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Achieving Patient-Centred Collaborative Care

https://policybase.cma.ca/en/permalink/policy9060
Last Reviewed
2019-03-03
Date
2007-12-01
Topics
Health systems, system funding and performance
  1 document  
Policy Type
Policy document
Last Reviewed
2019-03-03
Date
2007-12-01
Topics
Health systems, system funding and performance
Text
ACHIEVING PATIENT-CENTRED COLLABORATIVE CARE (2008) The Canadian Medical Association (CMA) recognizes that collaborative care is a desired and necessary part of health care delivery in Canada and an important element of quality, patient-centred care. The CMA considers patient-centred care to be the cornerstone of good medical practice. This is reflected in the first principle of the CMA Code of Ethics, which states that physicians have a fundamental responsibility to "Consider first the well-being of the patient." As patient advocates, physicians strive to ensure that their patients receive the best possible care. The CMA supports greater collaboration among providers in the interest of better patient care. In the context of clinical practice, the CMA defines collaborative care as follows: "Collaborative care entails physicians and other providers using complementary skills, knowledge and competencies and working together to provide care to a common group of patients based on trust, respect and an understanding of each others' skills and knowledge. This involves a mutually agreed upon division of roles and responsibilities that may vary according to the nature of the practice personalities and skill sets of the individuals. The relationship must be beneficial to the patient, and acceptable to the physician and other providers. If designed appropriately, collaborative care models have the potential to: * improve access to care; * enhance the quality and safety of care; * enhance the coordination and efficiency of care; and * enhance provider morale and reduce burnout within health professions. To realize this full potential, the profession acknowledges and accepts that it has a central role to play in the evolution of a team-based approach to care. These policy principles have been prepared by the Canadian Medical Association in order to ensure that the evolution of collaborative care in Canada is built around the needs of individual patients and groups of patients. This policy is founded on the CMA's document, Putting Patients' First: Patient-Centred Collaborative Care - A Discussion Paper. Principles for Collaborative Care The medical profession supports collaborative care, both in the hospital and in the community, as one of the essential elements of health care delivery in Canada. In the interests of enhancing the evolution of patient-centred collaborative care, the CMA proposes the following "critical success factors" and principles to address meaningfully the issues and barriers identified by physicians and bring clarity to the discussions. 1. PATIENT-CENTRED CARE First and foremost, medical care delivered by physicians and health care delivered by others should be aligned around the values and needs of patients. Collaborative care teams should foster and support patients, and their families, as active participants in their health care decision-making. New models should have the potential to empower patients to enhance their role in prevention and self-care. Models of collaborative care must be designed to meet the needs of patients. Collaborative models of practice must reduce fragmentation and enhance the quality and safety of care provided to patients. It is the patient who ultimately must make informed choices about the care he or she will receive. 2. RECOGNITION OF THE PATIENT-PHYSICIAN RELATIONSHIP The mutual respect and trust derived from the patient-physician relationship is the cornerstone of medical care. This trust is founded on the ethical principles that guide the medical profession as defined in the CMA Code of Ethics. The impact of collaborative models of practice on this relationship, and hence the patient's satisfaction and experience with their care, is unknown. Models of collaborative care must support the patient-physician relationship. Entry into and exit from a formal collaborative care arrangement must be voluntary for both the patient and the physician. A common Code of Ethics should guide the practice of collaborative care teams. Every resident of Canada has the right to access a personal family physician. † 3. PHYSICIAN AS THE CLINICAL LEADER Effective teams require effective leadership. A defined clinical leader is required to ensure proper functioning of the team and to facilitate decision-making, especially in complex or emergent situations. In collaborative care the clinical leader is responsible for maximizing the expertise and input of the entire team in order to provide the patient with comprehensive and definitive care. It is important to differentiate "clinical leadership" from "team coordination." The CMA defines a clinical leader as: "The individual who, based on his or her training, competencies and experience, is best able to synthesize and interpret the evidence and data provided by the patient and the team, make a differential diagnosis and deliver comprehensive care for the patient. The clinical leader is ultimately accountable to the patient for making definitive clinical decisions." Whereas, the team coordinator is defined as: "The individual, who, based on his or her training, competencies and experience, is best able to coordinate the services provided by the team so that they are integrated to provide the best care for the patient." The concept of "most responsible physician" has been and continues to be used to identify the individual who is ultimately responsible for the care of the patient. The "most responsible physician" is responsible for collecting, synthesizing and integrating the expert opinion of physician and non physician team members to determine the clinical management of the patient. Similarly, the presence of a defined clinical leader in a collaborative care setting creates clarity for patients, their families and the health care team by making lines of communication and responsibility clear, ultimately improving the quality and safety of care. In the CMA's opinion, the physician is best equipped to provide clinical leadership. This does not necessarily imply that a physician must be the team coordinator. Many teams will exist in which the physician will have a supporting role, including those focused on population health and patient education. We believe the most effective teams are ones in which the leadership roles have been clearly defined and earned. Some physicians may be prepared to play both roles; however, other members of the team may be best suited to serve as team coordinator. Currently, patients rely on, and expect, physicians to be clinical leaders in the assessment and delivery of the medical care they receive. In a collaborative care environment this expectation of physician leadership will not change. Team members will have specific knowledge and expertise in their respective disciplines. Physicians, by virtue of their broad and diverse knowledge, training and experience, have a unique appreciation of the full spectrum of health and health care delivery in their field of practice and are therefore best qualified to evaluate and synthesize diverse professional perspectives to ensure optimal patient care. The physician, by virtue of training, knowledge, background and patient relationship, is best positioned to assume the role of clinical leader in collaborative care teams. There may be some situations in which the physician may delegate clinical leadership to another health care professional. Other health care professionals may be best suited to act as team coordinator. 4. MUTUAL RESPECT AND TRUST Trust between individuals and provider groups evolves as knowledge and understanding of competencies, skills and scopes of practice are gained. Trust is also essential to ensuring that the team functions efficiently and maximizes the contributions of all members. Funders and providers should recognize the importance of team building in contributing to team effectiveness. Collaborative care funding models should support a more formalized and integrated approach to both change management and team building. As relationships are strengthened within the team, so too are trust and respect. Physicians and all team members have an opportunity to be positive role models to motivate and inspire their colleagues. All team members ought to make a commitment to respect and trust each other with the knowledge that it will lead to enhanced care for patients and a more productive work environment for all. To serve the health care needs of patients, there must be a collaborative and respectful interaction among health care professionals, with recognition and understanding of the contributions of each provider to the team. In order to build trust and respect within the team it is essential that members understand and respect the professional responsibility, knowledge and skills that come with their scope of practice within the context of the team. 5. CLEAR COMMUNICATION In collaborative care environments, it is essential that all members of the team communicate effectively to provide safe and optimal care. Effective communication is essential to ensure safe and coordinated care as the size of the team expands to meet patient needs. It is the responsibility of all team members to ensure that the patient is receiving timely, clear and consistent messaging. Physicians can take a leadership role in modeling effective communications throughout the team. In particular, there is an opportunity to enhance the consultation and referral process, in order to provide clear and concise instructions to colleagues and optimize care. Sufficient resources, including dedicated time and support, must be available to the team to maximize these communication requirements. Effective communication within collaborative care teams is critical for the provision of high quality patient care. Planning, funding and training for collaborative care teams must include measures to support communication within these teams. Mechanisms must be in place within a collaborative team to ensure that both the patients, and their caregiver(s) where appropriate, receive timely information from the most appropriate provider. Effective and efficient communications within the collaborative care team, both with the patient and among team members, should be supported by clear documentation that identifies the author. A common, accessible patient record in collaborative care settings is desirable to ensure appropriate communication between physicians and other health care professionals, to prevent duplication, coordinate care, share information and protect the safety of patients. An integrated electronic health record is highly desirable to facilitate communication and sharing among team members. 