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Access to the comprehensive spectrum of medically necessary care

https://policybase.cma.ca/en/permalink/policy8508

Last Reviewed
2020-02-29
Date
2006-08-23
Topics
Health human resources
Health systems, system funding and performance
Resolution
GC06-34
The Canadian Medical Association and its divisions and affiliates call on the Federal/Provincial/Territorial Conference of Health Ministers to ensure that all Canadians have timely access to the comprehensive spectrum of medically necessary care by developing, through an open and consultative process, a policy framework that includes: a) a national human resources plan; b) national wait time benchmarks; c) a patient wait time guarantee supported by a publicly funded safety valve; and d) a regulatory regime to best support the public-private interface.
Policy Type
Policy resolution
Last Reviewed
2020-02-29
Date
2006-08-23
Topics
Health human resources
Health systems, system funding and performance
Resolution
GC06-34
The Canadian Medical Association and its divisions and affiliates call on the Federal/Provincial/Territorial Conference of Health Ministers to ensure that all Canadians have timely access to the comprehensive spectrum of medically necessary care by developing, through an open and consultative process, a policy framework that includes: a) a national human resources plan; b) national wait time benchmarks; c) a patient wait time guarantee supported by a publicly funded safety valve; and d) a regulatory regime to best support the public-private interface.
Text
The Canadian Medical Association and its divisions and affiliates call on the Federal/Provincial/Territorial Conference of Health Ministers to ensure that all Canadians have timely access to the comprehensive spectrum of medically necessary care by developing, through an open and consultative process, a policy framework that includes: a) a national human resources plan; b) national wait time benchmarks; c) a patient wait time guarantee supported by a publicly funded safety valve; and d) a regulatory regime to best support the public-private interface.
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Building bridges: the link between health policy and economic policy in Canada : A Document prepared by the Canadian Medical Association (CMA)

https://policybase.cma.ca/en/permalink/policy1990

Last Reviewed
2019-03-03
Date
1996-01-30
Topics
Health systems, system funding and performance
  1 document  
Policy Type
Parliamentary submission
Last Reviewed
2019-03-03
Date
1996-01-30
Topics
Health systems, system funding and performance
Text
I. PURPOSE The objective of this document is twofold: (1) to provide the federal government with a better understanding of the current issues that are of concern to physicians across Canada and are material to the preparation of the 1996-97 federal budget; and (2) to propose some solutions. As part of the government's pre-budget consultation process, the CMA has formally presented a brief to the House of Commons Standing Committee on Finance on November 23, 1995. II. POLICY CONTEXT Canada faces a number of important policy challenges as it moves toward the 21st century. First and foremost is the fiscal challenge to reduce Canada's debt and deficit levels while, at the same time, fostering an environment which provides for future economic growth within a globally-integrated marketplace. As of March 31, 1995 total public debt (federal/provincial/territorial levels of government) was $787.7 billion; the interest paid on the total debt for 1994 was $64.3 billion, and the 1994 total public deficit was $40.8 billion. At a minimum, government is faced with the challenge of addressing short- and long-term economic policy objectives while meeting defined social policy imperatives. In a time of continued fiscal restraint and scarce public sector economic resources, difficult choices will continue to be made. CMA acknowledges that there is an urgent need, now more than ever, for the federal government to balance a number of competing policy challenges. At a time when profound deficit reduction measures are required, all segments of society are being asked to do more with the same or less. Having already dealt with this reality for quite some time, the health care sector is no stranger to this burden. In making policy choices, careful and deliberate thought needs to be given to the repercussions such decisions will have on the Canada of tomorrow and the health and well-being of Canadians. Attacking Canada's federal debt/deficit for short-term economic gain must be balanced against any decision(s) that would serve to increase our longer-term "social" deficit. At a time when Canada is undergoing significant social, political and economic changes, CMA remains dedicated to the delivery of high quality health care and to safeguarding the national integrity of the system. However, given the need for the federal government to gain control over the deficit and national debt, it seems clear that putting Canada's fiscal house in order remains a high priority. That being said, the government must also be clear with Canadians on its intentions and priorities with respect to a long-term commitment to health and social programs, including a cash commitment. Canadians are deeply concerned that reducing the federal deficit will result in the shifting of costs to other levels of government which they cannot absorb. This may very well lead to reduced access to government programs and services, and at some point in the future, higher social costs. This is highlighted in a recent poll where 58% of Canadians reported that they expect the health care system will be worse in the next ten years. 1 It would appear that Canadians believe that the fiscal agenda will overwhelm the social agenda to the extent that the social values and ideals that sustain them will be forgotten or worse, be lost. Surveys indicate that 84% of Canadians view Medicare as a defining characteristic of being Canadian. Furthermore, 84% of Canadians feel that the system provides high quality care. However, 65% of Canadians are concerned about continued accessibility to a full range of publicly-financed benefits. According to the same poll, 83% of Canadians see current financing of the system as being "unsustainable" over the longer-term. 2 While Canadians are expressing strong concerns over the future viability of what we currently have in the area of health care, physicians are also voicing similar worries. In a recent poll, 76% of physicians surveyed agreed with the statement that Canada's health care will be worse in 10 years. 3 III. MANAGING CHANGE AND MEETING POLICY OBJECTIVES Recognizing that change is one constant that will characterize Canadian society for the foreseeable future, any further policy changes affecting the health care system must also be considered in the context of Canadian values and economic policy. Good health policy and good economic policy must reinforce one another. CMA is concerned that any short-term economic decisions on the part of the government which do not reinforce good health policy may be detrimental to the best interests of Canada. If change is to come within an overall policy framework that is strategic, coordinated and fair and preserves (or augments) the integrity of Canada's health care system, we must be careful to avoid short-term, stop-gap initiatives. As the Government's 1994 Throne Speech stated "...the agenda of the government is based on an integrated approach to economic, social, environmental and foreign policy". Accordingly, in establishing an appropriate fiscal framework for health and health care, change must take place within the context of a longer-term integrated view. The principle of aligning good health policy with sound economic policy is critical to managing change while serving to lay down a strong foundation for future economic growth and prosperity in Canada. Moreover, by better synchronizing health and economic policy as a national priority, opportunities can be created to meet a number of important "higher order" policy objectives. They are: (i) Canada building; (ii) economic development; (iii) well being of Canadians and the future of health and health care in Canada, and (iv) putting Canada's financial house in order. Each is discussed in turn. i. Canada Building In many ways, Canada is at a social, political and economic crossroads. The challenge to this government is to balance short-term fiscal pressures against the longer-term need to re-position Canada to take advantage of greater economic opportunities while preserving that which is of fundamental importance to Canadian society as a whole. In this context, of the range of social programs that the federal government supports, Medicare is strongly viewed as a defining characteristic of being Canadian. Medicare is a high priority for Canadians. Some have argued that the declining federal cash commitment to funding Medicare serves to further fragment our health care system and speeds the process of government decentralization. What better opportunity for the federal government to clarify its funding support and relationship to health care in this country? In making a clear, significant and stable financial commitment in support of health care, the government will serve notice that it is prepared to play a leadership role in ensuring that Canadians will have a sustainable, high quality "national" health care system, a value they hold deeply as Canadians. ii. Economic Development From an international perspective, Canada's Medicare system has been acknowledged as one of our greatest assets. Agencies such as the World Economic Forum tell us that Canada's method of financing health care is one of our comparative economic advantages in an evolving new world economic order. Compared to the United States, this takes the form of lower public and private expenditures on health care while maintaining the same or better health status. In terms of our European trading partners, the fact that health insurance programs are financed primarily through consolidated revenues (rather than employment-based taxes), also confers a unit cost advantage to Canadian exporters. In this sense, good health policy and good economic policy reinforce each other and the bridge between the two should be strengthened. By producing "healthier" individuals at lower cost, this relative cost advantage can translate into economic benefits that all Canadian can share in terms of expanded employment opportunities, wealth creation and economic growth. As a 1995 report form the Conference Board of Canada stated "[Canadian business is] unequivocal in terms of the high value they place on the Canadian health care system. Their support rests on their faith that the system has the capacity to deliver high-quality care while keeping public costs under control. They are also aware that Canada's health insurance system seems to provide employers with a competitive advantage over companies in the United States". 4 While the CMA is in support of a publicly-financed health system, there are serious concerns that the series of recent reforms have not been carried out in a reasonable and rational manner. Prior to implementing any further reforms, there is a pressing need to evaluate the effects of these changes. Cutting alone should not continue to be considered a catalyst for change; as an investment in the future of Canada health care is far too valuable. If health policy and economic policy are to be better synchronized, governments must not only consider the level of current public sector resources that are allocated to the health care system, but they must also re-examine the current roles of the public and private sectors. iii. Well-Being of Canadians and the Future of Health and Health Care in Canada For over twenty-five years, the Medicare system has provided all Canadians with the assurance that "it will always be there when you need it", without fear of an individual or family being forced into bankruptcy due to their health care needs. However, the security that Canadians have enjoyed in knowing that their health care system was always there when they needed it is being challenged daily. For example, Canadians are experiencing difficulties in access because of hospital closures, lengthening waiting lists and the departure of physicians from their communities. As well, physicians and patients are increasingly experiencing difficulties in accessing new medical technologies. Canadians are becoming more and more concerned that the universal Medicare system which they have known and supported through their tax dollars may not be available when they need it the most. In stepping forward and playing a leadership role, the federal government can serve to reassure Canadians that preserving the fundamentals of our health care system remains a high priority by making a significant and predictable financial cash contribution. iv. Putting Canada's Financial House in Order CMA recognizes that the federal government must attend to its own fiscal house and is meeting its fiscal targets. CMA believes that we must not pass this massive debt burden - one in which 36 cents of every federal tax dollars goes to debt servicing - onto future generations. This is not, however, to suggest that a "slash and burn" strategy should be adopted: but rather we should seek a measured approach that gains control over spending while fostering an environment of economic growth. This would bring with it increased employment opportunities and expanding societal wealth. Such an approach should be measured, deliberate and responsible. Deficit reduction should not be fought disproportionately on the back of health care, which, if viewed in its proper context, should be considered as an investment good not a consumption good. Health care is an asset to all Canadians, not a liability. IV. CONCLUSION The CMA has attempted to set out a framework that serves as a basis for defining policy objectives to which the government should give serious consideration. These "four pillars" are: (1) Canada building; (2) economic development; (3) well-being of Canadians and the future of health and health care in Canada; and (4) putting Canada's fiscal house in order. In seeking to build stronger bridges between these policy objectives is the unshakeable principle that good health and good economic policy should go hand-in-hand, reinforcing rather than neutralizing one another. The CMA's four pillars are consistent with government policy objectives as set out in the Red Book, and its 1994 throne speech. Using the four pillars as a guide, the key issues that are of immediate concern to the medical profession in a pre-budget consultation context are as follows: * the Canadian Health and Social Transfer (CHST); * Registered Retirement Savings Plan (RRSP); * the Goods and Services Tax (GST); * Non-Taxable Supplementary Health Benefits (NTSHB); * the National Health Research Program (NHRP); and, * Tobacco Taxation. The CMA is prepared to work with the government and others in a collaborative effort, within the above framework to meet sound social, health, economic and fiscal policy objectives. CANADIAN HEALTH AND SOCIAL TRANSFER (CHST) ISSUE The Canadian Medical Association (CMA) is concerned that the decreasing federal cash commitment to health care will eventually result in no federal cash flowing to some provinces in the future. This will seriously undermine the federal government's ability to set and maintain goals and standards in the health care system across the country. CONTEXT * The CMA recognizes that federal finances must be brought under better control. However, 60% of Canadians feel that social programs require federal protection while expenditures are being reduced. 5 Reforms to social programs must be phased in over a defined planning horizon. * Beginning in 1996-97, the Canadian Health and Social Transfer (CHST), a combination of the Established Programs Financing and the Canadian Assistance Plan, will result in a reduction of cash transfers to the provinces and territories of $7 billion. PHYSICIAN PERSPECTIVE * Access to Quality Health Care: Our First Priority Canadian physicians want to maintain and enhance the delivery of high quality health care services. Canadians are experiencing difficulties in access due to hospital closures, lengthening waiting lists and communities losing physicians. Furthermore, physicians and their patients are increasingly experiencing difficulty in accessing new health technologies. Canadians are becoming concerned that the universal Medicare system which they have supported through their tax dollars may not be available when they need it the most. * The CHST Threatens The Principles Of National Health Insurance Continued reductions in the CHST will make it increasingly difficult for the federal government to maintain national standards in health care. Earmarked funding for health care will enable the federal government to ensure the principles encompassed under the Canada Health Act are protected. * A Strong Federal Role Must Be Maintained The Medicare system provides all Canadians with the assurances that "it will be there when you need it"; and "you and your family won't be forced into financial ruin". Surveys indicate that 84% of Canadians see Medicare as a defining characteristic of being Canadian. Furthermore, 84% of Canadians feel that the system provides high quality care. Canadians want governments to spend more energy on the protection of Medicare and other social programs. 6 From an international perspective, Canada's Medicare system has been acknowledged as one of our greatest assets. Compared to the U.S. this takes the form of lower public and private expenditures on health care while maintaining the same or better health status. CMA RECOMMENDS... * Stable, predictable and ear-marked cash transfers with a formula for growth is required to enable all provinces and territories to plan and deliver a defined set of comparable high quality health care services to all Canadians. * A $250 per capita cash transfer for health care for the next 5 years should be established and guaranteed within the CHST framework. After the 5 year period, the federal government must preserve the real value of the cash transfer by means of an appropriate escalator. RATIONALE * Considering all options, a per capita transfer is the fairest, most equitable method of allocating cash for the health care system. It will also operationalize the CHST in such a way so as to reassure Canadians that the federal dollars will continue to be available to sustain the health system. * The Medicare system is a unifying value and defining characteristic that is recognized as a valuable resource by business and provides Canadians with an important sense of well-being. * The above recommendations would assist in ensuring a strong federal role in setting and maintaining national health care standards as promised in the Red Book. Acting on these recommendations will demonstrate to Canadians that the federal government has listened to their concerns about the CHST and the future of the health care system. A federal cash contribution to health care in Canada is important for economic reasons. * Business is growing increasingly concerned that the competitive advantage provided by the Canadian health care system is eroding. Furthermore, the universal nature of the coverage provided by our health system means it cannot be viewed as a subsidy under current trade agreements (e.g., NAFTA). REGISTERED RETIREMENT SAVINGS PLANS (RRSP) ISSUE The Canadian Medical Association (CMA) is concerned about the ability of Canadians to accrue retirement savings that will enable them to retire in dignity. CONTEXT * The numbers of those over the age of 65 continue to expand, in 1994 11.9% of the population was over the age of 65, in 2016 this will increase to 16% and by 2041 increase to 23%. The numbers of those under 18 are shrinking, in 1994 they represented 25% of the population and by 2016 they will represent 20%. 7 These demographic trends are of concern to governments and taxpayers. Employment trends indicate that an increasing number of Canadians are self-employed. In 1994, self-employment accounted for an increasingly large share of total employment growth, 25% of the overall employment gain. In 1993, 35% of the total labour force were in employment situations that provide registered pension plans (RPPs). 8 * It appears that Canadians are becoming increasingly more self-reliant when it comes to providing for their retirement years. We understand the government's concerns with respect to the retirement income system, the CMA eagerly anticipates the release of the government's intentions in relation to seniors and pension reform. PHYSICIAN PERSPECTIVE * Ensuring Dignity in Retirement Canadian physicians treat retired patients on a daily basis and are aware of the challenges many of them face. In this context, Canadian physicians are concerned that all Canadians should have the opportunity to achieve a state of financial well-being to provide for themselves in their retirement years. Recognizing Canada's demographic trends and its current fiscal challenges, governments must ensure that suitable financial incentives are in place to encourage a greater reliance on private savings vehicles. * Equal Opportunities to Accumulate Retirement Savings The vast majority of Canadian physicians are self-employed professionals and therefore are not members of an employer/employee sponsored RPP. They, like many other individuals must plan for and fund their own retirement. The principle of equity demands that the self-employed and those employed but reliant on registered retirement savings plans (RRSPs) be afforded the same opportunities and incentives to plan for their retirement as those in employment situations that provide RPPs (i.e., pension equity). * Fair Treatment Of Retirement Savings For those individuals that may suffer the misfortune of declaring bankruptcy, creditors may seize the annuitant's RRSP assets. This is patently unfair. If an employed individual declares personal bankruptcy their RPP is currently protected from creditors, however, they too run the risk of loosing their RRSP to their creditors. CMA RECOMMENDS... * The federal government should strive for equity between RRSPs and RPPs. * The federal government should refrain from making changes to the retirement income system pending a review of the system. * The federal government should consider legislation that would deem RRSP assets credit proof. * The federal government should consider gradually raising the foreign investment limits applicable to RRSPs and/or RPPs. At the end of a defined period of gradual increases, the federal government should consider removing the foreign investment limit completely. RATIONALE * All Canadians should have an equal ability to accumulate retirement savings regardless of their employment status. Assuming the current demographic and employment trends persist, it is important to recognize the role that RRSPs will play in assisting Canadians to live healthy and dignified lives well past their retirement from the labour force. * In keeping with the principles of fairness and equity, retirement income plans should be treated equally under federal legislation (e.g., Tax Act , Bankruptcy Act). Sound investment decisions and strategies are required that will enable Canadians to accumulate retirement savings and achieve financial security in their retirement. * Given the complexity of the retirement income system, changes to RRSPs and or RPPs should only be considered in the context of a thorough review of the pension system and include a thoughtful, open and meaningful consultation process. * For the past ten years the government has supported the laudable objective of attaining equity between RRSPs and RPPs. * Experts have assured Canadians that: "The two fundamental goals (of retirement savings) are: (1) to guarantee a basic level of retirement income for all Canadians, and (2) to assist Canadians to avoid serious disruption of their pre-retirement living standards upon retirement". * As governments' continue to reduce publicly funded benefits and encourage greater self-reliance, there is a need to ensure that Canadians have the ability to invest and save private dollars for their retirement years. * RRSPs and RPPs are legitimate tax deferral mechanisms and should not be viewed as tax avoidance. Income set aside for retirement should be taxed when it is received as a pension. The tax system should encourage and assist Canadians to arrange for their financial security in retirement. GOODS AND SERVICES TAX (GST) ISSUE The CMA has strong concerns regarding the effect of treating most medical services as GST exempt. Unlike other self-employed professionals, physicians are disadvantaged by the fact that they are not able to claim refunds or collect Input Tax Credits (ITCs) for GST paid. Given that medical services are designated as tax exempt, physicians are forced to absorb the additional tax payable as a result of the GST. Moreover, if the government is to proceed with harmonization, this situation will be compounded. CONTEXT * The GST was designed as a tax on "consumers" and not businesses who provide goods and services. Approximately 95% of physicians' services are paid for by the provinces. Provinces do not pay GST based on their constitutional exemption and by agreement with the federal government. In making medical services exempt, GST is payable by the provider of the service and not recoverable as an input tax credit. Therefore physicians are in the position of paying non-recoverable GST on their inputs. Attempts to recover the GST from provincial governments through increased fees have not been possible since the provinces refuse to reimburse for increased costs due to GST since they are constitutionally exempt from GST. * Unlike other professional medical groups such as dentist, physicians do not have the ability to pass increased GST costs along in the form of higher fees. Unlike other institutional health care providers such as hospitals, physicians do not recover these extra GST costs through a rebate mechanism. Therefore, given that most medical services are exempt, physicians are forced to absorb the additional tax payable as a result of the GST. * Because most medical services are treated as exempt, an independent study estimated that self-employed physicians have been forced to absorb an additional $57.2 million of incremental sales tax (net of the Federal Sales Tax) on an annual basis. The study was submitted to the Department of Finance. By the end of 1995, it is estimated that the profession will have absorbed in excess of $286 million because of the current situation. * In the government's Red Book it states: "A Liberal government will replace the GST with a system that generates equivalent revenues, is fairer to consumers and small businesses, minimizes disruptions to small business, and promotes federal-provincial cooperation and harmonization". As self-employed professionals delivering quality health care services to Canadians, physicians face the same financial realities as do other small businesses. As such, the status of medical services as tax exempt is patently unfair to these small businesses. PHYSICIAN PERSPECTIVE * Access To Quality Health Care While hospitals have been afforded an 83% rebate, self-employed physicians must absorb the full GST load on equipment and other purchases. As a result of this differential tax arrangement, a number of physicians are leaving their community-based practices and moving back into institutions. Therefore, the GST is having an adverse effect on movement towards community-based care, and is impeding patient access to physicians who re-locate from the community to institutions. In this regard, good health policy is not reinforced by good economic policy. * Good Health Policy Should Reinforce Good Economic Policy Most of Canada's premiere medical researchers are employed by hospitals. As part of their research, physicians purchase goods and services that are inputs to their investigative activities. Given that physicians work within a facility, hospitals are eligible to claim the 83% on GST paid on input costs. However, some researchers have grown increasingly concerned that the GST that is recoverable by the hospitals is not returned for medical research and serves to "subsidize" other day-to-day activities. In essence, monies that have been earmarked for specific medical research are being allocated to other areas. Increasingly, physicians are organizing themselves within group practices. While this is, in part, a response to providing greater continuity of care to patients, it is also a reaction to the series of economic decisions that have been taken in the area of health care. Currently, it is estimated that the GST "costs" the average physician $1,500 - $2,000 per year. If physicians were able to claim ITCs, this could give them the added flexibility to employ other individuals in the provision of health care. While the direct effects of the GST are significant and measurable, the indirect effects are even more significant though less measurable. It is estimated that the 55,000 physicians employ up to 100,000 Canadians. Given the disproportionate effects of the GST on the medical profession as employers, the employment dampening effects could be significant. * Fairness For many years, the CMA has supported tax reform - provided such reform improves the overall equity and efficiency of Canada's tax system. In June 1987, for example, CMA wrote to the then-Minister of Finance stating "...we at the CMA strongly support the goals of tax reform and efforts to simplify the tax system while at the same time making it more equitable". We have subsequently reiterated our support for the broad objectives of tax reform on several occasions: it remains as strong today as ever. In the area of health care, self-employed physicians (as well as others) have not been accorded the same treatment under the GST as other health groups. For example, hospitals currently receive a rebate of 83% of GST paid on the assumption that the rebate level leaves them no worse off than under the previous tax regime (i.e., whole). As well, prescription drugs are zero-rated, with the same rationale: to ensure that they are whole. Recognizing that drug regimens can play an equally important role as some physician interventions, why would the government choose to distinguish between the two and zero-rate drugs and exempt medical services. CMA RECOMMENDS... * The CMA believes that there are three ways of proceeding to address physician concerns: (1) similar to the formula for Municipalities, Universities, Schools and Hospitals (MUSH), physicians would be accorded a rebate that would leave them no worse off under the GST; an independent study suggests that 69% would leave physicians whole; or (2) to zero-rate all medical services; or (3) to zero-rate those medical services that are funded by the government. RATIONALE The three options above serve to improve overall fairness and simplify the tax system. The CMA has submitted a proposal to the Department of Finance for consideration which recommends that health care services (including medical services) funded by the provinces be zero-rated. * The proposal to zero-rate health care services funded by the provinces means: - services provided by hospitals, charities and other provincially funded organizations would be zero-rated. - the system would treat all persons in the industry in the same manner and would thus be fairer and simpler to administer. - tax cascading would be eliminated. - in the context of the regionalization of health care in Canada difficult interpretive issues (such as what constitutes a hospital or facility) would be removed. - not all government services would become zero-rated but only those for which the provincial governments fund. The remainder would continue to be exempt and thus the government would derive revenues from the tax on inputs used in providing those services. - Some complexities would remain owing to the fact that some health care services would be zero-rated and some would continue to be exempt. Therefore, any person making a mixture of zero-rated and exempt supplies would still be required to allocate inputs between commercial and non-commercial activities. * Such a proposal would put all publicly-funded health care services on the same tax footing. * The proposal does not focus on self-employed physicians only, but has been developed in the broader context of those services that are publicly-funded. * The proposal attempts to be achieve a greater degree of flexibility in the face of regionalization of health care services in Canada. * It would reinforce the principles of fairness and simplicity in the tax system. * To summarize, the CMA has reiterated its position on several occasions. Some of the major recommendations are: (1) Canadian physicians should not pay more than other professions or occupations under the GST or its replacement; (2) all taxes on business expenses be fairly and fully removed under any replacement tax for the GST; (3) that the government assign a high priority to integrating provincial and federal sales taxes in a fair and equitable way; (4) that the federal government take a leadership role in ensuring that any integrated system not perpetuate existing tax inequities facing Canadian physicians; and (5) any provisions of a replacement tax should reinforce good health and economic policy. NON-TAXABLE SUPPLEMENTARY HEALTH BENEFITS (NTSHB) ISSUE The Canadian Medical Association (CMA) is concerned that Canadians' access to health care services will be threatened if the tax status of supplementary health benefits is changed from their current tax treatment. CONTEXT * Approximately, 70% or 20 million Canadians rely on full or partial private supplementary health care benefits (e.g., dental, drugs, vision care, private health care, etc.). As governments reduce the level of public funding, the private component of health expenditures is expanding. Canadians are becoming increasingly reliant on the services of private insurance. In the context of funding those health services that remain public benefits, the government cannot strike yet another blow to individual Canadians and to Canadian business by taxing the very benefits for which taxes were raised. * Changes in health care technology and health care management have resulted in decreased length of stays in hospitals and an increased reliance upon expensive health technologies. Many of these services are covered by private supplementary health plans, especially when individuals are discharged from hospital (e.g., drugs, private home/health care). PHYSICIAN PERSPECTIVE * Access To Quality Health Care Services: First Priority Changing the status of supplementary health benefits from non-taxable to taxable may contribute decreased access to care, and/or possibly, increased costs to these plans coupled with a reduction in service of government funded programs. * Good Tax Policy Should Support Good Health Policy Non-taxable supplementary health benefits is a good tax policy that serves to reinforce good health policy. This incentive fosters risk pooling which reduces the overall cost of premiums for supplementary health benefit plans. * Fundamental Fairness In The Tax System Incentives that enable access to a broad range of quality health care services (beyond those publicly funded) to include all Canadians should be encouraged and expanded. CMA RECOMMENDS... * That the current federal government policy with respect to employment-related supplementary non-taxable health benefits be maintained. RATIONALE * If the supplementary health benefits become taxable, it seems likely that young healthy people would opt for cash compensation instead of paying taxes on benefits they do not receive. It follows that employer-paid premiums would increase as a result of this exodus in order to offset the additional cost of maintaining benefit levels due to diminishing ability to achieve risk pooling. * The federal government is to be congratulated with respect to last years' decision to maintain the non-taxable status of supplementary health benefits. This decision is an example of the federal governments' commitment to maintain a good tax policy that supports good health policy. The federal government should explore opportunities and incentives that would expand access to supplementary health care benefits to all Canadians. * In terms of fairness, it would seem unfair to penalize 70% of Canadians by taxing supplementary health benefits to put them on an equal basis with the remaining 30%. It would be preferable to develop incentives to allow the remaining 30% of Canadians to achieve similar benefits attributable to the tax status of supplementary health benefits. NATIONAL HEALTH RESEARCH PROGRAM (NHRP) ISSUE The Canadian Medical Association (CMA) believes that the health care system must respect and foster medical education and medical research. The CMA also believes that more emphasis should be placed on health services research focussing on health system reforms and their effect on the health of Canadians. Given the magnitude of change, now is the time for an evaluation of the impact before proceeding with any further reforms. CONTEXT * Canada has experienced rapid and significant changes with respect to health care reform which remains a priority at all levels of government. This environment provides a unique opportunity for the federal government to fund a concerted national evaluation strategy of health reform to date. * On the whole, the CMA would continue to encourage the government to protect earmarked monies dedicated for research activities. PHYSICIAN PERSPECTIVE * Improving The Quality Of The Health Care: Our First Priority For a variety of reasons , in a more forceful way over the last year, the CMA and physicians expressed their concerns with respect to the future of health and the viability of the health care system. The pace of reform has been rapid and change profound. What has been accomplished needs to be evaluated. In this context, the physicians of Canada have reiterated the need to foster health and medical research. * Health Research Policy Reinforcing Economic Policy Establishing a medical and health services research program will assist in attracting and retaining world-class researchers in Canada. There are positive effects that may occur in the economy as a result of this type of research with respect to the health technology sector -- creating a demand for highly skilled jobs in addition to increasing exports in high-tech, value-added goods and services. CMA RECOMMENDS... * That the federal government continue its commitment to medical education, biomedical and health services research. * That the federal government provide funding for a national initiative in evaluating health reforms. RATIONALE * Changes within the Canadian health care system, a system that is viewed as a model around the world, should not be implemented without a sound evaluation strategy. However, with the limited funding available to health researchers and health policy analysts this aspect of health care reform is often neglected or, at best, given cursory acknowledgement. We should not undertake systemic reforms without analyzing the effects that these will have upon the quality of the health care delivered to Canadians. * It is in the government's best interest to ensure that change within the health care system does not continue without evaluating the effect this will have on Canadians' access to quality health services. Once a certain course is set it may be impossible to turn the ship around. TOBACCO TAXATION ISSUE The Canadian Medical Association (CMA) is concerned that the 1994 reduction in the federal cigarette tax will have a significant effect in slowing the decline in cigarette smoking in the Canadian population, particularly in the youngest age group (15-19). CONTEXT * In an effort to combat the smuggling of cigarettes into in Canada, the federal government announced, in early 1994, a reduction in the federal tax on cigarettes in the amount of $5 per carton. In addition, the federal government offered an additional matching reduction of up to $5 per carton for those provinces making reductions in provincial taxes. * At about the same time, in an attempt to counter the effects of the reduction in tobacco taxation, the government announced increased efforts to reduce the accessibility of tobacco products, particularly to minors, and also launched the Tobacco Demand Reduction Strategy in February, 1994. PHYSICIAN PERSPECTIVE * Smoking is the leading preventable cause of premature mortality in Canada. The most recent estimates suggest that more than 40,000 deaths annually in Canada are directly attributable to tobacco use. * Physicians are concerned that the reduction in tobacco taxation may reverse more than two decades of progress in reducing smoking rates. Based on an examination of four population-based surveys and data on tobacco consumption, a workshop convened by Health Canada in 1994 concluded that, in all likelihood, the prevalence of smoking in the Canadian population continued to decline from 1991 to 1993, reversed itself in 1993 and increased from 1993 to 1994. 9 * The effects of smoking on nonsmokers are of major concern to the CMA. More than 20% of Canadians have a health condition such as heart disease or acute respiratory disease, that is aggravated by secondary exposure to tobacco smoke. CMA RECOMMENDS * It is a matter of longstanding policy that the CMA supports the taxation of tobacco products at a level that will discourage their purchase, the revenue to be earmarked for health care budgets. 10 * The CMA has also recommended to the federal government (1994) that it institute a federal health protection assessment (a specially designated tax) on all Canadian cigarettes at the point of manufacture, regardless of their ultimate site of sale. * The CMA is also a co-signatory, along with eight other national medical and health organizations, of the brief Tobacco Taxation in Canada: New Directions, which was presented to the Honourable Paul Martin in February, 1995, and which sets out eight recommendations for the restoration of tobacco taxes, support for the Tobacco Demand Reduction Strategy and the taxation of the tobacco industry. RATIONALE * the government has made in health promotion campaigns against smoking, and which it has continued through the Tobacco Demand Reduction Strategy. _____________ 1 Posner M., Condition Critical. Maclean's. Vol. 108 No. 46, November 13, 1995, p. 46-59. 2 The Angus Reid Group, The Reid Report. Vol. 8, No. 7, July/August, 1993 and Vol. 8. No. 8. September, 1993. 3 The Medical Post 1995 National Survey of Doctors, Fall 1995, page 24. 4 Alvi S.: Health Costs and Private Sector Competitiveness, The Conference Board of Canada, Report 139-95, Ottawa, June, 1995, page 11. 5 Southam News/CTV/Angus Reid, Public Opinion On Government Cutbacks And The Policy Challenges Facing Canada, December 27, 1995. 6 The Angus Reid Group, The Reid Report. Vol. 8, No. 7, July/August, 1993 and Vol. 8. No. 8. September, 1993. 7 Mitchell, A. Population to hit 30 million in 1996: Globe and Mail, January 10, 1996. pp. B1-2. 8 Frenken, H. Capitalizing on RRSPs: Canadian Economic Observer, December 1995. p. 3.1-3.9. Statistics Canada - Cat. No. 11-010. 9 Stephens T. Workshop report: trends in the prevalence of smoking, 1991-1994. Chronic Diseases in Canada 1995; 16(1): 27-32 10 Canadian Medical Association. Smoking and Health: 1991 Update. Can. Med. Assoc. Journal 1991; 142 (2): 232A-232B.

