These questions need to be asked in the ED as well. The problem then becomes - what next? In Ontario - a referral can be sent to the CCAC to engage with patients urgently but the biggest gap is determining who the true coordinators are. Services can be sent into the home BUT this does not solve the problem. Ontario Health Teams have been created to coordinate the myriad of health care needs of individuals. These teams are in their infancy so there are no metrics to suggest they have been successful. As a first step, I would suggest an EMR that allows for complete access to a patient's medical history (medications, services, health care visits, lab and imaging results etc) and that a coordinator tracks visits and coordinates care for a set number of rostered patients. This would allow for a much better experience and potentially decrease some of the fragmentation and duplication of services.

I also agree that increasing bed capacity is not the solution - inefficiencies of the current system need to be addressed first.