The Health Care System in Canada: Overcrowding in Hospitals

Background: essay about health care system

The Canadian health care system is the topic of this essay. The health care system in Canada funds medically necessary health care, including care provided in hospitals or by a physician. Canadians covered under a provincial insurance plan, such as the Ontario Health Insurance Plan (OHIP), will receive care upon arrival at an acute care hospital. Wait times throughout the health care system have been increasing year after year. In hospitals, bed occupancy rates are considered safe up to 85%, however in 2015/2016, 60% of medicine wards in Ontario community hospitals were at an unsafe occupancy rate higher than 85%.

As the population ages, the number of hospitals with an unsafe occupancy rate continues to rise. One reason for this includes an increase in Ontario’s elderly population as the baby boomer generation, born between 1946 to 1965, ages. Utilization of health services increases with age, meaning that the elderly often require more family physician visits, more hospital admissions, longer hospital stays, and take more prescription drugs than their younger counterparts.

In addition to this, approximately 25% of acute care beds are being occupied by people who are considered Alternative Level of Care (ALC) patients whose needs may be better met in another setting and are often waiting for availability in long-term care (LTC). As beds are occupied by ALC patients, acute care hospitals are losing capacity to care for acutely ill patients. Patient flow involving the transition of patients from the acute care in-patient units to post-acute care hospitals, with many beds occupied by ALC patients, can result in overcrowding and ultimately patients being treated in hallways and other ad hoc spaces.

This demonstrates how the system's capacity is not optimally configured to address current ALC population needs, particularly for complex elderly patients who make up much of the ALC population. In addition to the system capacity, the current legislation also creates challenges for these patients. The Canada Health Act outlines the conditions which the provincial and territorial health insurance programs must conform in order to receive their federal transfer payments. OHIP does not cover home and community care for all Ontarians, leading to a barrier to access care for vulnerable persons and their caregivers in the community. This can lead to an increase in acute care for elderly.

The overcrowding in hospitals affects a number of stakeholders, including:

• the patient experience and quality of care;
• the caregiver and family member experience;
• the clinicians who may experience burn out, stress or harassment;
• hospital administrators who aim to please the aforementioned stakeholders;
• local health integration networks (LHINs) that govern specific areas;
• home care organizations such as the Community Care Access Centers (CCACs);
• government who is the primary funding source for hospitals.

In addition to these stakeholders, there are a number of non-government organization with an active interest in this issue, including:

• organizations which govern healthcare professions, such as the College of Physicians and Surgeons, the Ontario Medical Association, Ontario Nurses Association;
• organizations with a focus on better care, such as Health Quality Ontario; and more.

It is necessary to consider these stakeholders when exploring solutions for overcrowding in hospitals.

Analysis

There are a number of policy options to reduce the hospital overcrowding and the potential role of LTC in reducing it. Three solutions, with pros and cons, are suggested below.

Expand Primary Care

The first option is to expand primary care to ensure all Ontarians have access to a family physician, including seniors that are living at home or housebound. This approach involves ensuring physicians are trained to identify geriatric, memory or dementia issues, and chronic disease as well as improve the screening processes. Experience from the field supports that clinics such as these prevent unnecessary hospitalizations. This option will facilitate regular touchpoints with a family physician who build a relationship and facilitate conversations about the patients health and potential health concerns.

The relationship between a patient and physician is the basis for health system navigation and ensuring the patient feels supported in all aspects of their health and home life. It has been noted that some patients express to providers the challenges that are faced living at home, but the provider may not suggest a necessary change in environment when it may have been appropriate. Rather, a consistent relationship with the patient and physician will help the physician identify and suggest options to assist the patient when the timing is appropriate.

This option is challenging as it involves tremendous training for the physicians and change in workload to ensure the physician can spend suitable time with the patient on a regular basis. This may include the use of a clinic model such as the Geriatric Assessment Clinic model which is currently in a pilot phase to ensure primary care practices can support geriatric patients. This would involve identifying appropriate key performance indicators to ensure that comprehensive care is provided. A major issue with this solution is that it is preventative and does not deal with the current crisis.

For this model to be implemented, there would need to be legislative change to facilitate an increase in primary care physicians, provide incentives to the physicians for spending more time working with and understanding the needs of the patient, provide incentives for using a model such as the Geriatric Assessment Clinic model, and encourage the physicians to work with the LHINs to understand the current social services available to the patients.

Home Care

This option focuses on ensuring patients are able to live at home for as long as they would like and that they are able to receive community supports to meet their needs. Studies have shown that 37% of ALC patients waiting for LTC placement have care needs that are no more urgent or complex than those of people being cared for at home waiting for long term care. This leads to the ability of the Ontario elderly to age in place which plays a major role in the health and well-being of older adults. Meanwhile, keeping elderly at home will reduce the number of LTC beds needed.

This option may require more investments to build and sustain the capabilities of community-based providers and programs. Enhanced and sustained investments in the CCACs and other support services are essential in supporting seniors in the community. The LHINs and CCACs must work collaboratively to develop and improve upon programs, like the Homes First philosophy of supporting patients in their home while awaiting their choice of LTC facility, to provide the appropriate care to individuals that need it. In addition, there is a shortage of qualified peer support workers (PSWs) in some parts of the province and there are vast scheduling challenges as most elderly individuals need assistance early in the morning or before bed.

Community care must be supported through additional resources to integrate, coordinate and enhance CCACs, support services, and PSWs while exploring new models of care that have potential to improve the at-home experience of the elderly. The provincial government will need to identify space in the budget for this increase in home care support and programs. This option may have an opportunity to explore private funding from the patient or their family to receive excess care in addition to what is available.

Increase LTC Beds

This option is based on the current governments suggestion to increase the number of LTC beds by 30,000 in the next 10 years. On average, one ALC patient occupying a bed in the emergency department denies access to four patients per hour to that department. As mentioned, when hospitals function at 85% occupancy, crowding never exists, but as occupancy rates increase crowding is inevitable. By increasing the number of LTC beds, ALC patients can be transferred to LTC facilities. These beds will then be available for acute care services, thereby decreasing the occupancy rates and overcrowding of hospitals.

However, in 2004 and 2006 the government introduced 20,000 new LTC beds and redeveloped 16,000 existing beds. This was not a sufficient long-term solution as overcrowding is still an ongoing issue. The elderly population continues to grow and live longer. This means that there is an ongoing demand for LTC beds, and at the elderly population continues to grow this is not a sufficient solution. However, since the currently government has suggested this option it appears that funding has been reserved for this solution and the additional staff that would be required to assist 30,000 new LTC patients to ensure they receive quality care.

Recommendation

It is recommended that the current government use a combination of all suggested approaches by expanding primary care with the option for home care or LTC. This will allow for physicians to work with each patient to identify when they are no longer able to live independently. This will help the physician identify whether LTC or home care is appropriate for the patient. To finance this option, it is recommended that only a portion of the funds that have been reserved for LTC beds proposed by the government be used for these beds. It is recommended that the other portion to be shared between expanded primary care and home care options. This combination will reduce the unnecessary acute care visits and therefore reduce hospital overcrowding.