Seniors' Mental Health & Home Care The role of home care in promoting the mental health of seniors in Canada

By Karen Parent, Malcolm Anderson, Barbara Neuwelt

Introduction

The focus of this 2-year project is on preserving and promoting seniors' mental health and preventing mental health problems by enhancing the capacity of the publicly funded home care/home support system to support seniors' mental health. The project has two goals: to assess the mental health needs of seniors and the role home care does, and can play, in meeting those needs (Jan. - Dec. 2001), and to develop a Policy and Planning Guide and a Service Delivery Guide for home care planners and providers (Jan. 2002 - Jan.2003).

This article will discuss the findings from the research. Please note that the study is not about mental illness or the dementias but about mental health promotion for the general seniors population.

Mental health is defined as: the capacity of individuals to interact with each other and their environment in ways that enhance or promote their sense of well-being, sense of control and choice with their life, optimal use of mental abilities, achievement of their own goals (both personal and collective) and quality of life. Mental health is determined by the factors which affect an individual’s sense of well-being or quality of life, including the ability to think independently, make decisions, experience enjoyment, socialize, to feel in charge, to be able to make choices and to communicate wants and needs.

Context

In a previous study on home care and people with psychiatric disabilities, home care planners and providers spoke of their concern that home care may not be supporting the mental health needs of seniors as well as it could be due the task-oriented nature of services. At the same time they felt that they were in a unique position to promote good mental health because of their direct link to seniors in their own homes. Consequently, the Canadian Mental Health Association (CMHA) secured funding from the Population Health Fund of Health Canada to conduct research on this issue.

Methodology

Four local community research sites (in Kelowna BC, Weyburn SK, Montreal QC and the province of PEI), led by local CMHA branches and the CLSC Rene Cassin (Montreal), held a series of consultations with seniors and service providers to respond to the research questions. At the same time, a national study involving interviews, surveys and focus groups, asked the same research questions of a variety of stakeholders including seniors' organizations, home care planning bodies, governments, voluntary organizations, informal caregiver organizations, hospices, faithbased organizations, professional and para-professional organizations, home care and seniors' service agencies, and physicians.

Informants were asked the following questions:

Considering the definition of mental health described above, what factors or issues do you think influence seniors’ mental health? What do seniors need to maintain positive mental health?
How are home care organizations and provider agencies responding to meeting the mental health needs of seniors?
What barriers do home care organizations and provider agencies face in providing effective services to meet the mental health needs of seniors?
How could home care organizations and provider agencies be more proactive in meeting the mental health needs of seniors?
Are you aware of any innovative programs being provided by the publicly-funded home care organizations to meet the mental health needs of seniors?

Findings

The Mental Health Needs of Seniors

Participants identified the following factors which support good mental health in seniors: independence and autonomy, personal dignity, a sense of purpose, a positive outlook on life, a perception of being healthy, spiritual connection, coping well with loss, being valued, being able to stay in one's own home, being involved in decisionmaking about all aspects of one's life (particularly leaving one's home and care plans), a sense of security (both physical and emotional), financial security, stability, access to transportation and healthy relationships. They identified that most important of all is a good level of social contact that involves getting out and being active in the community, as well as visitors and phone contact with supportive family and friends.

In addition, participants spoke of the interaction between one's mental and physical health, the impact on seniors' mental health when they have a heavy burden of care giving for ill spouses/parents/friends, and the effect of world events such as the Sept. 11, 2001 tragedy.

The Role of Home Care

Participants felt that the way services are provided can support or detract from good mental health. For example, having a different home support worker every day can create anxiety, frustration, insecurity (strangers in my home), and isolation for people whose only visitor is the home care worker. A similar impact is felt when decisions are poorly communicated to the client, when care is threatened, and when seniors can't make sense of either the criteria for admittance or the fragmented service system. People spoke of the frustration of not being able to find out what was available or understand how to navigate the system.

The rigidity of service provision (length of time, timing of visit, what services are provided, and how) gives seniors no control or involvement in making services fit their needs. Particularly when services are very personal, this situation negatively impacts seniors' sense of autonomy, social connection, and personal dignity. When an individual's services are cut due to funding constraints, seniors feel their value is measured in money, affecting their sense of self-worth.

The services home care provides help to keep people mentally well. Home support was the most significant service, in terms of promoting mental health, identified across the country. Other studies have shown the value of home support in keeping people at home and preventing deterioration and illness. In addition, personal care and respite care were frequently mentioned. Other home care services that support good mental health are foot care (keeps them mobile), medication management (overmedication causes confusion and grogginess), meals on wheels (no anxiety about getting fed), friendly visitors (social connection), and palliative care (being able to stay in their own homes).

Finally, other community services that are significant promoters of good mental health are adult day programs, specialized health and social services, physician home visits, pastoral care, volunteer opportunities for seniors, meal programs, social activities, and wellness and exercise programs.

Participants also identified many of the roles home care professionals play which promote good mental health in seniors: individual advocacy, assessment and monitoring, and education of seniors and family about the expected course of their illnesses so they can make informed choices, were mentioned. Two examples of home care structures that support good mental health are the collaborative care model (helps mitigate the fragmentation of the system) and an open referral system (so even the postman can alert home care to a senior in difficulty).

The good mental health of seniors living independently also requires support and education for caregivers, information for seniors and family on mental health concerns as well as supports for seniors with mental health problems, elder abuse consultation, volunteers to assist with tasks seniors can't manage but are not provided by home care staff, and trustworthy people to hire to do household repairs. Sometimes these services are available in the community, through home care or other agencies, and in other communities these are not available.

