FUTURE HEALTH CARE SCENARIOS

　

　We have been talking about changes in social systems including economics, demographics, technology, personal social conditions, etc. - all of which suggest that we will have to continue to change the design of health care in the future. In the future health care will be very different because:

　

　

　Of course I cannot say what will be the best options for health care in your country. However I can tell you about some of the newer "care" designs that we are working with in Canada. Unfortunately I cannot bring you news of any perfect design!! However you might be interested in some of our ideas and we may have some ideas in common. I will guess that you might have good ideas for us to improve our systems. I look forward to your comments and to hearing more comments at the forum in the next session.

　

Public Health and Preventive Medicine in Canada 4^th edition, by Dr. C. Shah is an excellent reference on this topic and I have frequently used his material to prepare this talk. (I should add that he was pleased to hear that we are using his book in your country)

　In our country, the role of the provincial ministries of health, in most cases, has been revised to meet the increased role of regional and local boards of health. In most cases, provincial ministries have devolved service delivery responsibilities to regional boards while maintaining responsibility for:

　The main exception to this trend is the Ontario Ministry of Health, where the organizational structure remains more or less unchanged and oriented toward financing individual hospitals and agencies rather than regional boards.

　

　Service delivery involves those services that, in most provinces, fall under jurisdiction of the ministry of health with regard to budget, policies, and control. For the most part, the actual delivery of health services is now the responsibility of regional health boards, with the function of the ministry of health at the provincial level limited to financing health services, administration, and planning (covered below). Thus, regionalization represents the centralization of most services to regional levels from local bodies.

　Examples of "Care Scenarios"

　When illness, suffering, or symptoms occur, an individual usually relies on informal support, sometimes for prolonged periods. When this support is exhausted, the individual turns to local community-based health services, which can include primary care, secondary care, hospital care, home care, public health services, or private nursing homes. Community health services and some self-help groups may also deal with specific groups of people, e.g. Aboriginal peoples, battered women, and people with Alzheimer's disease.

　Canadian Government health insurance plans cover basic hospital and medical services in all provinces, but there are variations in the coverage of extended health services, whether in the home or in the community, paid by provincial or private insurance or by the individual. Affluent provinces provide a larger range of services financed through public revenue than poorer provinces do.

　

　The community programs are increasingly serving people with acute care needs as well as those with chronic illness. The most challenging patients have dementia or chronic mental illness or have 2 conditions eg. Parkinson's Disease and severe depression, Alzheimer Disease and hip fracture,

Home Care

　Most current health reform aims to strengthen and expand community-based and home-based care. This shift away from hospital-based care is motivated in part by fiscal constraints (home care is purportedly less expensive than institutional care) and in part by the belief that services provided in the home effectively meet the needs and preferences of patients, especially among the elderly. Only a small percentage of provincial health budgets is allocated to home care, but most provinces have increased these budgets in recent years. Currently the Canadian Federal Government which does not have health care authority is starting to explore means to transfer money to the provinces to strengthen home care.

　

History

　Until early in this century, the rich were cared for at home and the poor, homeless, or indigent were treated in hospitals. With the emergence of provincial and national health insurance plans the resulting expansion in the institutional sector, home care functions were transferred to hospitals and nursing homes. However, this pattern has gradually been reversing in the past 20 years. In most provinces, provision of home care services began with smaller, urban programs run by agencies such as the Victorian Order of Nurses. As a result of rising hospital costs and pressure on hospital facilities, home care programs were developed, mainly to relieve hospitals of the care of patients who only needed additional nursing services or physiotherapy. Comprehensive, government-oriented home care plans were developed by some provinces in the 1970s. In 1977, as a part of the Extended Program Financing services, legislation provided the first concrete financial support for home care programs. By the late 1990s, all provinces and territories have government home care directorates or division, although there is no common approach to funding and delivery. It still remains unclear whether the development and strengthening of home care programs is an effective cost-saving measure for provincial budgets, or whether it only reduces costs to health systems, and transfers of costs to patients and their families or local municipalities.

Types of Home Care

　

　I will now talk about different basic forms of home care.

　

　Home support services (such as homemaker, transportation and meals-on-wheels programs) provide autonomy and mobility for those with assessed functional deficits. These services are not primarily medical, and may be provided along with medical treatment. Although many people can remain at home without the help of these services for some time, early use of the services can prevent health decline and institutionalization. For example yesterday I spoke about the research evidence that pro-active provider initiated care can reduce mortality and admissions to hospital.

