Health Care's Next FrontierGO TO SATURDAY, MARCH 27, 1999
Research is Skimpy on How Much is Saved
Photo Essay by Tibor Kolley
During the late 1920s, Ardath Bitney's grandfather would wander around Regina, getting lost more often than not. Fellow citizens would keep an eye on the elderly man, who probably suffered from dementia, and almost daily police dutifully delivered him back home, where his daughter-in-law cared for him in addition to her other chores. The family not only provided care but paid all his medical bills until he died in 1931, at 80.
In 1967, Ms. Bitney's father was diagnosed with lung cancer. Thanks to the advent of medicare, the family was not saddled with huge medical bills. But unlike in previous generations, the caring and dying were done in a sterile institution.
In 1985, Ms. Bitney's mother passed away at 94. In her later years, she had grown confused and in need of help with activities of daily living, and people had suggested that she move into a nursing home. She refused. So, until her death, her elderly daughter, who lived in the same building, was her only caregiver.
Ms. Bitney's family medical history is, in a nutshell, the story of the evolution of Canada's health-care system. It also illustrates the challenge of a publicly funded medicare system: How do you reach out to those wandering the streets, those who are acutely ill and those with degenerative illness, and do so efficiently, effectively and without overburdening their families or cutting them off from their communities?
The answer to that complex question is, in many ways, found in the treatment of Ms. Bitney herself.
Today, at 90, she lives alone in a seniors residence in downtown Regina. While she has an array of minor health problems, Ms. Bitney remains active and independent. Her daughter, who lives across town, visits regularly, and the building has a variety of activities for frail seniors.
To ensure that she remains in the community, the Regina Health District provides weekly visits from an attendant who helps her bathe and runs errands, a nurse to help with medication, and hot meals delivered three days a week. Ms. Bitney supplements this with group meals in the complex and a cleaning lady she hires privately.
"Personally, I can't think of any services that I want that I don't have. I'm happy at home," she said.
There was a time, in her lifetime, when families provided all the care, and assumed all the costs. The creation of a medicare system eased the financial burden, but voguish technological fixes stripped away much of the community element of care. For many years, the elderly were shunted off to institutions, where they filled chronic-care and nursing-home beds by the tens of thousands.
Today, like Ms. Bitney, many people shun institutions. They are choosing to live and die at home again but don't want to be left to their own devices. They are demanding that the system adapt to them, not vice versa.
Chief among their demands is homecare, a service that has traditionally been the poor cousin of the health system, an add-on rather than an integral part of medicare. In Saskatchewan, where medicare was born of Prairie populism, this consumer-driven retooling and redefinition is well under way.
In Ardath Bitney's tiny apartment, not only is homecare taking root as an essential service, but medicare is being reborn.
Dawn McNeil, director of homecare for the Regina Health District, says the key to keeping the public health system relevant is not only to create homecare programs but to create a continuum of care.
"The biggest challenge is convincing people that none of us operate in isolation, that it's in everyone's best interest to look at the system holistically," Ms. McNeil said.
Cathy Peters, director of the health district's system-wide admission and discharge department, says Canadians need to profoundly rethink their view of the health-care system -- to make what academics call a paradigm shift.
"If we're going to have a system that really responds to needs properly and efficiently, the public has to realize that health care does not begin with admission and stop with discharge, that health care doesn't have to take place within four walls of the hospital," Ms. Peters said.
"Health care begins at birth, and ends at death, and the system has to be integrated and accessible in a way that we can always provide the right service to the right client in the right location at the right time."
In other words, the perfect system is seamless, one in which people don't realize they are in a system, one in which they can shift effortlessly from a doctor's office to a hospital to home and back again.
Keith Deiter, a 61-year-old truck driver who had quadruple-bypass surgery on Dec. 15, is an example of someone who has benefited from a smooth transition. He spent two weeks in the hospital, and since then has been getting weekly visits from a homecare nurse. (Because he is a diabetic, the wounds where veins were removed from his leg have been slow to heal and treatment has dragged on.)
