A major factor causing long emergency room (ER) wait times is the high number of alternate level of care (ALC) patients occupying acute care hospital beds, making it difficult to admit patients from the ER to hospital. ALC patients are unable to be discharged because the appropriate level of care they require is not always available.
Not a short term problem
This was released by the Canadian Institute for Health Information's (CIHI) in 2006: There were almost 73,000 patients designated as ALC patients among 2.4 million patients admitted to acute care hospitals outside of Quebec between April 1, 2004 and March 31, 2005.1 This is up by 13.6% from 2003-2004 and 19.6% from 2002-2003.
This was released by CIHI last week (January 14, 2009):
In 2007–2008, there were more than 74,000 hospital stays for alternate level of care (ALC) patients in Canada (outside of Quebec and Manitoba), representing more than 1.7 million hospital days, according to a new analysis by the Canadian Institute for Health Information (CIHI). The analysis, Alternate Level of Care in Canada, provides a first look at patients in acute care hospitals across Canada who no longer need acute services, many of whom are waiting to be discharged to a setting more appropriate to their needs.
Some highlights of the analysis include:
-- The equivalent of almost 5,200 beds was occupied by ALC patients in acute care hospitals.
-- Overall, dementia accounted for almost one-quarter of ALC hospitalizations and more than one‑third of ALC days in 2007–2008.
-- 83% of adult ALC patients were admitted to an acute care hospital through the emergency department, compared to 63% of non-ALC patients.
-- Most ALC patients were discharged to a long-term care facility (43%), while 27% were discharged home and 12% died during their hospitalization.
This is a national crisis in healthcare. Provinces are taking the lead to come up with answers. In Ontario Dr. Alan Hudson and Dr. Kevin Smith are dedicated to the task. The hospitals, community organizations, the associations, the integration networks and the governments are all collaborating.
And the media is even suggesting solutions.
Judy Steed's column is one example
Special to the Star
PROBLEM: In Canada, "bed blockers" – older people stuck in hospital, ready for discharge, lacking the home support they require – occupy 5,000 hospital beds and consume $200 million annually. They clog emergency departments and expand wait times for others.
SOLUTION: Hospitals in Denmark eliminated bed blockers by creating a stiff incentive to get elders moving. Municipalities are required to pay for those who stay in hospital past discharge dates. That got communities working to move seniors on – to rehab or home care.
. . . hospitals agree that community care is the answer. "I'm CEO of the Ontario Hospital Association and we think the solution is in the community," Tom Closson told me when he was CEO of the University Health Network. An effective long-term home care system is the answer, he says – only then will seniors discharged from hospitals and nursing homes be diverted from emergency departments.
Closson and his colleagues in community care and home care know that solutions will require spending and they know that provincial spending will be dependent on federal spending. They are counting on Mr. Flaherty taking note. Not only can investments bolster the economy, they can improve healthcare. Without it, they say, access, quality and human resources to care for the sick will be dramatically affected.
Thursday, January 22, 2009
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Success in transforming our health care system to meet Canada's needs now and in the future will only occur with innovation: innovation with regards to the ALC issue, and access to primary care. We, the Sudbury & District Nurse Practititioner Clinics, have launched a model where patients have access to NP-led care and other health care professionals such as physicians, social workers, nurses and dietitians – when they need to, in their community, via a nursing model. The lack of primary care in our area and the under-utilization of NPs got our idea off the ground, and now the MOHLTC is gearing up to open 25 NP-led clinics in Ontario, significantly impacting the orphan patient situation here - many of whom have no primary care for many years, and currently end up 'ALC'.
This is a model where the NP can practice her or his full scope of skills, and really make a difference for people without access to primary care. Though we spearheaded the first clinic (Sudbury Ontario), we soon found ourselves caring for 2000 patients who did not previously have access to a ‘family doctor’. Our patients come from all walks of life, all ages, and with every condition imaginable. Many have one or more chronic diseases, and sadly, we are diagnosing health conditions such as cancerous tumours and other serious issues frequently. We work with a small team of dedicated collaborating physicians, nurses, and other allied health care professionals, and when required, the patient is referred to a specialist's care. Our ability to care for a myriad of illnesses and provide preventative care includes prescribing medication, ordering lab tests, xRays, ultrasounds, mammograms and a wide variety of treatments.
What if the patient has something which needs a doctor's attention? Our collaborating physicians step in. Their time is focused on very complex cases. The same collaborations will be in place at the clinic’s 2nd site when it opens in the fall of this year, 2009. This is an integrated venture combining the resources of our team's expertise with the City of Greater Sudbury's support (the facility) and the Ministry of Health and Long Term Care. A total of 4500 patients will eventually be cared for by these two sites.
