Long Term Care Facilities An Important Piece of the Health Care System in Québec

The longevity of the residents of Québec has increased dramatically throughout the twentieth century. The number of persons aged 65 and over has multiplied by a factor of 9.4 since the beginning of the century, in comparison with a factor of 4.1 for the total population. Life expectancy at birth has gone from 68.6 years for women and 64.4 for men in 1951, to 80.84 for women and 73.69 for men in 1990-1992. More people, therefore, live to a greater age.

It is noteworthy that in Québec the number of those aged 65 or over has been doubling every 25 years since 1945. It is interesting to note also that within the group aged 65 and over, the number of those over 75 is growing, going from 33% in 1961 to 39% in 1990. Towards the year 2011, for the first time in history, there will be more seniors than 15- year-olds or younger, and they will represent more than 15% of the population (i.e. 1,247,886).

In general, people live longer and in better health than in the past. This longevity is associated, however, in many cases, with chronic health problems. According to a social and health inquiry conducted in 1992-1993(2), 20% of non-institutionalized persons aged from 65 to 74, and 29% of those aged 75 and over, suffer from a loss of functional autonomy. This loss of autonomy is generally accompanied by certain restrictions in both the type and quantity of their activities. While these limitations affect 7% of the entire population, regardless of age, 17% of the population aged 65 to 74 is affected, and 23% of those older than that. The main causes of these limitations are osteo-muscular, circulatory and respiratory diseases. There is also a growing number of serious suffering from mental impairment.

Present figures of elderly population in Québec (1999):

65-69:	291,547
70-74:	247,452
75-79:	186,294
80-84:	112,015
85-89:	60,771
90 + :	29,405
Total:	927,484

Since 1991, with the adoption of a new Law on Health and Social Services, Québec has been restructuring its long-term care institutional system as has never been done before. Starting from a dual type of setting (long-term care hospitals and nursing homes), it has been transformed into a single type of facilities which are now called: « residential and long-term care centres » (English name for the centres d'hébergement et de soins de longue durée CHSLD).

According to section 83 of the Act respecting health services and social services and amending various legislations (L.R.Q. C. S-4.2), this new kind of institution was assigned a mission defined in these words: "The mission of a residential and long-term care centre is to offer, on a temporary or permanent basis, alternative environment, lodging, assistance support and supervision services as well as rehabilitation, psychosocial and nursing care and pharmaceutical and medical services to adults who, by reason of loss of functional or psychosocial autonomy, can no longer live in their natural environment, despite the support of their families and friends. To that end, every institution which operates such a centre shall receive on referral the persons who require such services, ensure that their needs are periodically assessed and that the required services are offered within its facilities. The mission of such a centre may include the operation of a day centre or day hospital."

According to the provisions of this Act, residential and long-tem care centres (CHSLD) therefore have a double calling: that of expertise in the area of accommodation, or of providing alternative environments, and that of partnership in home care services. The mission of the residential and long-term care centres is further defined by the provisions regarding their responsibilities toward intermediate and family-type resources.

A residential and long-term care centre is first and foremost an alternative living environment, which defines the specific character of this type of institution. The daily challenge faced by each residential and long-term care centre is to create a living environment adapted, to the greatest extent possible, to the needs and wishes of the resident individuals suffering from loss of autonomy, within the limits set by group living.

A living environment exists within a community and, in this sense, does not constitute a closed environment. It is designed to be an open environment where everything possible is done to enable people to visit friends outside or to make use of the resources available in the neighbourhood. It should likewise be open to users' relatives and friends within the community. An alternative environment may consist of a main facility, a family-type resource or a nursing home. Whatever the type involved, care must be taken in each case to provide an environment where it is pleasant to live and where the freedom and personal living space of each individual are respected.

For the past 5 years, most of the residential and long-term care centres have developed a wide range of adapted environments to fulfill specific needs for their residents. For instance, some of them provide a secured environment for people with Alzheimer's disease. Living in a special area with staff trained specifically to encounter aggressive or dysfunctional behaviour, they are assisted on a day-to-day basis in their daily activities. L'Association des CLSC et des CHSLD du Québec (Québec Local Community Services Centres and Long-Term Care Centres' Association) promotes a specific approach which is called "enlarged prothetical approach" and offers seminars for those who wish to implement this organizational and clinical approach.

On the lead of the Association, other types of intermediate resources may eventually be created by the residential and long-term care centres to provide for the needs of a younger clientele or of a clientele with specific problems. Within this category may fall, for example, residences where palliative care can be given to AIDS victims, or homes for adults with degenerative diseases such as muscular dystrophy, whose needs are not those of the very elderly; or again it may be resourcecapable of offering appropriate care to the mentally impaired.

