Re­new­ing em­pha­sis on health sys­tems in­te­gra­tions

BY DALE SMITH

Policy - - Before The Bell | From The Editor - BY DALE SMITH

Across Canada, health care sys­tems are test­ing in­no­va­tions to im­prove care and more im­por­tantly, find im­prove­ments in both cost sav­ings and health out­comes. Be­fore the Bell spoke with a panel of ex­perts and stake­hold­ers to dis­cuss what it will take for some of these in­no­va­tions to get wide­spread adop­tion, and what is hold­ing us back from our suc­cesses.

Mike Villeneuve, CEO of the Cana­dian Nurses As­so­ci­a­tion, said that his as­so­ci­a­tion has some spe­cific con­cerns about health care sys­tem trans­for­ma­tion and how health hu­man re­sources are used as part of that trans­for­ma­tion.

“We are en­cour­aged by all of the health ac­cords of the last few years, but also a lit­tle bit frus­trated by the con­stant agree­ment in what’s in them with­out a move to a lot of ac­tion,” said Villeneuve. “There seems to be a bit of a bit of a mis­match be­tween the sys­tem we have, and our pop­u­la­tion health at large.”

Villeneuve said that the world is clam­our­ing for more than just acute care, but also long-term care, chronic dis­ease man­age­ment, end-of-life care, pal­lia­tive care, and hospice care. As an as­so­ci­a­tion, the CNA has con­cerns about how peo­ple can be de­ployed to meet those needs, while they are aware that there are prob­lems around turf within the nurs­ing com­mu­nity.

For Dr. Hugo Viens, pres­i­dent of the Que­bec Med­i­cal As­so­ci­a­tion, the de­bate over the com­pe­tency be­tween doc­tors and nurses is starting

to fall aside as younger doc­tors en­ter the sys­tem. With as much as 50 per­cent of the provin­cial bud­get in Que­bec be­ing de­voted to health­care, Viens said that there needs to be a greater fo­cus on pop­u­la­tion health and pre­ven­tion.

“We feel there needs to be a shift in the time­line of dis­ease, and work to­gether in go­ing to­ward pre­vent­ing dis­ease and ad­vo­cat­ing for a bet­ter health sys­tem that would reach peo­ple, ed­u­cat­ing them, to pre­vent dis­ease,” said Viens. “This is some­thing we need to fo­cus on if we want to be able to af­ford our health sys­tem for many years to come.

Viens said that over-di­ag­no­sis is an is­sue for doc­tors, given that as much as 30 per­cent of what doc­tors do is prob­a­bly un­nec­es­sary, in­clud­ing tests and hos­pi­tal­iza­tion, which could be avoided.

“We are in a model that thinks that do­ing more is bet­ter, but of­ten less is bet­ter,” said Viens. “There is new sci­ence that is be­com­ing more ac­knowl­edged that value care is not nec­es­sar­ily vol­ume care, and fee-for-ser­vice is prob­a­bly some­thing that needs to be ad­dressed.”

Viens said that while tech­nol­ogy is help­ing to some ad­dress prob­lems, it can ex­ac­er­bate the prob­lem of un­nec­es­sary test­ing es­pe­cially when it comes to early de­tec­tions of some can­cers, given that it may not change the out­comes.

Maria Judd, vice pres­i­dent of pro­grams at Cana­dian Foun­da­tion for Health­care Im­prove­ment, said that gov­ern­ments and stake­hold­ers need to come to­gether to ad­dress prob­lems. She said that CFHI’s man­date is to look for in­no­va­tions with the sys­tem and try­ing to make them more wide­spread.

“We iden­ti­fied an IN­SPIRED pro­gram, which is a sup­port­ive COPD [chronic ob­struc­tive pul­monary dis­ease] pro­gram, de­vel­oped by Dr. Gra­ham Rocker and team in Hal­i­fax,” said Judd. “We’re help­ing to spread that and its scal­ing, in­creas­ing and ex­pand­ing in ev­ery prov­ince in this coun­try.”

IN­SPIRED stands for “Im­ple­ment­ing a Novel and Sup­port­ive Pro­gram of In­di­vid­u­al­ized Care for pa­tients and fam­i­lies living with REs­pi­ra­tory Dis­ease,” where the first six months of im­ple­men­ta­tion saw pa­tients’ emer­gency room vis­its fall by 60 per­cent, hos­pi­tal­iza­tions fall by 63 per­cent, and days in hos­pi­tal fall by 62 per­cent by com­par­i­son with their pre­vi­ous ex­pe­ri­ence. CFHI’s web­site notes that the re­duc­tion in hos­pi­tal­iza­tions trans­lates into an es­ti­mated $977,000 in sav­ings, which is more than three times the an­nual oper­at­ing costs of the pro­gram.

With in­no­va­tions like this, why aren’t they get­ting greater adop­tion?

“Our health sys­tems are over­loaded,” said Judd. “We don’t have the ca­pac­ity to re­spond to new ways of do­ing things, and that’s where build­ing ca­pac­ity for im­prove­ment comes in.”

Dr. Damien Con­tan­dri­opou­los, pro­fes­sor at the school of nurs­ing at the Univer­sity of Vic­to­ria, said that health­care spend­ing has dou­bled over the past thirty years, but there has not been any sense of im­prove­ment in the sys­tem.

“There never have been as many physi­cians in Canada [as there are now] – same for nurses,” said Con­tan­dri­opou­los. “And still the sys­tem is crum­bling.”

Con­tan­dri­opou­los said that no­body is lead­ing the change within the health­care sys­tem, and that no­body has the ca­pac­ity to steer the sys­tem. What there is, how­ever, are in­ter­est groups who re­sist change when it means that money gets moved around.

“Pow­er­ful in­ter­est groups have the ca­pac­ity to slow down change,” said Con­tan­dri­opou­los.

Judd said that small changes can have div­i­dends when they are proven ef­fec­tive at the lo­cal level and start bump­ing up against lev­els above, which can spread those changes more broadly.

Viens said that while ev­ery­one agrees on prob­lems and so­lu­tions, they need to work on build­ing teams rather than silo­ing the kinds of care that doc­tors, nurses and other pro­fes­sion­als can pro­vide. He added that the cur­rent sys­tem is re­spond­ing to the kinds of re­wards that are built into it, such as the as­sump­tion that an emer­gency room visit will treat them faster than a clinic visit.

Con­tan­dri­opou­los said that an­other prob­lem is that the train­ing sys­tem of learn­ing-by-do­ing helps to en­trench cur­rent prac­tices. “You learn to be­have as a doc­tor by see­ing [how] other, more ex­pe­ri­enced doc­tors be­have, and this re­pro­duces the sys­tem, so it’s not easy to dis­rupt.

Sixth Es­tate Host Su­san Dela­court with Mike Villeneuve. Pho­to­graph cour­tesy of Twit­ter.

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