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The Lodge at Broadmead, Victoria, B.C.
George Derby Centre, Burnaby, B.C.
The Brock Farhni Pavilion, Vancouver, British
Columbia
Colonel Belcher Veterans’
Care Centre, Calgary, Alberta
Deer Lodge, Winnipeg, Manitoba
Parkwood Hospital, London, Ontario
Sunnybrook and
Women’s College Health Sciences Centre, Toronto, Ontario
The Perley and Rideau
Veterans’ Health Centre Ottawa, Ontario
Camp Hill Hospital Halifax, Nova Scotia
Ste Anne’s Hospital Ste Anne de Bellevue,
Quebec
VISITS TO VETERANS HEALTH CARE CENTRES
Members of the fact-finding task force of the Senate Subcommittee on Veterans Affairs were able to visit, tour and question the management of ten of the fifteen hospitals and residences that are home to 50 or more veterans. Together, the facilities visited are responsible for almost 70% or 2,826 of the 4,082 departmental, priority and contract beds spread across the country. They have one very important element in common; they are dominated by a veteran culture even though they may also have a substantial number of community beds.
The veteran culture is based on the memory of wartime service and of battlefront trauma, whether experienced personally or through the memory of long-dead comrades. It is of course an overwhelmingly masculine culture, although a number of female veterans are an honoured part of it, and as such, it can be marked by levels of aggression and of past abuse of alcohol that are higher than normal among the elderly. Each of the hospitals and residences visited value and wish to maintain their veteran culture, but each must deal with a different regional health authority, even within the same province, as well as with Veterans Affairs Canada. They appear to have few contacts with each other, to know little about each other's activities and programs. As a result, they must be treated individually.
Members of the task force were left with a strong impression of the strengths and weaknesses of each hospital and residence. Without exception, however, each offered veterans a superior level of care and superior opportunities for recreation. The following summary includes those recommendations which apply to the individual facility.
Victoria, B.C.
The Lodge at Broadmead is a new multi-level care residence that has 115 veterans priority beds and 110 community beds. The beds are spread among six lodges with 30-45 residents each. The three Level A lodges offer "intermediate level" care and are primarily for those residents who have little or no cognitive impairment and need a moderate amount of assistance with the basic activities of daily living. The three Level B lodges, offer "extended level" or "long-term" care and look after those who have moderate to severe cognitive impairment and require a relatively high level of assistance. Almost all the rooms are private, but couples can be accommodated in the 12 semi-private rooms that are available. Veterans have either an electric bed which can be operated by the occupant or, if they suffer from cognitive impairment, a hydraulic bed which is adjusted by a staff member. The Lodge operates its own kitchens preparing the food in bulk for the different dining rooms and residents seemed pleased with the quality of the meals.
The Lodge was well-planned to look after residents with a range of needs, from the largely independent residents free to come and go as they please, to those suffering from Alzheimer’s who must live in a protective environment. This flexibility is possible because each of the six lodges has been organised to offer a slightly different level of care, programs and services. The three A Level lodges are grouped along the main street near the main entrance and have access to outdoor conservatories and a therapeutic garden: residents are placed according to their interests and level of independence. The three B Level lodges, on the other hand, allow the physically infirm but mentally alert to live in a lodge with unsecured doors and separate dining and bathing rooms. Those suffering from severe cognitive impairment and behavioural problems are kept in a secure lodge where they have access to two therapeutic gardens. Many of the residents of the third lodge require palliative care as well as frequent assistance in the routines of daily living, such as transfers from bed to wheelchair to bathroom, eating, etc.
The Lodge is equipped with smoke detectors, automatic sprinklers and fire doors which divide it into fire zones. There is a comprehensive Fire Safety Plan and a Disaster Plan which are updated in co-operation with local officials. The Fire Safety Plan is based on horizontal evacuation by pushing residents in dining room chairs or by towing them on comforters. Although the Lodge is built on a slope which gives each of the two floors a ground level exit, management is considering purchase of EVAC chairs for the stairwells. Fire and safety training is part of the general orientation offered new staff members and is refreshed and upgraded regularly.
The one potential safety problem that has not been addressed is the question of providing a sheltered area where residents (and staff) can smoke. The indoor smoking area has been closed by political/bureaucratic fiat. As a result, veterans 80 and older are forced to go outdoors in the cold and wet to have a smoke. This is unacceptable and can only lead to the risk of a fire caused by surreptitious smoking.
2. The Subcommittee recommends that Veterans Affairs Canada work with the management of the Lodge at Broadmead and local veterans organizations to build and equip a warm, sheltered outdoor area in which veterans can smoke without being exposed to the elements.
The members of the task force benefitted from long meetings with senior management and staff. The most critical issues management faces are connected with cutbacks in funding and the downloading of additional responsibilities. The Lodge has been under severe financial pressure for the past few years. To date management has offset the cutbacks in funding by reducing the budgets for administration and services rather than by directly reducing the budgets for resident care, a process which can be called "death by a thousand cuts" as a little money is lost here, and there, and there, and here again, etc. Non-wage budgets have not been increased for at least 4 years and there is no contingency budget or compensation for events such as the recent power outage which cost the Lodge $10,000 for damages caused and emergency supplies used, an amount which has been covered by juggling accounts.
Although there have been no staff cuts, the level of resident care has suffered because the existing staff must now do much of the work that used to be done by the staff of acute care hospitals. Lodge staff are now expected to provide most of the post-operative care and rehabilitation residents need following surgery because patients are discharged after two days, rather than spending six to ten days in hospital. Palliative care absorbs an increasing amount of care giver time (typically 2-3 weeks) and it involves not only intensive nursing of the patient, but also comforting and counselling family members. Staffing levels do not take into consideration these additional duties, nor do they take into account the fact that while the family supports the veteran, family members in turn need support from the Lodge. Staff can, in effect, spend almost half their time dealing with family members. Nor is it easy to involve the residents’ doctors because they are not paid for consultations with Lodge staff or for counselling family members.
Staffing levels were described as "minimally OK", as far as safety is concerned, but as "inadequate" to provide the rehabilitation and rehabilitative maintenance many residents need. As a result, anything out of the ordinary can tip the balance and residents will not get the level of care they should get, and, in the case of veterans, are entitled to.