Documents

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Canada Health Act and the delivery of health care services

https://policybase.cma.ca/en/permalink/policy664

Last Reviewed
2017-03-04
Date
1996-08-21
Topics
Health systems, system funding and performance
Resolution
GC96-28
That the Canadian Medical Association and its Divisions work with governments and other groups to examine the principles and applicability of the Canada Health Act to the delivery and funding of contemporary medical and health care services in Canada.
Policy Type
Policy resolution
Last Reviewed
2017-03-04
Date
1996-08-21
Topics
Health systems, system funding and performance
Resolution
GC96-28
That the Canadian Medical Association and its Divisions work with governments and other groups to examine the principles and applicability of the Canada Health Act to the delivery and funding of contemporary medical and health care services in Canada.
Text
That the Canadian Medical Association and its Divisions work with governments and other groups to examine the principles and applicability of the Canada Health Act to the delivery and funding of contemporary medical and health care services in Canada.
Less detail

The Canadian Medical Association's brief to the Standing Committee on Finance concerning the 2007 budget

https://policybase.cma.ca/en/permalink/policy8566

Last Reviewed
2019-03-03
Date
2006-09-27
Topics
Health systems, system funding and performance
  1 document  
Policy Type
Parliamentary submission
Last Reviewed
2019-03-03
Date
2006-09-27
Topics
Health systems, system funding and performance
Text
Making Canadians healthy and wealthy In the face of an increasingly competitive global economy, Canada must create incentives for its citizens and businesses to invest so that greater investment will increase productivity and our standard of living. The first place to invest is in the health of the workforce. The CMA recognizes the benefits of aligning tax policy with health policy in order to create the right incentives for citizens to realize their potential. Global competitiveness is about getting Canada beyond commodities The latest Canadian economic outlook is mixed. Our economy is forecast to grow by 3 per cent in 2007 which is the fastest growing economy among the G7 countries, according to the International Monetary Fund's semi-annual World Economic Outlook. While this may seem impressive, this growth is fuelled by commodity prices. "The Canadian economy continues to perform robustly, benefiting from...the boom in global commodity prices,'' the IMF said. In fact this is one of the key concerns included in the latest outlook from TD Economics, namely that, "Weakening U.S. demand will lead to a pullback in commodity prices, including a drop in the price of oil to $50 US a barrel in 2007"1. What can the federal government do to mitigate these bumps in the global economy? Investing in "specialized factors" is the key to global competitiveness Canada's place in a competitive world cannot be sustained by commodities or what the godfather of competitive advantage theory, world-renowned Harvard Professor Michael Porter, calls "non-key" factors. Instead, Porter suggests that sustainable competitive advantage is based on "specialized factors" such as skilled labour, capital and infrastructure. These specialized factors are created, not inherited. Moreover, Porter makes the important distinction that the crafting of "social" policies must make them reinforcing to the true sources of sustainable prosperity.2 The demand for highly skilled labour forces does not fluctuate as commodity prices do. This submission follows Porter's line of thinking in suggesting that Canada should build on these specialized factors, emphasizing the health of our skilled labour force, enhancing the skills of our health care providers and making key investment in our electronic health infrastructure. Why the CMA is addressing Canada's place in competitive world The 63,000 members of the Canadian Medical Association are best known for taking care of Canadians - 32.3 million of them - individually and collectively. Through prevention, treatment and research, physicians are also vital in supporting business by ensuring that our work force is as healthy as can be. But our members are also an important economic force in their own right as they own and operate over 30,000 small businesses employing 142,000 people across the country. 3 What's more, small businesses, like the ones physicians run, invest in research and development proportionally on a far larger scale than big corporations. 4 In addition to the clinical services they provide, physicians are vitally engaged in advancing medical knowledge through teaching and research, leading to greater innovation. Health as an investment -"the greatest benefit to mankind" According to distinguished Yale economist, William Nordhaus, "The medical revolution over the last century appears to qualify, at least from an economic point of view, for Samuel Johnson's accolade as "the greatest benefit to mankind." 5 People demand and spend more money on health because it is useful. The goal of a competitive economy is to produce more wealth. The wealthier our citizens become, the more health care they demand. In other words health care is in economic terms a "superior good". Short, medium and long-run incentives for increased productivity The pursuit of productivity to ensure Canada's competitiveness in the world is not and cannot be a short-term goal. Productivity is apolitical. Setting the foundation for productivity requires dedication to long-term goals in education, physical infrastructure and health. However, there are recommendations that can create immediate incentives for citizens and businesses to kick start more productive activity sooner than later. Executive Summary The CMA's pre-budget submission presents the facts on how investments in citizens, businesses and health infrastructure make our economy more competitive. Improvements in the quality of care, and especially timely access to care, enable the Canadian labour force to increase its performance and fully reach its potential. Our submission is also sensitive to the constraints facing the federal government and so we have considered the return on investment for these recommendations. The CMA recognizes the benefits of aligning tax policy with health policy in order to create the right incentives for citizens to realize their potential. Accordingly, our proposals include tax incentives for healthy living and a recommendation to encourage savings for long-term health care. The time horizon for our 10 recommendations ranges from short-term wins such as getting Canadian doctors working in the U.S. back to Canada sooner than later to turning the tide of rising obesity in Canada. We hope that the Standing Committee on Finance considers these short-term returns on investment as well as the longer returns on investment. A Greek proverb said it best, "A society grows great when old men plant trees whose shade they know they shall never sit in". This can be a great legacy of the Committee. On behalf of the members of the Canadian Medical Association, I wish you all the best in your deliberations. Recommendations for Committee consideration Medicine for a More Competitive Canadian Economy6 -10 recommendations with investment estimates A. CITIZENS - healthy living Recommendation 1: That the government consider the use of taxes on sales of high-calorie, nutrient-poor foods as part of an overall strategy of using tax incentives and disincentives to help promote healthy eating in Canada. Recommendation 2: That the government assess the feasibility of an individual, tax-sheltered, long-term health care savings plan. B. BUSINESS - healthy workforce Recommendation 3: That the government advances the remaining $1-billion from the 2004 First Ministers Accord that was originally intended to augment the Wait Times Reduction Fund (2010-2014) to support the establishment of a Patient Wait Times Guarantee and deliver on the speech from the throne commitment. Recommendation 4: That the federal government provide the Canadian Institute for Health Information with additional funding for the purpose of enhancing its information gathering efforts for measuring, monitoring and managing waiting lists and extending the development and collection of health human resource data to additional health professions. Recommendation 5: That the government launch a direct advertising campaign in the United States to encourage expatriate Canadian physicians and other health professionals to return to practice in Canada. Investment: A one-time investment of $10-million. Recommendation 6: That the government provide a rebate to physicians for the GST/HST on costs relating to health care services provided by a medical practitioner and reimbursed by a province or provincial health plan. Investment: $52.7-million per year or 0.2 % of total $31.5- billion GST revenues. C. INFRASTRUCTURE - healthy systems Recommendation 7: That the government follow through on the recommendation by the Federal Advisor on Wait Times to provide Canada Health Infoway with an additional $2.4-billion to secure an interoperable pan-Canadian electronic medical record with a targeted investment toward physician office automation. Investment: $2.4-billion over 5 years. Recommendation 8: That the government establish a Public Health Infrastructure Renewal Fund ($350-million annually) to build partnerships between federal, provincial and municipal governments, build capacity at the local level, and advance pandemic planning. Recommendation 9: That the government recommit to the $100-million per year for immunization programs under the National Immunization Strategy. Recommendation 10: That the government Increase the base budget of the Canadian Institutes of Health Research to enhance research efforts in the area of population health and public health, as well as significantly accelerate the pace of knowledge transfer. Investment: $600-million over 3 years. Introduction It is well known that Canada's place in a competitive world cannot be sustained by commodities or what the godfather of competitive advantage theory, Michael Porter calls "non-key" factors. Instead Porter suggests that sustainable competitive advantage is based on "specialized factors" such as skilled labour, capital and infrastructure. These specialized factors are created, not inherited. Moreover, Porter makes the important distinction that the crafting of "social" policies must make them reinforcing to the true sources of sustainable prosperity.7 The demand for highly skilled labour forces does not fluctuate as commodity prices do. This submission follows that line of thinking in suggesting that Canada should build on these specialized factors, emphasizing the health of our skilled labour force, enhancing the skills of our health care providers as well as making key investment in our health infrastructure - electronic and otherwise. Outline: healthy citizens, businesses, infrastructure and affordable government The Canadian Medical Association (CMA) brief submitted to the Standing Committee on Finance will make 10 recommendations on how the federal government can make our economy more competitive by investing in three priorities: health, health care and health infrastructure. The brief will address these topics, aligning them with support for our (A) citizens, (B) businesses and (C) infrastructure. The CMA also recognizes that the federal government does not have unlimited resources and suggests actions to be taken in order to ensure that these recommendations are both affordable and sustainable. Accordingly, we will also provide a "balance sheet" of investments, return on investments, as well as revenue raising possibilities that could help create incentives for healthy living and, in turn, a more competitive economy. A. Citizens - healthy living Canadians must become fitter and healthier. Almost 60% of all Canadian adults and 26% of our children and adolescents are overweight or obese. 8 Dr. Ruth Collins-Nakai, the immediate past-president of the CMA and a cardiac-care specialist, recently said ""I have a very real fear we are killing our children with kindness by setting them up for a lifetime of inactivity and poor health,". Canada should follow the lead of European countries, which have recently recommended a minimum of 90 minutes a day of moderate activity for children. Kicking a soccer ball or riding a skateboard for 15 to 30 minutes two or three times a week is not good enough, she said. Obesity costs Canada $9.6 billion per year. 9 These costs continue to climb. The federal government must use every policy lever possible at its disposal in order to empower Canadians to make healthy choices, help to reduce the incidence of obesity and encourage exercise as well as a proper diet. Obesity and absenteeism affect the bottom line Obesity not only hurts our citizens it is also a drag on Canadian competitiveness. There is a direct correlation between increasing weights and increasing absenteeism. The costs associated with employee absenteeism are staggering. Employee illness and disability cost employers over $16-billion each year.10 For instance, the average rate of absence due to illness or disability for full-time Canadian workers was 9.2 days in 2004, a 26% increase over the last 8 years, according to Statistics Canada's latest labour force survey. While there is a growing awareness of the costs due to obesity are well known. The programs and incentives in place now are clearly not working as the incidence of obesity continues to grow. The benefits of turning the tide of obesity are also clear. In his remarks to the CMA in August 2006, Minister Tony Clement made the following statement: "And you know and I know that health promotion, disease and injury prevention not only contribute to better health outcomes, they help reduce wait times as well." The experts agree, "The economic drive towards eating more and exercising less represents a failure of the free market that governments must act to reverse it."11 Recommendation 1: That the government consider the use of taxes on sales of high-calorie, nutrient-poor foods as part of an overall strategy of using tax incentives and disincentives to help promote healthy eating in Canada. Tax-sheltered savings for long-term care - aligning tax policy and health policy Canada is entering an unprecedented period of accelerated population aging that will see the share of seniors aged 65 and over increase from 13% in 2005 to 23% in 2031. At the same time, the cost of privately funded health services such as drugs and long-term care are projected to increase at double-digit rates as new technologies are developed and as governments continue to reduce coverage for non-Medicare services in order to curb fiscal pressures12. Since seniors tend to use the health system more intensively than non-seniors, the rising cost of privately funded health services will have a disproportionately high impact on seniors. Canadians are not well equipped to deal with this new reality. Private long-term care insurance exists in Canada, but is relatively on the Canadian scene and has not achieved a high degree of market penetration. New savings vehicles may be needed to help seniors offset the growing costs of privately funded health services. One approach would be extend the very successful model of RRSPs to enable individuals save for their long-term care needs via a tax-sheltered savings plan. Recommendation 2: That the government assess the feasibility of an individual tax-sheltered long-term health care savings plan. B. Business - healthy workforce In spite of the fact that health as an economic investment has proven returns, governments have been letting up in their support of their citizens' health. The impact is felt not only in terms of poorer health but it also affects businesses through increased absenteeism, as well as governments through lower tax revenues. According to the Center for Spatial Economics, "...the cumulative economic cost of waiting for treatment across Ontario, Saskatchewan, Alberta and BC in 2006 is estimated to be just over $1.8-billion. This reduction in economic activity lowers federal government revenues by $300-million." 13 The total costs to the federal government are even higher if all 10 provinces were included. The estimate is based on four of the five priority areas identified in the 2004 First Ministers Health Accord: total joint replacement surgery, cataract surgery, coronary artery bypass graft, and MRI scans. If you wonder what all this has to do with Canadian business, ask yourself how many person/hours employers lose due to illness? How much productive time is lost due to the stress of an employee forced to help an elderly parent who cannot find a doctor? This challenging situation is going to get worse, as the population ages, and as our health professionals age and retire. Supporting the Patient Wait Time Guarantee The establishment of pan-Canadian wait time benchmarks and a Patient Wait Times Guarantee are key to reducing wait times and improving access to health services. The 2004 First Ministers' health care agreement set aside $5.5-billion for the Wait Time Reduction Fund, of which $1-billion is scheduled to flow to provinces between 2010 and 2014. To assist provinces with the implementation of the wait time guarantee while remaining within the financial parameters of the health care agreement, the federal government could advance the remaining $1-billion and flow these funds to provinces immediately. Recommendation 3: That the government advances the remaining $1-billion from the 2004 First Ministers Accord that was originally intended to augment the Wait Times Reduction Fund (2010-2014) to support the establishment of a Patient Wait Times Guarantee and deliver on the speech from the throne commitment. Making investments count and counting our investments It would be irresponsible for government to make investments if the results were not being measured. As management guru Tom Peters suggests, "What you do not measure, you cannot control." And, "What gets measured gets done." As billion dollar federal funding of health care reaches new heights, the value of measuring these investment increases. That is where the Canadian Institute for Health Information (CIHI) comes in. CIHI has been involved in developing wait time indicators and tracking Canada's progress on wait times. It is essential that we have an arm's length body responsible for collecting data on wait times as part of Canada's effort to improve timely access to care for Canadians. CIHI has also played an active role in health human resource data collection and research. Their financial support for the 2004 National Physician Survey resulted in a one-of-a-kind research file with input from over 20,000 Canadian physicians. Recommendation 4: That the federal government provide the Canadian Institute for Health Information with additional funding for the purpose of enhancing its information gathering efforts for measuring, monitoring and managing waiting lists and extending the development and collection of health human resource data to additional health professions. Direct advertising in the U.S. to bolster health human resources deficit The primary barrier affecting timely access to quality health care is the shortage of health care professionals. Canada currently ranks 26th in the OECD in terms of physicians per capita, at 2.1 MDs per 1,000 people. More than three million Canadians do not have a family physician. This situation will get worse as the population ages and as our health professionals age and retire. Fortunately, another short-term source of health professionals exists that Canada should pursue. Thousands of health care professionals are currently working in the United States including approximately 9,000 Canadian trained physicians. We know that many of the physicians who do come back to Canada are of relatively young age meaning that they have significant practice life left. While a minority of these physicians do come back on their own, many more can be repatriated in the short-term through a relatively small but focussed effort by the federal government led by a secretariat within Health Canada. Recommendation 5: That the government launch a direct advertising campaign in the United States to encourage expatriate Canadian physicians and other health professionals to return to practice in Canada. Investment: A one-time investment of $10-million. Re-investing the GST for 30,000 small businesses The continued application of the GST on physician practices is an unfair tax on health. Because physicians cannot recapture the GST paid on goods and services for their practices in the same way most other businesses can, the GST distorts resource allocation for the provision of medical care. As a result, physicians end up investing less than they otherwise could on goods and services that could improve patient care and enhance health care productivity such as information management and information technology systems. The introduction of the GST was never intended to fall onto the human and physical capital used to produce goods and services. The GST is a value-added tax on consumption that was put into place to remove the distorting impact that the federal manufacturers sales tax was having on business decisions. However, the GST was applied to physician practices in a way that does exactly the opposite. The federal government must rectify the situation once and for all. Based on estimates by KPMG, physicians have paid $1.1-billion in GST related to their medical practice since 1991. This is $1.1-billion that could have been invested in better technology to increase care and productivity. Recommendation 6: That the government provide a rebate to physicians for the GST/HST on costs relating to health care services provided by a medical practitioner and reimbursed by a province or provincial health plan. Investment: $52.7-million per year or 0.2 % of total $31.5-billion GST revenues. C. Infrastructure -healthy system Recovery of health information technology investments is almost immediate A Booz, Allen, Hamilton study on the Canadian health care system estimates that the benefits of an EHR could provide annual system-wide savings of $6.1 billion, due to a reduction in duplicate testing, transcription savings, fewer chart pulls and filing time, reduction in office supplies and reduced expenditures due to fewer adverse drug reactions. The study went on to state that the benefits to health care outcomes would equal or surpass these annual savings. Evidence shows that the sooner we have a pan-Canadian EHR in place, the sooner the quality of, and access to health care will improve.14 Mobilizing physicians to operationalize a pan-Canadian Electronic Health Record The physician community can play a pivotal role in helping the federal governments make a connected health care system a realizable goal in the years to come. Through a multi-stakeholder process encompassing the entire health care team, the CMA will work toward achieving cooperation and buy-in. This will require a true partnership between provincial medical associations, provincial and territorial governments and Canada Health Infoway (CHI). The CMA is urging the federal government to allocate an additional investment of $2.4-billion to Canada Health Infoway over the next five years15 to build the necessary information technology infostructure to address wait times16 as well as support improved care delivery. Both the Federal Wait Times Report and Booz Allen Study concur that this requires automating all community points of care - i.e., getting individual physician offices equipped with electronic medical records (EMRs). This is a necessary, key element to the success of the EHR agenda in Canada and recent assessments place the investment required at $1.9-billion of the $ 2.4-billion. CHI has proven to be an effective vehicle for IT investment in Canadian health care. For example, as a result of CHI initiatives, unit costs for Digital Imaging have been reduced significantly and are already saving the health care system up to 60-million dollars. In fact as a result of joint procurements and negotiated preferred pricing arrangements through existing procurement efforts with jurisdictional partners the estimated current cost avoidance is between $135-million to $145-million. Moreover, in the area of a Public Health Surveillance IT solution, a pan Canadian approach to CHI investments with jurisdictional partners has lead to benefits for users, the vendor and Canadians. The negotiation of a pan-Canadian licence enables any jurisdiction to execute a specific licence agreement with the vendor and spawn as many copies as they need to meet their requirements. The vendor still owns the IP and is free to market the solution internationally - clearly a win/win for both industry and the jurisdictions. Recommendation 7: That the government follow through on the recommendation by the Federal Advisor on Wait Times to provide Canada Health Infoway with an additional $2.4-billion to secure an interoperable pan-Canadian electronic medical record with a targeted investment toward physician office automation. Investment: $2.4-billion over 5 years. Establishing a Public Health Infrastructure Renewal Fund The CMA remains concerned about the state of Canada's public health system. Public health, including the professionals providing public health services, constitutes our front line against a wide range of threats to the health of Canadians. While there is much talk about the arrival of possible pandemics, Canada's public health system must be ready to take on a broad range of public health issues. The CMA has been supportive of the Naylor report which provides a blue print for action and reinvestment in the public health system for the 21st century. While this will take several years to achieve, there are some immediate steps that can be taken which will lessen the burden of disease on Canadians and our health care system. These steps include establishing a Public Health Partnership Program with provincial and territorial governments to build capacity at the local level and to advance pandemic planning. In addition, we call on the government to continue its funding of immunization programs under its National Immunization Strategy. Public health must be funded consistently in order to reap the full benefit of the initial investment. Investments in public health will produce healthier Canadians and a more productivity workforce for the Canadian economy. But this takes time. By the same token, neglect of the public health system will cost lives and hit the Canadian economy hard. Recommendation 8: That the government establish a Public Health Infrastructure Renewal Fund ($350-million annually) to build partnerships between federal, provincial and municipal governments, build capacity at the local level, and advance pandemic planning. Supporting the National Immunization Strategy Dr. Ian Gemmell, Co-Chair of the Canadian Coalition for Immunization Awareness and Promotion, has said, "Vaccines provide the most effective, longest-lasting method of preventing infectious diseases in all ages." strongly urge that immunization programs be supported. Healthy citizens are productive citizens and strong immunization programs across the country pay for themselves over time. Recommendation 9: That the Federal Government recommit to the $100-million per year for immunization programs under the National Immunization Strategy. Making medical research investments count - supporting knowledge transfer The Canada Institutes of Health Research (CIHR) was created to be Canada's premier health research funding agency. One of the most successful aspects of the CIHR is its promotion of inter-disciplinary research across the four pillars of biomedical, clinical, health systems and services as well as population health. This has made Canada a world leader in new ways of conducting health research. However, with its current level of funding, Canada is significantly lagging other industrialized countries in its commitment to health research. Knowledge transfer is one of the areas where additional resources would be most usefully invested. Knowledge Translation (KT) is a prominent and innovative feature of the CIHR mandate. Successful knowledge translation significantly increases and accelerates the benefits flowing to Canadians from their investments in health research. Through the CIHR, Canada has the opportunity to establish itself as an innovative and authoritative contributor to health-related knowledge translation. Population and public health research is another area where increased funding commitments would yield long-term dividends. Recommendation 10: That the government Increase the base budget of the Canadian Institutes of Health Research to enhance research efforts in the area of population health and public health, as well as significantly accelerate the pace of knowledge transfer. Investment: $600-million over 3 years. Conclusion The CMA recognizes the benefits of aligning tax policy with health policy in order to create the right incentives for citizens to realize their potential. Accordingly our proposals include tax incentives for healthy living as well as a recommendation to encourage savings for long-term health care. The time horizon for our 10 recommendations ranges from short-term wins such as getting Canadian doctors working in the U.S. back to Canada sooner than later to turning the tide of rising obesity in Canada. We hope that the Standing Committee on Finance considers these short-term returns on investment as well as the longer returns on investment. A Greek proverb said it best, "A society grows great when old men plant trees whose shade they know they shall never sit in". This can be a great legacy of the Committee. On behalf of the members of the Canadian Medical Association, I wish you all the best in your deliberations. Appendix 1 - Recommendations for Committee consideration 10 point plan with estimated investments and revenues Appendix 2 - The Information Technology Agenda in the Canadian Health Care Sector * The Health Council of Canada, the Presidents and CEOs from the Academic Healthcare Organizations and the federal advisor on wait times all agree on the need to accelerate the building out of the information technology infostructure for the healthcare sector * All these groups amongst others argue that there are large gains to be made on improving healthcare delivery and achieving efficiencies in operating the health care system * Automating health care delivery in Canada will lead to a more efficient healthcare system and will build industry capacity to compete in the international market place * A $10-billion investment is estimated to result in a return on investment (ROI) exceeding investment dollars by an 8:1 margin, and a net savings of $39.8-billion over a 20-year period. It is estimated that a net positive cash flow would occur in Year Seven of implementation, and an investment breakeven by Year 11, resulting in an annual net benefit of $6.1-billion.17 * Part of this investment is to automate the over 35,000 physicians who have a clinic in a community setting * It is estimated that $1.9-billion is needed to accomplish this task which when complete will facilitate better management of wait times, improved patient safety, helping to address in part the human resource shortage for providers as well as make a contribution to improved First Nation health. * Our recommendation is that the Federal government provide a further direct investment of $1-billion into Canada Health Infoway (CHI) that is targeted to the automation of physician offices. This funding would pay for 50% of the costs to automate a physician's clinic. * The funds would be allocated to provinces and medical associations through CHI once an agreement has been developed. A jointly developed program would ensure complementarity with a provincial health IT strategy and a program that has been designed by physicians such that it does the most to improve health care delivery * Physicians would be asked to pay the other 50% and through tax policy they would be able to claim a deduction for capital information technology acquisitions * This arrangement mirrors current programs funded by CHI on a 75%-25% cost sharing model with provinces but with physicians picking up approximately 25% of the costs Appendix 3 Can taxation curb obesity? A recent article in the New Scientiest.com1 asks, Can taxation curb obesity? "The economic drive towards eating more and exercising less represents a failure of the free market that governments must act to reverse."18 "We have market failure in obesity, because we have social costs greater than the private costs," according to Lynee Pezullo director of the economic advisory group Access Economics. "The government also bears the health costs, and people don't take into account costs they bear themselves. If people had to pay for their own dialysis they might bear these things in mind a bit more." When two-thirds of the population of countries like Australia or the US are obese or overweight, you can't handle the problem with simple solutions like education," Barry Popkin of the University of North Carolina, Chapel Hill. A Yale University professor is generating support for a "twinkie tax"1 on high-calorie foods like french fries. This tax works In California in 1988, Proposition 99 increased the state tax by 25 cents per cigarette pack and allocated a minimum of 20% of revenue to fund anti-tobacco education. From 1988 to 1993, the state saw tobacco use decline by 27%, three times better than the U.S. average.1 CMA is not alone in supporting a junk food tax In December, 2003, the World Health Organization proposed that nations consider taxing junk foods to encourage people to make healthier food choices. According to the WHO report, "Several countries use fiscal measures to promote availability of and access to certain foods; others use taxes to increase or decrease consumption of food; and some use public funds and subsidies to promote access among poor communities to recreational and sporting facilities." The American Medical Association is planning to demand the government to levy heavy tax on the America's soft drinks industry. Currently, 18 U.S. states have some form of "snack" food tax in place and five states have proposed policy and legislative recommendations. The economic costs of obesity are estimated at $238-billion annually, and rising. Along the same lines, the former Surgeon General, C. Everett Koop, believes that after smoking, "obesity is now the number one cause of death in [the U.S.]...we're not doing the same kind of things with obesity that we have done with smoking and alcohol as far as government programs are concerned ... It's got to be like smoking, a constant drum beat." 1 "U.S. Slowdown Underway Canada in for a Bumpy Ride" See www. td.com/economics/ (accessed Sept. 19, 2006) 2www.worldbank.org/mdf/mdf1/advantge.htm (accessed Sept. 19, 2006) 3 Source: Statistics Canada, Business Register 2005. 4 Source: Statistics Canada, Industrial Research and Development -2004 intentions, No. 88-202-XIB, January 2005. 5 Nordhaus notes that over the 1990-1995 period the value of improved health or health income grew at between 2.2 and 3.0 per cent per year in the United States, compared to only 2.1 per cent for consumption. See The Health of Nations: The Contribution of Improved Health to Living Standards William D. Nordhaus, Yale University www.laskerfoundation.org/reports/pdf/economic.pdf (accessed Sept. 18, 2006) 6 See Appendix 1 for 3-year investment details as well as short, medium and long-term returns on investment 7 www.worldbank.org/mdf/mdf1/advantge.htm Accessed September 20, 2006. 8 Source: ww2.heartandstroke.ca/Page.asp?PageID=1366&ArticleID=4321&Src=blank&From=SubCategory Accessed August 14, 2006. 9 P.Katzmarzyk, I. Janssen "The Economic costs associated with physical inactivity and obesity in Canada: An Update" Can J Applied Physiology 2004 Apr; 29(2):90-115. www.phe.queensu.ca/epi/ABSTRACTS/abst81.htm Accessed August 14, 2006. 10 Staying@Work 2002/2003 Building on Disability Management, Watson Wyatt Worldwide www.watsonwyatt.com/canada-english/pubs/stayingatwork/ Accessed July 31, 2006. 11 Swinburn, et al. International Journal of Pediatric Obesity (vol 1, p 133) (accessed Sept. 19, 2006) 12 Canada's Public Health Care System Through to 2020, the Conference Board of Canada, November 2003. 13 The Economic Cost of Wait Times in Canada, by the Center for Spatial Economics, June 2006. www.cma.ca/multimedia/CMA/Content_Images/Inside_cma/CMA_This_Week/BCMA-CMA-waittimes.pdf 14 Booz, Allan, Hamilton Study, Pan-Canadian Electronic Health Record, Canada's Health Infoway's 10-Year Investment Strategy, March 2005-09-06 15 See Appendix 1 and Appendix 2 for more investment details and background. 16 Final Report of the Federal Advisor on Wait Times, June 2006, Dr. Brian Postl 17 Booz Allen Hamilton Study, Pan-Canadian Electronic Health Record, Canada Health Infoway's 10-Year Investment Strategy, March 2005 18 Can taxation curb obesity? See www.newscientist.com/article/dn9787-can-taxation-curb-obesity.html (accessed September 20, 2006.) Medicine for a more competitive Canadian economy

