HEALTH and WEALTH
in the City of Ottawa
Low-income Canadians are sicker, more likely to go to the hospital and more likely to die at a younger age than wealthier ones — and Ottawa is no exception. As Andrew Duffy reports, health authorities are now trying inventive ways to close the health gap, and save both money and lives.
In Ottawa, your address can be powerful medicine.
Those fortunate enough to live in Rockcliffe, the Glebe, Old Ottawa South and the high-income areas of Kanata and Orleans have lower rates of diabetes, and make fewer trips to the hospital every year, than people who live in neighbourhoods such as Vanier, Lowertown, Bayshore and Pineview.
Studies conducted by Ottawa’s regional health authority, the Champlain Local Health Integration Network (LHIN), show that the differences can be dramatic.
In Orléans, for instance, there’s an average of 226.8 visits to the emergency department for every 1,000 residents. In the area that encompasses Overbrook, Vanier and Beechwood, the rate is 88 per cent higher.
Disparities persist when it comes to hospitalizations. In Ottawa, people living in the area that includes the Glebe, Old Ottawa South and Ottawa East used the fewest hospital beds: There were 60.4 acute care hospitalizations for every 1,000 residents in 201011, the last year for which statistics are available. The hospitalization rate was about 20 per higher in the Vanier area and in the area that encompasses the Industrial East, Riverview, Pineview and Elmvale neighbourhoods.
Those same neighbourhoods suffer some of the highest diabetes rates in the city.
The statistics on hospital use and diabetes produced by the Champlain LHIN reflect an uncomfortable truth: Money makes you healthier. Indeed, a raft of Canadian studies has established a direct link between income levels and disease rates. Put simply, low-income Canadians are sicker, more likely to go to hospital and more likely to die at a young age than wealthier individuals.
A 2008 study by the Canadian Institute for Health Information identified the ailments most closely tied to socio-economic status. The study, Reducing Gaps in Health: A Focus on Socio-Economic Status in Canada, examined hospitalization rates in the country’s 15 largest cities. Patients were grouped into three categories. Those in the lowest socio-economic group were hospitalized for substance-related disorders 3.4 times as often as those in the highest group. They were more than twice as likely to be hospitalized for chronic obstructive pulmonary disease (COPD), diabetes and mental health issues.
That disease burden is deadly. A large, long-term Statistics Canada study, released in July 2013, established a stark correlation between income and life expectancy. The study followed 2.7 million Canadians between 1991 and 2006; the subjects were grouped into five income quintiles. During the course of the 16year study, 426,979 people (16 per cent of those being tracked) died. Researchers found that mortality rates increased as income declined.
“Each successively lower level of income had a higher mortality rate,” the study concluded.
The most significant increase in mortality was recorded between the two bottom-most income groups. Low-income Canadians were much more likely than wealthier people to die from HIV/ AIDS, diabetes, COPD, suicide, alcohol-related or drug-related diseases.
In Hamilton, researchers found that people living in the city’s richest neighbourhood enjoyed a life expectancy of 86.3 years — 21 years more than those living in Hamilton’s impoverished north end. In Glasgow, Scotland, a 2008 study found a 28-year gap in life expectancy between the city’s best and worst neighbourhoods.
None of these statistics will come as a surprise to senior health officials in Ottawa. Every day, at Ottawa hospitals and at the city’s five community health centres, doctors, nurses and social workers come face-to-face with the impact of social class on bodies and minds. All of them recognize a social gradient exists when it comes to health.
“Poor people are sicker,” says Wanda MacDonald, chief executive of the Pinecrest- Queensway Community Health Centre. The centre offers health and social services to people living in an area with the city’s highest concentration of social housing. Founded in 1979 by a few local residents as a small referral service for new immigrants, it has evolved into a $22-million-ayear operation that offers employment services, social supports, and child and family services in addition to primary health care.
The centre’s programs, MacDonald says, have been designed to address the “social determinants” of health — factors such as income, education, housing and employment. Only such a broad-based approach, she contends, can close the wellness gap that exists between the city’s rich and poor.
Ottawa health authorities are increasingly mindful of the city’s health gap and are pursuing inventive ways to close it. But the work isn’t all high-minded altruism. There’s an emerging school of thought which holds that the health care system can cut costs and deliver better care by improving services for people at the bottom of the social pyramid.
That theory is predicated on the fact that those at the bottom of the pyramid — those who are sickest and suffer the highest rates of chronic disease — are also the heaviest users of the hospital system. Writing in The New Yorker, Dr. Atul Gawande said of the U.S. system, “The critical flaw in our health care system ... is that it was never designed for the kind of patients who incur the highest costs.”
