The Time is Now: Putting Community Care at the Heart of Medicare  OCSA Annual General Meeting Richmond Hill, ON October

The Time is Now: Putting Community Care at the Heart of Medicare OCSA Annual General Meeting Richmond Hill, ON October PowerPoint PPT Presentation

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Main Themes. The Canadian health care landscape, 2010Community care and the evolution of MedicarePenny wise, pound foolish: how we got here and what it tells us about ourselvesComprehensiveness: the principle that isn'tWhat's a core service? Ask the client!Mobilizing support

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The Time is Now: Putting Community Care at the Heart of Medicare OCSA Annual General Meeting Richmond Hill, ON October

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1. The Time is Now: Putting Community Care at the Heart of Medicare OCSA Annual General Meeting Richmond Hill, ON October 20, 2009 1

2. Main Themes The Canadian health care landscape, 2010 Community care and the evolution of Medicare Penny wise, pound foolish: how we got here and what it tells us about ourselves Comprehensiveness: the principle that isn’t What’s a core service? Ask the client! Mobilizing support – some strategies to think about

3. When Medicare Was Young (and So Were We) Medicare was a child of post-war recovery, optimism, and the science of the times Canada was a young country with few elderly Health meant doctors and hospitals and antibiotics In the 1960s there were no Statins and NSAIDS Hip and knee replacements Day surgeries So we defined “medically necessary” to mean (mostly) doctors and hospitals

4. How Canadians Think About Health and Health Care Health is the goal, but health care insurance is the publicly financed vehicle If it’s medical, it’s fundable - generously Community care is not fundamentally a societal responsibility (well, maybe home care nursing) Medicare defines much of our solidarity with each other The rest is dependent on the politics of the day and the jurisdiction

5. Public and Private Health Spending, Canada, 2007, Selected Categories

7. The Current Climate Greater accountability for performance Increased capacity to measure and evaluate Balanced budgets have given way to big deficits Sustainability argument takes two forms: Health care can’t continue to gobble up bigger and bigger share of provincial government budgets; OR The overall price tag is affordable but we’re not getting good value for money If either (or both) are true, changes are on the horizon

9. What Do We Want to Achieve? Better quality Faster, more equitable access to needed care Better value-for-money (VFM) Reduce disparities between population groups Prevent more, intervene less More seamless care (continuity, transitions) Less waste, redundancy, muda (useless work) More self-reliant, health-oriented public

10. Changing Public Expectations Higher quality and more independent housing for LTC residential clients Bring care to the condo rather than moving clients to care LTC public facility viewed as last resort for: The very old Very frail Significantly demented Without a lot of money With smaller nuclear families and high geographic mobility, intergenerational family caregivers are disappearing

12. Issue #1: TheCommunity Care:Residential Care Ratio Rhetoric supports transformation of system to community from facilities Canadian experience has been bed-oriented Home care budgets often among first to be scaled back in times of fiscal restraint In some LHINs as much as 40% of complex continuing care beds occupied by people with lesser care needs – at a cost of $150,000+ annually Question: Will provinces invest enough in community care to dramatically reduce dependency on beds?

13. Issue #2: Standards, Turf, and the Division of Labour Continuing Care—a medical service with social care components, or a social service with a medical component? Major arguments over scope of practice Nature and cost of care affected greatly by who does it A medical orientation increases costs and often neglects the social issues that affect client well-being Question: Can we develop an evidence-based model that optimizes efficiency, safety, acceptability, and job satisfaction?

14. Issue #3: Who Controls the Resources? Some move in Canada towards voucher systems and greater client/family choice of care pattern Some countries, e.g., Germany, devolve much more control to recipients and families Need to understand extent to which political and social culture affects feasibility of policies Question: Should more control lie with clients/families, and if so, how do we guarantee safety and quality?

15. Issue #4: Risk and Risk Management Canadian health care system generally risk averse In continuing care, often a trade-off among freedom and choice, cost-effectiveness, and safety Care recipients and families typically value quality of life over risk minimization Question: Who decides on and manages risk levels? What price are we willing to pay for reduced risk? What demarcates reasonable from unacceptable risk levels?

16. Issue #5: Dealing with Caregiver Burden Family caregivers play a prominent role in looking after clients living in the community It is prudent to encourage this role and many adopt it happily However, there is well-documented evidence of the extent of caregiver burden Different caregivers have different capacity and inclination to provide care Question: How do we calibrate the right amount of care to maintain the caregiver role without exploiting the caregiver?