30,000 people are currently without primary care in our community - typical for Northern Ontario. Many of our patients are people with serious chronic illness, multiple conditions, injuries, mental health and physical ailments of all types. They are babies, new mothers, people with diabetes, sexually transmitted disease and other infections, people needing family planning, cancer care, end-of-life care and diagnostic exams of all types. The list of ‘what the NP can do’ is a long and growing one, enabling the physicians who work with them to focus on more complex and critical cases. The NP-MD collaboration is a key element of the model.
Nurse Practitioners have been providing care under the ‘Extended Class’ category ( see http://www.cno.org ) for many, many years. Ours is a tried and proven scope of practice expansion, which is already part of successful, sustainable health care here and in other countries. Canada is now leading further primary care reform, with this NP-led model. The forward-thinking planners in Ontario’s Ministry of Health and Long Term Care (MOHLTC) are to be commended for launching this patient-centered initiative. With 25 NP clinics planned for Ontario, where well over 500,000 people do not have access to primary care, and our hospitals are struggling to cope - this innovation will go far in helping with the patient tide showing up in our EDs and ending up ALC. With the capacity for each NP to carry a patient load of 800 patients in a setting like ours, even if each of these new clinics had only 3 NPs, the orphan patient issue in Ontario would be drastically reduced quickly.
This model has proven to be highly satisfactory to the patients at our Sudbury clinic. Ontario’s new NP clinics will be staffed by experienced NPs, as well as new graduates, just as would be seen in all fields of practice. The MOHLTC is including physicians as part of the NP clinic model, and many physicians are looking to team up with the clinics already. The opportunity to help patients learn to manage their own health in a much more successful team approach is a welcome change for patient care in our communities.
Health care professionals in communities where NP clinics will be opened can look forward to a new partner in caring for the people of their area. They may seek to join the new teams as collaborating professionals.
We welcome your comments. http://sdnpc.ca . The NPs of the Sudbury District Nurse Practitioner Clinics .
Excellent use of time, resources and interdisciplinary team work! Recently Steven Lewis commented on Ross Bakers book 'High Performing Healthcare Systems', stating how the physician's of Canada are trying to bring in physician's assistants. The logic of this pursuit by physicians for another group of health care providers is that physicians assistants report to, and under, physicians. Steven Lewis comments further on how NP's have demonstrated, repeatedly, that there is value and impressive results possible when physician's and NP's collaborate - as a team. Adding physician's assistants to Canada's care provider mix will serve to maintain the historical hierarchical structure, power and financial control of health care dollars by the physician's guild, and buffer an opportunity for true interdisciplinary patient focused care. The fact that there are physician's working with NP's in the Sudbury clinic is welcome news; there are physician's who truely are collaborators and care for the wellbeing of their patients.
Canada needs more innovations and approaches to health care such as this example of the Sudbury District NP clinics. It is a timely example of 21st century health care redesign to meet the needs of an increasingly complex world.
Innovation is linked to the creativity agenda everyone is talking about because creativity is not just about the arts. It is about the extent to which our organizations enable or constrain us to create a future that is more than just a continuation of the past. These Clinics embody creativity. The main thing that stops us is the tendency for our leaders to dampen down the creativity of people on the front line for fear of criticism or failure or loss of control. We have the creativity to solve many of our problems we just have to be free to do so.
Advanced practice nursing in Canada is receiving attention locally and nationally as gaps in our healthcare system persist, specifically as they relate to access to care and wait times. Nationally, nurse practitioners (NPs) and nursing leaders have developed documents that begin to define the foundation required for the successful introduction, evolution, evaluation and sustainability of the NP role (Bryant-Lukosius and DiCenso 2004). Much work has been done to promote the role of the nurse practitioner across Canada as provinces and territories learn from one another and overcome barriers to furthering this advanced practice nursing role (CNA 2006).
The context within which the NP role is being implemented across Canada is important. The role has the opportunity to evolve as a catalyst for change that may strengthen our collective thinking about nursing in a preferred future. Today, healthcare is defined as a "Canadian value" as access to publicly funded services increasingly becomes a focus for concern across the nation. If we are to sustain our publicly funded healthcare system, transformation is required - along with a paradigm shift for clinicians from all healthcare professions, administrators, regulatory and legislative bodies, policy makers at all levels of government across ministries and sectors, and the general public. A main focus on illness and treatment of disease must be re-balanced to include an orientation based on wellness and holistic care, with greater emphasis on prevention of disease, illness and injury (Villeneuve and MacDonald 2006). At the same time, continued treatment of existing health problems is required, with a focus on self-care. These fundamental values are embedded in the current nursing paradigm and can help lead the way as new care delivery models are introduced. Read more here: http://www.longwoods.com/product.php?productid=18900
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