A rise in hallway health care and bloated emergency departments has become a norm in Ontario's health-care system. This first episode of a three-part series hears from physicians working in the home- and community-based care sector in the province, as they discuss the issues behind hospital overcrowding and the solutions based on the Ontario Medical Association's Prescription for Ontario: Doctors’ Solutions for Immediate Action advocacy document. Listen in as we hear from Dr. Devon Shewfelt, emergency physician at Alexandra Hospital Ingersoll in southwestern Ontario, and Dr. Russell Goldman, director of the Temmy Latner Centre for Palliative Care at Toronto's Mount Sinai Hospital.
A rise in hallway health care and bloated emergency departments has become a norm in Ontario's health-care system. This first episode of a three-part series hears from physicians working in the home- and community-based care sector in the province, as they discuss the issues behind hospital overcrowding and the solutions based on the Ontario Medical Association's Prescription for Ontario: Doctors’ Solutions for Immediate Action advocacy document. Listen in as we hear from Dr. Devon Shewfelt, emergency physician at Alexandra Hospital Ingersoll in southwestern Ontario, and Dr. Russell Goldman, director of the Temmy Latner Centre for Palliative Care at Toronto's Mount Sinai Hospital.
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Georgia Balogiannis: In this podcast, the Ontario Medical Association looks at current issues of interest in healthcare. Spotlight on Health gives you all the straight talk. We're Ontario's doctors and your health matters to us. I'm Georgia Balogiannis for the Ontario Medical Association.
Too many people are languishing in hospital beds instead of being cared for in the comfort of their own home. This first of a three-part series looks at the OMA's recent advocacy document for change, titled Prescription for Ontario: Doctors’ Solutions for Immediate Action. We hear from physicians on hospital overcrowding and the solutions that may provide appropriate levels of home care for infirm or palliative patients.
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Georgia Balogiannis: Dr. Russell Goldman is the director of the Temmy Latner Centre for Palliative Care at Toronto's Mount Sinai Hospital.
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Dr. Russell Goldman: I've been doing palliative care for the last 28 years and mostly my practise is focused on home care, so I've actually spent most of my career seeing patients in their homes although I do have exposure to working in other settings including acute care hospital, palliative care unit, long-term care facilities, doing some consultation in there as well. In terms of our patient population, about 60ish percent have cancer as a primary diagnosis and the other 40% have an illness. A serious illness like heart failure, dementia, and neurodegenerative conditions, sort of makes up the bulk of the other groups of patients that we see.
Generally, we see patients who are at or approaching the end of their lives. So many of our patients will just be referred in the last weeks or months of life, but we also have patients who were referred and that we’ll follow for an extended period of time. Having the capacity to squeeze people in and juggle my day to see people on short notice, I think is really a critical factor and something we don't necessarily take into consideration when we're doing system-level kind of planning.
It'd be great if we had this control centre where there's a central triage system and a patient comes in with an acute need that's followed by this dedicated home care team, and then you can identify who's nearby, which nurse or physician or somebody else might be able to see that person relatively quickly. We have all the tools and the ability, it’s just a matter of how our system's currently organised.
We know we're servicing an ageing population, that an increasing number of people are going to become housebound over time and want care at home. But most of our systems are actually designed around people coming to see us in fixed geography — hospital, clinic, offices. We haven't really oriented ourselves as a system to think about how do we bring care to people. So I think we see all the things that we do see, right? People ending up in the emergency department and in the hospital because we haven't facilitated the care coming to them.
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Dr. Goldman: In areas that historically have been challenged from a personnel perspective, the North, and rural areas, just in terms of shortage of primary care and perhaps other services as well, then that just gets compounded when you're dealing with house calls or people who are at home because if there's a shortage of staff, those are often the things that get cut first. I think in urban areas, the lack of access is often maybe due more to how we choose to organise care or create opportunities for the care of these patients.
Doctors don't work in the neighbourhoods that they serve more often than not, and so we sort look at some of those things around convenience where a doctor might see a patient on their way home or on their way to work or they pop out. Back in the old days when people sort of worked in the neighbourhoods that they lived in, but that's not the way things are, and so how do we adapt our system to the current realities?
I was asked to see a patient, a woman with dementia who was living with her daughter at home, and the thing that instigated the referral was that the patient was having mobility issues and was more challenged to get into their family doctor's office, but they were still getting out. And so when I came to see this woman at home, she was up walking around with her walker. She was eating and drinking well. Physically, she looked quite good. Her memory was quite impaired. I was also cognizant that people can deteriorate and change very quickly, and then it's a rush to access services.
