The end of hospitals

Can home care fix our crumbling health system?

by Julia Belluz

Luca Rossato/Flickr

For the last several years, there’s been a lot of apocalyptic chatter about whether the aging population—or “gray tsunami”—will overwhelm the health system. That, coupled with the fact that there seems to be a shortage of hospital beds, has politicians offering up home-care services as an alternative to hospital and long-term care, and health-policy wonks pondering what a system without hospitals would look like.

This week, Ontario Health Minister Deb Matthews was the latest such politico to announce the Liberal plan to invest $60 million in home-care for seniors and the disabled. Though details about the program were not yet available, Matthews said it would offer services ranging from a health professional’s house visit, to phone and online consultations.

The supposed benefits? Improved access, more cost-effective care, reduced visits to hospital, and less pressure on long-term care facilities. As Matthews’ campaign office spokesperson put it, a hospital stay can cost $1,000 per patient per day while long-term care rings in at $150 per day.

But is the suggestion that home-care programs are an efficient alternative evidence-based?

Science-ish called a leading researcher on home-care efficacy, Dr. Sasha Shepperd (PhD), and she said, “The only way you can say home care has saved on hospital care is if you close down the hospital, which politically is not a very popular thing to do.”

Otherwise, costs are simply being added to the health-care system by creating parallel services. “If you’re not going to close down hospital wards because you’ve got this home-care program, those beds will get filled up by other people.”

Dr. Marcus J. Hollander (PhD), a health policy analyst and home care expert, reiterated Dr. Shepperd’s take on the supposed cost-substitution effect of expanding home-care services. “In order to actually save money, you need to hold back residential care and reduce hospital beds. Simply putting money into home care itself will typically be an add-on cost.”

But closing down hospital wards while expanding care in the home is an unlikely and possibly dangerous solution. In a Cochrane review (co-authored by Dr. Shepperd) about home care to avoid hospital admission, researchers found that although care at home “provides an alternative to inpatient admission for some patients, the volume of such patients recruited to the included trials is low and some of these patients will require access to hospital services, thus making the closure of a ward or hospital in favour of hospital at home an unrealistic option.” In other words, patients who receive most of their care at home may still need to go to a hospital once in a while, so home care isn’t an actual substitute.

As for the actual evidence about whether home-care is cheaper than other types of care, Dr. Shepperd said it’s currently scant. “Overall, the evidence shows either there is no difference in cost between acute home-care and acute care in hospital or in some cases, home care is more expensive.” (See the cost analysis in this review of the effects of services in the home for patients discharged early from hospital.)

There is one thing we do know for sure about home care: patients tend to prefer it, which is probably why politicians create platforms around it. In the UK, where the primary-care system is much more advanced than ours, many evidence reviews on shifting acute care from the hospital into the community have been undertaken, such as this June 2011 report Getting out of Hospital. It suggests there are potential gains to be made from expanding at least some acute inpatient and day care services from hospital to the community, including better health outcomes for patients and greater patient satisfaction with services.

But before the government throws money into growing home-care services, Dr. Shepperd suggested gathering more evidence about its efficacy through randomized-controlled trials so that we can really understand the health and cost benefits associated with each type of health-care delivery.

Science-ish is a joint project of Maclean’s, The Medical Post, and the McMaster Health Forum. Julia Belluz is the associate editor at The Medical Post. Got a tip? Seen something that’s Science-ish? Message her at julia.belluz@medicalpost.rogers.com or on Twitter @juliaoftoronto




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The end of hospitals

  1. The homecare Dr.Shepherd is talking about is not what we in Canada call homecare.

  2. It is a long understood and accepted medical fact that on average people recover better at home. Clinical environments are generaly just not good for people emotionally/psychologically, and that has a huge impact on recovery.

    On top of that, the common practise of cramming four people into one room with a shared bathroom easily explains the rampant proliferation of bacteria and viruses. It’s not a healthy situation, and the statistics I’ve seen suggest that 1/3rd of people who die in hospital do so from something they’ve contracted IN the hospital. The c-difficile outbreaks are certainly linked to this over-crowding issue.

    Seems to me that the main benefit of a homecare policy is not only that you can take advantage of the enhanced recovery aspects, but that you free up hopsital beds at a quicker rate, thus requiring less of them over all. There’s no logical reason it would be otherwise, as long as the practice is spread universally, ie you don’t suddenly let others linger longer in hospital beds for no good reason other than you “suddenly have the space”. Governments will have to be very clear that if you can go home, you should go home.

    As mentioned in the article however, you will also have to combat the natural political resistance of the populace to cutting hospital spaces where appropriate, or at least not growing them at the same rate. 