　

　These services are provided to people with significant functional deficits, usually resulting from one or more medical conditions, who require these services in order to remain in their homes. Chronic care services are designed for people with stable conditions, or to delay deterioration and thus institutionalization.

　

　Acute home care is usually provided after hospitalization to people who are unable to travel to outpatient facilities, and it is provided on a short-term basis according to need It is designed to reduce the length of hospital stay and to assist the recovery process. People usually receive acute home care from two or three days to a maximum of 90 days.

　

　One of the most innovative programs is in New Brunswick, one of Canada's eastern provinces. It is administered free of charge to a case-load equivalent to that of a 200-bed hospital. Services include a range of palliative and acute care services such as nursing, physiotherapy, intravenous medication, nutritional counseling, respiratory care oxygen therapy, and sick room equipment. Meals-on-wheels, home-making, and other support services can be purchased by the patient, who must be formally admitted by an attending physician who directs the medical care plan and authorizes discharge. To be eligible, the patient must be acutely but not critically ill, and must require one or more professional services such as nursing, occupational therapy, or physiotherapy.

　

　Palliative home care is provided to terminally ill patients such as those with AIDS or cancer. The care is provided by a multidisciplinary team at home. I will talk more about Palliative care in a few minutes.

Features of Home Care

　Most home care programs are characterized by two features: centralization of control of services within the program, and an ongoing coordination of services to meet the changing needs of the patient. In some provinces, the provincial department of health plays an active role in the financing and administration of home care programs, while in other provinces, local agencies, municipalities, and hospitals assume the major responsibility for home care. There is also a substantial private section component to home care with services financed directly by the patient or family. Between 1977 and 1996, when Established Program Financing was in effect, home care services became associated with local public health units in some provinces. Since the change over to the Canada Health and Social Transfer Act of 1996, federal transfers to the provinces no longer require a home care component in health budgets, nor do they allocate separate money for them. Home care services must now compete with all other provincial health, post-secondary education, and social services for their budgets.

　At present, spending on home care programs accounts for just over $2 billion a year, or less than 4% of total public spending in the Canadian health system. Most provincial home care programs are funded by the government, but some charge user fees, often based on the ability to pay. For example in British Columbia, all public home care programs are fully or partially funded by the continuing Care Division of the Ministry of Health. Home care services such as case management, home nursing care and community rehabilitation are provided to those who qualify at no charge, while the homemaker services charge people according to income testing.

Day Care and Respite programs

　

　To complement home care programs, services outside the home are needed. Both the family members and the patients can benefit from day care and or respite programs. The patient may benefit by being stimulated by a change in environment, different people to talk with and some different activities. The care giver benefits when she is able to go to work or she has some time to do errands, such as banking, grocery shopping. (Our studies show that very little of the "free" time is spend on personal pleasure or socializing.)

　

　Day programs are usually offered in a community center or a special area in a hospital. In addition to providing meals, medication, and help with activities of daily living, the programs offer activities such as exercise, music, painting or conversation. By conversation I mean that the staff, for example, may read items from the newspaper and discuss these current events. Usually patients attend these programs on a regularly scheduled basis eg. Monday to Friday from 8:30 to 4:30 or part time such as 2 days per week. In some instances, the provider will offer transportation to and from the center.

　

　Another option that is available on a limited basis is respite care. Respite means rest or relief. For respite care, a patient can be admitted to a hospital, nursing home or chronic care facility for a limited period of time eg. 1 or 2 weeks. This admission gives the family care givers the opportunity for a "holiday" from the job of being a care giver. There are often long waiting lists for respite beds and families need to plan ahead.

Palliative Care Programs

　Dr. Hinahara's Peace House and your local peace program are very important international examples of Palliative Care.

　

　As you know, medicine can be either curative or palliative, according to the philosophy of treatment. Curative medicine is usually considered as traditional medicine; its objective is to ensure a patient's health. Palliative medicine is defined as relieving without curing, based on an acceptance of the inevitable. Palliative care is a relatively new field in Canada, having emerged in 1974, and the demand is increasing . It is directed to those suffering from a terminal illness, who have different needs from those with acute illness, and focuses on the management of pain and other symptoms. It also addresses the psychological, emotional, and spiritual needs of patients and their families when curative care is no longer appropriate.

