Building a health system that meets the needs of an aging population

1799

cover front smallSylvia Purdon and Jim Macquire, married 27 years with eight children and 14 grandchildren between them, share a passion for bird watching, outdoor walks and travel.

Originally a teacher and then a municipal politician, Sylvia spent the final six and what she deems ‘the best years of her working career’ at Corrections Canada. She remains passionate about community affairs and remains involved where and when she can.

Until recently, the outgoing couple spent half the year visiting family in Victoria, British Columbia and the other half in Muskoka, Ontario where Jim ran Wenona Lodge, a Muskoka resort that has been in his family since the 1920’s.

The first indication of Jim’s cognitive impairment appeared about four years ago. Since then, his diagnosis with Lewy Body Dementia – the same rare disease found to have caused the depression and hallucinations that contributed to actor Robin Williams’ tragic death – means they can no longer travel and have had to move into a retirement community of freehold homes in Gravenhurst, Ontario.

Time previously spent planning adventures is now dedicated to scheduling social visits around medical appointments. Still, the couple remains thankful for the team of professionals who work alongside them to ensure they are able to enjoy the best possible quality of life.

“It’s a lot of change in a short period of time but we’re managing as best we can and we’re grateful for the support that means Jim and I are able to carry on fairly independently,” Sylvia shares.

The sudden or gradual onset of diseases and chronic conditions that often come with age, profoundly affect the independence of otherwise active older adults like Sylvia and Jim. In their case, early detection, diligent care and consistent attention has supported them in maintaining a high quality of life. However, the same is not true for all older adults who face medical crises.

 MORE: THE DIGITAL HEALTH REVOLUTION

Dr. Chris Simpson, President of The Canadian Medical Association has called upon all levels of government to develop a national senior strategy so that older adults can remain healthy and at home for as long as possible.

With Canadian hospitals already struggling to provide care in an efficient and cost-effective manner, the demand is just beginning to pick up momentum as Baby Boomers, who started turning 65 in 2010, will place an unprecedented demand for care on hospitals, programs and services over the next two decades. Dr. Simpson is sounding the alarm, insisting on the need for increased investment in long-term care as well as home and community care services to support seniors to remain healthy and at home.

While the population demographic has changed over time, the health care delivery model has not. The current model was developed when the average Canadian was 27 years of age and had a shorter life expectancy than today’s adults, whose average age is 47 and who can expect to live longer lives, accompanied by multiple, complex health care issues.

Due to the extraordinary pressure on hospitals, patients unable to fully recover mobility following hospitalization cannot safely return to independent living at home. Since they don’t actually fulfill the criteria for a permanent long-term care solution either, they actually require an alternate level of care (ALC).

In our current model of care, older adults who require alternate levels of care (ALC) are remaining in hospital beds simply because home and community care is not available to support them following their discharge from the hospital.  ALC patients take up approximately 15 per cent of the country’s acute care beds which means acute care beds in hospitals are not available to those who need them and hospitals are in a near constant state of overcapacity.

They are essentially living in limbo between the hospital bed and a long term care bed even though what they ideally need is to avoid hospitalization all together or at least to fully recover so that they can return home to live independently.

The conundrum is captured in phrases such as ‘Code Gridlock’ and health sector lingo referring to ‘Bed Blockers’ that reveal the underlying resentment and a perception that older adults, specifically Baby Boomers, are threatening to drain precious health care and social service resources as ministries scramble to identify solutions.

Since older adults account for 20 per cent of emergency department visits, 40 per cent of hospitalizations and 58 per cent of hospital occupancy days, seniors, through no fault of their own, are easy scapegoats becoming the face of Canada’s health care crisis.

It’s not as though we haven’t been aware of the pressure an aging population places on health care resources. Monikers such as the ‘Aging Tsunami’ and the seemingly more respectful ‘Silver Tsunami’ imply the emerging crisis is a sudden, unavoidable and catastrophic single event that destroys everyone and everything in its path.

MORE: NEXT GENERATION OF DOCTORS PREPARE FOR ‘SILVER TSUNAMI’

More recently though, the metaphor of an iceberg is resonating, since it captures the essence of the challenge and also presents hope on the horizon and an opportunity for avoidance.

Despite the fact that much of an iceberg’s mass remains unseen, the tip is visible from a distance, acting as a warning system or an indicator, affording time to assess a situation, plan the navigation and prepare to change course where appropriate if we are to steer clear, avoiding certain disaster.

