$0#1)2345 - Quality Living Alliance for Seniors...health care needs. Loneliness, anxiety, fears,...

Personal Care Home

Industry Review

A Financial and Health Care Overview

Financial Report

Sabrina Philpott CPA CA

Beverley Russell

Michael Kirby

Susan Sullivan

Prepared by the Quality

Living Alliance for Seniors

April 2019

Health Care Report

Dr. Amanda Coleman

Laura Morgan

Table of Contents

Executive Summary 1

Conclusions and Recommendations 5

Part One: Financial Report 9

Part Two: Health Report 13

References 20

Personal Care Home Industry Review

Executive Summary

The Quality Living Alliance for Seniors is an association of Personal Care Home Owners dedicated to providing

exceptional care to seniors. The aim of the association is to ensure quality, compassionate, affordable care in

home-like environments that are designed to offer residents both the support they need and the independence

they desire.

In the last few months, the association has noticed concerning changes to the assessment process for persons

wishing to access personal care homes. Specifically, there is concern that government has determined mental

health care needs such as loneliness, anxiety, stress, fear of falling, social isolation, fear of living alone etc., to be

invalid singular reasons for accessing personal care homes. There must also be a physical health need identified.

In response, the alliance has prepared this report outlining the financial and health benefits of Personal Care

Homes (PCHs) to both seniors and government.

The core business of PCHs is to provide care to Level 1 and 2 residents. For the fiscal year 2017-18, 70% of

the residents of the province’s PCHs were classified as having Level 1 care needs, while a further 23.5% were

deemed to be Level 2 clients. Given the rapidly aging population of the province, the demand for seniors’ care

can reasonably expect to increase.

According to ATIPP information, government subsidized 81.6% of occupied personal care home beds in 2017-18.

The average cost of subsidized residents was $37 per day per resident. In comparison, home support subsidies

averaged out at $60 per day per client. Personal care homes provide 24 hours of care daily; home support clients

receive on average 3.5 hours of self-managed care, or 2.5 hours of agency-managed care per day. The daily care

costs increased significantly for long-term care residents, with government paying on average $209 per day per

resident. The cost of care escalates exponentially for seniors’ care in hospital acute care beds. The Canadian

Institute for Health Information (CIHI) reports the average hospital stay in NL is $6060, excluding physician costs.

The significant cost savings of PCHs over other available care options, coupled with the identified health benefits

of residing in PCHs, suggest that PCHs are advantageous care options for both residents and government.

1


The number of seniors deemed ineligible to enter a PCH increased by approximately 400% in the last

6 months of 2018 (See Part 1 – Financial Report, Table 4). On August 6, 2018, a memo was sent to the

regional health authorities that included a set of Guidelines for Regional Health Authority Staff: PCH Eligibility.

The guidelines stated,

“Whileitisrecognizedthatsocialisolation,lonelinessandpsychologicalsupportaresignificant

concerns, these issues alone do not fall within the mandate of PCHs to address those needs.

A person must have a personal care need or require assistance with instrumental activities.”

Given the increase in applicant denials for admission to PCHs, it seems reasonable to conclude that these

guidelines have negatively impacted the eligibility of seniors with mental health care needs to gain admission

to PCHS.

A person’s mental health can certainly have an impact not only on one’s quality of life but, as the literature

confirms on one’s physical health. (See Part 2 - Health Report) Dismissing these needs seems irresponsible,

especially in light of the considerable body of research work about the importance of addressing mental

health care needs. Loneliness, anxiety, fears, stress etc. are all very real needs and especially in seniors

can be debilitating to one’s general health if not adequately attended to.

209

60

37

Daily Cost Per Resident ($)

LongTermCare HomeSupport PersonalCareHomes

84.50%

75.0% 76.50%

80.10%

EasternHealth CentralHealth WesternHealth Total

Figure 1: Personal Care Home Occupancy Rates by RHA

2


The decision by a senior to enter a personal care home is not made lightly. It comes after careful

consideration of all aspects of the senior’s day-to-day life. As supported by numerous sources cited

throughout Part 2 of this document, if a senior concludes that his/her best care option is to reside in a

personal care home, it seems prudent to respect that choice. From a financial and a health perspective,

bypassing the PCH option ultimately results in the senior requiring the more expensive long-term care bed

or alternatively, admission to acute care. This is completely avoidable.

The demand for PCHs is increasing and in response, there are currently 11 PCHs in various stages

of construction in the province. This will result in approximately $236M in economic activity over the

construction phase and an estimated $153M in new infrastructure. Personal care homes in the province

account for $57.5M of direct job creation annually, as well as an additional $38.3M in yearly expenditures

that boost the local economy. This is especially significant in rural NL.

However, should government continue to restrict the number of Level I residents permitted to access

personal care homes, and deny the connection between mental health care needs and physical health

outcomes, one can reasonably predict 1) the closure of many of our current PCHs (especially in rural NL),

2) a halt to new home construction and 3) the loss of much needed jobs and related economic benefits.

One might also reasonably conclude that a ‘sicker’ or less healthy senior population will emerge when

these seniors are not in receipt of the care, they both choose and need, to lead healthy, productive lives.

3


Conclusions and Recommendations

Summary of Financial Findings

1. Personal Care Homes provide more than 4000 beds for seniors’ care at zero capital cost to government.

2. An examination of the 3 primary care options for seniors demonstrates clearly that PCHs are the best

bang for the buck. In short:

• $209 is the average cost of long-term care per resident / per day

• $60 is the average cost of Home Care per person (for an average of 2.5 to 3.5 hours a day)

• $37 is the average cost of 24-hour Personal Home Care per resident / per day

3. Personal Care Homes make significant contributions to the economies of the communities in which

they are located.

• 2500 jobs are created by PCHs – many of them in rural NL

• $57.5M is paid out annually in salaries

• $38.3M is expended for the overall operational costs of our facilities thus creating hundreds of

spin-off jobs

4. Currently 11 new Personal Care Homes are planned or under construction in the province.

• 450 employees are working on these projects

• $236M of economic activity is created (construction companies, architects, engineers,

tradespersons, suppliers etc.)

• $153M of infrastructure expenditure is created

Summary of Health Benefits of Personal Care Homes

The basic determinants of good health and healthy aging in seniors include proper nutrition, physical activity,

adequate sleep and rest, social interaction and cognitive stimulation. The Quality Living Alliance asserts that

PCHs meet these health determinants through the care and amenities they provide.