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Closing the Gaps: Advancing Emergency Preparedness, Response and Recovery for Older Adults

https://policybase.cma.ca/en/permalink/policy14384

Date
2020-12-15
Topics
Population health/ health equity/ public health
Health systems, system funding and performance
  1 document  
Policy Type
Policy endorsement
Date
2020-12-15
Topics
Population health/ health equity/ public health
Health systems, system funding and performance
Text
Closing the Gaps: Advancing Emergency Preparedness, Response and Recovery for Older Adults 29 Evidence-Informed Expert Recommendations to Improve Emergency Preparedness, Response and Recovery for Older Adults Across Canada DECEMBER 2020 CLOSING THE GAPS: ADVANCING EMERGENCY PREPAREDNESS, RESPONSE AND RECOVERY FOR OLDER ADULTS iii Table of Contents Report Development Contributors ...............................................................................................1 Organizational Endorsements...................................................................................................... 4 Abbreviations .................................................................................................................................... 7 Executive Summary .........................................................................................................................8 Background and Context ...............................................................................................................15 Domain 1: Individuals and Unpaid Caregivers ......................................................................26 Domain 2: Community-Based Services and Programs ....................................................... 35 Domain 3: Health Care Professionals and Emergency Response Personnel ................ 41 Domain 4: Care Institutions and Organizations ...................................................................46 Domain 5: Legislation and Policy................................................................................................51 Domain 6: Research.......................................................................................................................58 Glossary.............................................................................................................................................62 References ........................................................................................................................................64 Appendices .......................................................................................................................................78 Appendix A: Index of Recommendations and Enabling Bodies ..................................................................... A1 Appendix B: Emergency Preparedness for Older Adults Summary of Relevant Legislation and Framework .......................................................................................................................................................................................B1 1 Report Development Contributors In January 2019, the Canadian Red Cross in partnership with the National Institute on Ageing reviewed the latest evidence and expert opinions to inform the development of recommendations for governments, organizations and individuals to improve emergency preparedness, response and recovery for older adults. Enlisted experts that contributed to the development of the report are listed below. Co-Chairs, Canadian Red Cross/ National Institute on Ageing Emergency Preparedness for Older Adults Project Samir K. Sinha, MD, DPhil, FRCPC, AGSF Co-Chair and Director of Health Policy Research, National Institute on Ageing Director of Geriatrics, Sinai Health and the University Health Network, Toronto, Ontario Assistant Professor, Department of Medicine, Johns Hopkins University School of Medicine Associate Professor, Departments of Medicine, Family and Community Medicine, and the Institute of Health Policy, Management and Evaluation, University of Toronto, Ontario Sarah Sargent, MA Vice President, Canadian Operations Programs Canadian Red Cross Ottawa, Ontario Expert Contributors: Christina Baert-Wilson Senior Director, Community Health Canadian Red Cross Dartmouth, Nova Scotia Jane Barratt, PhD Secretary General, International Federation on Ageing Toronto, Ontario Sarah Burke, MA Acting Director, Respect Education Canadian Red Cross Victoria, British Columbia Dan Carbin, MSc Principal, Santis Health Toronto, Ontario Nancy Cooper, MHSA Director of Quality & Performance Ontario Long-Term Care Association Toronto, Ontario Leslie Eckel Knowledge Exchange Associate InterRAI Canada, University of Waterloo Waterloo, Ontario Sharon Goodwin, BScN, NP, MN, PhD Senior Vice President of Home and Community Care Victorian Order of Nurses (VON) Ottawa, Ontario Tyler Hague, MPA Manager, Disaster Risk Reduction Canadian Red Cross London, Ontario Irene Hobuleic Senior Director, Practice Quality and Risk Victorian Order of Nurses (VON) Toronto, Ontario Jessica Hseih, MSW, RSW Research Coordinator National Initiative for Care of the Elderly (NICE) Toronto, Ontario Andrea Iaboni, MD, DPhil, FRCPC Assistant Professor, Department of Psychiatry, University of Toronto Medical Lead, Geriatric Psychiatry, Toronto Rehab, University Health Network Toronto, Ontario REPORT DEVELOPMENT CONTRIBUTORS CLOSING THE GAPS: ADVANCING EMERGENCY PREPAREDNESS, RESPONSE AND RECOVERY FOR OLDER ADULTS 2 Sophia Ikura, MPA Executive Director, Population Health Solutions Lab Sinai Health Toronto, Ontario Mackenzie Kiemele Coordinator Canadian Association of Retired Persons (CARP) Toronto, Ontario Michael Nicin, MA, MPP Executive Director National Institute on Ageing Toronto, Ontario Shawna Peddle, MSc Former Director, Disaster Risk Reduction Canadian Red Cross Guelph, Ontario Arianne Persaud Communications and Public Affairs Manager National Institute on Ageing Toronto, Ontario Veronica Said, MA Consultant, Santis Health Toronto, Ontario Jennifer Savoy, BA Manager, Emergency Management and Programs Branch Public Safety Canada Ottawa, Ontario Dallas Seitz, MD, PhD Associate Professor, Department of Psychiatry, Hotchkiss Brain Institute, and O'Brien Institute for Public Health Cumming School of Medicine, University of Calgary Calgary, Alberta Samina Talat, MHSc Associate Vice President, Health Innovations Canadian Red Cross Mississauga, Ontario Laura Tamblyn-Watts, LLB National Director of Law, Policy and Research Canadian Association of Retired Persons (CARP) Toronto, Ontario Sandy van Solm, PhD Manager, Emergency Management/CEMC Region of Waterloo Waterloo, Ontario Melinda Wells, MPA Director, Global Relations and Humanitarian Diplomacy International Operations Canadian Red Cross Ottawa, Ontario Ivy Wong, MPA Policy Director National Institute on Ageing Toronto, Ontario Caberry Yu, BHSc, MD(c) Junior Research Fellow National Institute on Ageing Toronto, Ontario Lina Zita, BHA Development and Marketing Coordinator Older Adults Centres’ Association of Ontario Caledon, Ontario 3 Project Staff Nicoda Foster, MPH, PhD(c) Project Manager CRC/NIA Emergency Preparedness for Older Adults Project Office of the Director of Geriatrics Sinai Health and the University Health Network Toronto, Ontario Laura Romero, BSc Research Assistant CRC/NIA Emergency Preparedness for Older Adults Project Office of the Director of Geriatrics Sinai Health and the University Health Network Toronto, Ontario Acknowledgments Shionne Hitchman, BScH Research Assistant ARC/AAN Emergency Preparedness for Older Adults Project Office of the Director of Geriatrics Sinai Health and the University Health Network Toronto, Ontario Elsa Nana Nzepa, BSc Program Assistant CRC/NIA Emergency Preparedness for Older Adults Project Office of the Director of Geriatrics Sinai Health and the University Health Network Toronto, Ontario The authors would like to thank Veronica Said, Dan Carbin, Peg Christensen, Daphne Horn, Chris Walsh and Allan McKee for their important contributions towards the development of this report. REPORT DEVELOPMENT CONTRIBUTORS CLOSING THE GAPS: ADVANCING EMERGENCY PREPAREDNESS, RESPONSE AND RECOVERY FOR OLDER ADULTS 4 International Federation on Ageing ecagp lacgp <:JIW,Ot,Ui.r.u.DfMYOf A(;A0£1,11£ ( 1tt,1,1oDlf_tlNI: GC RIAT RIC PSYCIII.O.TltY OEG(ROHlO~YCHlAl lttE CAOT · ACE canadlan Association of Occupational Therapists Association canadienne des ergotherapeutes $ CAEPIACMU
CASW ACTS Canadian Frailty Network Reseau canadien des soins aux personnes fragilisees C GN~ ~ anadian Geron)ol?gical .f"'1.: Nursing Association ASSOCIATION (£ MEDICALE l CANADIENNE CANADIAN MEDICAL ASSOCIATION CANADIAN NURSES ASSOCIATION ~- CanAge. Alzheimer Society CANADA
CanadianAssociation .., .,. for Long Term Care CANAOl,6,N H:D[RATION OF NIJRSES UNIO»S LA F"EOERATION (ANAOIENNE DES SYNDIC ATS D'INFIRMIEAES ET INFIRHIERS t Canadian Home Care Association canadienne de soins et services a domicile Canadian Network for the Health and Housing of People Experiencing Homelessness Organizational Endorsements The Canadian Red Cross in partnership with the National Institute on Ageing would like to thank the following organizations who have given their support and official endorsement of this work. 5 Canadian Physiotherapy Association ft NICE Association canadienne de physiotherapie National Initiative for the Care of the Elderly Initiative nationale pour le soin des personnes a.gees ' ( ' ,., Closing the Gap® HEALTHCARE - _.. ,._ CS TCM I Canadian Society for !IP L Long-Term Core Medicin1 National Pensioners f.ederat'on Nationale Federation ~ des Retra.ltes J.1Hnostmeae a SENIOR CARE ® HUllldll RKJhb do nol hc1ve d bf~I befoie d,He Health CARERS CANADA PROCHES AIDANTS au CANADA ORGANIZATIONAL ENDORSEMENTS CLOSING THE GAPS: ADVANCING EMERGENCY PREPAREDNESS, RESPONSE AND RECOVERY FOR OLDER ADULTS 6 Long Term & Continuing Care Association of Manitoba L’Association de soins continus et à long terme du Manitoba ALBERTA CONTTNUING CAREASSOC/ATTON
AdvantAge Ontario Advancing Senior Care OACAO The Voice of Older Adult Centres La voix des centres pour aines OCSA Ontario Community Support Association ¦ Provincial Geriatrics Leadership Office Region of Waterloo THE GERONTOLOGICAL NURSING ASSOCIATION ONTARIO ONTARIO LONG TERM CARE ASSOCIATION ~TDRDNm The New Brunswick Association of NURSING HOMES L'Association des FOYERS DE SOINS du Nouveau-Brunswick ~~E ONTARIO \ Bringing Health Care Home @ caAregiver ORGANIZATION OPS OUIUIIO PlfS OU, SJ PP 0 1 1 WOf)!PS A SSO CIJ 1 l II: HEALTH COMMONS SOLUTIONS LAB ~ 7 Abbreviations AAN......................................................................................................................................................American Academy of Nursing ADLs.................................................................................................................................................................Activities of Daily Living ADRD........................................................................................................................Alzheimer’s Disease and Related Dementias ARC ...........................................................................................................................................................................American Red Cross CARP...............................................................................................................................Canadian Association of Retired Persons CDC ............................................................................................................................Centers for Disease Control and Prevention CILs .....................................................................................................................................................Centers for Independent Living CRC ...........................................................................................................................................................................Canadian Red Cross ED .......................................................................................................................................................................Emergency Department EMS .........................................................................................................................................................Emergency Medical Services LTC .....................................................................................................................................................................................Long-Term Care PTSD ..................................................................................................................................................Post-Traumatic Stress Disorder PDA ................................................................................................................................................................Personal Digital Assistant PPE ......................................................................................................................................................Personal Protective Equipment SAC ...............................................................................................................................................................Scientific Advisory Council SDM ..............................................................................................................................................................Substitute Decision Maker SMART .....................................................................................................................................Simple Triage and Rapid Treatment SWiFT ...............................................................................................................................................Seniors Without Families Team US .....................................................................................................................................................................United States of America ABBREVIATIONS CLOSING THE GAPS: ADVANCING EMERGENCY PREPAREDNESS, RESPONSE AND RECOVERY FOR OLDER ADULTS 8 Executive Summary Older adults consistently experience the greatest proportion of casualties during and after emergencies in Canada, and internationally, when compared to younger age groups (Fernandez, Byard, Lin, Benson, & Barbera, 2002; Mokdad, et al., 2005). For instance, in 1998, ice storms resulted in widespread power outages across Quebec that saw 600,000 people, that included older adults, forced from their homes and a high mortality rate among older persons due to a lack of available heating equipment, less optimal housing conditions, and poor coordination between emergency, health and social services (Plouffe, Kang, & Kalache, 2008). Over a decade later in 2010, more than half of all deaths resulting from heat waves in Quebec were among persons aged 75 years or older (Bustinza, Lebel, Gosselin, Belanger, & Chebana, 2013). In the 2017 wildfires in British Columbia and floods in Quebec, older adults were impacted the hardest due to their greater levels of vulnerability, while poorly coordinated protocols left them more vulnerable due to delays in initiating evacuation procedures (Global News, 2017; Roslin, 2018). More recently, 97% of Canada’s first 10,000 COVID-19 deaths have occurred in older Canadians 60 years of age and older (Grant, 2020), with the greatest proportion of deaths occurring in long-term care and retirement homes (Canadian Institute for Health Information, 2020; Government of Canada, 2020). Several research studies have demonstrated that these poor outcomes are linked to physiological age-related changes, such as impairments to sensory, cognitive and mobility disabilities; access and functional needs; social isolation and lack of access to familial and other social supports; having limited financial resources; and insufficient policies and procedures (Al-Rousan, Rubenstein, & Wallace , 2014; Fernandez, Byard, Lin, Benson, & Barbera, 2002; Killian, Moon, McNeill, Garrison, & Moxley, 2017). Furthermore, interruption to the timely provision of routine medical care is recognized as a likely contributor to mortality and morbidity associated medical complications during emergencies, especially in the immediate months following major natural disasters. The high proportion of deaths that also seem to occur in older adult congregate living settings is further indicative of fundamental issues that will need to be addressed in these settings as well. There exists a diverse continuum of capacity for older adults, from reduced capacity due to physical and cognitive impairments, as noted above, to active, engaged members of their communities. Older adults themselves should be empowered to reach out and connect with their peers, particularly those who are more vulnerable, supporting each other in anticipating and preparing for emergencies. The critical role of older adults who act as the sole or primary caregivers of other older adults, whether they be partners, family members, or friends, must also be recognized and supported. There is a clear need to better support emergency preparedness for older Canadians living at home in the community or in congregate settings. In order to improve preparedness and response to 9 emergencies, Canada needs greater consideration and adoption of evidence-informed, uniform and collaborative emergency management interventions. These efforts will require improved resources and capacity to meet the emergency needs of all older adults, regardless of the variety of circumstances and settings in which they may be living. In 2018, to address these gaps in emergency and disaster preparedness and management, members of the American Red Cross Scientific Advisory Council (ARC SAC) and the American Academy of Nursing (AAN) Policy Expert Round Table on Emergency/Disaster Preparedness for Older Adults agreed to conduct a scientific review of the latest evidence, current available legislation, and policies, in order to develop a set of recommendations that were then further reviewed and strengthened by a broader panel of experts with specific expertise in the fields of social work, education, public health, research, health policy, emergency management, geriatrics, and nursing. Through a rigorous consensus decision-making process, a comprehensive final set of 25 evidenceinformed recommendations were ultimately developed and endorsed by this group. This report is an extension and continuation of that work with an expanded focus that includes epidemics and pandemics. The COVID-19 pandemic has had its greatest impact on older adults in Canada and globally. The challenges experienced by older Canadians has demonstrated the need for improvements in preparedness planning targeting one of the most vulnerable group in our society. This report highlights areas where there are opportunities to better support older Canadians and their caregivers and the system more broadly, to be prepared before and successfully recover after the emergency. To adapt the recommendations for the Canadian context, the Canadian Red Cross and the National Institute on Ageing agreed to collaborate on an identical consensus-based development process employed by the ARC and AAN. The Canadian process resulted in 29 evidence-informed expert recommendations. This paper presents those recommendations, and the rationale behind them, for improving emergency preparedness, response and recovery interventions for older adults across Canada. In order to achieve a collaborative approach to improving emergency management nation-wide, the recommendations are categorized across six relevant emergency management domains: 1. Individuals and unpaid caregivers; 2. Community-based services and programs; 3. Health care professionals and emergency response personnel; 4. Care institutions and organizations; 5. Legislation and policy; and 6. Research. The intention of these recommendations is to provide interventions that can bridge the existing gaps in emergency preparedness, response and recovery, and facilitate better outcomes for older adults across Canada. EXECUTIVE SUMMARY CLOSING THE GAPS: ADVANCING EMERGENCY PREPAREDNESS, RESPONSE AND RECOVERY FOR OLDER ADULTS 10 Summary of Recommendations 1. Individuals and Unpaid Caregivers Domain Recommendation 1.1: Older adults and their unpaid caregiver(s) should be provided with tailored, easy-to-access information and resources related to emergency preparedness and guidance on how to develop customized emergency plans that consider the functional and health needs of older adults and appropriate strategies to support infection/disease prevention. Volunteer representatives of older Canadians and their unpaid caregivers should be recruited and involved in developing and disseminating resources and training material, to ensure their voices and perspectives are reflected. Recommendation 1.2: Older adults who are reliant on mobility aids should remove or minimize barriers affecting their ability to evacuate, and should take steps to ensure their safety within their surroundings. Recommendation 1.3: If registries for people with functional and other needs, including persons with disabilities, have been established by local emergency response agencies, older adults and/or their unpaid caregiver(s) should register so they can be better assisted/supported during emergencies. Recommendation 1.4: Older adults who have a sensory impairment, such as a visual or hearing disability, should take additional precautions to prepare themselves for emergencies. Recommendation 1.5: Older adults who live with chronic health conditions should maintain a readily accessible list of their current medical conditions, treatments (medications, durable medical equipment, supplies and other health care needs), health care providers, and emergency contacts, including substitute decision makers (SDMs). Recommendation 1.6: Older adults who take medications should work with their Health Care professionals to ensure they have access to at least a 30-day supply of medications during an emergency. Recommendation 1.7: Older adults who are reliant on medical devices that require electricity, should ensure they have back-up power supplies in place, especially if required while sheltering-inplace.
Older adults and/or their unpaid caregivers should contact their electricity company in advance to discuss their needs and ensure options for alternative power sources are available, especially addressing the need for access to power to charge cell phones and other mobile devices.
Older adults and/or their unpaid caregivers should seek assistance with obtaining and maintaining an alternative power source at home, if required, such as when being required to move heavy equipment and fuel or in accessing these resources in rural locations, and operating equipment. Recommendation 1.8: Older adults should be encouraged to continually maintain an adequate local support network that can be called upon during impending disasters and unexpected emergencies, especially if they live alone or lack easy access to relatives. 11 EXECUTIVE SUMMARY Recommendation 1.9: Unpaid caregivers of persons with Alzheimer’s disease and/or other dementias should be supported to identify signs of distress, anxiety, or confusion, and use strategies to redirect attention, and help them stay calm during emergencies. In addition, unpaid caregivers should be prepared to prevent wandering, and have plans in place to locate their care recipients if they do wander or require medical intervention(s) during an emergency. 2. Community-Based Services and Programs Domain Recommendation 2.1: Access should be increased to tailored community-based programs that educate older adults and their unpaid caregivers about emergencies that could affect their region and how best to prepare for and respond to them. Volunteer representatives of older Canadians and their unpaid caregivers should be recruited and involved in training material development and implementation, to ensure their voices and perspectives are reflected.
Community-based programs and organizations should collaborate with regional public health authorities in developing and disseminating education resources on infection control, disease and injury prevention practices for older adults and their unpaid caregivers during emergencies. Recommendation 2.2: Programs that provide disaster relief and/or essential community services, such as Meals on Wheels, and daily living assistance for older people (financial, medical, personal care, food and transportation) should receive emergency preparedness training and education, as well as should develop and adhere to plans and protocols related to responding adequately to the needs of their clients during emergencies. Volunteer representatives of older Canadians and their unpaid caregivers should be recruited and involved in training material development and implementation, to ensure their voices and perspectives are reflected. Recommendation 2.3: Community-based programs that provide in-home health and personal care for older adults should integrate strategies that minimize unnecessary personal contact and leverage resources (e.g. personal protective equipment such as gowns, masks, gloves, hand sanitizer etc.) in their emergency preparedness plans and protocols. Recommendation 2.4: Local governments should leverage data sources that identify at-risk individuals to enable emergency responders to more easily prioritize their search and rescue efforts following an emergency. 3. Health Care Professionals and Emergency Response Personnel Domain Recommendation 3.1: Health care professionals and emergency response personnel should receive training on providing geriatric care relevant to their discipline and how best to assist older adults and their unpaid caregivers before, during and after emergencies. The additional education and training should also increase their awareness of best practices and precautions to minimize the risk of infectious disease transmission or spread while responding to emergencies. Volunteer representatives of older Canadians should be recruited and CLOSING THE GAPS: ADVANCING EMERGENCY PREPAREDNESS, RESPONSE AND RECOVERY FOR OLDER ADULTS 12 involved in training material development and implementation, to ensure their voices and perspectives are reflected. Recommendation 3.2: Health care professionals and emergency response personnel should strive to mitigate negative outcomes among older adults during and after emergencies by adopting effective strategies designed to protect the physical and mental health of older adults they may come in contact with. Strategies can include assessing the psychological well-being of older adults for signs of distress and providing appropriate treatments or referrals as needed. Recommendation 3.3: Health care professionals and emergency response personnel should receive cultural awareness training to provide appropriate care and support for older adults with different cultural and religious backgrounds before, during, and after an emergency. Providers should have options for providing support to older adults and their unpaid caregivers who face language or cultural barriers to accessing supports (e.g., translators, written materials in languages other than English or French, etc.). This is of particular importance for personnel that work with Indigenous populations, in diverse community-settings and during times of evacuation due to emergencies. 4. Care Institutions and Organizations Domain Recommendation 4.1: Care institutions and organizations should include emergency preparedness and response education in their routine training courses.
Multi-modality educational tools and practices should be used to better facilitate knowledge acquisition and behavioral change.
Volunteer representatives of older Canadians should be recruited and involved in developing and disseminating resources and training material, to ensure their voices and perspectives are reflected. Recommendation 4.2: Additional strategies to improve the collection and transfer of identifying information and medical histories should be adopted into current standardized patient handoff procedures to better facilitate effective tracking, relocation and care of patients during an emergency. Recommendation 4.3: Care institutions and other organizations should strive to develop comprehensive emergency plans that include effective response strategies for protecting older adults against infectious disease outbreaks and reflect evidence-based standards supported by organizations such as Infection Prevention and Control Canada (IPAC).
Care institutions should also regularly assess and address any barriers they identify that could affect the implementation of their emergency plans that build on their routine practices. 5. Legislation and Policy Domain Recommendation 5.1: A national advisory committee should be created to inform emergency preparedness, response and recovery program development and strategies for older Canadians. Individuals who are representative of older Canadians and their unpaid caregivers should be involved to ensure their voices and perspectives are reflected. 13 EXECUTIVE SUMMARY Recommendation 5.2: All provinces and territories should support the implementation of tax-free emergency preparedness purchasing periods during specific times of the year or prior to an impending emergency. Governments should also provide targeted funding to directly support/ subsidize the purchase of emergency preparedness kits for older Canadians. Items covered should include an agreed-upon list of emergency supplies (such as batteries, portable generators, rescue ladders, radios and ice packs), air conditioners, personal protective equipment (such as masks, gloves and hand sanitizer) and additional mobility aids (canes, walkers, etc.). Recommendation 5.3: All provinces and territories should support the creation of a national licensure process or program for nurses, physicians, allied health professionals and other emergency medical service personnel to allow them to provide voluntary emergency medical support across provincial/territorial boundaries during declared states of emergency. Recommendation 5.4: All provincial and territorial governments should support legislative requirements that mandate congregate living settings for older persons (e.g. nursing homes, assisted living facilities and retirement homes) to regularly update and report their emergency plans that outline actions and contingencies to take in case of emergencies. These plans should include:
Back-up generators in case of extended periods of power outages, and coordinated plans with relevant community agencies (e.g. municipal fire agencies) for efficient evacuations.
Direction on appropriate interventions (i.e. selfisolation, wearing face masks, physical distancing, etc.) to control and prevent outbreaks and spread of infectious diseases amongst the population in times of emergencies.
Clear thresholds for temperature regulation, specifically, maximum and minimum temperatures permissible based on occupational and environmental health standards, and the steps required to regulate temperatures and minimize fluctuations.
An outline of staffing levels that should be maintained during emergencies to minimize care and/or service interruptions. All provinces and territories should work towards standardizing requirements for emergency plans in congregate living settings in accordance with the priorities outlined in the 2019 Emergency Management Strategy for Canada and ensure that their emergency plans for congregate living settings are aligned with directives outlined in their provincial/territorial pandemic and emergency plans. Recommendation 5.5: All provinces and territories should adopt a standardized approach to promoting collaborations between local pharmaceutical prescribers and dispensers (i.e. community pharmacists), physicians and nurse practitioners, to ensure an adequate supply of prescription medications are dispensed to persons with chronic health conditions prior to and during an emergency. This approach should also outline the need for collaboration between pharmaceutical providers, hospitals and relief agencies to ensure an adequate supply of prescription medications are available at hospitals, relief and evacuation shelters.
All persons should be able to obtain at least a 30-day supply of emergency prescription medications prior to and during an emergency. CLOSING THE GAPS: ADVANCING EMERGENCY PREPAREDNESS, RESPONSE AND RECOVERY FOR OLDER ADULTS 14 6. Research Domain Recommendation 6.1: There is a need to prioritize the creation and funding of research efforts to better support the development of a common framework for measuring the quality and levels of emergency preparedness among care institutions, organizations, paid providers, community organizations, and other groups that work primarily with older adults and their unpaid caregivers during and after emergencies. Recommendation 6.2: There needs to be a more concerted effort in utilizing outcomes from existing evidence to support the planning, design, and refinement of more evidence-informed emergency preparedness interventions, policies, and regulations in support of older adults and unpaid caregivers, as well as organizations and paid care providers that will be responsible for meeting their needs during and after an emergency. Recommendation 6.3: A network of emergency preparedness researchers, older adults, unpaid caregivers, volunteers and providers needs to be created to encourage partnerships in the ongoing unpaid evaluation of emergency preparedness interventions targeting older adults. Network members should advocate for an increased focus on emergency preparedness research among the various societies or journals that they are members of. Recommendation 6.4: There is a need to focus on research about unpaid caregivers and emergency preparedness to better instruct unpaid caregivers on how to take care of their vulnerable family members and friends during an emergency. Recommendation 6.5: There is a need to focus on research about emergency preparedness and response in Canadian community and congregate living settings for older adults (e.g. nursing, retirement and group homes and assisted living facilities). Research should:
Determine the existing levels of preparedness across these environments as well as highlight the challenges they face in being prepared.
Characterize the impact of the emergency on the older adult population and emerging best practices on how to address it as soon as it emerges. 15 BACKGROUND AND CONTEXT The Current State of Emergency Outcomes for Older Adults in Canada Natural disasters and infectious disease pandemics are two of the most frequent emergencies that pose great risks to public health and safety because of their ability to disrupt the day-to-day functioning of a population. As a result, emergency preparedness and response efforts include both large and small scale strategies designed to minimize harm, particularly to vulnerable groups such as older adults, defined as those aged 65 and older. Over the last decade, several large scale emergencies have highlighted the particular vulnerabilities of older adults who were the most affected by them. For instance, in 1998, ice storms resulted in widespread power outages across Quebec that saw 600,000 people, that included older adults, forced from their homes and a high mortality rate among older persons due to a lack of available heating equipment, less optimal housing conditions, and poor coordination between emergency, health and social services (Plouffe, Kang, & Kalache, 2008; Steuter-Martin & Pindera, 2018). Over a decade later in 2010, more than half of all deaths resulting from heat waves in Quebec were among persons aged 75 years or older (Bustinza, Lebel, Gosselin, Belanger, & Chebana, 2013). In the 2017 wildfires in British Columbia and floods in Quebec, older adults were impacted the hardest due to their greater levels of vulnerability, while poorly coordinated protocols left them more vulnerable due to delays in initiating evacuation procedures (Global News, 2017; Roslin, 2018). More recently, 97% of Canada’s first 10,000 COVID-19 deaths have occurred in older Canadians 60 years of age and older (Grant, 2020), with the greatest proportion of deaths occurring in long-term care and retirement homes (Canadian Institute for Health Information, 2020; Government of Canada, 2020). Close to 1700 outbreaks have been reported in LTC and retirement homes, accounting for approximately 80% of all COVID-19 deaths in Canada (Canadian Institute for Health Information, 2020; NIA Long- Term Care COVID-19 Tracker Open Data Working Group, 2020). The impacts that emergencies such as natural disasters and infectious disease pandemics have on older adults rarely end once the emergency has ended. Interruptions to medical care, especially for those living with chronic conditions, can cause increased morbidity and mortality in the months during and following a large scale emergency. Despite the gaps in emergency preparedness and response efforts that have been highlighted over the past decade, older adults continue to experience a greater proportion of emergencyrelated mortality rates and emergency-related declines in health, while continuing to report lower rates of emergency preparedness (Al- Rousan, Rubenstein, & Wallace , 2014; Brunkard, Namulanda, & Ratard, 2008; Cherniack, Sandals, Brooks, & Mintzer, 2008; Gibson & Hayunga, 2006; Kosa, Cates, Karns, Godwin, & Coppings, 2012; Mokdad, et al., 2005; Marshall, Ryan, Robertson, Street, & Watson, 2009). As the baby boomers continue to age, it is expected that the population of older adults aged 65 years Background and Context CLOSING THE GAPS: ADVANCING EMERGENCY PREPAREDNESS, RESPONSE AND RECOVERY FOR OLDER ADULTS 16 and older in Canada will significant increase over the next few decades. By 2030, the proportion of the total Canadian population aged 65 and over will increase to upwards of 23.4%, from 17.2% of the overall population in 2018 (Statistics Canada, 2020). This proportion is projected to increase reaching upwards of 29.5% of the overall population by 2068 (Statistics Canada, 2020). This rapid growth in our population of older Canadians will increase the demand for emergency services to meet the emergency preparedness, response, and recovery needs of those individuals at greater risk for negative outcomes. The need for more age-friendly emergency response services is further supported by the expected increase in the frequency and severity of extreme weather events that can in turn lead to infectious disease outbreaks when they result in changes to human conditions or exacerbate existing health conditions (Field, Barros, Dokken, Mach, & Mastrandrea, 2014; Kouadio, Aljunid, Kamigaki, Hammah, & Oshitani, 2012). Further, in addition to post-disaster infectious disease outbreaks, the frequency and risk of epidemics and pandemics are always imminent given the population density in metropolitan cities and the openness of country borders that facilitate travel and migration. Consequently, ensuring the safety of older adults will require greater efforts in the overall area of emergency management for this growing population, and especially for those living in congregate settings. Studies have highlighted the socioeconomic factors that make older adults more vulnerable to experiencing adverse outcomes during and after emergencies, and the insufficiencies present among various levels of emergency management to respond to the vulnerabilities of this group (Aldrich & Benson, 2008; Banks, 2013; Bustinza, Lebel, Gosselin, Belanger, & Chebana, 2013; Tricco, Lillie, Soobiah, Perrier, & Straus, 2013). Particularly, older adults have been found to experience more adverse outcomes during an emergency compared to their younger counterparts due to their complex and individualized capabilities and challenges. As one gets older, age-related changes begin to take place, such as a natural gradual weakening of one’s immune system known as immunosenesence, and an increased chance of having a chronic health condition or multi-morbidity, living in social isolation, and experiencing declines in sensory, cognitive and physical functioning (Aldrich & Benson, 2008; Kosa, Cates, Karns, Godwin, & Coppings, 2012). While these changes are often sufficiently managed in an older adult’s day-today life, emergencies such as natural disasters and infectious disease pandemic can impose additional barriers to accessing resources and supports, and put older adults with complex needs at an increased risk of harm. Emergency management for older adults can be further weakened by health care providers’ low levels of emergency and geriatric specific education and training; limited provision of community-based emergency training programs for older adults and their unpaid caregivers; statutes and regulations that impose barriers to individual preparedness; and lack of a standardized approach to emergency 17 BACKGROUND AND CONTEXT preparedness nation-wide (Pesiridis, Galanis, Sourtzi, & Kalokairinou, 2014; Scott, Carson, & Greenwell, 2010; Wyte-Lake, Claver, Griffin, & Dobalian, 2014). However, there exists a diverse continuum of capacity amongst older adults, from reduced capacity due to physical and cognitive impairments, as noted above, to others who are active, engaged members of their communities. Older adults should be empowered to reach out and connect with their peers, particularly those who are more vulnerable, to support each other in anticipating and preparing for emergencies. The critical role of older adults who act as the sole or primary caregivers of other older adults, whether they be partners, family members, or friends, must also be recognized and supported. To address this gap in emergency preparedness members of the American Red Cross Scientific Advisory Council (ARC SAC) and the American Academy of Nursing (AAN) Policy Expert Round Table on Emergency Preparedness for Older Adults agreed to conduct a scientific review of the latest evidence, current available legislation, and policies, in order to develop a set of recommendations that were then further reviewed and strengthened by a broader panel of experts with specific expertise in the fields of social work, education, public health, research, health policy, emergency management, geriatrics, and nursing. Through a rigorous consensus decision-making process, a comprehensive final set of 25 evidenceinformed recommendations were ultimately developed and endorsed by this group. To bring this work into the Canadian context, members of the ARC Scientific Advisory Council from the Canadian Red Cross (CRC) and the National Institute on Ageing (NIA) reviewed the ARC/AAN’s findings, further reviewed additionally relevant Canadian literature, policy and legislative aspects, and hosted an Expert Policy Round Table on Emergency Preparedness for Older Canadians in May, 2019, in Toronto, ON. The Canadian Round Table brought together 18 experts from a variety of fields, including social work, education, research, health policy, emergency management, geriatrics, and nursing. The Policy Expert Round Table reviewed the ARC/ AAN’s original 25 recommendations, particularly the legislative recommendations, which had been updated for the Canadian context, and any additional evidence applicable to older Canadians. The majority of recommendations were generally applicable to Canada and were agreed to be appropriate and supported by the Round Table. The subsequent advent of the COVID-19 pandemic invited an even broader review of the literature to include a focus on infectious disease pandemics and opportunities to address gaps in preparedness. This report’s reference panel initially put forward 26 final recommendations that aimed to implement emergency preparedness-related changes among the following relevant emergency management domains: 1) individuals and unpaid caregivers; 2) community services and programs; 3) health care professionals and emergency response personnel; 4) care institutions and organizations; 5) legislation/policy; and 6) research. The CRC/NIA’s later decision to expand the report’s focus to also address preparedness for CLOSING THE GAPS: ADVANCING EMERGENCY PREPAREDNESS, RESPONSE AND RECOVERY FOR OLDER ADULTS 18 infectious disease pandemics ultimately resulted in a final total of 29 recommendations being presented in this document. Report Recommendations Development Approach Initial Scoping Review and Development of an Ecological Analytical Framework In the initiation of this project, the American Red Cross Scientific Advisory Council and the American Academy of Nursing Policy Expert Round Table on Emergency Preparedness for Older Adults began a scoping review of the agerelated factors that make older adults more vulnerable to adverse outcomes during and after an emergency, with the primary focus being on large scale natural disasters. For the purpose of the scoping review, a disaster was defined as a natural or man-made phenomenon that causes interruptions or loss of life. Disasters based on this definition included the following: floods, hurricanes, tornadoes, nuclear explosions, and complex disasters. Disasters arising from malicious biological and chemical agents, and terrorism were excluded. The impact of natural disasters is far reaching and can lead to other types of disasters that, though unintended, can be severe in nature and cause harm. Examples of such disasters include health care disasters that can be defined as a disaster that prevents access to health care in times of emergency (Swathi, Gonzalez, & Delgado, 2017). A health care disaster also happens when the destructive effects of natural disasters can overwhelm the ability of a given area or community to meet the demand for Health Care (Zibulewsky, 2001). It is important to note the clear causal link between natural disasters and health care disasters, as natural disasters can lead to a breakdown in the health system’s responsiveness to the need for health services following an emergency leaving affected communities without access to Health Care. The scope and focus of this search was primarily on natural disasters, which have produced some results that have overlapping content but this was not the primary focus. Older adults were found to be more vulnerable to adverse outcomes during and after emergencies due to seven factors: an increased prevalence of chronic health conditions, physical, cognitive and sensory disabilities, weak social networks, accessibility and equity issues, and limited financial resources. This literature review also identified older adults and unpaid caregivers, community services and programs, health care professionals and emergency response personnel, care institutions and organizations, policy/legislation, and research as the relevant domains that contribute to disaster/emergency management for older adults. Adequate emergency preparedness was found to depend on synergy between relevant emergency management domains in order to mitigate the factors creating increased vulnerability among older adults during emergencies. Surrounding five of the six emergency management domains, and the seven factors of vulnerability, is the domain of research. It can identify and help to fill the existing gaps in knowledge and behaviour. 