By Gina Browne
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 nurse and an academic, I am interested in 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, I and my colleagues stress 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.
Improve care delivery
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 per cent reduction in the $8 billion spent on acute care in Ontario for the one per cent of citizens who account for almost half of hospital and home care spending 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 post-hospital discharge program for patients who have been hospitalized for congestive heart failure can cut hospital readmissions by over 60 per cent. Similarly, a primary care asthma intervention program yielded 50 per cent fewer emergency visits.
Keep watch on health
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 health care professionals, 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 conditions that determine a person’s overall health.
A report from the federation’s health care innovation working group was on the agenda at the July meeting of Canada’s provincial and territorial premiers. I have every hope, as the provincial leaders consider the many issues before them, that this different model of care, with nurses at the forefront, will get the support that it merits 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 sciences. She is co-author of a report, Better Care: An Analysis of Nursing and Health care System Outcomes, that is available on the website of the Canadian Health Services Research Foundation. Her article is distributed by Troy Media, at www.troymedia.com.