The features of Canadian healthcare vary from jurisdiction to jurisdiction but all health systems face the same pan-Canadian obligations and share similar challenges that reflect regional and national realities as well as global trends and tensions (Forest and Martin, 2018). How the country's health stewards approach those challenges – whether they eschew or pursue solutions to complex, seemingly intractable problems – is critical. It can either strengthen or still the ability to adapt and address the shifting needs of current and future populations.
This issue of Healthcare Quarterly examines several pressing and pernicious issues that have beset Canada's health systems. An aging population that within 10 years will include more than two million Canadians who are 65 and older and live with frailty and multiple morbidities (Muscedere et al. 2019). A surge in demand for services and age-related health concerns such as cataracts (Campbell et al. 2019). A health system with outdated models of care ill-equipped to provide quality comprehensive patient-centred care. Overuse of health resources in inappropriate settings and underserved populations. An opioid crisis, devastating and daunting, in which the harms associated with their use continue to rise while the number of opioids prescribed falls (Grywacheski et al. 2019).
These challenges call for full deployment of resources. But, as revealed in this issue of Healthcare Quarterly, too few clinicians are leadership trained due to lack of interest and access alike (Kirk et al. 2019). Too often, in-house research capacity is underutilized, misunderstood or unsupported (Bookey-Bassett et al. 2019). And healthcare risk management is unduly onerous, crowding out the key imperatives of keeping patients and providers free from harm (Stevens et al. 2019).
Luckily, this issue's authors provide promising examples of innovations that push past these impasses, with solutions developed, tested and implemented across Canada and embedded to great effect in other countries.
Caring for Seniors
The deeply absorbing article opening this issue of Healthcare Quarterly describes Denmark's multi-dimensional, interprofessional approach to caring for frail and older adults. As evidenced by John Muscedere and colleagues (2019), the search for service innovations outside the country can identify approaches highly applicable and potentially advantageous to Canada's efforts to improve care for the frail elderly. The article's authors were part of a Canadian Frailty Network-led contingent that travelled to Denmark to directly observe its leading practices. There they saw elderly and frail residents enjoy health and care in unique and nurturing ways – qualitatively different from how Canadian elders experience support. The delegation learned also that the Danish approach leads to system savings.
Back in Canada, a survey of seniors and caregivers in Hamilton, ON, provides a better understanding of what – and who – led them to the ED (Marr et al. 2019). Among the factors: lack of knowledge about where to go for alternate care and what conditions warrant a visit and when; lack of primary care options and timely access to them; and the belief that different care is required. Survey findings also showed that in deciding whether to visit the ED, older adults rely on input from others, but turn to only a small proportion of healthcare providers for advice. Authors suggest that patient and caregiver education could inform seniors and caregivers' decision-making and lead to more appropriate use of accessible services.
Effective Primary Care
This section of Healthcare Quarterly opens with a focus on the kind and quality of health care required by increasingly large cohorts of elderly people whose multi-faceted needs are not being met through traditional modes of practice. The article by Akhtar et al. (2019) describes new integrated care models that bring specialized primary care to frail elderly homebound adults living in urban centres. The authors present five succinct, substantive profiles of home-based primary care programs in Calgary, Winnipeg, Toronto and Montreal. Each profile explains how system integration with primary care was achieved, how teams were structured, and how patient referrals worked.
They offer a glimpse of what the future of healthcare could include – integrated home-based primary care (IHBPC). According to the authors, that will require "a focused commitment to integration of the provision of primary care with supportive community and home-care services …"
The next article (Aggarwal et al. 2019) leaves the city behind, moving to two rural, small-town Ontario communities with gaps in service for elderly residents. Local family health teams (FHTs) intervened, creating programs and services to support the growing numbers of patients with end-of-life and complex care needs. Based on case studies of Prince Edward and Couchiching FHTs, the authors demonstrate the teams' effectiveness in designing and implementing palliative care services and coordinated care programs that help keep patients at home and out of hospital. The FHTs mobilized and organized resources to provide more ready access to patient-centred services and supports to help patients and caregivers navigate care transitions and health and social services.
The final article reports on an Alberta study evaluating the impact that a primary care after-hours clinic had on avoidable ED visits and costs. Moe et al. (2019) report that findings show that in the period from the clinic's inception in 2005 to 2016–2017, the availability provided by the after-hours clinic led to 40,046 avoided ED visits, and a net cost saving of $4.7 million.