5


Meetings Seniors’ Needs

The goal of the personal care industry is to offer a holistic approach to the provision of care to its residents ensuring

that their physical, cognitive, emotional and spiritual needs are well addressed. The Quality Living Alliance for

Seniors regularly hears from both residents and their families about the improved health outcomes of residents

after just a few months of living in their homes. And, a recent survey by the NL Centre for Health Information entitled

Personal Care Homes, Resident Experience Survey (December 2018) found that:

i) 90% were satisfied with the Personal Care they received (bathing, toileting, dressing, morning

and night care etc.)

ii) 95% were satisfied with how often they received these services

iii) 90% were satisfied with the availability of staff

iv) 97% felt they were treated with courtesy and respect

v) 90% said they were content living in their personal care home.

Through numerous literature reviews, several needs were identified as significant determinants to the positive

health of seniors.

• Seniors want the right to make their own decisions.

• Ensuring the independence and dignity of seniors to make their own choices is paramount to their overall

happiness and by extension their physical and mental wellbeing. (See Part 2 – Health Report). This is

especially true in terms of decisions around their living arrangements

• Mental Health Needs have a profound effect on one’s physical health.

• One’s mental health and physical health are inextricably linked. (See Part 2 - Health Report). One cannot

treat one set of needs as superior to another. They are not. One’s physical health impacts one’s mental

health and just as surely, one’s mental health powerfully affects one’s physical health. However, the August

2018 Guidelines to RHAs seem to devalue the importance of mental health needs.

• The Quality Living Alliance for Seniors believes that denying entrance to a PCH based on needs such as

loneliness and anxiety puts into jeopardy the physical health of that senior.

• Concerns such as Loneliness, Anxiety, Fears are met in several ways in our PCHs. Regular social interaction

is a natural outgrowth of living in a PCH environment. There is always the company of others to enjoy, regular

outings and excursions provide opportunity for new experiences and social engagement, and the security

of knowing there is always staff on hand to attend to one’s needs certainly reduces anxieties and fears.

• Improved physical activity is essential to good health among seniors. PCHs offer regular fitness opportunities

and recreational programs designed to keep the senior as active as possible.

• Cognitive stimulation and social interaction have been identified through the literature reviews for this report

as essential to good health among seniors. PCHs naturally provide for these needs through the day to day

activities of the home, the opportunities for social engagement with residents, staff and visitors, and the

many recreational activities.

6


• Fatigue, energy loss and poor sleep are common complaints among seniors. The comfort and security

of a PCH address these needs. Residents sleep better knowing they are not alone, and that qualified

staff are available to them if needed during the night. Therefore, they are less fatigued the next day.

The physical activity of participation in various recreational activities also provides much needed

energy boosts.

Facilities and Amenities of PCHs:

• 24-hour care

• 3 home cooked, nutritious meals a day

• Medication management

• Regular physician and nurse visits

• Foot Care

• Medical transportation

• Daily recreational programs/ physical activities

• Community outings and excursions

• Daily room cleaning and laundry service

Many homes also offer:

• Emergency nurse call systems

• Security camera systems

• Cafes / coffee shops

• Fitness rooms

• Massage therapy rooms

• Beauty salons

• Theatre rooms

• Private dining rooms

• Libraries

• Games rooms

• Outside patios, gardening activities

7


Recommendations to Government

1. Reverse the directive of the August 6, 2018 Guidelines for Regional Health Authority Staff: PCH Eligibility

and allow assessors to approve admission to Personal Care Homes for persons with mental health concerns

such as loneliness, anxiety, stress etc. These are real needs and to deny them is a very regressive step.

2. Ensure that the new Levels of Care Framework being developed allows adequate pathways to Personal Care

Homes. Currently there are 14 levels of care identified but only 4 permit a senior to access a PCH. One of the biggest

determinants to healthy living for seniors as affirmed by significant research studies is the senior’s desire for

independence and an ability to choose one’s personal living arrangements. This is a matter of dignity and respect.

3. Provide information and education sessions to Personal Care Home owners and seniors’ groups around the

Income Based Financial Assessment Policy Manual for Long Term Care & Community Support Services that

came into effect on February 1, 2019. Currently, there is a great deal of confusion within the industry about

this new financial assessment process. Many home owners and managers are unaware of the changes and

seniors are confused about how these changes affect the information they need to provide when making

application for a subsidized placement.

8


Part One: Financial Report

Statistical and Financial Information

*Unless otherwise cited, information used in the compilation of this document was obtained from ATIPP documents for 2017-18, February

and March 2019.

There are currently 84 licensed Personal Care Homes (PCHs) in the province. Of these, 43 are within Eastern

Health, 22 in Central Health, 15 in Western Health, and 4 PCHs are found in the Labrador Grenfell Health region.

An additional 11 PCHs are currently under construction, with expected completion in the coming months. The

following analysis was completed without data from the Labrador Grenfell Health Authority and therefore none

of the information discussed below relates to the 4 homes in that region.

The total number of licensed beds in the province as of August 2018 was 4,090. There were 3,275 beds occupied

or an 80.1% occupancy rate. Occupancy rates are based on licensed beds. This is not an accurate reflection of

actual occupancy as many homes are licensed for more beds than they can accommodate.

See Figure 1 for occupancy rates by region.

209

60

37

Daily Cost Per Resident ($)

LongTermCare HomeSupport PersonalCareHomes

84.50%

75.0% 76.50%

80.10%

EasternHealth CentralHealth WesternHealth Total

Figure 1: Personal Care Home Occupancy Rates by RHA

9


Level I residents make up 70% of occupied beds, while level II residents account for 23.5%. See Figure 2 for

distribution of occupied beds by region. Central Health has the highest percentage of Level I residents, accounting

for 75.4% of all occupied beds. This could account for the lower occupancy rates in the Central Region since it

appears more difficult to qualify as a Level 1 resident since the Guidelines of August 6, 2018 were introduced.

During the period of August 2018 to December 2018 there were a total of 40 personal care home applicants

deemed ineligible to enter a personal care home. During the same period in 2017 there were fewer than 9

applicants deemed ineligible, with no regional health authority able to provide accurate numbers for that period.

This could be due to the fact that there was no data collected, or that there were actually no applicants deemed

ineligible. Based on the figures provided by the regional health authorities there was a 444% increase in the

number of seniors deemed ineligible to enter a personal care home from 2017 to 2018. See Figure 3 below.

