Improving Care for Elders
Excerpt from Chapter 5 in “A Physician in the Political Arena”
Improving care for elders is key to solving hallway health care, to creating a properly functioning health care system, and to keeping the workforce working. This issue is urgent as the province of Ontario heads into the tripling of the 90+ age group by 2036 and as people over 75 begin to account for the majority of all seniors as projected by the Ontario Ministry of Finance’s own population projections. Improving care for elders must not be a “nice to have” aspirational goal. It is an imperative. We are entering the era of the aging of the aged.
Politicians, policymakers, and those with the ear of the Premier need to understand the problem if they are to create the necessary solutions—that is, if they want to solve access to care and workforce productivity issues. Creating more primary care providers and building more hospitals and long-term care homes takes time and while those efforts are crucial, they are only part of the solution to a massive demographic shift needing significantly more health care supports in the community. More needs to be done, now.
The reality is that capacity and workforce issues were evident and solutions apparent for decades in the lead up to the demographic shift which began years ago. However, government vision was lacking, and investments were not sufficiently forthcoming at the time. The impact of the COVID-19 pandemic demonstrated the fracture lines in long-term care and lead to over $10 billion being invested to shore up capacity and staffing. Still, the demographic problem at hand must be understood in its entirety.
If hospitals are to function efficiently and if a truly patient-centred system is to be created, the issue of improving care for elders in the community needs to be addressed urgently. It must be a priority of the current government with the Ministry of Health working collaboratively and respectfully with the Ministry of Long-Term Care and the Ministry of Seniors and Accessibility to create programs that will integrate health services into the community, especially for the frail elderly.
It has been well-known for many years that the aging population has an impact on the workforce as it pertains to caregiving. A CBC News article from 2017, “Care of aging parents costs Canadians an estimated $33B annually”, highlights a report by CIBC economists indicating that “the much bigger costs to caregivers comes in the form of time taken off work” showing that “close to 30 per cent of workers with older parents take roughly 450 hours per year off work to attend to their care needs” which translates into “roughly $27 billion of lost income”, with lower-income Canadians incurring “higher direct costs and spending more time aiding aging parents than do higher-income earners” and “with women taking 30 per cent more time off than men do to provide that care”.
That was almost ten years ago when the population had just begun to age and when access to care was worsening but not as poor as it is today. Those numbers are likely worse now given current access problems. The same report indicated that costs associated with both direct and indirect care of elderly parents was expected to grow by more than 20% in real dollars over the next decade due to changing demographics. Imagine a future population with large numbers of people with no pensions, no savings, and no home as a backstop to help support them in their post-work years. That time is coming quickly on the government planning horizon and more must be done now to address it.
It's time to consider merging the Ministry of Seniors and Accessibility with the Ministry of Long-term Care to create a Ministry of Elder Care, which could create closer connections with community volunteerism, more mobile community care services, day programs and respite programs. This would also be the best way to address the utilization of a growing array of technologies that can help people live independently longer. Some of the necessary funding should come from the Ministry of Health in the form of integration funding so that the new ministry can have more direct oversight of the programs rather than being an appendage ministry dependent on carving out time and interest from the behemoth that is the Ministry of Health.
The Ministry of Health should understand hospitals cannot be everything to everyone and significant investments must be made to allow more care to be provided in the community, whether through mobile assessment and treatment systems such as the community paramedic programs and virtual triage programs, ambulatory clinics, or through urgent care centres. Concerns about possible interrelated staffing issues are widely understood but need not detract from moving forward with much needed innovation. It’s possible that greater retention of the health workforce will result when hospitals and their ERs can relieve some pressure by better integrating with the community.
According to the Canadian Association of Emergency Physicians as reported in the Montreal Gazette’s “Analysis: Rapidly aging population driving ER crisis in Quebec”, Canadian emergency departments welcome more patients over 65 than any other population age group, between 20 per cent and 40 per cent of all visits. Emergency department systems are not designed and are not prepared for the increasing levels of frailty of society’s most elderly citizens. Increasing frailty is a very significant challenge for providers to address and should be one of the policy drivers for more care to be delivered in place in the community, including health and emergency services. As indicated in the article, in some emergency departments “up to 30 to 40 per cent of the stretcher and ambulatory patients are elderly people, many of whom have significant comorbidity but, above all, a high level of frailty”.
We are only just entering the era of the aging of the aged and governments have not put in the necessary thought and resources to allow hospitals and the community to innovate and prepare. There is no time to lose.
Below is an excerpt from my book released a year ago in March of 2023, “A Physician in the Political Arena”, where I describe potential approaches to the challenges ahead to improving care for our elders.
5) Improving care for elders
“With the expected increase in Ontario’s elder population, it is unreasonable to think that all elders can be cared for in long-term care homes or readily access the services they need in hospitals. It is imperative to develop health services and programs that will allow elders to age at home with access to necessary health care.
There needs to be greater innovation within community care; programs like the community paramedicine services that can provide home visits, in-home testing, and healthy living support. The technological advances in health monitoring will lead to more effective point-of- care testing outside the hospital setting – either in a person’s own home or in a community setting. This expanded role for paramedics will reduce hospital visits and can better coordinate primary care and emergency care through point-of- care diagnostics in the community and in long-term care homes.
In the coming years, the challenge will be to create a flexible health care system so people can get the care they need when they need it. The system will need to place patients at the centre and ensure the health requirements of the patients, their families, and caregivers are driving care decisions. Patient-centred care will require the province to redirect funding priorities from administration to frontline services – quite frankly, where it belongs – to provide better, faster, and connected health care services within the community.
Elders should be able to access the support required within the community setting, with an appropriately funded aging-at-home strategy, including services such as paramedicine with remote home monitoring.
There needs to be an important discussion of how to remodel our health care system with the end goal of better responding to the care of elders, in their place of residence and when they must access long-term care or medical care. I believe strongly that we must approach the reform with a patient-centred focus and an understanding of technologies available to improve the need for staffing and infrastructure.”
The next Substack post will review Chapter 5 Section 6, “The Urgent Need for Reform of Canada’s Health Care System”, including a role for mezzanine care.
Dr. Merrilee Fullerton’s book “A Physician in the Political Arena” can be read here.
References
“Ontario’s Long-Term Report on the Economy 2024-2046, Chapter 1: Demographic Trends and Projections 2024”, Government of Ontario, Ministry of Finance, December 2024
https://www.ontario.ca/files/2024-12/mof-long-term-report-book-2024-12-31-en.pdf
“Care of aging parents costs Canadians an estimated $33B annually”, CBC, May 8, 2017
https://www.cbc.ca/news/business/caring-parents-costs-1.4101277
“How we reduced emergency admissions through an urgent care centre”, Pulse Today, UK, August 27, 2013
“Analysis: Rapidly aging population driving ER crisis in Quebec”, Montreal Gazette, December 16, 2024