Solving the problem of elderly patients in hospitals who don’t need to be there will require a major shift in our approach to elder care.
Hospital overcrowding is not a new issue. Limited bed spaces have plagued Ontario hospitals for years and are increasingly straining our system.
Not only are long wait times a normal expectation when patients arrive in the emergency department — a shameful situation — but providing care in a busy hospital hallway has also become an ordinary occurrence. The problem has become so significant that the Ontario government added 1,200 hospital beds last fall in response, a move that will cost $100 million and require the reopening of two shuttered Toronto hospitals.
This major investment underscores an even bigger problem. The two reopened hospital sites are dedicated exclusively to providing space for alternative level of care (ALC) patients. These are patients who remain in a hospital or other acute-care setting after they no longer need the services provided there. Because they cannot be placed in the care environment that would be most appropriate, they occupy beds that cannot then be used for those waiting for acute care.
The ALC problem is a significant one in many parts of Ontario. Around one in seven hospital beds in Ontario are dedicated to ALC patients. Many ALC patients share common characteristics: they are elderly, with a median age of 80, and often live alone. These patients are incapable of returning home after receiving care at the hospital due to their complex needs, and they deteriorate while awaiting placement in a more appropriate setting, most often a long-term-care home. The median wait time to receive residential care for ALC patients is 28 days.
ALC patients are a glaring reflection of our health system’s inability to address the needs of elderly patients with complex health challenges. At a time when the senior population is growing rapidly, the problem will only become more severe.
Our current approach is not working and it is bad medicine. Not only are high ALC rates costly, they constrain patients to stay in a setting that limits their mobility, accelerates their deterioration and makes them more susceptible to infections.
Attempts to tackle ALC rates have proven successful in some jurisdictions; for example, the use of prediction models to estimate time of discharge at the Royal Victoria Hospital in Barrie helped to arrange community support early and reduced ALC days (the proportion of a stay in hospital that is designated ALC) from 23 percent to 15 percent. However, most approaches focus on small-scale efficiencies and local factors, which have not succeeded in reducing the overall ALC burden.
Today, Ontario’s ALC rate remains troubling. Alongside the addition of new hospital beds last fall, the provincial government allocated an additional $40 million to providing specialized transitional care and supportive housing for seniors in long-term care and in the community.
While this is a good start, a long-term solution requires a fundamental shift in the way we care for the elderly. Involvement across the health care system, from front-line staff to hospital administrators and policy-makers, is needed. Practices like earlier screening of functional decline followed up by the arrangement of community supports, and applying best practices in discharge planning and patient-flow tracking systems, can all help reduce ALC days.
A clear component of the path forward must be to enable greater access to long-term care. We know that a major cause of ALC days is a shortage of long-term-care spaces. Canada currently spends 14 percent of its health care dollars on long-term care, which is lower than the average spent by 10 other OECD countries. A significant investment in more long-term-care spaces is needed to address the chronic shortage and to put supports in place that reflect the increasingly complex health needs of our aging population.
Many elders could with support remain at home. By bolstering community and home care supports, our system can become increasingly patient-centred in its care for our elderly population and can redirect patients who would otherwise be placed in long-term care.
At the same time, placement of ALC patients in long-term care is not always the best solution. Many can remain at home with increased supports and wish to do so. By bolstering community and home care supports, our system can become increasingly patient-centred in its care for our elderly population and can redirect some patients who would otherwise be placed in long-term care.
Increasing community supports must also include the often underappreciated members of the care team: informal caregivers. Many are reporting increasing levels of burnout and the inability to support their loved ones. Investments should focus on homemaking services, caregiver support and respite services, and new models of care such as group homes to care for high-risk seniors.
It is unlikely that these changes will be accomplished easily; these significant shifts require courage, collaboration and political will. We must come together and act decisively to meet the changing health care needs of our aging population and take pressure off our acute-care system.
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