"It's really great to have someone come to your home, especially when you're not mobile," Mr. Deiter said. He was unaware of the significance of the fact that his medical chart moved with him from hospital to home -- a bureaucratic concession that amounts to a revolution in health-care thinking.
To him, the surgeons, the nurses, the pharmacist, the family doctor, the nutritionist and the occupational therapist are all "people who are helping fix up my heart," and he fails to understand why these various groups would compete with each other for funds and patient control.
This common-sense view is what policymakers are now trying to put into place by knocking down traditional barriers and hierarchies.
Marcus Hollander, a health-policy analyst who is currently heading a national evaluation project on the cost-effectiveness of homecare, says five elements are required to create an integrated system:
-- A single point of entry for getting services;
-- Co-ordinated assessment and placement;
-- Co-ordinated case management;
-- A consistent classification system for services;
-- A single administration.
Since 1993, Saskatchewan, like a number of other provinces, has been trying to create just such a system, as much for financial reasons as philosophical ones. The first step was creation of regional health boards, responsible for all health services within a geographic area, with the idea that a single administration will spend money where it gets the best bang for its buck.
In the past five years, Saskatchewan has not reduced its health budget, but it has shifted significant sums out of acute-care hospitals and into community-based services such as homecare. Having a single point of entry to the system eliminates inefficiencies and helps avoid crises such as emergency-room overcrowding that is common elsewhere in the country. And having a single case file for each person served eliminates one of patients' principal complaints, that they are asked the same questions over and over again.
Placement co-ordinators, using various assessment tools, decide where a person is best cared for in the system: hospital, home, nursing home, rehabilitation facility, or any combination. In emergency rooms, there are quick-response teams that can assess problems and get people home, with up to 24-hour care, before they even tie up emergency-room resources.
"We don't have emergency-room overcrowding in Saskatchewan. It just doesn't happen here any more," said Susan Wagner, a professor of nursing at the University of Saskatchewan and a member of the Saskatoon District Health Board. "Homecare has played a key role in this because it eases the pressure on admissions."
It is this ripple effect -- diverting emergency-room patients, emptying acute- care beds, delaying admission to nursing homes -- that has caught the eye of cost-cutting governments and made homecare the saviour du jour of medicare. But those working in the system warn that homecare is not, in itself, a panacea, that simply dumping patients back into the community with inadequate planning and insufficient resources is no solution at all.
Yet the new approach of making homecare the linchpin of a continuous-care model has already made the system much fairer. Before regionalization and cutbacks, most provincial health-care systems were riddled with fiscal irrationality and unfairness. For example, a frail senior could be kept in an acute-care hospital bed for years at astronomical expense, but another living at home with a family caregiver could not access both homemaking and sitter services because that was considered extravagant.
Today, the guiding principle is risk management, allocating services in a manner that minimizes the time a person spends in an institution and maximizes his or her quality of life.
"If a person has 10 years to live and they spend eight in the community and two in an institution rather than the other way around, then we are doing something right," said Sue Neville, head of the Regina district's long-term-care program. "One of the easy solutions in health care is institutionalization. It gives the perception of having solved a problem, but if it's done inappropriately it just creates new problems."
In some jurisdictions, placing someone in a nursing home is often a preferred option because it shifts much of the financial burden from the state to the individual. In Saskatchewan, nursing homes are heavily subsidized, so there's no saving for government in shunting people into institutions. On the contrary, financial logic dictates that more resources be pumped into homecare to delay nursing-home admissions. Waiting lists for nursing homes in the province have been virtually eliminated, and those who truly need a nursing-home bed get it quickly.
Yet even in Saskatchewan, homecare suffers from the perennial problem of the traditional parts of the health-care system: seemingly unlimited demand.
Regina's system currently has about 2,900 clients, with about 85 per cent getting long-term care that could last years. Another 13 per cent are acute-care patients, most of whom leave homecare within a couple of months. The balance are palliative-care patients.