Subsidized residents make up 81.6% of occupied personal care home beds. See the breakdown per regional

health authority in Figure 4.

*No regional health authority was able to provide accurate data for the period requested. The numbers recorded in Figure 3 are based on estimates provided by each health authority. For Eastern Health there were 5 or fewer, and for Western Health there were fewer than 5

67. %

75.4%

6 .5% 6.4%

17.7% 4. % 5.4% 6. % 4.7% 0. % 0.7% 1.6% 0

200

00

600

00

000

200

00

EasternHealth CentralHealth WesternHealth

Figure 2: Distribution of Occupied Beds

Le el Le el Enhan e Care Le el

0

23

70

0

0

20230


Figure 3: Ineligible Personal Care Home Applicants

ug Sep20 7 ug Sep20

*No regional health authority was able to provide accurate data for the period requested. The numbers recorded in Figure 3 are based on estimates provided by each health authority. For Eastern Health there were 5 or fewer, and for Western Health there were fewer than 5

67. %

75.4%

6 .5% 6.4%

17.7% 4. % 5.4% 6. % 4.7% 0. % 0.7% 1.6% 0

200

00

600

00

000

200

00


Figure 2: Distribution of Occupied Beds

Le el Le el Enhan e Care Le el

0

23

70

0

0

20230


Figure 3: Ineligible Personal Care Home Applicants

ug Sep20 7 ug Sep20

*No reg iona l hea l th

authority was able to

provide accurate data

for the period requested.

The numbers recorded

in Figure 3 are based on

estimates provided by

each health authority.

Fo r E a s te r n He a l th

there were 5 or fewer

ineligible applicants,

and for Western Health

there were fewer than

5 ineligible applicants.

10


*The daily cost for home support is assuming that care is provided 7 days a week, which is not the case for all clients.

77. 0%

85.80% 87.70%


Figure 4: Subsidized Residents

36 39 376 67

22

320

0

0

0

00

0

200

2 0

300

3 0

Eastern Central Western

Figure 5: Daily Cost Per Resident/Client ($)

PersonalCareHome HomeSupport LongTermCare

In 2017-18 subsidized personal care home residents cost the province approximately $13.5K annually per

resident. This is $1,129 monthly per resident, or $37 per day. In comparison, home support cost the province

approximately $22K annually per client. This is $1,830 monthly per client, or $60 per day. Personal care homes

provide 24 hours of care daily, while home support clients receive on average 3.5 hours of self-managed care,

or 2.5 hours of agency-managed care per day. The daily cost increases significantly for long term care residents,

with the government paying on average $209 per day for residents in a long-term care facility. The cost of care

goes up significantly when individuals occupy hospital acute care beds with the cost per stay estimated at

$6,060, excluding physician costs. (Source: Canadian Institute for Health Information) See Figure 5 for an overall

cost comparison of all care options.


77. 0%

85.80% 87.70%


Figure 4: Subsidized Residents

36 39 376 67

22

320

0

0

0

00

0

200

2 0

300

3 0

Eastern Central Western

Figure 5: Daily Cost Per Resident/Client ($)

PersonalCareHome HomeSupport LongTermCare


11


Economic Benefits of Personal Care Homes

There are many financial benefits of Personal Care Homes to the economy of NL.

Personal Care Homes provide access to over 4000 beds for seniors’ care at zero capital cost to government. In

fact, the number of available beds will increase significantly in the coming months because of the construction

of 11 new Homes. Home Owners assume the entire financial responsibility for the construction, outfitting,

operation and maintenance of these homes. This is a tremendous gift to government.

Direct Job Creation and Economic BenefitsPersonal Care Homes account for the direct employment of approximately 2,500 employees creating 4.5M

direct person hours of employment per year. These workers fill various positions: personal care attendants,

maintenance staff, cooks, recreation directors, administrators etc. These employees work in all parts of the

province, both urban and rural communities, in some 84 homes. For the most part, they are second salaries

that allow families to afford a better standard of living. The benefits are obvious. In salaries alone $57.5M is

contributed to the economy. Grocery stores, corner stores, pharmacies, food establishments, recreational venues

etc. are all beneficiaries of these salaries. It is a direct infusion of cash into local economies. And, for some of

our smaller NL communities, it is a much-needed economic sustainer – residents are employed, municipal taxes

are paid, local businesses survive.

Indirect Job Creation and Economic Impacts

Apart from the $57.5M of direct job creation across the province and spin-off benefits to the economy of local

communities, many indirect jobs are also created through necessary business purchasing. All personal care

homes make major purchases from food suppliers, pharmacies, medical supply companies, furniture stores,

lawn and snow clearing companies, home improvement companies etc. From a recent survey of personal care

homes, we can extrapolate that $38.3M of spending occurs which in turn creates and sustains a large number

of indirect jobs throughout the province.

New Home Construction and Economic Impacts

There are currently 11 PCHs in various stages of construction in the province. This creates hundreds of

jobs and puts millions and millions of dollars into the economy. From surveying home owners, we estimate

that 450 employees are working directly in the construction of these homes. In addition, there is a major

expenditure on building supplies, building contractors, suppliers to these contractors, architects, engineering

firms, tradespersons. The economic activity over the construction phase is estimated to be approximately

$236M. The overall anticipated capital cost of this new infrastructure is conservatively estimated to be in the

range of $153M.

12


Part Two: Health Report

An analysis of Seniors’ Health Needs:

The role of Personal Care Homes in meeting these needs

Research conducted by Harvard Medical School, McMaster University and a host of other sources all point

to the same basic determinants for healthy aging: proper nutrition, physical activity, adequate sleep and rest,

social engagement, cognitive stimulation.

It is well documented that seniors seek the comfort of personal care homes for a variety of reasons. For some,

loneliness, lack of cognitive stimulation, anxiety and depression are the reasons. For others the stress of living

alone, being responsible for the maintenance of a house, especially following the passing of a spouse inspires

them to seek the support of a personal care home. For yet others, physical restrictions and ailments or an inability

to manage the daily requirements of caring for oneself are the impetus for deciding on a personal care home.

A review of relevant literature, research and evidence-based reports has yielded much validation for the benefits

of personal care homes to seniors as they age. A summary of some of those findings is presented here. As well,

a bibliography of notable research studies and references is provided for the reader’s convenience.

It should be clearly understood that this report does not intend to undermine or disregard the value of Home

First Initiatives or Home Support/In-Home Care. For many seniors these are the best choices at various points

in their lives and should be supported. However, the need for 24-hour personal care is equally valuable. One

care option does not trump the other.

