By THERESA BOYLE Health Reporter Sun., June 3, 2018

The number of patients who occupied hospital beds even though they no longer required hospital care hit a record level in Ontario this past winter, the Star has learned.

As a result, emergency room wait times also hit an all-time high.

Women’s College Hospital is performing knee replacement surgery as an ambulatory procedure, in which patients are sent home the same day.  (LUCAS OLENIUK / TORONTO STAR)

Almost 5,000 patients, most of them frail and elderly, were stuck in hospital beds because long-term-care homes were full or because it was unsafe for them to return home without more support, according to newly audited data from the Ontario Hospital Association (OHA) and the province’s Health Ministry.

This caused a bottleneck for patients admitted to hospitals through emergency departments. The 90th-percentile wait time for transfer to an in-patient bed was 40.9 hours, meaning 90 per cent of patients waited less than that time before being admitted.

It’s not surprising then that “hallway medicine” has become a major theme in the June 7 provincial election. There has been a lot of talk on the campaign trail about hospitals housing patients in “unconventional spaces” such as bathrooms and storage rooms. Health care always ranks as a top concern among voters, but rarely gets this kind of attention.

While health-care leaders are pleased that the topic is being debated, they are disappointed by the simplistic solutions being offered. The health system is struggling to meet today’s demands and is nowhere near prepared for the challenges that will come in 20 years, when the number of seniors will double, they warn.

“It is refreshing that for the first time in a political election we are talking about bed capacity,” said Alan Drummond, an emergency doctor from Perth, Ont., and spokesperson for the Canadian Association of Emergency Physicians. “But we’re just reacting. We’re not planning.”

Drummond says Ontario is not prepared for the looming onslaught of dementia and Alzheimer’s cases: “ We have no system. We have silos of health. There is no comprehensive long-term vision or plan for how we are going to pay for it.”

Of the 30,000 acute and non-acute beds in Ontario’s 143 hospitals, 4,756 were occupied in January by what are known as “alternate level of care,” or ALC, patients. These patients no longer required hospital care, but were stuck in hospitals while waiting for long-term care or home care, according to the new data. (Acute care beds are typically found in hospitals with emergency rooms, while non-acute beds are located in rehabilitation, complex continuing care and psychiatric hospitals.)

The previous record for ALC patients was set a year earlier when 4,553 were stuck in hospital beds. The longest ER wait times prior to January were in 2008, when the 90th percentile wait was 40.2 hours. (The province began tracking ALC numbers in 2011 and ER wait times in 2008.)

Overcrowding peaked in January even though officials opened 1,200 extra hospital beds and created 200 new supportive housing units for frail seniors leaving hospitals. They also facilitated the development of 600 new “transitional spaces” for ALC patients in community settings, such as former retirement homes.

Had that not happened, there would have been a “calamity,” said OHA president Anthony Dale. The creation of the transitional spaces was a “lifesaver,” he said, adding that more such innovative solutions are urgently needed.

“All the data shows that Ontario’s health system is continuing to race toward a very serious and growing capacity challenge,” Dale said. “It’s time to move beyond the election cycle and implement genuine evidence-based long-term planning for all health services.”

Health-care leaders are disappointed they are not hearing about more innovative solutions on the campaign trail. They note that the three major parties are vowing to fix crowded hospitals largely through the creation of more long-term-care beds.

“The current high-pitched narrative of ‘hallway medicine’ is once again encouraging simplistic, knee-jerk responses like ‘We just need to build more beds,’ and I worry this will cause us to lose focus on understanding how we got here in the first place and how we can fix and prevent it from happening altogether,” said Dr. Samir Sinha, director of geriatrics at Sinai Health System and University Health Network, and architect of the province’s seniors strategy.

The Liberals are promising to build 5,000 new long-term-care beds by 2022 and more than 30,000 over the next decade; the Conservatives are pledging 15,000 new long-term-care beds within five years and 30,000 by 2028; and the NDP are promising 15,000 over five years and 40,000 over 10 years.

Dr. Danielle Martin, vice-president of Women’s College Hospital, says Ontario’s health system is built upon a “20th-century model” and requires “21st-century solutions” to work better.

She said there are many demonstration projects and areas of excellence that should be scaled up. They achieve the triple aim of reducing costs, improving patient outcomes and enhancing patient experiences, she said.

Senior officials in the Health Ministry and local health integration networks (LHIN) say they have also been looking at these solutions, and have created plans to “scale and spread them” should they prove effective in reducing hospital overcrowding.