    To that end I’d suggest including home care statistics with the hospital statistics to cite the number of “potential” spaces created by having a homecare policy. Then people will be able to see that the number of spaces have increased substantially with the inclusion of homecare.

    • The problems with the hospital-contracted infections or nosocomial infections has in my experience more to do with the age and way that hospitals are laid out than over-crowding.  Have you noticed how in all the malls and airports there are bathroom sinks with sensors on everythiing from the taps to the soap dispensors & paper towel dispensors.  Further, there are no doors on the bathrooms but rather a type of maze that makes it impossible for people to see into the bathroom.  This way of building has not made its way into the hospital…..the place where bacteria is rampant.  One person gets c-difficile, then everyone in the room has it, then everyone on the unit has it.    Hospitals should be built and renovated with the expectation that NO ONE is washing their hands so as many doors as possible should be automated.   Also, there should be handwashing stations all over, with soap & water, given that the alcohol sanitizer is not even effective against nasty fecal bugs.
      As for sending people home quickly, I don’t know where you live but in Alberta we certainly get them out fast.   Unfortunately, we have a lot of people waiting for nursing home beds and other long-term care facitilities that are in acute care beds.  Believe me, no one is spending too much time in hospital just to fill a bed.  In fact, the favorite refrain of the ER physician here is “10 years ago, I would have admitted you for this but now I have no beds…”
      Our population has exploded and our hospital beds have shrunk.  I am all for having people at home but I also know that family members shouldn’t be put under the unfair burden of having to look after someone at home that requires the full-time care of a nurse.

      • I agree with your hospital design idea. To add to it, one thing that would help is to make most if not all basic surfaces in hospitals out of copper. Copper has this weird property that greatly shortens the lifespan of bacteria and prevents binary fission. Your average bacteria with a three day survival rate on average surfaces won’t even last an hour on a copper surface.

        http://www.sciencedaily.com/releases/2011/02/110216120436.htm

        In terms of beds, I agree that as of now people are cycled through very quickly, but one thing we’d have to be careful of is the slow creep of extended time in cases where homecare has significantly freed up space, should that happen.

        Your last point I think is the most salient. If we’re going to employ homecare as a strategy, we’re going to have to be cognizant of providing for people’s needs without merely dumping responsibility on households that can’t take up the slack.

        • We do have great homecare here in Calgary.  Believe me, they fast-track everyone out.  Social workers on each on every unit start discharge planning the minute someone is admitted.

          Like your idea about the copper surfaces.  Would be interested to know how much the nosocomial infections cost the healthcare system every year.

          I did want to mention something else – Alberta has a phone-in advice line manned by nurses.  It has worked great BUT has been hugely successful so now the wait is sometimes up to 2 hrs.  Typical govt has underfunded it and not kept up with the demand.  This service has kept many people away from ER rooms but if you can’t through to talk to someone what are you going to do?

          • Yeah we have “tele-health” here in Ontario and it’s very successful as well. So far I haven’t had to wait more than a few minutes to get through, but I’ve only had to use it a couple times so I can’t tell if that’s an average experience.

        • Good!

        • Phil, I wanted to let you know that a small article appeared in Canadian Nurse journal (Sept. 2011, vol 107 number 7, pg 9) stating the following:  “If hospitals replaced the most frequently touched surfaces in ICUs – for example, IV drip stands – with ones made from copper – they could kill 97% of bacteria and reduce the risk of hospital-acquired infections by 40%, according to US researchers.  Copper’s antimicrobial properties were found to cause the same reduction in bacteria as the terminal cleaning of rooms that is done after patients have been discharged.  Experts believe that up to 80% of infections in ICU patients come from bacteria present in their rooms.”
          Kudos to you Phil.  Now, if they would just implement all of the ideas for decreasing noscomial infections!

          • I’m really glad to see that. I hope the health planners latch onto this. No matter how many cleaners you have you could never match the overall improvements this would bring, and with so little maintenance effort.

            I think it’s great when something figured out by one branch of science can help in another.

            Cheers.

    • All true Phil. And there are abundant statistics if you look for them. Is the place unionized? Is iot a teaching hospital (i.e. high end service). Is it a research hospital (eg cancer).  Health economics is not an easy area because of the variables. 

  3. One faulty assumption in this piece is that community-based care is only effective if it results in concomitant reductions in hospital beds. Who decided that the number of hospital bed closures should be the criterion for measuring the success of such policies? Shouldn’t the goal be to accommodate the needs of an aging population (as well as the increasing percentage of people who are surviving disabling conditions) by making the most efficient use of EXISTING institutional beds, by providing less expensive and more satisfying care arrangements for those who don’t need to be in those beds? We need to be anticipating a growth in health care capacity, not simply a substitution of hospital care with “cheaper” home care with no net increase in capacity.