It is the general thesis of this report that Personal Care Homes offer valuable, favorable advantages to seniors

that result in quality living and extended life expectancy.

An examination of issues related to healthy aging

Loneliness and Health Risks

The Harvard study of Adult Development concludes the stark reality that loneliness kills (Vaillant 2008). Being

isolated is as detrimental to one’s health as smoking or alcoholism and can lead to numerous negative outcomes

with the biggest one being death. Research conducted by Pantell, 2013 has further corroborated this finding.

A meta-analysis done by Holt-Lunstad et al found loneliness to have a bigger adverse effect than air pollution,

physical inactivity, and obesity (2017). Other studies have linked social isolation to higher mortality in people

13


with coronary artery disease (Brummett, 2001), and accelerated progression of atherosclerosis in women with

coronary artery disease when they were depressed and isolated. As far back as 1982, Blazer noted increased

mortality in a 30-month period in elderly who perceive a lack of social support and in seniors who are not engaged

in regular social interaction. The effects of social isolation and health outcomes are even more pronounced in

elderly males who are living alone and have a high rate of mortality (Murphy 2008). It is felt that the stress felt

from loneliness triggers negative biological changes. Researchers Hawley and Cacioppo examined various

mechanisms to address the link between loneliness and premature death and these included a change in health

behaviors, cardiovascular activation, cortisol levels, and sleep. Since we are social creatures, Hawley feels there

is a loneliness loop that can be activated leading to premature death. To summarize the detrimental effects

of loneliness, it is best to quote researcher Perissinotto “ultimately, it is important for healthcare providers to

recognize that the health effects of loneliness extend deeply into many aspects of adult health including increased

risks of frailty, cardiac disease, dementia, diabetes, loss of function, and early death” (2019). The only thing to

be added to the above statement is the importance that our government recognize this as well. This has started

in the United Kingdom. They have a national strategy in place to help end loneliness which includes a huge

campaign and the appointment of a minister of loneliness.

Right to Choose One’s Care

The Eloranta 2008 research demonstrated that older persons want a sense of control over their lives and an

ability to influence the course their lives will take. This is not unlike the wishes of any adult. Usurp this aspect

of an adult’s life and depression and anxiety soar. Numerous studies including The World Report on Aging

and Health (Beard, 2015) discuss the necessity of promoting capacity-enhancing behaviors in order to have

successful aging. It continues with the importance for elderly to make their own decisions to increase their

functional ability. Therefore, if an elderly person feels their needs would be better met in a personal care home,

the right of the senior to make that choice should be respected. The decision to leave one’s home is a difficult

one at the best of times and not one that is made without a great deal of soul searching and consideration. A

senior who makes that determination should be afforded the respect and dignity of his/her own counsel. To

do otherwise is to deny the senior his/her independence and impose a style of living that is contrary to their

wishes. We need to empower the elderly and allow them to direct their care to avoid negative health outcomes.

Mental Health Care Needs

Studies such as the one done by Harandi, 2017 show a high correlation between social support and mental

health. Mental health is often more important subjectively to a person’s wellbeing than physical health. To not

evaluate a senior’s mental health care needs when approving eligibility to a personal care home (as directed in

the Guidelines to RHAs of August 2018) is to undermine the person’s health and wellbeing. It is also ignoring the

World Health Organization which identifies mental health as an essential dimension of overall health status. If

an elderly person is isolated and feeling lonely or is living with a fear of falling or is gripped by anxiety because

of being in the house without support, one can reasonably expect their physical health to decline. This was

demonstrated in a meta-analysis Holt-Lunstad carried out which determined that within a given time frame

adults who feel socially isolated are at a 50% greater risk of dying from any cause than those who feel socially

connected (2010). This is especially true if the person has no family close by or is widowed since both situations

14


lead to higher rates of social isolation, loneliness and mortality (Wilkins, 2003, and Hansen, 1989).

Anxiety and depression cause lack of sleep, headaches, muscle tension, sweating, palpitations, and GI troubles

to name a few. These physical ailments can be harder for an older person to deal with and cause significant

health problems. Depression is linked to higher risk of numerous diseases including cardiovascular disease,

metabolic syndrome, and diabetes (Moussavi 2017). As we age the likelihood of a cardiovascular event increases

and hence the more damage depression and anxiety can have due to the additive effect. Stek found a 2.1 times

higher mortality risk in the elderly who suffer from depression and loneliness (2005). One study demonstrated

people who suffer from depression have up to three times the likelihood of having multimorbidity (Stubb, 2017).

This is significant as multimorbidity has been shown to greatly increase our risk of mortality and health care costs.

Depression and anxiety both decrease our immune systems and can lead to increased infections (Andersson,

2016). Since the elderly cannot tolerate infections as well as the young this can be deadly or lead to long term

adverse effects (worsening dementia, etc.) Besides the suffering the person has to endure when suffering from

anxiety and depression, it is quite costly to the health care system. Prevention could go a long way here.

Adherence to Medical Treatment Regimes in Seniors

Social support leads to better adherence to medical treatment plans (DiMatteo, 2004). Holt-Lunstad coined

the term “health-relevant behavior” meaning the more people we surround ourselves with the better chance

we will engage in good health practices such as taking our medication, brushing our teeth. PCHs have a huge

impact on health-relevant behavior. It has been well documented that many seniors regularly forget to take their

medications, miss doctor’s appointment and generally ignore symptoms of poor health when they are alone.

PCHs offer medication management to all seniors who require such assistance, thereby ensuring better health

outcomes.

Regular Physician Care and Positive Health Outcomes in Seniors

Personal care homes provide easy access to medical care. With regular physician visits to PCHs, medical

conditions can be managed better and likely delay the need for higher level care. Studies have noted that the

perceived lack of availability of care leads to significant anxiety among seniors and an increase in emergency

room visits (Nyweide, 2017). With personal care homes providing regular access to a family physician these

situations are totally avoided.

“Self-rated Health Concerns”

“Self-rated health” refers to a person assessing their own health on a scale of poor health to excellent health.

Self-rated health has been shown to be predictive of mortality (Grand, 1990) and often outperforms objective

measurements (such as the form used to determine eligibility for a personal care home). This becomes even

more important as one ages. Several hypotheses have been made to explain this including an individual’s

ability to detect changes in their health before it can be picked up clinically. The self rated assessment gives an

overall assessment of the person’s whole health (physical, psychological, and environmental) and ties in their

personality, resources and ability to function with any disability. Therefore, a person’s perception of their own

15


health situation needs to be considered when a person is looking at in-home care versus a personal care home.

