Canada's health-care providers are struggling to retool the system to meet the needs of an aging population that is often facing multiple, chronic medical conditions.
The phenomenon of the growing ranks of the frail elderly in need of different phases of care that often can be provided in the community did not exist 25 years ago. Yet the country's health-care system remains mired in the 1950s, primarily focused on hospitals and with little in the way of community services to prevent the elderly from languishing in acute-care beds.
What Canada needs is an actual health-care system, one that makes navigating between hospital and back into the community as seamless as possible for patients, said Kevin Smith, chief executive officer of St. Joseph's Health System in Hamilton, Ont.
"If you have one thing wrong with you, we don't do a bad job," Dr. Smith said. "If you have complex, multiple issues, the system is not a system."
With little leadership out of Ottawa and budget constraints in provincial capitals, it is largely falling to health-care executives to find ways to care for seniors while keeping them from congesting primary-care centres.
In Toronto, one in every 10 acute-care beds is occupied by an elderly patient who has nowhere else to go. Nationally, the situation is just as bleak. Patients who no longer need acute care account for more than 1.7 million hospital days a year, according to a 2009 study by the Canadian Institute for Health Information.
"If hospitals are to achieve their current goals, they need to look outside their four walls," said Bob Bell, chief executive officer of University Health Network.
St. Joseph's has done just that. It is on the leading edge of a vertical integration trend to bring different types of health-care services under one roof, so that practitioners no longer operate in their own silos. As part of a corporate restructuring - the first of its kind in Ontario - St. Joseph's services span home care, long-term care, complex continuing care, rehabilitation, hospice and traditional acute care through its two hospitals.
With the restructuring, St. Joseph's can better co-ordinate primary health care through its acute-care hospitals in Hamilton and Kitchener with all other aspects of institutional and community-based care in Southern Ontario. Not only can it do so more cost effectively, Dr. Smith said, patients can be served in the most appropriate setting.
In earlier days, family doctors often helped patients navigate the system, he said. But with Canadians getting older and sicker, this is no longer possible. A better model is needed, he said, for the frail elderly patients who are battling diabetes, heart disease and possibly early dementia, and don't want to tell their story all over again when they make the transition from one care provider to another.
"A system that isn't more responsive to patients with multiple needs will not meet the needs of the future," Dr. Smith said.
With the proportion of Canadians who are seniors increasing, the future is rapidly approaching. Fourteen per cent of the population is older than 65 and that will rise to 23 per cent over the next 15 years.
These changing demographics are putting enormous strains on family doctors as patients with complex conditions consume more and more of their time. Yet Canada lags behind other countries, notably the United States, in using case managers who can co-ordinate care in the community for elderly patients, often leaving doctors and family members to pick up the slack.
"We're getting to the point where the capacity of the system as it has existed is being strained to the limit because of the changes in demographics," said University of Alberta professor and health policy researcher John Church.
Health-care providers are taking steps to reform the system. In another example of vertical integration, this time aimed at helping to free up beds, hospitals in Toronto are partnering with rehabilitation centres. University Health Network has joined forces with Toronto Rehabilitation Institute, Canada's largest such facility. The institute treats patients from the city's seven largest hospitals, including the three that comprise UHN. Sunnybrook Health Sciences Centre is also in merger talks with St. John's Rehab Hospital.
In British Columbia, the Fraser Health Authority is putting acute and community care services under the same umbrella by having primary care doctors partner with home health workers. The home health worker assumes responsibility for the doctor's patients once they return to the community.
Alberta is following the lead of British Columbia, Saskatchewan and New Brunswick by trying to prevent seniors who do not need emergency care from ending up in the hospital. The province's Emergency Medical Services is working in collaboration with hospitals in Edmonton and Calgary to find resources in the community for patients who have chronic illnesses or disabilities but who do not need to be in an acute-care bed.
But the Alberta government's effort to clear the bottleneck in hospitals is undermined somewhat by its push to have the private sector provide additional long-term care homes. Private operators charge much higher rates for room and board than the province. Patients who cannot afford the higher prices could languish longer in the hospital, critics say.
Overall reforms in Canada will be piecemeal unless the federal and provincial governments make community and home care an integral part of the country's universal medicare system, say health-care experts. What's more, they say, changing the focus from acute care to continuing care has the added appeal for cash-strapped governments of potentially lowering costs.
A new report calls for an integrated system of care delivery to provide lower cost, seamless care for seniors across a wide range of services. The services would be under one roof with a single budget and co-ordinated by case managers who can assess a patient's needs, develop customized care plans and authorize access to services.
"What we actually are doing is substituting more expensive hospital care for less expensive non-professional home support care," said Marcus Hollander, a Victoria-based health-policy researcher and co-author of the report.
In fact, an earlier study done by Prof. Hollander found that withdrawing support services such as housecleaning to help elderly people function in their own homes ended up costing the health-care system more.
British Columbia at one time provided housecleaning, cooking and other services to the elderly. But in the mid-1990s, some regions in the province stopped funding these services. People who were cut off from these services cost the health-care system an average of $3,500 more compared with those who continued receiving help, the study concluded. The health of many individuals who no longer received the help deteriorated and they ended up in hospital or a long-term care home.
"The tragic thing about this is we actually had systems of care like this in Canada in the late '80s and early '90s, and then there were changes in policy and budget crunches and things kind of withered away," Prof. Hollander said.
Dr. Smith is well aware that the missing link to providing a continuum of care for seniors is assisting the elderly who can manage on their own with a little help.
"We don't have well-thought-out strategies on the senior who doesn't need long-term care, but who needs a supportive housing environment," he said.