Each day in Canada, 7,550 hospital beds are filled with the elderly who don’t belong there—and it’s bad for their health
He was a frail old man living in Vancouver. Call him Mr. B. One night he developed excruciating back pain, and his doctor was summoned. Mr. B was a lucky man in that his doctor was John Sloan, a general practitioner whose practice consisted of treating the frail elderly in their homes. Sloan’s diagnosis was a compression fracture of the vertebrae due to osteoporosis. He prescribed pain medication, and recommended keeping him at home. “It hurts like hell for six weeks,” Sloan said, “and then it gets better.”
His family was skeptical. Aren’t hospitals where you go when you’re sick? But Sloan was a trusted doctor and diligent with his follow-up visits. One day, Mr. B had a setback, and the hired caregiver dialled 911. Three days later, Sloan received hospital reports, the first he knew his patient was admitted. Not good, he thought. He tried to convince the family to continue treatment at home, but they were awed by the medical resources deployed in aid of Mr. B. “He saw a psychiatrist. He saw a heart specialist. He saw a respiratory specialist. He saw an orthopaedic surgeon,” says Sloan. “The inevitable happened. He lost strength. He became confused.” He was put on antibiotics. He developed a C. difficile infection. Mr. B died in hospital.
Halfway across Canada, Mr. W was leading a largely independent life in his apartment in Toronto until last September. He was 100 years old, a retired Polish-born architect with a subversive sense of humour. He used a walker, but his intellect and imagination ranged beyond the walls of his apartment, abetted by the computer he’d learned to use seven years earlier. Last fall he grew weak. His son called Mr. W’s doctor, Mark Nowaczynski. Like Sloan, he’s a general practitioner specializing in treating frail elderly people in their homes. It was a Thursday. Nowaczynski diagnosed pneumonia, started him on antibiotics, arranged for additional home care by Monday. Give it time, he advised. Keep him out of hospital. By Friday night the antibiotics had yet to take full effect. The worried son dialled 911. Mr. W was admitted to hospital. An intravenous line went in his arm; a catheter in his bladder. He was confined to his bed, with the best of intentions. By Monday, Mr. W needed two people supporting him just to walk across the room.
The treatment—and mismanagement—of Canada’s older citizens represents one of the greatest challenges facing the national health care system. Not only does the greying boomer bulge represent a looming financial crisis, but existing models of care are inadequate, inefficient and frequently dead wrong, say many of those who navigate the system as patients and providers.
Today’s frailest patients often suffer from multiple chronic conditions, ingest a mix of drugs and frequently want for medical care until a crisis hits. Once they get to hospital they stay there, tied to machines, consuming high-tech resources to little effect, growing weaker until the dim hope of a nursing home bed is the best of two potential outcomes. A frail, elderly person suffers a five per cent functional decline for every day in hospital, says Nowaczynski. In 10 days, that’s a 50 per cent decline. “The hospitals are overwhelmed with these people,” he says.
On any given day, 7,550 acute-care hospital beds in Canada are filled with people who should be in long-term-care nursing homes or in rehabilitation. Annually, that’s 2.4 million hospital days, at $1,000 each—$2.4 billion a year—spent warehousing elderly people, often to their detriment, while denying space to critically ill patients. For these reasons, the Canadian Medical Association (CMA) wants long-term care included in a reformed universal medicare system. “Today we have 142 patient beds that are filled with people waiting to go into long-term care,” CMA president Dr. Jeff Turnbull said recently of a typical day at Ottawa Hospital, where he is chief of staff. The elderly would receive better care elsewhere at a fraction of the cost, if there was an elsewhere, he said. “Hospitals are not good places for people waiting for rehab or other circumstances,” he said. On that day, 38 admitted patients in Ottawa’s ER were waiting for beds.
The postwar model of hospitals bristling with high-tech equipment and doctors performing piecework on waiting rooms full of patients works reasonably well for those who are acutely ill, those with a family doctor, those who are mobile. But hospitalizing the feeble often inflicts harm while giving false comfort to their families, says Sloan, who is also the author of A Bitter Pill: How the Medical System is Failing the Elderly. The aggressive use of technology and specialists can literally be overkill. “The frail elderly need something completely different,” says Sloan. “The analogy is a Formula One racing car trying to pull a freight train,” he says. “It’s just the wrong job for a wonderfully sophisticated thing.” In hospital, the frail lose all control, he says. “They need to be allowed to make decisions about what’s going to happen to them as their inevitable decline occurs.”
The problem is so much more than a numbers game, but the statistics make a compelling case for reform. Already, those 65 and older consume 44 per cent of provincial and territorial health spending. Thirty years ago, health spending accounted for an average of 29 per cent of provincial program costs. Now it tops 39 per cent on average, and in Ontario, eats almost 46 per cent of program spending. Today, about 14 per cent of the population is 65 years or older. Their numbers will double in the next two decades, while those 85 and older will quadruple. What impact that will have on health care financing—while the workforce shrinks proportionately—is anyone’s guess.
Certainly the system would already be in collapse if not for the work of more than two million informal caregivers, usually spouses or adult children, whose work allows seniors to remain at home. The Canadian Institute for Health Information (CIHI) estimates the economic contribution of informal eldercare at $25 billion a year.
There’s no easy answer to the looming grey tsunami, but a prescription of common sense can work wonders. If older people want to stay at home, or at least out of hospital, honour their wish. In B.C., doctors can now bill $106 for a home visit, enough so Sloan, now in busy semi-retirement, has turned his home-care practice over to three doctors. There’s another such practice in Victoria. And there’s Nowaczynski’s House Calls program in Toronto. That hardly constitutes a trend, Nowaczynski concedes. “I think if we had a national conference, we could share the same taxi from the airport.” Nowaczynski, a gifted photographer, often packs his camera on house calls. His portraits of willing patients draw attention to the invisible elderly, a voice rarely heard in the health care debate.
Ontario’s $1.1-billion Aging at Home Strategy has seen an overdue investment in badly needed nursing home and rehab beds, and home-care services. It’s allowed Nowaczynski, at a cost of less than $500,000 a year, to lead a roving team including a social worker, occupational therapist, a nurse and nurse practitioner. Keep just 10 people a year out of nursing homes and the program pays for itself, he says.
Then there’s Dr. Samir Sinha, the dynamic new director of geriatrics at Mount Sinai in Toronto, who approaches eldercare with evangelical zeal. The hospital board gave him a mandate to do what’s best for its older patients, to make geriatrics a core priority, to have an integrated team deal with every aspect of their hospital stay—and, where possible, to meet their needs as outpatients or at home. “Our goal,” says Sinha, “is that people in the community never have to come visit our hospital.”
The program was in its infancy in mid-September when Mr. W arrived in the ER. He was screened as all patients 65 and older now are to determine his capabilities and risk factors. On Monday, a geriatric emergency nurse alerted Sinha to Mr. W’s fragile state. Where do you want to go from here, Sinha asked during his bedside consultation. “I want to go home,” said Mr. W. Out went the catheter and intravenous, in came physio and occupational therapists. Some two weeks later, Mr. W pushed his walker out the hospital door. Nowaczynski read Sinha’s discharge notes, and thought: “Finally, somebody who gets it.” He and Sinha have since formed a collaborative, interdisciplinary team.
They believe they have seen the future, and a part of it is reminiscent of the past: a time when the knock on a patient’s door made a world of difference. The two doctors recently paid a visit to the home of a rejuvenated Mr. W. As his 101st birthday approaches, he is busy writing his memoirs.