17. Issue #6: Anticipating Innovation and Avoiding Irreversible Mistakes Three main technologies have huge potential to preserve independence and enhance quality of life: Communications devices, e.g., call systems, automated monitoring and surveillance Medical interventions to manage chronic diseases (drugs, surgery, testing) Scientific breakthroughs, e.g., brain plaque removal, genetic engineering These will change how people stay independent and affect the need for facilities Question: How do we model innovation and maintain flexibility to adapt programs to changing profiles of need?

18. Issue #7: Primary Health Care – the Fulcrum for System Transformation Growing evidence that “middle of the curve” primary care is problematic, especially for chronic disease management (Marshall et al, UK; McGlynn et al, US; Katz et al, Manitoba) Good and comprehensive primary health care is essential to maintaining capacities and avoiding some acute episodes Interest in expansive model of PHC and geriatrics waning in Canada Question: what model of PHC will prevail and what incentives can reinvigorate PHC and encourage improved care for the at-risk elderly?

19. Issue #8: Enriching the Housing, Sharing the Responsibility Generally sound policy to separate housing needs from care needs People who secure care-compatible housing will need care at some point and want to age in place Need public policy that maximizes the impact of public spending in partnership with private spending Question: What should govt. do to encourage self-management without discriminating against those who make these choices?

20. So Why Does Community Care Go to the Back of the Line? Not as glamorous as medicine and technology Does not map onto a disease-specific model of health and illness Does not figure prominently in doctors’ thinking Canadians’ solidarity is highly concentrated on medical care Perception that families are responsible for their own Ageism

21. The Economics of Policy Remember this equation: expenditures = income Health care spending puts money in people’s pockets Many benefit enormously from the status quo Incomes are higher in institutions and specialized services Communities value visible and costly taxpayer-funded institutions People steeply discount future health benefits They also discount health benefits that do not originate in medical interventions

22. Overtrained or Underused? “The varying objectives and levels of specificity found in different professions’ scopes of practice are more than frustrating; they have encouraged a system that treats practice acts as rewards for the professions rather than as rational mechanisms for cost-effective, high quality and accessible service delivery by competent practitioners. …Scope of practice battles have come to resemble contests for more patients, more status and power, more independence, and more money.” --Finocchio et al. 1995

23. Framing the Debate Comprehensiveness is the great shrinking principle of the Canada Health Act A comprehensive system is also a more cost-effective system: Removes incentive to use more costly, covered care Greater likelihood of preventing or deferring needs Encourages partnerships and self-reliance Independence is easy to market

24. Making the Economic Case Highlight the findings of the cost-effectiveness literature Create real-case scenarios of differences in costs of meeting people’s needs in different settings Quantify how many people can be looked after in the community for the cost of one CCC or LTC bed Promote research that compares total health system costs of people receiving community care vs. no care Costs over time Incidence of falls, medication errors Use of doctors, hospitals, residential care, drugs

25. Toward A New Medicare Accord What most people need, most of the time, is what Medicare overlooks “Medically necessary” services address only a small portion of the needs of millions of people “Functionally necessary” defines what people need to: Remain independent Avoid excessive dependence on medicine Retain capacities Comprehensiveness is a false promise precisely because Medicare remains rooted in its hospital-doctor history

26. Mobilizing Support Survey community care clients and their families about their values, needs, and preferences Brand community services as the client-friendly option Do the accounting on community vs. institutional care Advocate for global budgets that span community through institutional services Endorse primary health care funding models that create incentives to seek the lowest cost and most effective care

27. The Politics of Health and Health Care Who gets to define what’s important gets first claim on resources Governments and LHINs need a political warrant to put community care at the centre of the system The public is easily persuaded that its interests are best served by more of the same Making different choices possible depends on doing the fundamental work of political mobilization

28. The Bottom Lines Integrating primary health care (in its robust definition), community-based services, and residential care will be key to the future Assessing, quantifying, and legitimizing the need for community-based care is critical to building and sustaining support for resource reallocation Financing methods and co-payments should be consistent across the system and encourage appropriate use of cost-effective services “Silent suffering” is a barrier to public awareness and sound decision-making Therefore, make the case loudly, and often

29. Contact Information Steven Lewis Access Consulting Ltd. 211 – 4th Ave. S. Saskatoon SK S7K 1N1 Tel: (306) 343-1007 E-mail: [email protected]

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