　

　Palliative care should involve psychological support, assistance in interpersonal skills, coordinated service delivery, symptom control, bereavement counseling, independent living, legal and financial issues, matters of spirituality, lifestyle, culture, and religion. It requires a multidisciplinary team approach, often supplemented by volunteers, and can be given in the home or in an institutional setting. Acute care facilities, which are geared to diagnosis and treatment, do not usually have the environment, skills, and flexibility needed to provide support to terminally ill patients and their families unless specialized facilities are available, such as designated palliative care beds and a palliative care team. In 1990, there were 345 palliative care programs in Canada, with 767 designated beds. Every province has reported palliative care beds that are operational.

　

　There are many types of palliative care programs available in Canada, and national standards do not exist. A decrease in the total number of palliative care programs prompted the formation of the Expert Panel on Palliative Care, made up of ten health care professionals from across Canada. In 1991, this panel made recommendations to the Cancer 2000 Task Force and extended its mandate to present a broad national vision for the palliative care community. The panel called for a radical restructuring of resources and priorities to make palliative care and the relief of suffering an essential fourth phase for those, who are terminally ill and to ensure equitable resource allocation.

　

　One of the best palliative care programs is located in Quebec City - the Michel Sarazzin Centre. There are at any one time 2000 people registered in the program, for a city whose population is less than 200,000. The centre, itself has only 35 inpatient beds. The rest of the people have very good access to staff with expertise in pain control, dietary alternatives, etc. The patients and their families know they have a safety net and that they can be admitted to the patient beds if they feel they can no longer manage at home. Because of the extensive support, they seldom request in- patient care.

　

　In Quebec, like the Peace House in Japan, when people are admitted, they are always encouraged to take with them art objects such as paintings or small pieces of furniture. These items help them to feel less alienated in an institution.

Primary Health Care and Community Health Centers

　

　At this point, it is appropriate to define some commonly used terms. Primary health care includes services provided at the first contact between the patient and the health care system. The contact is generally provided by physicians, dentists, chiropractors, pharmacists, nurse practitioners, midwives, optometrist, dietitians, and others. Services include treatment, promotion and maintenance of health, follow-up care, and the complete continuing care of the individual (including referral when required).

　Therefore, primary health care providers perform three essential functions beyond treating the patient:

　

　Most primary care in Canada is delivered by family physicians in solo or group practices where the physicians are paid on a fee for service basis. The fee for service arrangement is an incentive for physicians to provide more expensive and less time consuming services. Many preventative services and services that address broader health determinants take a longer time are sometimes neglected.

　

　In Canada there is growing emphasis on cost containment and alternative models of delivery health care. In Ontario the primary Health Care reform encourages more group practice and has initiated 24 hr nursing phone lines. Community Health Centers are seen as a viable option.

Community Health Centre

　

　A community health centre (CHC) has a voluntary board composed of members from the community. It receives an annual budget from the provincial government for specific health programs, and it provides a wide range of services such as medical, dental, social, and nursing by a multidisciplinary staff all under one roof. All the professionals, including physicians, are on salary. In all provinces except Quebec, these centres usually are located in under-served areas or serve groups that are often not well served, such as the poor, the elderly, Aboriginal peoples, and immigrant groups.

　

　In Quebec, these centres are part of the regionalized health and social service system, and are called local community service centres (centres locaux des services communautaires, or CLSCs), of which there are approximately 146. CLSCs integrate health and social services and emphasize prevention, health promotion, and provision of other personal services, including occupational health services at one location; they are also required to provide services for extended hours in the evenings and weeks. Outside Quebec, CHC programs are most extensive in Ontario, where, as of 2000, there are approximately 55; CHC's have also been established in Nova Scotia (four), New Brunswick (four), Manitoba (14), Saskatchewan (five), Alberta (two), and British Columbia (four).

Alternative Health Care Providers and Alternative Therapeutic Approaches

　

　Increasingly, significant numbers of Canadians (approximately 15%) seek the services of alternative health care providers, which includes reflexologists, naturopaths, homeopaths, and traditional healers. These practitioners usually work in solo practices and are paid out-of-pocket by those individuals seeking such services (11).

　There is a range of primary health care services provided by different professionals. The entry point to the primary health care system depends upon various factors, such as the economic status and education of consumers, health beliefs, type of health insurance, and the availability and accessibility of services and professionals.

　

　Also, there are newer approaches such as music therapy, art therapy, pet therapy that are showing promising results for people living with chronic illnesses. The evidence shows improved mental acuity and longer life even for people who have serious dementia.

　

　In conclusion I think the challenge for all of us is to be flexible with our health care design. Although systems can be designed to meet large population needs, system formulae must be adapted to meet individual, family and community needs.