John Muscedere, Carol Barrie, Karen Chan, Bruce Cooper, Kim Critchley, Perry Kim, Amanda Lorbergs, Isobel Mackenzie, Cynthia Martineau, Tom Noseworthy, Maureen O'Neil, Joyce Resin, Samir Sinha and Russell Williams
Scandinavian countries are widely acknowledged as leaders in innovative models of care for their aging populations. To learn what might be potentially applicable to the health system in Canada, the Canadian Frailty Network (CFN) led a contingent of government, administrative, research and patient representatives to Denmark to directly observe Danish approaches for providing healthcare for older adults living with frailty. In this paper and based on what we learned from these observations, we discuss healthcare challenges faced by Canada's aging population for which Danish strategies provide clues as to where and how to improve care and system efficiencies, thereby maximizing the value of Canadian healthcare.
In 2017, Canada and Denmark spent similar proportions (10.4% and 10.2%, respectively) of their gross domestic product (GDP) on healthcare (OECD 2018). Despite comparable health spending, the OECD healthcare data show that Canada ranks near the bottom for many performance indicators of availability and access to care, whereas Denmark consistently ranks above the OECD average (Barua et al. 2017). Both Denmark and Canada have steadily increased their healthcare spending over the past 40 years (OECD 2017); yet, in contrast to Canada, where relatively high healthcare spending has not led to measurable improvements in access to and satisfaction with care, strategies used by Denmark have improved healthcare productivity and quality.
In May 2018, a delegation of Canadian government, administrative, research, physician and patient representatives interested in the care of older adults living with frailty visited Denmark to meet with Danish Ministry of Health leaders and other regional leaders. The purpose of the visit was to gather insight into the success of Denmark's health system and aspects of holistic healthcare for older adults that might be instructive to Canada. The visit was led by the Canadian Frailty Network (CFN) in partnership with Healthcare Denmark, a public–private non-profit organization whose mandate is to promote Danish healthcare innovations internationally but not to deliver healthcare. The CFN is a pan-Canadian not-for-profit organization funded by the Government of Canada through the Networks of Centres of Excellence (NCE) program; CFN's mission is to improve the care of those living with frailty in Canada. As the Canadian contingent toured Danish hospitals, long-term care (LTC) facilities and rehabilitation centres, they were encouraged to explore how Danish innovations could inform practice and system changes in Canada to improve care support for older Canadians living with frailty.
Canada is home to 36.7 million inhabitants; of these, 16.9% are over 65 years old (Statistics Canada 2017a). By 2020, it is estimated that nearly 20% of Canada's population will be older than 65 (Statistics Canada 2015), and by 2050, one in four Canadian seniors will be older than 85 (Statistics Canada 2017a). With the aging population, there are an increasing number of persons living with frailty, which is defined as a state of increased vulnerability and functional impairment caused by cumulative declines across multiple systems (Fried et al. 2001; Rockwood et al. 2005). Although frailty is not inevitable with increasing age, it is more common in older adults and predicts adverse health outcomes, including institutionalization and mortality, better than age alone (Fried et al. 2001; Theou et al. 2018). Over one million Canadians over the age of 65 live with frailty, and, based on demographic shifts, this will increase to over two million within the next decade. To meet the care needs of an aging population and the increasing number of Canadians living with frailty, a careful examination of care models from federal, provincial and territorial and regional perspectives is required to identify opportunities to improve the quality and efficiency of healthcare in Canada.
Healthcare in Canada is based on a single-payer, publicly funded system in each of the 13 provinces and territories. The federal government sets and directs national principles for the healthcare system, provides financial support to the provinces and territories and provides funding for selected populations (i.e., First Nations, the armed forces and those incarcerated in federal institutions). Public healthcare funding is calculated at 10.4% of GDP (OECD 2018). The provincial and territorial health insurance plans cover all hospital care and doctors' visits but only a select portion of LTC, home care and rehabilitation services. Canada's healthcare system, established between 1955 and 1971 to deal with acute and episodic care for the young population, has remained largely unaltered and, consequently, is not designed to meet the challenges of a growing population of older adults living with chronic diseases and frailty.
