It’s been a busy few weeks and I have had the great privilege to travel a lot across the country and speak to a lot of people about seniors care. The CMA’s message – that we need a national seniors strategy with Ottawa taking a leading role – is resonating with patients, their families, ordinary people, citizens’ organizations, and the press.
I think that if we can fix seniors care, we will go a long way toward fixing the health care system in this country. And our health care system needs some fixing. According to the latest Commonwealth Fund Report, we rank next to last among 11 leading nations – only the US is worse. Many believe that with the introduction of Obamacare in the US, their value-for-dollar proposition will improve sufficiently to vault them above us.
I’m willing to bet that Canadians do not want to be at the bottom of any list that ranks national health care systems. Canadians highly value our health care system and the values upon which it was founded. It is an institution that is a big part of our national identity. So when a Commonwealth Fund Report measures quality (effective care, safe care, coordinated care and patient-centred care), access, efficiency, equity, and healthy lives and finds us next to the bottom of the pack, we need to take heed.
We need to spend smarter. We need to focus more on outcomes and quality, and less on volumes and activity. We need to serve and to be accountable to patients and their families rather than only to our institutions and structures.
Where to start? Well, let’s talk about how we can start to de-hospitalize the system.
Now, we will always need hospitals. Don’t get me wrong.
But increasingly, we need new ways to support seniors – so that they can age well at home, instead of as patients in hospitals. Today, between 15 and 20 percent of acute care hospital beds in Canada are occupied by patients – most of them seniors – who do not require acute care. We call them ALC (Alternate Level of Care) patients. They are in hospital simply because they have nowhere else to go. They are either on waiting lists for Long Term Care or they are waiting for a stretched home-care system to get the supports in place for them to be successful in their homes.
What are the consequences of this misalignment?
Well, first and foremost – seniors are not getting the care they need and deserve. Acute care hospitals are not designed or staffed to care for seniors with chronic disease. In hospitals, we put patients to bed – because that is what we do in acute care settings – we put sick people in bed. But these seniors are not acutely ill. They need a different kind of care environment. They need a care environment that lifts them up and restores them and helps them to live a dignified life. Not a small room with a bed and a chair, shared by 1-3 other people they don’t know, waiting for daily rounds by doctors and nurses who have nothing meaningful to contribute to them, warehoused while they wait for the next step in their care journey. What’s even worse is that we subject these seniors to a high risk of iatrogenesis. They fall. They develop hospital-acquired infections. They get deconditioned. They get depressed. Seniors with dementia suffer accelerated cognitive decline. The list goes on and on. It is a national embarrassment. Who wants to live in a hospital?
The other major consequence of this misalignment is that hospitals become full – and even overfull. Emergency Departments across the country are congested with long wait times for everyone. Elective surgeries get cancelled because there are no beds to put patients in afterwards. Tertiary care centres that offer highly specialized and complex care for regional populations can’t accept patients from smaller regional partner hospitals because they are full. Patients are put into “overcapacity” beds – hallways, alcoves, nooks and crannies and even closets sometimes. We call this situation and the slowdown in patient flow it causes, “Code Gridlock“. Increasingly, Code Gridlock is becoming the norm in hospitals across Canada.
Canadians are among the highest Emergency Department users in the industrialized world. (Osborn et al; 0.1377/hlthaff.2014.0947 HEALTH AFFAIRS 33, NO. 12 (2014)). At first glance, it might be tempting to say, “Hey, we just have to keep all these people with colds and minor ailments out of the ER – that will fix the overcrowding problem”. While it may be true that people with minor ailments should do their best to seek care elsewhere, doing so will not fix ER or hospital overcrowding nor will it fix what is wrong with seniors care. Having said that…. when seniors with multiple chronic illnesses come to the ER because there is nowhere else for them to go for their important but non-acute medical issue, they tend to be admitted to hospital more than they should. Why? Because that’s where the specialists are. Because that’s how you can get diagnostic testing fastest and easiest. One can understand the logic and the motivation. But that’s not what hospitals should be for. And when seniors get admitted to hospital, things often start to go wrong. Hospitals are toxic places for seniors who are not acutely ill. This is a tragically under appreciated fact.
We need to build a community-based infrastructure that provides access to teams that include primary care providers and specialists, rapid access to diagnostic testing and social services support. We need to reverse the trend of increasing poverty in seniors so that they don’t have to choose between their medications and food. We need to invest in affordable, safe housing for seniors. In short – we need to create a society that celebrates the triumph of aging – and that provides the care needed for seniors to age well at home. Chronic disease management doesn’t belong in the Emergency Department and on hospital wards. It belongs in the community where it can be delivered with higher quality, lower cost and better safety and efficacy.
In Canada right now, we have pockets of excellence and pockets of desperation. Only a national strategy that establishes a culture of relentless quality improvement through national standards and strategic, smart investments can get us where we need to go. How can we ever hope to improve without a plan? A national seniors strategy can leverage economy-of-scale efficiencies and help to share and scale-up successes. It can help to incorporate the social determinants of health and explore how tax policy and social programs can best be used to support seniors so they can age well at home.
Our partnerships with CARP, the Legion and The Canadian Labour Congress – among many others – reflects a growing consensus amongst a wide variety of stakeholders representing millions of Canadians. We need a national seniors strategy. All federal parties need to make this a key plank in their 2015 election platform.