Seniors Who Are Caregivers

The shift in responsibility away from publicly funded home care programs is placing pressure on the mental health of family members who are faced with carrying out functions once provided by home care staff. One example of this would be: in one region, 80-year old women are being trained to change dressings for husbands being sent home from hospital. This creates a heightened sense of anxiety, over and above the stress of a spouse in ill health.

Senior caregivers have a number of issues to address. They must be aware of, navigate and coordinate the myriad of formal services and informal supports. They may have their own health concerns, other family members to whom they provide care, problems with accessing transportation, and a home environment that is not physically conducive to care (e.g., too many stairs, poor design, narrow doorways inaccessible to a wheelchair). They may have to juggle care giving with work or other commitments, and there may be financial costs incurred with the responsibilities of care giving. In short, a number of pressures may be faced which put considerable pressure on the caregivers’ mental health. There are minimal supports for care giving seniors to assist them in their new role.

Barriers, Constraints and Challenges

The under funding of home care has brought with it interruptions to service and cuts in home supports. “The person least appreciated in the home care system is the home support worker. They’re key and core to helping the older person maintain his mental health." (Physician)

“More hours of care and housekeeping should be provided to reassure people that they are being encouraged to become more self-reliant and not be afraid that care can be made available when needed.” (Interviewee)

“Home care needs to be provided to a level that maintains seniors’ ability to make independent decisions related to where they live and how they socialize.” (Interviewee)

The "time-for-task" approach to service-provision threatens the long-standing role of home care in providing holistic (mind and body) client-centred care that includes social connection.

“Somewhere we’ve lost the ‘people’ in this – now it’s much more task oriented …it’s a holistic approach we’re supposed to be doing, and it’s not happening.” (Home care agency nurse)

“We should provide more non-specific support to those alone in the community, rather than task-oriented care.” (Home care organization)

Task-oriented care also misses the point of helping seniors to help themselves.

“A task-oriented ‘doing-for’ philosophy of care underlies long term care services. A ‘doing with’ (activation) philosophy focused on clients’ abilities would be more effective in improving and maintaining mental health and would be more cost-efficient in the long term.” (Home care organization)

“I try to do what I still can and then the home support worker withdraws from helping with this. I cannot do it all the time. One worker became nervous [when I worked with her on a good day] about this and said you could get me fired, you are doing my job.” (Kelowna consultation)

The inadequate education of staff in healthy aging, understanding seniors, and mental health issues creates a gap in capacity for supporting good mental health. High staff turnover makes continuity and developing good relationships difficult. Insufficient attention to alcohol and substance abuse means seniors with these difficulties are not being adequately cared for. With under funding and low incomes of many seniors, seniors cannot always get the care they need to keep them mentally healthy.

Finally, gaps in community services mean that even where home care is doing a great job, if seniors can't get other needed supports, home care is not enough (e.g. access to transportation, medical equipment).

Recommended Home Care System Features

“Unless we improve current human and fiscal constraints and push for a prioritization of preventive community health care and a shift in emphasis from ‘heroic’ medical models to a ‘wellness’ model focused on individual clients in the community setting, we will keep chasing the chimera that there is a cure for old age and its concomitant issues.” (Seniors organization)

“The priorities need to change from preferentially funding high-cost private medicine to a re-emphasis on community-controlled, public provision of the needed social and personal needs of seniors – not grabbing every last minute of life by any means possible, but a focus on quality-of-life in later years.” (Seniors organization)

What is the overall goal of home care? What services should the home care system be accountable for, and what services should be left to other community agencies? If there is more of a role for community agencies and less for home care in the provision of services such as day programs, meal programs and the like, then what is home care's role in coordinating all aspects of care and support to seniors? These are questions that must be explored.

The overarching issue is the need to reassess the mandate of the publicly funded home care system. Is the mandate truly reflected in the current shift away from the preventive/maintenance functions and towards acute episodic care? If so, then there is less opportunity for home care to explicitly influence the nature and extent of care that contributes to seniors' mental health. If not, if there is still a mandate for prevention/ maintenance, then in order to maximize home care's capacity to promote the mental health of seniors living in the community, the publicly-funded home care system must contain the following features:

Adopt a holistic (mental and physical) view of health in policy, vision, goals and objectives of the publicly-funded home care system. This would lead funders and providers to examine the array of services currently provided and assess whether they fully meet the objectives of a holistic approach to health.
Improve coordination and communication between all aspects of the home care system and of the health system (particularly between home care, the physician, the hospital and long term care). Improve communication between professionals, home support workers, families and clients.
Recognize the fundamental role of home support. This requires a recognition that the curative, dependency, illness (episodic) and clinically oriented medical model is subsuming home care budgets such that the caring, independence, health promotion/illness prevention social model is being eroded.
Explore the possibility that the responsibility for coordinating services for seniors - not only home care, but all services available in the community- and not only referrals, but coordination of care - should lay clearly in the hands of the home care system.
Enhance education and training for staff.
Address the needs of caregivers, both senior caregivers and caregivers of seniors.
Recognize the role of home care in being the social connection for isolated seniors and adjust services accordingly.
Maximize consistency of care by minimizing the number of different personal care workers and home support workers coming into a client’s home.
Institute a more flexible, client-centred approach.
Engage volunteers, both to supplement home care services and to provide volunteer opportunities for seniors.
Enhance awareness of services in the community and provide clear information about how to access and navigate the service system.
Develop a clear role for physicians.
Involve seniors in decision-making at the individual and the systemic levels.
Work with other players in the health care and community care system to address access to transportation, access to subsidies for low-income clients, and issues of substance abuse and elder abuse.

“Living fully until the very end of life with dignity and in comfort requires a full circle of support so the individual feels in control rather than isolated or a burden on family and friends. We have shifted from care to cure and need to stop denying the journey toward end of life and embrace it as an act of completeness and meaning.” (Seniors organization)