The only health care commitment made by the Ford campaign during the 2018 provincial election was that they would fix hospital overcrowding if elected. Since that time, reports have suggested that the problem of hospital congestion is worsening rather than improving.
Recently, the problem was brought into sharp focus by an article showing that 40 hospitals averaged greater than 100 per cent capacity for the first six months of 2019.
The government’s response to hospital overcrowding has been to promise that 15,000 long-term care (nursing home beds) will be built and to open “reactivation” centres offering transitional beds in closed hospital sites.
However, none of the 5,000 new long-term care licences awarded by the last government in 2017 have yet been approved to proceed for construction.
Reactivation centres offer transitional care mainly in old hospitals (like the old Branson site named in the recent announcement, the Church and Finch sites of the old Humber Hospital and the University Health Network’s Hillcrest site). These facilities admit mainly alternate level of care (ALC) patients from acute hospitals. These ALC patients by definition no longer require acute care and are waiting (in transition) for community facilities to become available, mainly in long-term care.
Frail seniors admitted to hospital with a worsening of a chronic health problem (like pneumonia on top of chronic emphysema) frequently experience marked generalized weakening as a result of their illness and lack of activity while in hospital. When assessed in hospital after the acute illness, they may appear incapable of returning home and are put on the long-term care waiting list. However, given a chance for a period of rehabilitation, evidence suggests that 30 or 40 per cent these ALC patients could likely return home with home-care assistance.
Is it time that we take a lesson from U.S. Medicare in trying to improve hospital overcrowding and the high proportion of ALC patients in our hospitals? There is no hallway medicine in America in part because of skilled nursing facilities (SNF’s), which are designed to rehabilitate frail seniors after an acute hospital stay and reduce the need for ALC designation.
SNF’s employ nurses, support workers, physios and physio assistants to provide care that emphasizes reconditioning weakened seniors after their acute hospital stays. Because these patients are medically stable and mainly in need of ambulatory strengthening, the clinical human resource requirement is less expensive in SNF’s than in hospitals. And because patients admitted to SNF’s are not expected to stay forever, there is less facility regulatory burden than in long-term care, which will be the citizen’s home forever.
Our old hospital reactivation centres are the closest thing Ontario has to SNF’s at present with the exception of an interesting collaboration between Sunnybrook Hospital and a community health agency providing care for discharged ALC patients in an older retirement home in Toronto.
This Sunnybrook collaboration is particularly interesting because there is a limit to the number of old hospitals that can be repurposed as SNF’s. However, engaging the retirement home industry in re-purposing older retirement homes or indeed, including SNF space in new retirement homes could encourage the private sector to help in addressing hospital overcrowding. Their response could alleviate the current hallway medicine crisis much more quickly than building new long-term care, which requires greater attention to regulation.
Interesting community agencies and private retirement home operators in helping to solve hospital overcrowding would require the ministry of health to set a reasonable rate for operation of an Ontario SNF. Using the U.S. Medicare example, patients would not pay a copay (like they pay in long-term care) for the first three months they were in an SNF. Thereafter, if they are unable to get home, an SNF copay could be charged to offset their “room and board” charges while they wait for a long-term care (or retirement home) bed.
Earlier discussions with the Retirement Home Regulatory Authority and with the retirement home industry suggest a willingness to develop SNF’s in Ontario. This solution would be more cost effective than maintaining deconditioned patients in acute hospitals or waiting to build long-term care beds.
It would also offer deconditioned seniors the opportunity of a safe space for short-term rehabilitation that could get them to where they really want to go- to their own home.
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