In most jurisdictions, the number of people residing in long-term care (LTC) facilities at a single point in time is usually greater than the number of people who are in acute care hospitals. Yet far greater resources, both human and financial, are invested in acute care hospitals. Most of this disparity is, of course, quite appropriate. Acute care hospitals, with their short length of stay, actually treat many more patients than do LTC facilities. LTC facilities are primarily places of residence, with medical care added on where appropriate, and the expensive high tech approach of hospitals is neither wanted nor needed.
Despite this, it is difficult to believe that current resources in nursing homes are even remotely adequate. These resources are not just financial, although finances are certainly an issue. In the last few years in Ontario, the routine reimbursement for nursing home physicians has decreased by 25%. As well, in order for a physician to bill, the new rules require that he or she have face-to-face contact with the patient. No remuneration is provided for conferences with the rest of the health care team. This is making it increasingly difficult to convince physicians that being an attending physician in a LTC facility is worthwhile. Remuneration to the homes has not kept up with 'medical inflation,' and each year it seems that fewer personnel with professional qualifications are actually working in our LTC facilities. Even the physical environment of many LTC facilities leaves much to be desired. Lack of governmental funding for construction means that in many provinces private companies are the predominant providers of LTC.
However, there is also an information gap in our LTC facilities. Part of this is because of a general lack of knowledge of medical issues in the nursing home setting. Only in the last two decades has any significant effort been invested in advancing medical care within the nursing home by conducting research on these residents. Numerous articles have attested to the fact that improved care can benefit a number of objective outcomes, such as incontinence, falls and fractures.
In this edition of G&A we have a superb series of articles on Heart Disease in the Nursing Home, edited by one of North America's leading geriatric cardiologists, Wilbert Aronow. There are articles on stable coronary artery disease, congestive heart failure and endocarditis prophylaxis. Two other articles in this series, acute coronary syndromes and pacemakers, will appear in a later issue. Our own Associate Editor, Madhuri Reddy, reviews the structure of LTC across the country, and Gina Bravo discusses the details of LTC in Quebec.
There is also an interesting article on quality indicators in LTC by Jean Chouinard. I believe that the fundamental reason for the lack of resources invested in LTC is the societal belief that it is not worth the investment. Obviously, as a geriatrician, I believe that LTC is absolutely worth the investment and establishing guidelines for quality LTC is of crucial importance. Unfortunately, it is often more difficult to measure quality in LTC, as the simple measures (mortality, return to work etc.) that are relevant in acute care are not necessarily so in LTC facilities. When colleagues of mine, who previously were unconcerned about quality in LTC, have parents or grandparents admitted to LTC facilities, it is amazing to watch them transform into believers! If we believe that the frail elderly in nursing homes (and not just our own family members) deserve quality care, we must work towards it. The first step in that effort is defining and measuring quality indicators.
Let us not forget that many of us will end up in LTC facilities, when quality of care will suddenly become of paramount importance. Enjoy this issue.