    • Yes, quite. A few points.  Not for profit facilities can be cheaper than for-profit  and the reverse is true. It depends on management and level of services – both count. The institutional care costs (aside from medical costs) are much the same in facilitie4s as in acute hospitals. I made the point earlier that acute hospitals are costed on average costs so an elderly in an acute bed does not use a lot of the services in that average cost. The main thing is the opportunity cost of not being able to handle surgery and trauma, as well as acute medical. 

  4. How about the avoidance of building more hospitals?  Recently I’ve read claims that there are patients who can’t get surgery because the hospital is full of “bed blockers” — people who could be cared for in other environments.  If we can move some of those folks to a home care situation surely that’s a more efficient use of the expensive hospital environment?

    I realize that health care professionals like hospitals because it’s “their” turf — a comfortable environment for them to work in where the patients can be efficiently processed, etc. but it is a very expensive place to treat them.

    • The “bed blockers” are elderly people waiting for nursing home beds.  They are not well enough to stay at home without 24h care.  The governments (provincial) need to build more nursing homes, which are by far cheaper beds than hospital beds.  The only way most of those people waiting on nursing home beds could go home would be if they had “nannies”.
      It is very frustrating for health care professionals who want the beds to be utilized by acutely people to have them blocked by people who need to be “babysat”.

      • Agreed, but wouldn’t it actually be cheaper to hire a full time “nanny” than build more nursing homes?

        After all, if a person already has a home and everything that comes with one, you would think that at least for some this would be more economical and of course they get the benefits of being in their own home.

        Just a thought.

        • Actually, people with dementia would likely need nannies (as in 3) – one for each shift and one to cover days off.  It really would be super expensive and hard to recruit enough staff.   Then there are issues of whether or not the home is set up for physical limitations – stairs, etc.   The govt. knows they need to build the nursing homes.  They just don’t want to spend the money.  They want the private sector to build and run nursing homes but there is no profit in them unless you cut corners and that means crappy care.

          • What’s with this “nanny” stuff? In Ontario, we’re referring to trained Personal Support Workers” (PSWs).

            We’re not a nanny state yet !-)

          • Well…some elderly people have nannies….they are people who live in the home with the elderly and are paid to provide 24 hour care….just like a live-in nanny would for a younger person.  If you find the term disrespectful, I am sorry but I know some people who employ them and they haven’t got special training as such but they are compassionate and they cook and do personal care.

          • Right on! Where ae these people getting their info??

          • Personally I’ve never understood how the for-profit model was supposed to actually be cheaper in many cases, or even how one considers it ethically sound for that matter. Diagnostics is about the only area I’ve seen it work.

            However I do support more use of the not-for-profit NGO model for many health services as a way to reduce excessive bureacracy, increase the amount of innovation and promote the development of more “centres of excellence” to help proliferate innovations that really work.

            After all, so far as I can tell, government’s suck at actually delivering just about anything. LOL

          • I do know how the private sector does things cheaper….they waste less money on multiple levels of management; on regularly changing the name of their organization; on studies on how they can make their workers more efficient; on expensive stationary that they have to throw out every time the organization goes through a name change….
            There is a global shortage of nurses and other health care professionals and yet….we get more and more levels of managers and less nurses working on the floor all the time.  A new CEO comes in and they pay off a bunch of managers with 2 years pay for early retirement – meanwhile, we are in a shortage of workers and they could have gotten two years of work out of these people but they paid them salaries for no work.  Do they care….no….it is taxpayer’s money and guess what?  That CEO got fired and the taxpayer gave him a payout on his contract.

          • The reason “for profit” organizations can be more efficient is that someone is paying attention to the bottom line in those organizations — we don’t hold our elected officials accountable for doing the same for the “not for profit” organizations — as soon as we become sophisticated enough to evaluate our elected officials for their management abilities as much as we watch their baby-kissing prowess the situation will change.

          • @healthcareinsider:disqus

            All the things you’re saying about the private sector is true, but also true of not-for-profit NGOs, except that the NGOs use the efficiencies to improve service rather than syphon it off as profit.

            And when NGOs are put in competition with one another for specialty funding of, for example, centres of excellence, they’re often MORE innovative than for-profit ventures since for-profits will often trade off effectiveness for efficiencies that increase profit margins.

            So the difference in motives creates a difference in operation, and if we’re all being honest, this shouldn’t surprise anyone.

          • Those out to lunch need a lot of care. You are right 24/7

        • In many ways, yes.

