Surviving the Borg

February 27, 2009
in Category: Articles, Civil Rights, Health, Mental Health, Seniors, Society
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More stories pour in about the crisis in our residential care homes.

No article I’ve written for Focus has provoked so many impassioned calls, emails, posts to my website, and interceptions in the street than my feature about long term care of the elderly (“Who has the Right to Control Your Life?“, January).

Many relatives of seniors said the stories of deteriorating conditions in care homes and people being unfairly stripped of their rights reflected their own experiences. “On Christmas Eve in 2006, my mother was abducted,” described one woman. “[They began] transferring her to different nursing facilities where they were drugging her with so many drugs that she could not lift up her own head…”

Another wrote, “[S]taff have frequently written reports itemizing problems, and the numerous reports are consistently ignored. Continuing issues such as filth-still there; toileting-constant struggle; activities-not very many that actually engage people…”

For these people, seeing the issues publicly aired was heartening.

But many frontline care attendants accused me of being negligently selective in my examples and grossly unfair to them.

“I can’t help but feel that the negativity of this article must have had a terribly demoralizing effect on the staff who try so hard, under sometimes difficult circumstances, to do their best to bring care and comfort to the residents,” wrote one. “It certainly demoralized me.”

“How dare you categorize all us care aide workers,” wrote another. “Shame on you.”

Interestingly, both sides were reflected in one particular relative’s opinion. “There are some outstanding caregivers out there. Some really quality, amazing human beings,” he said. “But there are many more of the other kind… On the bulletin board there’s a huge poster, ‘It is your duty to report neglect and abuse and document it.’ Well, see what happens when you actually report abuse and neglect. You are the one who is going to pay a heavy price. It’s like, ‘How dare you suggest that our staff have done this.'”

As for the doctors, lodge administrators, Vancouver Island Health Authority and provincial government… They were resoundingly silent. (We do know the article generated disquiet at various care homes and senior levels of government; their silence is deliberate.)

First, let me say that I recognize there are many admirable people working in long term care. They’re doing the best job they can while increasingly overworked. And some residents’ situations are better than others’. That said, my article didn’t pretend to comprehensively diagnose all the good and bad in care homes. It was focused on the extremely tenuous legal rights of the elderly (or of anyone, for that matter) under BC’s archaic, draconian “incapability” and mental health laws, and on the lack of accountability in our generally deteriorating residential care system.

So, as I heard more tales of abuses, even as my own carefully researched complaints received stony non-responses from those in authority and “how dare you”s from downtrodden staff, I realized all this actually highlighted the article’s central point: People’s basic human rights are being trampled, and nobody is accepting accountability.

To fully appreciate how dire the situation is, it’s important to understand that even just entering these homes, absent any abuses, is itself a harsh end to freedom for most retired people accustomed to their own routines. “When they go into a facility, that [personal routine] becomes a regimented, collective routine,” one care worker explained. At first, that may just mean structured meal times and limited personal space; eventually, it’ll likely mean others control how and when you bathe, exercise and go to the washroom. “It’s almost like the Borg in Star Trek,” she commented. “You become assimilated into the system.”

Worse, though, you’re simultaneously stepping into a legal abyss while becoming weaker and more vulnerable. You’re now in daily contact with health professionals and, at any time, a contracted doctor you’ve never known before may strip you of all your rights to make decisions about whether you can walk outside, have visitors, or refuse heavy sedation. Or he may not. It’s up to his or her discretion, with no scientific criteria or appeal process. Alternatively, staff may simply use that “possibility” as leverage over you sometimes.

Meanwhile, health professionals police themselves, and tend to be infamously delinquent in these responsibilities.

As for the care attendants helping with your everyday needs, they simply have no licensing or regulatory body.

Even relatives won’t necessarily truly advocate for you, so ingrained is our cultural deference to health workers.

And what sort of checks and balances do facility administrators and VIHA have in place? Here are some revealing examples:

BC’s Ombudsman has opened 150 investigations into unresolved problems at care homes.

In spite of numerous major scandals (Beacon Hill Villa, anyone?), not a single facility in this region has ever had its licence revoked. VIHA doesn’t even have established policies and procedures in place for stopping chronic medication errors. In one case, bumbling VIHA intervenors suggested facility staff wear orange bicycle safety vests when administering drugs, in hopes that, if others steered clear of them they’d make fewer medication errors. (The weird experiment apparently worked-and was soon cancelled.)

