He decided in January 2013 to do something about it by creating a medical clinic inside the Shepherds of Good Hope shelter in downtown Ottawa. Now, the police and paramedics are instructed to bring intoxicated homeless people to the shelter where health professionals can look after them during a crisis and then establish a relationship in the hopes of helping them manage their addictions, mental illnesses or other health challenges.
In the first six months, the program rerouted 750 ambulance trips away from local emergency rooms. But the program is much more than just detox. In total, Dr. Turnbull and his colleagues have created 220 beds in Ottawa homeless shelters, where the community has access to nurses, personal-support workers, addictions counsellors, social workers and professionals that can connect them with housing. The health team can administer IVs, oxygen and medication within the walls of the shelters. The team has even created palliative hospice beds in the shelters.
Dr. Turnbull says the program saves at least $3 million a year.
“We wrap those services around them,” he says. “We save very substantial amounts of money by providing better care in a community setting.”
Dr. Nathalie Fleming came to the realization a long time ago that hospital walls hold back improvements that could solve many of the problems facing the health-care system.
As an obstetrician who focuses on at-risk teenagers, Dr. Fleming struggled to find a way to convince more girls to visit the hospital to get ultrasounds, nutrition counselling and other important care. Many pregnant teenagers don’t see a doctor until the late stages of pregnancy; they typically have high rates of premature labour, babies with low birth weight and other problems that can lead to costly hospital stays and and long-term health and development issues.
Instead of expecting the young women to come to her, Dr. Fleming’s solution was to go to them. She and a nurse set up shop in St. Mary’s Home, a popular community centre in Ottawa, and start offering medical services to at-risk pregnant teens.
A decade later, the program has expanded to include prenatal and post-natal care, psychiatric services and a full-service family health team. The community centre also offers financial counselling and other resources. Teen mothers appreciate the program because it’s an easy one-stop shop and they don’t have to go to a hospital prenatal clinic, where they feel judged by the adult women in the waiting room, Dr. Fleming said.
“By basically moving things from the inside of the hospital to the outside of the hospital, by being able to reach the community... we’ve done a service to the patient,” Dr. Fleming says.
Around the world, health-care organizations are re-engineering their systems to move care outside of hospitals. Kaiser Permanente, a large non-profit health plan in the U.S. that runs its own hospitals and clinics, is providing more care to patients in their homes and over the Internet.
In Canada, Ontario will spend an additional $6 million this year to send more paramedics to the homes of people who frequently dial 911 to make sure they’re taking their medication and provide other help managing their chronic conditions. And the federally-funded Canadian Institutes of Health Research is looking at ways of implementing community-based models and giving research grants dedicated to this issue as part of an initiative called the Community-based Primary Health Care Innovation Teams.
Of course, talking about the need for change is easy. Making it happen is the hard part.
Changing the system
In order for any of these changes to occur, observers say, there has to be a wholesale overhaul in the culture of health care in Canada.
Hospitals – and patients – must get used to the idea that the best way to deliver care is to go outside the institution’s walls. Governments need to create innovative community-based care models, according to physicians and health policy experts.
“We can’t afford not to do this. We’re using the acute-care system, which is expensive, for care that should be provided at home,” Dr. Turnbull says. “We can do better.”