          Then, of course, you get to the hot potato of who pays for the “nanny” and how.  Currently there is no legislated framework on this, and common law is kind of messy in terms of hiring domestic servants when it intersects with tax law.  If you hire someone for an hour or two a day to clean, cook, etc., you just pay them and they charge GST, PST, HST, etc.  If they work for you full time they may get classified as employees, and you have to set up a business number, collect income tax, CPP & EI &all the other costs of having an employee.  With a little bit of leadership on the issue these problems could probably be avoided or at least minimized, but I’m not holding my breath.

          The advantage of a nursing home is that you have a variety of employees with different levels and types of training and experience (& different pay levels).  The person who vacuums the floors can call the doctor or nurse and they’re on the spot in a matter of minutes.  With home care, this could take a lot longer (unless you happen to be wealthy enough to hire round-the-clock private nursing care.)

          There’s also the issue of high levels of abuse of seniors by care-givers and vice versa, especially in cases where dementia is involved.  I’ve known home-care workers who refuse to enter certain homes unless there are at least three people present.  Infirm seniors are also frequent targets of home invasions and confidence scams.

          The real solution is to spend the money today educating doctors, nurses and other health care workers, building and maintaining facilities, and developing stragetic plans and tweaking laws and regulations, all for a pay-off we won’t see for at least a decade.

          Still not holding my breath.  And not enjoying what my imagination sees when the current generation of pension-less workers gets old.

          • Well, as soon as you are a “bed blocker”, the government is already taking money from you for blocking the bed.  What I mean is that your paying for that bed that you are waiting on in the nursing home.  If you get old age pension & CPP, then they are taking a very big chunk of that money.  No one in Canada lives for free and when you are ready to be discharged from the hospital, whether it be to home or a nursing home, you start paying for a portion of the bed.  Therefore, the patient would be charged for the nanny, just as they are charged to live in the nursing home.

          • Don’t know where you live shenping, but all of the above was done jhen the Long-Term Care Program was launched in BC in 1978. It is not as easy or as cheap as some would make it.  When the facility worker in BC unionized they came in very close to what equivalent people in hospitals were paid. Most provinces have programs in this respect so the family is not necessarily on their own.  

        • I worked in the home health care profession for years. the government doesn’t employ those workers, they make the family  go to agencies,where the family of the ill pay upwards of $25 an hour each and every hour of each and every day for untrained  workers to babysit their parents, until there is just no money left in the elderly person’s bank account and often the family’s as well. then the government attacks their pension, leaving absolutely nothing. Hospitalization is far less expensive and you know the patient is getting the care they need, without bankrupting the whole family. 
           Canada simply needs three times as many nursing homes for the elderly and disabled

        • Who is this ‘nanny’ you are talking about? Home care persons are either nurses or graduates of a junior college  training program. Both are unionized. Neither are ‘nannies’

          • We are not talking about health-care professionals here.  We are talking about care-givers who are brought in by family or by the elderly person themselves to provide 24 hr cooking, cleaning & even personal care for an elderly person.  They have not attended any college program.  They are doing the work a family member would do if one was available -  hence the “nanny” moniker.  I guess if you want you can call them a home-care aide.

          • Are these immigrants brought in under the Live-In Caretaker program? 

          • Once again, it depends on the jurisdiction and the number of people being looked after. More than 2 usually require a licensed facility or person.
            Once again, only 15% of seniors under 85 need any care at all other than what their family circle provides. 7% under 8t5 usually need facility (nursing home) care. The real problem  is with the 85+ with diminished abilities. .

          • Sorry I can’t reply to you on your last comment because you do not have a reply button….the important things to remember are : 1) you and I live in different provinces so the rules are totally different.  The care-providers that I am talking about – the nannies that the elderly are hiring are usually only for the maximum of 2 people – usually a husband & wife so they can stay in their own home;  2) there may not be a family willing/able to look after the elderly person/couple in the capacity that it is required (24 h) care – some of this 85 year old people have 60 to 65 year old children who go south for the entire winter.  The 85 year olds – maybe the husband has some mobility problems (uses a cane) & aphasia due to a previous stroke and the wife has some  muscle weakness – they need someone in the home in case she has a fall because he can’t call 911 due to his aphasia.
            Hence the nanny.

      • What you say is true in many cases — but there are those that the doctor doesn’t feel comfortable discharging without SOME support network.

