This past term, I was part of the inaugural class of “Aging Globally: Lessons from Scandinavia”, an experiential learning course offered at Western University through the Faculty of Health Studies. In the course, we learned about health care systems and care delivery in homecare and long-term care (LTC) in three Scandinavian countries – Norway, Sweden, and Denmark. The objective of the course was to identify what Canada can learn from these high performing Nordic health care systems with respect to management of chronic diseases and health-related quality of late life. During the semester I worked on a case study as part of an interdisciplinary team of Canadian health sciences students, as well as physical therapy, occupational therapy, and computer science students from Oslo Metropolitan University (OsloMet) in Norway.
The course ended with a 10 day trip to the countries we had been researching. In Norway we began with a 48 hour Innovation Challenge hosted by OsloMet’s Department of Universal Design of Information and Computer Technology. For the challenge I worked as part of a team of Canadian and Norwegian students to create a business plan for ‘ELDvR’ (i.e., a virtual reality platform designed to train and inform health professionals and caregivers about caring for older adults with Dementia and Alzheimer’s); our team was one of two teams to win the Innovation Challenge. Our class continued exploring the Nordic approach to the management of seniors care by learning about policies from the National Board of Health and Welfare in Stockholm and visiting the World Health Organization (WHO) European Regional Office in Copenhagen to learn about the WHO’s public health guidelines for aging.
Based on my experience in these Nordic countries I see opportunities for Canada, and Ontario, to address gaps in health care delivery for older adults. As such, the following recommendations for management of seniors care in Ontario are based on observations made about the systems that Norway, Sweden, and Denmark have in place. In Canada, health care delivery is under the jurisdiction of provincial governments, for which each of the provinces have vastly different strategies. To account for this complexity, within this article, health care system comparisons are made specifically between Ontario and the three Scandinavian countries visited.
In Norway, there is greater involvement of the federal government in the initial registration of immigrants into their national insurance program. This enables faster access to public resources, exemplified by the immediate registration with a general practitioner (GP) with no administrative or geographical limits, through the Regular GP Scheme introduced in 2001. The Regular GP scheme gives patients the right to a GP and is voluntary; only 0.4 percent of the population (about 20 000) opted out in 2012. The Norwegian government is also directly involved in supporting immigrants in navigating the complexities of their health care system through the Directorate of Integration and Diversity which coordinates reception centers and municipalities to help with the community integration process.
Canada on the other hand lacks in proactively assigning GPs in Ontario, Quebec, and British Columbia. In fact, landed immigrants are subject to a three month waiting period before they can be covered by public health insurance in these provinces. Moreover, even once they are covered by public health insurance, it is the responsibility of the individual to find a regular primary service provider or GP. The 2011-2012 Canadian Community Health Survey indicates that 45% of males, and 32% of females, that were new immigrants to Canada (0-9 years) did not have a regular medical doctor. However, through Health Care Connect (HCC) in Ontario, applicants are connected with local doctors and the success rate is high; 91.4% of patients were connected with GPs between 2009 and 2017. Unlike Norway, Ontario has more community-based NGOs, such as the federally-funded London Intercommunity Health Centre (LIHC). LIHC supports elderly immigrants through programs like ‘Seniors WrapAround’ which assists the elderly through creation of care plans. This approach enables elderly individuals an opportunity to develop strong social networks that they may be lacking.
According to the 2015 Migrant Integration Policy Index, Norway ranked fourth out of 38 countries in the health category, placing ahead of Canada which ranked 18th. This health ranking was based on four dimensions of indicators: 1) Entitlement to health services, 2) Policies to facilitate access, 3) Responsive health services, and 4) Measures to achieve change. Therefore, Norway’s central government approach to the integration of elderly immigrants may prove to be more effective and Canada may benefit from adopting their strategy. However, the localized work that organizations such as HCC are doing to increase accessibility of health care services are sufficient. Thus an option that may be better suited in Canada (i.e., in the absence of a national system for immediate registration with GPs) may be to create centralized provincial and territorial registration systems.