If the person feels they would have better care and comfort and therefore be healthier in a personal care home,

they should be able to make this choice. It will likely lead to overall better health outcomes. Similar results were

found by Lyyra 2006 where low, perceived non-assistance related support led to almost 2.5 times increase in

the risk of death in women and Stek 2005 found a 2.1 times higher mortality risk in the elderly who suffer from

depression and loneliness.

Increased Emergency Room Visits among Seniors

Emergency department visits for nonmedical reasons increase significantly when seniors are socially disconnected.

This has been shown to be a bigger issue in rural communities where less medical follow up for seniors is available.

(Toth 2017). This results in significant cost to the province and emergency departments are not equipped to deal

with the volume of traffic created by the nonmedical visits. Symptom burden, which includes conditions such

as shortness of breath, tiredness or fatigue, problems with balance and dizziness, leg weakness, poor appetite,

pain, stiffness, constipation, anxiety, and loss of appetite is often the reason for emergency visits among seniors

who have limited social support. (Salanitro 2012). Interestingly, an elderly person could exhibit a number of these

symptoms but still be ineligible for admission to a personal care home according to the August 2018 guidelines.

Yet, these very PCHs could be the solution to providing the necessary care and relief from such symptom burden

issues and in fact prevent ER visits and by extension, hospital admission.

Implications of Fatigue, Energy Loss and Lack of Sleep

Loss of energy and fatigue is a frequent and common complaint among senior citizens. By age 70, we have lost

about 30 percent of the muscle mass we had at age 20. This translates into decreased strength and an increase

in fatigue when attempting the same physical activity comfortably performed 10-15 years prior.

Seniors spend less time in deep sleep, the most important type of sleep required to restore energy. Without deep

sleep older adults wake more often during the night, have trouble falling back to sleep and consequently feel less

rested the next day. Melatonin which helps a person feel sleepy at night decreases with age and disappears in

older age. This is one reason insomnia is more prevalent in older persons. The result is that the activities of daily

living and the responsibilities of a house often become too much for an older adult even without any “physical

care need”. Having home-cooked, well balanced meals, someone to perform household cleaning chores, and the

security that comes from having a staff member available during late hours of the night can add tremendously

to both the quality and length of a senior’s life.

Loss of Spouse

There are few things in life more likely to lead to depression than losing a spouse, especially for seniors in their

twilight years. For the elderly, bereavement can have a devastating effect on their immune system and cause

them to lose interest in their own care. This may explain why many seniors experience a severe health decline

shortly after the loss of a spouse. For many surviving spouses the need to take on their deceased spouse’s

role is often overwhelming and unattainable. The fear of sleeping in a house alone can cause anxiety and

panic attacks. Finding people who can support you and relate to your loss is important and therapeutic. Eating

properly, exercising, new routines, new friends all help the surviving spouse and serve as a distraction from

16


their grief while acting as a real support to structure a new path forward. PCHs are perfect communities for this

new transition in life. Meeting the mental health needs for a surviving spouse who is trying to manage the loss

of their partner is just as important as any physical care need he or she may have.

The Home First Care Option

Home First Initiatives

The general intent of Home First Initiatives is to focus on the living arrangement preferences of the elderly

population and put more independence into their hands. Home First Initiatives generally offer in-home support

for seniors who would like to stay in their homes. This is an essential and a needed option for many of our elderly

since studies have shown independence is very important to seniors. (Eloranta 2008)

However, it must be emphasized that the ultimate ingredient to the success of Home Support or Home First

Initiatives is the ability of the senior to decide the nature of the right care, at the right time, in the right place.

The Eloranta 2008 study showed that when older people felt conditions of living were imposed on them it led

to the loss of a sense of control in one’s life and a decline in the desire to remain physically active. An inability

to influence essential components of their own lives resulted in negative health outcomes.

In NL, a critical issue of concern is the way in which the Home First model is being implemented. Prior to the

focus on Home First initiatives, if an older person made a decision to reside in a personal care home to satisfy

their needs, an assessment was completed and the application to the personal care home was approved.

Seniors’ dignity, their independent ability to decide for themselves how they wished to live was respected prior

to August of 2018. Ultimately, the senior had the RIGHT TO CHOOSE his/her care. Since the introduction of new

Guidelines for assessment to PCHs in August of 2018, the same older person must be assessed to be much

sicker physically to qualify for admission. The changes do not consider the senior’s mental health care needs or

the burden of living at home alone. Government may support these seniors with some in-home care. However,

the older person’s choice to influence their own life is stripped away. With the stroke of a pen, government is

abandoning the elderly who would like to go to a personal care home for any mental health care need they may

be suffering (anxiety, stress, loneliness etc.), thereby taking away their independence and negatively influencing

their health.

Documented Home First Limitations

1. In-home care has numerous limitations which the elderly may not be initially aware of. The benefits of

in-home care are limited in both the number of hours of care available to the senior and the activities the

attendants are permitted to carry out. (For example, in-home care workers cannot drive the elderly anywhere,

hence limiting their ability to help engage the elderly socially). Most often the number of hours provided

for care is under 4 hours a day. This still leaves 20 hours in a day with no help. Seniors still have needs

during this time. In-home care focuses on physical wellbeing while psychological wellbeing is often ignored.

17


2. Another important limitation of in-home care is caregiver burnout. As stated earlier, with in-home care

the senior is often without care for over 20 hours in a 24-hour period. Therefore, in-home care usually

requires family members or others to provide care, supervision, medication management, food preparation,

companionship etc. to loved ones. Studies show burnout among these family members and a significantly

higher burnout rate in caregivers who have a poor relationship with the senior prior to providing that care

(Steadman, 2007). In today’s fast-paced society, it is common that two adults are working while juggling busy

schedules after their 8-hour work day involving young children and their activities, as well as a multitude of

other family and household responsibilities. It is unreasonable for both the caregiver and the senior to endure

the kind of stress brought on by worrying about the safety and health of the senior. In some cases, it is even

possible that the stress can cause the senior to (consciously or unconsciously) place the caregiver through

considerable emotional abuse. This is unacceptable and completely avoidable. It is also conceivable that

the caregiver (or the stress of the situation itself) can knowingly or unknowingly inflict emotional stress on

the senior. Furthermore, research has shown increased risk of mortality in female caregivers particularly in

low social-socioeconomic status group (Miyawaki, 2019). This too is unacceptable.

