Originally published in the Calgary Herald, this piece by our medical director Dr. Charles Wong explores why the future of health care is in the home.
Physicians, health administrators, patients, and families all know that Canada’s hospitals are full of patients who don’t want to be there. What is surprising, though, is that many don’t need to be there.
Why are so many patients admitted to hospitals in the first place? As emergency physicians, one of our main tasks is to decide who requires hospitalization and who can safely return home. One of the most common rationales for admission is that a patient has “failed the road test,” like a senior unable to mobilize after a hip or knee sprain.
Such problems do not require acute care medicine, but a hospital bed is the only place where unscheduled personal support care can be provided immediately. Considering acute care beds cost our system up to $2,000 per day, this is tragically poor value for our system.
A mirror-image problem appears on the other side of a hospital admission. Patients there for other medical reasons, now resolved, are unable to be discharged because they are unable to “pass the road test.” Unsurprisingly, being laid up in a hospital bed for a week or two leaves many seniors in such a predicament.
Without an alternative in their toolbelts, physicians and hospitals line these patients up for nursing homes, which again, predictably, have become oversubscribed. As a result, most hospitals have become holding bays for patients awaiting nursing homes, resulting in the poorly named phenomenon of “bed blockers.”
Surveys (and common sense) repeatedly show that older Canadians fear institutionalization more than death itself. Yet, we’ve convinced ourselves there are only two settings for frail seniors: the hospital or the nursing home. Contributing to this assumption is the widely experienced reality of Canada’s broken home care industry.
Traditional home care is completely disconnected from physician care. If the slightest requirement for medical involvement appears, like medication changes or vital signs monitoring, patients are deemed to have “failed” home care and are moved to facilities where physician services are artificially siloed. Trying to keep complex, frail patients at home with no physician oversight has proven a consistent formula for failure.
What is needed is a complete reform of how we look after patients in the home. Alberta is leading the charge on this front by introducing a model of home care funding known as Client Directed Home Care Invoicing. In this program, the public health authority performs an in-depth assessment of a patient’s needs and qualifies them for a certain volume of public home care funding, which the client can then direct to a private provider of their choice. Patients are then placed in charge and can shop for services according to their own needs, encouraging providers to innovate and compete.
Publicly funded private home care produces patient-oriented outcomes. Patients can demand a stable core of caregivers, rather than a rotating cast of strangers. Accomplishing that involves providing sensible scheduling for caregivers, better wages, proper training, and career growth opportunities. Finally, strategically placing physician services in the home, replicating the model used at assisted-living or nursing facilities, ensures that patients can receive the care they need without occupying an expensive acute care bed.
In doing the above, a novel model of “medically supervised home care” being pioneered in Alberta has come closer to helping our system achieve the elusive “quadruple aim.” This system provides a “quadruple win” by improving health outcomes, enhancing the patient experience, dramatically reducing costs to the system, and finally raising the quality of work for providers. These benefits are self-reinforcing and create a positive flywheel.
Every few minutes, another hospitalized patient in Canada looks up to ask, “Can I go home now?” The answer should be yes, because the future of health care is in the home.
Dr. Charles Wong is a Calgary-based emergency room physician, health systems innovator, and medical director for a home care business.
