Wake Up Call for Care.

A recent article in the Globe and Mail which should resonate with New Brunswickers. Unfortunately Home Care has a history of being consistently ignored and misunderstood both here and across Canada. Not only do people indicate they want to stay at home (and I would assume even more so from the Covid19 experience) but they remain part of the community, taxpayers and valuable citizens. Our present default approach for seniors being sent to a facility, first hospitals and then care homes, when other options are available has caused challenges to our healthcare system by creating a bottleneck in hospitals and now sending people into a potential dangerous situation. Looking at Community Care in New Brunswick under the current situation of Covid19, indicates we have been extremely fortunate due to the aggressive shutdown of our borders rather than better managed at senior homes compared to other provinces. We should not be smug. Our current approach to senior care is wrought with silos, gaps and lack of key measurement for service quality. It requires immediate adjustment starting with fundamentals, developing a holistic approach to care. Having long term care under Social Development rather than health is one area requiring adjustment.

While the world is currently focused on the challenges in systemic racism,  we have a systemic issue in how we care for seniors in this province. It has been ignored far too long in spite of good data pointing to the change in demographics and people’s health. With good grace we will all reach the time where we may require these services. We must all ensure we have the ability to do so.

In the stay-at-home era, why have we so sorely neglected home care?

André Picard

André Picard Published June 15, 2020 Updated June 15, 2020
There’s no place like home.That truism has taken on a whole new meaning during the COVID-19 pandemic, owing to quarantines, isolation, lockdowns, shelter-in-place orders and other restrictions on movement.But in health care, the focus has been placed squarely on institutions.Out of fear of a mass influx of coronavirus patients that could overwhelm hospitals, beds were emptied in record time. Virtual care was embraced with the zeal of converts. Elective surgeries were cancelled. Patients listed as needing an “alternate level of care” – meaning they were discharged, but also classified as too “high-need” to go home – occupied as many as one-third of hospital beds and were shipped off to long-term care and nursing homes.Virtually no one was discharged to the safety of their own home. And those who were already getting home-care services saw these services cut back drastically.A survey of three large Canadian home-care providers – SE Health, Bayshore and VON Canada – found that in the weeks after lockdown, home-nursing care dropped 22 per cent; personal support workers’ services were reduced by 31 per cent; and home-based therapies such as physiotherapy and occupational therapy plummeted by 65 per cent for those big three providers.In short, the home-care sector, already underfunded and undervalued, was decimated.The idea – to free up resources for a crush of hospitalized patients – was well-intentioned but, in retrospect, deadly.More than 80 per cent of COVID-19 deaths in Canada have been in institutional care. In Ontario alone, there have been 2,049 deaths in congregate settings, 1,774 of them in long-term care facilities.One in every 50 residents of long-term care in Ontario has died of COVID-19.In addition, thousands of workers in these homes have been infected with the novel coronavirus.Meanwhile, you can count the number of home-care workers and clients who have been infected on your fingers and toes – and not just because hundreds of thousands of visits were cancelled.In institutional settings, COVID-19 proved deadly because it spread among highly vulnerable patients who were sharing rooms, bathrooms and support staff.Home care is one-on-one care. It is true that home-care workers see many clients, but rarely as many as those toiling in institutions.In individual home visits, the virus doesn’t have the opportunity to take root. Workers take care of one person at a time, so there is little chance of spread.There have been high rates of COVID-19 deaths in institutional care in many countries, but Canada is among the worst, if not the worst in the world.We now know the reasons all too well: Outdated infrastructure, lack of staffing, poor pay and benefits and disorganization, among others.Yet, as bad as conditions can be for personal-support workers and nurses in institutions, they are often worse in the community. For home care, workers earn $3 to $5 an hour less than they would in institutions, and it’s piecemeal work, so they are under pressure to work quickly.When it came to doling out personal protective equipment, home-care workers were the last in line, which is symbolic of the way the sector is neglected.Canada has one of the highest rates of institutional care and one of the lowest rates of home care among developing countries, so our high death rate is not a surprise. A flawed system again delivered poor results.In Canada, long-term care has become synonymous with being shipped off to an institution. While facilities are essential for some, they should be a last resort, not the default setting.The carnage in congregate care, if nothing else, obliges us to rethink elder care fundamentally.A good starting point is prioritizing home care.Ontario, for example, has a $64-billion annual health care budget, of which $3-billion goes to home care and $4.3-billion to long-term care. (Individuals supplement those costs, often paying thousands of dollars out of pocket.) There are a little less than 100,000 residents in long-term care, and more than 700,000 who get home-care services.This pandemic has shone a light on how we have brutally failed our elders.Who, going forward, will not think twice about placing a loved one in long-term care? Who will not ask: How can we keep Mom or Dad safe at home?The right care at the right place and at the right time needs to be the mantra of a patient- and family-centred care system.To fulfill that mission, one of our priorities has to be the allowance of people to age in place, to give them the choice of living at home and dying at home, with proper supports.As Shirlee Sharkey, chief executive of SE Health, says, “Two of the key lessons of the pandemic are: Home is a safe place to be. And home is where people want to be.”Sign up for the Coronavirus Update newsletter to read the day’s essential coronavirus news, features and explainers written by Globe reporters.

