We know our population is aging, and a recent study by the University of Manitoba shows the province could need up to 5,000 personal care home beds by 2030, or approximately 300 to 350 beds per year. If we are successful in solving some of the patient-flow problems discussed earlier, and given the demographic wave of frail elderly coming, how does a health-care delivery system such as Manitoba’s fund the improvement of home care and create some 300 to 350 spaces per year? Manitoba taxpayers already spend 44 per cent of the annual budget on health care. This is among the very highest in Canada.
We believe the system needs to create incentives for the development of housing options for the elderly as well as an efficient and effective home-care program. Currently the housing of the elderly in personal care home beds is mostly a function of the inability of the home-care program to provide 24-hour service/supervision. This is partly due to the ineffectiveness of doing this in individual homes only. It could be more effective if it were also delivered in supportive-living and independent-living environments.
We believe the whole home-care delivery model needs to be examined. For example, currently, home-care co-ordinators whose job it is to organize home care for patients being discharged from hospital are not employed by the hospital. They work in the hospital, but report to the Winnipeg Regional Health Authority, since home care is a regional program. There are many persons in similar situations in our hospitals, and these persons are serving two masters and are conflicted all the time as they try to balance regional priorities, staff issues, overtime, etc. with the hospitals’ need to discharge patients effectively. Any resulting poor performance, delays, etc. is a huge financial burden for the hospital where patient per diems, as discussed earlier, are $1,100 per day compared with $200 per day in a nursing home.
Other jurisdictions have developed more effective and efficient models for delivering home care. One such example is the Buurtzog or neighbourhood-care model developed in the Netherlands. It is run by self-managed teams of 10 to 12 caregivers. Patients usually see the same caregivers on a regular basis, resulting in care being delivered in a more holistic way. Quality care is emphasized, and the results are highly cost-effective, and patient satisfaction is very high. It results in patients requiring care for shorter periods and hospital readmissions being significantly reduced. Models such as this should be tried on a pilot basis, working with one of the hospitals in one of the neighbourhoods in its catchment area.
Given the current financial challenges the province faces, the pressing question is how to fund the 300 to 350 beds we will need annually. Assisted living, personal care and long-term care involve two separate cost components. There is a residential or space component and a health-care component. Individuals moving into assisted living or long-term care should not expect the residential component to be funded by taxpayers. It is inappropriate to allow families to sell a patient’s home, transfer the assets to the next generation and saddle the taxpayer with the patient’s residential costs. Those assets should be used to fund the patient’s living space until the patient dies. A model that can accomplish this is a public/private lease concept, a personal care home REIT (real estate investment trust), to fund new spaces. In essence, a patient’s current non-income-producing assets such as a home would be used to fund a space, with the capital being returned to the family at the end of residency. This life-lease funding model would provide significant funds to cover the costs of providing the needed personal care home beds.
Most of these proposed solutions are working in other jurisdictions. The major difference is that, because we use a block or global funding system there are no incentives for the system to improve and become patient-focused. Those incentives matter, and without them, we are doomed to mediocrity. We know Canada has one of the most expensive health-care delivery systems in the world and has among the poorest results. We know Manitoba has one of the most expensive health-care systems in Canada and among the worst results. Canadians and Manitobans deserve better. It is time to remove the ideological barriers to change and begin adopting, or at least piloting, models that have proven successful in Europe and other industrialized nations. Patients deserve it. No one should have to suffer pain and endure hardship on a long wait list.
Originally published in the Winnipeg Free Press, March 31, 2016
Wayne Anderson is chair of the Frontier Centre for Public Policy. He is past chairman of the board of St. Boniface General Hospital. He wrote this in co-operation with Dal McCloy, past chairman of Riverview Health Centre, and Judith Scanlan, R.N., PhD, past secretary of St. Boniface hospital’s board.