Factors Affecting the Quality of Long-term Care Delivery in Northern British Columbia
- leier51
- Nov 5, 2021
- 7 min read
Updated: Dec 4, 2021
In exploring multilevel models of health, I came across the Canadian Institute of Health Information's (CIHI) Rural Health Systems Model (CIHI, n.d.a). The model, as shown in Figure 1, serves as a guide for collecting and assessing information about key factors that impact the health needs of rural regions along with a region's overall health, health system use, and health system performance. According to CIHI, the model can be used to:
Determine what contributes to performance differences between rural communities
Identify health system comparators and benchmarks
Inform planning and decision making
Improve health care and health in rural regions
Figure 1
Rural Health Systems Model
From Rural Health Systems Model Visualization, by the Canadian Institute of Health Information, n.d.b (Rural Health Systems Model visualization | CIHI). In the public domain.
Application of the Rural Health Systems Model
I utilized the Rural Health Systems Model to explore key factors that impact quality of long-term care (LTC) delivery in British Columbia’s (B.C.) Northern Health Authority (NHA). To begin, I identified LTC quality of care indicators to serve as comparators for assessment. I selected four LTC indicators from CIHI’s national data set based on their relevance to quality of care: falls in the last 30 days, worsened pressure ulcer, potentially inappropriate use of antipsychotics, and restraint use. The four metrics, as indicated in Table 1, encompass two quality of care categories: safety and appropriateness of care (CIHI, n.d.c). Overall, the NHA scored below the B.C. average for 75% of the LTC metrics assessed. The NHA scored below the provincial average for worsened pressure ulcer and potentially inappropriate use of antipsychotics. For the safety indicator falls in the last 30 days, the NHA scored better than the provincial average. Interestingly though, the NHA’s favorable falls metrics could be attributed to their restraint use practices, which were substantially higher (less desirable) than the provincial average.
Table 1
Long-term Care Quality of Care Indicators
Quality Indicator | Quality of Care Category | Rate_Northern Health | Rate_British Columbia |
1. Falls in the last 30 days | Safety | 14.3% | 16% |
2. Worsened pressure ulcer | Safety | 4.7% | 3.4% |
3. Potentially inappropriate use of antipsychotics | Appropriateness of care | 36.4% | 24.7% |
4. Restraint use | Appropriateness of care | 17.3% | 6.7% |
After assessing the NHA’s quality of LTC performance indicators, I utilized the Rural Health Systems Model to explore factors that could contribute to the quality of LTC provided in the region. Starting at the model’s core, I assessed geographical and population factors. Next, I worked around the perimeter of the model, focusing on relevant health system and community context factors. I identified human resource infrastructure and service delivery models as key factors of relevance. Lastly, I examined the model for interactions among the factors identified.
Geographical and Population Factors
B.C. has five regional health authorities that provide health services within their respective geographical regions. As depicted in Figure 2, the NHA's geographic catchment comprises approximately two thirds of B.C.'s land mass (Government of B.C., 2021).
Figure 2
Health Authority Regions in British Columbia
From Regional Health Authorities, by the Government of British Columbia, 2021 (Regional health authorities - Province of British Columbia (gov.bc.ca)). In the public domain.
While its geographical area is vast, the NHA only delivers health services to approximately 300,000 people or ~6% of B.C.'s population (Northern Health, n.d.a; Statistics Canada, 2021). Furthermore, the fact that the NHA operates LTC facilities in a mere nine communities highlights the geographic remoteness of the region. While it is not clear if geographical factors such as travel time, travel cost and availability of travel directly affect the quality of service delivery in LTC environments in the region, it is well understood that staffing public sector LTC facilities in remote rural areas is a significant challenge for many health service providers (Lehmann et al., 2008; Towsley et al., 2011). A recent systematic review performed by Tuinman et al. (2021) on the association between nurse staffing levels and nursing sensitive outcomes in LTC reported a significant positive association between higher registered nursing staffing levels and nursing sensitive outcomes such as pressure ulcers and urinary tract infections. Furthermore, the review also reported a significant association between overall nursing staff levels and nursing-sensitive outcomes including falls, infection and pressure ulcers (Tuinman, et al., 2021).
Exploration of population factors that could impact quality of LTC service delivery in the NHA resulted in the identification of distinguishable differences between the NHA and the rest of the province. Though B.C. ranks among the highest in life expectancy among provinces and territories in Canada, people living in northern B.C. experience lower life expectancies: 78.8 years of age in the NHA compared to 82.4 years of age in B.C. (Rasali, 2016; CIHI, n.d.c). Northern areas of the province also scored lower compared to more urban areas in several determinants of health including socio-economic status (SES), developmental vulnerabilities in early years, and healthy activities of daily living (Rasali, 2016). The large proportion of indigenous people in the NHA is another distinguishing factor of the population. Indigenous people represent 20.5% of the northern population compared to the provincial average of 5.9% (CIHI, n.d.c; CIHI, n.d.d). Whether northern population factors such as SES, ethnicity and life expectancy impact LTC performance in the NHA is unclear. I question to what degree these population factors affect the general health and comorbidity status of NHA’s LTC population compared to other health regions in the province; and, whether the general health and comorbidity status of a region’s LTC population influences their quality of care metrics.
