Our health care system is based on an on-demand model of physicians and hospitals providing acute and episodic care. While this system works well for the vast majority of citizens, it is a poor match for many of those with chronic diseases.
As a practicing nurse and an academic, my particular interest is examining how health and social services can work together to improve people’s lives — and contain costs. In my view, problems arise when circumstances in the world change and conventional wisdom does not; the increasing prevalence of chronic illnesses among the Canadian population is a circumstance to which our health system has not yet adapted.
The truth is, a very few people use most of our expensive health care resources.
As part of a series of reports that formed the findings of the Canadian Nurses Association National Expert Commission, myself and my colleagues highlight that the small proportion of the population that use a disproportionate amount of current health care services are people with chronic illnesses, such as diabetes, heart disease, stroke, arthritis and asthma.
Within that group, however, we discovered that it is the poor, and a subgroup with a co-existing mental health issue (anxiety, depression, substance abuse, personality disorder, schizophrenia, dementia), who are the most frequent health care seekers.
For example, we learned that in 2010 only 1% of the Ontario population (about 130,000 people) used 49% of hospital and home care services. And that only 5% of the population (about 650,000 people) used 84% of those services. These statistics are mirrored across the country.
In our study, we asked how well these individuals are served by their many visits to emergency wards, stays in hospital and visits to family and specialist doctors, and explored whether they could be better served by other, less costly, models of care.
In other words: how can we transform the way we deliver care?
We found that proactive, targeted nurse-led care that focuses on supporting patients to manage their own chronic illness and circumstances is a better model than “usual” on –demand hospital and physician-led care. Other quality evaluations have found that nurse-led care is either more effective and equally or less costly that the current “usual care”, or equally effective and less costly.
Such nurse-led models of care can save millions of health care dollars a year by reducing hospital readmissions for those with chronic illness.
For example, a 10% reduction in the $8 billion spent on acute care for the 1% of citizens who account for almost half of hospital and home care spending in Ontario could result in a potential savings of $800 million a year — money that could be used for managing chronic diseases in the community or at home.
Research has also shown that a nurse-led post-hospital discharge program for patients who have been hospitalized for congestive heart failure can cut hospital readmissions by over 60%. Similarly, a primary care asthma intervention program yielded 50% fewer emergency visits.
Beyond the issue of cost-effectiveness, a nurse-led proactive, comprehensive model of health and social care makes sense because nurses, more than any other healthcare professional, have been trained to manage patient health, and include the social circumstances that determine health in general. They are also trained to identify specific situations that require more expert input from members of the care team.
For the past 50 years, we have had an insured on-demand physician-led model focused on episodic acute care. For people with multiple chronic conditions, it’s time to test the value of a nurse-led model, with a physician as one member of a team. Every member of the team can then do what they do best, with nurses enlisting all the health and social services that can augment the determinants of a person’s overall health.
In July, Canada’s provincial and territorial premiers will be meeting as the Council of the Federation and a report from the federation’s health care innovation working group will be on the agenda.
We hope that this different model of care, with nurses at the forefront, will be explored and endorsed for addressing the growing needs – and costs -- of patients with multiple chronic illnesses.
Gina Browne is an expert advisor with EvidenceNetwork.ca and a professor with McMaster University’s Faculty of Health Science. She is co-author of a report, Better Care: An Analysis of Nursing and Healthcare System Outcomes that is available on the website of the Canadian Health Services Research Foundation.