Planning in Uncertain Times

May 13, 2020

Planning in Uncertain Times.

Situations like Covid19 make planning difficult but not impossible. There is no point of reference or historical roadmap for this. We have never seen such a widespread and rapid shutdown.

So what to do? The future is unclear however not planning for various scenarios will create further challenges for your organization. Waiting for absolutes in times of chaos is both futile and dangerous. In practical terms if you wait until clarity for re-opening you run the risk of being behind your competition. You might then be engaged in potentially competing for limited resources. This might range from staff, gloves, masks, plexiglas, PPE, etc.

This is not limited to the re-opening only.

Most industries have been impacted negatively. The ripple effect of each industry segment into each other will be a unique experience to lead through.

When there is no reference point to start from, an organization must create one.

I suggest three actions.

  • Clarity
  • Understand your Mission. You must know your organizational purpose as all core decisions should come from this base.
  • Preparation
  • Research macro market information from credible sources. In Atlantic Canada utilise the Atlantic Provinces Economic Council (https://www.apec-econ.ca) Covid19 impact presentation. Communicate with associations and other organizations.
  • Project
  • The purpose is to cover broad possibilities to what may happen based on your information instincts and experience. This will be used to pivot direction as more information becomes available. Note forecasting is broad strokes in this case as too much detail has is not an efficient use of time.

Use 3 scenarios to cover as broad an area as possible.

Worst case scenario – give yourself permission to think negatively. Most leaders are glass half full people. Examining the worse case is necessary so that you avoid being blindsided by optimism. If lacking information speculate by using what you have or the place you are in to forecast forward. i.e. shutdown zero revenue – what are fixed expenses to determine break- even point, partial shutdown i.e. 40% of previous year etc. Straight line it. What does it look like?

Best case scenario – this is not a pie in the sky exercise. We know everyone has been hit to some degree. However if you can recover your loss in Q3 & Q4 you need to provide details of how and when you will accomplish this.

Middle of the road – like it sounds. In between best and worst, accounting for seasonality impact.

Forecasting provides a pathway for future decisions. Planning during the re-opening phase will place you behind your competitors and potentially threaten your recovery. Planning allows you a pivot point to adjust with new information.

Utilise the three scenarios focusing on the 4 segments below:

Revenue – 3 scenarios – Best, worst, in between

Staffing / volunteers – how many staff/volunteers are required for each scenario?

Expenses – what are fixed costs that must be paid, what percentage are your variable expenses to revenue?

Timelines – what future things normally impact your business seasonally?

Ensure you capture and record all of your assumptions.

Launch and review.

Once you determine the 3 scenarios, begin to move forward watching carefully as new information becomes available, pivoting as required to take advantage of opportunities or avoiding challenges.

Review your assumptions continuously at first. Many may be incorrect. Adjust and move forward.

Continually cycling through this process will provide you with the best available map in these uncertain times.