That's where sometimes things will fall apart and they'll end up in the emergency department in the hospital. So in this instance, she started getting some home care services and it was very low level, there wasn't a lot of need. And then during the summer she had a sudden change of status within 24 to 40 hours, just stopped eating, stopped drinking, and then died about a week later. I was relieved that we had kept her on and maintained that contact and provided her with the care that she needs.
So when she did deteriorate we were able to max out the services and increase the nursing visits and the frequency, but the team was all there already placed and ready to roll when things deteriorated. So much of this is trust. It's trusting the system, right? So the family trusts that they could call and somebody would respond in a timely fashion, then they had trust and they knew that the team was working closely together. I always say, we know how to do this work. We just don't do it on a consistent, large-scale basis, but we have all the needs and necessary tools. In some areas we just lack the personnel.
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Dr. Goldman: The way we pay people and the way we organise care and the way we do all of this is so… it hasn't changed in 50 years and there's all sorts of opportunities to create efficiencies and invest, right? And if we think about the cost of building more long-term care beds and how long those take to come online, and most people, even if they need a long-term care facility or they need a palliative care unit or something like that, most people want to be at home as long as possible.
But how do we create the opportunities for people to be at home as long as possible and then to transition them to where they want to be or where they might need to be when we can't provide the necessary care anymore at home. How do we compensate and account for that to be able to attract people to that work? Some of it's money, some of it's how we organise care so that people feel supported. There's lots we can do, we just need to do better.
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Georgia Balogiannis: Dr. Devon Shewfelt is a family physician from London, Ontario. He works in the emergency department at Alexandra Hospital, Ingersoll.
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Dr. Devon Shewfelt: My practise is community-based. I'm in a large family health organisation group of 16 physicians. I’ve had fantastic access to broad-based care for our patients, including nursing and nurse practitioners and dietitians and pharmacists, amongst others, and I've again been fortunate and my patients have been fortunate enough to be able to share in that breadth of knowledge that they provide. I provide really cradle to grave care for all broad population of patients, newborn from the hospital to someone in their nineties with complex medical issues.
The days are so varied and the experiences are so varied, but there are lots of folks that really need specialist care that just can't get timely access to it because of the strained resources that we have. A lot of family physicians are strained and stressed and the demand on their practise is significant to the point where they can only fit in so many patients. That access is a really big barrier.
The best examples of patients that presented in the emergency department, who would've been otherwise best cared for out in the community, or the more regular representation of that is just those complex geriatric patients where it's not that anything individually is wrong acutely day-to-day. If they're not set up with all of those same resources, especially so if they're only being supported by caregivers and family members that are already burnt out themselves, they really end up languishing and it's just that inevitable slow decline until they present again.
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Dr. Shewfelt : We find ourselves a lot in medicine thinking that we have to reinvent the wheel each time we do anything, and the truth is there are fantastic systems that work, but this is an existing system that provides home-based community care that absolutely — both based on subjective experience, but also on hard data — allows people to stay well and stay safe and stay at home where they, at the end of the day, oftentimes prefer to be. And so I think it serves their purposes as well, as well as ours.
Our patient population is ageing. They're living longer, and so they're not dying acutely in their sixties and early seventies. They're accumulating complex medical problems over the course of their lifetime and so as that function declines, as they become increasingly, frankly, lonely and bored and frail, they become that much more of a fine balancing act of management.
The access and the availability of beds and supports, and in the case of palliative care of specialty teams and staff — the population’s ageing faster than the availability is growing, and so it's really not a simple problem. It's a very complex and nuanced problem. The first thing I think about, honestly, is actually just leveraging virtual care. I think we're in the early stages of doing so. If I have a critically ill patient and I just need to run that patient by another emergency physician or otherwise, I can do so.
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Dr. Shewfelt: I think every patient deserves and has a right to die with dignity and their interpretation of what that means. They also have a right to determine for themselves, and certainly that changes the type of care and the delivery of care. I recognise that we're in a system that is far less than ideal and does not provide adequate care for large portions of the population, and systems change very slowly. I think there's a disparity across — in terms of access to palliative care — across Ontario largely on the basis of resources.
What that means is that people then have to die in a hospital setting or otherwise, and I know that I wouldn't ever want that for myself or for a family member either, depending on circumstances of course. With broad-based access to team-based care where you have physicians, may also have nurses, you have occupational therapists, have ready access to someone who can provide specialist opinion on how to best provide palliative care to their patient. We're going to be able to meet the population of Ontario where they are far more effectively.
Georgia Balogiannis: This podcast is brought to you by the Ontario Medical Association and is edited and produced by Jodi Crawford Productions. To learn more about the Ontario Medical Association, please visit oma.org.
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