In this article, we explore the role of substitute decision-makers (SDMs) in matters of sexual expression for continuing care residents with diminished cognitive capacity. We examine how Alberta’s current use of SDMs can enable an “all-or-none” approach to competence, wherein a person either has capacity to make all decisions or is incapable of making any. Three factors facilitate an environment in which this approach can influence residents’ sexual expression. These include the wording of current legislation, lack of resources for SDMs, and relational dynamics between SDMs and care staff. We provide a critical review of existing legislation and empirical evidence of its challenges in practice. Though we focus on the Alberta context, there is reason to believe that similar issues persist in other Western jurisdictions. We offer several recommendations for how we can better support residents’ sexual autonomy in continuing care and avoid pitfalls of the “all-or-none” approach to competence.

This systematic overview summarizes the published literature reflecting the effectiveness of services or models of care for persons with dementia living in their homes, in specialized institutional care or assisted living centres/congregate homes. A detailed search for literature found studies evaluating respite care, day programs, counselling, congregate living, and special care units in institutions and there is some evidence of the effectiveness of these programs. No scientifically rigorous effectiveness studies, specific for persons with dementia, were found for hospice care, case management or psychogeriatric outreach mental health programs. First and foremost, more research is needed that examines the effectiveness of different programs for specific persons and their caregivers with different characteristics and the measurement of family expenditures as well as costs of programs.

While there are 157,000 designated continuing care (CC) beds in Canada – beds that are only used by a rather distinct group of individuals – no comprehensive description of the CC resident population exists. An analysis of 1974–1997 Statistics Canada mortality data and 1992/93–1996/97 Alberta hospital utilization data was undertaken to provide a description of one segment of this population, those at the end of life. Statistics Canada data indicate that only a small (<3%) proportion of deaths take place each year in CC facilities, with these persons 84.5 years of age on average, and most often female (62.5%), widowed (61.9%), and Canadian born (61.8%). The primary cause of death/diagnosis varied considerably, as it did for CC residents in Alberta who were transferred to acute care hospitals before dying there. The average hospital stay for transferred persons was 14.0 days in length, with these hospitalizations normally characterized by few diagnostic tests or treatments (mean=0.9).

Canadian health regions are required to set priorities and allocate resources within a limited funding envelope. Program budgeting and marginal analysis (PBMA) was piloted in continuing care in Claresholm, Alberta, with the aim of improving overall benefit from available resources. A marginal-analysis expert panel was used to assess options for continuing-care delivery. Inputs into the decision-making process included evidence from the literature, regional and provincial reports, program budgeting information, and local knowledge. Recommendations included implementing adult, day-and-night support programs and converting long-term beds to convalescent beds. Changes were funded through allocating provincial Broda funding and altering nursing assistant and physiotherapy activity. PBMA was demonstrated to be an effective framework in aiding decision makers with redesigning services in Claresholm. This case study is one of several which indicate PBMA to be a valuable aid to priority setting in health care service provision.

This paper reports on the results of analyses using administrative data from British Columbia for 10 years from fiscal 1987/1988 to 1996/1997, inclusive, to examine the comparative costs to government of long-term home care and residential care services. The analyses used administrative data for hospital care, physician care, drugs, and home care and residential long-term care. Direct comparisons for cost and utilization data were possible, as the same care-level classification system is used in BC for home care and residential care clients. Given significant changes in the type and/or level of care of clients over time, a full-time equivalent client strategy was used to maximize the accuracy of comparisons. The findings suggest that, in general, home care can be a lower-cost alternative to residential care for clients with similar care needs. The difference in costs between home care and residential care services narrows considerably for those who change their type and/or level of care, and home care was found to be more costly than long-term institutional care for home care clients who died. The findings from this study indicate that with the appropriate substitution for residential care services, in a planned and targeted manner, home care services can be a lower-cost alternative to residential long-term care in integrated systems of care delivery that include both sets of services.

While American literature on sustaining restraint reduction is relatively robust, there is a lack of research published on the same issue in Canadian continuing care (CC) settings. Statistics from Canada's largest publicly funded and operated CC organization have revealed telling patterns in mechanical restraint use. Over a 4-year study period during a campaign to reduce mechanical restraint use, the organizational prevalence dropped from 24.68 per cent to 16.01 per cent. There was substantial variability in restraint prevalence among the organization's 11 centres (range: 0–39.86% of residents restrained) and all but 1 was able to achieve mechanical restraint reduction. Specific facilitators to achieving and sustaining restraint reduction are identified, including small facility size, provision of specialized care (e.g., Alzheimer's disease), and an on-site champion. Specific barriers, such as large facility size and an off-site champion are also discussed.

The ‘Barriers to Access to Care for Ethnic Minority Seniors’ (BACEMS) study in Vancouver, British Columbia, found that immigrant families torn between changing values and the economic realities that accompany immigration cannot always provide optimal care for their elders. Ethnic minority seniors further identified language barriers, immigration status, and limited awareness of the roles of the health authority and of specific service providers as barriers to health care. The configuration and delivery of health services, and health-care providers' limited knowledge of the seniors' needs and confounded these problems. To explore the barriers to access, the BACEMS study relied primarily on focus group data collected from ethnic minority seniors and their families and from health and multicultural service providers. The applicability of the recently developed model of ‘candidacy’, which emphasises the dynamic, multi-dimensional and contingent character of health-care access to ethnic minority seniors, was assessed. The candidacy framework increased sensitivity to ethnic minority seniors' issues and enabled organisation of the data into manageable conceptual units, which facilitated translation into recommendations for action, and revealed gaps that pose questions for future research. It has the potential to make Canadian research on the topic more co-ordinated.

This article describes the met and ummet needs of elderly residents of nursing care (NC) and residential care (RC) settings. Thirty-four residents of an RC home and 40 residents of two NC settings were assessed. Each resident and a respective staff member were interviewed using the Camberwell Assessment of Need for the Elderly (CANE) to indicate the resident's current met and unmet needs. The Clifton Assessment Procedure for the Elderly–Behaviour Rating Scale (CAPE-BRS) was completed by the staff member to indicate the participant's current level of dependency. In addition, the Mini-Mental State Examination was administered to participants and DSM-IV diagnosis was recorded. A high number of needs were found in both RC and NC settings, the level of dependency being proportional to level of need. There was a core set of needs in both samples related to difficulties with accommodation, food preparation, and self-care. Both NC and RC homes were meeting these needs; however, RC residents had a significantly greater level of unmet need for suitable daytime activities. The greatest predictor of type of setting was gender and there were significantly more females in RC. Controlling for gender, participants in NC had greater levels of dependency, particularly problems with apathy and social skills, as measured on the CAPE-BRS. It is possible that the greater level of social needs in NC residents had led to their placement in the more specialized NC settings. On the other hand, NC settings may be left caring for a group of residents that, because of their specific needs, have been difficult to place into RC. These findings have clinical implications for the future development of continuing care for the elderly. This study also highlighted that there is a substantial need for specialist services to address the unmet needs in these two types of continuing-care settings, such as interventions for social disturbances in NC and suitable daytime activities in RC. The CANE is a useful instrument to evaluate such needs in long-term-care settings.