Health System and Community Context Factors
To assess the adequacy of human infrastructure, also known as human resource levels, in LTC environments across the NHA, I performed a job posting search on the NHA’s Careers page. I limited the scope of my search to part-time and full-time direct care positions in LTC: health care aid, licensed practical nurse, and registered nurse positions. On October 29, 2021, 87 permanent and 21 casual positions were available (Northern Health, n.d.b). Given the health region only operates 15 LTC facilities across nine communities the number of available positions is substantial; and, suggests that a high number of vacancies exist within the region’s LTC environments. While it is unclear to what extent the pandemic has impacted the NHA’s human resource levels, it is likely that the region’s geographical remoteness contributes to its ability to recruit and retain LTC staff. Furthermore, the high number of LTC job postings may be indicative of staffing shortages which could be a contributing factor for Northern Health’s lower quality of LTC performance compared to provincial averages. Another factor that may affect the quality of LTC performance in the NHA is the very model that guides LTC service delivery in the region. It is well understood that northern B.C. has distinct geographical and population characteristics in comparison to other regions in the province. To what extent NHA’s service delivery model reflects these factors is not clear. For example, does the NHA’s LTC delivery model reflect its high proportion of indigenous people and lower SES levels? This information would help in determining whether the NHA’s service delivery model contributes to the quality of LTC performance in the region.
Interactions Among Factors and Conclusions
Assessment of geographical and population factors within the NHA highlighted the rurality of the region. Geographical elements such as travel time, availability, and cost are all factors that interact with and affect a region’s population and its demographics. The rurality of the region was also a relevant factor in assessing the NHA’s human resource infrastructure. Findings from my job postings search suggest a high vacancy rate among LTC positions in the region, which is consistent with literature that details the significant challenges the public sector faces staffing LTC facilities in rural and remote areas (Lehmann et al., 2008; Towsley et al., 2011). Moreover, literature supports a positive association between staffing levels and nursing sensitive outcomes, many of which are also quality of care metrics, in LTC (Tuinman et al., 2021). While I cannot report with certainty the extent to which factors such as geography, population and human resource infrastructure influence the quality of LTC service delivery in the NHA, my assessment did lead me to the conclusion that the region's rurality presents operational challenges that likely impact the quality of LTC delivery in the region. Further assessment is required to determine the extent to which rural health factors influence the quality of LTC service delivery in the NHA; and, whether these factors contribute to the region’s lower quality of care metrics in comparison to B.C.’s provincial averages. To what extent the NHA’s LTC service delivery model is meeting the needs of its people and contributing to quality LTC service provision in the region is a topic that I believe is worthy of exploring further.
References
Canadian Institute for Health Information (n.d.a). Rural Health Systems Model. Retrieved
October 21, 2021 from Rural Health Systems Model | CIHI
Canadian Institute for Health Information (n.d.b). Rural Health Systems Model Visualization.
Retrieved October 21, 2021 from Rural Health Systems Model visualization | CIHI
Canadian Institute for Health Information (n.d.c). Your health system: results by theme and
indicator for Northern Health. Retrieved October 21, 2021 from Indicator Results for
Canadian Institute for Health Information (n.d.d). Your health system: results by theme and
indicator for British Columbia. Retrieved October 21, 2021 from Your Health System in
D. Rasali, R. Zhang, S. Gustin & D Hay. Priority health equity indicators for BC_selected
indicators report. Provincial Health Services Authority. Priority health equity indicators for
Government of British Columbia (2021, June 9). Regional health authorities. Retrieved
October 22, 2021 from Regional health authorities - Province of British Columbia
Lehmann, U., Dieleman, M., & Martineau, T. (2008). Staffing remote rural areas in middle- and
low-income countries: A literature review of attraction and retention. BMC Health Services
Research, 8. https://doi.org/10.1186/1472-6963-8-19
Northern Health (n.d.a). Quick facts. Retrieved October 22, 2021 from Quick facts | Northern
Northern Health (n.d.b). Expect more: search for careers. Retrieved October 29, 2021 from
Towsley, G. L., Beck, S. L., Dudley, W. N., & Pepper, G. A. (2011). Staffing levels in rural
nursing homes: a mixed methods approach. Research in gerontological nursing, 4(3), 207–
Tuinman, A., de Greef, M. H.stitutional care. Journal of Advanced Nursing, 77(8), 3303–3316.
Statistics Canada (2021). Population estimates on July 1, 2021: British Columbia. Retrieved
October 22, 2021 from Population estimates on July 1st, by age and sex (statcan.gc.ca)
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