Taking action on continuing and chronic care

October 10, 2014

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Dear Member:

This is the first President’s Letter of my term. I am writing today about things you have likely read or heard in recent media reports. The capacity of the health care system – in particular, insufficient capacity – has received significant attention. It will likely also be a prominent part of commentary around the by-elections taking place this month.

The basic challenge is all too familiar to physicians and patients. Our acute care hospitals are often operating above their rated bed capacity, causing problems throughout the health care system. Waits in emergency rooms grow longer; needed surgeries are delayed. In calling attention to the issue, the Alberta Medical Association (AMA) Section of Emergency Medicine has stated that it believes the system is close to collapse. The problem is real, but what are the causes?

One possibility is simply that of acute care shortages. Reports from the Canadian Institute for Health Information (CIHI) suggest otherwise. In 2011, Alberta’s provincial government health expenditures were $696 more per person than the Canadian average ($4,486 vs. $3,790). Almost all of this difference was due to expenditures on hospitals. In Alberta, those expenditures were $2,066 vs. $1,538 for the rest of Canada. Perhaps hospital systems in Canada are generally underfunded, but it seems difficult, at least in relative terms, to argue that acute care resource shortages in Alberta are the main problem.

Another possibility is that we rely too much on hospitals – which are expensive – to meet our medical and social needs. Recently we have heard about two major challenges. First is the problem of individuals being forced to wait in acute care beds for appropriate placement in long-term or other care facilities. The second arises from individuals with complex chronic conditions who show up in hospital too often and remain too long because they do not receive the support they need in the community.

Continuing care and other supports

The government has recently committed to reviewing the numbers of beds for continuing care. Getting the numbers right will help, but we also need to bring a broader perspective to this issue. This means addressing factors such as:

  • Opportunities through other kinds of assistance such as home care and day programs that help people stay in their homes and communities. 
  • Improving access to acute care and other beds, but considered in a broad perspective including geographic distribution (keeping families together) and the economic barriers individuals face to obtain the right accommodations. 
  • The contributions of families, which are largely unmeasured, are a major source of support for many of our frail and elderly. They should be recognized and considered.

In general, we require better information and must broaden the debate about the access to continuing care, services and programs. Until we get the full picture, our policies and solutions will continue to be sub-optimal and will fail to deliver what is required.

The Canadian Medical Association has called for a national strategy on seniors’ care, an element of which is access to the right care in the right place and includes concepts such as “aging in place.” The AMA supports the development of such a strategy and will work with such organizations as the Alberta College of Family Physicians, which is bringing together several stakeholders interested in seniors’ care.

Chronic disease management

A recent report from the province’s Auditor General pointed to another challenge – that is a lack of support in the community for Albertans with chronic conditions. This results in patients ending up in hospitals too often and for too long.

To get the most out of our acute care resources, we must invest more in the community with a medical home for every Albertan. To do this we need several things, some of which I have recently discussed in the media. These are:

  • Stepping up the implementation of primary care networks (PCNs) – fully implementing what has been termed PCN Evolution to the medical home. 
  • Finding ways to use payments for physicians and other providers as incentives to support the best care right across the system. 
  • Improving and enhancing our information systems so that they can measure and record the patient’s entire journey, avoiding gaps along the way.

Concluding comments

To put all this another way, I believe we must view our relatively high acute care costs as an opportunity to make our system more sustainable. More importantly, we must make it more sensitive to the needs of Albertans.

The problems that exist in health care today have developed over many years. It is naïve to think that they can be corrected in a short time. However, endless debate is not helpful. We need to move quickly and implement the ideas that have been already developed to address the wide range of challenges we face. In particular, we can begin to promote and support better care in the community through the medical home model for complex patients, avoiding the deterioration that result in emergency room visits and hospital admissions. We can also deliver secure messaging systems to allow doctors to communicate more effectively and provide advice and feedback, especially during transitions of care between facilities and the community. These improvements can be implemented quickly as first steps.

For this letter and those that will follow, I look forward to any comments and ideas you may wish to share. Email president@albertadoctors.org or post a comment below.

Regards,

Richard G.R. Johnston, MD, MBA, FRCPC
President

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