In fact, the only way an iceberg can cause significant damage is if you steer your way into it. Given the body of water which is the health care system, we have on board the expertise to fuel our journey and able navigators in Local Health Integration Networks and Community Care Access Centres to find the most appropriate route that will deliver us safely to the other side of this obstacle.

Dr. Samir Sinha, expert lead of Ontario’s Seniors Care Strategy, Director of Geriatrics at Toronto’s Mount Sinai Hospital and passionate advocate for the health care needs of seniors, suggests that if we miss the subtleties of the current state of healthcare, seniors may be blamed for Canada’s health care crisis, instead of placing the responsibility where it belongs – within the system itself.

Insisting aging is not a disease but that it is a triumph, Sinha suggests, “We seem to be blaming older adults for causing inefficiencies in our health care system when perhaps, it is a lack of planning and as such, it is our responsibility to build a system that is more responsive to their needs.”

In Ontario, older adults represent only 14.6 per cent of the population and yet, due to complex health issues, they account for nearly half of all health care spending in Ontario. Still, it’s not their fault the system isn’t prepared to meet their needs.

MORE: THE EVOLUTION OF AN ORGANIZATION

In recognition of the need to revisit traditional approaches to care, Toronto’s Mount Sinai Hospital designated geriatrics as a core strategic priority in 2010, making it the first hospital in Canada to do so. As part of an ambitious plan, dedicated teams of health professionals screen every older adult who visit the hospital’s emergency department to identify their unique level of risk and programs that can help prevent emergency room visits

As a result of this innovative approach, older adults are returning home faster and more often following hospitalization. Ultimately, as a result of the risk assessment and risk mitigation, they also have a lower chance of readmission which reduces overall costs to the health care system. “It’s truly a win-win situation,” says Sinha.

In the Ontario Seniors Strategy, authored by Sinha and published in 2012, he put forth recommendations for elder-friendly hospitals, based on the success realized at Mount Sinai. The recommendations and Mount Sinai’s approach is attracting interest from Ontario hospitals, Local Health Integration Networks (LHINs), out-of-province Ministries of Health and beyond.

The innovative approach challenges deeply ingrained models of care delivery in favour of an elder-friendly, integrated approach.

Rigorous data collection for the purpose of evaluation bears out evidence demonstrating the approach is working. With only five ALC beds and not even one pressure ulcer recorded in the first two quarters of this year, Mount Sinai’s data is a testament to the commitment by hospital teams to return older adults to their homes, faster so that they can continue to live independently.

Mount Sinai’s ACE 1.0 strategy is improving quality of life for older adults and using health sector resources more effectively and efficiently. In fact, Mount Sinai saved $6.7 million over one year.

Dr. Sinha is proud of the results being achieved and suggests the ‘geriatricization’ of care in other hospitals, combined with the development of strategic community partnerships across the spectrum of care is the key to improving quality of life for older adults and to sustaining the health care system into the future.

“We are making tough choices,” says Sinha. “Hospitals are already receiving zero per cent increases and doctors are taking pay cuts in order to redirect monies so that more care can be provided in the community.”

The recognition that no one part of the system can provide all aspects of care but that each part plays an important role for a mix of care across the spectrum is essential if we are to relieve the pressure from within the health care system.

Sinha suggests the ALC crisis in hospitals is not a universal or unavoidable one and also that the management of older adults by individual institutions can help to reduce the risk of deterioration during hospitalization, having a direct impact on lengths of stay and the number of patients requiring alternate levels of care and admission to long term care due to the decline they are experiencing during hospitalization.

The next iteration of Dr. Sinha’s strategy, ACE 2.0, implemented January 1, 2015, capitalizes on the creation of Sinai Health System, which brings together three organizations to provide seamless care across the continuum. Beginning with a risk assessment in the emergency department and through acute care service at Mount Sinai, patients can access specialized care for neurological and musculoskeletal issues at Bridgepoint Active Health, followed by community care, including meal delivery to the frail elderly by Circle of Care.

What makes this partnership revolutionary is the integrated approach attaches care to the patient, rather than the patient to an organization or provider of care. The result is a seamless transition across all three organizations so that trust is embedded and communication is in place to prevent any lag in service or gap in time across the continuum that can have a negative and significant impact on health outcomes.

“I am really excited about our ACE 2.0 strategy because it truly does address the unique needs of patients across the continuum and beyond to ensure they are achieving the best quality of life they possibly can enabling them to live independently, at home, longer.”