Last July, complaints about the nutritionally-bereft delivery food came to VIHA’s Board directly. As per VIHA’s policy of creating bizarre mockeries of public accountability, questions to their Board have to be submitted in writing and then responses are read out verbatim with no discussion permitted. (But at least we know the responses have been carefully thought out, right?)

So why are our health experts letting notoriously bad hospital food spread to residential homes, where ailing seniors are actually being expected to live on this tasteless, anemic, food-like product?

“VIHA and its contracted service providers are required to comply with nutritional standards as set out in the Canada Food Guide,” VIHA’s Board clarified reassuringly.

Have you looked at this notoriously industry-influenced and decidedly unscientific guide? If meals were two pieces of white bread, a heaping tablespoon of sugared peanut butter, and a cup of powdered milk three times a day, so long as all that came with a daily can of green beans and one stick of reconstituted celery, it’d all be “A-OK” with the Canada Food Guide. (Yes, lodge doctors can recommend special individual diets; but it’s a difficult process and, of course, if substantial improvements were common, everyone would be doing it.)

All this isn’t professional behaviour and reasonable accountability in action; it’s a joke.

And if you try to sue them all? Few lawyers are knowledgeable about health, civil rights, mental capability or mental health law. Most that can earn livelihoods in this area do so by regularly consulting for and defending the government, lodges, health authorities, and doctors. It’s nearly impossible to get these experts to turn around and attack their biggest clients in court. If you do get a lawyer, she’ll find little leverage in BC’s emaciated legal protections for those deemed incapable or mentally disordered. Thus, the circle of disempowerment completes… forming a noose.

That’s why I’m confident that all truly “good” people working in residential care are as concerned as you and I. Those people aren’t complaining about my reporting being unfair to them, because they know who’s really being treated unfairly in all this. Surely, then, they’ll join in pushing for more accountability throughout the residential care system.

Rob Wipond

Thank you for reading.

View my other posts

18 comments

  1. Nicole & Stephen

    Your two articles “Who Has the Right to Control Your Life” and “Surviving the Borg” are dead-on the nail. Both my husband and I work in the Health profession. Many of the problems you have written about are issues – one of which is that care aides/attendants should be licensed – we have both expressed to some of our co-workers, employers and union to no avail. We wish you could have interviewed us, so we could share with you more stories to lighten the weight from our shoulders. Yes, indeed, people’s basic human rights are being trampled, including ours as hearing impaired health care workers with 2 degrees and 7 certificates between us. I’ve always told my husband, if the BC government decimates the Human Rights Commission, watch our rights as disabled workers begin disappearing (and they have) and then watch our seniors’ rights go down the drain afterwards (and they are). Thank you so much for writing with such refreshing frankness, Rob.

  2. Rob Wipond

    Thank you for your comments! It has been a somewhat “controversial” topic, and I think it is very important and weighty when people like yourselves speak out to be counted, because some people’s tendency is to dismiss it all as merely the opinion of one writer.

  3. Deanna Johnston

    Rob
    For beginners, I’m not a impassioned person.I write to you again so hopefully I can clarify a few things for you.
    I started my career as care provider in 1987,first as a ambulance attendant {EMT]I then went on and worked in nursing homes and hospitals as a RCA.
    I feel bad for those people you mentioned in your articles abuse etc.If in fact the lady that alligated that she was raped.Well I’m here to tell you right now if it was my mother there would be nobody this side of hell would stop me from taking her to my own doctor and have her checked out.Why was that not done?
    You also go on a lot about stripped of seniors rights.
    You know all our lives we managed our own money,we managed over the years to collect things,important stuff.All of a sudden a family member or doctor decides we have to inter into anursing home.we are delivered with a toothbrush and some of our cloths.Trying to ajust to a new and scary sitution.
    Next thing that happens.Advocates running around asking me if I’m happy and if I like the food.How do we feel now? upset thats how we would feel.Now it take a team of nurses and lpn’s and rca’s to start from the begining of admitting process to make the person welcome all over again and to calm them with a lot of kind words.
    Are these advocates certified by a guardian program?
    Are they appointed by the court?
    Why are they upsetting our residents/patients?
    I’m wondering if maybe there is not more that meets the eye concerning your two articles on senior care.You are sure one sided.
    I guess time will tell.
    Deanna

  4. Rob Wipond

    Deanna: Many doctors will not agree to see a patient without the current treating doctor referring that patient, right?