3. The Subcommittee recommends that Veterans Affairs Canada intervene with the provincial and Capital Health Board authorities to oppose any further increases in the workload of staff at the Lodge at Broadmead without a corresponding increase in staffing levels.
The Capital Health Region wants to absorb the Lodge at Broadmead and have it give up its separate food and laundry service. Management is not in favour of more than an affiliation or association with the Capital Health Region. With its budget of $12 million, the Lodge would have very little influence inside an organization with a budget in excess of $500 million. Nor would it be possible to maintain and develop the veteran culture that sets Broadmead apart as the largest veterans’ residence on Vancouver Island.
4. The Subcommittee recommends that Veterans Affairs strongly oppose any move to amalgamate the Lodge at Broadmead with the Capital Health Region.
Management agreed that national standards for the care of veterans would be very useful in ensuring some degree of uniformity of care, and in drawing attention to their special needs and entitlements. From their standpoint it could have the additional advantage of establishing a degree of independence from the policy vagaries of regional health authorities.
Since a single national standard would be very difficult and time-consuming to negotiate and implement, Veterans Affairs Canada should consider working together with the Canadian Council on Health Services Accreditation Standards to develop a standard measurement of client satisfaction and a standard of care appropriate for veterans. Certainly these standards should stress the need to educate new staff about the contribution of veterans and the needs of veterans and the elderly in general and provide for continuing education. These standards could then become a part of the accreditation process and be incorporated into the Department’s contracts with the individual facilities.
The Lodge at Broadmead should be encouraged to expand. It is a modern, well run, multi-level facility with 114 veterans on the waiting list for its 115 veterans priority beds. This represents a waiting time of 14 months before the veteran can be admitted. The Lodge is one of the few facilities that can accommodate both the veteran and his or her spouse. Since the waiting list for the community beds is even longer than that for veterans- about 4 years- the province and regional health authority should also be interested in providing more beds.
5. The Subcommittee recommends that Veterans Affairs Canada urge the province of British Columbia and the Capital Health Region to support the expansion of the Lodge at Broadmead and that the department contract for as many additional veterans priority beds as possible.
Veterans Affairs Canada and the management of the Lodge are working together to develop a Veterans Health Care Centre which will give veterans and their spouses access to a geriatric assessment and treatment program. These services will be complemented by a social and recreational program so that together they will offer the family caregiver respite, support, education and counselling. Developing a Veterans Health Care Centre at the Lodge will thus ease some of the pressure on those veterans and their families who are waiting for a bed to become available in the Capital Health Region.
6. The Subcommittee fully supports the initiative to develop a Veterans Health Care Centre and outreach program at the Lodge at Broadmead and urges Veterans Affairs Canada to fund and develop it as a model for the other regions.
Burnaby, B.C.
The original George Derby Centre was opened in 1947 as part of the Shaughnessy Hospital complex to assist veterans reintegrate following the acute care phase of their recovery by offering physical and occupational therapy programs as well as job retraining and rehabilitation. The complex was transferred to the province in 1974 and in 1988 a new George Derby Centre was opened as an intermediate care facility with 300 priority access beds for veterans.
The George Derby Centre was designed and is administered as a home and community for the resident veterans. The building is set in spacious grounds which resemble a park with walking paths, secluded areas and gardens. The property is on a slope and the four resident living areas all have direct access to the grounds and to outdoor courtyard areas, patios and sheltered gazebos. Inside, the front entrance of the three level building is the focal point of an "agora" or town centre that includes a multipurpose activity area, the gift shop/canteen, an indoor smoking area (about 60% of residents are smokers), and the library. Banking services, the dental office, the barber and beauty salon, the chapel and the creative artworks studio are further along the main street. Residents live in private rooms although there are 9 double rooms for those who prefer to share or for those who are waiting for a private room.
Within the intermediate level of care the Derby Centre can offer separate accommodation for those who are basically independent as well as for those who need more help because of age or physical disability and for those who require specialized psychogeriatic care. Management believes very strongly that all those who come in contact with veterans should be treated as part of a multidisciplinary team. Thus the team includes support staff, the nutritionists and kitchen staff and social workers and volunteers as well as the medical staff. A special effort is made to assign the same staff to care for individual residents who are cognitively impaired because they tend to become somewhat paranoid and frightened when approached by people they do not deal with regularly.
The residents have their meals in small dining rooms. Initially food service was based on re-thermalised meals, but the veterans rejected the idea of being given a tray three times a day. In 1994 the Centre began to cook meals the traditional way in its own kitchens. Residents are offered snacks throughout the day and evening and, since dehydration can be a serious problem among the elderly, can freely serve themselves juice, coffee and water at "fluid stations" located in different parts of the building.
Independent since the Shaughnessy Hospital was closed, the Centre maintains contact with its roots in rehabilitation and job training with an excellent occupational therapy program. The large creative artworks studio is particularly impressive and residents actually speak enthusiastically of "going to work" at their weaving, painting, ceramics and woodworking. Residents are also encouraged to "work" outdoors in the garden plots, vegetable gardens and in the greenhouse.
The members of the task force were impressed by the relationship between the Centre and the Simon Fraser Health Region. Only 20% of the veterans resident in the Centre have spent their adult lives in the region, the rest come from other parts of the province and from across Canada The Board of the Centre is determined to preserve a unique veteran culture and worked hard to negotiate an affiliation agreement with the Region that leaves it sufficient autonomy to set its own priorities. Amalgamation has been opposed because it would mean the loss of a separate board of directors and the autonomy of management. The Centre is associated with the Region for certain purposes, such as bulk purchasing of medical supplies and equipment, waste management, etc.
The Centre has not suffered from funding cuts. On the contrary, since the residents require more extensive care as they age, funding has been increased and the additional money has been used to increase nursing and support staff. It now receives its funding from the region, rather than from the province, a process that give rise to some worry about future levels of funding, because the regional health authority does not have much experience with veterans.
While staffing levels are not an immediate concern, getting funding for ongoing training is very difficult. Long-term care is just beginning to win respect as a nursing/care giving specialty that requires an emphasis on the whole patient and his or her family. Most attention is still given to the development of acute care qualifications
7. The Subcommittee recommends that Veterans Affairs Canada offer to help establish and finance ongoing training in long-term care of the elderly for the staff of the George Derby Centre.
