By David Wiercigroch
and Caberry Weiyang Yu
Hospital overcrowding is not a new issue. Limited bed spaces have plagued Ontario hospitals for years and are increasingly straining our system.
Not only are long wait times a shameful expectation when patients arrive in the emergency department, providing care in a busy hospital hallway has become an ordinary occurrence. The problem has become so significant that the Ontario government added 1,200 hospital beds last fall in response, a move costing $100 million and requiring the reopening of two shuttered Toronto hospitals.
This major investment underscores an even bigger problem. The two reopened hospital sites are dedicated exclusively to providing space for alternative level of care (ALC) patients. These are patients who remain in a hospital or other acute care setting beyond their need for the intensity of services provided there. Due to barriers to their placement in the most appropriate care environment, they occupy beds that can’t be used for those waiting for acute care.
The ALC problem is significant in many parts of Ontario. Around one in seven hospital beds in Ontario are dedicated to ALC patients. Many ALC patients are elderly, with a median age of 80, and often live alone. These patients are incapable of returning home after receiving care at the hospital due to their complex needs. They deteriorate while waiting in hospital for placement in a more appropriate setting, most often a long-term care home.
The median waiting time for ALC patients is 10 days.
ALC patients are a glaring reflection of our health system’s inability to address the needs of elderly patients with complex health challenges. At a time when the senior population is growing rapidly, the problem will only become more severe.
Our approach is not working and it’s bad medicine.
Not only are high ALC rates costly, patients must stay in a setting that limits their mobility, accelerates their deterioration and makes them more susceptible to infections.
Attempts to tackle ALC rates have proven successful in some jurisdictions, but most approaches focus on small-scale efficiencies and local factors that have not succeeded in reducing the overall ALC burden.
Today, the provincial ALC rate remains troubling. Alongside the addition of new hospital beds last fall, the Ontario government allocated an additional $40 million dedicated to providing specialized transitional care and supportive housing for seniors in long-term care and in the community.
While this is a good start, a long-term solution will require a fundamental shift in the way we care for the elderly. It will require involvement across the health-care system from front-line staff to hospital administrators and policy-makers. Practices like earlier screening of functional decline followed up by the arrangement of community supports, applying best practices in discharge planning and patient flow tracking systems can all help reduce ALC days.
A clear component of the path forward must be to enable greater access to long-term care.
We know that a major cause of ALC days is a shortage of long-term care spaces. Canada spends 14 per cent of its health-care dollars on long-term care, which is lower than the average spent by 10 other Organization for Economic Co-operation and Development (OECD) countries. A significant investment in more long-term care spaces is needed to address the chronic shortage and to put supports in place that reflect increasingly complex health needs.
At the same time, placement of ALC patients in long-term care is not always the best solution.
Many patients are capable of remaining at home with increased supports and wish to do so. By bolstering community and home-care supports, our system can become increasingly patient-centred in its care for our elderly population and redirect some patients who would otherwise be placed in long-term care.
Increasing community supports must also include the often underappreciated members of the care team – informal caregivers, who are reporting increasing levels of burnout and their inability to support their loved ones. Investments should focus on homemaking services, caregiver support and respite services, and new models of care such as group homes to care for high-risk seniors.
These big shifts require courage, collaboration and political will. We must act now to meet the changing health care needs of our aging population.
David Wiercigroch is a medical student at the University of Toronto and a contributor to EvideneceNetwork.ca, which is based at the University of Winnipeg. He is a graduate of the Master of Public Administration program at Queen’s University and has an interest in health system improvement through public policy. Caberry Weiyang Yu is a medical student at Queen’s University and a contributor to EvidenceNetwork.ca. She conducts research on health-care equity and access to care.