Insights (Essays) June 2019

Mind the Gap

Shirlee Sharkey

Mind the Gap 

"Mind the gap between the train and the platform."

This warning is heard daily by millions of passengers on the London underground network and dates all the way back to 1968. The expression ‘mind the gap’ has been appropriated by pop culture, gaining fame in the world of media, music and advertising. In the 1970s it morphed into a catchy jingle for a large jean store . . . can you guess who?

It was GAP, of course.

So what about healthcare? Should we follow London’s lead with a warning of our own? Mind the gap between healthcare settings.

According to 2018 data from Health Quality Ontario, the number of hospital beds occupied by patients waiting to receive care elsewhere continues to increase. Patients are also waiting longer to access home care, assisted living and long-term care from both the hospital and the community.

Changing the way people move through the health system is a burning platform because it relates to much larger issues like the aging population and hallway healthcare.

Let’s talk about the issue of hallway healthcare. There are three main ways to address it:

  1. Shorten hospital stays by discharging people faster;
  2. Avoid hospital deconditioning, especially among frail older adults; and
  3. The BIG opportunity – keep people out of hospital in the first place.

At the moment, we’re understandably putting most of our focus and energy into the first two areas – namely, dealing with people who are already IN hospital. Fortunately, we’re seeing pockets of innovation that are starting to spread and scale, like bundled care and reactivation models.

Yet across the system, there continues to be a big gap in addressing alternate level of care (ALC) issues at the right time, by the right people. For example, almost 60 per cent of ALC patients are waiting to be discharged to long-term care, while recent studies by SE Health and CIHI suggest that between 30 and 50 per cent of people entering long-term care could be cared for at home with support.

Guess what? There’s a gap there too.

In our current home care model, the services and supports people need for independent living are often insufficient and difficult to access:

  • Patients may undergo up to four assessments before a single minute of direct care is delivered;
  • Funding is focused on hours and tasks, rather than innovation and outcomes for their care; and
  • There is little flexibility and choice for patients and families to have their needs et in their home environment in a personalized way.

To effectively address hallway healthcare, we need to not only look at structures and enablers but also fundamentally rethink how home care is funded, accessed and delivered. This is especially true when it comes to keeping people out of hospital in the first place. In the community, only 30 per cent of the patients we see need care as a result of an acute episode; the other 70 per cent require long-term support for chronic conditions.

To stem the tide, we must put more energy and resources into addressing the gaps upstream; otherwise the 70 per cent of chronic patients will keep visiting emergency departments, no matter how quickly we discharge them. This thinking takes us back to 1974 and the Lalonde Report.

Today, as we work to transform transitions in care, let’s remember the goal is to design around the needs of people and families. Using a relay analogy, this means mastering how we pass the baton in the exchange zone. Achieving amazing local hand-offs will take time and require trust, communication, experience and training. And like a relay race, we need to stay in our own lanes and avoid duplication.

The core competencies of hospitals and community organizations are fundamentally different. Home care, for example, is often not curative. It should not be transactional. It must be customized, nimble and yes, sometimes messy, because what each client and family needs in their home environment is unique.

Transforming care transitions means finding the best way to leverage ALL of the incredible talent and assets we have in the system. The intent and design of Ontario Health Teams provide a great opportunity for this.

To truly mind the gap, we need to think and operate on multiple levels simultaneously:

  • Short-term, by addressing ALC
  • Medium term, by improving transitions, and
  • Longer term, by keeping people out of hospital and supporting independent living.

Let’s line things up and cross the threshold, before the train leaves the station!

About the Author

Shirlee Sharkey, BA, BScN, MHSc, CHE, ICDD, President and CEO Saint Elizabeth Adjunct Professor Lawrence S. Bloomberg Faculty of Nursing and Dalla Lana School of Public Health University of Toronto


This is an adapted version of a talk the author gave on May 31 at #InnovationEx, the signature annual event of the Joint Centres for Transformative Healthcare Innovation. Thanks to all the member hospitals for the opportunity to speak and share ideas.

Republished with Permission

Originally Published at 



Abhi Mukherjee wrote:

Posted 2019/07/21 at 07:22 PM EDT

Thank you Shirlee Sharkey for your thoughts and leadership through the healthcare transformation in Ontario.

I completely subscribe to your comment "Longer term, by keeping people out of hospital and support independent living."

I believe that we need to create a true healthcare system that is preventive and keeps us healthy. Investing resources upstream (education, monitoring, timely proactive interventions) would help us save tax dollars downstream that are spent today in providing care in an acute setting that could very well have been prevented/ delayed/ minimized.

There is momentum - people want change- I sincerely hope we demonstrate courage to be bold and innovative.
Thank you.


You must sign in to comment Sign In or Create an Account to add comments


Related Content


Why Am I Here?



Considerations on Caring for Caregivers in an Aging Society


Healthcare Quarterly

Implementation of Behavioural Supports Ontario (BSO): An Evaluation of Three Models of Care