MHST/NURS 620 Presentation

1. Nowhere to go. Discharge
challenges from hospital for
seniors faced by the Canadian
health care system.
By: Kristan, Angela and Diane

2. Objectives
Classmates will:
• Gain an awareness of the Alternate Level of Care (ALC)
situation in Canada
• Consider other models for elderly patients who no longer
require acute care but are challenged to be able to leave
hospital
• Understand the philosophy of Home First
• Articulate voices silenced
• for patients who are deemed ALC
• staff working with these patients
• family and informal caregivers

3. Objectives Continued
• describe how free choice influences discourse in patient
discharges and describe the relationship between discourse
and power as it relates to patient discharges and
• cite a solution or alternative course of action that could be
taken to eliminate the problems presented

4. Resources and Links
Bauer, M., Fitzgerald, L., Haesler, E., Manfrin, M. (2009). Hospital discharge
planning for frail older people and their family. Are we delivering best practice?
A review of the literature. Journal of Clinical Nursing. 2439-2546. http://0-
content.ebscohost.com.aupac.lib.athabascau.ca/ContentServer.asp?T=P&P=AN&
K=2010366599&S=R&D=rzh&EbscoContent=dGJyMNLe80Sep7Y4yOvsOLCmr02e
prdSsaa4SLWWxWXS&ContentCustomer=dGJyMPGrrk2zr7FJuePfgeyx43zx
Rogers, V., Gilmour, J. (2011). Shaping student nurses’ attitudes toward older
people through learning and experience. Nursing Praxis in New Zealand. 27(3).
13-21
http://0-
content.ebscohost.com.aupac.lib.athabascau.ca/ContentServer.asp?T=P&P=AN&
K=2010366598&S=R&D=rzh&EbscoContent=dGJyMNHX8kSeqK44yOvsOLCmr02
ep7JSs6a4Ta6WxWXS&ContentCustomer=dGJyMPGrrk2zr7FJuePfgeyx43zxo9%2
BK8gAA
Champlain CCAC Home First – YouTube
http://www.youtube.com/watch?v=Pnnsa8WGKDM

5. Tories hiding report showing senior wait times are growing, Liberals
claim. Calgary Herald. (February 9, 2014).
http://www.calgaryherald.com/health/Tories+hiding+report+showing+sen
ior+wait+times+growing+Liberals+claim/9490463/story.html
Canada's first seniors advocate says role needed across country: Isobel
Mackenzie says her office will pinpoint the most urgent issues in long-
term care. December 30, 2014.
http://www.macleans.ca/politics/canadas-first-seniors-advocate-says-role-
needed-across-country
Ernest Madu on World-Class Health Care-inspiring story telling us how it
is possible to provide the best health care to the neediest among us.
June 2007.
https://www.ted.com/talks/ernest_madu_on_world_class_health_care?la
nguage=en
Resources and Links

6. Resources and Links
How Ready Are You for Long-Term Care?
http://money.usnews.com/money/blogs/the-best-life/2011/12/20/how-ready-are-
you-for-long-term-care
Simpsons: Homer in a Nursing Home.
https://m.youtube.com/watch?v=wJUQXkgHM48
Statistics by subject: Seniors - Statcan
www5.statcan.gc.ca
Zakrazjsek, A.G., Schuster, E., Guenther, G., Lorenz, K. (2013) Exploring older adult
transitions from hospital to home: A participatory action research project. Physical
& Occupational Therapy in Geriatrics. 31 (4) 328-344. Retrieved from:
http://cnhs.lms.athhttp://cnhs.lms.athabascau.ca/mod/forum/discuss.php?d=4127
02abascau.ca/mod/forum/discuss.php?d=412702
Resources:
• ACE-Advocacy Centre for the Elderly. A community based legal clinic for low
income seniors. (advocacycentreelderly.org)
• Seniors Canada Online (www.seniors.gc.ca)
• Canadian Government Programs for Seniors (www.longtermcarecanada.com)