      • Most Canadian Hospitals are budgeted and remitted on the basis of average costs. Therefore having an elderly person who could be otherwise discharged  in an acute bed is not necessarily costing the average daily rate figures tossed around. But it is of significance if they are blocking the bed for other medically or surgically required procedures. It is really just a pain to be organized to give acute care and not do so for the above reasons.  Although modern medical procedures are expensive, all you save by caring for a person in the home is room and board, as often nursing care delivered at home is MORE expensive than a hospital because of time in transit, setting up, putting away.  

        To me your reply suggests a lack of understanding of home care. It is a lot more than just ‘baby sitting’. As for my competency in the matter, I was a management consultant in the hospital field for several years and I spend additional years ‘on the inside’ of the Long-Term Care Program.

        • I know how the costs of the hospital beds works.  I have worked both in the community and in several different areas in the hospital.  Everything is factored into the cost of the bed in each different area.  The cheapest area of the hospital is psychiatry – the beds there are approx. $800.00 to $1,000.00 per day.  The interventions are minimal. There is zero equipment and no electric beds.  
          I never discussed how homecare works, although in nursing school I did work as an aide for a homecare agency.   I also did some orientation with a homecare nurse. 
          I was just saying that if you wanted to get bed-blockers out of the hospital – those requiring 24 hr. care, you would require nursing home beds or some sort of 24h supervision for them.  They do not require 24 h NURSING care – most of them as they are not necessarily medically ill.  They just cannot live alone or with their elderly spouse in the home.

  5. The proposition of eliminating Canadian hospitals is simply ludicrous. 

    Hospitals have been in some form or other with us since the 1600′s. Our contemporary hospital incarnation is a conflation of a) surgical utility, b) diagnostic utility and c) hospitality and convalescence utility. Interestingly 90% of all health care dollars are spent on only 5% of the Canadian population (ref. Ontario Ministry for Seniors & Long term Care Stats.).

    Our mostly aged and frail seniors create care-traffic congestion in typical acute care hospitals and the core problem is one of medium-to-long term recovery needs, which is competing context of stressed hospital beds versus one’ own bed at home. 

    We require a hybrid model of a rentable temporary ‘home-hospital’ that is electronically nexus’ed into the  entire continuing-care team, so vital stats  monitoring can occur remotely; families can be technology aided in substantially reducing the burden of the nasty scut work (ambulation, exercise,  toileting, feeding, etc); and assistive equipment is custom designed to promote home-care  rehabilitation, if not re-habituation for age related mobility impairment, and in the worst case provide compassionate palliation. 

    Industrialized hospitals do these three things very poorly, but they are excellent at heroic interventions and do this affordably. They are terrible over priced hospitality providers and this care component should be done at home with new technology. In BC we are building this technology for the 21st century hosiptal-at- home (as has been profiled in the New Ideas Innovation competition sponsored by Health Ways Canada).

    We can do this of $30.00 per day versus $1200.00 per day in a typical BC hospital and $230.00 a day for a typical nursing home slot. The solutions are there, they simply need to be vetted and proven to work. Senior want to age in place, lets just give them what they want as customers and not medical welfare cases. It will take enlightened policy changes and fresh set of attitudes to get the policy wonks and medical-community online, as they are all late-adopters, while suffering people are not.Rees MoermanDigniti® Home-Hospital Project

    • Well of course they could never close the hospitals.  What would happen in the case of traumas?  One thing concerns me about your concept.  Where will you get staff.  There is a shortage of health care providers.  Already beds are closed in hospitals because of it.  While it is possible for one nurse to care for 6 or 7 ill patients on a nursing unit, it isnt when they are spread out around a community.  What happens when a couple patients decompensate and there aren’t hospital beds to put them in?

    • This new home-care concept is well advanced and has been conceptually reviewed by Health Canada, as well as by the Ivey School of Business, Health Innovation Team, which voted  it as the best new health innovation in Canada this year. The Digniti® system requires no new clinical or para care staff in the home. It reduces labor and injuries by 50 to 60%