19 BACKGROUND AND CONTEXT Bronfenbrenner’s Ecological Framework was adapted to illustrate the interacting relationship of the seven factors of vulnerability and the six emergency management domains identified (Figure 1). Systematic Review Process A subsequent systematic literature review was conducted with an expanded scope for the Canadian version that included a focus on preparedness for pandemics and spread of infectious diseases in addition to the original focus on preparedness for natural disasters. The objective of the systematic review was to examine existing gaps in emergency preparedness for pandemics among the six previously identified emergency management domains for older adults (see Figure 1) and to determine successful interventions. For the purposes of the expanded focus, a pandemic was defined as “an epidemic occurring worldwide, or over a very wide area crossing international boundaries and usually affecting a large number of people” (Kelly, 2011). Preparedness was defined as the capacity to respond to a public health threat that includes natural disasters and infectious disease outbreaks (Patel, et al., 2008). Research Older Adults and Caregivers Finances Care Institutions and Organizations (System Policies & Procedures) Health Care Professionals and Emergency Responders Community Services and Programs Research Policy/Legislation Figure 1. Adapted from: Bronfenbrenner, U (1977). Toward an experimental ecology of human development. American Psychologist, 32, 513- 531. ~ ~,, '). 4, :o.¾. ., ,, Research PsYcholOfJ/ca/ and Socia/ Factors 4,Jeasau ~ 'i \ ".--\ '\ \ 9 i /ft;> i if .I. CLOSING THE GAPS: ADVANCING EMERGENCY PREPAREDNESS, RESPONSE AND RECOVERY FOR OLDER ADULTS 20 The review was guided by the six research questions listed below (for a detailed summary of the search strategy, see Appendix A). 1. Individuals and Unpaid Caregivers Domain Question 1: What are the factors that make older adults more vulnerable to adverse outcomes during an emergency compared to younger adults? 1.1. Are there age and/or function-related factors that make older adults more vulnerable to adverse outcomes compared to younger adults? 1.2.
What is the incidence of psychological distress among older adults following an emergency (natural disaster or pandemic) compared to younger adults?
Is there a difference in the incidence of psychological distress among older adults across different socio-demographic factors (that is, education, income, race, geography, etc.) following an emergency (natural disaster or pandemic)?
Is there a difference in the incidence of psychological distress among older adults with dementia, dementia related disorders or other cognitive impairments? 1.3. Are there specific actions caregivers of older adults should pursue to minimize adverse outcomes of older adults they care for during or after an emergency (natural disaster or pandemic)? 2. Community-Based Services and Programs Domain Question 2: What are the strategies and resources that can be leveraged at the community and program levels to improve emergency (natural disasters or pandemic) preparedness for older adults? 2.1. Is there a need for more geriatric-focused supportive care strategies to better prepare older adults and/or family caregivers for emergencies? 2.2. Are conventional emergency preparedness resources effective at facilitating knowledge acquisition and behavioral change among older adults and/or family caregivers with low-literacy skills or among those who are not fluent in English or French? 2.3. What are the most effective formats that can be used to communicate guidance on preparedness, warning messages and messages on how to access recovery resources in times of pending emergency among older adults and/or family caregivers?
What types of community/not-for-profit led interventions can be implemented to facilitate positive recovery outcomes for older adults and/or family caregivers following an emergency (natural disaster or pandemic)? 3. Health Care Professionals and Emergency Response Personnel Domain Question 3: What are the strategies and resources that can be leveraged to improve emergency response among health care professionals and emergency response personnel during and after an emergency (natural disaster or pandemic)? 21 3.1. Is there a need for an increase in the use of geriatric-focused triage care strategies when assessing the needs of older adults before or during an emergency (natural disaster or pandemic)? 3.2. What are the age- and function-specific training methods that health care professionals and emergency response personnel should follow when caring for and assisting older adults with varying capabilities and limitations during an emergency (natural disaster or pandemic)?
What are the most effective methods to teach age- and function-specific education to facilitate knowledge acquisition and behavioral change? 3.3. What core competencies or skills do health care professionals and emergency response personnel need to facilitate the delivery of culturally appropriate and safe care during emergencies (natural disasters or pandemic) to older adults with different cultural and religious beliefs/preferences?
Are there specific accommodations needed for Indigenous older adults in the event of relocation following an emergency (natural disaster or pandemic)?
Are there differences in methods for providing support to Indigenous (on or offreserve) and other racialized older adults who live in Canada? 4. Care Institutions and Organizations Domain Question 4: What are the strategies and resources that can be leveraged at the organizational or institutional level to improve emergency (natural disaster or pandemic) preparedness and recovery efforts for older adults? 4.1 Is there a need for more geriatric-focused supportive care strategies or design elements to better prepare organizations or institutions (relief agencies and shelters) that may be required to provide care for older adults during or after an emergency (natural disaster or pandemic)? 5. LegislationPolicy Domain Question 5: Are there legislations or policies have been developed or adopted at the municipal, provincial or federal level to improve emergency (natural disaster or pandemic) preparedness and recovery efforts for older adults? 5.1. Is there evidence that shows the effectiveness/ positive impact of any particular piece of legislation or policy? 5.2. Is there any evidence to suggest any existing legislation or policy may contravene what existing evidence would support? 6. Research Domain Question 6: What research or evidence gaps have been noted in the literature that could better inform efforts to improve emergency preparedness and recovery efforts for older adults? BACKGROUND AND CONTEXT CLOSING THE GAPS: ADVANCING EMERGENCY PREPAREDNESS, RESPONSE AND RECOVERY FOR OLDER ADULTS 22 Search Strategy The search for academic literature was conducted in two phases. Phase one focused on natural disasters and was implemented between June 2017 and April 2019. Phase two focused on infectious disease pandemics and was implemented between March and May 2020. Searches for both phases were restricted to databases with literature relevant to the fields of medicine, public health, nursing, and health care, which included MEDLINE, HealthStar, UpToDate, Clinical Key, EBSCOhost, Cochrane, CINAHL, Scopus and Google Scholar. The reference lists of relevant articles were also manually searched. Phase one search was restricted to articles published in English between 2008 and 2019. Phase two had no date restrictions but limited articles to only those published in English. The search parameters were focused on identifying gaps that were not addressed by existing evidence based guidelines published by established agencies and public health authorities such as Public Health Agency of Canada (PHAC), Centers for Disease Control and Prevention (CDC), Public Health Ontario (PHO), etc. Study Selection The screening and shortlisting process was identical in both phases. The titles and abstracts of the populated articles were screened to identify peer-reviewed articles that were eligible for a full text review. Articles were selected based on the following inclusion criteria: titles and abstracts that contained the search terms or content relevant to emergency management outcomes for one of the six identified domains. Relevant populations of older adults included those that live in assisted living facilities, nursing homes, independently at home, and those that are homebound or homeless. There were no geographic restrictions for the study population. All articles that met the inclusion criteria were saved in the reference manager Mendeley for future review and referencing. Legislative and policy documents were retrieved using Google. A search to identify established best practice guidelines for infection control was also conducted using Google. The searches yielded a combined total of 4390 academic literature as well as 15 legislative/policy oriented documents and 19 guidelines. After screening and full-text review, 52 peer reviewed papers were selected for data extraction and inclusion in addition to the 15 legislative/policy documents and 19 guidelines. Review of the findings led to the generation of 29 evidence-informed recommendations. Media Scan and Content Analysis of Reports Given the focus of Domain 5 on policy/legislation, a media scan was conducted as a parallel process to identify news reports, discussion papers and policy/legislative documents from provincial to federal levels. A content analysis of predominantly media reports was conducted to identify disasters or emergencies in Canada that had not been captured by the academic literature between 2008 and 2018. News reports were reviewed for statistics that were reported on resulting causalities or number of people impacted. The scan was conducted with a special focus on rural and remote regions, and the First Nation, Inuit and Metis populations of Canada. Key themes were identified from the content analysis that were then integrated into the white paper. 23 Expert Interviews To gather information on the preparedness, response and recovery experience of Indigenous Older Adults in Canada, the Canadian Red Cross (CRC) undertook a series of interviews with provincial emergency response personnel in four provinces that highlighted key issues and good practices observed through the experience of collaborating with Indigenous communities on preparedness activities, as well as through CRC operational support in evacuation and recovery operations. The themes identified through these interviews informed the text that supports recommendation 3.3. Consensus Decision-Making Process In June 2018, the American Red Cross (ARC) Scientific Advisory Council (SAC) and the American Academy of Nursing (AAN) Policy Expert Round Table on Emergency/Disaster Preparedness for Older Adults hosted a Policy Expert Round Table on Emergency/Disaster Preparedness for Older Adults (Policy Expert Round Table) to evaluate the findings of our scientific review and the feasibility of the proposed recommendations. To facilitate an evaluation of the recommendations and potential remaining gaps in emergency preparedness, a consensus decision-making process was adapted for the Policy Expert Round Table because it is an effective method of facilitating a collective contribution to a solution or intervention by encouraging dialogue, with the aim of considering and addressing the opinions and concerns of each of the participating experts (Seeds for Change, 2010). Consensus decisionmaking is a problem-solving process that aims to develop solutions that are supported by all the contributors. This is in contrast to voting processes, which generate solutions that reflect and satisfy the opinions of the majority of the contributors, but not the entire group (Seeds for Change, 2010). Nineteen experts were invited to participate in the Policy Expert Round Table; however, only 15 participants were able to attend. The final group consisted of experts from a variety of backgrounds related to disaster preparedness for older adults, including social work, education, public health or public health research, health policy, emergency management, geriatrics, and nursing. To better facilitate engagement in the topic during group discussions, all the participants were emailed a copy of the summary of evidence tables from the American systematic literature review. This gave the participants an opportunity to become familiar with the findings that were used to formulate the initial recommendations and guide any external research of their own which could later be used in discussion and amendments to the recommendations. In August 2018, a draft of this US report was sent to all attendees of the Policy Expert Round Table, and additional experts and organizations who were not able to attend the Policy Expert Round Table. This gave all attendees another opportunity to provide final critiques of the recommendations, and all non-attendees an opportunity to contribute feedback to the recommendations. The combined contribution of the two rounds of review ultimately generated the 25 final recommendations presented in a white paper titled “Closing the Gap: Advancing Disaster Preparedness, Response and Recovery for Older Adults.” BACKGROUND AND CONTEXT CLOSING THE GAPS: ADVANCING EMERGENCY PREPAREDNESS, RESPONSE AND RECOVERY FOR OLDER ADULTS 24 In May 2019, the Canadian Red Cross and the National Institute on Ageing came together to host a similar Expert Policy Round Table using an identical process to adapt the initial recommendations to a Canadian context. The Round Table brought together 18 experts from a variety of fields, including social work, education, research, health policy, emergency management, geriatrics, and nursing. The Policy Expert Round Table used a consensus-based decision-making process to review and critique the existing scientific evidence that was retrieved during the scientific review, as well as the endorsed recommendations from the American Red Cross/ American Academy of Nursing Policy Expert Round Table on Emergency/Disaster Preparedness for Older Adults. Review of the recommendations by the panel led to the generation of 26 initial evidence-informed recommendations that aim to reduce the occurrence of adverse emergencyrelated outcomes for older adults by increasing emergency preparedness among individuals and unpaid caregivers, and leverage appropriate emergency-related resources and strategies among the remaining emergency management domains. To begin the decision-making process, the existing issues related to emergency preparedness, and the proposed recommendations for intervention, were introduced and explained to all the participants in one large group. This gave the participants an opportunity to briefly review the methodology, a summary of evidence tables and the recommendations for intervention. The recommendations were divided into six sections based on the emergency management domains that were determined to be responsible for adopting or enforcing a given recommendation. After reviewing the supporting documents, three rounds of breakout sessions divided the participants into smaller groups. Breakout session one was used to review the list of recommendations for individuals and unpaid caregivers, community services and programs, and health care professionals and emergency response personnel. Breakout session two was used to review the list of recommendations for care institutions and organizations, and legislation/policy. Breakout session three was used to review the list of recommendations for research. Participants were able to select which breakout session groups they wanted to be placed in by indicating their preferences during the week prior to the Policy Expert Round Table. Since there were 18 participants and six sets of recommendations, each panellist participated in one recommendation discussion per breakout session. In their discussion groups, each participant was asked to consider the following discussion questions when reviewing the recommendations:
What issues/topics related to this area are missing from the evidence available?
Are the current recommendations adequate to address the issues related to this area?
What further additions/edits do you suggest to the current recommendations and why? The goal of the research questions was to facilitate discussion regarding the feasibility of the recommendations and whether or not the proposed recommendations sufficiently addressed the current gaps in emergency preparedness, response and recovery for older adults. The time allocated to the breakout sessions was used to provide their comments and 25 critiques on the initial recommendations, make amendments to the initial recommendations, or propose additional recommendations that were not included in the initial draft, as well as to discuss and reach consensus on issues related to comprehension and syntax of each of the recommendations that were delegated to a specific group. A consensus was required before new recommendations were added to the list, or omissions or amendments were made to the initial recommendations. If participants reached a point of disagreement within their group, facilitators probed participants for additional comments, clarification, justification or new approaches to problem-solving in order to reach a consensus within the group. After the participants reviewed all the recommendations in their breakout groups, the Policy Expert Round Table concluded with a final face-to-face meeting with all 18 participants. This meeting gave each breakout group an opportunity to present the final copy of their proposed recommendations drafted from the outcomes of their discussions, and also provided the participants who were not present in the remaining two groups an opportunity to discuss the feasibility of these recommendations as well. Review of the recommendations by the panel led to the generation of the 26 evidenceinformed recommendations that aim to reduce the occurrence of adverse emergency related outcomes for older adults by increasing emergency preparedness among individuals and unpaid caregivers, and leverage appropriate emergencyrelated resources and strategies among the remaining emergency management domains. In May 2020, given the devastating impact that the COVID-19 pandemic was having on older adults, both the CRC and NIA agreed to expand this report’s focus to also include infectious disease epidemics. This led to a second phase systematic review being conducted to inform the updating of the existing recommendations and the creation of three additional ones. The report and its now 29 recommendations were circulated among the attendees of the Policy Expert Round Table, and additional experts and organizations who were not able to attend the Policy Expert Round Table in August 2019. This gave all attendees another opportunity to provide final critiques of the recommendations, and all non-attendees an opportunity to contribute feedback to the recommendations. The combined contribution of the rounds of review ultimately generated the 29 final evidence-informed expert recommendations presented in this white paper. BACKGROUND AND CONTEXT CLOSING THE GAPS: ADVANCING EMERGENCY PREPAREDNESS, RESPONSE AND RECOVERY FOR OLDER ADULTS 26 Domain 1: Individuals and Unpaid Caregivers Older adults, in particular those who are living with chronic health conditions, are low-income and/or have low literacy skills, tend to disproportionately experience adverse outcomes during emergencies. There is also an opportunity for less-vulnerable older adults to play an important role in reaching out and connecting with their peers (and their unpaid caregivers) in helping them anticipate and prepare for emergencies. Older adults can best ensure their needs and concerns are represented in the emergency management space, and should be encouraged to volunteer their time before, during and after emergencies. There is a clear opportunity to develop, implement and evaluate emergency preparedness and response activities at the individual level that can better improve knowledge and recovery outcomes for older adults and their unpaid caregiver(s). An investigation of the vulnerabilities of older adults during emergency was guided by Research Question 1: What are the factors that make older adults more vulnerable to adverse outcomes during an emergency compared to younger adults? (see Development Approach). The search strategies that were used yielded a combined total of 4,390 peer-reviewed journal articles, 13 of which were used along with five guidance documents for data extraction related to this specific question. The review of these 18 resources revealed that older adults who are reliant on medications, and life-sustaining or assistive devices to support their health and wellbeing, have an increased risk for experiencing an adverse outcome during an emergency. Older adults are also more susceptible to infectious diseases after diseases or as a result of a pandemic that may exacerbate their pre-existing health conditions. Consequently, in response to this gap, nine evidence-informed expert recommendations were developed with the aim of increasing the levels of emergency preparedness among older adults with health- and/or function-related declines, and their unpaid caregiver(s). Recommendation 1.1 Older adults and their unpaid caregiver(s) should be provided with tailored, easy-to-access information and resources related to emergency preparedness and guidance on how to develop customized emergency plans, that consider the functional and health needs of older adults and appropriate strategies to support infection/disease prevention. Volunteer representatives of older Canadians and their unpaid caregivers should be recruited and involved in training material development and implementation, to ensure their voices and perspectives are reflected. Recommendation 1.2 Older adults who are reliant on mobility aids should remove or minimize barriers affecting their ability to evacuate, and take steps to ensure their safety within their surroundings. Recommendation 1.3 If registries for people with functional and other needs, including persons with disabilities, have been established by local emergency response agencies, older adults and/or their unpaid caregiver(s) should register so they can be better assisted/supported during emergencies. 27 DOMAIN 1: INDIVIDUALS AND UNPAID CAREGIVERS Recommendation 1.4: Older adults who have a sensory impairment, such as a visual or hearing disability, should take additional precautions to prepare themselves for emergencies. Understanding the Unique Personal and Functional Needs of Older Adults During Emergencies An older adult’s access to the support services that they require to maintain their overall quality of life and independence, such as home care and community services, can be disrupted during emergencies, or while being evacuated or sheltering-in-place. These circumstances can be further challenged by a lack of age-friendly services, a lack of accommodations for older adults at shelters, and concerns around pet safety and evacuation. Indeed, households who own pets are less likely to evacuate than those without pets. This is likely because people are concerned that they will not be evacuated with their pets, which is often cited as one of the main contributors to why people do not evacuate during emergencies (Benson, 2017; Whitehead, et al., 2000). One of the many strategies that can be leveraged to improve emergency preparedness among older adults is to encourage self-preparedness through the provision of easy access to emergency preparedness educational materials and planning guides that are tailored to older adults. Many organizations currently provide access to online emergency preparedness resources, such as the Government of Canada’s Get Prepared Campaign and the Canadian Red Cross Be Ready Campaign, which provide resources specific to a variety of emergencies and links to additional community resources (Canadian Red Cross, 2019; Government of Canada, 2015). While many of these resources aim to encourage older adults to prepare for a variety of emergencies, they do not provide solutions to overcome the unique challenges that many older adults face when preparing for, responding to, and recovering from an emergency. To address this current gap in emergency preparedness resources for older adults, Recommendation 1.1 aims to encourage older adults and their unpaid caregivers to access preparedness information and resources tailored for older adults, and to be particularly mindful of their functional and health-related needs when developing an emergency plan. For those organizations developing and distributing these resources, involving older adults in preparation and delivery is critical to ensuring the needs, concerns, and perspectives of older Canadians are considered (Marshall, Ryan, Robertson, Street, & Watson, 2009; Al-Rousan, Rubenstein, & Wallace , 2014). Resources should also be tailored to meet the language needs of diverse communities to increase accessibility where needed among older adults from racialized communities. Emergencies such as pandemics affect the most vulnerable groups and particularly those who experience social adversities that are exacerbated by the intersection of factors such as age, race and income (Navaranjan, Rosella, Kwong, Campitelli, & Crowcroft, 2014; Tricco, Lillie, Soobiah, Perrier, & Straus, 2013; Blackmon, et al., 2017). By making emergency preparedness information more accessible and encouraging older adults from diverse groups and their unpaid caregivers to take the initiative in evaluating their needs and developing appropriate plans to accommodate their expected challenges, this can help older CLOSING THE GAPS: ADVANCING EMERGENCY PREPAREDNESS, RESPONSE AND RECOVERY FOR OLDER ADULTS 28 adults be more confident in their abilities to be self-reliant when responding to an emergency or provide the additional resources needed to help emergency response personnel better assist older adults with functional limitations. Older age is often associated with a decline in motor functioning which can put older adults at risk of harm if they are unable to access their daily assistive devices, such as walkers and wheelchairs, or their unpaid caregivers during an evacuation (Bhalla, Burgess, Frey, & Hardy, 2015). Health professionals such as occupational therapists can be a valuable resource in the preparation and development of an emergency plan that factors in the functional needs of older adults reliant on assistive devices. Occupational therapists can also identify and help address environmental barriers to accommodate the needs of older adults and people with disabilities in order to facilitate effective emergency preparedness (Jeong, Law, DeMatteo, Stratford, & Kim, 2016). For example, at evacuation shelters, people with disabilities require ramps wide enough to accommodate wheelchairs (American Occupation Therapy Association, 2006). In addition to functional needs, emergency plans should also reflect strategies to prevent health emergencies resulting from either a pandemic or infections following natural disasters such as floods (Kouadio, Aljunid, Kamigaki, Hammah, & Oshitani, 2012). Consequently, emergency preparedness resources for older adults should include strategies for the primary prevention of infectious disease transmission in the home (Centers for Disease Control and Prevention, 2020; Finkelstein, Prakash, Nigmatulina, McDevitt, & Larson, 2013). However, as outlined in Recommendation 1.2, by preparing to overcome barriers to preparedness, such as environmental barriers that prevent successfully and timely evacuation, older adults can independently ensure that they have developed a more effective emergency evacuation plan. Strategies to address environmental barriers include installing wheelchair ramps, evacuation chairs and/or arranging for home evacuation and transportation assistance from a family member, friend, or unpaid caregiver, (Government of Canada, 2018). Allied health professionals such as occupational therapists can help adapt living spaces in order to maximize independence, safety and security, and are therefore able to plan accordingly for safe and effective evacuations (Fagan & Sabata, 2011; Stark, Landsbaum, Palmer, Somerville, & Morris, 2009). The Potential Role of Registries for People with Functional and Other Needs, Including Persons with Disabilities Registries for people with functional and other needs, including persons with disabilities, who live in the community are resources and data sources that have been established in many municipalities to provide emergency response agencies with a reference of the functional needs of residents in a community to allow emergency responders to better serve them. While registries can act as a resource for quickly locating persons with functional or other needs, it is not being recommended as a primary source of assistance for older adults or emergency response agencies to prepare for and respond to emergencies. This is because governments and aid agencies cannot guarantee that their assistance will be provided due to the high demands for response assistance during emergencies, which limits the availability of these services. In addition, Round Table discussion of the limitations of registries identified 29 DOMAIN 1: INDIVIDUALS AND UNPAID CAREGIVERS that vulnerability can be event-specific, and these registries can quickly become outdated, and have proven to be sometimes ineffective at identifying individuals in their target audience because many persons avoid registering because they do not consider themselves to be vulnerable, or out of fear of the stigmas associated with being labeled as ‘vulnerable persons.’ There was also concern that registries often instill the incorrect assumption that persons who have registered will be provided with priority assistance during an emergency. In reality, severe emergencies such as natural disasters and pandemics can be so resource restricting and demanding that emergency services cannot be guaranteed regardless of the severity of an individual’s condition or needs. With these limitations in mind, the Round Table participants arrived at a consensus that older adults who live in municipalities that have established registries should consider registering for this service, however, establishment of these registries should not be a requirement, as stated in Recommendation 1.3. Instead, it is intended that Recommendation 1.1 through Recommendation 1.9 will facilitate sufficient self-preparedness at the individual level by providing the guidance needed to develop an emergency plan that is customized to meet the health and functional needs of an individual older adult. Supporting Older Adults with Sensory Impairments Vision or hearing impairments can make it challenging for older adults to safely respond during an emergency, such as when navigating their surroundings at night or in an unfamiliar environment, or being able to effectively recognize emergency warnings (Cloyd & Dyer, 2010). While many preparedness resources already recommend that persons with sensory impairments make changes to their environment or take extra precautions that will make it easier for them to protect themselves during an emergency, Recommendation 1.4 proposes additional considerations to better prepare older adults with sensory impairments to respond to emergencies. Older adults with hearing impairments may find it difficult to hear emergency updates, instructions or communicate in a noisy environment (Banks, 2013; Cloyd & Dyer, 2010). To better assist older adults with a hearing impairment to communicate with emergency personnel, strategies should be adopted to help notify assisting personnel of their hearing impairment as outlined in the Government of Canada’s Emergency Preparedness Guide for People with Disabilities/Special Needs (Government of Canada, 2018). Strategies include moving their lips without making a sound or pointing to their ear/hearing aid. An effective strategy for notifying others of their hearing impairment will help signal to assisting personnel that they should adjust their communication approach to better accommodate persons with a hearing impairment. Many emergency preparedness guides urge for the installation of alert devices and emergency plans that incorporate oral communication with support network members; however, these guides often neglect to provide recommendations specific to persons who are hearing impaired, and therefore may be unable to use traditional emergency devices (Government of Canada, 2018). To tailor emergency communication plans to better meet the capabilities of persons with CLOSING THE GAPS: ADVANCING EMERGENCY PREPAREDNESS, RESPONSE AND RECOVERY FOR OLDER ADULTS 30 hearing impairments, non-verbal communication devices, such as text messages and teletypewriters should be adopted for communication. Since these communication devices do not depend on verbal communication, they can allow persons with hearing impairments to quickly and effectively contact support network members to ask for assistance, provide updates on their status and location, and better mimic everyday communication devices used by persons who are hearing impaired. Additionally, emergency plans that encourage the installation of alert devices that use lights or vibrations in addition to sound, such as bed shaker alarm devices, may be more effective at alerting persons with hearing impairments of an emergency than conventional alert devices that solely produce loud sounds when activated. Plans should also include additional batteries to power devices in case of a long-term power outage. Persons who are visually impaired are likely to experience challenges in navigating their surroundings during an emergency, particularly in a poorly lit shelter or in unfamiliar places, which can cause them to respond more slowly to emergencies or have difficulty following guidance outlined in emergency protocols (Lamb & O'Brien, 2010). To increase preparedness and enable older adults and their unpaid caregivers to respond effectively to emergency directives assistive devices, such as mobility aids (canes, walkers), and strategies, such as, a buddy system or guide animals, should be incorporated into emergency plans. To plan for unexpected interruptions or evacuations, it is also recommended that older adults with visual impairments and/or their unpaid caregivers include alternative evacuation routes and transportation methods into their emergency plan. By tailoring their surroundings and their emergency plans to better meet their needs, older adults with sensory impairments can create a plan that will allow them to be prepared during an emergency. Recommendation 1.5: Older adults who live with chronic health conditions should maintain a readily accessible list of their current medical conditions, treatments (medications, durable medical equipment, supplies and other health care needs), health care providers, and emergency contacts, including substitute decision makers (SDMs). Recommendation 1.6 Older adults who take medications should work with their health care providers to ensure they have access to at least a 30-day supply of medications during an emergency. Recommendation 1.7 Older adults who are reliant on medical devices that require electricity, should ensure they have back-up power supplies in place, especially if required while sheltering-in-place.