Denmark is widely recognized as a leader for its care of older citizens (Barua et al. 2017), using an approach to citizen wellness that can be described as You take responsibility for your health and we will take care of your illness. Denmark encourages its 5.7 million citizens to assume responsibility for wellness and reassures them that medical treatments and social supports will be available when needed. Free and equal access to healthcare is considered a fundamental right of all Danish citizens. Both Canada and Denmark have similar aging demographics. In Denmark, 18.6% of the population is over 65, with adults over 80 representing the fastest-growing segment of the population (OECD/European Observatory on Health Systems and Policies 2017). Over the past 25 years, Denmark transformed its healthcare delivery with initiatives specifically for older adults. For example, within 48 hours of hospital admission, all older adults undergo a nurse-led multidisciplinary geriatric assessment to inform on a treatment plan including a discharge plan with the guiding principles of dignity, self-governance, safety and security irrespective of their level of infirmity.
Danish healthcare is a national single-payer system, with public spending on healthcare calculated at 10.2% of GDP (OECD 2018). Nationally, the Ministry of Health is responsible for healthcare policies, legislation, economic frameworks and quality control. In recognition of the challenges for providing healthcare to older adults, Denmark recently established a dedicated Ministry for Elderly Care to work alongside the Ministry of Health in efforts to strengthen patient management pathways between general practitioners (GPs), hospitals and municipalities. Denmark's five regional health authorities manage and finance most public hospitals, GPs, specialists in private practice and hospices using block grants and activity-related contributions from the national budget. A defining feature of the Danish healthcare system is its decentralization of responsibilities of healthcare provision to municipalities. Local health authorities comprising elected councils are responsible for the delivery and financing of elderly care services such as nursing homes, home care and programs for disease prevention, health promotion and rehabilitation. Municipalities are financed in part through block grants, reimbursements from the Ministry of Health, but most funds allocated for health and social services are derived from local taxes (Pedersen et al. 2005). Although municipalities have full autonomy to decide on the methods and levels of service for its citizens, quality standards must be met to ensure equal access to healthcare independent of location and economic resources.
Within these different delivery models (Table 1), we further describe three Canadian healthcare delivery challenges for older adults living with frailty. The Danish strategies provide guidance for improving care delivery, thereby maximizing the impact of Canadian healthcare investments.
|Table 1. Comparison of levels of government responsible for healthcare delivery in Canada and Denmark|
|Provincial and territorial governments
|Regional and local authorities
Canadian Challenge: Insufficient Resources for Many Seniors to Live at Home Independently
Most (87%) Canadians 55 years of age and older want to live in their present home for as long as possible (CIHI 2012). Living at home is equated with the maintenance of autonomy, comfort and convenience (Roy et al. 2018), but it is often not possible because of physical or cognitive limitations. As physical impairments accumulate with age, activities of daily living become more difficult and residing at home becomes increasingly difficult (Skilbeck et al. 2018). The number of older adults in Canada with frailty and chronic conditions, who have complex needs requiring both medical and non-medical support, is increasing, with the highest prevalence in those age 80 and over (Statistics Canada 2017b). The further development of resources to support older adults who want to live at home is an urgent need.
Caring for older adults living with reduced capacities requires an integrated, multidisciplinary approach that shifts the focus from a disease-centred to a person-centred model. Most care providers in Canada understand the importance of integrated care, but changing current practice remains a significant challenge. Canadian healthcare remains largely fragmented and, in turn, is a source of burden for the 5.4 million Canadian caregivers for older members of their family or friends (Canadian Medical Association 2016). An effective strategy would be easily accessible and centred on integrated home-care services with care coordination across disciplines.
