Decades ago, almost all care was home care. Friends and family cared for people who were sick. If you were able to afford a doctor's fees, he or she woul treat you at home. Very few patients were admitted to hospitals. While care in the home for serious and long-term illness is still not as common as it once was, there is growing interest in alternatives to institutional care. Public funding for province/territory-wide home care began in the 1970s and 1980s. Many of today's home care services used to be provided in acute and long term care institutions. Home care allows some patients to recover at home and fills gaps between the services that a client would traditionally need in the hospital, and the care the community services can provide in the home.

　

　Public home care programs include client assessment, case coordination and management, nursing services and home support, such as Meals-on-Wheels, help with bathing and dressing, homemaking and respite services. Some programs also offer physiotherapy, occupational therapy, oxygen therapy, specialized nursing and other services. The above are examples of extended health care services that may be required by patients in the community after institutional discharge.

　

　The need for effective discharge planning by health care professionals has become more urgent and complex in light of recent healthcare initiatives. In the 1990s turbulence in the healthcare environment forced administrators and health care professionals to reconsider the continuum of how and when healthcare is delivered. One endpoint of that continuum of care is discharge.

　

　The continuity between home and hospital has been impacted by restructuring in both Canada and Japan. Policy makers have had to create frameworks that acknowledge changing demography and the transfer of care from hospital to home. This workshop will provide a comprehensive overview of critical issues that need to be addressed in order to create health system that provides high quality, seamless care between the hospital and home setting. During these two days we will discuss issues of discharge planning including: overview of changes in the health care system; demographics of patient populations; characteristics of hospital care; characteristics of discharge patients; review of research in hospital home care; overview of risk assessment; overview of assessment forms; transitions across various continuous care settings; education for the health care workers in care management of the early discharge patients; skills for the health care workers in care management of the early discharge patient; and the future "care" scenarios.

　This lecture provides a brief overview of Canada's health system and the impact of economic restructuring and health care expenditures. The constants of geography and demographics are important in discussing health care in Canada. Canada has approximately 30,491,294 citizens compared to 120 million citizens in Japan. Canada is a very large country with a diverse, aging population that is widely scattered from Corner Brook, Newfoundland to Coquitlam, British Columbia. These factors are important drivers for the way our health care system is now, and will be in the future.

　

　Canada's population is comprised of 30,491,294 people. There are just over 800 public hospitals to serve its citizens. Canada's health care system has a complex and changing mix of health care provider. While we know quite a bit of supply of registered nurses and physicians, we know much less about other health care providers and how recent changes have affected the working lives of all the people who make the system work. The nurse to population ratio is 748: 100,000; the physician to population ratio is 185: 100,000; and the physiotherapist to population ratio is 48: 100,000.

　After accounting for inflation and population growth, total health care spending rose steadily from 1975 until the early 1990s. The mid-1990s saw relatively small annual drops in expenditure per capita. The trend reversed in 1997 and 1998, the latest years from which inflation-adjusted figures available. Unadjusted for inflation, per capita spending is estimated to have grown by 4% in 1999. In 1999, total public and private health care spending was expected to reach $86 billion, up 5% or about $100 per person more than 1998. Canada's ratio of total health care spending to its Gross National Product - fourth among G7 countries in 1997 - was estimated at 9.2% in 1999. Data on health care spending show substantial shifts over the last 20 years.

Both Canada (9.3%) and Japan (7.3%) share relatively low health care expenditures (Gross National Product) relative to the United States (14%).

　Since the mid-1970s, the share of total health care dollars devoted to hospitals, the largest single category of health expenditures, has dropped every year. After relatively rapid growth through the mid-1980s, the growth of spending on physician services slowed during the 1990s. In 1997, drug costs overtook spending on physician services, to become the second-largest component of health expenditures. Over the past 20 years, health care expenditures in hospitals have been reduced by approximately 10%. Physician services decreased by 1% in contrast to pharmaceutical costs which increased approximately 7%. Other health care expenditures increased by 6% which is reflected in privatization costs.

　Canada's health care sector is changing. The number of beds and overnight admissions has been decreasing for more than a decade. Canadians' length of stay in hospital has decreased from 41.1 million in 1990-91 to 35.5 million patient days in 1995-96.

In the past 7 years, the number of public hospitals decreased by 14%. There has been a reduction in acute care beds by 25%, and the number of outpatient visits increased due to early discharge.

　This reorganization has not been seen as particularly successful. It is interesting to note that public opinion on Canada's health care system has declined. In 1991 in a national survey 61% rated the health care system as excellent and in 1998 only 29% rated the system as excellent. In conclusion, there was a consistent decline in hospital expenditures and as a result a decline in total days spent in hospital. The shift in care from hospital to home has raised concerns about increased financial, physical and emotional burdens placed on families, especially women. Much of the care is assumed by informal caregivers and 27% of caregivers said that it affected their health and had reproach as a result of their health care activities.