Older adults and/or their unpaid caregivers should seek assistance with obtaining and maintaining an alternative power source at home, if required, such as when being required to move heavy equipment and fuel or in accessing these resources in rural locations, and operating equipment. 31 DOMAIN 1: INDIVIDUALS AND UNPAID CAREGIVERS Supporting Older Adults with Chronic Health Issues The resource-straining effects of severe emergencies continue to threaten access to resources needed to support the complex needs of older adults with chronic health conditions during an emergency. Emergencies such as natural disasters can detrimentally affect one’s health by not only disrupting health services but also by creating power outages that can interrupt medical interventions that depend on electricity, such as life-supporting devices or medications that must be refrigerated during storage. During the 1998 ice storm at least 600,000 people, including older adults in long-term care institutions, were forced from their homes into hotels or other shelter with emergency power backup (Steuter-Martin & Pindera, 2018). Lack of mobility, pre-existing medical conditions, lack of heating equipment, less optimal housing conditions, and poor coordination between emergency, health and social services contributed to the high mortality rate among older Quebec residents. Older adults were at increased risk because of increasing frailty combined with social isolation among individuals (van Solm A. , 2016). Barriers to accessing electricity and medications can be detrimental to the health of older adults due to the high prevalence of chronic health conditions, such as hypertension, high cholesterol, and diabetes within this subpopulation (National Council on Aging, 2018). Recommendation 1.5 aims to encourage the creation and/or incorporation of a resource for incorporating an individual’s medical history into their preparedness plan by encouraging older adults to prepare an outline of their medical condition(s), medical treatment(s) and their health care provider(s) and emergency contacts for their emergency kit. Having a summary of their medical history as a part of their emergency kit will help older adults minimize disruptions to their care during emergencies (Centers for Disease Control and Prevention, 2020; Kosatky, et al., 2009). In doing so, unpaid caregivers and health care providers who may be unfamiliar with their conditions will have the medical information necessary to effectively support their health needs, or continue their care in the case of a medical emergency or after relocation to a care facility or shelter. Improving Access to Necessary Medications During Emergencies Shortages of essential medications can often lead to an exacerbation of a pre-existing chronic medical condition. To prevent running out of medications and subsequent surges in medication refill requests during emergencies, as was experienced at the Staten Island University Hospital ED during Hurricane Sandy and at shelters during Hurricane Katrina, Recommendation 1.6 encourages older adults to work with their health care providers to obtain access to a supply of emergency medications for their emergency kit. It is essential that older adults explore their possible options for obtaining additional supplies of medications when preparing for emergencies (Ford, Trent, & Wickizer, 2016). Retrospective reviews of medical services provided during emergencies repeatedly cite surges in medication refill requests as a leading cause of medical services (Currier , King, Wofford , Daniel, & deShazo , 2006; Greenstein, Chacko, Ardolic, & Berwald, 2016; Jhung, et al., 2007; Kraushar & Rosenberg, 2015; Ochi, Hodgson, Landeg, Mayner, & Murray, CLOSING THE GAPS: ADVANCING EMERGENCY PREPAREDNESS, RESPONSE AND RECOVERY FOR OLDER ADULTS 32 2014). This high demand for prescription medications suggests that evacuees may benefit from reduced barriers to accessing medications during emergencies, increased education from health care professionals on the benefits of preparation through having enough medication during an emergency, or increased access to more information on how to access emergency medication supplies prior to an emergency. It is important that older adults are provided with the resources to adequately self-prepare to support their pharmaceutical needs during an emergency. Supporting Older Adults with Electronic Life-Supporting Devices To prevent interruptions to the supply of power to electronic life-supporting devices, as outlined in Recommendation 1.7, preliminary efforts should be made to contact the user’s electricity company to inquire about priority service restoration during emergencies to persons who have life-supporting devices at home, as well as alternative power sources that can be safely used at home. It should be noted that older adults may require assistance with obtaining and maintaining an alternative power source at home, such as when moving a generator and fuel, as well as accessing these resources in rural locations and operating them. During these instances, support network members may be a reliable source of assistance. By establishing plans to safely, effectively, and independently support the health of an older adult who is dependent on a life-supporting device during an emergency, scenarios that can lead to deteriorating health and hospitalizations can be prevented/avoided. Recommendation 1.8 Older adults should be encouraged to continually maintain an adequate local support network that can be called upon during impending disasters and unexpected emergencies, especially if they live alone or lack easy access to relatives. Developing and Maintaining a Personal Support Network Having a support network can greatly aid older adults by providing the emotional and material resources they need to reduce the stress of preparing for and surviving an emergency. Many older adults live without a spouse or a family member, and are more susceptible to social isolation and/or dependent on unpaid caregivers for assistance (Gibson & Hayunga, 2006). Dependence on the assistance of unpaid caregivers is so prevalent among older adults that 90 per cent of adults who are 65 years or older and living with a disability who report receiving assistance are supported by unpaid caregivers, (Gibson & Hayunga, 2006) while approximately 50 per cent of adults who are 85 years or older report living alone (Fernandez, Byard, Lin, Benson, & Barbera, 2002). An emergency can leave those that rely on daily assistance stranded and unable to care for themselves if rescuers and their unpaid caregiver(s) cannot reach them. To reduce the negative impacts of social isolation, Recommendation 1.8 advises all older adults to establish a support network they can depend on for assistance in preparing for and responding to all emergencies relevant to their region. Support networks act as protective factors against emergency events, especially among seniors. According to a study done in Quebec, a well-established social network benefits older 33 DOMAIN 1: INDIVIDUALS AND UNPAID CAREGIVERS adults’ overall health during extreme heat events (Laverdiere, et al., 2016). For older adults with chronic health conditions, each member of their support network should be able to provide basic support for their health, such as access to their medication list, and should have the knowledge needed to identify and operate all required medical equipment. It is intended that by being able to provide basic support, support network members will be able to work together with the person they are caring for to provide the assistance needed to prevent interruptions to their medical care and avoid hospitalizations. It is also important that their support network consist of at least two people who live in close proximity to them because this will enable members to provide assistance within minutes, which will prevent prolonged periods of being incapacitated or stranded. Recommendation 1.9 Unpaid caregivers of persons with Alzheimer’s disease and/or other dementias should be supported to identify signs of distress, anxiety, or confusion, and use strategies to redirect attention and help them stay calm during emergencies. In addition, unpaid caregivers should be prepared to prevent wandering and have plans in place to locate their care recipients if they do wander or require medical intervention(s) during an emergency. Supporting the Unique Needs of Older Adults Living with Dementia A decline in working memory and an impaired ability to filter out irrelevant information are two changes in cognitive function associated with Alzheimer’s disease and related dementias (ADRD). These changes can impede the more than 500,000 older Canadians living with Alzheimer’s disease and related dementias from identifying a disaster situation, following emergency preparedness recommendations, adapting to changes in their routine and environment, or following emergency warnings and instructions (Alzheimer Society of Canada, 2019; Alzheimer Society of Canada, 2018). In addition, new behavioural problems can arise, existing behaviours can become exacerbated, or function can deteriorate rapidly, if there are interruptions to the administration of dementia-related medications (Cloyd & Dyer, 2010). Re-establishing routines and valued occupations can also help disaster survivors cope with stress and anxiety (American Occupation Therapy Association, 2006). Dementia can also be compounded by the occurrence of delirium. Delirium is a state of confusion that comes on suddenly and is characterized by an inability to think clearly and pay attention, as well as an unawareness of one’s environment (American Delirium Society, 2015). The most common causes of delirium include infection, medications, electrolyte or blood sugar disturbances, hypoxemia, and low blood pressure (Cloyd & Dyer, 2010). Since individuals with more advanced dementias require daily assistance to help them perform their activities of daily living (ADLs) and protect them from dangers, it is necessary that their unpaid caregiver(s) be educated about the unique precautions that should be taken to reduce the occurrence of adverse behaviors and outcomes for the person they are caring for during an emergency. In particular, unpaid caregivers should receive education and support CLOSING THE GAPS: ADVANCING EMERGENCY PREPAREDNESS, RESPONSE AND RECOVERY FOR OLDER ADULTS 34 on addressing distress, anxiety, wandering, and confusion; approaches such as validation and gentle persuasion to address moments of agitation; how to communicate with and soothe older adults living with ADRD when they are in crisis; and methods of communication that aid in orientation and memory retention. Comfort Keepers of Canada is an organization that provides home care for older adults. Due to its vast experience with seniors suffering from dementia, Comfort Keepers of Canada suggests tips on how to prevent older adults with dementia from wandering which also include maintaining a calm and stress-free environment, especially during an emergency. With the help of health care professionals, caregivers can be better equipped to provide care during an emergency. For example, nurses, therapists and social workers can all provide interventions that take the form of education, training, and support for caregivers of persons with dementia. These interventions can include behaviour management strategies, communication skills, cognitive reframing, and mindfulness techniques that have been shown to greatly increase a caregiver’s ability to care for their loved ones (Etters, Goodall, & Harrison, 2008; Piersol, et al., 2017; Sorensen, Pinquart, Habil, & Duberstein, 2002). Further, emergencies such as infectious disease pandemics can present unique challenges for unpaid caregivers. It is important for unpaid caregivers of older adults with Alzheimer’s or advanced dementia to stay abreast of any relevant information regarding the pandemic and use strategies that can protect themselves and the older adult (Centers for Disease Control and Prevention, 2020). As an additional precaution, unpaid caregivers should register their care recipient for an emergency response service for persons with ADRD (Dyer, Regev, Burnett, Fest, & Cloyd, 2008), such as the Medic Alert Safely Home program, to provide emergency response assistance if their care recipient wanders away. 35 Community-based organizations and their staff are likely to be engaged in response and recovery efforts for older adults and their unpaid caregivers, depending on the level to which their services and programs support older adults and their unpaid caregivers. Therefore, a clear opportunity exists to develop, implement and evaluate preparedness and response activities for Community-Based Services and Programs that can better facilitate knowledge translation and exchange within the community and increase levels of preparedness, response and recovery efforts and outcomes among designated populations and those personnel that have the responsibility to support them. An investigation of existing community-based resources that can contribute to improving emergency preparedness, response and recovery outcomes for older adults was guided by Research Question 2: What are the strategies and resources that can be leveraged at the community and progam levels to improve emgergency (natural disaster or pandemic) preparedness for older adults? (see Development Approach). The search strategies that were used yielded a combined total of 4,390 peer-reviewed journal articles, five of which were used along with eight guidance documents for data extraction related to this specific question. The findings from these resources identified that there is a greater need for seniors-tailored community-integrated preparedness and response services to encourage and facilitate increased levels of preparedness and support recovery. Consequently, in response to this gap, four evidence-informed expert recommendations were developed with the aim of addressing identified opportunities noted for community-based services and programs to better support emergency preparedness and response. Recommendation 2.1 Access should be increased to tailored communitybased programs that educate older adults and their unpaid caregivers about emergencies that could affect their region and how best to prepare for and respond to them. Volunteer representatives of older Canadians should be recruited and involved in training material development and implementation, to ensure their voices and perspectives are reflected.
Community-based programs and organizations should collaborate with regional public health authorities in developing and disseminating education resources on infection control, disease and injury prevention practices for older adults and their caregivers during emergencies. Improving Community-Based Emergency Preparedness Educational Programs Many of the adverse outcomes that older adults face during and after an emergency can be avoided by simply being informed about the dangers associated with the emergency that could affect their region, the appropriate precautions they should take to keep themselves safe, and adopting behavioural changes that facilitate adequate self-preparedness. When interviewed about their self-perceived preparedness for emergencies, older adults have been found to report low levels of preparedness. In a study that investigated nation-wide preparedness of older adults, 23.6% of the 1,304 participants interviewed reported that they had an emergency evacuation plan, 24.8% did not have access to a car or other form of transportation in case of an emergency, and DOMAIN 2: COMMUNITY-BASED SERVICES AND PROGRAMS Domain 2: Community-Based Services and Programs CLOSING THE GAPS: ADVANCING EMERGENCY PREPAREDNESS, RESPONSE AND RECOVERY FOR OLDER ADULTS 36 only 4.9% reported that at least one of their health care providers had discussed what to do during an emergency with them (Al-Rousan, Rubenstein, & Wallace , 2014). Another study was conducted by Marshall, Ryan, Robertson, Street and Watson to measure community knowledge about and attitudes toward the threat of a pandemic influenza as well as community acceptability of strategies to reduce its effect (Marshall, Ryan, Robertson, Street, & Watson, 2009). Computer-aided telephone interviews were conducted with a cross-sectional sample of rural and metropolitan residents of South Australia among 1,975 households. Of those who responded, 50% indicated that they had never heard of a pandemic influenza or were unaware of its meaning. Only 10% were extremely concerned about the threat of a pandemic influenza (Marshall, Ryan, Robertson, Street, & Watson, 2009). Despite the widespread publicity regarding influenza and advocacy to build a base level of awareness and understanding among the population, it was found that the majority of adults in the community, particularly older adults, were unaware of the possibility of a pandemic influenza strain (Marshall, Ryan, Robertson, Street, & Watson, 2009). To increase the low levels of emergency preparedness found in the general public, community-based emergency preparedness training courses have been piloted and found to be effective tools for encouraging behavioral change. For example, in the United States, PrepWise is a disaster preparedness program designed to assist older adults in developing a tailored home-based disaster preparedness plan (Catizone, 2017). During the training sessions, the participants were guided through seven learning modules: (1) knowing types of emergencies and what to do, (2) vulnerability assessment (alerts/warnings, evacuations, transportation, communication, sheltering, personal care, and medical care and equipment), (3) developing a personal emergency support network (formal list of family/friends and local community members), (4) making an emergency plan, (5) keeping a supply of medications, (6) making an emergency supply kit, and (7) making home, school, work, and car travel safer (Ashida, Robinson, Gay, Slagel, & Ramirez, 2017). Upon follow up, it was reported that enrolment in the PrepWise program led to a greater understanding of disaster preparedness requirements, such as preparing an emergency kit and designating alternative shelters to be used in the event of an emergency (Ashida, Robinson, Gay, & Ramirez, 2016; Ashida, Robinson, Gay, Slagel, & Ramirez, 2017). The PrepWise program was also found to encourage participants to seek out additional emergency support network members to whom they could turn to for help, in addition to family members most participants had identified prior to being enrolled in PrepWise (Ashida, Robinson, Gay, Slagel, & Ramirez, 2017). Similar successes in using community-based emergency preparedness training sessions were also found with the Ready CDC disaster preparedness education program, which was designed to increase knowledge, influence attitudes and strengthen community resiliency. Ready CDC uses the following tactics: (1) gain attention, (2) present stimulus material, (3) provide learning guidance, (4) elicit performance and provide feedback, and (5) enhance retention and transfer to facilitate behavioural change (Thomas, et al., 2018). When levels of behavioural 37 change through the Trans-Theoretical Model (TTM) were evaluated within a sample of 212 CDC staff and public health employees who had completed the Ready CDC disaster preparedness education program, 44 per cent of enrollees progressed to at least one stage higher or remained at the “maintenance” stage for assembling an emergency kit, and 45 per cent of participants progressed to at least one stage higher or remained at the “maintenance” stage for developing a written emergency plan (Thomas, et al., 2018). In addition, during follow up, the 25 per cent, 27 per cent, and 43 per cent of participants in the “pre-contemplation”, “contemplation”, and “preparation” stages at baseline for assembling an emergency kit, respectively, were identified as having progressed to the “preparation” stage (Thomas, et al., 2018). These results suggest that community-based emergency preparedness sessions are effective methods for conveying emergency preparedness information to the public and facilitating behavioural change. Recommendation 2.1 outlines a strategy for the development of nation-wide community-based emergency preparedness education programs for older adults. The program’s content should include, but not be limited to, modules about the different types of natural and man-made disasters that affect a given region, the effects and associated dangers of these disasters, as well as guidance and participatory learning on how to perform a personal vulnerability assessment, how to make an emergency plan and kit, the importance of developing and maintaining a social support network, and strategies and resources to aid recovery. For those organizations developing and distributing these materials, involving older adults and local public health authorities in the preparation and delivery is critical to ensuring the needs, concerns, and perspectives of older Canadians are considered. Engaging with local public health authorities will provide another layer of expertise and infrastructure in the development and evaluation of health interventions to mitigate negative health outcomes. In Canada, the University of Manitoba, along with the Natural Resources Institute, arranged a workshop for practitioners in risk and hazard management titled Canadian Risks and Hazards in 2004. The organizers believed that a workshop titled around disaster management or emergency management would not attract the wide range of participants that they desired because those fields may be perceived to be too narrow in focus (Public Safety and Emergency Preparedness Canada, 2004). This issue emphasizes the lack of community knowledge on the connection between hazards, risks, disasters, and preparedness in Canada. Community-based emergency preparedness programs should aim to achieve accessibility for persons with lower literacy skills, non- English speakers and Indigenous seniors, and the incorporation of age-friendly considerations into its structure, such as appropriate visuals, and distribution of emergency kits that are easy to transport, if applicable. Community-based emergency preparedness training classes that have been adapted to address the unique needs of older adults should maximize the positive impact they have among older adults. Recommendation 2.2 Programs that provide disaster relief and/or essential community services, such as Meals on Wheels, and daily living assistance for older DOMAIN 2: COMMUNITY-BASED SERVICES AND PROGRAMS CLOSING THE GAPS: ADVANCING EMERGENCY PREPAREDNESS, RESPONSE AND RECOVERY FOR OLDER ADULTS 38 people (financial, medical, personal care, food and transportation) should receive emergency preparedness training and education as well as develop and adhere to plans and protocols related to responding adequately to the needs of their clients during emergencies. Volunteer representatives of older Canadians and their unpaid caregivers should be recruited and involved in training material development and implementation, to ensure their voices and perspectives are reflected. Better Leveraging Community Support Services to Aid in Emergency Response Efforts Community-accessible resources have been found to be associated with facilitating higher levels of preparedness among older adults. In a 2017 study that examined the socio-demographic factors that influence levels of emergency preparedness among persons 50 years and older, participants who discussed emergency plans with their physician were more likely to be prepared than older adults who did not (Killian, Moon, McNeill, Garrison, & Moxley, 2017). Similar to physician visits, community agencies and programs that have a significant proportion of older users could act as an accessible portal for encouraging older adults to access emergency preparedness and recovery aids and services. Recommendation 2.2 highlights need for community services and programs to receive emergency preparedness training and education to provide appropriate supports for older adults (Centers for Disease Control, 2020). An additional benefit to incorporating emergency preparedness and recovery efforts into the scope of services provided by community agencies and programs, as well as managers of housing for older adults, is the additional social support that these resources can provide. One Canadian study suggested that leveraging interRAI assessment databases to identify at-risk and vulnerable older adults who are more likely to experience negative outcomes as the result of an emergency could benefit them in all phases of emergency management. InterRAI is a collaborative network of researchers that develops tools with common metrics for clinicians to assess patients. InterRAI tools are now used across Canada and around the world in a variety of settings, including home and community care (van Solm, Hirdes, Eckel, Heckman, & Bigelow, 2017). Leveraging this data could support community service agencies to identify and prioritize older adults who are most at risk of negative outcomes after an emergency. Similarly, to facilitate a holistic recovery, community and local government services could provide further social support, in addition to tangible resources, particularly for older adults who have been identified as having limited or no social support. Recommendation 2.3 Community-based programs that provide in-home health and personal care for older adults should integrate strategies that minimize unnecessary personal contact and leverage resources (e.g. personal protective equipment such as gowns, masks, gloves, hand sanitizer, etc.) in their emergency preparedness plans and protocols. Enabling community-based programs to provide safe in-home supports for older adults during emergencies Many older adults, particularly those who reside at home, are the recipients of communitybased in-home services that are medical and/ 39 or supportive but non-medical in nature. Older adults with complex and often interrelated medical and social comorbidities often rely on these services in their day-to-day life. Emergencies as a result of a natural disaster or pandemic can lead to the disruptions in the delivery of in-home services for older adults as was seen during the COVID-19 global pandemic. The COVID-19 pandemic presented new challenges for care teams that provide in-home services for older adults as emergency protocols were needed to ensure minimal risk for the transfer and spread of the virus. Enabling community-based programs to provide safe in-home care during emergencies can minimize the risk of service interruptions and thereby any impact on older adults. Recommendation 2.3 notes the importance of community-based programs that provide in-home supports leveraging strategies that require minimal personal contact or the use of resources such as personal protective equipment in emergency preparedness. Emergencies such as pandemics and natural disasters both present new challenges with infection control where new pathogens continually emerge. In the event of a pandemic, hygiene and the use of personal protective equipment are seen as two important lines of defense (Bloomfield, Exner, Carlo, Nath, & Scott, 2012). For instance, during the COVID-19 pandemic several best practice guidelines in the use of personal protective equipment were developed and promoted by Infection Prevention and Control Canada (IPAC) (Infection Prevention and Control, 2020), Ontario Health (Ontario Health, 2020) and the World Health Organization (World Health Organization, 2020). Evidence showed that the virus was transmitted between people through droplets and close contact. Many of the recommendations outlined were updated to support health care and other organizations decision-making around the use of PPE and PPE conservation to minimize shortages. Where contact is required, best practice guidelines recommend the use of preventive measures such as maintaining physical distance and performing hand hygiene frequently with an alcohol based hand rub. The International Scientific Forum on Home Hygiene developed a risk-based approach to hygiene that breaks down the chain of infection transmission while addressing other risk factors. An individual’s hands and other environmental sites and surfaces are all a part of the chain of transmission that, if understood, can highlight areas where hygiene based interventions can be used to stop transmission (Bloomfield, Exner, Carlo, Nath, & Scott, 2012). Promoting proper hand hygiene (Ontario Agency for Health Protection and Promotion (Public Health Ontario), Provincial Infectious Diseases Advisory Committee, 2014) and proper environmental cleaning (Ontario Agency for Health Protection and Promotion (Public Health Ontario), Provincial Infectious Diseases Advisory Committee, 2018) inhome and community care settings can minimize the risk of infectious disease transmission. Other strategies that can be used by Home and Community Care providers include screening for both provides and clients in addition to wearing the necessary protective equipment while providing in home support. The Ontario Ministry of Health provided clear guidance on steps to take (Ontario Ministry of Health, 2020; Ontario Ministry of Health, 2020). Other strategies that emerged during the COVID-19 pandemic included an increased use DOMAIN 2: COMMUNITY-BASED SERVICES AND PROGRAMS CLOSING THE GAPS: ADVANCING EMERGENCY PREPAREDNESS, RESPONSE AND RECOVERY FOR OLDER ADULTS 40 of virtual care through telehealth, telemedicine and other virtual platforms. Virtual care programs were expanded during the COVID-19 pandemic to enable care providers in acute hospital care settings to provide new consults and follow-up appointments for their patients (Stamenova, et al., 2020). Acute care physical therapy, occupational therapy, and speech-language pathology telehealth strategies can add value by mitigating COVID-19- related harm and influencing recovery (Exum, et al.). Recommendation 2.4 Local governments should leverage data sources that identify at-risk individuals to enable emergency responders to more easily prioritize their search and rescue efforts following an emergency. Enabling the Development of Repositories of Data Sources to Support Local Government Emergency Response Efforts During the panel discussion, experts recognized that while many registries of people with functional needs, including persons with disabilities, exist for and are easily accessible to municipal authorities, they can be difficult for territorial and provincial authorities to access. To increase the efficiency and identification of at-risk persons by emergency response personnel, it is recommended that local governments create a repository of their data sources. The establishment of a repository of data sources will act as a singular, easy-to-access reference to facilitate a fast-integrated response from neighbouring provincial or federal emergency services. For example, it is intended that providing all national and local aid agencies with a repository of data sources, such as available registries, will help to facilitate the cooperation of different aid agencies to provide the workforce needed to assist with evacuations, distribute emergency supplies and provide medical care. 41 Response and recovery efforts for older adults can vary, depending on the level of training emergency health care professionals, emergency response personnel and other potential first responders receive. Health care professionals indeed play a critical role in emergency preparedness and response because they are often the first point of contact for health-related guidance and care. An investigation of the levels of emergency related competency for health care providers and emergency response personnel was guided by Research Question 3: What are the strategies and resources that can be leveraged to improve emergency response among health care professionals and emergency response personnel during and after an emergency (natural disaster or pandemic)? (see Development Approach). The search strategies that were used yielded a combined total of 4,390 peer-reviewed journal articles, 12 of which were used along with two guidance documents for data extraction related to this specific question. The review of these 14 resources revealed that some health care professionals feel insufficiently prepared to provide appropriate care for older adults during emergencies such as natural disasters. Further, more efforts can be made to increase awareness of precautions for infectious disease spread and control during emergencies. To address the gaps, three evidence-informed expert recommendations were developed with the aim of augmenting training for health care professionals and emergency response personnel to include additional culturally-aware considerations for assisting and caring for older patients and residents during and after an emergency. Recommendation 3.1 Health care professionals and emergency response personnel should receive training on providing geriatric care relevant to their discipline and how best to assist older adults and their unpaid caregivers before, during and after emergencies. The additional education and training should also increase their awareness of best practices and precautions to minimize the risk of infectious disease transmission or spread while responding to emergencies. Volunteer representatives of older Canadians should be recruited and involved in training material development and implementation, to ensure their voices and perspectives are reflected. Improving the Knowledge and Skills of Health Care Professionals in Geriatric and Emergency Health Care Principles Obtaining training in geriatric care is essential to ensuring that health care professionals are aware of the unique needs of older adults and how best to assist them, particularly during situations when they may be required to provide care during an emergency. In a report by Karen V. Lamb (2010), An Overview: Disaster Preparedness for Gerontological Nurses, the author identifies that cognitive impairment associated with dementias can be exacerbated during an emergency and produce feelings of confusion and delirium (Lamb & O'Brien, 2010). A Canadian study on nurses’ experiences with emergency management strongly recommends more extensive curricula in nurses’ training on how to provide better assistance during an emergency (Kulig, et al., 2017). It is recommended that health care providers and emergency response personnel be knowledgeable about how best to assist older adults in these situations. Using a multi-modal approach to DOMAIN 3: HEALTH CARE PROFESSIONALS AND EMERGENCY RESPONSE PERSONNEL Domain 3: Health Care Professionals and Emergency Response Personnel CLOSING THE GAPS: ADVANCING EMERGENCY PREPAREDNESS, RESPONSE AND RECOVERY FOR OLDER ADULTS 42 education can be effective in improving the knowledge, confidence and skills of health care professionals to respond to emergency situations (Pesiridis, Galanis, Sourtzi, & Kalokairinou, 2014; Roush & Tyson, 2012; Scott, Carson, & Greenwell, 2010). Lamb also emphasizes the need for nurses to be aware of the risks of providing care during a disaster (Lamb & O'Brien, 2010). Treatment can become a challenge because there is a possibility that medical records or resources, such as medications, oxygen, and dialysis, may not be available (Lamb & O'Brien, 2010). When combined with stress, limits to basic supplies, medications, and extreme changes in surroundings and temperature (Lamb & O'Brien, 2010), emergency situations can greatly exacerbate medical conditions and limit access to care interventions (Ardalan, et al., 2010). Considering that 80 per cent of older adults have at least one chronic health condition requiring medication and sometimes medical equipment, medical providers should be knowledgeable about alternative and effective methods for managing chronic conditions, and how to play an active role in emergency preparedness planning strategies at their local shelter or other temporary emergency care facilities (Bhalla, Burgess, Frey, & Hardy, 2015; Byrd, 2010). Therefore, emergency response personnel should be knowledgeable about conditions that are more likely to affect older adults, and how to effectively interact with or assist persons also living with dementia if they become agitated, confused, and anxious or wander away. Strengthening health care professionals’ and emergency response personnel’s knowledge of infection control practices can also support the provision of safe care to older adults in times of emergencies. The prolonged impact of natural disasters on a community can lead to the collapse of health facilities and health care systems, or disruptions in health programs (Kouadio, Aljunid, Kamigaki, Hammah, & Oshitani, 2012). Improved training for health care providers and emergency response personnel in infection control practices and increased awareness of best practices that can be used across all settings (Ontario Agency for Health Protection and Promotion, Provincial Infectious Diseases Advisory Committee, 2012; Ontario Agency for Health Protection and Promotion, Provincial Infectious Diseases Advisory Committee, 2012). Recommendation 3.2 Health care professionals and emergency response personnel should strive to mitigate negative outcomes among older adults during and after emergencies by adopting effective strategies designed to protect the physical and mental health of the older adults they may come in contact with. Strategies can include assessing the psychological well-being of older adults for signs of distress and providing appropriate treatments or referrals as needed. Better Addressing the Mental Health Needs of Older Adults During Emergencies While there is a preconceived notion that older adults are more emotionally fragile than younger adults, there are mixed reports about an existing difference in the incidence of psychological distress among older adults compared to younger adults following an emergency, which has indicated that older age may be a protective factor. When investigating potential differences between older adults and younger adults in the onset of psychological disorders following natural and 43 man-made disasters, anxiety and depressive symptoms have been found to not have a significant difference in incidence rates among older adults compared to younger adults (Parker, et al., 2016; Siskind, et al., 2016). However, differences were found in the incidence of posttraumatic stress disorder (PTSD). In a 2016 study conducted by Parker and colleagues, PTSD was found to have a significantly greater incidence among older adults compared to younger adults. Similar results were also found by Jia and colleagues (2010), who reported a greater prevalence of PTSD symptoms among a sample of survivors of the 2008 Sichuan earthquake (Jia, et al., 2010). Conversely, Siskind and colleagues (2016) found that older adults were 2.85 times less likely to experience PTSD symptoms compared to younger adults in a meta-analysis of the mental health outcomes of older adults following humaninduced disasters (Siskind, et al., 2016). However, differences in the onset of psychological distress among persons of different socio-demographic statuses have also been reported. Obtaining less than a high school education and/or a bachelor’s degree, being unemployed or becoming unemployed due to a disaster, living in social isolation, or witnessing three or more events associated with a disaster were associated with a greater likelihood of developing PTSD (Blackmon, et al., 2017; Ruskin, et al., 2018; Welch, et al., 2016). A study was conducted by Cheung, Chau and Yip (2008) to assess the impact of the 2003 SARS outbreak on suicide rates in Hong Kong. The study used suicide statistics for the period 1993-2004 and compared the profile of older adult suicide cases in the pre-SARS, peri-SARS and post-SARS periods. Results from the study showed an excess of older adults suicides in April 2003 as compared to the month of April of the other years. Results were consistent with a year over year comparison, as older adult’s suicide rates in 2003 and 2004 were significantly higher than that in 2002, suggesting that the suicide rate did not return to the level before the SARS epidemic (Cheung, Chau, & Yip, 2008). Cheung, Chau and Yip speculated that the spike in older adult suicide rates could be because of loneliness and disconnectedness among the older adults in the community. As such, maintaining and enhancing mental wellbeing of the public over the period of an epidemic is arguably just as important as curbing the spread of the disease (Cheung, Chau, & Yip, 2008). A historical gap in emergency management has been the prevention and/or treatment of psychological effects that survivors experienced during and after an emergency. During flooding in Quebec in 2017, one of the most widespread challenges among survivors was psychological distress, with 25% of individuals encountered by officials exhibiting symptoms (CBC News, 2017). Training of responders in psychological first aid could also assist in thoughtful and compassionate handling of older adults during response and into recovery (Ardalan, et al., 2010). Overall, while findings suggest that extensive additional resources do not need to be directed towards protecting the psychological well-being of older adults during emergencies, it is still recommended that health care professionals and emergency response personnel make greater efforts to assess the psychological well-being of older adults during and after an emergency and provide appropriate treatments in order to provide early interventions for the existing proportion of older adults that do develop a psychological disorder. Greater emphasis should also be given DOMAIN 3: HEALTH CARE PROFESSIONALS AND EMERGENCY RESPONSE PERSONNEL CLOSING THE GAPS: ADVANCING EMERGENCY PREPAREDNESS, RESPONSE AND RECOVERY FOR OLDER ADULTS 44 to assessing the psychological well-being of older adults who satisfy at least one of the many sociodemographic factors that have been linked to a greater likelihood of developing a psychological disorder during or after an emergency. An example of how to achieve this will be to increase older individuals’ access to services provided by counsellors, occupational therapy and social workers post-emergency, as they can play a role in addressing the resulting psychological distress by providing education and training in coping skills using a community-based rehabilitation approach (Jeong, Law, DeMatteo, Stratford, & Kim, 2016). Recommendation 3.3 Health care professionals and emergency