The challenge we face is complex: an aging population that wants greater convenience, autonomy, and engagement, and better health at a lower cost. This challenge won’t be met by putting more money, whether public or private, into the system. We need to develop new ways of doing things that aren’t just about spending more. Here are just a few examples of what that can look like.
1. Cue the Queue
One of the biggest challenges we face in Canadian health care is wait times for elective procedures and appointments. In almost every case, we can reduce waits without spending more if we use a centralized intake process for specialty services.
When I first started my practice a decade ago, if I had a patient who needed a knee replacement, I’d refer him or her to the orthopaedic surgeon whose name I knew. That surgeon kept his wait list in the top drawer of his secretary’s desk. If he went on vacation for the month of August, the wait list just grew.
Now, as a result of the concerted effort to reduce wait times in many parts of the country, when I refer a patient with late-stage osteoarthritis of the knee, that person is seen within a few weeks by a nurse and a physiotherapist. These highly trained professionals educate patients about the nature of osteoarthritis, teach them exercises to improve their pre-operative strength, counsel them on the importance of weight loss, and use a checklist to determine whether they’re good surgical candidates. If they are, they can either wait for the surgeon of their choosing or see the next one available.
Let me illustrate this important point about the next available surgeon. At six p.m., when I’m rushing home to my hungry six-year-old, I sometimes stop at the grocery store. I grab whatever I need and head for the checkout line. And then I play the guessing game. Which line shall I choose? If I get it right, I’m home in twelve minutes. If I get it wrong, and I’m in the training line, or behind the teen counting coins from his pocket, it’s twenty minutes. Now, if I make the same stop at the bank, I get in a single line—just one line—and am served quickly by the next available teller. The banks have figured out the beauty of applied queuing theory. Grocery stores have not.
By adopting the bank-line method and instituting a single common queue, we’ve reduced wait times and increased the appropriateness for surgery of those patients who are awaiting surgical consultation. And because groups like the Wait Time Alliance insisted on actually monitoring wait times, we’ve been able to measure our progress and identify when things start to go off track.
There is no reason why this model can’t be applied to the majority of specialty care. If you have two specialists in a geographic region who offer the same services, you can do centralized intake. What’s required is a willingness on the part of specialists to give up “ownership” of their wait lists and a willingness on the part of referring family doctors and patients to move away from the notion of a referral as a personal introduction. We also need to identify the kinds of specialty care where expertise can be pooled.
This concept makes some patients and doctors uncomfortable. Don’t we all have the right to be treated by someone we trust? Certainly. But most patients who see a specialist do so on the recommendation of their family doctor or a friend or family member—opinions that are rarely based on anything concrete. Just because your friend had her bowel surgery done by Dr. Smith doesn’t mean that Dr. Jones wouldn’t do just as good a job. Just because I went to medical school with Dr. Pink doesn’t mean that he’ll treat you better than Dr. Green will. And in fact, if I’m honest, while I know Dr. Pink and believe him to be an intelligent person and a nice guy, I have no idea if his patients’ outcomes are any better—or worse—than those of Dr. Green’s patients. If a patient waiting for surgery wants to be seen by the surgeon with the lowest infection rates or the highest patient satisfaction ratings, fair enough. But that information is rarely publicly available in Canada. For patients who prefer to wait for a particular specialist, a longer wait may be worth it. But for many of us—myself included—being seen by a competent, well-trained professional as quickly as possible is the priority.
Centralized intake won’t fix all the wait lists in Canada. But combined with other reforms, it would have a major impact. In particular, once a single common queue is implemented, we can begin to maximize the contributions of other, non-physician professionals to bring wait times down and improve the patient experience of care without spending more money.
2. Broaden Our Horizons
It can be easy to fall into the trap of thinking that health care is about doctors. But if we made better use of the tremendous expertise of other health care providers—and of the non-clinical staff in our health care organizations—we could go a long way toward delivering on the Triple Aim.
Centralized intake and assessment for hip and knee surgery is just one example. Too often, surgeon time is the bottleneck that causes the wait list to grow. But a nurse, nurse practitioner, physiotherapist, or pharmacist can do many of the tasks traditionally done by physicians (and often better than we can). Whether it’s assessing patients’ appropriateness for surgery or explaining to them how to start insulin or seeing them for a follow-up on their blood pressure, non-physicians can lead terrific models of care delivery.