The same is true in Canada. Hospitals are purpose-built for emergencies: a pedestrian struck by a car; a beer-league hockey player with chest pains; the middle-aged woman who breaks her leg on an icy sidewalk. Hospitals are less adept at managing complex and chronic diseases, particularly when patients present with the kind of social challenges connected to poverty: the 40-year-old homeless man with an acquired brain injury who’s also battling alcohol addiction; the 60-year old woman with heart disease, obesity and diabetes who can’t afford healthy food; the 70-year-old man with COPD and high-blood pressure who has no family doctor and lives alone. When these patients return to the community, if they’re unable to visit a doctor for follow-up care, or receive the necessary in-home support or physiotherapy, they inevitably return to the clinic of last resort: the hospital.
The Ottawa Hospital calls the patients who most often use its services “familiar faces.” They’re the ones who make frequent use of the emergency department and are repeatedly admitted to hospital wards. Not all of them are poor, but it is an all-too-common trait.
“When you look at those people, the one thing that unifies them — not always but predominantly — is that they’re poor,” says Dr. Jeffrey Turnbull, chief of staff at The Ottawa Hospital.
“The hospital is a very good system for those acutely ill people who have entitlements and are bright and know how to use it. But when you’re chronically ill and you don’t have those same entitlements, it doesn’t give you very good care. And it’s very expensive.”
These familiar faces — others call them high-needs patients — are increasingly the subjects of study and innovation. Earlier this year, researchers at the Champlain LHIN produced the region’s first detailed profile of Ottawa’s highneeds patients.
It found that just 2.5 per cent of patients accounted for 37 per cent of the region’s health care costs, more than $1 billion a year.
The Champlain LHIN identified 26,744 people as “high-needs patients based on their use of multiple services (e.g. surgery, rehab services and home care); 36 per cent of these had a diagnosed mental health condition.
According to the Ministry of Health, high-needs patients represent just five per cent of Ontario’s population, but consume twothirds of the health care budget.
These patients include seniors with complex conditions and others with multiple chronic diseases.
“There’s a small number of people generating a huge demand on services,” says Wendy Muckle, cofounder and executive director of Ottawa Inner City Health, which has been offering health services to Ottawa’s homeless since 1998.
Ottawa Inner City Health offers a blueprint for a health care system that’s at once more equitable, less costly, and produces better outcomes for those most in need. It serves the population at the bottom of Ottawa’s socio-economic pyramid, the chronically homeless, offering them palliative care, an alcohol management program, an infirmary and a “diversion program” aimed at keeping them out of emergency departments and police lock-ups. The programs take health services to the places where homeless people will use them.
Says Muckle: “The homeless need mental and physical health services, substance abuse and housing services all at the same time. If you’re not doing that, you might as well stay home. It’s a waste of money.”
Turnbull says the same model can serve other expensive, highneeds patients: the frail elderly and those with complex, chronic diseases complicated by mental health issues or substance abuse. “I think you can address those populations and get better outcomes by doing things differently,” he says. “By and large, those people have chronic diseases. By and large, they don’t have access to the services that you and I would get because of multiple factors including poverty and class.”
The hospital is now drawing up plans to take more services directly to the frail elderly and aboriginal communities. Turnbull says the hospital believes it can better serve these patients while reducing the demand on emergency departments and hospital wards.
“Hospitals recognize that there’s not just a health services imperative, but a financial imperative. You save money by doing this and you provide better outcomes,” he says.
Cutting budgets normally demands a reduction in services or longer wait times (the most common method of rationing). But targeting high-needs patients offers the possibility of a rare win-win scenario: better health care and reduced costs.
Hoping to capitalize on that formula, the province has launched a program, Health Links, which encourages hospitals, family doctors, long-term care homes and community organizations to better co-ordinate the care of high-needs patients to reduce the number of emergency department visits and hospital re-admissions.
In Ottawa, the Champlain LHIN is co-ordinating the introduction of the $6-million plan to optimize service delivery for local highneeds patients.
“If we can get it right for them, we can bring down costs for the health care system,” says Chantale LeClerc, chief executive officer of the Champlain LHIN.
When it’s in place, the Health Links program will identify highneeds patients and ensure each of them has an individualized care plan to ensure they have a family doctor and the necessary community supports.
Sometimes, it will mean addictions counselling, or connecting to home care officials, or ensuring that treatment goals are discussed and agreed upon.
Says LeClerc: “Even if you were to make a modest, 10 per cent improvement — some of these people have 30 or 40 visits to the emergency department in a year — it’s a huge, huge savings, particularly when you multiply that across the province.”