response personnel should receive cultural awareness training to provide appropriate care and support for older adults with different cultural and religious backgrounds before, during, and after an emergency. Providers should have options for providing support to older adults and their unpaid caregivers who face language or cultural barriers to accessing supports (e.g., translators, written materials in languages other than English or French, etc.). This is of particular importance for personnel that work with Indigenous populations, in diverse community-settings and during times of evacuation due to emergencies. Cultural awareness and training for health care professionals and emergency response personnel is a key tenet to ensuring older adults with different cultural and religious backgrounds receive appropriate care and support before, during and after an emergency (James, Hawkins, & Rowel, 2007). The Aboriginal Nurses Association of Canada (2009), the Canadian Agency for Drugs and Technologies in Health (2018), the Canadian Association of Occupational Therapists (2011) and the College of Nurses of Ontario (2019) have developed cultural awareness and cultural safety guidance for health providers that could be considered in this regard. In 2012, Dr. Samir Sinha delivered a report to the Ontario Ministry of Health and Long-Term Care, Living Longer, Living Well, in which he identified that many health, social and community care providers were unaware of the cultural needs, health and social conditions and services that may or may not be available locally to support older Indigenous adults. In the province of Ontario, as the prevalence rates for having three or more chronic conditions are higher for the Indigenous population as compared to the non-Indigenous population, it is understandable why Indigenous people rely disproportionately on the need for emergency care, and are more likely to self-report having “poor” or “fair” health (Sinha, 2012). As a result, a key recommendation of the report was to promote the development of cultural competency training for all health, social and community services providers working with older Indigenous populations. Some professional associations have taken other approaches to increase the degree of cultural awareness in care settings by building capacity in communities experiencing vulnerabilities to participate in care delivery. For instance, the Canadian Association of Schools of Nursing (CASN), the Aboriginal Nurses Association of Canada (ANAC) and the Canadian Nurses Association (CNA), in collaboration with nursing schools across Canada, actively promoted the recruitment of First Nations, Inuit and Métis people into nursing programs and enabled them 45 to complete these programs by removing barriers, such as finances, and building structures of support (Hart-Wasekeesikaw, 2009). Increasing the number of First Nation, Inuit and Métis nurses facilitates improved access to culturally safe and appropriate care for Indigenous people. This collaboration with the CASN, ANAC and the CNA also aimed to integrate principles of cultural competence and cultural safety into curricula for all nursing students that instill an understanding of the historical and contemporary contexts of Indigenous communities (Hart-Wasekeesikaw, 2009). In 2018, the Canadian Association of Occupational Therapists released a position statement highlighting the role of occupational therapy in Indigenous health. Its purpose is “to enable occupational therapists to provide effective, respectful, culturally safe, and collaborative services with First Nation, Inuit, and Métis persons, families, communities, and nations”. A fundamental recommendation from this report is to develop partnerships and alliances in order to best provide space for Indigenous worldviews, knowledge and self-determination, in recognizing that moving forward is a shared responsibility (Canadian Association of Occupational Therapists, 2011). Within Indigenous communities, providers and personnel providing preparedness, response and recovery support need to consider and acknowledge the history as well as the knowledge, beliefs and perspectives about emergency preparedness held in Indigenous communities. Within the context of preparing for an emergency, recognizing the role of Indigenous older adults as community leaders and designing inclusive preparedness education activities that acknowledges and leverages their important role within community is important to successful emergency preparedness. In addition, developing preparedness materials that address additional traditional and ceremonial items that would be taken from the home in an evacuation, such as medicine pouches, eagle feathers, and sweet grass can also help to support Indigenous older adults to prepare for an emergency. When responding to an emergency, response personnel should develop an awareness that certain operational procedures have been observed to trigger trauma in some older Indigenous adults who survived the residential school system, the 60s Scoop and other traumatic episodes. Procedures that trigger these traumas should be replaced with culturally safe practices. In addition to how Indigenous communities are evacuated, it is equally important to recognize that many Indigenous older adults live with family members, and evacuating within the kin system is important. Separation from family and unpaid caregivers can be especially challenging. When recovering from an emergency, personnel should create space to acknowledge and grieve the cultural losses associated with evacuation, and provide activities that maintain a connection to home communities (e.g. sweat lodge, smudging ceremony, dancing/singing/sewing activities for children). DOMAIN 3: HEALTH CARE PROFESSIONALS AND EMERGENCY RESPONSE PERSONNEL CLOSING THE GAPS: ADVANCING EMERGENCY PREPAREDNESS, RESPONSE AND RECOVERY FOR OLDER ADULTS 46 Domain 4: Care Institutions and Organizations Care institutions and organizations that are responsible for the livelihood of their residents or patients during an emergency must make decisions that will support the health and well-being of their residents/patients. During emergencies such institutions and organizations should, for example, know when it is appropriate to evacuate or shelter-in-place and what to do in each case. An evaluation of the quality and levels of emergency preparedness within care institutions and organizations was guided by Research Question 4: What are the strategies and resources that can be leveraged at the organizational or institutional level to improve emergency (natural disaster or pandemic) preparedness and recovery efforts for older adults? (see Development Approach). The search strategies that were used yielded a combined total of 4,390 peer-reviewed journal articles, 17 of which were used along with nine guidance documents for data extraction related to this specific question. A review of these 26 resources revealed that greater action can be taken to prevent threats to an older patient’s/ resident’s health that can arise when severe emergencies disrupt the operations at care institutions and organizations, as well as patient handoff procedures. Consequently, in response to this gap, three evidence-informed expert recommendations were developed with the aims of increasing the levels of emergency preparedness knowledge among health care providers and care facility staff, as well as better facilitating effective patient hand-off during an emergency. Recommendation 4.1 Care institutions and organizations should include emergency preparedness and response education in their routine personnel training courses.
Volunteer representatives of older Canadians should be recruited and involved in developing and disseminating resources and training material, to ensure their voices and perspectives are reflected. A 2012 study by Roush and Tyson that assessed the knowledge of emergency preparedness among nurses enrolled in a community-accessible emergency preparedness workshop, many of whom were employed at a nursing home, found that the majority of participants had no formal emergency planning and response training and many reported low or no proficiency ratings in emergency preparedness knowledge (28%). After completion of the workshop, the proficiency ratings increased to 76% and the majority of participants reported that they planned on including portions of the content from the workshop into courses for students, colleagues and/or patients (Roush & Tyson, 2012). Findings from this and other studies suggest that some health care providers working within and outside of a geriatric health care setting would benefit from additional training in their knowledge of how to respond to emergencies and care for older adults during these times (Lamb & O'Brien, 2010). To address this gap in education and improve disaster management in hospitals, the New York City Department of Health and Mental Hygiene (NYC DOHMH) developed the Elderly Populations in Disasters: Hospital Guidelines 47 for Geriatric Preparedness toolkit (Ahronheim, Arquilla, & Gambale Greene, 2009). The toolkit outlines training in geriatric care for health care professionals that includes guidelines for managing geriatric patients, common age-related misdiagnoses, when to obtain a geriatric medicine consultation and appropriate dosages for common psychiatric medication for frail elderly, as well as the development of reference charts to help make appropriate medical assessments for older adults during emergencies (Ahronheim, Arquilla, & Gambale Greene, 2009). Given that this toolkit provides a focus on geriatric-specific care needs to hospitals aiming to address a variety of circumstances common among older adults during emergencies, it may be beneficial for all care institutions and organizations to develop similar emergency toolkits based on the services that their organization provides. Health care professionals can collaborate to create an interprofessional toolkit that integrates different care approaches for older adults informed by each discipline. For example, nurse professionals and therapists can apply the integrated theory of health behavior change to develop education curricula that foster knowledge and improve health outcomes among older adults (Ryan, 2009). Further, adult learning theories are at the core of the training received by physical and occupational therapists. They practice client-centeredness, which tailors responses to be primarily focused on their client needs’ (Papadimitriou & Carpenter, 2013). Building resources through interprofessional and collaborative approaches can enable more efficient care and response to the needs of older adults during emergencies. Advanced education and certification courses in emergency and disaster preparedness management in Canada are small; in 2004, there were fewer than 10 people who were both practitioners and academics in the field of emergency management (Public Safety and Emergency Preparedness Canada, 2004). The growth of emergency preparedness or management education was a gap identified by the Round Table attendees that was attributed, in part, to the absence of a lead entity that could advocate for the importance of this education across the country. Each province has adopted a different approach to education and credentialing around emergency preparedness/management, which has had an unfortunate effect of reducing cooperation and coordination. To solve this problem, Public Safety and Emergency Preparedness Canada initiated a federal/provincial/territorial working group to address the education requirements for Canadian emergency managers. Additionally, the United Nations Office for Disaster Risk Reduction has published the Global Assessment Report on Disaster Risk Reduction (DRR), which highlights the need for disaster risk reduction strategies to improve emergency and disaster preparedness, response and recovery efforts in the future, and outlines the required credentials and academic needs to foster future DRR professional expertise. Recommendation 4.1 addresses the need for institutions to include emergency preparedness and response training delivered through a multimodal platform. When teaching health care providers and hospitalbased staff about emergency preparedness, multi-modality teaching methods have been found to be an effective tool. A 2016 study by Collander and colleagues examined the efficiency of a multi-modality disaster preparedness training course for hospital-based health care providers, DOMAIN 4: CARE INSTITUTIONS AND ORGANIZATIONS CLOSING THE GAPS: ADVANCING EMERGENCY PREPAREDNESS, RESPONSE AND RECOVERY FOR OLDER ADULTS 48 called Hospital Disaster Life Support (HDLS) (Collander, et al., 2008). The program was taught using lectures, disaster exercises (pneumonia and bomb simulations), skills sessions and tabletop sessions. Upon assessment of the participants’ changes in knowledge acquisition and behaviours related to emergency preparedness, the results of a 1 to 5-point Likert scale, with 5 being the most favorable, showed that the mean response was 4.24. Comparisons of pre- and post-test scores revealed that all participants significantly improved their mean pre-test and post-test scores for emergency preparedness knowledge, the mean test score was 89.5% for the group. Recommendation 4.2 Additional strategies to improve the collection and transfer of identifying information and medical histories should be adopted into current standardized patient handoff procedures to better facilitate effective tracking, relocation and care of patients during an emergency. Improving Transitions of Care for Patients During Emergencies In the US, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) requires all facilities to have a standardized approach to patient hand-off procedures, which adequately supports communication between providers when patients are transported for diagnostic testing or procedures (Nursing, 2006). Similarly, in Canada, health care facilities typically have policies related to patient-hand off that enables communication between providers when patients are being transported. There are other patient transport policies that are specific to certain patient populations, such as Critical Care Services Ontario‘s Life or Limb Policy, developed through a collaboration among Critical Care Services Ontario, CritiCall Ontario, Local Health Integration Networks, Emergency Medical Services and several Hospital Administrators (Ministry of Health and Long-Term Care, 2013). The policy ensures that life or limb threatened patients, i.e. a patient at risk of losing their life or limb, receives care within a 4 hour window and clearly outlines the procedures that are to be followed when patients are being transported. Within the implementation guide are CritiCall Ontario’s five step switchboard processes that start when CritiCall Ontario calls hospital switchboards in order to process a referral for a life or limb case, and ends when hospitals implement their Critical Care Surge Capacity Management Plan to reserve a bed and allow for patient transfer. This streamlined process ensures quick communication between physicians and prompt patient transfer. Though these policies are not specifically geared towards natural disasters, it provides a framework that can be operationalized to minimize harm and errors should patients need to be transported urgently during critical periods. However, additional tracking strategies should be incorporated into traditional patient hand-off procedures to better facilitate patient/resident transfers during emergencies. To prevent interruptions to treatment after relocation, both electronic-based and non-electronicbased methods should be used to facilitate successful delivery of patient identification and their associated medical history to the receiving organization after relocation. Specifically, it is recommended that documents should include demographic characteristics, appearance specifications, and medical information. The inclusion of content specific to patient identification is intended to assist in 49 matching patients to their medical histories in the event that their medical files are misplaced or inaccessible due to disaster, or to assist in identifying patients, particularly those who are unable to successfully do so themselves. Electronic-based tracking methods identified through a systematic review of patient tracking methods used internationally included electronic triage tags such as smart tags and other sensors to determine triage level, radio-frequency identification tags, and personal digital assistants (PDAs) for triage in these situations (Smith & Macdonald, 2006). A similar approach should be adopted in Canada. A strong correlation was further noted between the impact of evacuations on increased hospitalization, mortality, stress and trauma, particularly among nursing home residents with cognitive impairment (Brown, et al., 2013). This reiterates the critical need for care institutions to have emergency management plans, as well as robust transition of care plans in place for when patients need to be evacuated. It also emphasizes the importance of reviewing and updating these plans on a regular basis (Blanchard & Dosa, 2009; Dosa, et al., 2010; Laditka, Laditka, Cornman, Davis, & Richter, 2009; Nomura, et al., 2013; Thomas, et al., 2012; Willoughby, et al., 2017). Improved transitions can be be further supported by enhancing the integration of hospitals into community emergency preparedness planning (Braun, et al., 2006). Supporting integrated planning between hospitals and community care settings can facilitate systems for patient tracking and communication during emergencies and ease transitions post emergencies. Recommendation 4.3 Care institutions and other organizations should strive to develop comprehensive emergency plans that include effective response strategies for protecting older adults against infectious disease outbreaks and reflect evidence-based standards supported by organizations such as Infection Prevention and Control Canada (IPAC).
Care institutions should also regularly assess and address any barriers they identify that could affect the implementation of their emergency plans that build on their routine practices Developing comprehensive organizationwide emergency preparedness strategies that include infectious disease prevention Care institutions such as hospitals and long-term care and nursing homes are prone to regular infectious disease outbreaks. Outbreaks can often be localized to a given unit or section of the facility and can be contained with early identification and intervention. These care settings become more vulnerable to large scale outbreaks during emergencies such as pandemics as infectious diseases spread rapidly among patients and residents. Recommendation 4.3 highlights the importance of care institutions and other organizations having emergency plans that include effective response strategies that address infectious disease spread and outbreaks. During the COVID-19 pandemic, Canada stood out amongst other industrialized countries in reporting the highest proportion of its deaths having occurred in long term-care and retirement homes (Canadian Institute for Health Information, 2020). The vulnerability of long-term care homes to respiratory disease outbreaks such as COVID-19, influenza and others is well recognized DOMAIN 4: CARE INSTITUTIONS AND ORGANIZATIONS CLOSING THE GAPS: ADVANCING EMERGENCY PREPAREDNESS, RESPONSE AND RECOVERY FOR OLDER ADULTS 50 (McMichael, et al., 2020). One study conducted in a skilled nursing facility in Kings County, Washington identified staff working in multiple facilities while ill and transfers of residents from one facility to another as potential challenges that introduced the virus into facilities, which was consistent with other studies (McMichael, et al., 2020; Lai, et al., 2020). Vaccination and timely introduction of antiviral treatments among workers in care institutions and other organizations is thought to be one of the most effective strategies to minimize the risk of infectious disease outbreaks (Cheng, Chen, Chou, Huang, & Huang, 2018; Rainwater- Lovett, Chun, & Lessler, 2014). Studies that assessed vaccination among care institution staff identified skepticism towards vaccination as a barrier to uptake (Huhtinen, Quinn, Hess, Najjar, & Gupta, 2019). Institutions that had on-site immunization programs for employees as well as policies that required immunization as a stipulation for employment showed high rates of vaccination among staff (Lai, et al., 2020). Nonpharmaceutical approaches can also be effective in preventing disease spread as indicated by the supported use of PPE as a preventative measure for spread (World Health Organization, 2020; Rainwater-Lovett, Chun, & Lessler, 2014). Closures of care institutions and facilities can also minimize the spread of infectious diseases among staff and residents alike. During the COVID-19 pandemic, many care institutions such as hospitals, long-term care homes closed their doors to non-essential visitors and restricted access to staff only. Early closures of these homes can be effective in containing disease outbreaks and shortening outbreak periods (Inns, et al., 2018). Other strategies include suspending new admissions, cohorting patients/residents by unit, active reinforcement of routine hygiene practices and use of disinfectant agents for regular cleaning of surfaces among others (Buffington, et al., 1993; Lee, Lee, Lee, & Park, 2020). Routine surveillance and regular reports are also recommended for early identification of infections (Ontario Agency for Health Protection and Promotion (Public Health Ontario), Provincial Infectious Diseases Advisory Committee, 2020). Bundled interventions have been demonstrated as the most effective approach to managing infection outbreaks in care facilities (Hayden, et al., 2015). Infection Prevention and Control Canada (IPAC) provides a repository of evidence-based guidelines with recommendations rooted in epidemiological studies that demonstrate the effectiveness of infection control interventions such as hand hygiene, routine cleaning practices, isolation among others across different health care settings (Ontario Agency for Health Protection and Promotion (Public Health Ontario), Provincial Infectious Diseases Advisory Committee, 2014; Ontario Agency for Health Protection and Promotion (Public Health Ontario), Provincial Infectious Diseases Advisory Committee, 2018; Ontario Agency for Health Protection and Promotion, Provincial Infectious Diseases Advisory Committee, 2012; Ontario Agency for Health Protection and Promotion, Provincial Infectious Diseases Advisory Committee, 2012; Siegel, Rhinehart, Jackson, & Chiarello, 2007; Canadian Committee on Antibiotic Resistance, 2007). Many of these guidelines are endorsed and published by agencies such as Public Health Ontario. Canadian care settings should leverage these guidelines and education resources to support the development of their emergency plans. 51 Federal, provincial and local governing bodies all play a regulatory role in emergency preparedness and response by outlining and enforcing how, and to what extent, relevant bodies and organizations should contribute to more effective emergency preparedness and response efforts through their policy and legislative powers. A review of existing gaps in emergency preparedness, response and recovery policies and legislation relevant to the outcomes of older adults was conducted. The investigation was guided by Research Question 5: Are there legislation or policies that have been developed or adopted at the local, provincial or federal levels to improve emergency (natural disaster or pandemic) preparedness and recovery efforts for older adults? (see Development Approach). The search strategies that were used yielded a combined total of 4,390 peer-reviewed journal articles, nine of which were used along with 15 legislative and policy-oriented documents that were used for data extraction related to this specific question. A review of the documents revealed that while some provinces and territories have developed and implemented new policies/ legislation in response to past experiences related to previous emergencies, there is still a gap in the application of these policies to address the needs of older adults and their unpaid caregivers. For the provinces that have not adopted legislation regarding emergency preparedness, available legislation as well as the current pandemic can serve as guides in making sure older adults are protected in times of emergencies. The gaps in legislation present a challenge in ensuring that sufficient supports are available to consistently address the needs of older adults during emergencies across Canada. Through the development of five policy/legislative evidenceinformed expert recommendations, an opportunity to implement legislation that can better improve emergency outcomes for older adults is proposed. Recommendation 5.1 A national advisory committee should be created to inform emergency preparedness, response and recovery program development and strategies for older Canadians. Individuals who are representative of older Canadians and their unpaid caregivers should be involved to ensure their voices and perspectives are reflected. Establishing a National Advisory Committee on Emergency Preparedness for Older Adults In 2017, the US Senate introduced Bill S. 1834 to amend title XXVIII of the Public Health Service Act to include the establishment of a National Advisory Committee on Seniors and Disasters (Protecting Seniors During Disasters Act, 2017). The Advisory Committee was intended to be established by the Secretary of the Senate, with the consultation of the Secretary of Homeland Security and the Secretary of Veterans Affairs. The duties tasked to the Advisory Committee included evaluating and providing input on activities related to the medical and public health needs of older adults during all-hazard emergencies, and providing advice and recommendations to the Secretary with respect to older adults, medical and public health grants and cooperative agreements related to preparedness and response activities authorized under the Secretary. To ensure that the committee has the expertise required to better serve its designated tasks, Bill S. 1834 outlines a list of appropriate representatives that the committee should comprise; representatives Domain 5: Legislation and Policy DOMAIN 5: LEGISLATION AND POLICY CLOSING THE GAPS: ADVANCING EMERGENCY PREPAREDNESS, RESPONSE AND RECOVERY FOR OLDER ADULTS 52 identified on the Bill include: the Director of the Centers for Disease Control and Prevention (CDC), the Administrator of the Center for Medicare & Medicaid Services (CMS), the Administrator of the Federal Emergency Management Agency (FEMA), at least two non-federal health care providers with expertise in medical disaster planning, preparedness, response or recovery and representatives from other relevant Federal agencies, such as the Department of Energy and the Department of Homeland Security (DHS). While the effectiveness of this committee has not yet been evaluated, the Canadian experts recognized the importance of the mandate of the committee established in the US and the potential impact it could have on emergency preparedness for older adults. To date, there has been no such committee established in Canada. Existing resources such as The Emergency Management Framework of Canada (see Summary of Relevant Frameworks and Legislations in Appendix B) could facilitate the creation of a national advisory committee that could inform decision-making and planning related to emergency preparedness and older adults. Federal groups such as Public Safety Canada may also have a role in the management and operation of this committee. Further, the engagement of older adults to participate as members of this committee would ensure that the perspectives of this population are appropriately integrated into any resulting outputs and products from the committee. Older adults have been found to play essential roles in policy development because they can provide insight on “salient barriers to active ageing and options for post-earthquake redevelopment that had not been previously considered” (Annear, Keeling, & Wilkinson, 2014). Other recommended members would include relevant private sector providers and geriatric care professionals (geriatricians, geriatric psychiatrists, gerontological nurses, social workers and pharmacists, physical and occupational therapists, and other geriatric care experts), and non-governmental organizations that work in preparedness, response and recovery for seniors, such as the Salvation Army and the Canadian Red Cross. Gerontologists can also provide insight and guidance on common geriatric syndromes, such as dementia, delirium, and psychosis, as well as common areas that older adults may require assistance with, such as taking medications, mobility, understanding emergency instructions and accessing social support, which are commonly managed by geriatric health care providers. Recommendation 5.2 All provinces and territories should support the implementation of tax-free emergency preparedness purchasing periods during specific times of the year or prior to an impending emergency. Governments should also provide targeted funding to directly support/subsidize the purchase of emergency preparedness kits for older Canadians. Items covered should include an agreed-upon list of emergency supplies (such as batteries, portable generators, rescue ladders, radios and ice packs), air conditioners, personal protective equipment (such as masks, gloves and hand sanitizer, etc.) and additional mobility aids (canes, walkers, etc.). Supporting Improved Self-Preparedness Activities When faced with the financial burdens associated with emergencies, older persons repeatedly experience less robust economic recovery than 53 younger age groups (Fernandez, Byard, Lin, Benson, & Barbera, 2002). Younger age groups tend to be less vulnerable to property damage due to a greater likelihood of having insurance, higher credit values, greater financial savings, and their reduced likelihood of living at or near the poverty line (Fernandez, Byard, Lin, Benson, & Barbera, 2002). The qualifications for receiving financial aid may also help explain why older adults may use them less than other age groups. This is often because older adults live on a fixed income or lack employment. Furthermore, in cases where aid is received, it is often difficult to obtain money to replace uncovered losses, making older adults more dependent on support from charities and their Social Security benefits (Fernandez, Byard, Lin, Benson, & Barbera, 2002). In Canada, Emergency Preparedness Week is a national awareness initiative that has taken place annually since 1996 during the month of May. It is a collaborative event undertaken by federal, provincial and territorial emergency management organizations that support emergency preparedness activities at the local level. Emergency preparedness week encourages Canadians to take three simple steps to become better prepared to face an emergency: 1) know the risks, 2) make a plan, and 3) get an emergency kit (Government of Canada, 2015). Tax-free emergency supplies can act as an incentive for older adults to purchase resources for their emergency kit or provide the price reductions needed to help older adults with limited resources access these essential supplies. Currently, 16 states in the United States have implemented tax-free weekends, however, only three have included ‘weather related’ preparedness or ‘severe weather’ preparedness supplies as part of the selected items that are eligible for a tax break or tax exemption. To provide all older adults with access to reduced costs for emergency supplies, it is recommended that all provinces and territories adopt tax-free emergency supplies and/or provide funding to support low-income seniors to purchase emergency kits. Supplies should include, but not be limited to, batteries, portable generators, mobility aids (canes and walkers), air conditioners, rescue ladders, radios, and ice packs. Furthermore, evidence shows that having a basic home kit comprised of non-pharmaceutical interventions such as hand hygiene and masks in addition to adequate ventilation, temperature control measures among other things greatly reduces the spread of illness and indirectly contributes to avoidable hospitalizations (Finkelstein, Prakash, Nigmatulina, McDevitt, & Larson, 2013). Thus, subsidizing these emergency essentials for older adults will improve emergency preparedness efforts. Recommendation 5.3 All provinces and territories should support the creation of a national licensure process or program for nurses, physicians, allied health professionals and other emergency medical service personnel to allow them to provide voluntary emergency medical support across provincial/territorial boundaries during declared states of emergency. Enhancing the Portability of Health Care Professional Expertise During Emergencies It is apparent that access to medical services must be provided as part of all emergency responses to support emergent medical needs. It is recommended that steps be taken to support the preliminary recruitment of health care providers DOMAIN 5: LEGISLATION AND POLICY CLOSING THE GAPS: ADVANCING EMERGENCY PREPAREDNESS, RESPONSE AND RECOVERY FOR OLDER ADULTS 54 to facilitate a faster and standardized assembly of emergent medical teams during emergencies. In the United States, the Medical Reserves Corps (MRC) acts as a database of medical and nonmedical volunteers who can provide medical support in their community during emergencies, and this has been demonstrated to be very effective. It is recommended that similar resources be created and made available in Canada. To increase the availability of medically trained volunteers during an emergency, actions should be taken to adopt inter-provincial licensing across all provinces and territories. All relevant health care providers should work with their respective professional provincial or territorial boards and legislators to pass the required legislation in their respective province or territory. In Canada, licensing is provincially regulated. During emergencies, provinces utilize their own resources first; however, in cases where there is a need for specialists, Canada has the mechanisms to call on extra resources. For instance, the Public Health Agency of Canada (PHAC) has the mechanisms to clear health care providers in a relatively short amount of time. Creating a national licensure program in Canada would facilitate shorter response timelines and ensure help is available when needed. For instance, the Atlantic Colleges of Physicians and Surgeons are working together to harmonize a number of processes and procedures as well as working on common Atlantic Colleges’ approaches to certain licences for physicians. The US has adopted a similar model whereby 31 states are licensure compact states for nursing (Nurse Licensure Compact, n.d.), 14 states and one territory are licensure compact states for emergency management services (EMS) personnel, (National Registry of Emergency Medical Technicians, n.d.), and 24 states are licensure compact states for physicians (Interstate Medical Licensure Compact, n.d.). A potential option for Canada is to allow health care providers to practice in different provinces or territories by pre-applying through PHAC for inter-provincial work during an emergency. Recommendation 5.4 All provincial and territorial governments should support legislative requirements that mandate congregate living settings for older persons (e.g. nursing homes, assisted living facilities and retirement homes) to regularly update and report their emergency plans that outline actions and contingencies to take in case of emergencies. These plans should include:
An outline of staffing levels that should be maintained during emergencies to minimize care and/or service interruptions. 55 All provinces and territories should work towards standardizing requirements for emergency plans in congregate living settings in accordance with the priorities outlined in the 2019 Emergency Management Strategy for Canada and ensure that their emergency plans for congregate living settings are aligned with directives outlined in their provincial/territorial pandemic and emergency plans. Improving Environmental Control Efforts in Nursing Homes and Assisted Living Facilities In Ontario, the Long-term Care Homes Act (2007) states that all nursing homes must have air conditioning and back-up generators to provide power for all support and life-supporting equipment in the case of an emergency. If central air conditioning is not available in the facility, there should be a designated cooling area for every 40 residents. However, this is not the case for all provinces and territories. For instance, in British Columbia, the legislation does not include requiring homes to have additional contingencies in their emergency plans to ensure that, in the event of a power outage, temperatures are kept at reasonable levels to avoid the exacerbation of existing health issues among nursing homes and assisted living plans in long-term care facilities. The panel recommends calling on all provinces and territories to standardize their requirements and ensure that the appropriate measures are in place to restore power within a reasonable timeframe, and mandate that facilities have additional contingencies to ensure that temperatures are maintained at appropriate levels. In addition to maintaining favorable in-house temperatures and ensuring constant power supply, emergency plans for congregate living settings should include contingencies to maintain appropriate staffing levels during emergencies. The COVID-19 pandemic highlighted significant challenges with maintaining appropriate staffing levels in settings such as group and retirement homes for older adults. Participation House, a group home in Markham, Ontario experienced high rates of staff resignations during the pandemic where staffing levels were described as “critical” (Rocca, 2020). The group home experienced a severe outbreak of the virus during the pandemic with 95% of its residents (40 of 42) and 38 of its staff members becoming infected (Riedner, 2020). Studies have shown that, among other things, staffing levels and patterns can have significant impact on outcomes in congregate living settings (Trivedi, et al., 2012; Li, Birkhead, Strogatz, & Coles, 1996; Lin, et al., 2011; Harrington, Zimmerman, Karon, Robinson, & Beutel, 2000; Horn, Buerhaus, Bergstrom, & Smout, 2005; Kim, Kovner, Harrington, Greene, & Mezey, 2009). Consequently, effective emergency planning will require actions to maintain appropriate staffing levels to minimize the risk of widespread and prolonged outbreaks in these settings. Ensuring that staff are adequately trained and prepared for an emergency will also improve outbreak efforts in nursing homes and assisted living facilities. In a study conducted by Bucy, Smith, Carder, Winfree and Thomas to determine how States required residential care and assisted living facilities to mitigate, prepare and respond to infections among their residents, found that 31 states had defined infection control policies some DOMAIN 5: LEGISLATION AND POLICY CLOSING THE GAPS: ADVANCING EMERGENCY PREPAREDNESS, RESPONSE AND RECOVERY FOR OLDER ADULTS 56 of which require staff to be trained in infection control) (Bucy, Smith, Carder, Winfree, & Thomas, 2020). Ten states include language surrounding epidemics, primarily regarding reportable disease and requirements for reporting to local Public Health departments, and two describe pandemic emergency preparedness. Only six States referenced resident isolation practices as an effective way to combat the spread of infections (Bucy, Smith, Carder, Winfree, & Thomas, 2020). Similarly, in Canada, the 2007 Emergency Management Act (Government of Canada, 2007) requires the federal Minister of Health to develop, test and maintain mandate-specific emergency plans for the federal Health Portfolio. Health emergency management in provinces and territories are governed by specific legislation specific to each jurisdiction that requires provincial and territorial governments to have comprehensive emergency plans. Each province and territory, in accordance with the legislation, has outlined emergency plans, some of which are specific to influenza and/or pandemics. Some provinces, such as Alberta, have stipulated actions for vulnerable groups (i.e. seniors) and health care workers and services in their Pandemic Influenza Plans (Alberta Government, 2014). The COVID-19 pandemic resulted in provincial governments issuing more specific guidance for community and health care settings to support evidence-informed decision making and actions in these settings. Lastly, legislation should take into account emergency plans for situations where a lack of infrastructure poses itself as an obstacle to physical distancing or self-isolation. Isolation is a recommended strategy to control disease outbreak in congregate living environments however many facilities have reported infrastructure challenges has a barrier to implementing isolation protocols among their residents (Huhtinen, Quinn, Hess, Najjar, & Gupta, 2019; McMichael, et al., 2020). Not being able to physically separate during an emergency can serve as a barrier to managing and controlling a disease outbreak. Recommendation 5.5 All provinces and territories should adopt a standardized approach to promoting collaborations between local pharmaceutical prescribers and dispensers (i.e. community pharmacists), physicians and nurse practitioners, to ensure an adequate supply of prescription medications are dispensed to persons with chronic health conditions prior to and during an emergency. This approach should also outline the need for collaboration between pharmaceutical providers, hospitals and relief agencies to ensure an adequate supply of prescription medications are available at hospitals, relief and evacuation shelters.