Three years ago, amid growing concerns about the state of healthcare risk management and frustration over complex processes and bedevilling tools, an initiative was launched to help Canadian healthcare leaders more effectively identify, manage and report on organization-wide risks. The article by Stevens et al. (2019) follows the creation and implementation of a national standardized system and common solution for integrated (enterprise) risk management in Canadian healthcare organization. Authors chart the project's progress and purpose – including a stronger focus on patient and provider safety – and report national results and benchmarks from the first three years.
The importance of non-clinical physician leadership – and its symbiotic companion physician engagement – is rarely challenged as a lever for change. And yet, time, resources and encouragement to develop these undisputedly essential skills are scarce and physician interest in pursuing supports (or acknowledging need) underwhelming. Despite evidence, expectations that physicians come with leadership skills built-in abound. In a revealing article, academic physician leaders Kirk et al. (2019) share their experiences – and emotions – about their foray into executive coaching, reflecting on results personal and professional.
Roles in Healthcare
In a sector hungry for resources and greater access to knowledge, where dedicated research time is sacred, it seems somewhat ironic that author Sue Bookey-Bassett and colleagues (2019) must unmask the role of the clinician-scientist and its contribution to healthcare. Healthcare Quarterly's final article relates the history and evolution of the role, outlines barriers and challenges to its development, and recommends better ways to employ and engage this resource. Authors share effective strategies used by Toronto's University Health Network to maximize the value of clinical scientists and improve their experiences.
– The Editors
Aggarwal, M., H. Cluett, H. Campbell, D. Korzeniowski, C. Jones, L. O'Donnell et al. 2019. "Innovation in Ontario's Family Health Teams: How Palliative and Coordinated Care Programs Are Filling Service Gaps and Keeping Patients at Home." Healthcare Quarterly 22(2): 36–41. doi:10.12927/hcq.2019.25838.
Akhtar, S., M. Loganathan, M. Nowaczynski, S. Sinha, A. Condon, V. Ewa et al. 2019. "Aging at Home: A Portrait of Home-Based Primary Care across Canada." Healthcare Quarterly 22(2): 30–35. doi:10.12927/hcq.2019.25839.
Bookey-Bassett, S., A. Bianchi, J. Richards and H. Kelly. 2019. "Overcoming Challenges to Support Clinician-Scientist Roles in Canadian Academic Health Sciences Centres." Healthcare Quarterly 22(2): 60–65. doi:10.12927/hcq.2019.25834.
Campbell, R.J., M.W. ten Hove, S.R. El-Defrawy and P.L. Hooper. 2019. "Cataract Surgery Quality and Capacity." Healthcare Quarterly 22(2): 6–10. doi:10.12927/hcq.2019.25843.
Forest, P.G. and D. Martin. 2018. "Fit for Purpose: Findings and Recommendations of the External Review of the Pan-Canadian Health Organizations – Summary Report." 55–57.
Grywacheski, V., L. Sabad, L. Kushtova, M. Bender, N. Rennie, R. Cheng et al. 2019. "Opioids in Canada." Healthcare Quarterly 22(2): 11–13. doi:10.12927/hcq.2019.25842.
Kirk, V.G., A. Kania-Richmond and K. Chaput. 2019. "Executive Coaching for Leadership Development: Experience of Academic Physician Leaders." Healthcare Quarterly 22(2): 54–59. doi:10.12927/hcq.2019.25835.
Marr, S., L.M. Hillier, D. Simpson, S. Vinson, S. Goodwill and D. Jewell. 2019. "How Do Older Adults Decide to Visit the Emergency Department? Patient and Caregiver Perspectives." Healthcare Quarterly 22(2): 23–29. doi:10.12927/hcq.2019.25840.
Moe, J., R. Oland and G. Moe. 2019. "Impact of a Primary Care After-Hours Clinic on Avoidable Emergency Department Visits and Costs." Healthcare Quarterly 22(2): 42–47. doi:10.12927/hcq.2019.25837.
Muscedere, J., C. Barrie, K. Chan, B. Cooper, K. Critchley, P. Kim et al. 2019. "Frailty and Aging: How the Danish Experience Might Inform Canada." Healthcare Quarterly 22(2): 14–21. doi:10.12927/hcq.2019.25841.
Stevens, P., J. Willcox and L. Borovoy. 2019. "Integrated (Enterprise) Risk Management in Canadian Healthcare Organizations: Common Barriers and a Shared Solution for Effective and Efficient Implementation in Canada." Healthcare Quarterly 22(2): 48–53. doi:10.12927/hcq.2019.25836.
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