Different Situations Require Different Decision Approaches

The Value of Contrarian Decision Making

In times of emergency and stress it is even more important that decisions are made with the best available information at hand. It takes a strong leader to resist the pressures of the public, the shareholder or co-staff and managers to delay making decisions when they perceive we should. Or, in making decisions that might be against popular convention. It is not to say some decisions do not require immediate action, only that when applicable other approaches should be considered.

One such approach is Contrarian Decision making. While Contrarian may sound negative or even angry, it provides a check and balance to potential situations rather than a “follow the crowd” culture.

Leadership is situational and contingent, meaning that a once successful approach may not work in a different situation. It focuses on thinking gray which means not creating an opinion until you have heard all the facts and opinions. This can be uncomfortable as it means holding on until the decision absolutely must be made.

The Contrarian Approach has two key characteristics:

Many times staff and co workers will bring decisions to the leader out of habit, fear or insecurity. One  responsibility of a leader is to build a strong team around them, encouraging, helping, and coaching.

The first characteristic of Contrarian Leadership is to delegate decisions where appropriate. The critical question “Is this decision mine to make or is it the person or group who is bringing this to me?” This does not absolve the leader from being responsible for the decision. It simply puts the trust in the individual or team to make the correct and informed decision.

Decision making is a muscle that grows stronger with use. Appropriately delegating the responsibility with support, allows your team to grow, your organization to be stronger. A side benefit is once your team is trained in this concept the leaders time will be freed up for focus on areas that require their expertise and experience. The key here is the understanding of which decision you can delegate. It will be situational or contingent upon the issue.

The second characteristic is to ask “when does the decision have to be made?” Most managers and bureaucrats have been conventionally trained to not put off decisions, to make them now and allow them to move onto the next task. The leader however, needs to ask when does this decision need to be made, now? 1 hour from now?  A day?  A month?

Putting off the decision, if possible, allows for the gathering of more information. As time passes situations affecting the decision may change.

The challenge here is to decide when this is not procrastination but a sincere attempt to gather more information. Again, situational and contingent upon the issue.

Dr. Steven Sample author of The Contrarian Guide to Leadership defines this about the process of Contrarian Decision making:

“One must always keep in mind that leadership is an art, not a science. In this sense, leadership is more akin to music, painting and poetry than it is to more routinized endeavors.”

We have seen and will see the benefits and the criticisms of utilizing this approach in our current situation.  We should ask ourselves when we might be critical of our leader’s responses, whether they are using this methodology or procrastinating. The difference is subtle but huge for outcomes.

Together Nudging Change

Much continues to be debated regarding the state of Eastern Canada provincial governments and our industries approach to changing demographics as we lead the country in aging. There has become an increasing lament of seniors becoming a “burden” as demographics swell with a forecast tipping point in 2030 when our +65 population will become 50 percent larger than it is today. While positive work has been done regarding immigration it may not be enough to fulfil the immediate upcoming needs in the regions workforce. This brings us to a decision point. As with all change management, expecting dramatic change in one swing at the bat is both dangerous and short sighted. Anyone with change experience knows that gradual well thought out change, adjusting as you progress, tends to create permanent difference without as significant upheaval both for society and organizations. So, if we change our way of approaching the issue, not fearing the forecasted changes but welcoming them as an opportunity to keep our youth in the region with promising work and futures ,we can plan multiple approaches to fulfil our needs. If we look at retiring seniors as an asset to change rather than a burden we can use this experienced segment of our population to bridge the workforce needs while we change or educational and post secondary educational facilities to fulfil what is expected in the future. This should be added to any organizations recruitment plane .This allows “nudge management” as we transition, fulfilling many immediate needs while working on medium and long term solutions such as immigration and education reform. The approach will create a “win win” for bridging staffing needs with experienced persons, providing those already retired with monies and a continued sense of purpose while keeping our young people in the region with good full time employment. This challenge wasn’t created over night and we should not expect to solve it in that time span either. If we work together, rather than segmenting we can make this place better for all and be a shining example for the rest of Canada as they enter into their demographic change.