      Many assistive features are automated. The equipment is highly intuitive and designed to be used by the non-ambulatory patients and the families supporting them with care. The at-distant monitoring interface allows 24/7 tele-medical nursing to guide home-care through internet conveyances like Skype, as the bed platform has built in monitors and communication and vitals monitoring devices. This active video-conference system allows on to have a teaching moment with skilled tele-nurses and at-home care providers and their families.  You are convalescing at home but technically you are still admitted to your local hospital. The whole idea is to reduce nursing and para-carelabour and empower the patient/family. One or twice a week a community care nurse checks in on you at home. Further medical interventions in acute symptom deteriorations would result in re-admiitance to the local hospital until the patient is again stabilized and returned home to continue rehabilitation. With implementation of this new technology long term hospital stays would become obsolete.The technology allows patients to be to full immersion bathed-in-place, modesty-enclosed full toileting within 6″ proximity to the bed perimeter, or alternatively a wearable bidet is provided if there is profound incontinence. There is a built-in ambulation/harness refom-device which assists with lifting, placement and supported walking for gait and balance reform.  There is a galley system for dysphagia-feeding for difficult feeding issues which plague many very frail patients. The bed has a built in compression-sore mitigation system which eliminates bed sores. It has an air purification system which removes  dust, bacteria and airborne-virus and all contact surfaces have nano-metalic alloys which kill pathogens on contact. It has a lighting system which is diurnal and matches the solar lumens progression to give the bedroom zone enough internal light to mimic ‘sunlight’ to promote vitaimin-d formation and reduce mood disorders such as SAD. The system has many other support features and is the next revolution in compassionate affordable care. It will indirectly build hospital capacity without needing one dollar from the provincial governments. The greatest poverty is not lack of money — but lack of imagination

      • I’m glad you admit that you are essentially a commercial health firm – not always the best answer when your primary goal is to sell service.

         I was involved in the BC Long-Term care program for a few years. It was supposed to be a low-cost alternative to having all persons (not necessarily seniors) back up in the acute hospitals. IOn fact, the unions rapidly organized these workers so that the low-cost alternative became a high-cost alternative. It’s goal was to supplement dependencies by appropriate levels of care, and at that time folded in other programs (Canada Assistance Plan, new facility beds from CMHC social housing units, for example).  While several homemaker services were raised and employed, they too became a two-fold problem – training and union organization. What the program was intended to be was a continuum of care APPROPRIATE to the needs of the client – from acute, through  rehabilitative to long-term facility care finally home care (which includes both home nursing and homemaker service. The original program included handyman service.

        What care in the home saves as compared with the hospital is room and board. If the client needs acute care he or she needs to be in an acute hospital bed. What the client gets at home are those supplemental services that enable one to stay in the home – bathing, meal preparation (perhaps meals on wheels, housecleaning and so on. This means the client must be professional assessed as to needs.) An assessor is usually a nurse or a social worker.

        Finally   people think that the old age demographic is all old-aged people.  Our experience showed that about 15% of the young elders (over 65 but under 85) will require care of some sort, ranging from acute rehab, facility (Ontarians read ‘nursing home’) to care in the home. Patients over 85 are called ‘the very old’ and require more care than the under 85. Too often the only care-giver is the female spouse, who eventually wears out. So there must be respite care to give her a break. Old age doers not necessarily mean no holidays, so there should be provision for a facility resident to leave the facility for a week or two and not have to give up the room.  While the number of acute beds may be reduced somewhat by alternate programs if the elderly are simply blocking beds the idea that we are going to do without them is simply ludicrous.  BC has had ‘hospital replacement days’ where an early discharge to the home is made possible by delivering post-surgical nursing care at home.  But Hell, what about maternity, accidents, acute disease, and children?

        I think the BC Program was shrunk and altered when Premier Campbell was elected in 2001 

        • A lot has changed technologically with new materials less expensive manufacturing methods and conjugation of allied  technologies to vastly lower costs of fairly complex assistive-equipment. In the last 10 years elder-care innovations in Japan, Europe and some regions in the the USA have seen some amazing new care modalities. There is underway a revolution in assistive and adaptive equipment and when integrated with communication technology can greatly improve the quality of life of patients, families, nurses and doctors (and even insurance companies who pay for these services like the provincial medicare systems). 

          Good, safe reliable assisitve equipment is expensive, but like renting an airplane seat you don’t have to buy the whole plane, just use what you need for you’re aging journey, and then the next person takes you slot when you have rehabbed. You can do this for the same price as your daily food tab in any BC hospital room (which in BC is about $30.00 per day which the Province is now nicking you for anyway. Might as well heal at home for long term stroke-patients, knee surgeries, trauma recoveries, cerebral palsy, parkinsons, arthritus, etc.).

          As for being a commercial enterprise, the Canadian and Provincial Governments are doing pretty much squat in this area, and if inventors and ethical geriatric developers don’t create change and better systems it won’t happen, and our provincial health budgets will grow to 75% of all taxes instead of the current 50%. Our Universities have delivered very little of meaningful consqeunce in this area in the last decade or so other than tons of reports but no solutions. 

