The Premier's Council on Improving Healthcare and Ending Hallway Medicine (the "Council") released its first interim report (PDF) earlier this month (the "Report"), providing an overview of the key challenges facing the Ontario healthcare system and setting the stage for recommendations to follow. The Report paints a picture of a system under strain, and emphasizes that putting an end to "hallway health care" will take more than an influx of new beds.
The Council is preparing a second report, which will include recommendations for the provincial government on how better care can be delivered in Ontario. The recommendations in the second report will address these four themes:
- A need to integrate care around the patient and across providers, taking into account differences between communities across the province.
- Increasing demand for and opportunity to embrace innovation in healthcare, particularly through the use of virtual care and apps.
- The potential for greater efficiency in the system, including streamlining and aligning system goals to support high quality care.
- The critical role of a long-term plan to ensure that healthcare professionals, services, and facilities are able to meet Ontario's changing needs.
This bulletin summarizes the key findings provided under each chapter of the Report, outlining the main challenges, opportunities and emerging themes identified in the Council's initial work.
II. Chapter 1: The Patient Experience
The Council heard from over 340 patients. Many patients described a lack of privacy and dignity involved in receiving care in a public location, such as a hallway.
Hallway health care is a term used to describe the circumstances where patients are waiting for a hospital bed in an unconventional or unexpected location, such as a hallway or a health facility that is not designed for the care required.
The following are some of the relevant findings described in the Report:
- 41% of Ontarians who went to the emergency department and 93% of Ontarians who went to a walk-in clinic received care for a condition that could have been treated by their primary care provider.
- Visits to emergency departments across the province increased by about 11% over the last 6 years, to 5.9 million in 2017/2018.
- In November 2018, only 34% of patients admitted to a hospital were admitted to an inpatient bed from the emergency department in under 8 hours.
- Patients in Ontario who require admission to an inpatient bed spend an average of 16 hours in the emergency department before beds become available.
- The median wait time for long-term care home placement in Ontario in 2017/2018 was 146 days, and the median wait time for home care was approximately 6 days.
- When Ontarians are able to access services and supports, they are generally happy with the results; 92% of respondents in a survey conducted about home and community healthcare rated their overall experience as excellent, very good or good.
The Council is concerned that patients cannot access mental health and addictions services when they need them most. The Report points to the following findings:
- Approximately 1 in 3 adults who went to the emergency department for mental health and addictions care did not previously access physician care for their mental illness.
- There has been a 72% increase in emergency department visits and a 79% increase in inpatient admissions for children and youth with mental health issues over the last 11 years.
The Report emphasizes that most mental health and addictions issues are more appropriately treated in the community; however, long wait times for community treatment can result in the worsening of some patients' conditions, giving them no other options but to seek emergency care or return home.
III. Chapter 2: Stress on Caregivers and Providers
The Report describes the strain on family and friends who are caregivers of patients, as well as on healthcare providers, as indicative of the challenges currently facing the healthcare system.
The following are some relevant findings described in the Report:
- Approximately 26% of patients who received home care for six months or longer in the first half of 2017/2018 had a primary family or friend caregiver who experienced continued distress, anger or depression in connection with their caregiving role, which is a 21% increase over the last 5 years.
- 59% of healthcare providers in four Ontario hospitals reported high levels of stress.
In preparing its recommendations, the Council will consider the need for increased capacity in the community, staffing levels, training and support.
IV. Chapter 3: Different Healthcare Needs
The Report describes how the healthcare needs of Ontarians are changing. This shift is reflected in Ontario's long-term care homes, where the typical resident is over the age of 85, has chronic health conditions and needs extensive help with personal care. This is placing significant strain on healthcare resources and contributing to the problem of hallway health care.
Hospitals are experiencing the shift in patient needs as well, including an increase in patients admitted for general internal medicine. General internal medicine patients were found to account for approximately 39% of emergency department admissions and have a median number of six co-existing conditions, requiring significant support and resources.
In making recommendations to the government, the Council will also consider unique needs and cultural considerations of distinct populations in Ontario, including Indigenous and French-speaking individuals.
V. Chapter 4: Immediate and Long-Term Capacity Pressures
According to the Report, capacity pressures are also contributing to hallway health care in Ontario. The main causes of the capacity challenge are as follows:
- Ontario does not have the appropriate amount of hospital or long-term care home beds.
- There is insufficient capacity in community care settings, such as home care and mental health and additions care, to prevent people from resorting to the hospital.
- The province is not using the beds across the system as effectively as possible.
The following are some relevant findings described in the Report:
- In October 2018, almost 16% of days in hospital were spent by patients that were waiting for care in a different setting.
- In November 2018, there were approximately 4,665 patients requiring an alternate level of care ("ALC", a term used to describe care needed by a patient who is occupying a hospital bed does but not require the intensity of resources provided).
- As of October 2018, the range of patients requiring an ALC across Ontario was between 5% and 34%.
- Over 9% of people designated as requiring an ALC who have been waiting more than 30 days have specialized mental health needs.
- Long-term care homes are currently at 98% capacity, with roughly 78,910 residents in 627 long-term care homes across the province.
- As the population ages, so will the number of patients with dementia, which will cost Ontario close to $325 billion between 2008 and 2038 in healthcare, lost wages and other costs.
Ontario's rising population will significantly impact the availability of healthcare in Ontario. The Report points out that if no additional capacity is created, the hospital bed rate in Ontario will decline from approximately 222 beds per 100,000 people in 2018 to approximately 173 beds per 100,000 people in 2041.
VI. Chapter 5: Responsibility and Accountability in the System
The lack of integration in Ontario's healthcare system is the final factor identified in the Report as contributing to hallway health care. The Report characterizes Ontario's current healthcare system as "decentralized, large and siloed".
There are currently 21 health-related government agencies supporting the design and delivery of healthcare in Ontario. The Report finds that these agencies are not always well-aligned, and that there is limited strategic oversight to ensure their coordination and efficiency.
VII. Opportunities for Improvement
The Report identified three opportunities for improvement:
1. Digital and Modern Healthcare
Ontario's healthcare system can make better use of technology as a tool to help coordinate and deliver services. The following are some relevant findings described in the Report:
- Only 16% of Ontarians can make an appointment with their healthcare provider by email or on a website.
- Less than 10% of appointments in 2018 were conducted virtually in Ontario.
Moving forward, the Council will focus on considering technological solutions to challenges identified in the Report, for example by facilitating the integration of care or smooth transitions between care settings.
2. Integrated Healthcare
Fostering an integrated healthcare system entails connecting the full continuum of services, providers and facilities into a cohesive partnership with a common objective, providing wrap-around services to patients and improving health outcomes. Delivering integrated healthcare includes considering the impact of social determinants of health and emphasizing pre-emptive interventions. The Council will consider how to streamline certain functions within the system, such as care-coordination.
3. Efficiency in the System
The Report's findings portray the consequences of an overburdened system. The central message in the Report is that hallway health care is a symptom of broader challenges facing Ontario's healthcare system.
The recommendations in the second report will address a balance of short and long-term needs across the healthcare system, and will focus on building a more efficient system for patients, providers and caregivers, setting Ontario's system up for greater success.