Insights (Essays)

Insights (Essays) March 2012

Integrated Chronic Disease Care in the Community: Delivery Where it Works

Jane Coutts and Terrence Sullivan

The story of healthcare in Canada today is one of growing numbers of chronically ill patients poorly served by a system designed for acute, episodic care. Changing that story is essential — but is it possible? How?

The solution, it’s generally agreed, lies in community-based, multidisciplinary teams, dedicated to the care of chronically ill people, who face multiple health challenges but respond to well-managed, co-ordinated care. Integrated care delivered by teams with common, clearly stated goals, and a patient-centred focus that emphasizes self-management is the key to keeping the chronically ill from the crises that send them back to hospital. But how to create that world?

That was the subject of the 2012 CEO Forum, organized by the Canadian Health Services Research Foundation. The forum is an annual event bringing together health leaders from across the country to share strategies for improving healthcare. This year, we asked a number of clinical leaders to tell us about how to ensure high-quality ambulatory and community care for people with complex chronic conditions. 

The result was glimpses into several effective projects, a long list of barriers to change and some better understanding of how to make progress — along with warnings that the process is not likely to be rapid or to produce sweeping change easily.

The statistics are familiar but no less grim for that. One per cent of patients account for one-quarter of healthcare costs, 5 per cent of patients use up half the healthcare budget. And 81 per cent of Canadians over 65 have at least one chronic condition. The people those numbers represent are in and out of hospital with everything from congestive heart failure and chronic obstructive pulmonary disease to mental health problems. Too often, after admission and stabilization they are “discharged to nothing,” as speaker Irfan Dhalla of St. Michael’s Hospital in Toronto put it. “There’s a high-voltage drop in intensity of care after discharge” he said, quoting a U.S. study that found 21 per cent of Medicare patients were back in hospital within 30 days of discharge — and in 50 per cent of those cases, the patient did not see a physician before being readmitted to hospital.[1] The situation is not much different in many parts of Canada.[2]

That collapse of care between hospital and community should never be allowed to happen. In B.C., the HomeViVE (Home Visits to Vancouver’s Elders) program supports the frail elderly at home, through a team of caregivers who believe sending the very old into emergency is akin to dropping something fragile from a great height. In Toronto, a group of downtown hospitals transfers vulnerable patients from inpatient wards to a “virtual ward” on the day they’re discharged; care continues at home through a multidisciplinary team. In Montreal, Pointe-de-l’île health and social service centre is testing “telehomecare.” The program puts high-tech monitors into the homes of newly-discharged chronically ill patients, who enter their health data on a screen. One nurse oversees results from 80 patients at once, but there’s also homecare backup and patients can call for support any time.

Further afield, accountable care organizations (ACOs) are being introduced in the U.S.A. Designed to provide care to Medicare patients, ACOs are groups of doctors, other providers and hospitals who benefit financially (or share the risk) if they meet certain standards for high-quality, coordinated care. Adalsteinn Brown of the University of Toronto told the meeting ACOs are organized around patients, not hospitals or political boundaries. But he cautioned that Canadian healthcare’s obsession with trying to create structures, rather than developing patient-centred care, may get in the way of developing ACO-style organizations here.

Thomas Lee, network president of the Partners Healthcare System (attached to Brigham and Women’s and Massachusetts General hospitals in Boston) told the meeting how you work together, rather than structure, is what matters. Their key to bringing professionals and organizations together is to focus on an overarching goal — which for his group is “to increase value for patients.” That translates, among other things, into asking patients what their health goals are. The answers often differ from the process goals institutions aim for. “I would make yourselves the world leaders in measuring outcomes that matter to patients,” he told the meeting.

The forum focused on efforts to manage chronic disease linked to hospitals and institutions. That focus was to show that we can overcome the barriers that keep general internal medicine doctors (who for the most part work in hospitals) from caring for patients in the community. Those barriers are perpetuated by organizational and funding structures and our need to do a better job training people to work in teams.

The institutional focus is a mistake, said Canadian Nurses Association CEO Rachel Bard “If we want a revolution…we need to change our frame of reference,” she said, calling for community care that would keep people from going into hospitals in the first place. Shirlee Sharkey of Saint Elizabeth Health Care added “The broader issue is not the hospital/ community/ home care divide, it’s person-centred care.”

Kaveh Shojania, director of the Centre for Patient Safety at the University of Toronto told the meeting he was getting the message change by baby steps was more likely than revolution. “I think we are all saying change begins locally.”

On the evidence, that’s true — but is it enough? No. Incrementalism has not delivered us the healthcare system we need in 2012 and it is not helping the people who most depend on healthcare.  We need to do more to move away from solo general practice and towards integrating general internal medicine with community and primary care, based on the meeting. We need to train and pay healthcare providers as team workers from the beginning. If this requires us to ditch rules and practices that are barriers to better care so be it. Perhaps motivated professional teams can push what policy makers find hard to advance.

Changes do begin locally, but they must not be allowed to remain local. Our responsibility is to forge links from project to project, from institution to community and from jurisdiction to jurisdiction across the country, with the patient at the centre of everything we push for.

[1] Jencks et al, NEJM 2009; 360: 1418-28


About the Author(s)

Jane Coutts is an Ottawa-based writer and editor who specializes in healthcare issues. She is a former health policy reporter for The Globe and Mail and later worked for the Canadian Health Services Research Foundation before starting her own business, Coutts Communicates.
Terrence Sullivan, PhD, is the chair of the CEO Forum. He is the former President and CEO for Cancer Care Ontario and current chair of the Canadian Agency for Drugs and Technologies in Health (CADTH).





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