The Board and management of the George Derby Centre want to expand the Centre and develop it into a multi-level facility offering both intermediate and extended-care programs. This would allow the resident veterans "to age in place" rather than being forced to move should their health deteriorate to such a degree that they need extended level care. Although its resident population makes it more of a provincial and even a national institution, it will need the financial support of the regional health authority to expand and become multi-level.
8. The Subcommittee recommends that Veterans Affairs Canada continue to assist the Board of the George Derby Centre in every way possible to become a multi-level facility.
Vancouver, British Columbia
The Brock Farhni Pavilion was opened in 1983 and, since 1993, has been administered by St. Vincent’s Hospital. It provides extended care to veterans in 150 priority beds. Virtually all the veterans are wheelchair bound and a great many also suffer from some degree of cognitive impairment. About 60% are smokers. Most residents live 4 to a room, but there are some double and single rooms. The single rooms are highly prized and assigned according to an internal waiting list which is based on need and/or length of residence.
Although it is only fifteen years old, the Pavilion was the most institutional and least homelike of the residences visited. Its feel and ambience was old fashioned and Victorian - dark and oppressive. The main entrance opens onto the second floor where there is a veterans lounge, a chapel, administration and services offices (including a Veterans Affairs office) and the Artworks Studio. Unlike other residences, however, these are not arranged or decorated to resemble an ‘agora’ or Main Street – a natural area to attract veterans. The veterans lack a room large enough to let them all assemble at the same time, but they do have an indoor smoking area, a sun room with a separate air circulation system. Veterans complain that temperature control in the sun room is inadequate: the furniture and floor also need refinishing.
The visit was not well-timed because British Columbia was threatened by an immediate strike of nurses and the attention of the Brock Farhni management was focused on a last minute meeting with the leadership of the nurses in an effort to have the Pavilion staff declared essential. As a result, management had not been able to prepare a program to brief us about programs and conditions at the Pavilion and could not spend a lot of time answering questions. They were able to clearly indicate that their most immediate priority is to make the pavilion more home-like by re-painting, re-decorating and buying new furniture. A relatively small investment could also turn nearby unfinished space into a recreation and assembly hall big enough to accommodate all residents for special occasions. The Subcommittee fully supports the need to give the Pavilion a more homelike atmosphere.
9. The Subcommittee recommends that Veterans Affairs Canada take the initiative in ensuring that the department, veterans organizations and the management co-operate in re-decorating the Brock Fahrni Pavilion and in acquiring some new furniture. In particular, they should study the feasibility of transforming the second floor into an attractive main street and of developing a recreation and meeting hall large enough to seat at least 200 persons.
The Pavilion was the subject of a ‘loss prevention’ report in May of 1998 which evaluated the safety of the building. The major finding was that the automatic sprinkler system protected only the first two floors and not the top two floors where the veterans had their rooms.
10. The Subcommittee recommends that the sprinkler system in the Brock Fahrni Pavilion be extended to cover the top two floors if this work has not already been done.
Most of the visit was spent talking to veterans. According to them, the quality of medical care at the Pavilion is ‘top drawer’. The local Veterans Affairs office was highly praised for their helpfulness by veterans and by the daughter of a veteran who attended our meeting. The daughter was particularly appreciative of the local DVA officials who had moved quickly to help her father get new dentures and glasses The recreational arts crafts program was also highly praised for giving the veterans something useful to do.
Food is supplied under contract from the kitchens of the nearby Children’s Hospital of British Columbia. The quality of the meals was disputed. The first veteran to speak said the vets were well looked after between meals, but the food was "lousy". His chief complaint was that the food seems ‘manufactured’ and artificial - none of it is fresh – the turkey dinner, for example, featured an artificial turkey roll with no dark meat. This view was challenged by other veterans. One said he had lived in four homes, and that Brock Farhni was the best of them. As someone familiar with institutional food, he found the meals at Brock Farhni ‘damn good’ most of the time, a view which was supported by other veterans.
Veterans were more united in their criticism of a lack of night staff. It seemed to take forever sometimes for staff to respond to a bell pull, so much so, that one veteran asserted that toggle switches instead of push buttons, should be installed to prevent wear and tear on thumbs. Another veteran complained that he had to wait every morning to go to the bathroom until a hoist become available: if he could afford one, he would buy one for his personal use.
11. The Subcommittee recommends that Veterans Affairs Canada evaluate the night time staffing levels on the veterans’ wards at Brock Farhni Pavilion and have them increased if necessary.
There was not sufficient time to discuss safety issues with management. The veterans’ cigarettes, however, are carefully controlled, somewhat to the chagrin of the smokers. The cigarettes are kept under lock and key, and it can take some time to find the staff member with the key to the cabinet in which the cigarettes are kept – a form of health promotion.
Colonel Belcher Veterans’ Care Centre,
Calgary, Alberta
The Colonel Belcher Hospital for Veterans moved into its current building in 1943. Designed as an acute care facility it underwent a number of expansions and renovations before its transfer to the Province of Alberta in 1979. In 1991 it ceased to be an acute care hospital for 355 patients and became a long-term care facility for veterans. In 1995 it was transferred to the Calgary Regional Health Authority. At present it is called the Colonel Belcher Veterans’ Care Centre and has 135 long-term care beds for veterans. There are 71 private rooms and 32 double rooms.
The physical plant of the building is badly outdated and inefficient, so much so that the province allocates an additional $1.2 million to offset its additional operating expenses. The building has no sprinkler system and the comfort, if not the health, of veterans is prejudiced because the air conditioning and heating equipment cannot maintain an even temperature when the outside temperature changes rapidly. The building also has many drawbacks as a long-term residence for those requiring extended care: because it was built for 355 patients, veterans must travel long distances from their wards to get to the dining room, the chapel and the auditorium. In the dementia ward the long corridors reflect the light; to the patients, the floor gives the appearance of being covered with puddles of water. Patients are also confused because the corridors come to a dead end rather than make a circle of the ward.
