Much has been written about the Ontario government’s decision to send seniors back to long-term care homes against their will, but much fails to recognize the complex underlying issues that have created this crisis and the real solutions needed to remedy it.
The health care system, especially acute care, as we know it now, is not organized to meet the needs of the current population, but it could be.
People over 65 are the main consumers of acute care, often for serious cardiovascular and respiratory conditions and hip fractures. Many of these patients are medically complex, fragile, and frequently affected by chronic illnesses and cognitive impairments. They are particularly vulnerable to nosocomial complications, such as delirium and functional decline, which, in turn, lead to the alternate level of care (ALC) label.
It is essential to understand that ANS is an administrative designation: it is not a diagnosis or clinical condition. The NSA designation is applied to patients when the medical condition that brought them to the hospital is deemed resolved. Yet these patients still have chronic health problems, now compounded by nosocomial delirium and functional decline, which remain incompletely treated.
The ANS reflects a system that leaves patients’ needs unmet. SLA is not inevitable and it is not solved by discharging patients without considering their post-hospital needs.
The solution is to make hospitals age-friendly. Senior-friendly hospital measures have been shown to prevent delirium, hospital falls, functional decline, LTC admission, and reduce health care costs; yet only a handful of hospitals in Canada have implemented them.
Early consideration of rehabilitation, whether in hospital, in dedicated programs in LTC homes, or in immediate settings, is essential, especially for older people who often need more time to get well. Thus, age-friendly hospital practices should be made mandatory and a strong federal quality assurance system, linked to accreditation and reporting, should be implemented.
More fundamentally, a person cannot become an NSA if they are not hospitalized in the first place. As noted above, the primary acute care admission diagnoses in older adults are fractures and exacerbations of chronic heart and lung disease, many of which are preventable. When cared for in interprofessional primary care settings, patients with chronic conditions are less likely to be hospitalized.
A recent evaluation, funded by the Ontario Ministry of Health, showed that memory clinics focused on primary care can reduce hospitalizations, delay admission to LTC, and save $26,000 per patient per year; yet 80% of Ontarians do not have access to it. Additionally, improving home care and community services, including age-friendly rehabilitation, and ensuring they are better integrated with primary care will further reduce pressures on acute care and LTC homes. .
The alternate level of care is not an inevitable consequence of aging, but the product of a health care system that does not sufficiently meet the complex care needs common to the population. Any government wishing to address the health care crisis must invest in integrated community and primary care services, supported by specialist geriatric services, to reduce the likelihood of hospitalization.
This should be complemented by elder-friendly acute care measures to prevent nosocomial complications and necessary rehabilitation services to support recovery and reintegration into the community. Of course, all of this relies on the presence of sufficiently trained and paid health personnel.
Hospitals as we know them today are not suitable for the elderly and this has consequences for all those who need care. This can be corrected.