6. CLARIFICATION OF ROLES AND SCOPES OF PRACTICE In order for the team to function safely and efficiently, it is critically important that the scope of practice, roles and responsibilities of each health care professional on the team be clearly defined and understood. In turn, the patient, as a team member, should also have a clear understanding of the roles and scopes of practice of their providers. Collaborative care must first and foremost serve the needs of patients, with the goal of enhancing patient care; collaborative care is not contingent upon altering the scope of practice of any provider group and must not be used as a means to expand the scope of practice and/or independence of a health professional group. Changes in the scope of practice of all provider groups must be done with oversight from the appropriate regulatory authority. Where non-physicians have been provided with an opportunity to undertake activities related to patient care typically unique to the practice of medicine (e.g., ordering tests), they must not do so independently but undertake these activities within the context of the team and in a manner acceptable to the clinical leader. The role and scope of practice of each member of the collaborative care team should be clearly understood and delineated in job descriptions and employment contracts. A formal process for conflict resolution should be in place so that issues can be dealt with in a timely and appropriate manner. 7. CLARIFICATION OF ACCOUNTABILITY AND RESPONSIBILITY In the context of providing optimal care, providers must be accountable and responsible for the outcome of their individual practice, while sharing responsibility for the proper functioning of the collaborative care team. This individual responsibility is required so that regardless of the number and diversity of providers involved in the team, patients can be assured that their well-being is protected and that the team is working toward a common goal. In collaborative care teams, a physician should be identified as the person most responsible for the clinical care of individual patients, and as such must be accountable for the care rendered to patients. This is consistent with the commitment made by the physician in the doctor-patient relationship, mirrors the clinical training of the physician relative to other providers, is reflective of the current state of tort law as it applies to medical practice, and is compatible with the structure of care delivery in hospitals and in the community. Clearly, this type of arrangement does not eliminate the necessity for all providers to be accountable for the care that they provide. It is essential that all providers be responsible and accountable for the care that they provide and for the well-being of the patient. As clinical leader, the physician should be responsible for the clinical oversight of an individual patient's care. 8. LIABILITY PROTECTION FOR ALL MEMBERS OF THE TEAM As discussed earlier in this paper, the resolution of the multiplicity of liability issues that result from care delivered by teams requires clearly defined roles and responsibilities in the team setting and the absolute requirement for appropriate and sufficient liability coverage for each health professional. The August 2006 statement of the Canadian Medical Protective Association, Collaborative Care: A medical liability perspective, identifies issues of concern to physicians and proposes solutions to reduce those risks. All members of a collaborative care team must have adequate professional liability protection and/or insurance coverage to accommodate their scope of practice and their respective roles and responsibilities within the collaborative care team. Physicians, in their role as clinical leaders of collaborative care teams, must be satisfied with the ongoing existence of appropriate liability protection as a condition of employment of, or affiliation with, other members on collaborative care teams. Formalized procedures should be established to ensure evidence of this liability protection. 9. SUFFICIENT HUMAN RESOURCES AND INFRASTRUCTURE Collaborative models of health care delivery hold the promise of enhancing access to care for patients at a time of serious health human resource shortages. However, effective patient-centred collaborative care depends on an adequate supply of physicians, nurses and other providers. Governments and decision-makers must continue to enhance their efforts to increase the number of physicians and nurses available to provide health care services. Collaborative care should not be seen as an opportunity for governments to substitute one care provider for another simply because one is more plentiful or less costly than the other. In addition, governments must understand that co-location of individuals in a team is not a requirement for all collaborative care. Where team co-location does not exist, appropriate resources must be dedicated to ensure communication can be timely, effective and appropriate between providers. Governments, at all levels, must address the serious shortage of physicians to ensure quality patient care for Canadians. The effective functioning of a collaborative care team depends on the contribution of a physician. Governments must enhance access to medical care by increasing the number of physicians and providers, and not by encouraging or empowering physician substitution. 10. SUFFICIENT FUNDING & PAYMENT ARRANGEMENTS Funding must be present to support all aspects of the development of collaborative care teams. At the practice level, remuneration methods for physicians, irrespective of their specialty, must be available to facilitate collaborative care arrangements and environments in which physicians practice. All care delivery models, including collaborative care teams, must have access to adequate and appropriate resources. This includes, but should not be limited to, funding for health human resources, administration/management infrastructure, liability protection, clinical and team/administrative training, team building, and information technology. Remuneration models should be established in a manner that encourages providers to participate effectively in the delivery of care and team effectiveness. Reimbursement models must be configured to remunerate the communicator, coordinator, manager, and other roles and responsibilities of providers necessary for the success of collaborative care practice. The ability of a physician to work in a collaborative care team must not be based on the physician's choice of remuneration. Similarly, patients should not be denied access to the benefits of collaborative practice as a result of the physician's choice of payment model. Collaborative care relationships between physicians and other health care providers should continue to be encouraged and enhanced through appropriate resource allocation at all levels of the health care system. Physicians should be appropriately compensated for all aspects of their clinical care and leadership activities in collaborative care teams. Physicians should not be expected to incur the cost of adopting and maintaining health information technology capabilities that facilitate their ability to participate in collaborative practice teams. Governments must fund and support in an ongoing manner, both financially and technically, the development and integration of electronic health records. 11. SUPPORTIVE EDUCATION SYSTEM Canada is renowned for a quality medical education system and for the early efforts to enhance interprofessional training. The success of collaborative care requires a commitment towards interprofessional education and is contingent upon the positive attitudes and support of educators. To facilitate a sustainable shift toward collaborative practice, these efforts must be continued and enhanced in a meaningful way. However, governments and educators must ensure that the availability and quality of medical education is not compromised for medical trainees. Interprofessional education, at the undergraduate, postgraduate and continuing education levels, is necessary to facilitate a greater understanding of the potential roles, responsibilities and capabilities of health professions, with the overall goal of building better health care teams founded on mutual respect and trust. Governments must understand the importance of interprofessional education and fund educational institutions appropriately to meet these new training needs. Educational opportunities must exist at all levels of training to acquire both clinical knowledge and team effectiveness/leadership training. Interprofessional education opportunities must not come at the expense of core medical training. High quality medical education must be available to all medical trainees as a first priority. 12. RESEARCH AND EVALUATION More research and evaluations are necessary to demonstrate the benefits of collaborative care, to foster greater adoption by providers and to attract the necessary investment by governments. Quality management systems must be built into the team to ensure efficiencies can be recorded. Measures of the quality of care, cost effectiveness and patient and provider satisfaction should be evaluated. Research into the effectiveness of collaborative care models on health outcomes, patient and provider satisfaction and health care cost effectiveness should be ongoing, transparent and supported by governments. Quality assessment measures must be incorporated into the ongoing work of collaborative care teams. † Where the term "family physician" is used, it is also meant to include general practitioners.
Documents
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Ensuring equitable access to health care: Strategies for governments, health system planners, and the medical profession

https://policybase.cma.ca/en/permalink/policy11062
Last Reviewed
2018-03-03
Date
2013-12-07
Topics
Health systems, system funding and performance
Population health/ health equity/ public health
  1 document  
Policy Type
Policy document
Last Reviewed
2018-03-03
Date
2013-12-07
Topics
Health systems, system funding and performance
Population health/ health equity/ public health
Text
Ensuring equitable access to effective and appropriate health care services is one strategy which can help to mitigate health inequities resulting from differences in the social and economic conditions of Canadians. Equitable access can be defined as the opportunity of patients to obtain appropriate health care services based on their perceived need for care. This necessitates consideration of not only availability of services but quality of care as well.1 There is far ranging evidence indicating that access to care is not equitable in Canada. Those with higher socio-economic status have increased access for almost every health service available, despite having a generally higher health status and therefore a decreased need for health care. This includes insured services (such as surgery), as well as un-insured services such as pharmaceuticals and long-term care. Those from disadvantaged groups are less likely to receive appropriate health care even if access to the system is available. They are more likely to report trouble getting appointments, less testing and monitoring of chronic health conditions, and more hospitalizations for conditions that could be avoided with appropriate primary care. There is a financial cost to this disparity in equitable care. Reducing the differences in avoidable hospitalizations alone could save the system millions of dollars. Barriers to equitable access occur on both the patient and health care system or supply side. Common barriers include: (see pdf for correct display of table) Demand Side or Patient Barriers Supply Side or System Barriers Health literacy Services not located in areas of need Cultural beliefs and norms Patients lack family physicians Language Lack of management of chronic disease Cost of transportation Long waits for service Time off work for appointments Payment models which don't account for complexity of patients Access to child care Coordination between primary care and speciality care and between health care and community services Payment for medications or other medical devices/treatments Standardization of referral and access to specialists and social services Immobility- due to physical disabilities, and/or mental health barriers Lack