But each month there are more than 300 admissions and only about 200 discharges, with cases becoming increasingly complex. So, in many ways, the homecare sector is inheriting many of the problems hospitals have struggled with in recent years: increasing demand but funding that, while growing, is not keeping pace.
Homecare is also an anomaly in the public health-care system because, in many instances, user fees are charged, even to those with low incomes. That approach has become increasingly difficult to justify as the services shifted to the community grow more medical in nature and policymakers promote the notion of a seamless system.
Under the Canada Health Act, only medical services are insured. That means patients, at home or in hospital, don't pay for doctors, nurses or related care. But at home patients pay, at least in part, for assistants who bathe them, for meals and for cleaning -- services provided in hospital with no user fees.
Because homecare services are not guaranteed under the Canada Health Act, there are also widely varying standards and services offered from province to province. In Saskatchewan, everyone pays for the first 10 units (hours or meals) of non-medical service at $5.55 each. After that, payments are based on income, to a maximum of $320 monthly.
Despite a rapid growth in homecare and tightening of criteria, the share of revenue that comes from fees is less than 10 per cent in Saskatchewan and actually falling. There is a growing sentiment for removing fees altogether because administration costs make collecting them almost a losing proposition.
A far more contentious issue, and one that tests the very philosophy of continuity of care, is: At what point does it become too expensive to care for someone at home instead of in an institution?
In Saskatchewan, homecare administrators try not to exceed the cost of hospital care -- the non-medical portion of which is roughly $2,100 a month. But there are always exceptions, such as for ventilator-dependent children who live at home and palliative-care patients.
Michael Huck knows that he is close to the province's limits. The 48-year-old has a form of muscular dystrophy, a degenerative disease that has left him a quadriplegic. He gets homecare assistance four times daily -- getting up, lunch, supper and bedtime -- and occasionally needs an overnight sitter if he is having breathing problems. But aside from his chronic condition, he is in good health and doesn't need any medical assistance.
"Without homecare, I would be in Wascana Rehab Centre," he said. "The traditional medical model approach is to take people like me and lock them away." For Mr. Huck, homecare provides something far more fundamental than an insured medical service. "It's an issue of participation in society, of citizenship. Without homecare I would be a second-class citizen, I would be robbed of my ability to be a part of the community."
He believes that recognizing this reality is the next challenge for the health system. Governments may well be on the verge of creating a continuum that ensures a smooth provision of medical services from birth to death, but they must now use that modest achievement as a launching pad for promoting wellness and equality as well.
Saskatoon -- Late last year, Sherry Duncan Paterson had surgery to remove painful gallstones from her bile duct. The operation went off without a hitch, but she later developed a serious infection that sent her back to hospital.
The antibiotic treatment required to fight off the stubborn infection consisted of two drugs administered four times daily over an eight-week period.
Not long ago, Ms. Paterson would have been forced to spend that time in hospital. But today many intravenous drug treatments are administered in the home.
For Ms. Paterson, the greatest thing about homecare was that it allowed her to get on with her life. "Doing the IV therapy at home allowed us to go back to being a family," she said while preparing lunch for her two daughters. "I already spent two weeks in the hospital, and eight more weeks would have been unbearable."
For the health system, the payoff was, at least on the surface, rather more quantifiable: a saving of more than $15,000.
But for all the remarkable claims made about the cost-efficiency of homecare, there is very little research to support them.
In the case of intravenous therapy, for example, the simple home-versus- hospital cost calculation is simplistic. Because unless the hospital bed that Ms. Paterson freed up for eight weeks is actually shut down, her homecare treatment becomes an additional cost to the health system.
"Society is very uncomfortable with an empty hospital bed, so the best thing we can do with it is blow it up. If we don't, there won't be any cost savings," said Steven Lewis, chief executive of the Saskatchewan Health Services Utilization and Research Commission. Despite the hue and cry about hospital closings and bed reductions, Mr. Lewis believes governments have not gone far enough.