You might be seen by a physician assistant in the emergency department or a nurse educator in a cancer clinic. You might get your primary care from a nurse practitioner. Your pharmacist might prescribe your medication renewal for you. In many cases this means that the care of a non-physician provider will replace at least part of what the doctor used to do rather than being added to that care, unless there is good evidence that the extra care provides better health outcomes and a better experience for the patient. In that case we may decide that the additional cost is acceptable. The concept of substituting rather than adding care will require teams to build deep trust and partnerships, but it’s the only way we can improve the system at a cost we can all afford.
3. Use Hospitals Wisely
Every health care system needs hospitals. If I get hit by a car, or need my appendix taken out, or develop a life-threatening blood infection, I want to be taken to the hospital.
But much of what threatens our health doesn’t kill us quickly, and it doesn’t require big teams working on us around the clock. As the population ages and chronic disease rises, we should move care to where people need it: in their homes, or as close to their homes as possible. It’s been said so many times that it feels almost trite to repeat it: the future of health is in primary care, home care, and self-care.
This doesn’t mean that we should close hospitals or reduce the number of beds in Canada. We already have the lowest number of beds per capita among developed countries; the fat in Canadian hospitals was cut long ago. But we do need approaches that won’t require us to massively increase the number of beds as the population ages. That’s because the hospital is the most expensive part of the health care system, and because nobody wants to be there unless it’s absolutely necessary.
And, of course, the front door to the hospital in Canada is the emergency department. Our EDs are the canaries in the coal mine: whether it’s a backlog of patients on the ward waiting for long-term care or trouble accessing family doctors after hours, the ED is often where we see the first signs of trouble elsewhere in the system.
There are alternatives to hospitals and the ED. Michael Decter, the former deputy health minister I quoted earlier, has referred to the “six components of the out-of-hospital universe”: primary health care, home care, the community pharmacy, community-based paramedicine or ambulance care, palliative care, and rehabilitation. Informal caregiving could be added to that list. And when patients with complex problems require more than what these seven out-of-hospital environments currently offer, we need better options than sending them to the emergency department or admitting (and readmitting, and re-readmitting) them to hospital.
Let’s come back to Susan. If her family doctor—or one of his colleagues—had been available that winter morning when she started to feel weak, she might have gone to see him instead of going to the ED. Had she gone early enough, hopefully he could have given her advice that would help her get better at home. But what if she had arrived dehydrated and weak, clearly in need of IV rehydration? One look at her and the family doctor would have had no other option but to call 911 himself. In most communities there is no easy way to set up investigations and treatments in a timely manner outside the ED.
After Susan developed heart failure, every few months she landed back in the ED and was readmitted to hospital to deal with her chronic condition. That’s an expensive and unpleasant way to manage exacerbations of chronic illness that are entirely predictable. We don’t always know when they’ll happen, but we know they will.
If Susan and her family doctor could have accessed specialty advice, urgent blood tests, X-ray exams, and IV treatments without having to call 911 every time she had such an exacerbation, her care would have been much better. If they could have accessed more intensive home supports for her, she might not have ended up sitting in hospital for weeks waiting for a long-term care bed.
Our downtown Toronto neighbourhood encompasses many family doctors like Susan’s physician. They’re solo practitioners, or they work in small groups of two or three doctors. They have large practices, sometimes culturally or linguistically based, often Chinese- or Portuguese-speaking like many of my neighbours. They have many older patients who don’t speak English well and who have complex medical needs. And they can often be fairly isolated from other services.
Like many Canadian emergency departments, the local ED is overloaded, especially in the evenings and on weekends. And it’s clear that gaps in communication and coordination with family doctors have resulted in fractured care and longer wait times for patients like Susan.
So a team of creative people led by two brilliant and brave women—Drs. Pauline Pariser and Gillian Hawker—set about to see how they could help. They launched a project called SCOPE (Seamless Care Optimizing the Patient Experience), which aims to help those family doctors in our neighbourhood keep patients like Susan out of the ED and prevent hospital admission when possible. This is all part of the mandate of Women’s College Hospital as the “hospital to keep people out of hospital.”
The target group of family doctors was identified through a method known as hot-spotting. The team looked at frequent flyers among the patients in the local emergency department and identified their family physicians. Solo doctors whose practices had high ED usage rates were offered the chance to join SCOPE.