of needs based planning to ensure that population has necessary services Cognitive issues, ie. Dementia, that adversely affect ability to access and comply with care Attitudes of health care workers To tackle barriers on the patient side there is a need to reduce barriers such as transportation and the prohibitive cost of some medically necessary services. Further, there is a need to increase the health literacy of patients and their families/caregivers as well as providing support to health care providers to ensure that all patients are able to be active participants in the management of their care. On the system side the strategies for action fall into four main categories: patient-centred primary care which focuses on chronic disease management; better care coordination and access to necessary medical services along the continuum of care; quality improvement initiatives which incorporate considerations of equity as part of their mandate; and health system planning and assessment which prioritizes equitable access to care. Recommendations are provided for CMA and national level initiatives; health care planners; and physicians in practice. Despite a commitment to equal access to health care for all Canadians there are differences in access and quality of care for many groups. By removing barriers on both the patient and system side it is hoped that greater access to appropriate care will follow. Introduction: In Canada as in many countries around the world there are major inequities in health status across the population. Those lower on the socio-economic scale face higher burdens of disease, greater disability and even shorter life expectancies.2 Many of these disparities are caused by differences in social and economic factors such as income and education known as the social determinants of health.3,1 While many of these factors are outside of the direct control of the health care system, ensuring equitable access to effective and appropriate health care services can help to mitigate some of these disparities. The alternative can also be true. In health systems where access to care and appropriateness are unequal and skewed in favour of those of higher socio-economic status, the health system itself can create further inequities and add greater burden to those already at an increased risk of poor health. Physicians as leaders in the health care system can play a role in ensuring equitable access to care for all Canadians. Equitable Access to Health Care in Canada: Equitable access can be defined as the opportunity for patients to obtain appropriate health care services based on their perceived need for care. This necessitates consideration of not only availability of services but quality of care as well.4 Due to burden of disease and therefore need, those with lower socio-economic status should be utilizing more services along the continuum.5 That, however, is not the case. Individuals living in lower income neighbourhoods, younger adults and men are less likely to have primary care physicians than their counterparts.6 Primary care physicians deliver the majority of mental illness treatment and they are the main source of referrals to psychiatrists or other specialists. However, much of the care for people with mental illnesses, especially on the lower socio-economic end of the scale, is delivered in emergency rooms, which is both costly and episodic. This is due not only to a lack of primary care access but to a lack of community mental health services.7 Those with higher socio-economic status are much more likely to have access to and utilize specialist services.8 Examples include greater likelihood of catheterization and shorter waits for angiography for patients with myocardial infarction9; and greater access to in-hospital physiotherapy, occupational therapy, and speech language therapy for those hospitalized with acute stroke10. Low income men and women with diabetes were just as likely to visit a specialist for treatment as high income individuals despite a significantly greater need for care.11 There is a correlation between higher income and access to day surgery.12 A Toronto study found that inpatient surgery patients were of much higher income than medical inpatients.13 Additionally, utilization of diagnostic imaging services is greater among those in higher socio-economic groups.14 Access to preventive and screening programs such as pap smears and mammography are lower among disadvantaged groups.15 Geography can cause barriers to access. In general rural Canadians have higher health care needs but less access to care.16 People in northern and rural communities typically have to travel great distances to obtain health services as many, especially specialist services, cannot be obtained in their home community.17 Those living in the most rural communities in Canada are the least likely to have a regular family doctor, or to have had a specialist physician visit.18 According to data from the Society of Rural Physicians of Canada, 21% of the Canadian population is rural while only 9.4% of family physicians and 3% of specialists are considered rural.19 This lack of access to specialists and other medically necessary services can lead to delays in treatment and harm to health including unnecessary pain and permanent disability.20 Further, travel for necessary treatment often comes with a significant financial cost.21 It is not just access to insured services that is a problem in Canada. Many Canadians do not have access to needed pharmaceuticals. Researchers have reported that those in the lowest income groups are three times less likely to fill prescriptions, and 60% less able to get needed tests because of cost.22 The use of appropriate diabetes preventative services, medication, and blood glucose testing, has been shown to be dependent on out of pocket expenditures.23 Rehabilitation services are difficult for some Canadians to access as well. Services such as physiotherapy and occupational therapy are often not covered unless they are provided in-hospital or to people on certain disability support programs. This leads to long wait times for services that are covered or no access at all.24 Adding to these inequities is the fact that different programs are covered in different provinces and territories.25 Access to mental health services is a major challenge for Canadians. According to data from Statistics Canada, more than half a million Canadians who had a perceived need for mental health care services, reported that their needs were unmet. Access to counselling services was the most frequent unmet need reported.26 A number of important mental health professionals - notably psychologists and counsellors - are not funded through provincial health budgets, or are funded only on a very limited basis. Access to psychologists is largely limited to people who can pay for them, through private insurance or out of their own pockets.27,2 Access to subsidized residential care, long-term care, home care and end-of-life care is problematic as well. Those with means can access high quality long-term care services within their community, while those with inadequate resources are placed in lower quality facilities sometimes hours away from family and friends.28 Even with expansions promised by governments, home care will not be able to meet the needs of underserved groups such as those living in rural and remote areas.29 Finally, only a fraction of patients have access to or receive palliative and end-of-life care. Those living in rural or remote areas or living with disabilities have severely limited access to formal palliative care.30 Difficulties in access are particularly acute for Canada's Aboriginal peoples. Many live in communities with limited access to health care services, sometimes having to travel hundreds of miles to access care.31 Additionally, there are jurisdictional challenges; many fall through the cracks between the provincial and federal health systems. While geography is a significant barrier for Aboriginal peoples, it is not the only one. Aboriginals living in Canada's urban centres also face difficulties. Poverty, social exclusion and discrimination can be barriers to needed health care. Of all federal spending on Aboriginal programs and services only 10% is allocated to urban Aboriginals. This means that Aboriginals living in urban areas are unable to access programs such as Aboriginal head start, or alcohol and drug services, which would be available if they were living on reserve.32 Further, even when care is available it may not be culturally appropriate. Finally, Canada's Aboriginal peoples tend to be over-represented in populations most at risk and with the greatest need for care, making the lack of access a much greater issue for their health status.33 However, these examples are only part of the story as accessing care which is inappropriate cannot be considered equitable access.34 Those of lower socio-economic status are more likely to use inpatient services; show an increased use of family physician services once initial contact is made;35 and have consistently higher hospitalization rates; 36 This could be due to the higher burden of need or could demonstrate that the services that are received are not addressing the health care needs of those lower on the socio-economic scale.37 Women and men from low-income neighbourhoods are more likely to report difficulties making appointments with their family doctors for urgent non-emergent health problems. They were also more likely to report unmet health care needs.38 In terms of hospitalizations, people with lower socio-economic status were much more likely to be hospitalized for ambulatory care sensitive conditions (ACSC) and mental health39; admissions which could potentially be avoided with appropriate primary care.40 They were also found to have on average longer lengths of stay.41 According to a study of hospitals in the Toronto Central Local Health Integration Network, patients considered to be Alternate Level of Care were more likely to have a low-income profile.42 Further, people with ACSC in low-income groups, those living in rural areas, or those with multiple chronic conditions were twice as likely to report the use of emergency department services for care that could have been provided by a primary care provider.43 There is a financial cost to this disparity. According to a 2011 report, low-income residents in Saskatoon alone consume an additional $179 million in health care costs than middle income earners.44 A 2010 study by CIHI found increased costs for avoidable hospitalizations for ambulatory care sensitive conditions were $89 million for males and $71 million for females with an additional $248 million in extra costs related to excess hospitalizations for mental health reasons.45 Areas for Action: As the background suggests, equitable access is about more than just utilization of services. There are patient characteristics as well as complex factors within the health system which determine whether equitable access is achieved. Recent work has categorized access as having considerations on the supply of services and demand of patients for care. On the demand or patient side we must consider: ability to perceive; ability to seek, ability to reach, ability to pay, and ability to engage. On the supply side or health system considerations include: approachability; acceptability, availability and accommodation, affordability, and appropriateness. 