those infections contribute to deaths in many more cases.
  • ...8 more annotations...
  • The CDC is launching a public education campaign for nursing homes aimed at preventing more bacterial and viral infections from starting and stopping others from spreading. A similar effort was rolled out for hospitals last year.
  • "One way to keep older people safe from these superbugs is to make sure antibiotics are used appropriately all the time and everywhere, particularly in nursing homes," said CDC Director Tom Frieden in announcing the initiative. Studies have estimated antibiotics are prescribed inappropriately 40 per cent to 75 per cent of the time in nursing homes. Here's why that worries the CDC: Every time someone takes antibiotics, sensitive bacteria are killed but resistant bacteria survive and multiply - and they can spread to other people. Repeated use of antibiotics promotes the growth of antibiotic-resistant bacteria. Taking antibiotics for illnesses the drugs weren't made to treat - such as the flu and common colds - contributes to antibiotic resistance.
  • Antibiotics also wipe out a body's good infection-fighting bacteria along with the bad. When that occurs, infections like Clostridium difficile can get out of control. C. diff. leads to serious diarrhea that each year puts 250,000 people in the hospital and kills 15,000. If precautions aren't taken, it can spread in hospitals and nursing homes. Health-care facilities already have infection-control procedures in place, such as providing private rooms and toilets for infected individuals. But the CDC is pushing them to do more on the prescribing side, advising nursing homes to track how many and what antibiotics they prescribe monthly and what the outcomes were for patients, including any side-effects.
  • Other recommendations include placing someone, such as a consulting doctor or a pharmacist, in charge of antibiotics policies and training other staff in following them. Some of the CDC's suggestions could challenge nursing homes' culture and how staffs, residents and their families interact. While nursing home residents and staff are among the people most at risk for the flu, annual shots aren't mandatory. Nor do homes always track who gets them.
  • That's starting to change at Evangelical Lutheran Good Samaritan Society, a nonprofit that provides a spectrum of senior care services in many states. Starting this year, it will collect data on staff vaccinations at one of its 167 nursing homes and share the pilot project's results with other homes, said Victoria Walker, chief medical officer. But better handling of antibiotics in nursing homes may also require tactful communication with residents' families and nursing home doctors accustomed to treating antibiotics as a default remedy.
  • "There's a real fear of undertreatment and that it is better to err on the safe side, and that means treating with antibiotics but forgetting about all the harms. But giving antibiotics can be just as harmful as not," said Walker. Family members may push for an antibiotic treatment when they visit a loved one in a nursing home who seems sick, even if they don't know precisely what's wrong. Doctors and nurses may go along because they don't know either and it's easier to treat than not. "The family will check in and ask what the doctor did and the nurse will say 'nothing' because they don't see monitoring as doing anything," said David Nace, director of long term care at the University of Pittsburgh, who contributed to the CDC guidelines.
  • "Practitioners are guilty of saying, 'it's just an antibiotic.' ... We don't appreciate the real threat," he said. Antibiotics are routinely prescribed to treat urinary tract infections, which are common in nursing homes, but too often when a UTI is only suspected, not confirmed, studies have found. The Infectious Disease Society of America is developing guidelines to help institutions implement programs to better manage antibiotics. In addition to fostering antibiotic resistant bacteria and causing C. diff infections, antibiotics also can produce allergic reactions and interfere with other drugs a nursing home resident is taking. Those risks aren't always fully considered, says researcher Christopher Crnich, who has published articles on antibiotic overuse. He is a hospital epidemiologist at William S. Middleton Veterans Hospital in Madison, Wisconsin. "Bad antibiotic effects don't come until weeks or months later, and frankly all we [prescribers] see is the upside when we're dealing with a sick mom or dad," Crnich said.
  • The Centers for Disease Control in the United States has raised concerns about the use of antibiotics in nursing homes.
1 - 20 of 68 Next › Last »
Showing 20 items per page