    Further, what if the current doctors simply do not authorize you to take your mother out at all? If you do then take her out, they will be quite within the law to call the police on you, and then there will be a police record saying that you a) deliberately endangered your mother’s welfare and b) deliberately disobeyed doctor’s orders and c) knowingly broke the law. Good luck maintaining any kind of authority in your mother’s situation after that.

    It is written into BC law that if you are certified under the Mental Health Act, you have the right to a second opinion with a doctor of your choice. Yet I can tell you with 100% confidence that psychiatric patients are routinely denied that right in our psychiatric hospitals. They are physically incarcerated in the hospital, and that’s that.

    Some years ago, after the Ombudsman investigated and found the same thing occurring, a pilot program was run in BC where patient legal advocates were stationed right in psychiatric hospitals. That program was cancelled, and the gov’t told me why: too many patients were demanding their rights and protesting their incarceration and treatment.

    It’s easy to blame the advocates for stirring the patients up, and that’s what health professionals tend to do in these situations. I’ve been accused of it myself. And in some cases, it may well be a factor. However, wouldn’t the simple solution be to have higher levels of protection for the rights of patients in the first place? For doctors and caregivers to be more honest and forthright with everyone about the importance of advance directives etc? That’s what most other provinces and countries do (though in capability law more than mental health law); BC is very archaic that way.

  5. Catherine Leong

    One more letter…The reason I am writing these letters is because being a caregiver myself I am going to stand up for Me and for all the Great Caregivers out there. Believe me there are MANY not just a few like was stated in your article by a relative “.There are some outstanding caregivers out there. Some really quality, amazing human beings,” he said. “But there are many more of the other kind… I myself do not agree with the last part of his statement “that there are many more of the other kind. Alot of us go above and beyond the call of duty. We take pride in our profession and at the end of the day we can honestly walk away with our heads held high knowing that WE made a difference to someone in such a short time. How can this relative come up with such a statement . Has he been to other facilities and asked who are the good caregivers and bad caregivers and then tallied them up. Please give me a break it’s such a shallow statement and before a strong statement such as this is written it should be proven to be an accurate and a truthful statement with some evidence to back it up.. ( Like many in your articles)
    Another statement that I have a problem with is the fact that you wrote “ As for the care attendants helping with your everyday needs, they simply have no licensing or regulatory body. We may not hold a licensed but we are Certified which means we are trained to do this job. We do meet the requirements for this position. If you are not certified you are not hired simple as that. You tell me what difference does a piece of paper make anyway? Does that piece of paper make someone work better or show more compassion……..I really don’t think so. It all comes from Within.
    Here’s another area that Accountability would be useful………so if many caregivers are so uneducated, so impassioned as stated by you , not suited because they are not licensed, then where do we look for accountability. Do we look at the College , or perhaps the Instructor of the RCA program, or the RCA. Would it be fair to say the Instructor? Interesting isn’t it. One thing you are right about is that we do not have a regulatory body but really would that make a difference in what concerns are in your articles. Doctors, nurses, lawyers, chiropractors , social workers , teachers the list goes on has a regulatory body but have any of these professions done any wrongdoings in their careers? Yes they have so with having a regulatory body did this prevent this. NO it did not. So can you explain to me what is your point here. Thought for the day “A piece of paper DOES not make us better than the next person.”

    Well tell we meet again Rob.

  6. Rob Wipond

    Catherine: Thanks for your thoughts. First, if you haven’t, I encourage you to read all the discussions after both these articles, because they address many of the same issues you’re raising. In particular, I elaborate on the fact that when caregivers react extremely negatively to being challenged or criticized, that worries me greatly, because of course reacting caringly to needs and complaints is really the main part of the job. In any case, to answer some of your questions:

    I made it very clear that the opening section of this article was simply a collection of varied opinions I’d come across and tendencies found during my own research, and that neither this article nor the previous article was intended to provide a definitive, comprehensive overview of care homes. I don’t believe such a thing is easy to do, and certainly one would need a lot of time and money and resources and a book length, but hopefully, the Ombudsman’s investigation may be able to help us all with this process. That aside, I still think it can be important to hear people’s varied perspectives, however limited by their own personal experiences they may sometimes be.