Research by the commission shows that in 1992 between 48 and 65 per cent of days spent in hospital by adults were for non-acute care. In other words, more than half the time patients spent in hospital was convalescing and being monitored, tasks that, for the most part, could easily be done at home.
While those numbers have undoubtedly come down after a wave of cutbacks in the hospital sector, days of non-acute care are still prevalent in the institutional setting. In the past decade, the average hospital stay has gone down only one day.
In Saskatchewan, spending on acute care has dropped 14 per cent since 1991, to $585-million; during the same period, the province's homecare budget has doubled to $67-million. And three-quarters of patients in Saskatchewan still leave hospital without homecare.
In the most extensive research done to date on the question in Canada, Mr. Lewis's commission found that adult surgical and medical patients could be discharged from hospital, on average, two days sooner. Those patients could be provided homecare, without any effect on their health outcome, at a savings of $830 per case.
The source of savings is easy to explain: A day in hospital is expensive, about $360 in Saskatchewan; for the same money, a patient can get more than six hours of nursing. (Providing one hour of nursing costs about $65, an hour of help by a homecare aide $49, an hour of homemaking $25.)
For individuals, however, there were some troubling revelations in the Saskatchewan agency's research. Notably, 60 per cent of patients who were deemed to require homecare did not receive any.
Further, much of the cost saved was shifted to patients and, more specifically, their unpaid caregivers. Researchers estimated the value of caregiver time at $564 and out-of-pocket expenses at $94.
Research to date has focused on substitution of homecare for acute care. So has the attention of governments, who like homecare's potential for quick savings and the political mileage they can get out of stories of patients being treated in the community and happy to be so.
But Mr. Lewis says that in the long term, two other types of homecare clients seem to have tremendous potential to generate cost savings: those who might otherwise be in long-term residential care, and those whose use of health services can be reduced by low-intensity preventive homecare and social housing.
"I think institutional care is the real battleground of the future. If you blow an acute-care case and leave someone in hospital to convalesce, it's $800 down the drain. But if someone is in an institution who doesn't need to be, it's going to cost the system hundreds of thousands of dollars."
The third type of homecare, preventive, is the least studied and most taken for granted. It is also the area where, as demand grows, services are being dropped. Seniors who need help with activities of daily living are the ones being shunted aside, and academics warn that such an approach is foolhardy in the long run.
"Because bed substitution is seen as generating big cost savings, prevention and maintenance in the community has gotten short shrift," said Susan Wagner, a professor of nursing at the University of Saskatchewan and a member of the board of the Saskatoon Health District.
"Everybody is so focused on the acute side that care for the frail elderly and those with chronic disabilities has taken a big hit. We're going to pay heavily for that down the road," she said.
Mr. Lewis agrees. He says that seniors are being vilified for getting services that are portrayed as frills while there are perfectly sound public-policy reasons for spending health budgets on homemakers who clean, shop and provide attendant services such as bathing.
"Not giving Mrs. Smith a homemaker is not going to kill her, but [not having one] may prevent her from being in a situation where she falls and breaks a hip, or it may delay her admission to a nursing home by six months some five years down the road," Mr. Lewis said.
Put another way, you can provide a lot of homecare to a lot of people who, on the surface at least, don't desperately need it, and get it all back in the savings generated by a handful of cases. "As a health system, we should concentrate on saving big dollars over the long term rather than nickel-and-diming seniors," Mr. Lewis said.
And the way to find out how best to save those big dollars, he said, is by investing in research.
"One of the big scandals in this country is how we got so far into medicare with so little knowledge. We're willing to spend $80-billion a year on the system but reluctant to spend a few million to research whether the money is well spent," Mr. Lewis said, shaking his head.
"If we want to know if a homecare system is a good investment, we have to do the intelligence work. If we don't, we'll pay for the lack of foresight -- just as we're doing in the acute-care sector today."
Photo Essay by Tibor Kolley