August 31st the Ontario Ministry of Health did a curious thing. They posted on their website a report by Dr. David Walker, who had been appointed ALC lead back in January. There was no press release, no press conference, no op/eds were written supporting Walker’s 32 recommendations. Walker had submitted his report at the end of June, and for two months the government mulled it over before deciding to make it public on the eve of an election. During that election there was virtually no talk of Walker’s report.
ALC is the term for alternate level of care patients — those who have completed their acute care treatment in hospital but are not stable enough to return home.
Normally this kind of treatment of a report indicates a “thanks, but no thanks” attitude by government. However, at a meeting with public service reform commissioner Don Drummond, the Ontario Health Coalition was told that the government has actually accepted the recommendations of Walker.
This is despite the fact that the 32 recommendations involve considerable investment of resources at a time when austerity is said to rule the thinking at Queen’s Park.
While many of these recommendations will involve savings in other areas of health care delivery, it is unlikely that such savings would come quickly enough to meet what the auditor had called “aggressive” targets for cost savings within the Ministry of Health and Long Term Care.
To his credit, Walker took a system approach to ALC, making significant recommendations for hospitals, long-term care, home care and community support services.
Much of the thrust in his report revolves around “assess and restore” functions, suggesting that a permanent long-term care bed may not be the best solution for many frail seniors.
With enhanced resources, many of these seniors could be placed in a short-term bed with the goal of restoring their capacity to return home. Walker suggests that for those who cannot return home, but are functioning well enough to avoid institutional care, that a group home might be a viable alternative.
He recommends “a considerable shift” in how long-term care homes function to serve a higher needs population, including specialized units that can address significant behavioural issues, dialysis, bariatric, palliation, multiple medical conditions, and ventilation assistance.
To that end, Walker recommends “targeted investments” for adding new human resources specialized in responsive and challenging behaviours in long-term care homes, developing and deploying “Mobile Behaviour Teams” and expanding community-based supports, such as homemaking or supportive housing.
He also recommends that the Ministry engage in health human resource planning to meet the needs of an aging population and consider funding for educational programs for existing health practitioners.
Walker also believes that long-term care homes should build a surge capacity, something that is presently missing among the high occupancy rates and long waits to access a nursing home bed.
For hospitals, Walker recommends they adopt “Senior Friendly” principles, looking at a variety of issues from “convenience of parking” to “navigating the physical and care pathways inherent to complex organizations” to “active prevention of de-conditioning.” He recommends that these principles become part of the accreditation process for hospitals. Walker also is pitching a short-term “capacity relief” by adding new ER beds that restrict length of stay to 72 hours or less.
Walker has also recognized that many small and rural hospitals have nowhere to send their ALC patients. Rather than push them out the door, Walker is recommending that these patients no longer be counted as ALC and that these hospitals be given resources to provide longer-term care.
Like many other reports we have seen recently, Walker sees greater involvement of the Local Health Integration Networks with primary care, suggesting the LHINs appoint a Primary Care Lead as part of their senior administration. Walker believes that doctors should be playing a role in early identification of seniors at risk and establishing supports early on. Such supports could avoid hospital admission long before it is required.
One of the first acts of the McGuinty government was to delist community-delivered physiotherapy from OHIP coverage. Now Walker is calling on the MOHLTC to review OHIP funded community rehabilitation services (particularly Designated Physiotherapy Clinics) to meet the needs of the elderly, including stroke and fracture patients.
Walker points out other countries have successfully realigned seniors services in a way that reduces reliance on conventional long-term care homes. Denmark, for example, has not built a new nursing home since 1987. Instead a varied range of dwellings for older persons was developed.
Many of the issues that Walker has addressed have already begun to be implemented, including involving the CCAC (Community Care Access Centre) in hospital discharge planning.
What is lacking in the report is costing for an ambitious reform agenda.
Despite a call by Walker for enhanced hospital services, the fear would be the government would try to fund these new community supports by attacking the budgets of hospitals long before such initiatives would have any impact on bed occupancy or ER utilization.
Hospitals are already stretched to the limit, the average occupancy at an unheard-of 98 per cent. Any reduction in demand for hospitals services would have to be first applied to reducing overcrowding.
How pliable for-profit long-term care homes would be in taking on more specialized care is also debatable. Most specialized units are presently in public municipally run homes. Transferring care from public to private care providers also runs the risk that cash-strapped governments will look for greater financial contributions from those consigned to these beds. For-profit homes also have a history of transferring accommodations costs into the nursing envelope to increase their ability to make profit. This could also undermine efforts to enhance front line care.
The for-profit homes also look to increase profits by having a greater mix of preferred beds over basic accommodation. Walker is looking a changing that mix to make available more affordable basic accommodation. He could be in for a fight on this issue.
Walker still prefers the “Homes First” approach that has been recently adopted by the LHINs, however such an approach must have adequate resources to work, something that appears to presently missing. Under “Homes First” most hospital patients are sent home with community supports to wait for a long-term care placement.
While Walker talks about making hospitals more senior friendly, let’s not forget that the health minister recently washed her hands of the growing issue around exorbitant parking fees that doctors say are impacting care. “Convenience” of parking was also one of the issues Walker specifically highlighted.
Many of Walker’s recommendations have timetables ranging from the immediate to 2013. This is not very long to establish real alternatives in the community, especially in light of planned fiscal restraint on the sector.
Let’s not forget that earlier this year the budget assumptions including reducing the rate of increase for long-term care by half, and for home care by two-thirds.
Since then Don Drummond has been talking about even more severe levels of austerity.
Under such conditions, how receptive will the government be to building a surge capacity in long-term care, especially if it involves maintaining both staffing and available beds?
It will also be difficult to implement given Walker expects a two-year review of the current bed distribution, including both geographic location and the balance between basic and preferred beds. Assessment of need will be difficult in the midst of such a comprehensive restructuring of seniors services.
There’s much to be recommended in Walker’s report. Whether it will successfully transition from paper to reality is an open question, especially given the need for considerable resources to make it happen.