46 The following table highlights some of the current barriers to equitable access. (See PDF for correct display of table) Demand Side or Patient Barriers Supply Side or System Barriers Health literacy Services not located in areas of need Cultural beliefs and norms Patients lack family physicians Language Lack of management of chronic disease Cost of transportation Long waits for service Time off work for appointments Payment models which don't account for complexity of patients Access to child care Coordination between primary care and speciality care and between health care and community services Payment for medications or other medical devices/treatments Standardization of referral and access to specialists and social services Immobility- due to physical disabilities, and/or mental health barriers Lack of needs based planning to ensure that population has necessary services Cognitive issues, ie. Dementia, that adversely affect ability to access and comply with care Attitudes of health care workers Patient based actions for improving equitable access: Low health literacy can lead to difficulties for some Canadians in perceiving a need for care.47 Evidence suggests that more than half of Canadian adults (60%), lack the capacity to obtain, understand and act upon health information and services in order to make health decisions on their own.48 Many physicians are undertaking strategies to minimize this lack of health literacy among their patients. Examples include plain language resources as well as teach-back exercises which allow physicians to determine whether patients have fully understood the information provided.49 These efforts should continue to be supported. Understanding how the health system works and where to access services can be a problem for some individuals.50 Beliefs about the need and value for certain services can also undermine the ability of patients in seeking care.51 Work needs to be done to ensure that disadvantaged groups are aware of the services that are available to them and the benefits of taking preventative steps in their health. Low-income Canadians are ten times more likely to report unmet needs of health care due to the cost of transportation.52 Other barriers include a lack of child care, and ability to get time off work to attend necessary health appointments.53 Strategies that provide patients with transportation to appointments or subsidies for such travel have seen some success. Extended office hours and evening appointments can increase access for those unable to take time off work. Additionally, programs that provide patients with home visits from health care providers can help to eliminate this barrier. Further support and expansion of these programs should be explored. There is also the inability to pay for services not covered by provincial plans such as pharmaceuticals, physiotherapy and other rehabilitation services.54 According to a 2005 report on diabetes in Canada, affordability and access to medical supplies was the biggest challenge for those Canadians living with diabetes.55 Access to services such as mental health counselling, subsidized residential care, and long-term care are also hindered by the inability to pay. Even if patients are able to obtain care they may not be able to fully engage. Language difficulties, low health literacy, cognitive challenges (ie. Dementia), cultural mores and norms, and discrimination or insensitivity of health care workers, may all act as barriers to full participation in care.56 Efforts should be made to develop teaching methods to improve engagement of patients and their families/caregivers from disadvantaged groups.57 Strategies to remove or minimize the barriers created by a lack of health literacy should be developed and shared with physicians and other health care providers. Further, programs which facilitate access to services including interpretation and translation of key health information should be supported.58 Finally, an understanding of a patient's cultural and social context is important. The Royal College of Physicians and Surgeons of Canada and the Association of Faculties of Medicine of Canada have developed training modules for physicians who will be working with Canada's Aboriginal peoples.59 Similar programs have been developed by the Canadian Paediatric Society, and the Society of Obstetricians and Gynaecologists of Canada. More of this training is needed and should focus on groups who are likely to experience disadvantage in health care access and appropriateness. Recommendations for action: CMA and National Level Initiatives The CMA recommends that: 1. Governments develop a national strategy for improving the health literacy of Canadians which takes into account the special needs of different cultures. 2. Governments provide accessible and affordable transportation options for patients requiring medical services when such services are unavailable locally. 3. Governments, in consultation with the life and health insurance industry and the public, establish a program of comprehensive prescription drug coverage to be administered through reimbursement of provincial/territorial and private prescription drug plans to ensure that all Canadians have access to medically necessary drug therapies. 4. Governments examine methods to ensure that low-income and other disadvantaged Canadians have greater access to needed medical interventions such as rehabilitation services, mental health, home care, and end-of-life care. 5. Governments explore options to provide funding for long-term care services for all Canadians. 6. Governments ensure that necessary interpretation and translation services are provided at all points of care. Physicians in Practice The CMA recommends that 7. Physicians be supported in addressing the health literacy of their patients and their families/caregivers. 8. Physician education programs continue to emphasize the important cultural and social contexts in which their patients live. System based actions for improving equitable access: On the system side there are two main areas that need to be addressed: making sure that people can access the services that they need (approachability, availability and accommodation, and affordability); and ensuring that once they have accessed the system that services are appropriate for their health needs (acceptability and appropriateness). Strategies for action include: patient-centred primary care which focuses on chronic disease management; better care coordination and greater access to necessary medical services along the continuum; quality improvement initiatives which incorporate equity as part of their mandate; and health system planning and assessment which prioritizes equitable access to care. 1. Patient-centred primary care which focuses on chronic disease management and which includes programs to increase access to those most at need. Comprehensive primary care offers the biggest possibility for increasing equitable access and reducing health disparities. Data from a large population study in Ontario indicates that inequities in access to primary care and appropriate chronic disease management are much larger than inequities in the treatment of acute conditions.60 Currently many primary care services are located outside of the neighbourhoods with the greatest need for care. While some are accessible through public transportation, there is still a need for more convenient access for these communities. Community health centres (CHC) offer a good model for addressing this challenge through location in disadvantaged neighbourhoods and the provision of culturally appropriate care.61 Additionally, CHCs offer a number of different health, and sometimes social services, under one roof making access to many different types of care more convenient for patients. More work needs to be done to to reduce barriers in access to Canadians living in rural and remote communities. Telemedicine is one strategy that has increased access for rural Canadians. The Ontario Telemedicine Network is one example of this innovative approach. Patients in rural communities can have access to specialists in urban centres through their local health providers. Examples include cardiac rehab follow-up, tele-homecare to support lifestyle changes, and psychiatric or mental health consultations.62 Programs which encourage recruitment and training of health professionals from rural and disadvantaged populations have been found to increase access as these individuals are more likely to return to their home communities to practice.63 Medical schools have been attempting to increase the diversity in their schools for a number of years. However, work still needs to be done. Data from the 2012 student component of the National Physician Survey shows that 278 of the 2000 students who responded to the survey (13.9%) come from families considered to be in the top 1% of earners in Canada. This is compared to only 46 (2.3%) of students whose family incomes place them in the bottom quintile of earners. 64 One of the suggested strategies for increasing diversity in medical schools is increasing the knowledge about the medical profession among rural and disadvantaged young people. An innovative program in Alberta called Mini Docs allows children between the ages of six and 12 to learn about being a doctor and how to stay healthy. The children get to wear medical scrubs for the day and use harmless medical tools such as stethoscopes and bandages. The day long program is run by medical students.65 Strategies to remove financial barriers to access, such as scholarships, should be expanded. Further, there is a need to modify the admissions process to recognize the differences in access to programs such as MCAT preps and overseas volunteer experiences based on the availability of financial resources as well as the necessity of employment for some students while in medical school. This necessary employment may limit the time available for volunteer and community service.66 Another strategy that can be effective in increasing access is programs that seek to link primary care providers with unattached and underserved patients. Programs such as Health Care Connect in Ontario and the GP and Me program in British Columbia actively seek to link sometimes hard to serve patients to appropriate primary care. The College of Family Physicians of Canada has developed a blueprint for comprehensive primary care for Canadians. The concept, a 'patient's medical home' seeks to link Canadians with a comprehensive health care team led by a family physician. These medical homes will take many forms but will be designed to increase both access and the patient-centredness of care.67 Another barrier to access is timeliness of service. Many patients are forced to use walk in clinics or emergency departments as they cannot receive the required care from their primary care providers. Use of walk-in clinics or emergency departments for primary care may lead to lost opportunities for prevention and health promotion.68 Advanced access programs can help to improve equitable access to care by facilitating timely appointments for all patients.69 The AIM (Access improvement measures) program in Alberta uses a system designed by the Institute for Healthcare Improvement to redesign practice to focus on same day appointments and elimination of unnecessary delays.70 Primary care which prioritizes chronic disease management offers the greatest potential for increasing appropriateness of care and reducing system costs. Those most likely to have chronic diseases are also those who face the biggest barriers to equitable access.71 Currently many people with ACSC do not receive the appropriate tests to monitor their conditions, management of their medications, or supports to self-manage their disease.72 Some programs do exist to encourage more effective management of chronic disease. The Champlain Local Health Integration Network (LHIN) in Ontario has developed a cardiovascular disease prevention network to improve care through the use of evidence based practices and better integration between all areas of the health care continuum.73 Primary Care networks in Alberta have similar goals designed to connect multiple physicians, clinics and regions together to support the health needs of the population.74 Further work is necessary to expand these types of programs and to provide appropriate compensation models for complex patients. Payment models in some jurisdictions undermine access by failing to take morbidity and co-morbidity into consideration in designing rates such as equal capitation.75 Finally, there is a need to encourage greater self-management of disease. Practice support programs in British Columbia are providing training to support physicians in increasing patient self-management and health literacy.76 Additional programs of this nature are necessary in all jurisdictions. 