    About regulatory issues, you are absolutely right, and of course I discuss these very issues you raise in this article. I point out that care attendants have no regulatory body, and note that even though health professionals do have such bodies, they typically aren’t very effective. The answers are simple: ALL these workers need regulatory bodies, and the legislation and accountability structures overseeing these bodies has to be much more effective, e.g. more civilians should be on health professional disciplinary bodies, and their findings should be a matter of public record. The Ombudsman has made these same recommendations in the past, and I’ve discussed this issue in several other articles. See here:
    http://robwipond.com/?p=57

    So that’s the point of bringing it up: We need to develop more effective accountability at all levels for all workers. And personally, I would blame lack of accountability within VIHA and the provincial gov’t more for most problems in care homes than I would blame care attendants, and so did most of my sources. And right at the root of the issue, as I keep emphasizing, is the issue of the legal rights of the patients themselves. Those rights have to be clearly defined in law and vigorously upheld in practice, because how else can we build an accountable system if the people the system supposedly serves have virtually no rights?

  7. Nicole & Stephen

    You have brought up a point, again and again, in your articles and in your replies that both my husband and I have discussed with a workplace superior, a couple of our peers, our friends and families – the lack of accountability within VIHA and the provincial government. It’s a fact that in a family situation, if a parent or parents are dysfunctional, then the dysfunction is going to filter down to the children. It is likewise within our Health Care system; VIHA and the BC government are the dysfunctional parents and their dysfunction has filtered down through management to the Health employees and to the people under our care.

    When there is violence in the workplace from the residents or clients towards the workers themselves, we have to look at the bigger picture. (A few years ago, a resident suffering from severe dementia viciously strangled a co-worker who sustained black bruises about her neck from this attack. In another incident, a resident was being physically pushed out of a second story window by another resident who had to be restrained by a number of our strongest RCAs, one of whom sustained a broken nose.) Where is this coming from? When management turns a blind eye to the complaints of its employees and blatantly refuses to protect them, VIHA doesn’t either nor does our BC government. It becomes a vicious dysfunctional circle in which Human Rights are being violated on every level.

    When I took a course in early 2007, a teacher who also works high up in VIHA, told the class that when he first started at VIHA it was a new adventure and everyone was gung-ho in making the system function better. Now, he and a few others are beginnint to feel differently and are often frustrated. He said, “VIHA has become a huge, unwieldy green monster devouring itself. The right hand doesn’t know what the left hand is doing.”

    There are many other things my husband and I would like to say on this topic on this site, but it would literally take a book as my own diary and private notes can attest to these couple of years.

    Thank you, Rob, for looking at all sides of this terrible situation in a very fair and balanced way. It gives us some comfort that we are not alone in our own observations and experiences.

  8. Rob Wipond

    Nicole @ Stephen: Excellent point! This has come up elsewhere, too. For example, a health employees union in Ontario has been publicly campaigning for better safety procedures at Toronto’s Centre for Addiction and Mental Health, because some of their staff have been assaulted. However, left out of their campaign has been an acknowledgement of the fact that many patients at CAMH have no legal rights at all, are being forcibly drugged and electroshocked against their wills, and are frequently victims of other types of abuse e.g. a patient recently died there after being tied up and left for five days.

    So clearly, the proper way to protect the safety and rights of staff is to at the same time work to protect the safety and rights of patients.

    Unfortunately, I hear about this frustration with VIHA all the time, from inside and outside its walls. Very, very few people have much good to say about VIHA. It is as if VIHA is at war with the community it serves.

  9. Nicole & Stephen

    Your last statement in the above comments is so true, Rob.

    And speaking about an Ontario health union publicly campaigning for better safety procedures because of staff being assaulted, a Violence Survey is being done right now in BC. I have been passing this survey out where I work, but my husband and I also signed a petition to eliminate elder abuse while we were at a convention last year. I now receive excellent emails on a regular basis from this group and I sometimes put them up on the bulletin board in an effort to make our fellow co-workers aware that we must continue to speak up for those who cannot, and for those who can but are too afraid, we have the responsibility to encourage them to do so. Unfortunately, some of our co-workers have either forgotten that this is part of what we were taught to do or some are too frustrated to care anymore with a system that constantly stonewalls everyone and is becoming so money and corporate-orientated.