7. Awareness – Background Information
• Advances in medical care and prevention have increased the life expectances of
older adults, as well as shifted the major causes of death from infectious
diseases and acute illnesses to chronic diseases that require ongoing medical
care
• As older adults are living longer with chronic illness, health care providers are
challenged with providing high quality and cost effective care that addresses
older adults’ needs as they move from one health service to another
• Health care transitions, such as moving from an acute stay in the hospital to
home, represent a critical moment in older adults’ continuum of care when
communication breakdown, lack of planning and follow-up, and major life
adjustments without necessary supports can pose threats to health and
participation for this population
• Problematic components that contribute to a poor transitioning experience and
create barriers to a successful transition for the patient, caregiver and the
service provider:
• lack of preparedness, lack of coordination, collaboration and communication
among hospital and community-based service providers, lack of information
regarding resources and health care contacts, and patients and caregivers not
understanding the necessary steps to manage their care and treatment (Zakrajsek,
2013)

8. ALC – “Alternate Level of Care”
• Used to identify patients who are admitted to hospital but no
longer require the level of care provided at that facility
• These patients are ready to leave the hospital, but there may
be obstacles to an immediate discharge (Byrick, n.d.)

9. Awareness - Background Information
• More than half (54%) of seniors who waited in acute care were discharged to a residential care
facility
• Persons with symptoms of dementia, including challenging behaviours, were more likely to have
waited in acute care prior to residential care admission, suggesting that they were waiting for
specialized services such as behavioural support
• Persons with complex care needs without a strong support system were more likely to have
waited in acute care before home care admission, suggesting that they were waiting for a
caregiver to be available or services to be put in place
• There is an ongoing concern that acute care beds in Canada are occupied by seniors who are
waiting to be discharged to a more appropriate level of care. These individuals, who no longer
require acute care services, are commonly designated as alternate level of care (ALC) patients
• The majority of seniors express the desire to remain at home, and there is evidence to suggest
that providing care at home is a cost-effective alternative
• Projections show that the proportion of seniors in Canada’s population will nearly double in the
next few decades (from 15% in 2011 to 25% in 2036); the number of ALC patients is therefore
expected to increase as well. For example, in Ontario, the number of ALC patients—the majority
of whom are above age 75—is expected to increase by 32% over the next 10 years. This shifting
demographic will increase the pressure on both acute care and residential care facilities
• Seniors admitted to residential care with ALC days waited an average of 26 days before being
discharged, compared with an average of 7 days among those admitted to home care (Canadian
Institute for Health Information, 2012)
• Nursing home capacity would need to increase by 75% over the next decade to meet the
projected demand (Costa et al., 2012)

10. Awareness – Delayed Discharge
• Delays in discharge from acute hospitals are a critical
challenge for many health care systems
• These are where a patient exceeds the length of stay deemed
medically necessary, commonly associated with older adults
• They often have a substantial influence on patient flow
throughout the hospital including emergency department
crowding, cancelations of day procedures, and poor
coordination of sub-acute and community care resources
• Patients who experience a delayed discharge are at increased
risk of accelerated functional decline, social isolation, as well
as the loss of independence and are a reflection of health
system quality (Costa et al., 2012).

11. Questions (posted individuallywithintheforumso
classmatescananswerappropriately)
• In your opinion, what can our health care system do to
address the demand of nursing homes? Dream big!!
• Please share examples, either from personal or professional
experience, of challenges that older adults have faced when
transitioning from hospital to home or LTC facility.
• In your opinion, what resources would help facilitate the
transition of ALC patients home? (Might not be appropriate in
my section but in another?)

