It's Time To Panic About Long Term Care

No amount of micromanagement will prevent the collapse of the acute care system unless radical action is taken.

The health care system never lacks for drama. Some of it - medical tribal infighting comes to mind - is just that: drama, and nothing more. It can be safely ignored except perhaps as entertainment. The more newsworthy drama - tax policy, bureaucratic restructuring - will have palpable long-term consequences for the system, but mainly at the local level...a clinic closed here, longer waits there, and so on. And sick as it sounds, the shameful tragedies - overdose deaths, youth suicide - don't strain the system all that much, because caring for the living is much harder than caring for the dead. So most of the time, things rarely end up as bad as they're made out to be. The system trudges along as it always has and always will. 

There is one area, however, where this does not hold true: the shortage of long-term care (LTC) capacity. And no matter how much the powers that be might try to shrug it off, you've read it here first: if radical action is not taken to expand long-term care, and fast, we can count down to the systemic collapse of the acute care hospital system in months.

Once upon a time, hospitals were places where people with acute illnesses, medical and surgical, went to be worked up, treated, then sent home. Sometime in the 1980s, and particularly in the 1990s when the number of acute-care hospital beds was slashed, hospital wards began to fill with so-called "alternative level of care", or ALC patients. These are mostly frail seniors, over half with dementia (table 2 in linked document), who don't require acute medical care, and are waiting for discharge to a LTC bed, rehabilitation facility, or home with proper supports (figure 5 in linked document).    

When you hear or read about hospitals putting patients into ridiculously unsafe conditions, it's not because people with acute illness are staying too long. Hospitals have become extremely efficient at reducing the average length of stay for people with acute illnesses, despite ever-increasing complexity for most medical problems. No, the persoalan is ALC patients that have nowhere to go. Some estimates place the proportion of acute care beds taken up by ALC patients at 10-13%. That's dozens of full hospitals' worth of frail seniors who don't need to be where they are. Not only is being in hospital a terrible use of resources and the chief cause of overcrowding, it's hazardous to an ALC patient's health, putting him or her at risk for hospital-acquired injury and infection. So why not get the people that need long term care into long term care?

Buried in a routine report to one of Ontario's regional health authorities (LHINs), one can find statistics for the current inventory of LTC beds in Ontario. While there will always be regional variances, Ontario numbers will never be too far off from the rest of Canada. In 2015, with hospitals as crowded as they were and continue to be, Ontario had 134 LTC beds per 1000 seniors over the age of 80. Presenting the number of beds in reference to seniors over 80 is not arbitrary. The proportion of seniors living in long term care climbs dramatically past age 80, from below 5% under age 75 to almost 30% by age 85 or older.

By 2020 - and we're just over halfway there from 2015 - simple demographics will drop the ratio of LTC beds to 114 per 1000 seniors over 80, or roughly 15%. In other words, the relative supply of long-term care beds is falling by almost a sixth, with no indication of a major expansion in home care services or hospital capacity to make up the difference. With acute-care hospitals running at or above capacity, does anybody in a position of authority really think the system can withstand more bottlenecks and overcrowding? No, this failure to expand LTC will end in one of two ways: tragedy or catastrophe.

Envisioning how it unfolds is not hard, and bear in mind this is independent of human health resource problems like local doctor shortages. It will likely happen in the winter, when an uptick in admissions from influenza or norovirus puts every hospital in a region past its limit of being able to provide proper care. Either a disabling accident or death will occur in a patient languishing in an inadequately-supervised hallway, or someone with a treatable acute illness like a heart attack or intestinal bleed will die because his or her ambulance was turned away one too many times. These happen now, of course, but we'll see a series of them across the country in a very short time frame, making them impossible to ignore. Hospitals will do what they can, cancelling almost all scheduled surgeries and stopping just short of literally kicking patients out the door. Many mid- and senior-level administrators will lose their jobs in the name of "accountability", as has been threatened by the Quebec government. The firings will satisfy Twitter and the talk radio audience, but ultimately do nothing to address the underlying problem. 

Aside: as one of my supervisors in internship once said, we need to use the term "scheduled surgery" instead of "elective surgery". The word elective gives the false impression of a surgery being unnecessary, like a nose job. In reality these operations run the gamut from hysterectomy to joint replacement to spinal fusion...hardly something the patient "elects" to undergo without good reason.  

At this point we will see a second round of preventable deaths, which is where human resource problems will be unavoidable. There will be waves of nurses and clerical staff taking urgent stress leave, particularly where well-liked senior administrators have lost their jobs. There will be nurses here and there to pick up the patient care slack, drawn from the part-timer and outpatient worlds, but smaller ERs will close due to staff resignations and stress leaves, magnifying the pressure on big-city hospitals. Unlike most disasters, this will not result in political leaders parachuting in to express dismay and present solutions, because in reality there is no quick solution. The new wave of deaths will result in either a very public lawsuit filed against everyone under the sun, a Coroner's inquest, or both. Of course, neither proceeding will address the underlying persoalan either (though taxpayers will almost certainly prefer the price tag of an inquest over a that of a legal settlement).

Logically, senior officials will need to fall on their swords somewhere. Resignations or firings of Assistant Deputy Ministers and/or Directors won't register a blip, but if big-province Deputy Ministers resign or a provincial government falls, the accountability crowd will giggle in delight. Of course, (and all together now), none of this will address the underlying problem. From there, all bets are off, and the odds of radical, ill-conceived, and reckless reforms grow exponentially.

There is nothing in this hypothetical set of events that is terribly interdependent, nor does it include an "unknown unknown" like SARS or a novel antibiotic-resistant bacteria. This is simply what Canada is on track to experience in the next year or two, if policymakers continue to turn a blind eye to the unavoidable reality of demographics, and focus their energies on pointless micromanagement schemes and vote-buying goodies.

So despite the calls from hither and yon, now is not the time for Canadians to worry about paying for more cancer screening, or a restructured primary care, or robots in the operating room, or universal drug coverage, or dental care, or eye care, or anything else that's beneficial but not essential for the integrity of the acute care system. Rather, it's time to build safe, secure housing for the elderly and infirm, and build a lot of it, with all the urgency we can muster. If we don't, things can only get worse from here.

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Ditulis Unknown — Friday, September 1, 2017 — Add Comment — accountability, bureaucracy, Canada, capacity, finance, health care, health policy, home care, hospitals, Ontario, overcrowding, politics, regional health authorities, wait times