Isobel Mackenzie has worked with seniors for the past 20 years and now, as British Columbia’s seniors advocate, she is calling for better home-care services for seniors. Credit: Adrian Lam
Isobel Mackenzie has worked with and for seniors for more than 20 years. She’s spent time in long-term care, home care and community services, but it’s the time she’s spent in living rooms, discussing care plans with families, that has most shaped her vision on how best to serve the oldest among us.
“I can remember one couple as if it were yesterday, and the degree to which they were just stumbling through,” she says. “I was fussing and fretting over things I didn’t think they were doing right, but it didn’t matter. They were happy and getting the big things right, so who cares if every once in a while they forgot to pay a bill? In the grand scheme of things, bills eventually got paid.”
For others, whether it was the ability to get a glass of water in the kitchen, or opening the curtains in their home each morning, their pride and dignity were very much wrapped up in doing those things for themselves. While some young and able-bodied might look at that and say “shoot me” if that ever becomes my life, Mackenzie says people will be surprised by what becomes meaningful as they age.
“Who are we to say what kind of quality of life that is? It’s up to the person experiencing it. We’ve got to respect that, as ultimately what everyone fears is a loss of autonomy.”
Mackenzie is British Columbia’s seniors advocate — the first to hold the position that was created in 2014, the first of its kind in Canada. Seeing the degree of frailty through which a person can still have a meaningful life at home, versus having to go into a care home, has formed the basis of her thinking.
“We all think we can be objective, but that objectivity is within a lens we view things through,” Mackenzie says. “For me nothing better illustrates that than how different people in the health-care system view the ability of a person to live independently. It’s viewed through a lens of risk and risk-tolerance. All of us have a different point on that risk scale that we’re comfortable with for ourselves, and we project that onto others.”
Adult children do the same — they’re often terrified of risk, so when their parent has a fall, they move them into long-term care to keep them safe.
But given what has unfolded in care homes during the COVID-19 pandemic, Mackenzie anticipates there will be a shift away from them and a push to better allow people to age in place. She is tracking this in B.C. and expects to see a pattern by this time next year.
Mackenzie is passionate about making sure those who want to remain in their own home have every possible support. Robust clinical indicators and assessments show that people can live successfully at home with the same degree of frailty as someone in a long-term care home.
Currently, every Canadian in every province has the ability to be in a publicly funded nursing home.
At the highest degree of frailty, it does depend on personal resources, which is the public policy that needs to evolve. Currently, every Canadian in every province has the ability to be in a publicly funded nursing home. The cost is shared with the government by way of subsidy. She says we should be prepared to provide that same level of support to keep people at home, but “no province really does that successfully in a systemic way.”
If Mackenzie had her way, a senior anywhere in Canada could make a phone call, explain their situation, and instead of being handed a list of referrals to try and navigate themselves, they’d get a case manager — a single point of contact — to arrange everything they need, from care workers to grab bars, to facilitate aging in place. Their share of the cost would be based on what they’re able to pay.
After months of news stories about deaths in long-term care and seniors struggling to meet their needs while isolated at home, 2020 may finally mark a turning point.
“I think it’s a wake-up call to the vast majority of Canadians who have no personal connection to long-term care, but have an impression that in Canada we take care of our elderly, that there are these nice nursing homes people can go to if they need assistance,” Mackenzie says.
“If we look at the fault lines that have been revealed by COVID, there’s been a realization that life in long-term care may not be quite what people think it is.”
Ditto for seniors living in the community on very low incomes, who made ends meet by using the internet at the library and going to a seniors’ centre for a free lunch.
“When all those things were stopped for a long period of time, they were left struggling. COVID didn’t create these issues, but it has revealed and exacerbated some of them.”
Instead of asking hard questions and looking at evidence about the reality of seniors’ care, Canadians have allowed themselves to be reassured by glossy brochures. While there have been calls for a national seniors’ strategy in recent years, Mackenzie says vision statements alone won’t foster change. What’s needed are concrete and measurable national standards, with accountability in place to meet and maintain them.
She was encouraged to see the federal government’s throne speech commitment to work with the provinces and territories to create national standards for long-term care and take action to help people stay in their homes longer. While it’s fine to say everyone is entitled to live with dignity and have access to care, what does that actually mean? Whether it’s hours of care provided to residents in a care home or what basket of integral services people in the community are entitled to, to help them live at home, Mackenzie says spelling things out in standards is key. British Columbia started collecting and measuring data on care hours and had a standard to measure it against. Without that, she says there would be far less staffing in the province’s care homes than there is now.