3. In-home care inhibits opportunities for the elderly to socialize with the broader community. Humans are

social creatures and without interaction our health is compromised. Because of our individuality, the amount

of interaction each person needs varies as does their perception of support. This is why the right to choose

care is so important (Note: assessment forms do not take this into account). Researcher Kiely et al noted

that long term care residents who were socially engaged lived 3x longer then those who did not engage

socially (2000). Two other studies carried out by Keller and Lyyra found that men and women with the

highest perceived social networks lived longer (2003 and 2006 respectively). Recently, (March 2019) Ellwardt

published a study that demonstrated that participants with the highest number of balanced relationships

experienced the least amount of stress. It is felt the socialization component makes the difference in objective

health outcomes. Personal care homes are, by nature, equipped to deliver socialization activities and

involve the elderly in healthy cognitive stimulation activities such as enjoying time with others, participating

in recreational activities, etc. It is much more difficult for a senior living in an independent home to do this.

Obstacles to overcome include finding available activities (some areas of Newfoundland will not have any),

transportation, and cost.

4. Physical activity is essential to wellbeing (Kim 2019). Studies show that low physical activity in the elderly

increase mortality (Glass, 1999) Walking is one of the best activities a senior can do to help with arthritis,

cardiovascular health, lowering the risk of stroke, colon cancer and diabetes, improving blood circulation,

muscle strengthening, maintaining a healthy weight, improving balance and coordination and decreasing

the likelihood of falling. It is known that walking improves confidence and mood and reduces anxiety and

depression. Even small amounts of walking each day have shown a 30% to 50% reduction in the participant’s

risk of cardiac arrest. Walking also boosts our immune system. Studies have shown that walkers get sick

less often. One study from Harvard Health Publications, 2014 demonstrated regular walking could reduce

by half the number of people over 45 who fracture hips by strengthening bones and preventing osteoporosis

18


and osteoarthritis. A study out of the University of Georgia (2008) found that regular walking reduced elderly

adults’ risk of developing physical disability by 41%. A study at St. George’s University Hospital NHS

Foundation Trust in London, found that walking 25 minutes a day added up to seven years to a participant’s

life expectancy. Given the climate realities of NL, seniors are unable to walk from November until May, with

the exception of a few days. Personal care homes are perfect “walking tracks” and the weather is always

perfect inside. Personal care homes also offer a partner to walk with helping deter loneliness as well as

having a buddy to help keep you “on track” with new routines.

Conclusion

Decisions about how best to live out one’s senior years are complex and must consider a variety of factors.

Paramount among those factors is the senior’s Right to Choose his /her preferences. As referenced above,

many studies have been conducted which clearly conclude that a senior’s ability to be in control of decisions

concerning his/her personal living arrangements have a direct correlation on one’s overall health outcomes.

Conversely, when a senior’s independence, dignity and opinion are undermined, one often sees a decline in

health outcomes. Seniors themselves are often best equipped to determine how much care and the type of

care they need.

Equally important is the understanding that one’s mental health needs must be significant factors in making

determinations around care options. Low care needs should never mean no care is provided. Mental health

issues of common concern for seniors include anxiety, stress, loneliness, fear of falling, social isolation and fear

of living of alone. These are serious needs that require as much attention as any physical health need. There

is a plethora of research that corroborates this assertion. Furthermore, there is much evidence that affirms that

ignoring one’s mental health needs results in poor physical health. To disregard these needs is to put at risk the

senior’s physical health. This is unacceptable and avoidable. Solutions to the concerns listed above are best

met by providing adequate social interaction and support. Rarely would 3 or 4 hours of in-home support a day

remedy this situation. 24-hour care as provided by Personal Care Homes is an easy, affordable and quality

response to meeting these needs. Furthermore, it has been demonstrated that PCH placement delays, if not

prevents admission to more expensive care options such as long-term care homes and acute care hospital beds.

19


References

1. Vaillant G. Aging Well: Surprising Guideposts to a happier Life from the Landmark Study of Adult Development 2008.2. Pantell M, Rehkoph D, Jutte D, Syme SL, Balmes J, Adler N. Social isolation: a predictor of mortality comparable to traditional clinical

risk factors 2013. Am J Public Health; Nov 103(11): 2056-623. Perissinoto C, Holt-Lunstad J, Periyakal VS. A practical approach to assessing and mitigating loneliness and isolations in older

adults. J Am Geriatr Soc 2019. Feb.

4. Holt‐Lunstad J, Robles TF, Sbarra DA. Advancing social connection as a public health priority in the United States. Am Psychol. 2017; 72:517‐530.

5. Russell D, Peplau LA, Cutrona CE. The revised UCLA loneliness scale: concurrent and discriminant validity evidence. J Pers Soc

Psychol 1980; 39:472‐480.6. Cacioppo JT, Hawkley LC. Perceived social isolation and cognition. Trends Cogn Sci. 2009; 13:447‐454.7. Cacioppo JT, Cacioppo S, Boomsma DI. Evolutionary mechanisms for loneliness. Cogn Emot. 2014; 28:3‐21.8. Cacioppo JT, Hawkley LC, Crawford LE, et al. Loneliness and health: potential mechanisms. Psychosom Med. 2002; 64:407‐417.9. Wilkins, K. Statistics Canada, Health Reports. Social support and mortality in seniors (Catalogue 82-003) 2003; 14 (3) May 2003: 21-3410. Holt-Lunstad, J, Smith TB, Layton, JB, Social relationships and mortality risk: A Meta-analytic Review. 2010; PLoS Med 7(7): e100031611. Hanson BS, Isacsson SO, Janzon L, et al. Social network and social support influence mortality in elderly men. The prospective

population study of “Men born in 1914” Malmo, Sweden. American Journal of Epidemiology 1989; 130(1): 100-11.12. Seeman TE. Social ties and health: the benefits of social integration. Annals of Epidemiology 1996; 6(5): 442-51.13. Dalgard OS, Lund Haheim L. Psychosocial risk factors and mortality: A prospective study with special focus on social support, social

participation, and locus of control in Norway. Journal of epidemiology and community Health 1998; 52(8): 476-81.14. Grand A, Grosclaude P, Bocquet H, et al. Disability, psychosocial factors and mortality among the elderly in a rural French population.

