État des connaissances - Organisation des soins et services médicaux en milieu d’hébergement et de soins de longue durée

ABSTRACT

Objectives:The Ministère de la Santé et des Services sociaux (MSSS) would like the medical management arrangements and multidisciplinary care models used in long-term care facilities in other countries to be explored. The objectives of this report are, therefore, to document, in Canada and other OECD (Organisation for Economic Co-operation and Development) member countries, i) the offer of medical care and services and how medical care is provided, ii) the composition of medical care and services teams and the roles and responsibilities of their members (physicians, nurses, specialized nurse practitioners and pharmacists), and iii) physician involvement in the facilities’ management. Conclusions:RESULTS: The availability of physicians in long-term care facilities varies around the world. Some countries and provinces (e.g., the U.S., Ontario and British Columbia) have standards or legislation governing how care is provided. The implementation of standards appears to create value by clarifying medical expectations and providing more medical care and services in a timely fashion. Physician involvement outside of normal work hours varies as well (i.e., daytime from Monday to Friday). To meet the needs of residents outside these hours, access to telephone support and telemedicine between the facility’s care team and a physician seem to be methods used in some provinces and countries (e.g., Ontario, France, Norway and Australia). As for the number of medical visits per 2 year per resident, it seems to vary between 7 and 10, according to information from British Columbia, Manitoba and the United States. In the United States in 2015, there was the equivalent of 1.37 full-time equivalent (FTE) physicians per 1,000 occupied nursing home beds. This is far from the ratio recommended by U.S. experts of one FTE physician per 10 skilled nursing facility beds (facilities with, among other things, temporary physical rehabilitation beds) and 100 nursing facility beds. In Ontario, it is recommended that 4 hours per week be spent on medical practice in long-term care facilities for every 25 to 30 residents. Different practices and types of collaboration are used among different professionals working in long-term care facilities in order to optimize the provision of care for the residents. The three main types of skill mix described in the literature are (1) delegation (the physician assigns a task to another health care professional but remains responsible for it), (2) substitution (expanding the responsibilities of a health care professional, who may then provide some of the same services as the physician and becomes responsible and autonomous in performing these tasks), and (3) supplementation (increasing the scope of a health care professional’s work by allowing them to provide additional services that complement or extend those provided by the physician). Although a combination of all three types is reported in practice, physician substitution with different professionals, such as specialized nurse practitioners (SNPs) and physician assistants, is the one most documented in the publications reviewed. CONCLUSION: The results presented in this state-of-knowledge report provide relevant avenues for reflection on the organization of medical care and services in long-term care facilities. The topics discussed include the different staffing models in place across the OECD countries, the variability in the level of physician involvement in the management of these facilities (and the form of this involvement), and the several forms of skill mix. These results provide insight on the organization of care and services and the sharing of responsibilities among the various members of the care team. Given the aging of the population, the increasing complexity of the residents’ profile, and the difficulties recruiting qualified workers, efforts will certainly have to be made to adjust the way things are done and to continue to offer quality care and services. This reflective work is all the more necessary given the significant impact the COVID-19 pandemic has had on the health and social services system. Lastly, there are several tensions in the mission of long-term care facilities, which is to offer quality care and services in a quality living environment. The combination of these two goals in the reflection on the organization of medical care and services is essential for ensuring residents’ well-being. Methods:The Institut national d'excellence en santé et en services sociaux (INESSS) has prepared a state-of-knowledge report based on the scientific literature and websites of organizations, learned societies and government bodies. A total of 58 primary studies, 9 reviews, 9 expert opinions published in a scientific journal, reports from 7 governments and 23 organizations were examined.