Dr. Danielle Martin says Ontario’s health system requires “21st-century solutions” to work better.  (SUPPLIED)

But it will take political will from the next government to get such innovations off the ground, Dale said.

“There is so much potential in change and innovation, but the truth is that for the next several years the system will be under massive strain as new ideas are implemented and new capacity is created,” Dale warned, explaining that it will take time for new long-term-care beds to be built. “It will take the full attention of the next government, the leadership of its top minister and a spirit of honesty and collaboration to fundamentally address this challenge. Failure is not an option.”

The Star canvassed health-care and opinion leaders across the province to seek examples of innovative solutions to the system’s challenges. Here are some of their responses:

Dr. Andy Smith, president of Sunnybrook Health Sciences Centre

One solution to improving hospital wait times is, interestingly, not investing in hospitals but instead building community resources such as “transitional spaces” for patients who no longer require hospital care and are waiting to move into long-term-care homes or other settings.

Pine Villa is a new “reactivation care centre” on Eglinton Ave W. and since February it has been accepting patients from Sunnybrook, many of whom have lost muscle mass and strength because of inactivity and bed rest in hospital.

At Pine Villa, they get stronger with the help of recreation therapy, rehab and social activities. Some 20 per cent improve so much that they no longer require long-term care and can return to their own homes.

The 69-bed former retirement home is a partnership between Sunnybrook, the Toronto Central LHIN and two community agencies, SPRINT Seniors Care and LOFT Community Services. It’s an example of how different sectors in the traditionally siloed health-care system can work together.

Kevin Smith, president of the University Health Network

What if your health care could be provided by a single team that includes all care providers so that frustrations often experienced at points of transition — from primary care to hospital to home care — are eliminated?

This is possible under a “bundled care model” that has been piloted throughout the province. Instead of patients seeking out every aspect of their care independently, providers from different sectors work together on the same team to care for you.

A care co-ordinator from one of these sectors, say home care, takes charge of organizing your entire journey through the health system. One organization, say the same home-care agency, is funded to make this model of care work and is held accountable. Your surgeon, nurse, physiotherapist and personal support worker (PSW) may work for different organizations, but when it comes to your care there are no silos.

Dr. Samir Sinha, director of geriatrics at Sinai Health System and University Health Network

Here are three ways we can provide better care to frail older adults, reduce 911 calls, and take pressure off hospitals and long-term-care homes.

When doctors make house calls to patients who are homebound because of physical, cognitive and social problems, these patients get care they likely would not otherwise receive. It may sound expensive, but it has been proven to be cost-effective. Chronic conditions are less apt to flare up, so patients make fewer calls to 911 and fewer trips to hospital.

By doing more preventive care, rather than just the “you call, we haul” care, paramedics can connect seniors to primary care and home-care providers and to services such as Meals on Wheels. A small amount of Health Ministry dollars allowed Toronto paramedics to last year establish a community paramedicine program for frequent 911 callers. It cut 911 calls in half and hospital visits by 67 per cent.

Naturally Occurring Retirement Communities — or NORCs — are condominiums, apartment buildings and other communities where more than 70 per cent of residents are seniors. The Health Ministry, through the LHINs, recently began supporting NORCs with a view to helping seniors age in place. It does this by funding a mix of meal, social and personal care services.

Deborah Simon, Ontario Community Support Association  (CASSANDRA RUDOLPH)

Deborah Simon, CEO, Ontario Community Support Association

A great example of a community-based program supporting the reduction of ALC — which could be easily scaled up for the province — is an agency in the Mississauga area that serves more than 300 clients in a supportive housing hub. The agency put in 24-7 access to PSWs in the client’s units. With this type of round-the-clock support, 60 emergency room visits were avoided last year. As well, 15 residents got to live in their homes longer rather than move into long-term care.

Candace Chartier, CEO, Ontario Long Term Care Association

Some people waiting in hospital for long-term care have severe behavioural issues related to dementia and/or mental health conditions. They can be highly aggressive and need more intensive and specialized, flexible staffing support than is available in traditional long-term-care homes.

It’s time to look at this problem from the perspective of the entire health system, using new models of care and a dose of innovative and disruptive thinking. The goal is to leverage existing expertise in long-term-care homes to provide a better care environment for people who need support, while simultaneously relieving pressure on hospitals and community.

In one case study we looked at, with additional government funding and specialized and flexible staffing, a long-term-care home was able to enhance their services to care for a senior who had previously been in the hospital for two years.