2. Better care coordination and greater access to necessary medical services along the continuum of care. Patient-centred care which integrates care across the continuum and which includes community services will be necessary to ensure not only greater access but greater acceptability of care.77 Innovative programs focused on increasing the coordination in terms of transition from hospital to home have shown some success in preventing readmissions particularly when vulnerable populations are targeted.78 Health Links in Ontario aims to reduce costs, based on the assumption that much of the utilization of high cost services, such as emergency department visits, could be prevented with better coordinated care. One of the pilot sites in Guelph aims to assign one person in primary care, likely a doctor or a nurse, to be the primary contact for patients deemed high need and to intervene on behalf of these patients to ensure better care coordination.79 Further work is needed to ensure greater coordination in speciality care. As the evidence demonstrates, access to specialist services are skewed in favour of high-income patients. To reduce this inequity it may be necessary to standardize the referral process and facilitate the coordination of care from the primary care providers' perspective.80 A new program in British Columbia is designed to reduce some of these barriers by providing funding and support to rapid access programs which allow family physicians to access specialist care through a designated hotline. If no specialist is available immediately there is a commitment that the call will be returned within two hours. Specialists available through this program include cardiology, endocrinology, nephrology, psychiatry, and internal medicine among others.81 Similar programs in other jurisdictions could help to increase coordination between primary and speciality care. Care coordination is only part of the problem, however. There is also a need to increase the access to services that are medically necessary across the care continuum. These include a lifetime prevention schedule82, diagnostic testing, specialty services, and access to appropriate rehabilitation services, mental health, long-term care and end of life care. 3. Quality improvement initiatives which incorporate considerations of equity as part of their mandate. Equity has become a key component of many quality improvement initiatives around the world. The Health Quality Council Ontario identified nine attributes of a high-performing health system: safe, effective, patient-centred, accessible, efficient, equitable, integrated, appropriately resourced, and focused on population health.83 The POWER study, a large study of Ontario residents found that where there were targeted programs for quality improvement fewer inequities were observed. In particular they referred to the actions of Cancer Care Ontario and the Ontario Stroke Network. Both of these groups had undergone large quality improvement initiatives to standardize care and increase coordination of services through evidence-based guidelines and ongoing performance measurement. Considerations of accessibility and equity were specifically included. As a result of these efforts, the POWER study found that acute cancer and stroke care in Ontario were quite equitable.84 Similar efforts are underway in other jurisdictions. The Towards Optimized Practice initiative in Alberta supports efforts in medical offices to increase the use of clinical practice guidelines for care as well as quality improvement initiatives.85 Encouraging more health services and programs to undertake such quality improvement initiatives could help to reduce the inequities in access for all Canadians. 4. Health system planning and assessment which prioritizes equitable access to care Considerations of equity must be built specifically into all planning considerations. Too often services are designed without adequate consideration of the specific needs of disadvantaged groups. Planners need to do a better job of understanding their practice populations and tailoring programs to those most in need of care.86 This planning should be done in consultation with other sectors that play a role in influencing the health of their practice populations. Further, assessments of the equity and use of services is also needed. Some services may be designed in a way that is more appropriate for some than others, resulting in higher utilization among some groups and a lack of access for others.87 Innovative work is taking place in the Saskatoon Health Region to try and understand these barriers. Health care services are undergoing specific health equity assessments to ensure that all services meet the needs of diverse populations. This includes looking at the full spectrum of services from preventative care and education programs to tertiary level care such as dialysis. In Ontario, the local health integration networks (LHIN) have now been tasked with developing equity plans for their services. Clear goals and performance measurements are part of this work.88 One of the tools available to support this work is a health equity impact assessment tool developed by the Ontario Ministry of Health and Long-Term Care. This tool is intended for use by organizations within the health system as well as those outside the system who will impact on the health of Ontarians. The main focus of the tool is to reduce inequities that result from barriers in access to quality health services. Additionally, it is designed to identify unintended health impacts, both positive and negative, before a program or policy is implemented.89 Further work is needed to ensure that equity is included in the deliverables and performance management of health care organizations and provider groups across the country.90 To support these planning programs appropriate data will need to be collected. This data needs to be comprehensive for all services and needs to include specific data points which will allow planners as well as providers to understand the composition of their populations as well as measure and report on considerations of equity.91 Recommendations for action: CMA and National Level Initiatives The CMA recommends that: 9. Governments continue efforts to ensure that all Canadians have access to a family physician. 10. Appropriate compensation and incentive programs be established in all jurisdictions to support better management of chronic disease for all Canadians. 11. Governments provide funding and support to programs which facilitate greater integration between primary and speciality care. 12. With support from government, national medical organizations develop programs to increase standardization of care and the use of appropriate clinical practice guidelines. 13. Appropriate data collection and performance measurement systems be put in place to monitor equitable distribution of health services and greater appropriateness of care. Health System Planners The CMA recommends that: 14. Needs based planning be mandated for all health regions and health system planning. Equity impact assessment should be part of this planning to ensure that services meet the needs of all Canadians. 15. Chronic disease management and other supportive strategies for vulnerable patients at risk of frequent readmission to the acute care system be prioritized in all health systems. 16. Quality improvement initiatives be mandated in all care programs. These programs should include a specific focus on standardization of care and continuous quality improvement and should include equity of access as part of their mandate. Physicians in Practice The CMA recommends that: 17. Physicians be supported in efforts to offer timely access in primary care settings. 18. Physicians be supported in continued efforts to include all patients in decisions about their care and management of their illnesses. 19. Physicians be supported in continued efforts to standardize care and utilize evidence based clinical practice guidelines with a particular emphasis on the management of chronic disease. 20. Physicians be encouraged and adequately supported to participate in community-based interventions that target the social determinants of health. Conclusion: Despite a commitment to equal access to health care for all Canadians there are differences in access and quality of care for many groups. For those that are most vulnerable, this lack of access can serve to further exacerbate their already increased burden of illness and disease. The strategies discussed above offer some opportunities for the health sector and the medical profession to intervene and mitigate this inequity. By removing barriers on both the patient and system side it is hoped that greater access to appropriate care will follow. While these strategies offer some hope, these actions alone will not be sufficient to increase the overall health of the Canadian population. Action is still required to tackle the underlying social and economic factors which lead to the disparities in the health of Canadians. References: 1 This paper represents a focus on equitable access to care. For a more general policy statement on the role of physicians in addressing the social determinants of health please see: Canadian Medical Association. Health Equity and the Social Determinants of Health: A Role for the Medical Profession. Ottawa, ON; 2012. Available: http://policybase.cma.ca/dbtw-wpd/Policypdf/PD13-03.pdf 2 The Canadian Medical Association is currently developing a policy paper on access to mental health services in Canada. It is anticipated that this policy statement will be completed in 2014. 1 Levesque JF, Harris M, Russell G. Patient-centred access to health care: conceptualising access at the interface of health systems and populations. Int J Equity Health 2013. Available: http://www.equityhealthj.com/content/12/1/18 (accessed 2013Mar 12) 2 Mikkonen J, Raphael D. Social Determinants of Health: The Canadian Facts. Toronto (ON); 2010. Available: http://www.thecanadianfacts.org/The_Canadian_Facts.pdf (accessed 2011 Jan 14). 3 Commission on the Social Determinants of Health. Closing the gap in a generation: Health equity through action on the social determinants of health: Executive Summary. Geneva (CH) World Health Organization; 2008. Available: http://whqlibdoc.who.int/hq/2008/WHO_IER_CSDH_08.1_eng.pdf (accessed 2011 Jan 7). 4 Levesque JF, Harris M, Russell G. Patient-centred access to health care: conceptualising access at the interface of health systems and populations. Int J Equity Health 2013. Available: http://www.equityhealthj.com/content/12/1/18 (accessed 2013Mar 12) 5 Oliver A, Mossialos E. Equity of access to health care: outlining the foundations for action. J Epidemiol Community Health 2004; 58: 655-658. 