As well as being leaders in the area of alternative environments, residential and longterm care centres provide professional care and services to persons experiencing loss of autonomy. Recent years have seen this aspect of the mission of the residential and long-term care centres grow significantly in a great many centres. Two factors account for this growth: a tightening of the norms for admission and an increase in the need for care and services on the part of the users. Québec's government has tried to keep up with these client changes, but it has never been able to cope completely with the progression of the elderly population in need of long-term care services. The need for more resources is constantly arising and the Ministry of Health and Social Services is working toward different financing scenarios and types of local or regional services organizations to face the coming « gerontoboom ».

On his side, Québec's Association of Local Community Services Centres and Long-Term Care Centres is helping its members with proposals in creating a network of integrated services on a local basis. This orientation should promote a more efficient use of resources and, therefore, a proper response to specific needs. In fact, residential and long-term care centre professionals are capable of providing a wide range of care and services.

These services are provided to the users within a framework adapted specifically to the residential and long-term care centres' clientele and to the conditions of long-term residence. A "socializing" model is preferred, i.e. one that is based on each person's ability to adapt, and on the bio-psychosocial concept of the person.

In conjunction with local community organizations, most of the residential and longterm care centres have developed programs such as temporary lodging (designed to provide a respite, a place of convalescence or social protection), day centres or day hospitals. Some have also put in place intensive functional rehabilitation programs or mobile psychogeriatric teams. The goals of all these programs is to help the persons experiencing loss of autonomy to remain, for as long as possible and in the best conditions, in their own homes.

The typical users of residential and long-term care centres are the elderly or very elderly, whose average age is around 84. We can no longer ignore the reality that such users generally suffer from more than one medical ailment on the physical level, and may be more and more affected on the psychological and social level also.

The illnesses encountered are, more often than not, chronic and degenerative. They result in physical impairments (reduced mobility, increased danger of falls, sensorial problems, incontinence, etc.) as well as psychological effects (mental impairment, anxiety, depression) and social ones (isolation, solitude, exhaustion of support systems). These different impairments bring about functional handicaps (limited ability to carry out ordinary daily activities) as well as psychological difficulties (cognitive and emotional) and social problems (loss of social roles, strong dependence on environment for the fulfilment of needs).

The users of the different home care programs, such as day centres, day hospitals, temporary lodging and intensive functional rehabilitation, are sometimes more autonomous than the resident users, although they also are generally experiencing significant loss of autonomy. An ever-increasing number of those admitted to or registered in residential and long-term care centres are suffering from serious mental impairment. The majority of mentally impaired users suffer from Alzheimer's disease. Others, however, show symptoms of mixed dementia, vascular dementia or dementia resulting from multiple coronary attacks.

Other users identified for residential and longterm care centres are: very elderly persons with slight loss of functional autonomy, elderly persons with cognitive deficiencies, adults and elderly persons with psychiatric histories, persons with intellectual deficiency and a loss of physical autonomy, and persons with multiple problems.

Residential and long-term care centres are not alone in providing services to adults and elderly experiencing loss of autonomy. They work in partnership with many other groups in the health and social services networks and the community - such as families, friends, community organizations, support groups, local community service centres, rehabilitation centres for the physically handicapped, rehabilitation centres for persons with intellectual deficiency, partnerships with rehabilitation centres for persons suffering from alcoholism or other problems of addiction, and partnerships with hospitals.

A descriptive picture of residential and longterm care centres:

Some centres are public-funded (around 350 facilities), including long-term care units in general hospitals and long-term care units or facilities for psychiatric adults. Others are private, partly financed by government subsidies (around 100 facilities), while others are privately owned without any public financing (around 40 facilities).

There are also intermediate resources which are financed within a contractual basis. Finally there are a certain number of family-type resources financed with public funding. The total capacity of all these facilities is approximately 47,970 beds.

Conclusion

Residential and long-term care centres in Québec have evolved greatly in the past 20 years. We are justified in thinking, nonetheless, that even greater changes are about to come, due, on the one hand, to the unprecedented aging of the population and, on the other hand, to the involvement of the residential and longterm care centres (CHSLD) in the major restructuring of the health and social services network.

Public expectations regarding the roles to be assumed by the residential and long-term care centres are high. Citizens have the right to adequate numbers of warm and vital alternative environments. They want to be assured of receiving superior professional services adapted to their needs within these institutions. Finally they expect the CHSLDs to put their expertise at the service of persons in the community suffering from loss of autonomy. Residential and long-term care centres are now in a trend of mobilization with their partners in the health care services. As an important piece of the system, they will face the major challenges ahead with an integrated and client-centred approach regarding their ways to deal with the increasing needs of the elderly for the next 30 years. Working together with hospitals, local community services centres, non-profit organizations, families, municipal services and others, they will use their limited resources to get the most of every existing possibility to fulfill their mission with a shared passion and a clear vision of the future.