Wade Petranik, CEO, Dryden Regional Health Centre

Many communities in northern Ontario are in the process of building what are known as Rural and Northern Health Hubs. These hubs are integrated health systems that function as single accountable organizations. They are designed to meet the unique challenges of small populations and the vast geography of northern Ontario by doing the following:

•Support and follow patients across a continuum of care, without gaps and cracks where they may become lost and frustrated.

•Reduce never-ending referrals, hand-offs, and queues for service.

•Provide easy access to patient health information so providers can deliver the most effective care.

•Share scarce expertise and resources across primary care, community-based services, and hospitals.

•Reduce administrative bureaucracy and duplication.

Dr. Sarah Newbery, North of Superior Healthcare Group

Dr. Sarah Newbery, chief of staff at the North of Superior Healthcare Group, and rural generalist

I am participating in a new program for patients with musculoskeletal problems such as lower back pain. In the past, many of these patients would have faced long waits for MRIs and appointments with surgeons, only to find they were not surgical candidates. Some would have been prescribed opioids and even become opioid-dependent.

Now I have a new tool in my tool box to help them. I can refer them to a rapid access clinic where they see specially trained physiotherapists and chiropractors and a surgeon if surgery will benefit them. All are taught exercises to help manage their pain.

Under the new musculoskeletal strategy, wait times are reduced, patient outcomes are improved and the risk of becoming opioid-dependent is lessened. It works well for referring physicians, too.

Dr. David Urbach, surgeon-in-chief, Women’s College Hospital

Transforming common in-patient surgeries like joint replacements into ambulatory procedures takes pressure off hospitals. Patients are operated on and discharged within the same day. Emerging post-operative virtual-care technologies — including new tablet apps —allow hospitals to follow up with patients when they return home.

Single wait lists for surgery help to cut wait times. When patients get to the front of the queue, they see the next available surgeon.

Sue VanderBent, CEO, Home Care Ontario

Home care is key to taking pressure off hospitals. Families want and need more home care, but an aging population and government underfunding has meant patients are getting less. Front-line home caregivers have been asked to do more with less for too long.

Here’s what we need to do: Improve scheduling of visits and eliminate 15-minute visits; direct all funding to front-line care rather than administrative duplication; and better utilize technology, for example, by giving visiting nurses access to real-time patient information, such as recent medication changes.

Dr. Ed Brown, Ontario Telemedicine Network (OTN)  (JOHN WARREN)

Dr. Ed Brown, CEO, Ontario Telemedicine Network (OTN)

Our current health-care system was founded in a different era, circa 1960. Back then, medicare and its system of physician and hospital payment was revolutionary, enabling people to get the care they needed without fear of financial ruin.

However, health-care needs have changed. People are living much longer — but often with serious chronic diseases that are hard to manage and land them in hospital regularly. People need more than episodic visits with their doctor to manage these complicated illnesses.

Technology-based models of care can be transformational when it comes to meeting those needs. They securely connect patients, at a distance, to health-care professionals via computers and smartphones. With the aid of tablets and tracking devices, they provide chronic disease monitoring and health coaching at home to support self-management, helping keep patients out of the ER.

Dr. Ritika Goel, family physician, Inner City Health Associates

The top 1 per cent of health-care users account for about 30 per cent of health-care costs, and are more likely to be seniors and those living on low incomes. This makes sense as the main determinant of one’s health is not access to doctors, nurses and hospital beds, but one’s income and housing. In Canada, one in eight seniors lives in poverty and makes up an increasing proportion of our homeless population.

If we truly want to start tackling health-care costs and keep seniors at home, we must look upstream. This means expanding the basic income policy which has been shown to decrease emergency room usage and downstream costs. It means boldly investing in affordable housing units, which cost much less than avoidable hospital visits. Rather than just having fewer seniors in hallways, let’s keep them out of our hospitals altogether.

Donald Drummond, economist

Rather than more money, health care in Ontario needs new perspectives and governance. The focus should be the population’s good health. This will require improving and integrating socio-economic plans. Incentives should encourage health rather than be driven by the quantity of interventions. We need to eliminate unnecessary tests, ineffective treatments and harmful prescriptions. Work should be allocated according to comparative advantage, extending the scope of practice for nurses and many other professionals.

Rather than leaping to more long-term-care beds as the front-line response to the aging population, greater effort should be made to accommodate the elderly in their homes. Better co-ordination of care for the very sick, who account for much of health-care costs, would produce savings and higher satisfaction. We need to clarify the accountability for the co-ordination of care.

Read more:

Horwath promises 4,500 more nurses in NDP’s first year of government

Editorial | Fixing Ontario’s health system will take more than campaign rhetoric

Kathleen Wynne responds to Star investigation on crowding at mental-health unit