Journal of Clinical Epidemiology 1990; 43(8): 773-82.15. Glass TA. Population-based study of social and productive activities as predictors of survival among the elderly Americans. British

Medical Journal 1999; 319(7208): 478-83.16. Tu, YC, Wang, RH, Yeh, SH. Relationship between perceived empowerment care and quality of life among elderly residents within

nursing homes in Taiwan: A questionnaire survey. International Journal of Nursing Studies 2006; 43: 673– 680.17. Hage AM, Lorensen M. A philosophical analysis of the concept empowerment; the fundament of an education-programme to the

frail elderly. Nurs Philos 2005; (6) 235-246.18. Beard JR, Officer A, de Carvalho IA, Sadana R, Pot AM, et al. The world report on ageing and health: A policy framework for healthy

ageing. The Lancet 2015.

19. Moussavi S, Chatterji S, Verdes E, Tandon A, Patel V, Ustun B. Depression, chronic diseases, and decrements in health: results from the World Health Surveys. Lancet 2017; 370, 851–858.

20. Andersson NW, Goodwin RD, et al. Depression and the risk of severe infections: a prospective analysis on a nationwide representative

sample. Int J Epidemiol 2016; 45(1): 131-9.21. Stubbs B, Vancompfort N, Veronese N, et al. Depression and physical health multimorbidity: primary data from 190 595 people across

43 low- and middle-income countries. Psychological Medicine 2017; 2107-2117.22. House JS, Landis KR, Umberson D. Social relationships and health. Science 1988; 241: 540-54523. Harandi TF, Taghinasab MM, Nayeri TD. The correlation of social support with mental health: A meta-analysis. Electron Physician;

2017. Sep 25; (9):5212-5222.24. DiMatteo MR. Social support and patient adherence to medical treatment: a meta-analysis. Health Psychology 2004. 23: 207-18.25. How Canada Performs. The conference Board of Canada: The health report card 2015.

26. Murphy BM, Elliott PC, Le Gradne MR, Higgins RO, Ernest CS, et al. Living alone predicts 30-day hospital readmission after coronary

artery bypass graft surgery. Eur J Cardiovasc Prev Rehabil 2008; 15: 210-15.

20


27. Brummett BH, Barefoot JC, Siegler IC, Clapp-Channing NE, Lyte BL, et al. Characteristics of socially isolated patients with coronary

artery disease who are at elevated risk for mortality. Psychosom Med 2001; 63: 267-7228. Wang HX, Mittleman MA, Leineweber C, Orth-Gomer K. Depressive symptoms, social isolation, and progression of coronary

atherosclerosis: the Stockholm female coronary angiography study. Psychother Psychosom 2006; 75: 96-102.29. Avlund K, Lund R, Holstein BE. The impact of structural and functional characteristics of social relations as determinants of functional

decline. J Gerontol 2004; 59B: s44-s51.30. Miyawaki A, Tanaka H, Kobayashi Y, Kawachi I. Informal caregiving and mortality-who is protected and who is not?

A prospective cohort study from Japan. Soc Sci Med 2019; 223(2): 24-30.31. Kiely DK, Simon SE, Jones RN, Morris JN. The protective effect of social engagement on mortality in long-term care.

J Am Geriatr Soc 2000; 48:1367-72.32. Keller BK, Magnuson TM, Cernin PA, Stoner GA, Potter JF. The significance of social network in a geriatric assessment population.

Aging Clin Exp Res 2003; 15: 512-17.33. Lyyra T, Heikkinen R. Perceived social support and mortality in older people. J Gerontol 2006; 61B: S147-S152.34. Kauppi M , Kawachi I, Batty GD, et al. Characteristics of social networks and mortality risk: Evidence from 2 prosprective cohort

studies. Am J Epidemiol 2018; 187(4): 746-53.35. Stek ML, Vinkers DJ, Gussekkloo J, et al. Is depression in old age fatal only when people feel lonely? Am J Psychiatry 2005; 162(1);

178-8036. Rudolph JL, MD, SM, et al. Hospitalization in community-dwelling persons with alzheimer’s disease: frequency and causes.

J of the Amer Geriat Soc 2010; 58(8).37. Sloane PD, Schifeling CH, Beeber AS, et al. New or worsening symptoms and signs of community-dwelling persons with dementia:

incidence and relation to use of acute medical services. J Am Geriatric Soc 2017; 65(4): 808-14.38. Blazer, D. Social support and mortality in an elderly community population. American Journal of Epidemiology 1982; 115: 684-94.39. Ljungquist B, Berg S, Steen B. Prediction of survival in 70-year olds. Archives of Gerontology and Geriatrics 1995; 20(3): 295-307. 40. Salanitro AH, Hovater MS, et al. Symptom burden predicts hospitalization independent of comorbidity in community-dwelling older

adults. Journal of the American Geriatrics Society 2012; 60(9).41. Kim HJ, Min JY, Min KB. Successful aging and mortality risk: the Korean longitudinal study of aging. J AM Med Dir Assoc 2019; 13(2)42. Kandasemy D, Platts-Mills TF, Shah MN, et al. Social disconnection among older adults receiving care in the emergency department.

J Emerg Med 2018; 19(6): 919-25.43. Eloranta S, Routasalo P, Arve S. Personal resources supporting living at home as described by older home care clients. International

Journal of Nursing Practice 2008; 14: 308-14.44. Sheppard KD, Brown CJ, Hearld KR, et al. Symptom burden predicts nursing home admissions among older adults. J pain Symptom

Manage. 2013; 46(4): 591-7.45. Steadman PL, Tremont G, Duncan Davis J. Premorbid relationship satisfaction and caregiver burden in dementia caregivers. J Geriatr

Psychiatry Neurol 2007. 20(2): 115-119. 46. Stevens TB, Richmond NL, et al. Prevalence of nonmedical problems among older adults presenting to the emergency department.

Acad Emerg Med 2014; 21(6): 651-58.47. Kobayashi L, Steptoe A. Social isolation, loneliness, and health behaviors at older ages: longitudinal cohort study. Annals of Behavioral

Medicine 2018; 52(7): 582-593.48. Ellwardt L, Wittek R, Hawley L, Cacioppo J. Social network characteristics and their associations with stress in older adults: closure

and balance in a population-based sample. The Journals of Gerontology 2019.

