Problems arise when circumstances in the world change and conventional wisdom does not.
The present federally funded Canadian healthcare system has been driven principally by insured physicians and hospitals providing acute and episodic care that is a poor match to the changing demographics of persons with chronic disease living longer. The current health system consumes nearly one-half of provincial budgets.
There are solutions.
Recent analysis of 2005 expenditures by member countries of the Organisation for Economic Co-operation and Development on health and social services has empirically demonstrated that, after adjusting for overall gross domestic product per capita, it is the ratio of social service expenditures to health service expenditures that is better associated with improved outcomes in key health indicators and not the amount spent on health services.
Models of proactive, targeted nurse led care that focus on preventive patient self-management for people with chronic disease are either more effective and equally or less costly, or are equally effective and less costly than the usual model of care.
Additional key components of more effective and efficient healthcare models involve community based, nurse led models of care with an interdisciplinary team that includes the primary care physician. Such complex intervention requires specially trained or advanced practice nurses who supplement the care provided by physicians and other healthcare professionals. The proactive, comprehensive, coordinated model of community care is patient and family centered, targeted at community-dwelling individuals with complex chronic conditions and social circumstances.
Telemonitoring offers added effectiveness and efficiencies to healthcare, especially for remote populations.
The monitoring, evaluation and performance measurement system for the provision of healthcare should build on and link to pan-Canadian efforts already under way, such as the Longitudinal Health and Administrative Data Initiative.
Nurse-led models of care can be financed by costs averted from hospitals and emergency departments to home or community care. For example, after managing the current hospital caseload of patients awaiting alternative levels of care, the number of hospital beds could be reduced to free up funds for this reallocation of funding.
In Ontario alone, representing 37% of the Canadian population, independent reports estimate that millions of dollars could be saved in direct healthcare costs within one year by:
- having nurses provide leading practices in home wound care
- integrating nurse-led models of care to reduce high hospital readmissions by 10% for those with chronic conditions
- providing 25% of palliative care in the home as opposed to in acute hospital settings
- providing community care for patients in hospital designated as needing an alternative
- providing proactive community care and patient self-management for those with congestive heart failure and other chronic conditions
Getting from problems to solutions is possible.
These recommended models of nursing for chronic illness align with the Principles to Guide Health Care Transformation in Canada put forward by the Canadian Nurses Association and the Canadian Medical Association (CMA) in July 2011.
Further, the models align with the CMA’s proposed Charter for Patient-centred Care and other recommendations made in the 2010 report Health Care Transformation in Canada: Change That Works, Care That Lasts. For example, the following points apply fundamentally to both the CMA’s recommendations and the models recommended here:
- The central role of all levels of government is to provide for and sustain the well-being of its citizens and future generations.
- The question of direction for government is one of continued growth and expansion of health (illness) care or sustainability of the quality of life and the human service system that determines health.
- Addressing the source of and reasons for excessive and growing health expenditure would include (a) providing nurse-led proactive, comprehensive and preventive care for those with chronic illness, (b) financing by reducing resources for current acute hospital care, and (c) having physicians and nurse practitioners continue to practise acute and episodic care.