6 Bierman AS, Angus J, Ahmad F, et al. Ontario Women's Health Equity Report : Access to Health Care Services : Chapter 7. Toronto (ON) Project for and Ontario Women's Health Evidence-Based Report; 2010. Available: http://powerstudy.ca/wp-content/uploads/downloads/2012/10/Chapter7-AccesstoHealthCareServices.pdf (accessed 2012 Dec 10). 7 Kirby M, Goldbloom D, Bradley L. Changing Directions, Changing Lives: The Mental Health Strategy for Canada.Ottawa (ON): Mental Health Commission of Canada; 2012. Available: http://strategy.mentalhealthcommission.ca/pdf/strategy-text-en.pdf (accessed 2013 Mar 12). 8 Allin S. Does Equity in Healthcare Use Vary...; Frolich N, Fransoo R, Roos N. Health Service Use in the Winnipeg Regional Health Authority: Variations Across Areas in Relation to Health and Socioeconomic status. Winnipeg (MB) Manitoba Centre for Health Policy. Available: http://mchp-appserv.cpe.umanitoba.ca/teaching/pdfs/hcm_forum_nf.pdf (accessed 2013 Feb 6); McGrail K. Income-related inequities: Cross-sectional analyses of the use of medicare services in British Columbia in 1992 and 2002. Open Medicine 2008; 2(4): E3-10; Van Doorslaer E, Masseria C. Income-Related Inequality in the Use... Veugelers PJ, Yip AM. Socioeconomic disparities in health care use: Does universal coverage reduce inequalities in health? 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Can Fam Physician 2009; 55: 178-179.e1-5; Williamson DL, Stewart MJ, Hayward K. Low-income Canadians' experiences with health-related services: Implications for health care reform. Health Policy 2006; 76:106-121. 16 The Ontario Rural Council. TORC 2009 Rural Health Forum: Rethinking Rural Health Care: Innovations Making a Difference. Guelph, ON; 2009. Available: http://ruralontarioinstitute.ca/file.aspx?id=1fb3035d-7c0e-4bfa-a8d7-783891f5c5dc (accessed 2013 Sep 18). 17 Browne A. Issues Affecting Access to Health Services in Northern, Rural and Remote Regions of Canada. Available: http://www.unbc.ca/assets/northern_studies/northern/issues_affecting_access_to_health_services_in_northern.pdf (accessed 2013 Mar 13). 18 Sibley LM, Weiner JP. An evaluation of access to health care services along the rural-urban continuum in Canada. BMC Health Services Research. Toronto (ON); 2011. Available: http://www.biomedcentral.com/1472-6963/11/20 (accessed 2013 Mar 13). 19 Society of Rural Physicians of Canada. National Rural Health Strategy- summary. Shawville, QC; 2008. Available: http://www.srpc.ca/PDF/nrhsA.pdf (accessed 2013 Sep 18). 20 Health Charities Coalition of Canada. Position Statement: Access to Health Care. Ottawa, ON; 2013. Available: http://www.healthcharities.ca/media/23883/posstatement_accesshealthc_final_en.pdf (accessed 2013 Sep 18). 21 Society of Rural Physicians of Canada. Rural Canadians need and deserve equitable access to health care. Shawville, QC; 2006. Available: http://www.srpc.ca/PDF/September-20-2006.pdf (accessed 2013 Sep 18). 22 Mikkonen J, Raphael D. Social Determinants of Health: The Canadian Facts.... 23 Kwan J, Razzaq A, Leiter LA, et al. Low Socioeconomic Status and Absence of Supplemental Health Insurance as Barriers to Diabetes Care Access and Utilization. CJD 2008; 32(3) : 174-181. 24 Barnes S, Dolan LA, Gardner B, et al. Equitable Access to Rehabilitation : Realizing Potential, Promising Practices, and Policy Directions. Toronto (ON) Wellesley Institute; 2012. Available : http://www.wellesleyinstitute.com/wp-content/uploads/2012/06/Equitable-Access-to-Rehabilitation-Discussion-Paper1.pdf (accessed 2013 Feb 6). 25 Bowen, S. Access to Health Services for Underserved Populations in Canada. In Certain Circumstances: Issues in Equity and Responsiveness in Access to Health Care in Canada: A collection of papers and reports prepared for Health Canada. Ottawa (ON) Health Canada; 2000. Available: http://www.hc-sc.gc.ca/hcs-sss/alt_formats/hpb-dgps/pdf/pubs/2001-certain-equit-acces/2001-certain-equit-acces-eng.pdf (accessed 2013 Feb 6). 26 Statistics Canada. Canadian Community Health Survey: Mental Health, 2012. Ottawa, ON; 2013. Available: http://www.statcan.gc.ca/daily-quotidien/130918/dq130918a-eng.pdf (accessed 2013 Sep 18). 27 Kirby M, Goldbloom D, Bradley L. Changing Directions, Changing Lives... 28 EMC News. CCAC publishes long-term care waitlists monthly. Brockville (ON); 2013. Available: http://www.emcstlawrence.ca/20130404/news/CCAC+publishes+long-term+care+waitlists+monthly (accessed 2013 Apr 11). 29 Health Charities Coalition of Canada. Position Statement on Access to Home Care Revised for Approval Ottawa (ON); 2011. Available: http://www.healthcharities.ca/media/2720/HomeCarePos_statmnt_Sep22_11_Final_EN.pdf (accessed 2013 Mar 12) 30 Canadian Hospice Palliative Care Association. Fact Sheet: Hospice Palliative Care in Canada. Ottawa(ON); 2012. Available: http://www.chpca.net/media/7622/fact_sheet_hpc_in_canada_may_2012_final.pdf (accessed 2013 Mar 25). 31 Bowen, S. Access to Health Services for Underserved Populations..... 32 Place J. The Health of Aboriginal People Residing in Urban Areas. National Collaborating Centre for Aboriginal Health. Prince George, BC; 2012. Available: http://www.nccah-ccnsa.ca/Publications/Lists/Publications/Attachments/53/Urban_Aboriginal_Health_EN_web.pdf (accessed 2013 Sep 18). 33 National Collaborating Centre for Aboriginal Health. Access to Health Services As A Social Determinant of First Nations, Inuit And Metis Health. Prince George (BC) National Collaborating Centre for Aboriginal Health; 2011. Available: http://www.nccah-ccnsa.ca/docs/fact%20sheets/social%20determinates/Access%20to%20Health%20Services_Eng%202010.pdf (accessed 2013 Feb 6). 34 Levesque JF, Harris M, Russell G. Patient-centred access to health care... 35 Allin S. Does Equity in Healthcare Use Vary...; Williamson DL, Stewart MJ, Hayward K. Low-income Canadians' experiences... 36 Canadian Institute for Health Information. Hospitalization Disparities by Socio-Economic Status for Males and Females. Ottawa(ON); 2010. Available: https://secure.cihi.ca/free_products/disparities_in_hospitalization_by_sex2010_e.pdf (accessed 2013 Feb 6); Van Doorslaer E, Masseria C. Income-Related Inequality... 37 Allin S. Does Equity in Healthcare Use Vary... 38 Bierman AS, Johns A, Hyndman B, et al. Ontario Women's Health Equity Report: Social Determinants of Health & Populations at Risk: Chapter 12...;Williamson DL, Stewart MJ, Hayward K. Low-income Canadians' experiences... 39 Canadian Institute for Health Information. Hospitalization Disparities by Socio-Economic Status... 40 Canadian Institute for Health Information. Hospitalization Disparities by Socio-Economic Status... ;Roos LL, Walld R, Uhanova J, et al. Physician Visits, Hospitalizations, and Socioeconomic Status: Ambulatory Care Sensitive Conditions in a Canadian Setting. HSR 2005; 40(4): 1167-1185. 41 Curtis LJ, MacMinn WJ. Health-Care Utilization in Canada: 25 Years of Evidence: SEDAP Research Paper No. 190. Hamilton (ON) Social and Economic Dimensions of an Aging Population Research Program; 2007. Available: http://catalogue.iugm.qc.ca/GEIDEFile/23002.PDF?Archive=102297992047&File=23002_PDF (accessed 2013 Feb 14). 42 Murphy K, Glazier R, Wang X, et al. Hospital Care for All... 43 Canadian Institute for Health Research. Disparities in Primary Health Care Experiences Among Canadians With Ambulatory Care Sensitive Conditions. Ottawa(ON); 2012. Available: https://secure.cihi.ca/free_products/PHC_Experiences_AiB2012_E.pdf (accessed 2013 Feb 14). 44 Saskatoon Poverty Reduction Partnership. From poverty to possibility...and prosperity: A Preview to the Saskatoon Community Action Plan to Reduce Poverty. Saskatoon (SK): Saskatoon Poverty Reduction Partnership; 2011.Available: http://www.saskatoonpoverty2possibility.ca/pdf/SPRP%20Possibilities%20Doc_Nov%202011.pdf (accessed 2012 Mar 13) 45 Canadian Institute for Health Information. Hospitalization Disparities... 46 Levesque JF, Harris M, Russell G. Patient-centred access to health care... 47 Bowen, S. Access to Health Services for Underserved Populations... 48 Canadian Council on Learning. Health Literacy in Canada: Initial Results for the International Adult Literacy and Skills Survey. Ottawa (ON); 2007. Available: http://www.ccl-cca.ca/pdfs/HealthLiteracy/HealthLiteracyinCanada.pdf (accessed 2013 Apr 19). 49 Parnell TA, Turner J. IHI 14th Annual International Summit. Health Literacy: Partnering for Patient-Centred Care. April 9, 2013. 50 Bowen, S. Access to Health Services for Underserved Populations... 51 Bierman A, Angus J, Ahmad F, et al. Ontario Women's Health Equity Report : Access to Health Care Services : Chapter 7.... 52 Williamson DL, Stewart MJ, Hayward K. Low-income Canadians' experiences... 53 Bierman A, Angus J, Ahmad F, et al. Ontario Women's Health Equity Report : Access to Health Care Services : Chapter 7...; Williamson DL, Stewart MJ, Hayward K. Low-income Canadians' experiences... 54 Williamson DL, Stewart MJ, Hayward K. Low-income Canadians' experiences... 55 Chiu S, Hwang SW. Barriers to healthcare among homeless people with diabetes. Diabetes Voice 2006; 51(4): 9-12. Available: http://www.idf.org/sites/default/files/attachments/article_473_en.pdf (2011 Feb 20), 56 Bierman A, Angus J, Ahmad F, et al. Ontario Women's Health Equity Report : Access to Health Care Services : Chapter 7.... Willems S, De Maesschalck S, Deveugele M, et al. Socio-economic status of the patient and doctor-patient communication: does it make a difference? Patient Educ Couns 2004; 56: 139-146; Williamson DL, Stewart MJ, Hayward K. Low-income Canadians' experiences... 57 Willems S, De Maesschalck S, Deveugele M, et al. Socio-economic status of the patient... 58 Bierman A, Angus J, Ahmad F, et al. Ontario Women's Health Equity Report : Access to Health Care Services : Chapter 7... 59 Indigenous Physicians of Canada and the Association of Faculties of Medicine Canada, "First Nations, Inuit, Métis Health, Core Competencies: A Curriculum Framework for Undergraduate Medical Education" Updated April 2009, online: http://www.afmc.ca/pdf/CoreCompetenciesEng.pdf (accessed October 20, 2010). 60 Bierman AS, Shack AR, Johns A. Ontario Women's Health Equity Report : Achieving Health Equity in Ontario: Opportunities for Intervention and Improvement: Chapter 13. Toronto (ON) Project for and Ontario Women's Health Evidence-Based Report; 2012.Available: http://powerstudy.ca/wp-content/uploads/downloads/2012/10/Chapter13-AchievingHealthEquityinOntario.pdf (accessed 2013 Feb 6). 61 Bierman AS, Angus J, Ahmad F, et al. Ontario Women's Health Equity Report : Access to Health Care Services : Chapter 7... ;Bowen, S. Access to Health Services for Underserved Populations..... 62 Williams, R. Telemedicine in Ontario: Fact not Fiction: How to enhance your practice and enrich the patient experience. Ontario Telemedicine Network: Toronto, ON; 2013. Available: http://otn.ca/sites/default/files/telemedicine_in_ontario-_fact_not_fiction_02-26.pdf (accessed 2013 Sep 19). 63 Bowen, S. Access to Health Services for Underserved Populations... 64 National Physician Survey- 2012 student component 65 Alberta Medical Association. Mini Docs. Edmonton (AB); 2012. Available: https://www.albertadoctors.org/about/awards/health-promo-grant/2011-12-recipients/mini-docs (accessed 2013 Apr 18). 66 Dhalla IA, Kwong JC, Streiner DL et al. Characteristics of first-year students in Canadian... 67 The College of Family Physicians of Canada . A Vision for Canada: Family Practice: The Patient's Medical Home. Toronto, ON; 2011. Available: http://www.cfpc.ca/uploadedFiles/Resources/Resource_Items/PMH_A_Vision_for_Canada.pdf (accessed 2012 Mar 15). 68 Bierman A, Angus J, Ahmad F, et al. Ontario Women's Health Equity Report : Access to Health Care Services : Chapter 7... 