          Economically we are running out of runway here. Canada has one of the worst records for medical care innovation in advanced western nations being 18th. (even behind Hungary and Estonia). We Canadians, as the record shows, are not good early adopters or risk takers of new health ideas. But were out of money so we will need to try new things or be happy with really poor service, cut backs and third word medicine in some regions. Many of the comments seem to support this inherent Canadian bias.In BC we have serious capacity problems needing 9,000 care-beds of acute and long term care, which are not available, and will not be there when the boomers need them. In Ontario there is a need of 45,000 additional care beds, and Canada as of today needs 83,000 beds. There are none,  and no one is there clinically to do the work anyway. The new form of ‘nursing-home at home’ will not be your granny’s style of labour intensive, outdated and poorly designed equipment. The bet new technology drives out unsustainable legacy and entrenched costs and empowers the patient to be physically supported by their own efforts and 24/7 access to the entire continuing care team. It is not perfect but miles ahead of anything than is out there right now. Why take a ‘tractor’ to work when you can get a ride on a ‘helicopter.’ Disruptive tech will do this as cell phones in Africa have jumped ahead of wire systems skipping a whole generation of outmoded tech.Alzheimer’s/dementia patients (which are 50% of nursing home patients)  are special cases and the requirements differ somewhat, but again some very innovative  environmental modalities have been proven successful with enabling equipment does provide some relief, security and improved support for care giving families. There are no 100% solutions, but a lot of small improvements that in total are far better than old style nursing homes which only provide 2.8 hours per day of care per patient or expenisve hospitals which are expensive and alienating.  We can choose to stay with what we have in Canada,  which is heading into systemic bankruptcy or choose to innovate. The choice is individual, the outcomes personal and the consequences very real. The systemic problems of senior-care will not be solved by continuing to do things the same way. As Apple Computer has shown in computing and social tech, intuitive, adaptive, and compassionate design can work if well implemented. We have in Canada a basic mistrust of anything other than the status quo. However, we do not have enough nurses as 35% will retire in the next 5 years. In our small community out of 11 Doctors in our home-town hospital seven just quite last week in protest of low pay and over-work, and the taxpayer is at tilt at the same time. This is a harbinger of the future. We also have the oldest demograhic with the higest community ratio of seniors in Canada so what we are seeing here will happen in the rest of Canada in the next 15 years. So we either embrace new models by testing them in willing communities that have the risk appetite to try something new or we suffer and go back to the 1970s when seniors were warehoused in smelly, soiled, depressing hovels until they died (read Dr. Jesse Mantel’s PHd. work who retired as a teaching nurse at U. Vic/ [ref.. Priory Movement in the Prairies in the 70's and 80's] to reform senior care back then, and its implications now). A negative and distrustful attitude does little to build community risk-taking. Pilots don’t design and build airplanes. They fly them safely and well and tell the engineers how to improve them.Doctors and nurses don’t design and build the care systems, they drive them and utilize them. System engineers solve these kind of problems and all great solutions to macro health issues in the last 50 years were tech driven.

          • Good sales pi0tch. What kind of technology do oyu have to clean up poop?
            the clients of Long-term were certainly better looked after than the 19780′s you refer to.  But even at that I would not go into a facility.

          • Engineers don’t do sales pitches, they solve problems.

            The integrated incontinence system deploys a wearable bidet with a dermal liner. It essentially captures urinary and faecal wastes upon excretion when need occurs, and has an embedded/enclosed  warm-washing sequence, followed with a misting with bactericides, followed by a mist emollient finish to reduce chaffing, followed by a disinfecting air stream … until the dermal surfaces are completely dry. 
            With bed-bound seniors keeping skin dry is essential as this is where most infections and epidermal micro tears occur. The wearable device looks like a small wetsuit (limited to groin area) with wicking liners and is connected to a waste exbilical (waste tube).
             
            It is very easy to connect and disconnect.  Basically it works like a ‘mini car wash’ for your backside. It sounds futuristic but it works quite well and is discrete, reasonably comfortable, and provides better modesty needs. As far as managing involuntary incontinence, which 25% of seniors in nursing homes have.  When comparing to adult diaper use, which in nursing homes are only emptied on a schedule … and not demand,  the new option is far more preferable. It also beats using bed pans or urinary pots which require the help of an aide, six or seven times a day.

            Again, a lot of these waste management issues were technologically solved in the NASA and Soyuz programs and are now appropriated to this medical sector. 

            Frail senior care in the 1970s and 1980′s were very poor in state run nursing homes, as many, many patients were geriatric welfare charges and had almost no social security or savings. This is why Tommy Douglas fought so hard for medicare because of the abuses to seniors. There has been great improvements in geriatric care environment in the last 40 years, but we are starting to slide backward. 

            When you in turn possibly become old, broke, and non-ambulatory, despite saying you won’t go into such a nursing-home, you will not have a choice. At that point, if you are indigent, or too ill to care for your self … a social worker makes the choice for you.