All persons should be able to obtain at least a 30-day supply of emergency prescription medications prior to and during an emergency. Ensuring Access to Medically Necessary Medications During Emergencies Older adults often live with multiple chronic health conditions that require ongoing management, which can include the help of prescription medicine. In Canada, prescription length policies are set largely by the regulatory bodies for physicians and pharmacists at the provincial level. Though there were no studies found related to access to medication during times of emergencies in Canada, there were many reports 57 that emerged from the US and other jurisdictions regarding the challenges that were experienced accessing prescription medications for people who were evacuated to shelters. For instance, in the aftermath of Hurricane Katrina, many older adults were relocated to public shelters miles away from their homes. Reflective discussions of the medical care provided in the Astrodome in Houston, TX, and the Mississippi Coliseum and the Mississippi Trade Mart in Jackson, MS, have exposed the impact that existing barriers to accessing at least a 30-day supply of emergency prescription medications can have on one’s health. In Jackson, MS, the Department of Medicine, in partnership with local medical facilities deployed a pop-up Katrina clinic in the Mississippi Coliseum and Mississippi Trade Mart shelters (Currier , King, Wofford , Daniel, & deShazo , 2006). Though many of the 2,394 evacuees left their homes with the conventionally recommended threeday supply of medications, most people required access to additional supplies of their medications to manage chronic health conditions (Aldrich & Benson, 2008; Currier , King, Wofford , Daniel, & deShazo , 2006). It was reported that the most common medical needs at the clinic were for prescription refills, particularly for cardiovascular, antihistamine/decongestant, psychotropic, analgesic and diabetic medications (Currier , King, Wofford , Daniel, & deShazo , 2006). A review of several pharmaceutical and drug prescribing policies in Canada has highlighted that emergency refill policies are not uniform across provinces and territories, and the issue was rarely addressed specifically. One province, British Columbia, allows physicians to provide prescriptions with renewals for up to a one-year period (two years for birth control). Additionally, pharmacists can independently renew most medications for a period of up to six months. During severe emergencies, where persons can be displaced for extended periods of time, ranging from a few days to a few months, it is critical that persons who are dependent on medications are able to evacuate their homes with a pharmaceutical supply that can support their health and well-being, particularly if they must evacuate to an isolated area or stay at a relief shelter where pharmaceutical supplies can be limited at warehouses and coordinating centres for emergency response (Currier , King, Wofford , Daniel, & deShazo , 2006). Consequently, it is recommended that all provinces and territories adopt a standardized approach to collaboration between local pharmaceutical prescribers and dispensers, specifically community pharmacists, physicians and nurse practitioners. To further facilitate access to prescription medications during emergencies, particularly in relief shelters, this approach should emphasize the need for inter-organizational collaboration between pharmaceutical providers and relief agencies to ensure that an adequate supply of prescription medications are available. DOMAIN 5: LEGISLATION AND POLICY CLOSING THE GAPS: ADVANCING EMERGENCY PREPAREDNESS, RESPONSE AND RECOVERY FOR OLDER ADULTS 58 Domain 6: Research A holistic review of the identified literature revealed that research in the field of emergency preparedness, response, and recovery for older adults is highly underdeveloped. The unpredictability of both the timing and types of emergencies make traditional research designs and methodologies difficult. Nevertheless, there is a clear opportunity to develop and evaluate preparedness initiatives and their potential impact during response and recovery efforts, as well as the outcomes for designated populations and those personnel and organizations with a responsibility for supporting them. Recommendation 6.1 There is a need to prioritize the creation and funding of research efforts to better support the development of a common framework for measuring the quality and levels of emergency preparedness among care institutions, organizations, paid providers, community organizations, and other groups that work primarily with older adults and their unpaid caregivers during and after emergencies. Recommendation 6.2 There needs to be a more concerted effort in utilizing outcomes from existing evidence to support the planning, design, and refinement of more evidence-informed emergency preparedness interventions, policies, and regulations in support of older adults and unpaid caregivers, as well as organizations and paid care providers that will be responsible for meeting their needs during and after an emergency. Prioritizing Emergency Preparedness and Response Research A review of the existing literature relevant to emergency preparedness, response, and recovery for older adults has highlighted a gap in this research field. Current research efforts have highlighted that older adults experience a disproportionately greater vulnerability to adverse outcomes during and after emergencies compared to younger adults; however, there is limited available research that evaluates interventions that can be implemented to induce more positive outcomes for older adults. Specifically, there are insufficient studies that evaluate best practices for assisting and caring for older adults with health and functional declines, and the most effective methods for delivering services and resources to them. Regarding system operations, there is research that documents the effects of surge capacity operations in the ED and patient tracking methods that are used internationally, but a lack of available research on the most effective policies and procedures to ensure a favorable outcome during surge capacity operations or patient hand-offs during emergencies. The development of a research agenda related to emergency preparedness, response and recovery for older adults is essential to facilitating greater experimental exploration of emergency-related interventions for older adults. Researchers should also develop a common framework for measuring the quality and levels of emergency preparedness among various institutions and organizations. A common evaluation framework can reduce the variability and biases that can be associated with comparing systems that have been evaluated using different frameworks, which can differ based on their chosen metrics and domains of measurement. 59 In a 2004 research report done by Public Safety and Emergency Preparedness Canada, participants acknowledged that there is little research related to emergency management in Canada. This highlights the need to encourage more graduate students to pursue research projects in emergency management. Furthermore, the outcomes of those projects needs to be translated to practitioners to bridge the gap between knowledge and practice (Public Safety and Emergency Preparedness Canada, 2004). There has been some work done to measure general preparedness among Canadians published in the 2014 report titled Emergency Preparedness in Canada. The report used data from the Survey of Emergency Preparedness and Resilience (SEPR), a cross sectional survey conducted by Statistics Canada for the first time in 2014, to investigate emergency preparedness activities and risk awareness among Canadians aged 15 and over from across the 10 provinces. Based on the survey, emergencies involving the outbreak of serious disease were named as a likely hazard by about half of those in each province, with the exception of Newfoundland and Labrador (37%), Prince Edward Island (40%) and New Brunswick (44%), where the proportion was about four in ten for each (Emergency Preparedness in Canada, 2014). Canadians believe a number of natural and human-induced disasters are events that their community is likely to face. Winter storms (86%) and extended power outages (76%), followed by outbreaks of serious or life-threatening disease (51%) and industrial or transportation accidents (50%) were the most frequently named events (Emergency Preparedness in Canada, 2014). Further, older adults aged 65 and older were highlighted as being less likely to have a large social network to turn to in an emergency (Emergency Preparedness in Canada, 2014). Though the SEPR provides a baseline to support understanding of preparedness across Canada, responses were collected from Canadians living in only the 10 provinces, excluding the territories. It also excluded Canadians living in institutions such as nursing and long-term care homes, which includes older adults who would be in greater need of support in emergency or disaster situations. Applying Relevant Research Findings to Real-Life Emergency Health Practices Recommendation 6.2 further supports the utilization of research in policy making by proposing that published studies related to emergency preparedness and recovery be made open access. Providing open access to emergency preparedness and recovery research can help facilitate greater experimental investigation in the field of emergency preparedness and response. Recommendation 6.3 A network of emergency preparedness researchers, older adults, unpaid caregivers, volunteers and providers needs to be created to encourage partnerships in the ongoing unpaid evaluation of emergency preparedness interventions targeting older adults. Network members should advocate for an increased focus on emergency preparedness research among the various societies or journals that they are members of. Establishing a Network of Emergency Health Researchers Unfortunately, emergency management research in Canada has not been identified as a priority. As a result, Recommendation 6.3 suggests creation of a national network for emergency DOMAIN 6: RESEARCH CLOSING THE GAPS: ADVANCING EMERGENCY PREPAREDNESS, RESPONSE AND RECOVERY FOR OLDER ADULTS 60 management and emergency preparedness comprised of providers, older adults and volunteers. The network could be leveraged for information sharing but would primarily advocate for an increased focus on emergency preparedness research. It was also suggested by Round Table participants that the network could be supported by an organization connected to all universities offering emergency management programs and conducting emergency management research, as well as by the federal and provincial authorities responsible for emergency management. The panel further recommends that this current network of emergency preparedness researchers be continued to support the progression of research efforts related to emergency preparedness for older adults. The tasks of the research group should include evaluating the efficiency of existing policies and procedures within care institutions/ organizations and government, identifying gaps in knowledge and knowledge delivery, and delegating priorities for research. It is intended that this group of researchers will fill the current gap in emergency preparedness, response and recovery research to support the development of evidencebased policies. Recommendation 6.4 There is a need to focus on research about unpaid caregivers and emergency preparedness to better instruct unpaid caregivers on how to take care of their vulnerable family members and friends during an emergency. Conducting Research on Emergency Preparedness Among Unpaid Caregivers Being an unpaid caregiver can at times be demanding. Dealing with an emergency, in addition to caregiving responsibilities, can quickly become overwhelming, with potentially devastating consequences. Consequently, it is essential for unpaid caregivers to be appropriately supported whereby they can identify potential challenges and take the steps necessary so that they and the older adult they are caring for can be prepared. The Round Table attendees recognized the vital role that unpaid caregivers play in emergency preparedness and reduction of casualties following a major event among older adults. The literature reviewed has highlighted the different levels of responsibilities and roles in reducing negative outcomes following an emergency. Research literature has consistently noted a need for evidence-informed strategies to address challenges to emergency preparedness, particularly among households with frail older adults and their unpaid caregivers (Levac, Toal- Sullivan, & O'Sullivan, 2012). Recommendation 6.4 notes the importance of conducting additional research with a particular focus on unpaid caregivers, which can further bridge this gap and provide an evidence base to develop strategies that can mitigate negative outcomes among older adults following an emergency. Recommendation 6.5 There is a need to focus on research about emergency preparedness and response in Canadian community and congregate living settings for older adults (e.g. nursing, retirement and group homes, and assisted living facilities). Research should:
Determine the existing levels of preparedness across these environments as well as highlight the challenges they face in being prepared. 61
Characterize the impact of the emergency on the older adult population and emerging best practices on how to address it as soon as it emerges. Preparing Congregate Living Settings for an Emergency Canada’s recent experience with the COVID-19 pandemic and the high number of deaths it has experienced to date in its long-term care homes (Canadian Institute for Health Information, 2020) has shown that there are gaps in the system which have rendered congregate living settings vulnerable in the midst of an emergency. Recommendations 6.5 highlights the need for more research to understand the existing levels of emergency preparedness in congregate living settings for older adults. Comprehensive emergency plans should reflect contingencies for a multitude of emergencies ranging in scale and nature, including pandemics. Emergency plans in congregate living settings for older adults should include clear protocols for pandemics. In a study conducted by Lum, Mody, Lona and Ginde (2014), a national survey to identify characteristics of residential care settings associated with having a pandemic plan in the US found that a majority of the residential care settings that lacked a pandemic influenza plan were smaller, for-profit, and non-chain-affiliated and also had lower staff vaccination rates (Lum, Mody, Levy, & Ginde, 2014). Understanding these characteristics may help target settings that need to develop plans to handle a pandemic, or other emergencies. Having a robust program of research on emergency preparedness in congregate living settings for older adults can facilitate the development of a body of evidence for best practices to address emergencies as soon as it emerges. Research should target all levels of emergency management including the resident/ patient, providers/staff, programs and institutions. Surveillance data, such as data from the COVID-19 pandemic, can provide the basis for new and ongoing studies. DOMAIN 6: RESEARCH CLOSING THE GAPS: ADVANCING EMERGENCY PREPAREDNESS, RESPONSE AND RECOVERY FOR OLDER ADULTS 62 Alzheimer’s Disease: a form of dementia that causes problems with memory, thinking, behavior and independent functioning; it is the most common cause of dementia (https://www.alz.org/alzheimers- dementia/whatis- alzheimers). Care Institution: an organization that provides health care and related services to the provision of inpatient and outpatient care, such as diagnostic or therapeutic services, laboratory services, medicinal drugs and other health services. Congregate Living Settings: refers to a range of congregate living environments (nursing and retirement homes, assisted living facilities, etc.) where older adults live or stay overnight and use shared spaces (https://www.publichealthontario.ca/en/diseasesand- conditions/infectious-diseases/respiratorydiseases/ novel-coronavirus/congregate-livingsettings- resources#:~:text=Congregate%20 living%20settings%20refer%20 to,Correctional%20facilities). Dementia: a general term used to categorize a group of diseases associated with progressive declines in cognitive abilities, including memory, communication, language, attention, reasoning, judgement and visual perception that negatively impact independent functioning (https://www.alz.org/alzheimers-dementia/whatis- dementia). Epidemic: the occurrence of disease cases in excess of normal expectancy (https://www.who.int/environmental_health_ emergencies/disease_outbreaks/en/). Emergency: a state whereby a territory is facing an event with public health consequences; here used to encompass a natural disaster or pandemic (https://www.who.int/emergencies/crises/en/). Emergency Response Personnel: personnel responsible for providing assistive services during an emergency, including firefighters, police, civil defense/emergency management officials, sheriffs, military and manufacturing and transportation personnel. Geriatric Care Professionals: practitioners that specialize in treating the physical, mental, emotional and/or social problems among older adults, including nurses, dentists, social workers, occupational and physical therapists, and pharmacists. Health Care Disaster: these happen when the destructive effects of a natural disaster can overwhelm the ability of a given area or community to meet the demand for healthcare (https://www.ncbi.nlm.nih.gov/pmc/articles/ PMC1291330/). Healthcare Professionals: an individual that has been certified and authorized to provide preventable, curable, rehabilitative, and promotional health services (http://www.who.int/hrh/statistics/Health_ workers_classification.pdf). Incident Command System: a standardized tool for enabling an effective command, control, and coordination of an emergency response, allowing agencies to work together to facilitate a consistent response (https://ops.fhwa.dot.gov/publications/ics_guide/ glossary.htm). Glossary 63 Natural disaster: an act of nature of such magnitude as to create a catastrophic situation in which the day-to-day patterns of life are suddenly disrupted and people are plunged into helplessness and suffering, and, as a result, need food, clothing, shelter, medical and nursing care and other necessities of life, and protection against unfavourable environmental factors and conditions (https://www.who.int/environmental_health_ emergencies/natural_events/en/) Pandemic: an epidemic occurring worldwide, or over a very wide area, crossing international boundaries and usually affecting a large number of people (https://www.who.int/bulletin/ volumes/89/7/11-088815/en/#:~:text=A%20 pandemic%20is%20defined%20as,are%20not%20 considered%20pandemics.) Personal Protective Equipment (PPE): items worn or used to provide barrier to help prevent potential exposure to an infectious disease. Shelter-in-place: a precaution taken when hazardous materials (chemical, biological or radiological) are released in the air. This requires seeking a small, interior room with no or minimal windows within the building one already occupies. State of Emergency: a circumstance declared by a government when a disaster has occurred and is severe or is imminent and expected to require state aid to supplement local resources to prevent or alleviate damage, loss and hardship within a region (http://ready.nj.gov/about-us/state-of-emergency. shtml). Unpaid Caregivers: individuals who provide help and care to members of their household and to people who reside in other households. GLOSSARY CLOSING THE GAPS: ADVANCING EMERGENCY PREPAREDNESS, RESPONSE AND RECOVERY FOR OLDER ADULTS 64 Ahronheim, J. C., Arquilla, B., & Gambale Greene, R. (2009). Elderly populations in disasters: Hospital guidelines for geriatric preparedness. New York: New York City Department of Health and Mental Hygiene. 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The impact of forced transitions on the most functionally impaired nursing home residents. Journal of the American Geriatrics Society, 60(10), 1895-1900. doi:10.1111/j.1532-5415.2012.04146.x 77 Thomas, T. N., Sobelson, R. K., Wigington, C. J., Davis, A. L., Harp, V. H., Leander-Griffith, M., & Cioffi, J. P. (2018, January/February). Applying instructional design strategies and behavior theory to household disaster preparedness training. Journal of Public Health Management and Practice, 24(1), e16-e25. doi:10.1097/PHH.0000000000000511 Tricco, A. C., Lillie, E., Soobiah, C., Perrier, L., & Straus, S. E. (2013, September). Impact of H1N1 on socially disadvantaged populations: Summary of a systematic review. Influenza and other Respiratory Viruses, 7(Suppl 2), 54-58. doi:10.1111/irv.12082 Trivedi, T. K., DeSalvo, T., Lee, L., Palumbo, A., Moll, M., Curns, A., . . . Lopman, B. A. (2012, October 24). Hospitalizations and mortality associated with norovirus outbreaks in nursing homes, 2009-2010. JAMA, 308(16), 1668-1675. doi:10.1001/jama.2012.14023 van Solm, A. (2016). Application of interRAI assessments in disaster management: Identifying vulnerable persons in the community. Retrieved from UWSpace: https://uwspace.uwaterloo.ca/ handle/10012/10795 van Solm, A. I., Hirdes, J. P., Eckel, L. A., Heckman, G. A., & Bigelow, P. L. (2017, November/December). Using standard clinical assessments for home care to identify vulnerable populations before, during, and after disasters. Journal of Emergency Management, 15(6), 355-366. doi:10.5055/jem.2017.0344 Welch, A. E., Caramanica, K., Maslow, C. B., Brackbill, R. M., Stellman, S. D., & Farfel, M. R. (2016, April). Trajectories of PTSD among lower Manhattan residents and area workers following the 2001 World Trade Center disaster, 2003-2012. Journal of Traumatic Stress, 29(2), 158-166. doi:10.1002/ jts.22090 Whitehead, J. C., Edwards, B., Van Willigen, M., Maiolo, J. R., Wilson, K., & Smith, K. T. (2000, December). Heading for higher ground: Factors affecting real and hypothetical hurricane evacuation behavior. Environmental Hazards, Volume 2(4), 133-142. doi:10.1016/S1464-2867(01)00013-4 Willoughby, M., Kipsaina, C., Ferrah, N., Blau, S., Bugeja, L., Ranson, D., & Ibrahim, J. E. (2017, August 1). Mortality in nursing homes following emergency evacuation: A systematic review. Journal of the American Medical Directors Association, 18(8), 664-670. doi:10.1016/j.jamda.2017.02.005 World Health Organization. (2020). Rational use of personal protective equipment for coronavirus disease (COVID-19) and considerations during severe shortages. Retrieved from file:///C:/Users/mmedn7f/ Downloads/WHO-2019-nCov-IPC_PPE_use-2020.3-eng.pdf Wyte-Lake, T., Claver, M., Griffin, A., & Dobalian, A. (2014). The role of the home-based provider in disaster preparedness of a vulnerable population. Gerontology, 60(4), 336-345. doi:10.1159/000355660 Zibulewsky, J. (2001, April). Defining disaster: The emergency department perspective. Baylor University Medical Center Proceedings, 144-149. doi:10.1080/08998280.2001.11927751 REFERENCES CLOSING THE GAPS: ADVANCING EMERGENCY PREPAREDNESS, RESPONSE AND RECOVERY FOR OLDER ADULTS 78 Appendices Appendix A: Index of Recommendations and Enabling Bodies The index below provides an outline of the 29 recommendations presented in this whitepaper and an identification of the emergency management domains that have been determined to be responsible for adopting or enforcing a given recommendation. Recommendations Relevant Federal Agencies Provincial & Local Governments Care Institutions & Organizations Health Care Professionals & Emergency Response Personnel Community-Based Services & Programs Individuals & Unpaid Caregivers Domain 1: Individuals and Unpaid Caregivers Recommendation 1.1: Older adults and their unpaid caregiver(s) should be provided with tailored, easy-to-access information and resources related to emergency preparedness and guidance on how to develop customized emergency plans that consider the functional and health needs of older adults and appropriate strategies to support infection/disease prevention. Volunteer representatives of older Canadians and their unpaid caregivers should be recruited and involved in developing and disseminating resources and training material, to ensure their voices and perspectives are reflected. X X X X X X Recommendation 1.2: Older adults who are reliant on mobility aids should remove or minimize barriers affecting their ability to evacuate, and take steps to ensure their safety within their surroundings. X X Recommendation 1.3: If registries for people with functional and other needs, including persons with disabilities, have been established by local emergency response agencies, older adults and/or their unpaid caregiver(s) should register so they can be better assisted/supported during emergencies. X X X X Recommendation 1.4: Older adults who have a sensory impairment, such as a visual or hearing disability, should take additional precautions to prepare themselves for emergencies. X X X Recommendation 1.5: Older adults who live with chronic health conditions should maintain a readily accessible list of their current medical conditions, treatments (medications, durable medical equipment, supplies and other health care needs), health care providers, and emergency contacts, including substitute decision makers (SDMs). X X Recommendation 1.6: Older adults who take medications should work with their health care providers to ensure they have access to at least a 30-day supply of medications during an emergency. X X Recommendations Relevant Federal Agencies Provincial & Local Governments Care Institutions & Organizations Health Care Professionals & Emergency Response Personnel Community-Based Services & Programs Individuals & Unpaid Caregivers Recommendation 1.7: Older adults, and their unpaid caregivers, who are reliant on medical devices that require electricity, should ensure they have back-up power supplies in place, especially if required while sheltering-in-place.
Older adults and/or their unpaid caregivers should contact their electricity company in advance to discuss their needs and ensure options for alternative power sources are available, especially addressing the need for access to power to charge cell phones and other mobile devices.
Older adults and/or their unpaid caregivers should seek assistance with obtaining and maintaining an alternative power source at home, if required, such as when being required to move heavy equipment and fuel or in accessing these resources in rural locations, and operating equipment. X X X Recommendation 1.8: Older adults should be encouraged to continually maintain an adequate local support network that can be called upon during impending disasters and unexpected emergencies, especially if they live alone or lack easy access to relatives. X X X Recommendation 1.9: Unpaid caregivers of persons with Alzheimer’s disease and/or other dementias should to supported to identify signs of distress, anxiety, or confusion, and use strategies to redirect attention and help them stay calm during emergencies. In addition, unpaid caregivers should be prepared to prevent wandering, and have plans in place to locate their care recipients if they do wander or require medical intervention(s) during an emergency. X X X Domain 2: Community-Based Services and Program Recommendation 2.1: Access should be increased to tailored communitybased programs that educate older adults and their unpaid caregivers about emergencies that could affect their region and how best to prepare for and respond to them. Volunteer representatives of older Canadians and their unpaid caregivers should be recruited and involved in training material development and implementation, to ensure their voices and perspectives are reflected.
Community-based programs and organizations should collaborate with regional public health authorities in developing and disseminating education resources on infection control, disease and injury prevention practices for older adults and their unpaid caregivers during emergencies. X X X Recommendation 2.2: Programs that provide disaster relief and/or essential community services, such as Meals on Wheels, and daily living assistance for older people (financial, medical, personal care, food and transportation), should receive emergency preparedness training and education, as well as develop and adhere to plans and protocols related to responding adequately to the needs of their clients during emergencies. Volunteer representatives of older Canadians and their unpaid caregivers should be recruited and involved in training material development and implementation, to ensure their voices and perspectives are reflected. X APPENDIX A – A1 Recommendations Relevant Federal Agencies Provincial & Local Governments Care Institutions & Organizations Health Care Professionals & Emergency Response Personnel Community-Based Services & Programs Individuals & Unpaid Caregivers Recommendation 2.3: Community based programs that provide in-home health and personal care for older adults should integrate strategies that minimize unnecessary personal contact and leverage resources (e.g. personal protective equipment such as gowns, masks, gloves, hand sanitizer etc.) in their emergency preparedness plans and protocols. X Recommendation 2.4: Local governments should leverage data sources that identify at-risk individuals to enable emergency responders to more easily prioritize their search and rescue efforts following an emergency. X Domain 3: Health Care Professionals and Emergency Response Personnel Recommendation 3.1: Health care professionals and emergency response personnel should receive training on providing geriatric care relevant to their discipline and how best to assist older adults and their unpaid caregivers before, during and after emergencies. The additional education and training should also increase their awareness of best practices and precautions to minimize the risk of infectious disease transmission or spread while responding to emergencies. Volunteer representatives of older Canadians should be recruited and involved in training material development and implementation, to ensure their voices and perspectives are reflected. X X X Recommendation 3.2: Health care professionals and emergency response personnel should strive to mitigate psychological distress among older persons during and after emergency by making an effort to assess the psychological well-being of older adults and provide appropriate treatments as needed. X X Recommendation 3.3: Health care professionals and emergency response personnel should receive cultural awareness training to provide appropriate care and support for older adults with different cultural and religious backgrounds before, during, and after an emergency. Providers should have options for providing support to older adults and their unpaid caregivers who face language or cultural barriers to accessing supports (e.g., translators, written materials in languages other than English or French, etc.). This is of particular importance for personnel that work with Indigenous populations, in diverse community-settings, and during times of evacuation due to emergencies. X X Recommendations Relevant Federal Agencies Provincial & Local Governments Care Institutions & Organizations Health Care Professionals & Emergency Response Personnel Community-Based Services & Programs Individuals & Unpaid Caregivers Domain 4: Care Institutions and Organizations Recommendation 4.1: Care institutions and organizations should include emergency preparedness and response education in their routine personnel training courses.
Multi-modality educational tools and practices should be used to better facilitate knowledge acquisition and behavioral change.
Volunteer representatives of older Canadians should be recruited and involved in developing and disseminating resources and training material, to ensure their voices and perspectives are reflected X X X Recommendation 4.2: Additional strategies to improve the collection and transfer of identifying information and medical histories should be adopted into current standardized patient handoff procedures to better facilitate effective tracking, relocation and care of patients during an emergency. X Recommendation 4.3: Care institutions and other organizations should strive to develop comprehensive emergency plans that include effective response strategies for protecting older adults against infectious disease outbreaks and reflect evidence-based standards supported by organizations such as Infection Prevention and Control Canada.
Care institutions should also regularly assess and address any barriers they identify that could affect the implementation of their emergency plans that build on their routine practices. X Domain 5: Legislation and Policy Recommendation 5.1: A national advisory committee should be created to inform emergency preparedness, response and recovery program development and strategies for older Canadians. Individuals who are representative of older Canadians and their unpaid caregivers should be involved to ensure their voices and perspectives are reflected. X X X X X Recommendation 5.2: All provinces and territories should support the implementation of tax-free emergency preparedness purchasing periods during specific times of the year or prior to an impending emergency. Governments should also provide targeted funding to directly support/ subsidize the purchase of emergency preparedness kits for older Canadians. Items covered should include an agreed-upon list of emergency supplies (such as batteries, portable generators, rescue ladders, radios and ice packs), air conditioners, personal protective equipment (such as masks, gloves and hand sanitizer) and additional mobility aids (canes, walkers, etc.). X APPENDIX A – A2 Recommendations Relevant Federal Agencies Provincial & Local Governments Care Institutions & Organizations Health Care Professionals & Emergency Response Personnel Community-Based Services & Programs Individuals & Unpaid Caregivers Recommendation 5.3: All provinces and territories should support the creation of a national licensure process or program for nurses, physicians, allied health professionals and other emergency medical service personnel to allow them to provide voluntary emergency medical support across provincial/territorial boundaries during declared states of emergency. X Recommendation 5.4: All provincial and territorial governments should support legislative requirements that mandate congregate living settings for older persons (e.g. nursing homes, assisted living facilities and retirement homes) to regularly update and report their emergency plans that outline actions and contingencies to take in case of emergencies. These plans should include:
Back-up generators in case of extended periods of power outages, and coordinated plans with relevant community agencies (e.g. municipal fire agencies) for efficient evacuations.
Directions on appropriate interventions (i.e. self-isolation, wearing face masks, physical distancing, etc.) to control and prevent outbreaks and spread of infectious diseases amongst the population in times of emergencies.
Clear thresholds for temperature regulation, specifically, maximum and minimum temperatures permissible based on occupational and environment health standards, and the steps required to regulate temperatures and minimize fluctuations.
An outline of staffing levels that should be maintained during emergencies to minimize care and/or service interruptions. All provinces and territories should work towards standardizing requirements for emergency plans in congregate living settings in accordance with the priorities outlined in the 2019 Emergency Management Strategy for Canada and ensure that their emergency plans for congregate living settings are aligned with directives outlined in their provincial/territorial emergency plans. X X Recommendation 5.5: All provinces and territories should adopt a standardized approach to promoting collaborations between local pharmaceutical prescribers and dispensers (i.e. community pharmacists), physicians and nurse practitioners, to ensure an adequate supply of prescription medications are dispensed to persons with chronic health conditions prior to and during an emergency. This approach should also outline the need for collaboration between pharmaceutical providers, hospitals and relief agencies to ensure an adequate supply of prescription medications are available at hospitals, relief and evacuation shelters.
All persons should be able to obtain at least a 30-day supply of emergency prescription medications prior to and during an emergency. X X X X Recommendations Relevant Federal Agencies Provincial & Local Governments Care Institutions & Organizations Health Care Professionals & Emergency Response Personnel Community-Based Services & Programs Individuals & Unpaid Caregivers Domain 6: Research Recommendation 6.1: There is a need to prioritize the creation and funding of research efforts to better support the development of a common framework for measuring the quality and levels of emergency preparedness among care institutions, organizations, paid providers, community organizations, and other groups that work primarily with older adults and their unpaid caregivers during and after emergencies. X Recommendation 6.2: There needs to be a more concerted effort in utilizing outcomes from existing evidence to support the planning, design, and refinement of more evidence-informed emergency preparedness interventions, policies, and regulations in support of older adults and their unpaid caregivers, as well as organizations and paid care providers that will be responsible for meeting their needs during and after an emergency. X Recommendation 6.3: A network of emergency preparedness researchers, older adults, unpaid caregivers, volunteers and providers needs to be created to encourage partnerships in the ongoing unpaid evaluation of emergency preparedness interventions targeting older adults. Network members should advocate for an increased focus on emergency preparedness research among the various societies or journals that they are members of. X Recommendation 6.4: There is a need to focus on research about unpaid caregivers and emergency preparedness to better instruct unpaid caregivers on how to take care of their vulnerable family members and friends during an emergency. X X Recommendation 6.5: There is a need to focus on research about emergency preparedness and response in Canadian community and congregate living settings for older adults (e.g. nursing, retirement and group homes and assisted living facilities). Research should:
Determine the existing levels of preparedness across these environments as well as highlight the challenges they face in being prepared.
Characterize the impact of the emergency on the older adult population and identify best practices on how to address future emergencies. X X APPENDIX A – A3 Appendix B: Emergency Preparedness for Older Adults Summary of Relevant Legislation and Framework Policy/ Legislation Province/ National Link Alberta’s Pandemic Influenza Plan by the Government of Alberta Alberta https://open.alberta.ca/publications/alberta-s-pandemic-influenza-plan Community Care and Assisted Living Act British Columbia https://www.bclaws.ca/civix/document/id/complete/statreg/02075_01 Pharmacy Disaster Preparedness (2009) a professional practice policy statement British Columbia http://library.bcpharmacists.org/6_Resources/6-2_PPP/5003-PGP-PPP25.pdf Preparing for Pandemic Influenza in Manitoba (Public Health Emergency Preparedness and Response) Manitoba https://www.gov.mb.ca/health/publichealth/pandemic.html Long-Term Care Homes Act Ontario https://www.ontario.ca/laws/statute/07l08 Ontario Health Plan for an Influenza Pandemic (2013) Ontario http://www.health.gov.on.ca/en/pro/programs/emb/pan_flu/pan_flu_plan.aspx Quebec Pandemic Influenza Plan-Health Mission (2006) Quebec https://publications.msss.gouv.qc.ca/msss/en/document-001259/ An Emergency Management Framework for Canada (2017) by Public Safety Canada National https://www.publicsafety.gc.ca/cnt/rsrcs/pblctns/2017-mrgnc-mngmnt-frmwrk/index-en.aspx Canadian Pandemic Influenza Preparedness by Pan-Canadian public Health Network National https://www.canada.ca/en/public-health/services/flu-influenza/canadian-pandemic-influenza-preparedness-planning-guidancehealth- sector.html Department of Public Safety and Emergency Preparedness Act National https://laws.justice.gc.ca/eng/acts/P-31.55/ Emergency Management Act (S.C. 2007, c.15) National https://laws-lois.justice.gc.ca/eng/acts/E-4.56/ Emergency Preparedness in Canada (refer to the highlights on Page 3) National https://www.getprepared.gc.ca/cnt/rsrcs/pblctns/yprprdnssgd/index-en.aspx Federal/Provincial/Territorial Public Health Response Plan for Biological Events by Pan-Canadian Public Health Network (refer to Appendix L for the Response Plan) National https://www.canada.ca/en/public-health/services/emergency-preparedness/public-health-response-plan-biological-events.html North American Plan for Animal and Pandemic Influenza (by Public Safety Canada) National https://www.publicsafety.gc.ca/cnt/rsrcs/pblctns/nml-pndmc-nflnz/index-en.aspx Quarantine Act (2005) National https://laws-lois.justice.gc.ca/eng/acts/q-1.1/page-1.html APPENDIX B – B1 253901-05 1/20