Family doctors enrolled in SCOPE are provided with a “one number to call” service that helps them access advice from specialist doctors, gives them rapid access to urgent imaging for their patients, and assists with home care coordination. It also links them to the Acute Ambulatory Care Unit at Women’s College Hospital.
The AACU is located where you’d expect to find the emergency department in a regular hospital, but it doesn’t have a jam-packed waiting room or stretchers in the hallways. Instead, it’s a calm place. On a busy day all the stretchers and rooms may be full, but people are flowing in and out of it the way they do through a clinic space. It isn’t a walk-in service. Many patients who come to the AACU have done so because their family doctor is participating in the SCOPE project.
If Susan had gone to her family doctor’s office right at the beginning of a mild exacerbation of her heart failure, he could have tinkered with her medications so that over the ensuing few days she’d pee away the extra fluid accumulating in her lungs. But for more severe symptoms, the only way to get her through would have been to give her IV medication and monitor her for a few hours—and there wouldn’t have been anywhere for her to go other than the emergency department. She might spend several hours waiting there, and then another ten hours getting stabilized before being sent home. Or she might have been admitted to the hospital for a day or two. The routine would have always been the same: some blood work, a chest X-ray, some IV medications, and monitoring.
But if Susan’s family doctor had been part of SCOPE, he would have had an alternative for her. He could have phoned the internal medicine specialist in the AACU on what I call the “magic cell phone”—magic because it’s answered! by a doctor!—and that person would have told him to send her over. She wouldn’t have had to wait. They’d have been expecting her, and the AACU doctor would have known what she needed because he’d have had a phone conversation with her family doctor. The AACU doctor and staff could have gotten a chest X-ray rapidly, given her some IV medicine, monitored her, and then sent her home with a connection to a home-care worker who could have checked on her the following day. Susan would have been well taken care of, and the experience would have been so much more pleasant. And the potential savings to the health system would have been significant, especially if a hospital admission had been avoided.
Patients like Susan aren’t the only ones who can benefit from this model. One December, a woman whose family doctor was participating in SCOPE started experiencing severe pain in her bones. Blood tests revealed that she was developing kidney problems. She was given an appointment with a kidney specialist—a nephrologist—in mid-January. But by December 23 she’d become immobile. She was very frightened.
Instead of sending her to the ED, where she’d almost certainly have been admitted to hospital for a number of days over the busy holiday season, her family doctor arranged for her to be seen in the AACU at Women’s College Hospital the next morning. She was there for six hours. She had a chest X-ray, an ultrasound, and a series of blood and urine tests. A pharmacist took a full history of her medications. She was examined by an internal medicine doctor. She was given a set of signs to watch for so that she’d know when to seek further medical attention, and was sent home with a short-term plan. Some of the blood work took time for the results to come back, so she returned two weeks later. A nurse practitioner went over all the results with her.
It wasn’t until she met with the nephrologist in mid-January that she fully understood what SCOPE had done for her. Instead of having to send her for the many tests after meeting her, he already had all the results in front of him. With all that data, he was able to give her a diagnosis of probable (confirmed later) multiple myeloma—bone marrow cancer. It was not a happy diagnosis to receive, but she was glad to finally have all the pieces put together and to get on with the treatment plan.
We used to talk about “wrapping services around the patient.” I never understood what that meant. As far as I could tell, it often seemed to mean throwing more and more health care at people: case workers, system navigators, specialized clinics for one body part or another. The SCOPE project instead wraps services around the primary care provider, helping family doctors take better care of complex patients in the community, close to home. New buildings and fancy technology aren’t needed. What’s needed is a willingness on the part of hospitals to organize their care differently, supporting primary care and home care workers who need backup. That way, patients can stay home instead of lying on stretchers in the emergency department or being admitted to hospital. SCOPE is one promising example, and others are emerging in communities across the country.
Of course, SCOPE is primarily about helping patients who need face-to-face care fairly quickly. But many elements of health care actually don’t require that at all. This is where technology comes in.
4. Get Disruptive
Technology and virtual ways of providing care have the potential to transform health care, but not if we just layer them on top of our existing systems.