She says the lack of standards is why members of the Canadian Armed Forces were shocked by what they saw in the care homes they were sent in to support.
“They just couldn’t believe it because of where they come from and the standardized nature of their training.”
The standardization can start with titles. Although a nurse is a nurse in every province, a care aid in B.C. is called a personal support worker in Ontario. “In practical terms, we have to pay these people more and we need to respect it as a profession. That will be the catalyst for raising the standards because people will view it as a job that they can stay in for life because it produces a reasonable annual income.”
In addition to more money, Mackenzie is a proponent of introducing credentialing at the provincial level by way of a national exam, which would bring uniformity to training and could incorporate training standards around personal protective equipment and infection control.
“We won’t be able to change it overnight. It will probably take four or five years...but I think all the elements are there to start,” she says.
“Each province already has a regulatory college for its nurses. The federal government could give direction here and require each province to have a care aid registry.”
As part of further targeted measures for personal support workers and acknowledgement of their essential service in caring for vulnerable seniors, the throne speech mentioned a federal wage top-up for them.
There was also a vague commitment to increasing old age security once a senior turns 75, and boosting the Canada Pension Plan survivor’s benefit.
Mackenzie says a third of Canadian seniors are on the guaranteed income supplement, which is not an insignificant number of people.
“They’re toddling along on the brink,” she says. “They can hold it together with duct tape as long as nothing happens, but they’re one major bill away from disaster.”
Even with a boost in payments, some people will continue to get left behind, depending on their health status. While income is one side of the ledger, the other side is filled with expenses for everything from hearing aids and wheelchairs to dental care and incontinence products. Those aren’t things people have a choice over, and their significant costs could effectively push someone into poverty. Right now, there’s no system that pays for them.
Mackenzie says the lack of standards is why members of the Canadian Armed Forces, shown here at a Montreal long-term care home, were shocked by what they saw in the care homes they were sent in to support. Photo: Cpl. Genevieve Beaulieu
“A lot of these decisions are made by people who see only the numbers on paper. They’re not actually touched by anyone who is struggling financially as a senior,” Mackenzie says. “Providing more income to everybody isn’t going to address the inequity that exists. That is going to require us to look at what are the things we provide to people free of charge or income-tested, which is probably the more sustainable way of doing it.”
It’s not new ground. Recognizing medication needs would increase as people aged, every province collectively decided some time ago to offer drug coverage for people over 65.
“But there’s a whole other basket of things we need to think about,” Mackenzie says. “Again, the role the federal government can play is around the standards and setting expectations around what they are going to extract in exchange for the money they give. No one likes to have the strings attached...but (a lack of them) is what’s leading us to this patchwork across the country.”
The body ages the same whether it’s in Corner Brook or Cranbrook, so the care, services and funding available to people should reflect that.
Mackenzie acknowledges these are tough policy decisions.
“But at the end of the day, Canadians have to look in the mirror and ask the question: To what extent am I going to financially support the last three years of a person’s life? What am I prepared to provide and to what degree is it universal?”
In search of a national seniors advocate
British Columbia’s seniors advocate, Isobel Mackenzie, is a bit of a rare breed in Canada. Since 2017, she has had a counterpart in Newfoundland and Labrador, Suzanne Brake, and in New Brunswick, Norman Bossé serves as an advocate for children, youth and seniors. There’s a push to create similar offices in Ontario and Manitoba, but with Alberta’s decision last year to phase out the role, for now, they are a party of three.
Mackenzie says a network of provincial seniors advocates could drive the effective collaboration that child and youth advocates have achieved. Ideally, there would also be a national seniors advocate in the mix, who is not a minister reporting to the federal cabinet.
While her office does not have the statutory authority to tell health authorities or ministers what to do, its power is its ability to compel service providers and governments to share information and to speak directly to the public.
“I believe they need to know. The change is going to be driven by the public at the end of the day, so just give them the information.”
Currently, reams of data are collected from Canada’s home and long-term care populations, but there is no cohesiveness in analyzing it to better drive decisions.
“If you had a council of provincial seniors advocates, that’s a piece of work that could be done,” Mackenzie says. “And certainly if you had a national seniors advocate, you could start to look at these things from a national level. I think that would be very valuable.”