69 Ibid 70 Access Improvement Measures. Edmonton (AB): Alberta Primary Care Initiative. Available at: http://www.albertapci.ca/AboutPCI/RelatedPrograms/AIM/Pages/default.aspx (accessed 2013 Mar 12). 71 Bierman A, Angus J, Ahmad F, et al. Ontario Women's Health Equity Report : Access to Health Care Services : Chapter 7... 72 Canadian Institute for Health Research. Disparities in Primary Health Care Experiences... 73 Bierman AS, Shack AR, Johns A. Ontario Women's Health Equity Report : Achieving Health Equity in Ontario: Opportunities for Intervention and Improvement: Chapter 13... 74 About Primary Care Networks. Edmonton (AB): Alberta Primary Care Initiative. Available at: http://www.albertapci.ca/AboutPCNs/Pages/default.aspx (accessed 2013 Mar 12). 75 Glazier RH. Balancing Equity Issues in Health Systems: Perspectives of Primary Healthcare. Healthcare Papers 2007; 8(Sp):35-45. 76 General Practice Services Committee. Learning Modules-Practice Management. Vancouver (BC): Government of British Columbia & British Columbia Medical Association. Available: http://www.gpscbc.ca/psp/learning/practice-management (accessed 2013 Mar 12). 77 Bierman A, Angus J, Ahmad F, et al. Ontario Women's Health Equity Report : Access to Health Care Services : Chapter 7... 78 Bierman AS, Shack AR, Johns A. Ontario Women's Health Equity Report : Achieving Health Equity in Ontario: Opportunities for Intervention and Improvement: Chapter 13... 79 Improving Care for High-Needs Patients: McGuinty Government Linking Health Providers, Offering Patients More Co-ordinated Care. Toronto (ON) Ontario Ministry of Health and Long-Term Care; December 6, 2012. Available: http://news.ontario.ca/mohltc/en/2012/12/improving-care-for-high-needs-patients.html (accessed 2012 Dec 10). 80 Curtis LJ, MacMinn WJ. Health-Care Utilization in Canada: 25 Years of Evidence... 81 Shared Care Partners in Care Annual Report 2011/12. Vancouver (BC): Government of British Columbia & British Columbia Medical Association. Available: https://www.bcma.org/files/SC_annual_report_2011-12.pdf (accessed 2013 Mar 12). 82 British Columbia Medical Association. Partners in Prevention: Implementing a Lifetime Prevention Plan. Vancouver, BC; 2010. Available: https://www.bcma.org/files/Prevention_Jun2010.pdf (accessed 2013 Sep 18). 83 Bierman AS, Shack AR, Johns A. Ontario Women's Health Equity Report : Achieving Health Equity in Ontario: Opportunities for Intervention and Improvement: Chapter 13... 84 Ibid. 85 Toward Optimized Practice. Edmonton (AB). Available at: http://www.topalbertadoctors.org/index.php (accessed 2013 Mar 12). 86 Ali A, Wright N, Rae M ed. Addressing Health Inequalities: A guide for general practitioners. London (UK); 2008. Available: http://www.rcgp.org.uk/policy/rcgp-policy-areas/~/media/Files/Policy/A-Z%20policy/Health%20Inequalities%20Text%20FINAL.ashx (accessed 2012 Jan 16); Gardner, B. Health Equity Road Map Overview. Toronto (ON): Wellesley Institute, 2012. Available: http://www.wellesleyinstitute.com/wp-content/uploads/2012/09/HER_Systemic-Health-Inequities_Aug_2012.pdf (accessed 2013 Feb 6). 87 Bowen, S. Access to Health Services for Underserved Populations... 88 Gardner B. Health Equity Into Action: Planning and Other Resources for LHINs. Toronto(ON) Wellesley Institute; 2010. Available: http://www.wellesleyinstitute.com/wp-content/uploads/2010/09/Health_Equity_Resources_for_LHINs_1.pdf (accessed 2013 Feb 6). 89 Ontario Ministry of Health and Long-Term Care. Health Equity Impact Assessment (HEIA) Workbook. Toronto, ON; 2012. Available: http://www.health.gov.on.ca/en/pro/programs/heia/docs/workbook.pdf (accessed 2013 Sep 30). 90 Bierman AS, Johns A, Hyndman B, et al. Ontario Women's Health Equity Report: Social Determinants of Health & Populations at Risk: Chapter 12...; Gardner, B. Health Equity Road Map...; Glazier RH. Balancing Equity Issues in Health Systems... 91 Bierman AS, Shack AR, Johns A. Ontario Women's Health Equity Report : Achieving Health Equity in Ontario: Opportunities for Intervention and Improvement: Chapter 13...
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Health and health care for an aging population

https://policybase.cma.ca/en/permalink/policy11061
Last Reviewed
2018-03-03
Date
2013-12-07
Topics
Health care and patient safety
Health systems, system funding and performance
  1 document  
Policy Type
Policy document
Last Reviewed
2018-03-03
Date
2013-12-07
Replaces
PD00-03 - Principles for medical care of older persons
Topics
Health care and patient safety
Health systems, system funding and performance
Text
In 2010, 14% of Canada's population was 65 or older. With the aging of the baby boom generation, this proportion is estimated to rise to about 25% in 2036 (1). The aging of Canada's population is expected to have a major impact on the country's economy, society and health care system over the next 25 to 30 years. Though age does not automatically mean ill health or disability, the risk of both does increase as people age. In 2006, 33% of Canadians aged 65 or older had a disability; the proportion climbed to 44% among people aged 75 or older (2). Nearly three-quarters of Canadians over 65 have at least one chronic health condition (3). Because of increasing rates of disability and chronic disease, the demand for health services is expected to increase as Canada's population ages. Currently Canadians over 65 consume roughly 44% of provincial and territorial health care budgets (4), and governments are concerned about the health care system's capacity to provide quality services in future. The CMA believes that to provide optimal care and support for Canada's aging population, while taking care to minimize pressure on the health-care system as much as possible, governments at all levels should invest in: * programs and supports to promote healthy aging; * a comprehensive continuum of health services to provide optimal care and support to older Canadians; and * an environment and society that is "age friendly." This policy describes specific actions that could be taken to further these three goals. Its recommendations complement those made in other CMA policies, including those on "Funding the Continuum of Care" (2009), Optimal Prescribing (2010) and Medication Use and Seniors (Update 2011). 2) Providing Optimal Health and Health Care for Older Persons: This section discusses in detail the three general areas in which the CMA believes governments should invest: a) Promotion of "Healthy Aging" The Public Health Agency of Canada (PHAC) defines healthy aging as "the process of optimizing opportunities for physical, social and mental health to enable seniors to take an active part in society without discrimination and to enjoy independence and quality of life." It is believed that initiatives to promote healthy aging, and enable older Canadians to maintain their health, will help lower health-care costs by reducing the overall burden of disability and chronic disease. Such initiatives could focus on: Physical activity. Being physically active is considered the most important step that older Canadians can take toward improving health, even if they do not start being active until later in life. However in 2008, 57% of seniors reported being physically inactive (5). Injury prevention. Falls are the primary cause of injury among older Canadians; they account for 40% of admissions to nursing homes, 62% of injury-related hospitalizations, and almost 90% of hip fractures (6). The causes of falls are complex, and both physiology (e.g. effect of illness) and environment (e.g. poorly maintained walkways) can contribute. Most falls can be prevented through a mix of interventions: for the person (such as strength and balance training); and for the person's environment, (such as grab bars and railings, slip-proof floor surfaces, walkways that are cleared of snow and ice in winter.) Nutrition. In 2008, 28% of men and 31% of women over 65 were obese (BMI = 30); this is higher than the population average. Underweight is also a problem among seniors, 17% of whom report a BMI of 20 or less (7). The reasons for nutrition problems among older Canadians are complex; they may be related to insufficient income to purchase healthy foods, or to disabilities that make shopping or preparing meals difficult. Mental health. An estimated 10-15% of seniors report depression, and the rate is higher among those with concomitant physical illness, or those living in long-term care facilities (8). Depression among older people may be under-recognized and under-treated, since it might be dismissed as a normal consequence of aging. Poor mental health is often associated with social isolation, a common problem among seniors. Recommendations: Governments and National Associations The CMA recommends that: 1. Governments at all levels support programs to promote physical activity, nutrition, injury prevention and mental health among older Canadians. Health Service Delivery The CMA recommends that: 2. Older Canadians have access to high-quality, well-funded programs and supports to help them achieve and maintain physical fitness and optimal nutrition. 3. Older Canadians have access to high-quality, well-funded programs aimed at determining the causes and reducing the risk of falls. 4. Older Canadians have access to high-quality, well-funded programs to promote mental health and well-being and reduce social isolation. Physicians and Patients The CMA recommends that: 5. Older Canadians be encouraged to follow current guidelines for healthy living, such as the 2012 Canadian Physical Activity Guidelines for adults 65 and over. 6. Physicians and other health care providers be encouraged to counsel older patients about the importance of maintaining a healthy and balanced life style. 7. All stakeholders assist in developing health literacy tools and resources to support older Canadians and their families in maintaining health. b) A Comprehensive Continuum of Health Services Though, as previously mentioned, age does not automatically mean ill health, utilization of health services does increase with increasing age. Patients over 65 have more family physician visits, more hospital admissions and longer hospital stays than younger Canadians (the overall length of stay in acute inpatient care is about 1.5 times that of non-senior adults) (9). In addition, seniors take more prescription drugs per person than younger adults; 62% of seniors on public drug programs use five or more drug classes, and nearly 30% of those 85 and older have claims for 10 or more prescription drugs (10). Heavy medication use by people over 65 has a number of consequences: * The risk of adverse drug reactions is several-fold higher for seniors than for younger patients. * Medication regimes, particularly for those taking several drugs a day on different dosage schedules, can be confusing and lead to errors or non-adherence. * Patients may receive prescriptions from multiple providers who, if they have not been communicating with each other, may not know what other medications have been prescribed. This increases the risk of harmful drug interactions and medication errors. For seniors who have multiple chronic diseases or disabilities, care needs can be complex and vary greatly from one person to another. This could mean that a number of different physicians, and other health and social-services professionals, may be providing care to the same person. A patient might, for example, be consulting a family physician for primary health care, several medical specialists for different conditions, a pharmacist to monitor a complex medication regime, a physiotherapist to help with mobility difficulties, health care aides to clean house and make sure the patient is eating properly, and a social worker to make sure his