Disruptive technology offers products or services that are cheaper, simpler, or more convenient than the traditional way of doing things. What makes it disruptive is the fact that a smaller company or entity with fewer resources can successfully challenge the established order. Disruption happens when a new approach targets a group that has been overlooked, gaining a foothold by doing things in a way that’s more attractive to consumers, often at a lower price.
Rather than focusing on small, incremental improvements to existing technology (like moving from a giant desktop computer to a slightly smaller desktop computer), disruptive innovation looks to find new approaches to tackling old challenges (like inventing the tablet). Early versions of disruptive technology often can’t do as much as the traditional “gold standard” technology, just as the first laptops didn’t have the computing power of a desktop. In health care these are often “good enough” approaches to care that gain acceptance, improve, and sometimes even go on to destroy the market for much more expensive and traditional approaches. Whether it’s a finger prick blood test for HIV that’s slightly less accurate but can be administered anywhere, including in a small rural clinic, or the deployment of more easily trained health care providers to perform tasks that used to be performed by doctors, disruptive innovations push the boundaries of our established ways of doing things and lower the price of care.
One night when I was working in the emergency department in a small northern Ontario community, a young girl was brought into the ED by her distraught grandmother. Her family lived in rudimentary housing on a nearby Aboriginal reserve. The temperature control on the water tank hadn’t been working for months and they couldn’t get it fixed, so if the hot water tap was turned on, the water came out scalding hot. The grandmother was taking care of the kids. While she was tending to the baby, the little girl turned the kitchen tap on with her feet dangling in the sink. She suffered immediate severe burns on both legs.
The traditional approach to caring for this child would have been to fly her and one family member hundreds of kilometres away to the nearest pediatric burn centre for weeks of monitoring and daily dressing changes. Instead, we called on the Ontario Telemedicine Network. OTN connects patients with a care team in a major centre through the use of video communication.
We admitted that little girl to our small rural hospital and immediately got onto a video call with a burn specialist. She evaluated the size and severity of the burns and helped us figure out how best to dress them, how much fluid to give the patient, and which antibiotics to give her. She continued to assess those burns every day through remote videoconferencing. The patient was able to stay where her whole family could be with her. The system was saved the costs of travel, family accommodation, and a stay in a tertiary care hospital. That was my first contact with disruptive technology in health care, and I was amazed.
It seemed futuristic and far-fetched at the time—this was the early 2000s—but telemedicine has now become normal across rural communities in many parts of Canada. And it works. For example, during a three-year research trial, a stroke rehabilitation program conducted through telemedicine rather than traditional face-to-face visits demonstrated no difference in treatment outcomes. I suspect that in the early days, a cardiologist listening to someone’s heart through video technology would have said it was “good enough” but not as good as laying hands on the patient. And maybe a psychotic patient being assessed by a psychiatrist through technology would prefer to be in the same room as the doctor asking all those personal questions. But the increased convenience, equivalent health outcomes, and lower cost make virtual care the kind of disruptive technology we need to pursue. We can give tablets to providers in big hospitals so that they can walk around and take notes as they go, and that may represent a process improvement—but it isn’t disruptive. It’s just layering technology on top of the existing system. We need to seek disruption.
5. Help People Die with Dignity
Sometimes it makes sense to use everything within our powers to try and cure or interrupt the progression of illness. But at other times those efforts merely reduce patients’ quality of life for the valuable, limited time they have left. People who are not physically strong may not be able to benefit from, or even handle, intense treatments. So whereas traditional therapeutic care strives to get resolution to health problems, palliative care seeks to control or eliminate symptoms in order that we can live well for as long as we have. And that can be a long time! The transition to a palliative set of goals doesn’t always mean that the patient will die immediately. It does mean that the goals of treatment change, which, if the process is managed well, can be a relief for patients, families, and their care teams.
Still, our palliative care systems in Canada have traditionally been focused on care at the very end of life. Instead of encouraging an early connection for those with incurable illness and providing support for a longer period of time, many of these programs and services have eligibility criteria that require a prognosis of less than three months. The result is that people often spend their final year or years of life bouncing in and out of hospital, receiving treatments that aren’t benefiting them, before finally being transitioned to palliative care that would have helped them cope well with their situation sooner. For most people, there isn’t a single moment when it becomes suddenly clear that we need to shift from a curative to a palliative framework. Instead, doctors and patients can slowly shift the orientation away from more invasive tests and procedures and toward a broader focus on quality of life. Too often, we don’t have reliable systems in place to help people through that process.