12. Reflection – Home First
Background
Patients waiting for long term care in hospital face significantly long hospital stay. Home First is
a philosophy which supports patients who no longer require acute care but their condition is
such that they may be required to move to Long Term Care.
Most patients will tell you that they would prefer to go home but many are denied this
opportunity
To support patients to go home in the Home First Philosophy , the patients are provided with
high levels of services such as nursing, therapy and personal support care in order to support
them and their informal caregivers so that they can go home rather than wait in hospital.
The premise is that patients / families are better able to make life changing decisions in their
own home environment.
This philosophy exists across Ontario. Despite many successes there has been slow uptake in
some areas
75% of patients – do not return to hospital (L Debuck, June 11, 2015)
Debuck, L., (June 11, 2015). Personal communication

13. Reflection Capability and
Decision Making
• It is important for health care providers to remember that if
patients are able to understand and realize the consequences
of their decision (have insight) then they are considered
mentally capable of making decisions even if it means living at
risk (Government of Ontario)
• Rogers and Gilmour describe ageism whereby “potential for
improved health and wellbeing” is curtailed due to the
attitudes of nurses caring for them (Rogers, Gilmore, 2011 pg.
13).
Government of Ontario. (2000). A guide to the substitute decisions. Queen’s Printer for Ontario. Retrieved from:
http://www.attorneygeneral.jus.gov.on.ca/english/family/pgt/pgtsda.pdf
Rogers, V., Gilmour, J. (2011). Shaping student nurses’ attitudes toward older people through learning and experience. Nursing
Praxis in New Zealand. 27(3). 13-21.

14. Reflection Questions
1. For Seniors who want to go home but are challenged
with cognitive disability and poor physical function
what challenges are faced by them – related to power
relations between them and hospital staff – nurses /
therapists / their informal caregivers such as family
2. Who’s voices are silenced – the patient/family/home
care workers, others? Why? How can health care
professionals advocate?

15. Action
• Power struggles are one of the most prominent domains of
discourse analysis. Whether political, sociological or
psychological, the struggle for power is at the root of many
societal issues. Power relations within a health care system is
no exception and from the premise of patient discharges I will
provide a brief discourse analysis outlining how free choice
influences the relations between discourse and power in a
health systems context. Subsequent to this I will offer a few
possible perspectives toward the alleviation of the issues that
have ensued as a result.

16. Action
• Discharging patients from a hospital setting is almost always a challenge.
This challenge is heightened when there is a discrepancy between the
desires of the patient and the health care professionals caring for them.
The purpose of the discharge procedure is to ensure patients who are
leaving the hospital are prepared to do so. This requires a certain
standard of mental and physical wellness in addition to access regarding
information concerning ongoing care. This is often a struggle despite
the discharge protocols and expert discharge planners in place to aid in
a smooth transition. One of the most common examples of this strained
process occurs when the nurse, or other health professional, believes
the patient is best suited toward a discharge to a long-term care facility
and the patient or their family members disagree. Subsequently, a
power struggle ensues. The nurse acting in what he/she believes is in
the best interests of the patient and yields a positive clinical outcome in
consideration of decreasing the possibility of re-admission to hospital.
On the other hand, the patient with awareness of their choices acts and
makes decisions based on what feels right for them, what they are
comfortable with, what they desire; which is not always compliant with
medical recommendations or insight.

17. Action
• Communication is an intertwined and fundamental element of what is going on within the power struggle
between health care providers and patients when there are glitches in the discharge process. This makes a
discourse analysis of the situation an excellent basis for interpretation and study of a hospital systems discharge
framework. Clarity in communication involves looking beyond what is simply being said or surface actions into the
social contexts that they are originating from. In terms of a long-term care discharge, there are many societal
considerations. News and media have illustrated various examples questioning the quality of long term care that
may contribute toward a distrust of the hospital system and sway persons in need of these facilities away from
seeking them as a living solution.
• (a) What is the discourse in power between the patient and health care professional?
• Generally there is an authoritative discourse between the nurse and patient. The nurse is viewed as the “expert”
concerning health matters however, realistically speaking the patient is the expert concerning their own body.
From this baseline communication may become a challenge and research illustrates that nurses often miss clues
that their patients need to be heard and listened to in order for effective communication and results/choices to be
made by the patient (Barrere, 2007). If the patient has spent the majority of their hospital stay feeling unheard or
not-respected, at the point of discharge when there is a choice for them to make, they may not even consider the
points being brought forth by the health professional and just desire to leave the system entirely.
• (b) What solutions or actions could be utilized to smooth the discharge process?
• Education and teaching strategies that discuss how to establish equitable discourse and symmetrical nurse-patient
communication (Barrere, 2007) are paramount to a sustainable solution. In addition to this other literature
suggests that nurse/patient role playing (Brooks, 2008), strategies aimed at empowering patients (Virtanen, 2007)
as well as self-objectivity and more empathetic communication techniques all have the potential to enhance the
hospital systems discharge process.
•