    But we have to stand up and continue to care. It’s not just for those residents in the care homes. It’s for our parents, and for ourselves as well if and when we get too enfeebled. It’s our responsibility to do so. We have to look at the other side of the coin as well – always.

    Thank you again, Rob.

  10. Deanna Johnston

    When I first read your article on Who has the right to control your life,I was very angry with the coments seemingly directed @ all health care profession care givers. I apologize, I replyed in such a blunt way to you.I really feel for the patients and their families.
    It seems so cold and mean to take an elder family member out of their envirament and place them into a nursing home or extended care.I really feel bad for these people.{not an easy decision].
    On the average,correct me if I’m wrong{I know you will] It cost on the average $4000.00 to house a patient in a nursing home or ecu.
    Why can’t the goverment subsidize a family member to look after their love one in their own home?
    I feel everybody should have a advance directive to carry out one’s wishes.
    What if they don’t want strangers looking after them?
    What if they don’t want to eat hospital food?
    I personly have never woke up in the middle of the night and craved some hospital food.It is very low in sodium, I guess that should be a good thing.From what I’ve seen its not as bad as decribed in your article.If anything I think it improved over the years with more fresh vegetables,fruit and great looking deserts.
    To some elders their spouses are their caregivers.
    What about caregiver burnout.Who helps?
    Who gives the caregiver a break?
    What if the person’s health deterates so the caregiver can’t possibly look after them
    The advance directive has to make a decision right? Has their rights been violated?

  11. Rob Wipond

    Deanna: I appreciate your sentiments; at the same time, I did understand your frustration. You’re working in a very difficult environment, and my article did not speak to some of the biggest concerns you personally had.

    I’m not sure about the cost of housing a patient. Are you suggesting it’s $4000/wk or per month? It likely differs at different facilities, and definitely differs based on the assessed needs of the client. Ten years ago I obtained a figure of over $3,000 wk for a stay in our local psychiatric hospital. There is certainly talk going on out there politically around the issue of trying to find ways to support at-home caregivers more.

    Due to some particular protests, the food seems to now be better at some facilities than at others.

    An advance directive can be useful, the more detailed the better, and then the “substitute decision maker” is the one expected to make unforeseen choices. Clearly, if we had legislation in place to allow both of these things, and then procedures in place for objective, independent out of court assessments in individual situations of conflict, that would help in a lot of situations.

    Definitely, caregivers of all kinds, both professional and amateur, need more support.

  12. Deanna Johnston

    Rob.I’m not frustrated where I work or the enviroment I work in.I guess you might say I’m lucky to work where I do with a great team of care providers.I guess I was just thinking of those people who have to leave their enviroment that they worked so hard for. To some people they are content in ecu or a nursing home.
    My question was if the goverment can pay for a person to stay in a nursing home or ecu why can’t theyhelp a family member take care of their love one at home? We have such a bed shortage as it is.I think that would make sense.
    I think thats where accountability starts.
    If a person wants to die at home should that not be a choice of that person?

  13. Rob Wipond

    Deanna: Yes, I see now that other people posting at the same time as you were expressing their frustration with the difficulty of the job generally, but you did not.

    I agree, it would be great if there were more support for at-home care for those who want it and have the opportunity to choose it. And I know that both federally and provincially legislation around it is being discussed, but I honestly don’t know enough right now to comment on all the ins and outs as to why it’s taking so long to make it happen. You can find some info on it by conducting searches online, though, because the topic has received media attention in the past few years.

  14. Patsy

    Thank-you again, Rob for your balanced, objective reporting on the fundamental needs in eldercare. The angry responses you received sadden me as the apparent lack of “listening” and “hearing” hinders solutions.

    A short story that brought me back to reading your blog:
    My elderly aunt recently passed away in a facility on the lower mainland. From her home where she was living independently, she was moved numerous times to seniors living, assisted living, another assisted living, always to facilities that did not offer the level of care she then needed and could not cope with her needs. She was improperly diagnosed, improperly medicated, just evicted until she landed in a public extended care facility where she finally started to receive the medical care she needed. It was a horrific year for her. Then she died.
    One of her greatest sorrows was no access to a garden. All of her life, she gardened to cope with her mental illness, in times when medication did not exist for her generation. The modern standard of care does not recognize the beauty of natural spaces, and the peace and harmony nature brings to people. Concrete boxes seem to be the mode of contemporary care (witness the closure of Cowichan Lodge which had exemplary natural space).