With an aging population and the advanced chronic illness it can bring, we desperately need new approaches to dealing with illness that can’t be cured. These approaches must respect what frail patients and their families want. Palliative care is not about hastening the end of life or denying people cures. It’s about helping patients decide what they want by having a realistic conversation about their options.
The PATH clinic in Nova Scotia is one place where that conversation is occurring. PATH is essentially a program that helps older people and their families plan. Through guided conversations, decision aids, and education, seniors can better understand their health status, anticipate what lies ahead for them, and learn what they can do about it; in short, the program enables them to navigate through the process of making health care decisions. PATH also offers training for health care teams so that they can improve the quality of those conversations.
For older people with serious health conditions, including those who have one or more advanced or progressive illnesses and have been in and out of hospital, a process like this is critically needed. It would have been a great program for Susan when she was in her last year of life and kept being admitted to the hospital.
Eventually, the end comes for us all. Although most Canadians want to die either at home or in some other safe, comfortable, non-hospital setting, more than half of all deaths occur in hospital. As we’ve seen, hard-wired patterns across our systems mean that patients, particularly older adults, are shipped to acute care—from home or a long-term care facility—when they’re very ill, even when these patients and their providers have agreed that curative care is not the preferred way to go. So if we really want to support Canadians in dying where they want to die—which is usually not in acute care hospitals—we’re going to need to scale up successful models of home palliative care.
In recent years, our palliative systems have been very focused on cancer. Yet there is a growing recognition that too many patients with chronic conditions for which we don’t have cures—such as end-stage lung disease, and the heart failure that Susan had—do not yet have adequate access to palliative and end-of-life care. For those who do, their care is far superior.
When I was a trainee in the hospital setting, we’d always ask older people with chronic conditions whether they’d want to be resuscitated if their heart stopped beating or they stopped breathing while they were in hospital. Did they want tubes put down their throats? Shocks administered to their chests? Did they want to be hooked up to a breathing machine?
We rarely sat down and asked them how they wanted to spend whatever time they might have left and how we could help them achieve those goals. That’s the conversation we all deserve to have if we’re lucky to live long enough. Yes, we’re back to focusing on relationships as the core of positive patient experience.
The notion of partnering more deeply with patients is surfacing all over the health care system. Barbara Balik, a health care leader in the U.K., has nicely summarized this by noting that countries have been slowly evolving from providing care “to patients” to providing it “for patients” to providing it “with patients.”
Redesign of health care delivery, if done in true partnership with the people who use the system, can achieve the Triple Aim. We can reduce wait times by reorganizing processes of care; we can offer people with chronic illness alternatives to treatment in the ED and dying in hospital; we can introduce technology in exciting ways that will improve value in the system. And we can do all that without infusing more money into it. But in order to know how to design programs that achieve those goals, patients need to be involved from the start. It’s the patients who’ll tell us where the system’s fault lines are and help us design better approaches. They’ll also help us evaluate our new models by telling us how to measure what matters to them.
Patient experience—one of the three prongs of the Triple Aim—is about how people experience their own care and the care of their loved ones as they go through the system. But patient engagement extends beyond involvement at the individual level. Making decisions about the ways we organize care, especially when those new models challenge the status quo and require a culture shift, should be done with citizens—not just communicated to them after the fact.
Consider the Northumberland Hills Hospital in the town of Cobourg, Ontario, which faced difficult choices during its 2010 fiscal year. The 110-bed hospital had run operating deficits for three years in order to maintain the twenty-three services that its community had come to expect. Instead of making tough decisions and then trying to explain them publicly, the NHH board embarked on a public consultation about how to balance its budget. In that small community, heavily invested in its hospital as both an employer and a provider of services, the board struck a Citizens’ Advisory Panel of randomly selected people. Panel members got a crash course in the hospital: over a period of ten months, they toured the wards; heard from experts, stakeholders, and service providers; and talked to their neighbours. They hosted town hall meetings. They deliberated. Eventually they brought recommendations to the hospital board about how to balance its budget. This meant making some hard calls, like closing programs, but the decisions were made based on the community’s priorities.
Of course, as we begin to implement system solutions that allow us to do more with less, a good number of our terrific ideas won’t pan out. What do we do when that happens?