Learnings from Denmark
In Denmark, caregivers often help older citizens residing in their homes with transportation and practical tasks; however, basic cleaning and personal care are generally viewed as the responsibility of home help provided by the municipality (Lewinter 2003). Nevertheless, like Canada, caregiver burden is a growing concern. Danish children who care for their older parents report greater stress in their daily routines, negative effects on psychological well-being and difficulty finding time for self. Denmark has implemented innovative reablement service programs that facilitate older adults living with, or at risk of, frailty to restore, improve and maintain physical and mental function, with the guiding principle of Add life to remaining years, not years to remaining life. Reablement programs are focused on doing things in cooperation with individuals rather than doing things for individuals. For instance, reablement can range from providing physical rehabilitation after surgery to teaching a widower how to cook more nutritious meals at home. Denmark considers reablement advantageous because it reduces the number of older adults relying on supportive care services on a long-term basis and being institutionalized. Reablement training is not intended to resolve specific medical issues but instead focuses on providing resources for individuals to regain functional abilities and confidence in these abilities after illness or hospitalization (Crotty et al. 2010). Reablement is provided by interdisciplinary teams of healthcare and social workers who carry out an intense goal-oriented program in the residential setting for a limited (e.g., 12-week) period. Danish officials estimate that reablement has lowered home-care expenditures overall by 10%. Danish municipalities also proactively conduct annual preventive home visits for all adults over 75 to identify those who are frail or at risk of frailty who need home-care services and may benefit from a reablement program. Reablement and preventive home visits are provided free of charge to all Danish residents in need. Importantly, the programs are based on individual home-based assessments and consider personal and family goals. Preventive home visits in combination with reablement programs have reduced admissions to institutional care, with the majority (88%) being satisfied with the program and 66% reporting that their quality of life has improved (Sundheds 2017).
Although continued evaluation is necessary to demonstrate the effectiveness and cost-effectiveness of preventive home visits and reablement programs on clinical outcomes and healthcare expenditures (Aspinal et al. 2016; Hendriksen and Vass 2005), Denmark perceives these initiatives as investments in the health and wellness of its citizens and considers it "the right thing to do." In keeping with this philosophy, Denmark began increasing the number of home nurses in the mid-1980s while, at the same time, reducing the number of nursing homes (Olejaz et al. 2012). Now Denmark diverts the responsibility of providing healthcare and services for older adults to municipalities. To better serve each municipality, Denmark increased the number of nurses trained to deliver chronic care management in conjunction with GP practices and municipal health centres. Resource allocation for municipally guided home care determined together with an elected council of older adult citizens helps ensure that healthcare services are tailored to their community needs.
Canadian Challenge: Restricted Access to Long-Term Care and Increasing Complexity of Residents' Care Needs
In Canada, LTC is delivered by a mix of public, private for-profit, private not-for-profit and religious-based providers. Although LTC is subsidized through provincial and municipal plans and agencies, residents pay a portion of the accommodation costs to the LTC home on a per diem amount basis (e.g., $59.82/day for basic long stay in 2018 in Ontario), which may be a combination of co-insurance or self-pay (OLTCA 2018). Across Canada, the availability of LTC beds varies. For example, the number of citizens age 80 or older per LTC bed varies from 5.4 in Manitoba to 10.8 in New Brunswick (Wilson 2017). As a result, waiting lists for accommodation are long, and one can expect to wait over five months for LTC placement in Ontario, where there are 6.2 citizens over 80 years old per LTC bed (OLTCA 2018). These long waiting times reflect an imbalance between supply and demand because of varying regional availability of LTC, lack of other community-based care alternatives, lack of incentives to adopt other care measures and lack of ability for LTC homes to transition residents to less intense care when appropriate (Sutherland 2012).
According to the 2016 census, nearly 7% of Canadians age 65 or older and 30% of those age 85 and older live in LTC homes or retirement residences (Statistics Canada 2017a). Compared with those living in retirement residences, older adults living in LTC homes have more complex care needs and the majority are frail (Mustard et al. 1999; OLTCA 2018). About half a million Canadians live with dementia, and many older adults with dementia are LTC home residents. In fact, 90% of LTC home residents have some form of cognitive impairment and up to one third have severe cognitive impairment (OLTCA 2018). Together, both dementia and frailty challenge the provision of quality care for older adults living in LTC homes (Clegg et al. 2013).