The few veterans that were capable of meeting with the task force found their rooms uncomfortably cold or warm at times, but other than this they voiced no complaints. Their food is prepared in bulk on site and moved to the ward dining rooms. According to management, the preparation of the food on site is very competitive with re-thermalised food in price. Since the kitchen staff prepare the food, serve it and help the veterans unwrap items, they come to know and respect their individual likes and dislikes. The veterans spoke very highly of the staff, an attitude which was shared by the son of a dementia patient who went out of his way to praise the quality of care his father was receiving on the dementia ward.
The major problem faced by management was the inordinate amount of time it is taking the Alberta health care system to decide on whether to move Colonel Belcher to a new building, specially designed to meet the needs of the elderly in which case only minor renovations would be carried out to the existing facility, or to undertake very costly renovations to modernize the existing building and bring it up to the standards required by a long-term care facility.
The Calgary Regional Health Authority launched a major study of the present and future needs of veterans in August 1996. Fifteen months later it accepted the recommendation that it would be more cost effective to build a new facility. The funding request and a detailed plan for the design and operation of the new care centre was submitted to Alberta Health and Public Works Supply and Service in January 1998. This plan would provide 175 private rooms to respond to projected peak demand. It would also include space to accommodate the needs of veterans still living in the community; in particular, day programs, a wellness centre and respite care. As projected, the new centre could operate with a small surplus within the budget of the current facility and the $1.2 million provincial supplement.
The modernization of the existing facility would be very disruptive to the veterans and their families. It is very likely that veterans would be forced to relocate to a variety of other facilities during the work. This would break up existing patterns of life and friendship and cause a great deal of anguish. In the process veterans also would be subjected to two moves which would add to their disorientation and stress as well as make it more difficult for their families to visit them. Consequently, the interests of the veterans and their families as well as cost effectiveness argue in favour of the decision to move Colonel Belcher Veterans’ Care Centre to a new premise. Since it will take at least 3 years and possibly as much as 5-6 years to design and build a new veterans’ care centre following a provincial decision to provide the funding.
12. The Subcommittee recommends that the Minister of Veterans Affairs intervene with the relevant ministers and officials of Alberta as soon as possible to win their support for an immediate decision to finance construction of a new facility for the Colonel Belcher Veterans’ Care Centre.
Management has a number of priorities for the next three years. Only a small percentage of veterans are in electric beds; more would make life more comfortable for those veterans capable of operating them and reduce the work load of staff. Staff education is even more urgent. Recruiting nursing assistants is difficult: a very basic six week course costs $3,000-$4,000, but the pay is only $8-$10 per hour. There is an urgent need to offer in-house training, but it would require time and resources to develop the necessary staff education programs. A full-time, rather than part-time, social worker, is needed to work with veterans and their families.
13. The Subcommittee recommends that Veterans Affairs Canada help design and implement an appropriate training program for staff at the Colonel Belcher Veterans’ Care Centre and that it provide additional funding for electric beds and for increased assistance from a social worker.
Deer Lodge, Winnipeg, Manitoba
The Federal Government transferred the Deer Lodge facility to the Province of Manitoba in 1983, reserving 155 priority access beds for veterans. In 1989 the present complex was built, providing a total of 406 beds (later increased to approximately 450), of which 155 are designated veterans priority. A major objective in the construction of a new facility was to provide the specialised programming necessary to keep the elderly in the community with a mixture of day programs, temporary accommodation and long-term care.
Deer Lodge has been planned to give the impression of a small town, complete with an attractive ‘Main Street’ which is the natural focal point of services and activities for the residents. The wards are well laid out and have a home-like atmosphere. On the veterans ward the residents have individual rooms. A large majority (about 82%) suffer from some degree of cognitive impairment and most need wheelchairs. The corridors are free of the clutter of stored equipment and wheelchairs that can make older institutions a hazardous obstacle course: the rooms have been designed to accommodate modern equipment and to store wheelchairs.
The Lodge has a feature that the members of the Subcommittee believe should become common to all veterans facilities – rooms designed to accommodate couples. These particular rooms are designed as a suite with separate bed areas. According to management, a more flexible design would consist of adjoining rooms connected by a common door. To allow for the likelihood that each spouse will require a different level of care, these rooms should be located in the extended-care ward of multi-level institutions. The tour, however, also highlighted two problem areas.
The bathing facilities on the veterans ward, however, are outdated, inefficient and do not respect the privacy of those being bathed. To permit veterans in wheelchairs to bathe in comfort, the baths must be accessible on at least three sides and must be designed to permit an easy transfer from wheelchair to bath. Each bath should be in a separate room with sufficient space for a toilet and hand basin as well.
14. The Subcommittee recommends that Veterans Affairs Canada contribute to the costs of upgrading the bathing facilities in the veterans wing of Deer Lodge.
Air circulation in Deer Lodge must be improved. The combination of vaulted ceilings and low passages through partition walls blocks the flow of fresh air and traps stale air in rooms and offices. Finding the best solution to the problem should be left to architects and air conditioning engineers, but will probably involve something other than installing false ceilings which, in the event of a fire, would lower the level of smoke in the corridors. Whatever the solution chosen, Veterans Affairs Canada must ensure that it is both effective at improving air quality and safe in an emergency.
15. The Subcommittee recommends that Veterans Affairs Canada ensure immediate steps are taken to improve air quality in Deer Lodge and require that any solution chosen not prejudice the safety of veterans in an emergency.
The veterans and their families that met with the task force were unanimous on one point. Up until the autumn of 1998 the level of care at Deer Lodge was considered at least excellent, and some believed it could not be improved upon. The Lodge in fact was considered to be the best of the local homes and had a long waiting list of those anxious to become residents. This situation changed for the worse in the fall of 1998.
In 1998 the regional health authority decided that it would be more cost efficient to contract out food services for hospitals and nursing homes rather than let individual facilities prepare or contract for their own meals. The result was an abrupt decline in the quality of meals and consequently in the morale of veterans and their families. The members of the Subcommittee were presented with a petition signed by 1,600 about the quality of the food. Nothing served to the veterans was at the right temperature, and nothing had any flavour. Meat courses were indistinguishable from each other by taste or texture. Sometimes the meat and the toast were so hard that they could not be eaten. One wife believed the food had made her husband very sick. She presented the Subcommittee with a petrified slab of something she said had been served to her husband as a slice of beef. Some veterans said that the food was so bad they were eating few, if any, of their meals, claims that were borne out by reports of rapid weight loss and by management’s admission that they had had to purchase more scales so that they could weigh residents more often.
