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.
All too often such informal arrangements collapse. A health crisis causes overwhelmed caregivers to punch 911, and a bad situation gets worse. Last month, an 86-year-old woman was rushed to a Toronto-area hospital suffering from a stroke and heart attack, after hospitals closer to home said they weren’t accepting patients. She was admitted after 16 hours and given a temporary bed in emergency. She languished there for a week before finally getting a room, says her son, who requested anonymity. “If mom did not have my sister spending every day, all day, with her, we do not believe she would survive,” he says. “We are living the hell of Canada’s failing health care system.”
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.
The Toronto town hall on March 1 will be moderated by Maclean’s Ken MacQueen with opening remarks by Dr. Jeff Turnbull, CMA President. The panel features Mary Jo Haddad, President and CEO, the Hospital for Sick Children; Dr. Mark MacLeod, President, Ontario Medical Association; Durhane Wong-Rieger, President and CEO, Institute for Optimizing Health Outcomes; Andrew Coyne, National Editor, Maclean’s. For tickets and information on this event and the series, visit macleans.ca/healthseries.
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