Learnings from Denmark
In Denmark, older adults living with multimorbidity, frailty or dementia may reside in one of many types of LTC dwellings: conventional nursing homes, modern close-care accommodation (i.e., subsidized housing for older adults with care staff and facilities) or at home. Regardless of dwelling, permanent personal (e.g., bathing, shaving) and practical assistance (e.g., chores, meal preparation) are paid for by the state. Although the aging demographics of Denmark are similar to those of Canada, about 3.4% of adults age 65 or older live in Denmark's conventional nursing homes (compared with 7% in Canada) and typically represent the oldest segment of the population (i.e., age 90 and older) (Schulz 2010). Despite the choice of LTC dwellings, Denmark's policy priority is home-based care. In fact, Denmark has not constructed a new conventional nursing home since 1987. Instead, Denmark built a wide range of close-care dwellings explicitly for older adults (Schulz 2010). Close-care dwellings consist of small, individual apartments that are physically connected with a shared common room and garden. Residents of close-care dwellings maintain autonomy and privacy but also indicate the level of care and services they desire. The success of the close-care accommodation may be attributed to the adoption of an integrated care system that coordinates the exchange of information, including admission/discharge notifications, rehabilitation plans and care reports, between care providers. The information flow allows for older adults to receive timely follow-up care in their respective dwellings, which has been credited with reducing the length of hospital stay by 22%, or 1.5 days, between 2008 and 2013 (Sundheds 2017).
To improve the lives of people in residential care, a significant innovation in the city of Aalborg, Denmark, has resulted in the development of a "nursing home of the future" that focuses on acknowledging differences between resident care needs and thus adjusts care accordingly. Although the severity of an individual's physical and cognitive impairments dictates the level of support and type of programming offered by the nursing home, the overarching objective for nursing care in Denmark is to provide daily integration of sense stimulation, mobility and social interaction. In Aalborg, this is achieved using themed spaces such as common cooking areas, gardens and a music room. The Canadian contingent was struck by the community spaces within the nursing home in Aalborg: fitness, library services, information and technology services and a restaurant in the nursing home designed to welcome community members to use them and interact with the residents living with frailty. Moreover, assistive technologies to foster independence among residents with frailty and dementia are an important feature of the environment. For example, smart-floor technology increases resident safety by illuminating bathroom lights when the foot touches the floor and sounding an alarm to nursing home staff when residents fall or leave the premises. Other technologies, such as wash columns, douche toilets and ceiling hoist systems in bathrooms and bedrooms, significantly reduce the staff required to bathe, toilet and transfer residents.
Canadian Challenge: Limited Access to Nutritious Food
Two-thirds of older adults living with frailty are malnourished based on a meta-analysis of international studies conducted outside of Canada (Verlaan et al. 2017). A growing body of evidence suggests that nutrition has a direct impact on the severity of frailty (Clegg et al. 2013). Older adults require fewer calories because of less physical activity, decreased muscle mass and reduced metabolic rate, albeit the quality of the calories consumed must be nutrient rich and contain high-quality protein (Nowson and O'Connell 2015). Malnourishment among older adults occurs, in part, because of low food intake (Allard et al. 2016), which is multifactorial and attributable to poor appetite, poor motivation and altered food preferences (Callen and Wells 2003). Malnourishment compounds the complexity and cost of patient healthcare by increasing the risk of infection and accelerating loss of muscle mass, which leads to mobility limitations and longer hospital stays (Curtis et al. 2017). The goal of Canadian healthcare institutions to provide nutritious meals is constrained by available funds, and it is more accurately stated as "to provide the best quality food available as efficiently as possible within budget constraints" (Padanyi et al. 2009). This has contributed to a managerial orientation of food services decision-making rather than a patient-centred care orientation.
Most LTC home residents do not consume adequate amounts of nutrients (Keller et al. 2018). A challenge of meal preparation in Canadian LTC homes is the limited daily food budget, which is allocated to each facility in an "envelope" that is dedicated to raw food expenses and nutritional supplements. The food budget envelope varies by province, but in 2017, publicly funded LTC homes in Ontario had a daily (i.e., three meals) food budget of $9.00 per resident (MOHLTC 2017). The heterogeneity of Canadian LTC home residents also challenges the provision of nutritious foods. In large urban centres, Canadian LTC home residents represent diverse cultural backgrounds, races, ethnicities, religious affiliations and economic status. Although food and liquid intake can be increased by providing culturally appropriate meals (Keller et al. 2014), preparing meals in keeping with residents' cultural preferences is time consuming and difficult within current budgetary constraints.