Needless to say, families were very bitter that men who had served their country, sometimes suffering torture at the hands of their captors in the process, should be treated to this kind of food. Most veterans pay a charge for their food, a circumstance which added insult to injury. But whether or not the veteran was being charged a per diem, he or she must eat this food for the rest of their lives. The veterans noted that the changes had been instituted to save money, and asked: "How can you be saving money if much of what you serve is thrown out?" They also asked why the "Meals on Wheels" organization could serve decent meals from a central location, but the Winnipeg hospitals and health care facilities could not. These are excellent questions for the regional health authority that made the decision to adopt this system of meal preparation.
While veterans and their families generally felt that staffing levels were adequate, they did raise some issues. Staff members have complained to family members that the new food system is so labour-intensive that they have less time to help veterans. In this regard, a spouse timed 5 staff members one Sunday lunch time and found it took them 25 minutes to serve 13 residents lunch. A spouse also complained that when a patient experienced chest pains, a nurse came to his room but could not stay long because she had to help wheel residents into the dining room for supper. The spouse stayed with her husband and noted the floor seemed to have no staff that night.
The crisis over food service pre-occupied the members of the Subcommittee when they met with senior management. To begin with, lunch was served – the same lunch the residents would have served them. The quality of these lunches was terrible: the soup (whatever kind it was supposed to be) was lukewarm and inedible, the sandwich and dinner roll were cold, and the tea water was barely hot enough to extract tea from the teabag.
Senior management checks the quality of the food provided and gets feedback from patients and staff- the reaction of residents to the food has left some staff members in tears. The food is prepared and cooked locally by the Riverview Health Centre, not by a Toronto organization as some veterans believe. The provider has made changes and some believe that the quality of the re-thermalised meals has actually improved slightly.
16. The Subcommittee recommends that Veterans Affairs Canada intervene directly with the Province of Manitoba and the supplier of meals to insist that the latter improve the quality of the meals served veterans at Deer Lodge.
17. The Subcommittee recommends that Veterans Affairs Canada help Deer Lodge management train staff in techniques of handling re-thermalised meals.
Members of the Subcommittee, senior managers and the Veterans Affairs Officials present, however, all agreed that concrete action to improve the food had to come out of the meeting of members of the task force with veterans and their families.
A number of immediate steps to improve meal time were considered. The most promising of these was to focus immediately on breakfast because veterans had had nothing to eat since the previous night. Rolls and muffins could be substituted for the toast that was too hard to chew. More use could be made of the small kitchen attached to each ward. Volunteers and family members, for example, could help staff run a breakfast and brunch club which would allow interested veterans to prepare their own home cooked breakfasts under supervision. The presentation of meals could also be altered by working on a suggestion of the Veterans’ Council to reduce the number of items that veterans had to open, unwrap or uncover each meal. Milk, juices, tea and coffee do not have to be prepackaged for the individual trays, but can be quickly served from bulk dispensers. Rather than being re-warmed on individual trays, some breakfast foods such as porridge and scrambled eggs might be improved by being re-warmed in bulk and stirred before serving.
18. The Subcommittee recommends that Veterans Affairs Canada and its local officials continue to help the management of Deer Lodge find and implement short-term ways of improving the quality of meals.
London, Ontario
In 1980 Parkwood Hospital was contracted to provide 200 beds for chronic care and in 1989 opened the Western Counties Wing to provide extended care for an additional 170 veterans. In 1997 both facilities became part of the St. Joseph’s Health Centre. The site of the Hospital and Western Counties Wing includes a nine hole therapeutic putting green, the Veterans’ Memorial Park which will be linked to the surrounding wetlands and diverse woodlands by a network of paths. The memorial park already includes a monument, a memorial wall and grove of Japanese cherry trees as well as flower beds.
Parkwood Hospital is a modern, well laid out facility, but is, nevertheless, very much a hospital. There is no main street in the veterans wing and no effort has been made to develop the entrance area as natural "agora" or town centre. Whether they live in the hospital or the veterans wing, most patients (hospital) and residents (veterans wing) are in wards of 4 beds. The complex is noteworthy for its extraordinary range of recreational facilities and equipment which include a bowling alley, shuffleboard, exercise machines, and art, woodworking and textile studios indoors, and an outdoor putting green. It also boasts a large auditorium.
For some reason the nursing station on the dementia ward is surrounded by walls too high to see over when seated. This completely isolates the occupant from the patients and makes any form of informal interaction very difficult. The long, wide corridor begins at the nursing station and ends at the door to a very attractive enclosed patio. Patients tend to go to the end of the corridor where they endlessly try to open the locked door to the patio or they aimlessly congregate in room just to right. Relatively minor changes could make the nursing station more open and inviting and the traffic pattern in the corridor could be changed to encourage patients to walk around in a circle
19. The Subcommittee recommends that Veterans Affairs Canada offer Parkwood Hospital assistance in making the dementia ward more homelike and functional.
Parkwood Hospital was one of the few multi storey facilities that has devoted obvious thought to the problems of evacuating bed ridden patients down the staircases, a vertical evacuation, in addition to their horizontal evacuation to temporary safety behind a fire door on the same floor. They have bought a limited number of "EvacuSleds" which store under the mattress of a bed until needed. These allow one staff member to secure the patient to the mattress, slide the "EvacuSled", mattress and patient to the floor and then tow them to safety. The "EvacuSled" rolls on small wheels and pulls easily over different types of flooring. It is also designed to slide down staircases. Although it can be tipped semi-upright to pass through a doorway, the fact it is moving a standard mattress makes it very bulky and difficult to manoeuver in confined spaces.
The Parkwood Hospital has implemented a unique system of a "Food and Travel Pass" to ensure that patients and residents are not served foods or beverages that are dangerous to them at social functions. Staff had noted that there were about 700 events per year that involved food and drink. Food-servers on these occasions had no way of knowing what, if any, food restrictions applied to the individual. The solution was a reusable patient identification card that identifies the patient, their unit, diet and allergy precautions, and suggested alternatives to the food and drink that was not recommended. The Pass is worn or carried at all on-site group activities with food or drink, at all off-site activities, and is available for personal outings. The Sunnybrook Health Science Centre (now the Sunnybrook and Women’s College Health Sciences Centre) has recently decided to adopt the "Food and Travel Pass".