Since older adults, and especially those with dementia, like Jim are particularly vulnerable to rapid decline with sudden or prolonged changes to their environment, Dr. Sinha emphasizes the importance of considering the impact of hospitalization on a frail senior. Any decline may have a lasting, negative impact on quality of life and ultimately, ineffective and inefficient utilization of health care resources.

MORE: THE CASE FOR MORE STRATEGIC HOSPITAL-CCAC PARTNERSHIPS

The elimination of silos means patients are the common denominator. Throughout the three organizations, the patient is referred to as ‘our’ patient, since they operate as three parts of one whole, on a continuum, for the benefit of the patient.

“This partnership is more cost-effective bringing care closer to home which is the goal, ” Says Sinha. “It’s so exciting, it’s mind-blowing,” he offers with the enthusiasm that makes him a true leader in his field.

Ultimately, Sinha imagines an even more ambitious approach to care that would offer a ‘hospital at home’ approach. Although it seems like an impossible dream, he rationalizes that if one-third of COPD, pneumonia or heart disease patients are considered acutely ill but if their needs consist of a daily visit by a physician, and twice daily visits by a nurse to monitor symptoms and implement intravenous therapies, then it’s feasible to suggest hospitalization is not actually required.

Such an approach , representing a radical departure from the norm may mean less hospitalization to manage older adults with ongoing medical conditions. Preventing hospitalization among this vulnerable population means a lower risk of deterioration resulting from hospital-acquired infections, dehydration and complications associated with dementia.

It’s no secret among health sector stakeholders that Dr. Sinha’s strategy at Mount Sinai represents an appealing solution. Since word has gotten around, Mount Sinai has hosted visits from other LHINs and out-of-province Ministries of Health as well as other hospitals. After all, it did save Mount Sinai $6.7 million dollars over one year.

Among those motivated by the Seniors Strategy report, is the Simcoe Muskoka Local Health Integration Network (SM-LHIN) which has undertaken public consultation followed by a review of their programs to examine the elder-friendliness of existing services to identify opportunities for improvement.

Based on their Community Care Access Centre’s (CCAC) approach, an assessment of Jim’s symptoms prompted an immediate referral to the behavioural support team. The intervention helped him successfully manage and overcome a serious bout with depression so that he could actively participate in his recovery.

Since that time, the couple has been working alongside a multi-disciplinary team of professionals who continue to provide home and community care. They are the ones on the front line who have supported Jim and Sylvia to remain together at home, living independently.

Sylvia is grateful for the ongoing support from the CCAC to identify and secure the care Jim needs in a timely way so that he can avoid visits to hospital that can have a profound and significant impact on his ability to recover, due to his dementia.

She admits it’s been difficult to cope with so much change and she understands also that friends and neighbours find it difficult to cope as well. “The phone stopped ringing, which was tough but it’s difficult for all of us to cope with change,” she shares.

Realizing the importance of maintaining social connections, she enjoys her computer a lot more than she used to and as part of the residential social committee, she still has an opportunity to interact with others and to remain involved in activities that make a difference.

She notes the importance of her role in Jim’s care. By working alongside Jim’s team of health care professionals, she observes their approaches and learns what works and what does not. She’s also aware of signs and symptoms to watch for and feels like an important part of the team.

If the CCAC is the navigator and health providers, the expert crew, then Sylvia might be likened to the eyes and ears in the crow’s nest – providing valuable information so that experts below can make the best decisions to navigate the their journey.

“We truly feel like we are in charge of the process which gives us a sense of control,” says Sylvia. “Jim’s  awesome care team including his family doctor, his pharmacist, his dedicated nurse Monica who works in tandem with his specialist, Dr. young, all of whom are reachable to provide the guidance on a moment`s notice that gives us autonomy and responsibility for his care.”

Sylvia beams that Dr. Young said at Jim’s last appointment in mid-February that barring any sudden changes, he did not need to see Jim for four months, which is awesome news! “We know there are no guarantees and we know Jim’s condition will get worse but Dr. Young looks him straight in the eye  when he says we’re going to make sure you have the best quality of life we can achieve for every one of those days.”

Jim and Sylvia still try to get out for walks when they can. The walks are shorter than they used to be but when the winter weather subsides , they’ll be out and about again, enjoying nature, making the most of each and every day, looking for rare birds around Sparrow Lake.