At Socialstyrelsen (i.e., the National Board of Health and Welfare), I learned about how Sweden creates a value-based LTC transition process. One such example is through the development of an Elderly Guide, a public database containing quality indicators for elderly care and special housing units – otherwise known as LTC homes – in each municipality. This information is used by older adults and their families to compare municipality services and LTC homes to guide them during the placement process. Additionally, the rankings function as a quality control mechanism for municipalities. In 2012, Sweden’s LTC regulations were further enhanced by a revision to the Social Services Act, which resulted in a policy that enabled elderly couples to continue to live together even after one of them needs to move into supported accommodation.
In Ontario, the spouse of an individual who is eligible for LTC may apply with their partner, however they will be categorized as ‘low priority’. This low priority categorization means the spouse is not allowed to stay with their partner until they become eligible for entry into LTC. Older adults in need of increased supportive care apply for a bed in a LTC home and once offered a spot, have 24 hours to make their decision. If an individual refuses an offer, their file is removed from waitlists for all of their choices, the file becomes closed, and re-applications are only eligible after 3 months. Due to this structure, the Ontario Long-Term Care Association (OLTCA) reports the average time for placement in LTC in Ontario as of October 2017, is 143 days. How can the province reduce these long waitlists and the frustration felt by many families? It could start by removing certain administrative barriers and providing more information about services offered to create a LTC transition process more aligned with the needs of the elderly.
During a tour of the Louise Marie Home in Copenhagen (a LTC home), I learned about their implementation of Sekoia, an electronic task management system consisting of 30 apps that allows care staff to record health data, share information, and report observations. Any changes to medications after a patient is hospitalized are updated directly to Sekoia. This allows staff at special housing to be on the same page with the treatment plan as hospital staff. The system is also designed to help with telemedicine and communication with loved ones as each apartment has a monitor equipped with Sekoia. In the municipality of Odense, Denmark’s 4th largest community, the use of Sekoia’s technology is expected to bring cost savings of 1.5 million dollars annually in addition to an increase in care quality by reducing time spent on administrative tasks.
Saint Elizabeth Health Care in Ontario has been developing innovative strategies of their own to improve care services. As one of Canada’s largest social enterprises in providing home care, health solutions and education, Saint Elizabeth has created a ‘Caregiver Coach’ helpline and teamed up with start-up X2 AI to use their chatbot Tess, now known as Elizzbot, to provide mental health care to staff. Elizzbot acts as a virtual therapist, assessing mental states and giving employees a tool to manage their stress and anxiety. What sets Elizzbot apart from other chatbots is Elizzbot doesn’t use pre-selected responses. Based on the success of a pilot project, Saint Elizabeth is currently working to include Elizzbot in its ‘Caregivers in the Workplace’ program. Although not a task management system like Sekoia, Elizzbot still functions to support health care professionals in the workplace.
What does Ontario have to learn?
In these Scandinavian countries there is an emphasis on enhancing information sharing and developing e-health systems for care professionals so they can maximize their time spent on delivering care, thereby improving efficiency and quality of care. Recognizing an opportunity for improvement, Ontario passed the Patients First Act in 2016, to create a more integrated health care system that puts patients’ needs at the forefront of care decisions. Two main objectives in the Patients First Act are one, providing faster access to the right care and two, delivering better coordinated services. Thus, as a method of obtaining these objectives, Ontario would benefit from prioritizing implementation of welfare technologies and assistive living devices to improve care quality. Furthermore, creating a better transition process into LTC homes such as increasing the time applicants have in making their decision about an offer or providing more assistance in this decision would add more value to the process.
Ontario is moving in the right direction through its implementation of the Better Seniors’ Care strategy and Patients First mandate, but there are many improvements to be made in the field of care delivery for older adults. As countries deal with their own complex health issues, an aging population is a common demographic shift that health care systems worldwide must adapt to. By evaluating strategies that have already been implemented, we can assess whether these same strategies can be applied in Ontario’s seniors care system. Being capable of knowledge transfer between diverse communities is a key lesson I have learned throughout my course and one that will be very valuable in assessing the approaches to health and aging across the world.
Aayushi has a Bachelor of Medical Sciences from Western University and currently works as a summer analyst at the Ivey International Centre for Health Innovation. She will be heading to McGill University in the fall to pursue a Master of Science in Experimental Medicine.