            80% of seniors in Canada do not have the funds for the $6,000.00 per month that it costs for the basic nursing home slot. So 80% of nursing home residents are 100% subsidized by the Government. That is why we have a money crisis.  Todays seniors have far more complex care issues, live longer and stay sick longer than previous generations. The average senior lives 2,8 years in a nursing home and the cost of this type of care consumes the majority of all care dollars. Over half the entire Canadian medicare budget of 185 billion dollars is spent on frail care for only 1% of the entire population. We get very poor value for these expenses and very unhappy patients and very tired stressed nurses.

            A typical Canadian hospital bed cost $35,000.00 per month to support and each hospital bed is over capacity by 16% on average. That means we can only deliver care to 86% of the sick population at any time. Bed blocker are chocking the system up with complex care needs abd are served in the wrong venue. The system is broken. 

            The average nursing home co-pay is about $1500.00 to $2,000.00 per month. Private nursing homes are 3 times this rate. If you are in the USA double these values.There are 950,000 disabled frail persons in Canada and 2.8 million family, friends and volunteers that do unpaid care supporting this disabled class of Canadians. It will only get worse when the boomers get sick, frail and need care.

          • To dignity below:  Sold. Extremely interesting concepts. Sorry if I seemed to make fun of you.

      • sounds great, and what is this fantastic bed going to cost the patient? you never said that yet, and what about the alzheimer’s patient who will just be totally freaked out by this bed. You have obviously never been attacked by a confused violent person who doesn’t remember where they are or who you are.

        • The cost the patient/family is about 30 dollars a day, which is 1/3 the cost of a typical nursing home slot and 1/20th. the cost of a hospital slot. It costs the taxpayers nothing. 

          Disruptive technology is able to lower costs by reinventing how services and problems are dealt with. Just like computers drop in price every year health tech is also dropping in price. It is government red tape that keeps innovation strangled. The nanny state will not let us have ‘nannies’, other than the paper ones.  

          By the way I am an engineer, have a masters in clinical psychology specializing in geriatric needs, and I am also a graduate in palliative nursing. 
          So, no … I am very familiar with patients in pain, fear, distress, and have psychiatric needs, who when stressed can on occasion be violent.  

          I am very familiar with the trying state of our senior systems medical status. Every day I collegially work with nurses, doctors, geriatricians, social planners, occupational health specialists, research scientists, and politicians to improve the quality-of-life for seniors. 

          I don’t have to do this in Canada as the door is open to do it much more easily in three other countries. I am here because the need is here. 

  6. There are many people who who do not need 24/7 acute care or Emergency care who end up in ER and in hospital (especially on Fridays before long weekends) only because they can’t cope at home, and their family isn’t cohesive enough to supply care.

    Caring for these people in hospital and caring for people who are stable but awaiting a personal care home placement is a huge expense because extensive home care and long term care are both much cheaper to provide than acute care.

    It also means that a bed and attention can’t go to someone else who is waiting to be cared for, in ER waiting to be admitted and slowing down ER services for instance. Your analysis that beds would not be saved is flawed, because it’s bed days that will be saved, a lot of them.

    • Everything you are saying is very true.  Some people even drop off family members for respite.

  7. In Ontario, are you aware of how many hospital beds have been closed already in the past 10 years; are you aware of how many people in Ont. are in need of Nursing Home–incl. those in Retirement Homes, at home whose health needs have advanced to require that level of care? Lt’s deal with the reality of what is.

  8. This article is falling into the trap of what other “regular” media articles fall into, in terms of using evidence to identify issues with the policy. The HomeCare that the reviewers are discussing in the Cochrane review is not refering to the program that the health minister has promised funding towards. Furthermore, supporting HomeCare in Canada is an integral part of being able to provide lower-cost higher-quality care. Take for example the House Calls service (which has erroneously been referred to as Home Care in this article); works to provide homebound elders with primary and specialty care in the community. The people that receive this care are able to manage quite well in the community! They go shopping with their friends, often live at home with a partner, just are unable to go see their regular doc to deal with regular things, like getting their prescription refilled, monitoring their medication and use, discussing end-of-life directives, etc. Instead of them having an urgent issue, and being rushed to the Emerg, these people can live out their lives quite happily in the community. It provides higher quality care, and saves the province money. If you’d like to consider high quality reviews that support the “Home Care” that you are referring to in your article, consider a MEDLINE search for “House Calls” instead.

    P.S. Long Term Care, is also another level of care in Ontario — which is not what the $60 mil is to be contributing towards. That funding is under different policies from the MoHLTC

  9. Just as in most publications, perhaps there needs to be an appropriate response from the author to respond with amendments?

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