One way to keep seniors out of hospitals
Give retirement homes incentives for better care, Dr. Barry Bruce writes.
Retirement homes are the equivalent of “dark matter” for the health-care system. Although these homes are not recognized as healthcare institutions by Ontario’s Ministry of Health and Long Term Care, data obtained from one large acute-care hospital shows that retirement home residents could occupy 10 per cent of all hospital beds at a given time. That’s enormous in terms of impact and dollars — about $2 billion a year for Ontario.
Retirement homes are privately owned, for-profit institutions. Nothing wrong with that! However, given that people generally go there only because they are no longer able to cope independently due to health problems, they are also de facto health-care institutions, not the hotel-spas they are made out to be.
Although they are private, retirement homes all too often use a publicly-funded option for their residents who become ill. There is no financial penalty. There is no particular incentive to prevent and manage illness at “home” — rather, disincentives exist because well-qualified staff are expensive.
What’s it actually like behind the scenes?
Although there are variations from home to home, these complex and vulnerable patients very often do not receive the medical care and supervision required. There are several reasons for this.
The patient’s physician might not practise close to the retirement home, but nevertheless, tries to manage by talking to staff on the telephone in between patients. Fee schedules make retirement home work very low-paying for physicians, and charting systems are not oriented toward physician needs. The quality and quantity of staff in retirement homes vary depending on the necessity of attending to the financial bottom line, and of keeping monthly rates competitive. Patients almost invariably take several chronic medications, which are administered a number of times a day. Not all retirement homes employ a registered nurse with sufficient training to understand the complexities of medication, various other treatments, and complex diagnoses.
Ideally, retirement homes would offer efficient and exemplary medical and nursing care. However, there are few incentives and little clinical oversight. In the Retirement Homes Act, it even states that “The licensee (i.e.., the retirement home) is not responsible for ensuring that services provided by an external care provider meet the prescribed care standards.”
As part of a more general program of preventing hospital usage, the clinical and financial dots need to be connected. With better care, retirement home residents would happily use hospital and other services less, thus saving the Ministry of Health hundreds of millions of dollars annually.
I propose that the ministry and the Ontario government provide retirement homes with financial incentives linked to clinical performance, and funded out of hospital-sector savings.
Retirement homes could also be incentivized and required to provide a certain number of long-term care (i.e., nursing home) and palliative beds, thus relieving downstream as well as upstream pressure on hospitals and providing inplace care for deteriorating patients.
Making it profitable for retirement homes to provide better medical care for their residents is only one of many strategies for reducing pressure on hospitals through improved community care. Recognizing retirement homes as healthcare institutions is long overdue. No hospital should expand until this and other available community strategies are maximally implemented. The system will function better, health-care dollars will be saved and most importantly, healthier, happier patients and their families will thank us.
Dr. Barry Bruce is a family physician in Eastern Ontario in an award-winning family health team, chief of staff in a large urban hospital and has provided retirement-home care for years. He is recipient of the OMA “Physicians Care” award, “Family Physician of the Year” for Ontario, and the Order of Ottawa. Twitter: 1Team4Health