The meeting with veterans focused on the quality of the meals which are re-thermalised, and the shortage of staff at mealtimes. A veteran immediately called the food "terrible" complaining that it was never fresh and seemed manufactured and another commented "the food here, you wouldn’t eat it". Morning eggs, whether scrambled or boiled, and the toast were singled out for particular criticism. At other meals some veterans found the vegetables undercooked and complained it was too difficult to get unpopular items off the menu.
The conclusion that the meals at the Parkwood Hospital are no better than passable is confirmed by an independent survey of patients and residents. A bare majority of those surveyed rated the food as good, more than a third rated it fair-to-terrible and just over one-in-ten rated it excellent. These survey results are a clear indication that a continuing effort must be made to improve the quality of meals.
20. The Subcommittee recommends that Veterans Affairs Canada strongly encourage the plan to change the service style from tray style to bulk dining room service in the Western Counties Wing of Parkwood Hospital. The same plan should also be considered for the Hospital itself.
Veterans complained that there was not enough staff at mealtimes to help open and unwrap containers and cut the meat. They were particularly appreciative of the work of the volunteers and believed that without this outside help, they would be in "sad shape". Both veterans and their family members were unhappy about what they perceived as a lack of continuity in care giving. It seemed that they always had to deal with a different nurse or nursing assistant.
21. The Subcommittee recommends that Veterans Affairs Canada work with the management and staff of Parkwood Hospital to provide more assistance at mealtimes and greater stability in the staff assigned to care for the individual veteran.
Spouses felt they were supported by staff and expressed confidence that the veterans were well looked after. They are told to ask for help it they need it or to ask for a meeting with the veterans caregivers.
The tour of the Hospital and veterans’ wing and the meeting with veterans and their families made it clear to the members of the task force that the veterans and their families have a good professional relationship with the staff and management. The atmosphere, however, is not very homelike and some veterans voiced the suspicion that Veterans Affairs Canada funding was being diverted to support St. Joseph’s Health Centre, which Parkwood Hospital had become a part of in 1997.
The management of the Parkwood Hospital went out of their way to answer the questions of members of the task force: they provided a briefing book which included a response to the questionnaire we had sent them, answered questions during the meeting, and forwarded additional requested material.
Their Veterans Program is very comprehensive. It begins with a filmed account of the personal experiences of some veterans in war and what these experiences had meant to them. This video is used to educate new staff members about the unique and traumatic events which have left veterans disabled and shaped their personalities.
The elements of the program are supported by research funded by the Parkwood Hospital Foundation. On the basis of this research, staff receive regular training in how to interpret, deal with and modify the behavioural problems commonly found in long-term care facilities, such as aggression, wandering, resistance to care, etc. Research is also behind the search for better methods of controlling the chronic pain that can dominate the lives of the elderly. The Hospital is also experimenting with the creation of therapeutic outdoor spaces for patients with dementia. Patients and residents with cognitive impairment, as well as their families, have been drawn into the process of planning the redesign of the secure garden areas accessible to them. It is interesting to note, however, that the material on the dysphasia diet management program makes no reference to the ongoing work being done at Ste Anne de Bellevue to give modified foods the shape, colour and appearance of the original food.
Parkwood can only offer limited assistance to the 50-60 spouses and families who must travel substantial distances to visit veterans who are residents or patients. The veteran and spouse can spend one or two days in the Independent Living Unit, a self-contained suite on the premises. The Hospital will also set up a cot and set aside a quiet area for the spouse of a veteran who is dying. An innovative solution under consideration is the idea of boarding the out-of-town spouse with another veteran’s spouse living in the city and willing to offer accommodation. This would ease the cost of staying overnight and help develop a relationship with the spouse and family of another veteran.
22. The Subcommittee recommends that Veterans Affairs Canada encourage Parkwood Hospital to proceed on an experimental basis with the idea of boarding out-of-town visitors with city spouses willing to offer accommodation.
Sunnybrook and Women’s College Health Sciences Centre,
Toronto, Ontario
The fact-finding task force revisited the Sunnybrook and Women’s College Health Sciences Centre and was very pleased to learn from both management and veterans that the recommendations of the First Report had been promptly addressed. Given the deaths of three patients in a fire in June 1997 and the death of another patient shortly after he had been found on the floor and been put back in bed, the First Report had focussed on safety issues.
At the time we met with the management of Sunnybrook, the new sprinkler system for the chronic care Kilgour or "K" Wing, the location of the fire, had been installed and was undergoing final testing. Other measures to improve safety in the Wing were also underway. The Cognitive Support Patient Service Unit had submitted a proposal for the development of a special behavioural care unit for dementia patients who are aggressive toward other residents, staff or visitors. At any one time about 5% of dementia patients suffer from regular outbreaks of physical aggression and can benefit from being treated in secure but homelike surroundings by staff with special training. The separate treatment of these patients, almost all of whom are men, will, when the special unit is built, increase the safety and comfort of the other dementia patients and their visiting spouses and family as well as the safety and security of staff and volunteers.
The Kilgour Wing and its wards were not designed for patients who need increasing amounts of care and assistance and almost all of whom are dependent on electric wheelchairs and scooters to keep their mobility. Since the rooms are too small to store the equipment the veterans need and use, it must it kept in the corridors where it presents a real danger in the event of fire or other emergency requiring the rapid evacuation of the Wing.
The hospital is committed to modernizing K Wing and in the process reducing the number of beds in each of the nine patient care units from an average of 43 to 37 beds. The four bed rooms will be reduced to three beds, allowing the washrooms to be increased in size to make them wheelchair accessible and providing additional storage space. Redesign of the nursing station and elimination of the conference room and offices will provide space for a dining/activities room with a small kitchen and more storage space for the single and double rooms. Two shower rooms and a separate tub room will replace the current cramped and outdated shower and bath rooms.
The task force toured and had lunch in the first of the nine units to be renovated at a cost of just under $700,000 each. It is a great improvement as far as safety is concerned, and goes a long way to making the surroundings more homelike and pleasant for both residents and staff. The renovations to the rooms and bathrooms add to the comfort of residents and make it easier to assist and care for them. Financial restrictions, however, mean that the hospital can only afford to renovate one unit each year, that is, it will take another seven years to complete the work.