Learnings from Denmark
In Denmark, food is considered integral to good health. Hospitals in Denmark hire dedicated nutrition assistants to teach patients about the importance of a nutritious diet and impart knowledge that can be applied after hospital discharge (Lassen et al. 2008). By introducing dedicated staff to provide dietary counselling, Danish hospitals reduced the amount of food waste and improved patient diets post discharge (Lassen et al. 2008). Patients reported high satisfaction of consulting with an individual who showed an interest in their nutrition, and this approach has transformed the hospital experience for patients.
In 2016, new Danish legislation required each municipality to develop a dignity policy describing how food and nutrition are secured for elderly care. During the visit to Denmark, the notion food must be treated as medicine was evident at the Regional Hospital Horsens' kitchen, where trained food service workers, based on input from care staff, physicians and the dietitian, prepared visually appealing, nutritious meals made from "scratch," including herbs grown on site. Food served to patients in Horsens was considered Danish "comfort" food or familiar foods that the older patients would make for themselves at home. Moreover, nutritious snacks were available to patients between meals by circulating a food cart that encourages individuals to eat at any time they wish. The effect of these food strategies on clinical outcomes is not yet clear, but the caring and compassionate approach to mealtimes is thought to improve the older patients' quality of life. What was most impressive was that this reorientation to food services was accomplished within the standard food services budget allocation for this organization.
A fundamental difference in Canadian healthcare is the perspective of food as hospitality. Although optimized nutritional care is associated with fewer days in the hospital and better satisfaction with care (Curtis et al. 2017), low food intake among institutionalized older adults must be addressed. Adopting the Danish food perspective may be one solution. Innovative approaches to encourage older adults to eat their meals could improve healthy aging outcomes (Keller 2007). Because appetite declines with aging and during acute illness, both LTC homes and hospitals are challenged to provide food options that meet protein and nutrient requirements and bring joy to an individual. LTC home residents spend many months or years in a home, where mealtimes are often considered a highlight of the daily routine. Creating an environment with social interaction, culturally familiar foods or choices to accommodate personal food preferences can improve the mealtime experience and increase food intake (Watkins et al. 2017). Because Canada's older adults represent a heterogeneous population in terms of health status, ethnic origins, financial situations and living arrangements, the process of creating familiarity may involve the type or flavour of food, timing of meals and language spoken at meals. Although it may not be possible to provide staff who speak all the languages of LTC home residents, other strategies learned from Denmark may encourage greater food consumption. For instance, in Danish nursing homes, the kitchen and food preparation facilities were open concept, so that cooking smells could stimulate the senses of residents. Redesign of Canadian LTC homes could consider kitchenettes where smells of food preparation permeate in living areas and allow older adults to detect and desire the food being cooked.
Many Canadian jurisdictions have developed and initiated programs to improve the health of older adults with frailty and their caregivers. Examples of "pockets of excellence" include Prince Edward Island's Caring for Older Adults in Community and at Home (COACH) program, which is delivered by an integrated interdisciplinary expert care team of health professionals, including a geriatric nurse practitioner, the client's GP and a care coordinator. In collaboration with resources in partner programs, the COACH team provides direct client care at home to prevent, and proactively manage, health crises. The team encourages advanced care planning and access to community supports, with the goal of improved quality care for older adults living with frailty. Pilot data demonstrated that the COACH program reduced the volume of hospital inpatient admissions by two-thirds, emergency visits by one-third and primary care visits by half (Government of Prince Edward Island 2018). Another Canadian "pocket of excellence" is the partnership between the Fraser Health Authority, the Nova Scotia Health Authority and the private sector. Together they designed the Community Action and Resources Empowering Seniors (CARES) model, which increases the ability of GPs to identify and manage older adults who are frail or at risk of frailty. In this model, a GP uses the clinical frailty scale (Mitnitski et al. 2012; Rockwood et al. 2005) as a case-finding tool with a subsequent electronic comprehensive geriatric assessment to develop and deliver individualized care plans. Preliminary findings show that after six months in CARES, all individuals classified as vulnerable or mildly frail improved in their degree of frailty (Theou et al. 2017). The widespread adoption of these programs by Canadian provinces and territories requires that all stakeholders embrace the personal, societal and economic values of person-centred and integrated care approaches. Challenges to implementation in Canada include culturally diverse communities as well as numerous rural and remote communities. Importantly, the spread and scale of these programs require policy changes and resource commitment to prioritize the healthcare of older adults with frailty and their caregivers.