    It is long past time to recognize that the final years of a person’s life could be a reward, not an inconvenience. The care that we should be aspiring to providing should move above and beyond the care providers who are kind and brilliant at what they do (bless them). Food should be a delight, a social gathering. Daily activities should enhance every person’s day. Bedding shouldn’t have patches and holes. Physiotherapy, occupational therapy are a necessity. Concerns and worries should be listened to. When a woman with aphasia says she has been raped, the meaning isn’t necessarily sexual, it may be that her dignity is scarred and she needs to be listened to openly. My “entitled”, “spoiled” background causes me to believe that elderly people should no longer be put on ice flows.
    You’ve inspired me to look at the Universal Declaration of Human Rights…elderly people are not exempt.

    http://www.un.org/en/documents/udhr/

  15. Rob Wipond

    Thanks again for your comments, Patsy. Years ago I went out with a person doing “horticultural therapy”. Basically, he was simply taking interesting plants to late-term seniors homes of different types to pass them around and talk about them, and helping people grow their own little porch or indoor plants. Nevertheless, it was incredible to see how excited they often were to engage with him and his plants, and to get involved in nurturing a little life they’d helped create.

    Yes, you’re so right. We spend so much cultural energy on encouraging people to work and build towards a great retirement — and to see that for so many that retirement is becoming a living hell, is extremely tragic, and worrying for us all.

  16. d

    My family is trying to get my 98 year old Mom out of Victoria General Hospital. She was admitted for a stroke which parlyzed one of her legs and arm. It also affected her swallowing but its slowly starting to come back. We made out our advanced care directive ahead of this but the hospital seems to be ignoring our wishes. She wants to go home and we are quite prepared to take care of her at home ( we have a home support person(s) to back us up). She has now been in hospital just over 3 months. ITs now time to go home and I have demanded that if there is nothing more medically wrong with her and she’s stable to release her. What is our right??
    What is our rights Can we take her out or will we be charged???

  17. Rob Wipond (author)

    I don’t have enough information to tell you — it depends in part if she has been declared mentally “incapable” or not, or whether she’s been deemed to be mentally ill or not. If you’ve asked for clarification and haven’t gotten any, then don’t waste any time arguing with different people. What you should do is deliver a letter cc’d to both her treating physician and the hospital CEO requesting written clarification as to her status and reasons for it, and specifically asking if she is being held against the will of her and her family or not. Indicate also your family’s unity of opinion and your request to take her home, and that you’re prepared to provide whatever her doctors think is necessary (if you are). Once you get that letter it will be clearer what to do. But be careful about fighting this on your own — they tend to exploit people’s lack of knowledge about their rights. Contact a lawyer knowledgeable about incapacity and mental health laws. You can find one through the Lawyer Referral Service:
    http://cbabc.org/For-the-Public/Lawyer-Referral-Service
    Be careful also, though, because many lawyers are very ‘cosy’ with the health authority. You’ll want to ‘vet’ the lawyer carefully if you are going to work with him/her.

    And the short answer is, unless she and/or the family have been officially notified in writing that she is incapable of making her own decisions or has been certified under the mental health act, then she’s free to leave on her own at any time.

  18. Teresa

    So
    We are all talking about a very difficult, emotional and challenging topic. I have recently been trying to support and find the care necessary for my mother-in law. She is 90, has severely compromised vision and dementia. I do see the issue of ensuring people have choice and rights; however, our family struggled with the opposite side of the spectrum. When she was living on her own (which she insisted on); she would cancel VIHA assistance as well as meals delivered to her. Even with family visiting every day; eventually she could not manage. She, of course, would insist she was fine and only when she no longer recognized those family that brought her to the Dr. was there an admission of a problem by a physician. She has unfortunately made decisions that have severely compromised her health and well being and jeopardized her safety. The amount of stress it has caused the family is unbelievable. Representative agreements are necessary. I would also like to credit the many dedicated front line workers of VIHA. It is a challenging job and you aren’t given the support and accolades you need and deserve. That being said, few hands can only do so much. Providing adequate funding and staffing is essential. I also do see that personalized care that provides options for families and individuals is necessary.

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