　Canada reorganized the community services and in some provinces, privatized the services. In Japan, the trend toward privatization have companies with little or no health care drawn into the sector by newly available government funds (Matushita Electric works, Shimiazu Construction and Seven-Eleven). The new national insurance program provides seniors 65 and older new access to services ranging from household help to nursing care. Saphir (2000) reports that 2 million out of a potential 18 million have applied for these benefits. In Canada this move towards privatization has lead to a reduced number of nursing personnel and a disruption in the continuity of care.

　

　In order for these non-regulated privatized companies to be competitive, costs are cut by using fewer services and non-regulated personnel.

　Looking at the projected demographics, there will be an increased need to have an effective and efficient discharge planning process as hospital and community service utilization will have increased in correspondence to the increase in elderly population. Japan is predicted to have the highest increase in elderly population over 65 years of age at 27%, by 2025 in comparison to other developed countries, such as Canada at 15% and the United States at 18.5% (Modern Healthcare, Nov. 15, 1999, p.46).

　

　Traditionally there are two cohorts of patients that are high users of community health services - young mothers and the elderly. It is well documented that the elderly are high users of health care services. In addition to this cohort there is now many acutely ill patients with coexisting chronic conditions requiring community services. Governments are concerned with the aging population and the increased demands and costs of community care.

　On the positive side, there is an increase in what is now commonly called "the walking well". Though these individuals require supportive services such as: assistance with meals; activities of daily living; and adult day care, they are still able to function on an independent level and may remain in their homes.

　It should be emphasized that the majority of elderly are still in their homes and maintain a high quality of life and do not access services until they need support of services. Dr. Watanabe noted that clients in intermediate care facilities were elderly females with a low degree of independence and dementia and had lived previously alone in their homes prior to admission. In Canadian home care services, the rates of home care utilization were highest among seniors, particularly women, who lived alone. It is important to note that the care provided for these Individuals is still primarily provided by the families and results in the need for families to balance caregiving and work. Statistics Canada found that aprox. 2. 1 million Canadians provided support for more than l seniors. 80% of caregivers were family members including spouses or partners, adult children, siblings and extended family members. Most caregivers (61 %) were women. On average female caregivers spend 5 hours a week compared to male caregivers at 3 hours a week. Informal support is an important part of health care in Canada. A better understanding of who provides care and how it affects them helps to make sure that we recognize the important role that friends and families play in the care of patients and that we support caregivers in their role. In order to assure a high level of care, health professionals have to be assertive advocates for family caregivers.

　Canada's health care institutions are often the most visible symbols of the health care system in our communities. The majority of hospitals offer short-term diagnostic and treatment services for patients with a wide range of illnesses and injuries. Some also have separate groups of beds, wings or buildings devoted to long-term care. Other hospitals specialize in treating particular groups of patients, such as children, mothers giving birth and patients with cancer or psychiatric conditions. Still others are devoted to providing rehabilitation services or long-term care. Care for seniors and pregnancy and childbirth account for the most acute care hospitalizations. In 1997/98, seniors made up 12% of the Canadian population, but they accounted for 31% of acute hospital stays and half of the days in hospitals. Heart and stroke disease, respiratory conditions and digestive problems were the leading causes of overnight hospitalization for Canadians age 65 and over. There is some evidence to suggest that it is not primarily the aging of the population per se, but rather the more intensive manner in which they are being treated that has led to a higher use of health care services among seniors.

　As a result of the restructuring in the health care system, some characteristics of the hospital care are shorter lengths of stay and more acutely ill patients.

　Traditional hospital care has been replaced by care in the home and self help groups, adult day care centres and community centres. The community provides wellness programs, disease management programs and disability management programs.

　Community centres are used in conjunction with health-focused programs. These centres use a developmental approach to focus on the psychosocial wellness of the public by providing various programs for all ages. Wellness programs in the community consist of activities that require social interactions and stimulating activities. These programs provide respite for the caregivers. At the community level, high priority has to be given to develop a broader array of programs that support family caregivers. There are other facilities in the community that provide services for discharged patients, such as adult day care centres.

　Adult day care facilities provide services for targeted individuals, such as: seniors and their caregivers, alzheimer patients, cognitively and physically impaired patients as well as the "walking well".

　The focus for adult day care facilities is respite care, social interaction using stimulating activities, and to provide medical care. Some of the activities at adult day care facilities may include computer skills, social activities, pottery and knitting.

　High readmission rates, especially for older people and newborns, result in higher costs and diminished quality of life. Dennis et al. reviewed a study that attributed the likelihood of readmission to early discharge, the absence of home care, and inadequate medical care during hospitalization. Decision making is an important component of discharge planning. It is important that the necessary information is obtained in order to have a more efficient and compassionate plan for the continuum care for the patient.