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CMA Pre-budget Submission

https://policybase.cma.ca/en/permalink/policy14259

Date
2020-08-07
Topics
Physician practice/ compensation/ forms
Health information and e-health
Health care and patient safety
Health systems, system funding and performance
  1 document  
Policy Type
Parliamentary submission
Date
2020-08-07
Topics
Physician practice/ compensation/ forms
Health information and e-health
Health care and patient safety
Health systems, system funding and performance
Text
RECOMMENDATION 1 That the government create a one-time Health Care and Innovation Fund to resume health care services, bolster public health capacity and expand primary care teams, allowing Canadians wide-ranging access to health care. RECOMMENDATION 2 That the government recognize and support the continued adoption of virtual care and address the inequitable access to digital health services by creating a Digi-Health Knowledge Bank and by expediting broadband access to all Canadians. RECOMMENDATION 3 That the government act on our collective learned lessons regarding our approach to seniors care and create a national demographic top-up to the Canada Health Transfer and establish a Seniors Care Benefit. RECOMMENDATION 4 That the government recognize the unique risks and financial burden experienced by physicians and front line health care workers by implementing the Frontline Gratitude Tax Deduction, by extending eligibility of the Memorial Grant and by addressing remaining administrative barriers to physician practices accessing critical federal economic relief programs. RECOMMENDATIONS 3 Five months ago COVID-19 hit our shores. We were unprepared and unprotected. We were fallible and vulnerable. But, we responded swiftly.
The federal government initiated Canadians into a new routine rooted in public health guidance.
It struggled to outfit the front line workers. It anchored quick measures to ensure some financial stability.
Canadians tuned in to daily updates on the health crisis and the battle against its wrath.
Together, we flattened the curve… For now. We have experienced the impact of the first wave of the pandemic. The initial wake has left Canadians, and those who care for them, feeling the insecurities in our health care system. While the economy is opening in varied phases – an exhaustive list including patios, stores, office spaces, and schools – the health care system that struggled to care for those most impacted by the pandemic remains feeble, susceptible not only to the insurgence of the virus, but ill-prepared to equally defend the daily health needs of our citizens. The window to maintain momentum and to accelerate solutions to existing systemic ailments that have challenged us for years is short. We cannot allow it to pass. The urgency is written on the faces of tomorrow’s patients. Before the onset of the pandemic, the government announced intentions to ensure all Canadians would be able to access a primary care family doctor. We knew then that the health care system was failing. The pandemic has highlighted the criticality of these recommendations brought forward by the Canadian Medical Association. They bolster our collective efforts to ensure that Canadians get timely access to the care and services they need. Too many patients are succumbing to the gaps in our abilities to care for them. Patients have signaled their thirst for a model of virtual care. The magnitude of our failure to meet the needs of our aging population is now blindingly obvious. Many of the front line health care workers, the very individuals who put themselves and their families at risk to care for the nation, are being stretched to the breaking point to compensate for a crumbling system. The health of the country’s economy cannot exist without the health of Canadians. INTRODUCTION 4 Long wait times have strangled our nation’s health care system for too long. It was chronic before COVID-19. Now, for far too many, it has turned tragic. At the beginning of the pandemic, a significant proportion of health care services came to a halt. As health services are resuming, health care systems are left to grapple with a significant spike in wait times. Facilities will need to adopt new guidance to adhere to physical distancing, increasing staff levels, and planning and executing infrastructure changes. Canada’s already financially atrophied health systems will face significant funding challenges at a time when provincial/territorial governments are concerned with resuscitating economies. The CMA is strongly supportive of new federal funding to ensure Canada’s health systems are resourced to meet the care needs of Canadians as the pandemic and life continues. We need to invigorate our health care system’s fitness to ensure that all Canadians are confident that it can and will serve them. Creating a new Health Care and Innovation Fund would focus on resuming the health care system, addressing the backlog, and bringing primary care, the backbone of our health care system, back to centre stage. The CMA will provide the budget costing in follow-up as an addendum to this submission. RECOMMENDATION 1 Creating a one-time Health Care and Innovation Fund 5 It took a global pandemic to accelerate a digital economy and spark a digital health revolution in Canada. In our efforts to seek medical advice while in isolation, Canadians prompted a punctuated shift in how we can access care, regardless of our location or socio-economic situation. We redefined the need for virtual care. During the pandemic, nearly half of Canadians have used virtual care. An incredible 91% were satisfied with their experience. The CMA has learned that 43% of Canadians would prefer that their first point of medical contact be virtual. The CMA welcomes the $240 million federal investment in virtual care and encourages the government to ensure it is linked to a model that ensures equitable access. A gaping deficit remains in using virtual care. Recently the CMA, the Royal College of Physicians and Surgeons of Canada and the College of Family Physicians of Canada established a Virtual Care Task Force to identify digital opportunities to improve health care delivery, including what regulatory changes are required across provincial/territorial boundaries. To take full advantage of digital health capabilities, it will be essential for the entire population, to have a functional level of digital health literacy and access to the internet. The continued adoption of virtual care is reliant on our ability to educate patients on how to access it. It will be further contingent on consistent and equitable access to broadband internet service. Create a Digi-Health Knowledge Bank Virtual care can’t just happen. It requires knowledge on how to access and effectively deliver it, from patients and health care providers respectively. It is crucial to understand and promote digital health literacy across Canada. What the federal government has done for financial literacy, with the appointment of the Financial Literacy Leader within the Financial Consumer Agency of Canada, can serve as a template for digital health literacy. We recommend that the federal government establish a Digi-Health Knowledge Bank to develop indicators and measure the digital health of Canadians, create tools patients and health care providers can use to enhance digital health literacy, continually monitor the changing digital divide that exists among some population segments. Pan-Canadian broadband expansion It is critical to bridge the broadband divide by ensuring all those in Canada have equitable access to affordable, reliable and sustainable internet connectivity. Those in rural, remote, Northern and Indigenous communities are presently seriously disadvantaged in this way. With the rise in virtual care, a lack of access to broadband exacerbates inequalities in access to care. This issue needs to be expedited before we can have pride in any other achievement. RECOMMENDATION 2 Embedding virtual care in our nation’s health care system 6 Some groups have been disproportionately affected by the COVID-19 crisis. Woefully inadequate care of seniors and residents of long-term care homes has left a shameful and intensely painful mark on our record. Our health care system has failed to meet the needs of our aging population for too long. The following two recommendations, combined with a focus on improving access to health care services, will make a critical difference for Canadian seniors. A demographic top-up to the Canada Health Transfer The Canada Health Transfer (CHT) is the single largest federal transfer to the provinces and territories. It is critical in supporting provincial and territorial health programs in Canada. As an equal per-capita-based transfer, it does not currently address the imbalance in population segments like seniors. The CMA, hand-in-hand with the Organizations for Health Action (HEAL), recommends that a demographic top-up be transferred to provinces and territories based on the projected increase in health care spending associated with an aging population, with the federal contribution set to the current share of the CHT as a percentage of provincial-territorial health spending. A top-up has been calculated at 1.7 billion for 2021. Additional funding would be worth a total of $21.1 billion to the provinces and territories over the next decade. Seniors care benefit Rising out-of-pocket expenses associated with seniors care could extend from 9 billion to 23 billion by 2035. A Seniors Care Benefits program would directly support seniors and those who care for them. Like the Child Care Benefit program, it would offset the high out-of-pocket health costs that burden caregivers and patients. RECOMMENDATION 3 Ensuring that better care is secured for our seniors 7 The federal government has made great strides to mitigate the health and economic impacts of COVID-19. Amidst the task of providing stability, there has been a grand oversight: measures to support our front line health care workers and their financial burden have fallen short. The CMA recommends the following measures: 1. Despite the significant contribution of physicians’ offices to Canada’s GDP, many physician practices have not been eligible for critical economic programs. The CMA welcomes the remedies implemented by Bill C-20 and recommends the federal government address remaining administrative barriers to physicians accessing federal economic relief program. 2. We recommend that the government implement the Frontline Gratitude Tax Deduction, an income tax deduction for frontline health care workers put at risk during the COVID-19 pandemic. In person patient care providers would be eligible to deduct a predetermined amount against income earned during the pandemic. The Canadian Armed Forces already employs this model for its members serving in hazardous missions. 3. It is a devastating reality that front line health care workers have died as a result of COVID-19. Extending eligibility for the Memorial Grant to families of front line health care workers who mourn the loss of a family member because of COVID-19, as a direct result of responding to the pandemic or as a result of an occupational illness or psychological impairment related to their work will relieve any unnecessary additional hardship experienced. The same grant should extend to cases in which their work contributes to the death of a family member. RECOMMENDATION 4 Cementing financial stabilization measures for our front line health care workers 8 Those impacted by COVID-19 deserve our care. The health of our nation’s economy is contingent on the health standards for its people. We must assert the right to decent quality of life for those who are most vulnerable: those whose incomes have been dramatically impacted by the pandemic, those living in poverty, those living in marginalized communities, and those doubly plagued by experiencing racism and the pandemic. We are not speaking solely for physicians. This is about equitable care for every Canadian impacted by the pandemic. Public awareness and support have never been stronger. We are not facing the end of the pandemic; we are confronting an ebb in our journey. Hope and optimism will remain elusive until we can be confident in our health care system. CONCLUSION

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Committee Appearance: House of Commons Standing Committee on Health (HESA)

https://policybase.cma.ca/en/permalink/policy14381

Date
2020-11-30
Topics
Health systems, system funding and performance
  1 document  
Policy Type
Parliamentary submission
Date
2020-11-30
Topics
Health systems, system funding and performance
Text
Committee Appearance: House of Commons Standing Committee on Health (HESA) November 30, 2020 Dr. E. Ann Collins President of the Canadian Medical Association Committee Appearance November 30, 2020 House of Commons Standing Committee on Health (HESA) FINAL PRESENTATION November 30, 2020 ____________________________________________________________________________ Thank you, Mr. Chair. It’s my honour to appear before you today. My name is Dr. Ann Collins. In a three-decade career, I have taught family medicine, run a full-time practice, served with the Canadian Armed Forces and worked in nursing home care. Today, as President of the Canadian Medical Association, I am proud to represent our 80,000 members, so many of whom have been working all-out for over 9 months and counting. Our health systems and the people who work in them were stressed well before then. Now we are at a tipping point. I am deeply concerned about the mental health of Canadians. And I am deeply concerned about my physician colleagues and health care providers who work alongside them. Psychological trauma is anticipated to be the longest lasting impact among health care workers in the post-pandemic environment. After almost a year on the front lines in untenable circumstances, burnout is a grave concern. We’re sounding the alarm. When Canadians banged their pots and pans, they shouted their support for those risking their lives on the front lines. The pots are now nestled in kitchen drawers, but the pandemic has not stopped. It’s worse. And the risk to frontline workers persists. At the pandemic’s onset, a lack of coordination of emergency supply stockpiles among federal and provincial governments led to inadequate deployment of supplies such as ventilators and a widespread void of sufficient PPE for frontline health care workers. Physicians were faced with the ethical dilemma of being unprotected while treating patients and potentially putting their families at risk – in addition to having to make decisions about allocating life-saving intervention. The explicit anxiety haunting frontline physicians is palpable. They are at high risk of developing symptoms of burnout, depression, psychological distress, and suicidal ideation. Gruelling work hours, uncertainty, fears of personal and family risk, experiences with critically ill and dying patients – these conditions create unprecedented anxiety. Physician burnout was a nationwide challenge long before the COVID-19 pandemic emerged. In 2018, 30% of physicians reported high levels of burnout. The outcomes of human health resource issues, system inefficiencies and over-capacity workload creates a culture of sustained burnout. No amount of therapy, yoga and mindfulness will make it go away. And the consequences reach much further, Mr. Chair. They lead to bad patient outcomes. We are calling on all levels of government and health authorities to work together to protect Canadians and health care providers during the second wave of COVID-19 through a series of four strategic investments and actions. First, that all governments recognize and raise awareness of the need to support health care providers as part of their public education messaging on COVID-19. There is nothing benign about remaining mute on this subject. Patient safety depends on the mental health stability of medical professionals. Second, that the federal government invest in the creation of a mental health COVID-19 task force that mobilizes national mental health associations and professionals to support the mental health needs of care providers during and following the resurgence. And, that the government increase funding to jurisdictions, enhancing access to existing, but strained, specialized mental health resources for health care providers. Third, our vulnerable populations and people living in rural/remote areas are disproportionately affected. The federal government must fund and implement sustainable evidence-based mental health services and supports to respond to the increased demand for mental health care resulting from COVID-19. We must also intensify access to critical social support services and embed virtual care. We welcome the commitment to expand broadband across the country. It has the capacity to create equitable access to virtual care. But the success of digital health care relies not only on broadband expansion, but the development of digital health literacy programs and measures to ensure equity of access for marginalized populations. Lastly, we simply cannot ignore the risk of a health care shutdown. Avoiding this is absolutely critical. Adherence to public health measures is needed as well as new federal investment. A Health Care and Innovation Fund of $4B in federal funds would address the backlog of medical services, expand primary care teams and boost the capacity of public health. These measures don’t exist in a vacuum. It is their combination that blazes a path to Canadian health security. Canadians need the confidence that their health care system is there for them, that the physicians and frontline health care workers are in good shape. With burnout becoming the most significant challenge to the health care system, we face a degradation of care for our patients. Every tipping point needs a steadying hand. Canada is reaching out for it. Great victories require two elements: a common enemy and solidarity. We have a common enemy. Its viral. But without solidarity, there will only be more harm and loss. This virus doesn’t care about politics. It doesn’t recognize federal, provincial or territorial lines. It doesn’t care about a perceived stake. And, these case numbers aren’t numbers. They are lives. And we must fight for them. All of us. Together. Mr. Chair, let me thank the committee for the invitation to share the convictions of Canada’s physicians.

Documents

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Funding and delivery of long-term care in Canada

https://policybase.cma.ca/en/permalink/policy8518

Last Reviewed
2020-02-29
Date
2006-08-23
Topics
Health systems, system funding and performance
Resolution
GC06-45
The Canadian Medical Association will develop a discussion paper with policy principles and a full range of options for the funding and delivery of long-term care in Canada.
Policy Type
Policy resolution
Last Reviewed
2020-02-29
Date
2006-08-23
Topics
Health systems, system funding and performance
Resolution
GC06-45
The Canadian Medical Association will develop a discussion paper with policy principles and a full range of options for the funding and delivery of long-term care in Canada.
Text
The Canadian Medical Association will develop a discussion paper with policy principles and a full range of options for the funding and delivery of long-term care in Canada.
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Letter - CMA’s 2006 Pre-Budget Submission to the Minister of Finance

https://policybase.cma.ca/en/permalink/policy2031

Last Reviewed
2013-03-02
Date
2006-04-19
Topics
Health human resources
Health systems, system funding and performance
  1 document  
Policy Type
Parliamentary submission
Last Reviewed
2013-03-02
Date
2006-04-19
Topics
Health human resources
Health systems, system funding and performance
Text
On behalf of the Canadian Medical Association (CMA), I am pleased to present you with our pre-budget submission for your government's consideration. The CMA appreciates the opportunity to provide input into this government's first budget and to identify strategic investment opportunities for the long term health of Canadians. While Canada's health system faces many challenges, we believe that immediate action by the federal government in four key areas will offer both short term and long term benefits. They are: (1) the establishment of a Canada Health Access Strategy to support a patient wait-times guarantee; (2) a proposed Visa position buyback program and a repatriation program to immediately address shortfalls in health human resources; (3) a strengthening of Canada's public health infrastructure; and (4) a remedy for GST-induced distortions in the health care system.We believe these proposals fit well with the government's stated priorities. While information on each of these recommendations is attached for your information and consideration, I would like to provide you with an overview of each. 1. CANADA HEALTH ACCESS STRATEGY The CMA has been advocating for the implementation of maximum wait time thresholds or care guarantees for a number of years and is pleased that the government has included this as one of its top five priorities. As a first step, the CMA worked with six other specialty societies as part of the Wait Times Alliance (WTA) to develop a set of pan-Canadian wait-time benchmarks or performance goals released last August. We believe this work served as a catalyst for the provincial and territorial governments to move some way toward meeting their commitment in announcing pan-Canadian wait-time benchmarks last December. We must continue to work with governments and the academic community to improve access to medical care beyond the five priority health issues identified in the First Ministers' 2004 10-year health care plan. The second step in implementing patient wait-time guarantees is the issue of honouring the commitment and providing for patient recourse. As a member of the WTA, the CMA strongly supports accelerating the timetable to reduce wait times nationwide. However, the federal government needs to do its part to assist provinces in advancing the timetable by stepping up the flow of funds earmarked for the last four years of the accord. Our proposed Canada Health Access Strategy is comprised of three components directed at making this happen: supporting provinces to expand capacity and to handle surges in demand; supporting the creation of regional and/or national referral networks; and establishing a Canada Health Access Fund for a "safety valve" to help Canadians access care elsewhere when necessary. Details on how this Strategy would work are attached. The point is that this Strategy is necessary to assure Canadians that they get the care they need when they need it. Recommendation 1. The federal government advance the remaining $1 billion from the 2004 First Ministers Accord that was originally intended to augment the Wait Times Reduction Fund (2010-2014) to support a Canada Health Access Strategy by: (a) expanding provincial surge capacity : $500 million to be flowed immediately to provinces on a per capita basis in return for agreement to accelerate the timetable for bringing down wait times, as was promised in the recent federal election campaign; (b) improving national coordination of wait time management: $250 million to support creation of regional and/or national referral networks, a more coordinated approach to health human resource planning, expansion of information technology solutions to wait time management and facilitation of out-of-country referrals; and (c) establishing a Canada Health Access Fund: $250 million initial investment in an alternative patient recourse system or "safety valve" when and if clinically-indicated maximum wait time benchmarks as agreed to by provinces/territories last December are exceeded. Addressing Shortfalls in Health Human Resources As identified by Minister Clement in a recent speech at the "Taming of the Queue III" wait-time conference, addressing shortages in health human resources is a key element of any strategy for reducing lengthy wait-times. Unfortunately, we face serious physician shortages, starting with family physicians. The bad news is that it can take several years to educate and train the necessary professionals. The good news is that there are some strategies that can be undertaken to address the situation in the short term. 2. VISA POSITION BUYBACK FUND One such strategy is our Visa Position Buyback proposal that would eliminate the backlog of 1,200 qualified international medical graduates (IMGs) over the next five to seven years. Currently, these qualified IMGs, who are either Canadian citizens or landed immigrants, are unable to access the necessary residency training. One existing source for training capacity exists with the positions purchased by foreign governments for visa trainees. We estimate that there are over 900 current visa trainees at all rank levels. By implementing the Visa Position Buyback program, the government is able to take an immediate step that will produce tangible results as soon as a two to four years from now. This initiative would be part of a longer term plan to fully address the shortages in health human resources and help the government meet its commitment to implement a properly functioning patient wait-time guarantee. Recommendation 2a. The federal government allocate $381.6 million toward the training of up to 1,200 IMGs through to practice over the 2007/08 to 2015/16 period. Funding would be made available in two installments: an immediate investment of $240 million and the remaining $140 million subject to a satisfactory progress report at the end of five years. Repatriate Health Professionals Working in the United States Fortunately, another short-term source of health professionals exists that Canada should pursue. Thousands of health care professionals are currently working in the United States including approximately 9,000 Canadian trained physicians. We know that many of the physicians who do come back to Canada are of relatively young age meaning that they have significant practice life left. While a minority of these physicians do come back on their own, many more can be repatriated in the short-term through a relatively small but focussed effort by the federal government led by a secretariat within Health Canada. Recommendation 2b. The federal government should establish a secretariat within Health Canada that would provide funding to national professional associations to conduct targeted campaigns to encourage the repatriation of Canadian health professionals working in the United States, and act as a clearinghouse on issues associated with returning to Canada (e.g., citizenship, taxation, etc.). 3. PUBLIC HEALTH INFRASTRUCTURE RENEWAL The CMA remains concerned about the state of Canada's public health system. Public health, including the professionals providing public health services, constitutes our front line against a wide range of threats to the health of Canadians. While there is much talk about the arrival of possible pandemics, Canada's public health system must be ready to take on a broad range of public health issues. The CMA has been supportive of the Naylor report which provides a blue print for action and reinvestment in the public health system for the 21st century. While this will take several years to achieve, there are some immediate steps that can be taken which will lessen the burden of disease on Canadians and our health care system. These steps include establishing a Public Health Partnership Program with provincial and territorial governments to build capacity at the local level and to advance pandemic planning. In addition, we call on the government to continue its funding of immunization programs under its National Immunization Strategy. Recommendation 3a. The federal government should establish a Public Health Infrastructure Renewal Fund in the amount of $350 million annually to establish a Public Health Partnership Program with the provincial/territorial governments for the purposes of building capacity at the local level and advancing pandemic planning. In addition, the $100 million per year for immunization programs under the National Immunization Strategy should be continued. 4. A REMEDY FOR GST-RELATED DISTORTIONS IN THE HEALTH SYSTEM The CMA and many other national health organizations are concerned about the increasing, unintended and negative consequences the GST is having on health care. For example, the 83% rebate originally provided for under the so-called "MUSH" formula is no longer tax neutral and is acting as a deterrent in some cases toward increased use of ambulatory care services such as day surgeries. Over the past 15 years the physicians of Canada have faced a large and growing unfair tax burden due to the GST. Since physicians' services are tax exempt under the law, physicians are unable to either claim input tax credits or pass on the tax because of the prohibition under the Canada Health Act of billing patients directly. This puts physicians in a unique and patently unfair catch 22 that now amounts to over $65 million per year, which further acts as a deterrent to repatriating or retaining Canadian physicians. Recommendation: 4a. That the federal government, in the course of reducing the GST from 7% to 5% further to its campaign commitments, remove the large and growing deterrent effects of the GST on the efficient and effective delivery of health care in Canada. In summary, the CMA is providing you with recommendations on strategic investments to help your government honour its commitment to timely access to care and to improve the health of Canadians. Our recommendations are financially reasonable, making good use of Canadians' tax dollars. We look forward to meeting with you on April 19 to discuss our proposals with you. Sincerely, Ruth L. Collins-Nakai, MD, MBA, FRCPC, MACC President c.c. The Honourable Tony Clement, Health Minister

Documents

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Monitoring health care access and quality indicators

https://policybase.cma.ca/en/permalink/policy760

Last Reviewed
2017-03-04
Date
1996-08-21
Topics
Health systems, system funding and performance
Population health/ health equity/ public health
Resolution
GC96-19
That the Canadian Medical Association insist that appropriate mechanisms for objective monitoring of access and quality indicators and benchmarks for national standards be developed by providers, governments and consumers to track identified areas of perceived deterioration in access to quality of health care.
Policy Type
Policy resolution
Last Reviewed
2017-03-04
Date
1996-08-21
Topics
Health systems, system funding and performance
Population health/ health equity/ public health
Resolution
GC96-19
That the Canadian Medical Association insist that appropriate mechanisms for objective monitoring of access and quality indicators and benchmarks for national standards be developed by providers, governments and consumers to track identified areas of perceived deterioration in access to quality of health care.
Text
That the Canadian Medical Association insist that appropriate mechanisms for objective monitoring of access and quality indicators and benchmarks for national standards be developed by providers, governments and consumers to track identified areas of perceived deterioration in access to quality of health care.
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