Sunnybrook has re-evaluated its evacuation plans. As part of this process they have carried out tests of various equipment, such as the EvacuSled and the EVAC chair, that might be useful. Although they found the EvacuSled had potential, it was much slower in carrying out a lateral evacuation than the traditional blanket method- using a blanket, a patient was removed to a safe area before the EvacuSled got out of the room and a 40 bed unit was emptied in 17 minutes. While vertical evacuation is still based on the arrival of police and fire assistance within 8 minutes, an improved version of the EvacuSled would be re-considered. To assist in an evacuation, hospital security officers have been equipped with "air packs" to allow them to continue working.
Sunnybrook is in the process of developing Guidelines for Responding to a Resident Fall for use in staff training. Currently in their third draft, these Guidelines are being tested against reality before being put into permanent form. Progress has also been made to reduce the risk, in the event of layoffs, of having staff experienced in handling the elderly "bumped" out of their positions by more senior staff with no specialized training or experience in gerontology. The new contract with the union will stipulate that only the most junior staff members can be bumped, rather than permitting a wholesale chain reaction to be set in motion, as happened in 1997. Special training in dementia should now be available locally; with time, it is hoped that this or equivalent training will become a necessary qualification to work in the dementia units.
The members of the Veterans Council reported that in their opinion the health centre staff were doing a "magnificent" job of looking after veterans despite cutbacks. Even though staffing levels in the Kilgour Wing had not actually increased, the staff to patient ratios will improve as patient units are remodelled. Progress was also being made in equipping patients who could benefit from them with electric beds.
Management of the Health Sciences Centre, Veterans Affairs Canada and the National Council of Veteran Associations were all praised for ensuring that the interests of veterans were safeguarded in negotiating the composition of the governing structures and major programs of the amalgamated hospitals. As a result, the Act of amalgamation provided for a Veterans Committee and entrenched the duty of the hospital to honour the commitments to veterans. The Act entitled Veterans Affairs Canada to appoint two members of the Board of Trustees, one of whom is to serve as the Chair of the Veterans Committee.
The Veterans Council also noted that the quality of the re-thermalised meals had improved to such an extent that some veterans considered they were superior to the meals that had been produced by Sunnybrook’s own kitchens. The variety and quality of meals was good and hot items arrived hot, and chilled items, cold. The morning toast was a problem that would finally be solved by having service associates make toast to order on each floor.
The most urgent priorities of the Veterans Council are safety related: to speed development of the special behavioural unit for 8-10 patients who could not be safely kept on the general wards; and to accelerate the renovation of the wards to reduce the danger posed by the clutter of equipment in corridors. The Subcommittee concludes that for safety reasons this work must be undertaken and finished quickly. Since a shortened work schedule will reduce the cost of these projects, and staff to patient ratios will improve as re-built units are opened, the Subcommittee believes that Veterans Affairs should explore ways of assisting in their financing.
23. The Subcommittee recommends that Veterans Affairs Canada ensure that the Sunnybrook and Women’s College Health Sciences Centre can complete the Behaviourable Care Unit and the modernization of Kilgour Wing without delay.
The Veterans Council believes that staffing levels at supper time and at night time in the Kilgour Wing are still a problem. The shortage seems to be particularly acute at suppertime. To ease the situation, a veterans organization offered to supply and pay for additional staff. This solution could not be implemented because the union contract stipulates that, if called in, part time staff must be paid for at least four hours of work at $16 per hour. Accelerated modernization of the wards will eventually ease the problem somewhat, but in the meantime the it should be possible to make other arrangements. For example, veterans organizations fulfill a charitable function vis-à-vis patients, replacing absent family members who traditionally have had the right to provide family members with private attendants. The unions concerned might be prepared to allow a veterans organization to provide attendants to assist specific veterans who must be fed individually.
24. The Subcommittee recommends that Veterans Affairs Canada explore ways of providing veterans in Kilgour Wing of Sunnybrook and Women’s College Health Sciences Centre with the assistance of additional staff at suppertime.
The Perley and Rideau Veterans’ Health Centre
Ottawa, Ontario
Veterans began to move into the new Perley and Rideau Veterans’ Health Centre in 1995. In the early 1990’s it became obvious that the old Rideau Veterans Home and the National Defence Medical Centre would not be able to meet the future needs of veterans in the Ottawa region and western Quebec. In 1992 Veterans Affairs Canada, the Ontario Minister of Health and the Perley Hospital, a local chronic care facility, agreed to build a modern health care centre to replace the hospital services and long-term care provided by the existing Perley Hospital and Rideau Veterans’ Home. The Federal Government provided the lion’s share of the cost of building, $36 million, while the province contributed $19.5 million and the Perley Hospital, $9.5 million. In May of 1993 the province approved an annual operating budget of $31.5 million for the proposed health centre, but stipulated that this amount would not be increased until the operating costs of similar facilities had caught up.
The Perley and Rideau Veterans Health Centre is among the most modern of the veterans’ complexes that the task force visited. Sited on the outskirts of Ottawa, the Health Centre has been designed to resemble a small community by grouping the most popular services just off the main entrance and along a "main street". The Centre has 450 beds, of which 250 are veterans priority, and is organized to offer three kinds of care: continuing care (285 beds), Special Approach care (145 beds), and respite care (20).
When the task force visited the Perley Rideau in June 1998 the veterans who live there, their families and management were all reeling under the impact of ongoing cutbacks to their provincial and federal funding.
In 1996 the government of Ontario arbitrarily removed the "hospital" status of the Perley and Rideau Health Veterans’ Health Centre under the Public Hospitals Act of Ontario and re-classified it as a "charitable institution". Re-classification brought with it a devastating decrease in the level of provincial funding, from $187 per resident per day in 1996 to a projected $94 per resident per day in 2003, the reduction to be spread evenly over the intervening years. Under the Transfer Agreement, the federal agreement to fund the operating costs of 175 beds was tied to the provincial contribution: consequently, this would also decline.
Management and the Board of Directors have done everything in their power to oppose the loss of hospital status and the loss of funding this entails. The reductions of the first year had been met without a major impact on the veterans, but the reductions necessary to meet the second year reduction (1998) had involved staff cuts. Plans for 1999 and thereafter will reduce direct nursing, change a professional nursing staff to a less qualified care giving staff, lead to the lay off of non-nursing professionals, reduce the amount spent for food, etc.