Learning from Denmark requires consideration of drivers to change. How does the Danish healthcare system achieve successful spread and implementation of innovation? One possibility is that Denmark has accelerated the development and adoption of transformative and innovative technologies in healthcare institutions because of two key drivers: showcasing its healthcare inventions nationally and globally and emphasizing citizen engagement. It may be fruitful for Canada to consider a showcase model like that of Healthcare Denmark, whose role is to promote Danish healthcare innovation through both government and industry funding. Promoting Canadian best practices to generate constructive discussions, investments and improvement could be integrated into existing organizations such as the Canadian Foundation for Healthcare Improvement. The second driver is citizen engagement. Denmark's government supports community engagement, and, subsequently, Danish citizens take ownership of technological changes and modernization of healthcare. At its core, the Danish health and social care structure is grounded in the value of dignity from cradle to grave and heavily relies on citizen engagement to ensure that the system considers all factors that affect the quality of life and healthcare experience for an individual. Patient groups in Denmark are a tremendous source of citizen engagement and are known to heavily influence public debate. Danish Patients is an umbrella organization for 15 patient associations in Denmark that contribute to developing a patient-focused health system of international standard. Although differences in political structures result in greater distinctions between municipal government and healthcare in Canada, greater support for local involvement and community integration could shift Canada to adopt a wider range of patient-centred approaches to healthcare.
Improving the outcomes and quality of life of aging Canadians will rely on social, political and citizen support across care sectors and health disciplines. Older adults living with or at risk of frailty represent an important population that will continue to challenge every municipality, region and province in Canada. The transformation of healthcare for older adults will require an increased pace of discovery, innovation and timely adoption of novel solutions. Aging populations are a global phenomenon, and there are many people, care systems and nations working to address the care challenges posed by aging. It makes sense for Canada to learn from others. The visit to Denmark was one attempt to inform care changes in Canada. Correspondingly, there are many local innovations in Canada from which we can learn and that may be scaled to a provincial or national level. Most importantly, for knowledge to improve the lives of older people living with frailty, it must be implemented into practice. More efforts are needed in this direction.
About the Author
John Muscedere, MD, FRCPC, is scientific director of the Canadian Frailty Network and professor of critical care medicine in the Faculty of Health Sciences at Queen's University in Kingston, ON. He may be contacted by e-mail: John.Muscedere@kingstonhsc.ca or phone: 1-613-549-6666 ext. 4642.
Carol Barrie, CPA, CA, is the executive director and chief operating officer at the Canadian Frailty Network, Kingston, ON.
Karen Chan, MPA, is assistant deputy minister, Health and Social Services, Government of Yukon, Whitehorse, YK.
Bruce Cooper, MSW, is deputy minister, Department of Health and Social Services, Government of the Northwest Territories, Yellowknife, NT.
Kim Critchley, MN, PhD, is deputy minister of Health and Wellness, Province of Prince Edward Island, Charlottetown, PE.
Perry Kim, PhD, is assistant scientific director, Canadian Frailty Network, Kingston, ON.
Amanda Lorbergs, PhD, is manager of Research and Knowledge Translation, Canadian Frailty Network, Kingston, ON.
Isobel Mackenzie is the seniors advocate for the Province of British Columbia, Victoria, BC.
Cynthia Martineau is vice president, Strategy, Planning and Integration, South East Local Health Integration Network in Kingston, ON.
Tom Noseworthy, MPH, MD, FRCPC, is professor of community health sciences, University of Calgary, and CEO, British Columbia Academic Health Sciences Network in Vancouver, BC.
Maureen O'Neil, OC BA, Hon DUniv, Hon LLD, Hon LLD, is former president of the Canadian Foundation for Healthcare Improvement, Ottawa, ON.
Joyce Resin, MSW, is a consultant in citizen engagement and chair of the Canadian Frailty Network Citizen Engagement Committee, Vancouver, BC.
Samir Sinha, MD, DPhil, FRCPC, AGSF, is director of geriatrics, Sinai Health System and University Health Network and provincial lead, Ontario's Seniors Strategy, Toronto, ON.
Russell Williams is chair, Canadian Frailty Network, Montreal, QC.
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