18. Resources
• Barrere, C. (2007). Discourse analysis of nurse-patient communication in a hospital setting: implications
for staff development. Nurses Staff Development. May-June Issue. PubMed online. Retrieved from:
http://www.ncbi.nlm.nih.gov
• Bauer, M., Fitzgerald, L., Haesler, E., Manfrin, M. (2009). Hospital discharge planning for frail older people
and their family. Are we delivering best practice? A review of the literature. Journal of Clinical Nursing.
2439-2546
• Brooks, F. (2008). Nursing and public participation in health: an ethnographic study. International
Journal of Nursing Studies. Jan;45(1):3-13. Elsevier Science.
• Clancy, C.(December 30,2014). Canada’s first seniors advocate says role needed across country: Isobel
Mackenzie says her office will pinpoint the most urgent issues in long-term care. MacLeans. Retrieved
from: http://www.macleans.ca/politics/canadas-first-seniors-advocate-says-role-needed-across-country
• Champlain CCAC Home First – You Tube (May 31, 2011). Youtube.com
• Costa, A. P., Poss, J. W., Peirce, T., Hirdes, J. P., (2012). Acute care in patients with long-term
• delayed-discharge: evidence from a Canadian health region., BMC Health Services Research. p 1-10
• Debuck, L personal communication, ( June 11, 2015).
• Government of Ontario. (2000). A guide to the substitute decisions. Queen’s Printer for Ontario.
Retrieved from: http://www.attorneygeneral.jus.gov.on.ca/english/family/pgt/pgtsda.pdf
• Hinton, D., (February 9, 2014). Tories hiding report showing senior wait times are growing, Liberals claim.
Calgary Herold. Retrieved from:
http://www.calgaryherald.com/health/Tories+hiding+report+showing+senior+wait+times+growing+Liber
als+claim/9490463/story.html

19. Resources Continued
• Madu, E., Ted Talks. (June 2007). Ernest Madu on world-class health care-inspiring story telling us how it is possible to
provide the best health care to the neediest among us. Ted Talks. Retrieved from:
https://www.ted.com/talks/ernest_madu_on_world_class_health_care?language=en
• Moeller, P. (Dec 12, 2011). How ready are you for long-term care? US News. Retrieved from;
http://money.usnews.com/money/blogs/the-best-life/2011/12/20/how-ready-are-you-for-long-term-care
• Mulholland, (Tuesday May 21, 2013). CTV News. Nursing home abuse not isolated experts say. Retrieved from:
http://www.ctvnews.ca/mobile/canada/nursing-home-abuse-incident-not-isolated-say-experts-1.1290010
• Ontario Health Coalition. (May, 1999). Fact Sheet on Long Term Care. Retrieved from:
http://www.ontariohealthcoalition.ca/wp-content/uploads/Fact-Sheet-May-1999-General-LTCARE.pdf
• Rogers, V., Gilmour, J. (2011). Shaping student nurses’ attitudes toward older people through learning and experience.
Nursing Praxis in New Zealand. 27(3). 13-21.
• The New York Times. (June 7, 2013). Fine print and red tape in long term care policies. Retrieved from:
http://mobile.nytimes.com/2013/06/08your-money/fine-print-and-red-tape-in-long-term-care-policies.html?referrer=&_r=0
• Simpsons, (n.d.). Homer in a nursing home. Retrieved from : https://m.youtube.com/watch?v=JUQXkgHM48
• Virtanen, H. (2007). Empowering discourse in patient education. Patient Education Counsel. May;66(2):140-146. Epub.
• Zakrajsek, A., G., Schuster, E., Guenther, D., Lorenz, K. (2013). Exploring older adult care transitions form hospital to home: A
participatory action research project. Physical and Occupational Therapy in Geriatrics. 31(4). 328-344.