Towards Patient Centred Care Part 1: Many Service Gaps in Post-Acute Care

It’s not secret that we need to develop some innovative solutions to meet the ever-increasing demand for healthcare these days and that health is already eating up increasingly worrisome portions of our provincial budgets. Where older adults are concerned, service is in short supply; insufficient home care services, caregiver assistance and respite, access to primary care, rehabilitation… Increasing the availability of services in these areas WOULD seem costly… Except, when you consider that the alternative is institutionalization.

It’s also no secret that we are not currently doing a fantastic job of providing good care options for patients who need more than primary care but who are not necessarily in need of acute care either. Currently, one of the only answer we have to this problem is the standardized Alternate Level Care (ALC) bed, which is less than ideal. It leaves some seniors lying in hospital beds – exposed to the deadly infections that abound in hospitals and/or (at best) muscle loss. For this privilege, they sometimes earn the nickname “bed blockers” from hospital staff who need the beds to accommodate the incoming patients that need emergency or acute care.

As a result, seniors are occasionally being forced to take the first available bed in a Long Term Care facility that can be up to hundreds of miles from their loved ones. The fact that hospitals are not allowed to force seniors and their families to take up residence in a home they do not want is not discouraging some facilities from pressuring them anyway. Truth be told, ALC beds are not the fix we need. If anything, they aremore representative of the system’s failure.

Surely, this is something that could be avoided with better discharge planning, home care and caregiver support. We need to improve the discharge planning process to help patients navigate that system.

In Ontario, there are Local Health Integration Networks (LHINs) that work with local health providers and community members to determine the health services priorities of their regions. They are responsible for planning, funding and planning health services in their respective communities. The LHINs also fund the Community Care Access Centres (CCACs) that provide home care, community care (for specialized supports) and Long-Term Care Options.

There might be merit to the idea that each region should customize its healthcare programs to the needs specific to their area. There is undoubtedly a need for Community based care as well… Unfortunately, these enormous structures can sometimes be quite difficult to navigate and can sometimes have the effect of diffusing the accountability for patient outcomes.

The CCACs can be helpful partners but as the most recent Ottawa Council on Ageing’s ALC report points there is no single body accountable for the continuity of seniors care under this very fragmented healthcare system. Thanks to the fragmentation, some LHINs also miss the boat when it comes to best practices and some of these best practices really ought to be Provincial policy directives. The ALC report points out that that although dementia is the primary diagnosis contributing to ALC rates, community-based dementia care designed to keep people with dementia out hospitals (if they do not need to be there) should be a part of every LHIN ALC planning. Yet many LHINs have not adopted such measures. In attempting to grant autonomy to the regions the Ministry of Health and Long Term Care (MOHLTC) is missing out on the opportunity to implement cost-saving best-practices across the board.

Aging at Home Strategy

In 2008 the Government of Ontario invested $1.1 billion dollars in the Aging at Home Strategy, the funding was set to expire in 2012. No one can really tell us where the money went, what the outcomes will be or which benchmarks have been met. The Aging at Home strategy represented an important paradigm shift at the time– acknowledging older adult’s right to age at home in dignity as opposed to forcing them into seniors’ ghettoes for lack of options. But seniors welfare was not the only consideration that directed this new policy orientation; we also know that institutionalization is the most expensive way to deal with older persons and that providing them supports to age at home is far more cost effective.

Another interesting aspect of the strategy was that 20% of the funding was earmarked for innovative projects inviting new projects to support non-traditional partnerships and new preventative wellness services. The Ministry will no doubt have learned about some effective new approaches and innovations through these projects. Since the LHINs each have their own way of dealing with Ageing at Home, which approach, if any has been the most successful? It would be great if they could report on their findings.

Mostly, we would like a breakdown of how the money has been spent. After all, the Ageing at Home was purchased with Ontario tax dollars. Given that the funding is almost tapped out, it would be appropriate for the Government to report on what Ontarians have bought themselves through the Aging at Home Strategy. As far as we are aware, despite considerable interest, no such report is forthcoming.

Towards Ageing at Home and Real patient Centred Care

If the purpose is to keep Canadians at home, wouldn’t it be most effective to promote recovery, tailor discharge planning and care to the individual so he does not find himself in acute care again just a few short weeks later? In order to do this, really do this; we need to stop thinking about the creation of systems with clients in their “catchment areas” who can fend for themselves when it comes to navigating the healthcare systems. “Patient centred care” is a catchphrase that we like to throw around but if we really look at what we currently have in place – it becomes immediately apparent that we’re not there yet.

As CARP has previously reported, some LHINs have freelanced programs with rather unpleasant results. A program developed with the aim of expediting patient discharges caused many seniors to feel they were unceremoniously shooed out without so much as a concern for what would happen to them next. One woman told us that while she was away and unable to help her father had been discharged from the hospital with a broken hip. When he arrived home, he had been forced to crawl up the stairs to his home (with a broken hip) because no one was there to help him. We have reported on programs that given patients the impression they were in a senior-hostile environment at certain hospitals in Ontario:

CARP takes on ‘Home First’ Program 

Joseph Brant CEO Responds to CARP’s Open Letter 

Click here to read the second part of this series: Towards Patient Centred Care Part 2: Virtual Wards and Good Old Fashioned Homevisits