When appeals to the provincial Minister of Health proved unsuccessful, the Board of Directors felt they had no option except to resort to the courts to enforce the agreement or "contract" of May 1993. By the time of the meeting in June 1998, the refusal of the federal government to join the lawsuit as an interested party had just added to their anger and frustration.
The cutbacks were already having an impact on the lives of the veterans living at the Health Centre. Veterans and their families reported that staff was very short at lunch times and on week-ends. At meal times the lack of staff meant that some veterans could not finish their meals and one wife testified that her husband had little to eat when she could not be there to feed him. Other wives were spending increasing amounts of their time looking after their spouses; and some families which could not spent the additional time had hired personal attendants to stay with the veteran. Staff shortages and demoralisation had also led to some activities being cancelled and to other activities starting late. The Perley-Rideau cadre of volunteers - the equivalent of about 15 1/2 full-time staff - were working so hard that there was some concern that burnout might force them to stop coming.
Constant staff changes confuse and demoralize the veterans and their families. Nowhere is this more true than on dementia wards. According to family members, however, trusted and favourite care givers are disappearing from the wards or are being re-assigned. Most of the time they are not replaced, but if they are, it is with less-skilled strangers.
To date the management and staff of the Perley and Rideau Veterans’ Health Centre have done an exceptional job in adjusting to reduced funding and in moderating the impact on veterans as much as possible. The members of the Subcommittee’s fact-finding task force are fully aware of the challenge they face. In framing its recommendations the Subcommittee must remain aware that the issue of provincial funding of the Perley and Rideau Veterans’ Health Centre is before the courts. Nevertheless, the welfare of veterans who live in the Centre necessitates the following recommendations.
25. The Subcommittee recommends that Veterans Affairs Canada meet regularly with the Board and Management of the Perley and Rideau Veterans’ Health Centre to review the latter’s plans to deal with the crisis brought about by the ongoing cuts to its funding. It further recommends that Veterans Affairs Canada offer to do everything possible to mitigate the impact of these cutbacks.
26. The Subcommittee recommends that Veterans Affairs Canada ensure that the money it has saved and will save through reduced per diem contributions to the operational costs of the Perley and Rideau Veterans’ Health Centre is returned to the Centre in ways that directly benefit veterans.
27. The Subcommittee recommends that Veterans Affairs Canada ensure that the Board and Management of the Perley and Rideau Veterans’ Health Centre are aware of and respect the responsibility of Veterans Affairs Canada to guarantee an appropriate level of care for veterans, regardless of provincial standards.
Halifax, Nova Scotia
Planned and quickly built in 1917, the first Camp Hill Hospital was a "temporary" structure that remained in service until a new 250 bed facility was built in 1948. In 1978 Veterans Affairs Canada and the government of Nova Scotia finally arranged for the province to accept responsibility for the Hospital and for providing 285 priority beds in return for a substantial federal contribution to the costs of a new hospital complex. Construction of a new acute care hospital began in late 1981 and veterans moved into its new Veterans Memorial Building in 1987.
The Camp Hill facility has 175 veteran priority beds. The veterans that the task force interviewed were very satisfied with the level of their care and treatment. In particular, it should be noted that management does not accept the economic and other arguments that are used to justify the resort to re-thermalised food. Twice a month veterans are encouraged to dine with friends or family members in a restaurant located in the hospital.
The task force was impressed by the emphasis the Hospital placed on helping veterans stay in their homes as long as possible. The Hospital runs a geriatric day hospital to offer respite to those people looking after the elderly at home and management is looking for additional funding to finance research into out patient and home care support.
The Hospital has developed a number of innovative products to help the elderly and disabled. The risk of falling and breaking a hip is a fear of every elderly person and of their family and care givers. Under the best of circumstances a broken hip takes a long time to heal and the patient must undergo intensive physiotherapy to regain mobility. In a great many cases, however, a broken hip does not heal properly and results in permanent disability. Thus any product that can reduce the risk of a broken hip, represents an important breakthrough. The Camp Hill Hospital has developed a "hip pad" that the elderly can wear under their clothing to protect their hip bones in the event of a fall. To date patients wearing the device have reported 80 falls without a single incidence of a broken hip. Another idea that needs development money is a one-handed can opener for veterans living at home.
The Subcommittee believes that Camp Hill Hospital should be encouraged to continue research into and development of improved out patient services and products of use to veterans.
28. The Subcommittee recommends that Veterans Affairs Canada offer to finance and support the research of Camp Hill Hospital into improved out patient services and that it offer research and development funding for "hip pads" and other innovative devices.
At the same time the members of the task force were concerned about the plans to evacuate the hospital in an emergency and believe that these should be reviewed.
29. The Subcommittee recommends that Veterans Affairs Canada and the management of Camp Hill Hospital review the Hospital’s evacuation plans.
Ste Anne de Bellevue, Quebec
The Subcommittee reported on the visit to Ste Anne’s Hospital in its First Report and has not revisited it. Nevertheless, it wants to emphasise the role the hospital should play, not only in relationship to setting and developing a standard of acceptable care for veterans (a subject which was treated in the First Report), but also in knitting the veterans priority access beds scattered across the country into a network. Many considerations argue in favour of Ste Anne’s being developed as the resource centre for the network of veterans’ priority beds, and as a centre of excellence in geriatric care in general and in the care of veterans in particular.
The major problems of Ste Anne’s Hospital are that the number of its residents is declining and that its wards are badly outdated. The Subcommittee wishes to re-state its support for the recommendation made in the First Report:
30. The Subcommittee recommends that the Department indefinitely postpone the transfer of Ste Anne’s Hospital to the Province of Quebec, that the Department amend veterans legislation to permit the spouses of disabled veterans to occupy beds reserved for veterans, and that Ste Anne’s Hospital be gradually modernized to this end.
While retaining control of the hospital, Veterans Affairs Canada should reach an agreement with the province of Quebec to admit other groups with a close affinity to veterans, most particularly, Canada Service Only veterans, and members of the wider community who could benefit from the special treatment and programs offered by the hospital.