49. Vaillant G. Aging Well: Surprising Guideposts to a happier Life from the Landmark Study of Adult Development 2008.50. Pantell M, Rehkoph D, Jutte D, Syme SL, Balmes J, Adler N. Social isolation: a predictor of mortality comparable to traditional clinical

risk factors 2013. Am J Public Health; Nov 103(11): 2056-6251. Wilkins, K. Statistics Canada, Health Reports. Social support and mortality in seniors (Catalogue 82-003) 2003; 14 (3) May 2003: 21-3452. Holt-Lunstad, J, Smith TB, Layton, JB, Social relationships and mortality risk: A Meta-analytic Review. 2010; PLoS Med 7(7): e100031653. Hanson BS, Isacsson SO, Janzon L, et al. Social network and social support influence mortality in elderly men. The prospective

population study of “Men born in 1914” Malmo, Sweden. American Journal of Epidemiology 1989; 130(1): 100-11.54. Seeman TE. Social ties and health: the benefits of social integration. Annals of Epidemiology 1996; 6(5): 442-51.55. Dalgard OS, Lund Haheim L. Psychosocial risk factors and mortality: A prospective study with special focus on social support, social

participation, and locus of control in Norway. Journal of epidemiology and community Health 1998; 52(8): 476-81.56. Grand A, Grosclaude P, Bocquet H, et al. Disability, psychosocial factors and mortality among the elderly in a rural French population.

Journal of Clinical Epidemiology 1990; 43(8): 773-82.

21


57. Glass TA. Population-based study of social and productive activities as predictors of survival among the elderly Americans. British

Medical Journal 1999; 319(7208): 478-83.58. House JS, Landis KR, Umberson D. Social relationships and health. Science 1988; 241: 540-54559. Harandi TF, Taghinasab MM, Nayeri TD. The correlation of social support with mental health: A meta-analysis. Electron Physician;

2017. Sep 25; (9):5212-5222.60. DiMatteo MR. Social support and patient adherence to medical treatment: a meta-analysis. Health Psychology 2004. 23: 207-18.61. How Canada Performs. The conference Board of Canada: The health report card 2015.

62. Murphy BM, Elliott PC, Le Gradne MR, Higgins RO, Ernest CS, et al. Living alone predicts 30-day hospital readmission after coronary

artery bypass graft surgery. Eur J Cardiovasc Prev Rehabil 2008; 15: 210-15.63. Brummett BH, Barefoot JC, Siegler IC, Clapp-Channing NE, Lyte BL, et al. Characteristics of socially isolated patients with coronary

artery disease who are at elevated risk for mortality. Psychosom Med 2001; 63: 267-7264. Wang HX, Mittleman MA, Leineweber C, Orth-Gomer K. Depressive symptoms, social isolation, and progression of coronary

atherosclerosis: the Stockholm female coronary angiography study. Psychother Psychosom 2006; 75: 96-102.65. Avlund K, Lund R, Holstein BE. The impact of structural and functional characteristics of social relations as determinants of functional

decline. J Gerontol 2004; 59B: s44-s51.66. Miyawaki A, Tanaka H, Kobayashi Y, Kawachi I. Informal caregiving and mortality-who is protected and who is not?

A prospective cohort study from Japan. Soc Sci Med 2019; 223(2): 24-30.67. Kiely DK, Simon SE, Jones RN, Morris JN. The protective effect of social engagement on mortality in long-term care.

J Am Geriatr Soc 2000; 48:1367-72.68. Keller BK, Magnuson TM, Cernin PA, Stoner GA, Potter JF. The significance of social network in a geriatric assessment population.

Aging Clin Exp Res 2003; 15: 512-17.69. Lyyra T, Heikkinen R. Perceived social support and mortality in older people. J Gerontol 2006; 61B: S147-S152.70. Kauppi M , Kawachi I, Batty GD, et al. Characteristics of social networks and mortality risk: Evidence from 2 prosprective cohort

studies. Am J Epidemiol 2018; 187(4): 746-53.71. Stek ML, Vinkers DJ, Gussekkloo J, et al. Is depression in old age fatal only when people feel lonely? Am J Psychiatry 2005; 162(1);

178-8072. Rudolph JL, MD, SM, et al. Hospitalization in community-dwelling persons with alzheimer’s disease: frequency and causes.

J of the Amer Geriat Soc 2010; 58(8).73. Sloane PD, Schifeling CH, Beeber AS, et al. New or worsening symptoms and signs of community-dwelling persons with dementia:

incidence and relation to use of acute medical services. J Am Geriatric Soc 2017; 65(4): 808-14.74. Blazer, D. Social support and mortality in an elderly community population. American Journal of Epidemiology 1982; 115: 684-94.75. Ljungquist B, Berg S, Steen B. Prediction of survival in 70 year olds. Archives of Gerontology and Geriatrics 1995; 20(3): 295-307. 76. Salanitro AH, Hovater MS, et al. Symptom burden predicts hospitalization independent of comorbidity in community-dwelling older

adults. Journal of the American Geriatrics Society 2012; 60(9).77. Kim HJ, Min JY, Min KB. Successful aging and mortality risk: the Korean longitudinal study of aging. J AM Med Dir Assoc 2019; 13(2)78. Kandasemy D, Platts-Mills TF, Shah MN, et al. Social disconnection among older adults receiving care in the emergency department.

J Emerg Med 2018; 19(6): 919-25.79. Eloranta S, Routasalo P, Arve S. Personal resources supporting living at home as described by older home care clients. International

Journal of Nursing Practice 2008; 14: 308-14.80. Sheppard KD, Brown CJ, Hearld KR, et al. Symptom burden predicts nursing home admissions among older adults. J pain Symptom

Manage. 2013; 46(4): 591-7.81. Steadman PL, Tremont G, Duncan Davis J. Premorbid relationship satisfaction and caregiver burden in dementia caregivers. J Geriatr

Psychiatry Neurol 2007. 20(2): 115-119. 82. Stevens TB, Richmond NL, et al. Prevalence of nonmedical problems among older adults presenting to the emergency department.

Acad Emerg Med 2014; 21(6): 651-58.83. Kobayashi L, Steptoe A. Social isolation, loneliness, and health behaviors at older ages: longitudinal cohort study. Annals of Behavioral

Medicine 2018; 52(7): 582-593.

22

[email protected]

facebook.com/qualitylivingallianceforseniors

qualitylivingallianceforseniors.ca

$0#1)2345 - Quality Living Alliance for Seniors...health care needs. Loneliness, anxiety, fears,...

Documents

Transcript of $0#1)2345 - Quality Living Alliance for Seniors...health care needs. Loneliness, anxiety, fears,...