or her income is sufficient to cover health care and other needs. Complex care needs demand a flexible and responsive health care system. The CMA believes that quality health care for older Canadians should be delivered on a continuum from community based health care, (e.g. primary health care, chronic disease management programs), to home care (e.g. visiting health care workers to give baths and footcare), to long-term care and palliative care. Ideally, this continuum should be managed so that the patient can remain at home, out of emergency departments, hospitals and long term care unless appropriate, can easily access the level of care he or she needs, and can make a smooth transition from one level of care to another when needed. Care managers are an essential part of this continuum, working with caregivers and the patient to identify the most appropriate form of care from a menu of alternatives. Care managers can co-ordinate the services of the various health professionals who deliver care to a given patient, and facilitate communication among them so that all work to a common care plan. A family physician who has established a long-standing professional relationship with the patient and is familiar with his or her condition, needs and preference is ideally placed to serve as manager of a patient's overall care, supported by geriatric and other specialists as appropriate. Not all of the patient's caregivers may be health professionals; more than 75% of the care of older Canadians is delivered by unpaid informal caregivers, usually relatives. The role of the family caregiver can be demanding financially, physically and emotionally. Though governments have instituted tax credits and other forms of support for caregivers, more may be required. The Special Senate Committee on Aging has called for a National Caregiving Strategy to help put in place the supports that caregivers need. (11) Finally, many of the services required by seniors, in particular home care and long-term care, are not covered by the Canada Health Act. Funding of these services varies widely from province to province. Long-term care beds are in short supply; as a result more than 5,000 hospital beds are occupied by patients waiting for long-term care placement (12), making them unavailable for those with acute-care needs. CMA's Health Care Transformation Framework (2010) makes a number of recommendations aimed at improving access to continuing care in Canada. Recommendations: Governments and National Associations The CMA recommends that: 8. Governments and other stakeholders work together to develop and implement models of integrated, interdisciplinary health service delivery for older Canadians. 9. Governments continue efforts to ensure that older Canadians have access to a family physician, supported by specialized geriatric services as appropriate. 10. Governments and other stakeholders work together to develop and implement a National Caregiver Strategy, and expand the support programs currently offered to informal caregivers. 11. All stakeholders work together to develop and implement a national dementia strategy. 12. Governments and other stakeholders work together to develop and implement a pan-Canadian pharmaceutical strategy that addresses both comprehensive coverage of essential medicines for all Canadians, and programs to encourage optimal prescribing and drug therapy. 13. Governments work with the health and social services sector, and with private insurers, to develop a framework for the funding and delivery of accessible and sustainable home care and long-term care services. Medical Education The CMA recommends that: 14. Medical schools enhance the provision, in undergraduate education and in residency training for all physicians, of programs addressing the clinical needs of older patients. 15. Medical students and residents be exposed to specialty programs in geriatric medicine and other disciplines that address the clinical needs of older patients. 16. Continuing education programs on care for older patients be developed and provided to physicians of all specialties, and to other health care providers, on a continuous basis. Health System Planners The CMA recommends that: 17. Health systems promote collaboration and communication among health care providers, through means such as: a. Interdisciplinary primary health care practice settings, that bring a variety of physicians and other health professionals and their expertise into a seamless network; b. Widespread use of the electronic health record; and c. A smooth process for referral between providers. 18. All stakeholders work toward integration of health care along the continuum by addressing the barriers that separate: a. acute care from the community; b. health services from social services; and c. provincially-funded health care services such as physicians and hospitals, from services funded through other sources, such as pharmacare, home care and long term care. 19. Programs be developed and implemented that promote optimal prescribing and medication management for seniors. 20. Research be conducted on a continuous basis to identify best practices in the care of seniors, and monitor the impact of various interventions on health outcomes and health care costs. Physicians in Practice The CMA recommends that: 21. Continuing education, clinical practice guidelines and decision support tools be developed and disseminated on a continuous basis, to help physicians keep abreast of best practices in elder care. c) An Age-Friendly Environment: One of the primary goals of seniors' policy in Canada is to promote the independence of older Canadians in their own homes and communities, avoiding costly institutionalization for as long as feasible. To help older Canadians successfully maintain their independence, it is important that governments and society ensure that the social determinants of health care addressed when developing policy that affects them. This includes assuring that the following supports are available to older Canadians: * Adequate Income: Poverty among seniors dropped sharply in the 1970s and 1980s. In 2008, 6% of Canada's seniors were living in low income, as opposed to nearly 30% in 1978. However, there has been a slight increase in poverty levels since 2007, and it may be necessary to guard against an upward trend in future (13). Raising the minimum age for collecting Old Age Security, as has been proposed, may weigh heavily on seniors with lower incomes, and make prescription drugs, dental care and other needed health services unaffordable. * Employment Opportunities: it has been recommended that seniors be encouraged to work beyond age 65 as a means of minimizing a future drain on pension plans (14). Many older Canadians who have not contributed to employee pension plans may be dependent on employment income for survival. However, employment may be difficult to find if workplaces are unwilling to hire older workers. * Housing. Nearly all of Canada's seniors live in their own homes; fewer than 10% live in long-term care facilities. Options are available that permit older Canadians to live independently even with disabilities and health care needs, such as: o Home support for services such as shopping and home maintenance; and o Assisted-living facilities that provide both independent living quarters and support services such as nursing assistance, and cafeterias if desired. * An Age-friendly built environment. To enable seniors to live independently, the World Health Organization's "Age-Friendly Communities" initiative recommends that their needs be taken into consideration by those who design and build communities. For example, buildings could be designed with entrance ramps and elevators; sidewalks could have sloping curbs for walkers and wheelchairs; and frequent, accessible public transportation could be provided in neighbourhoods where a large concentration of seniors live. * Protection from Abuse. Elder abuse can take many forms: physical, psychological, financial, or neglect. Often the abuser is a family member, friend, or other person in a position of trust. Researchers estimate that 4 to 10% of Canadian seniors experience abuse or neglect, but that only a small portion of this is reported (15). CMA supports awareness programs to bring the attention of elder abuse to the public, as well as programs to intervene with seniors who are abused, and with their abusers. * A Discrimination-Free society. Efforts to boost income and employment security, health care standards and community support for older Canadians are hampered if the pervasive public attitude is that seniors are second-class citizens. An age-friendly society respects the experience, knowledge and capabilities of its older members, and accords them the same worth and dignity as it does other citizens. Recommendations: Governments and National Associations The CMA recommends that: 22. Governments provide older Canadians with access to adequate income support. 23. Governments devote a portion of national infrastructure funding to providing an adequate supply of accessible and affordable housing for seniors. 24. Older Canadians have access to opportunities for meaningful employment if they desire. 25. Communities take the needs and potential limitations of older Canadians into account when designing buildings, walkways, transportation systems and other aspects of the built environment. Health System Planners The CMA recommends that: 26. The health system offer a range of high-quality, well-funded home care and social support services to enable older Canadians to remain independent in the community for as long as possible. 27. Physicians receive advice and education on optimal community supports and resources to keep seniors independent and/or at home. Physicians in Practice The CMA recommends that: 28. Training and programs be provided to physicians and other care providers to enable them to identify elder abuse, and to intervene with abused people and their abusers. 3) Conclusion: Aging is not a disease, but an integral part of the human condition. To maximize the health and well-being of older Canadians, and ensure their continued functionality and independence for as long as possible, CMA believes that the health care system, governments and society should work with older Canadians to promote healthy aging, provide quality patient-centered health care and support services, and build communities that value Canadians of all ages. 1 Public health Agency of Canada. "Growing Older: Adding Life to Years. Annual report on the state of public health in Canada, 2010." Accessed at http://www.phac-aspc.gc.ca/cphorsphc-respcacsp/2010/fr-rc/index-eng.php 2 Statistics Canada: A Portrait of Seniors in Canada (2008). Accessed at http://www.statcan.gc.ca/pub/89-519-x/89-519-x2006001-eng.htm 3 Canadian Institute for Health Information. "Seniors and the health care system: What is the impact of multiple chronic conditions?" (January 2011.) Accessed at https://secure.cihi.ca/free_products/air-chronic_disease_aib_en.pdf 4 Canadian Institute for Health Information. National Health Expenditure Trends, 1975 to 2010. Accessed at http://www.cihi.ca/cihi-ext-portal/internet/en/document/spending+and+health+workforce/spending/release_28oct10 5 PHAC 2010 6 PHAC 2010 7 PHAC 2010 8 Mood Disorders Society of Canada. "Depression in Elderly" (Fact sheet). Accessed at http://www.mooddisorderscanada.ca/documents/Consumer%20and%20Family%20Support/Depression%20in%20Elderly%20edited%20Dec16%202010.pdf 9 Canadian institute for Health Information. Health Care in Canada, 2011: A Focus on Seniors and Aging. Accessed at https://secure.cihi.ca/free_products/HCIC_2011_seniors_report_en.pdf 10 CIHI 2011 11 Special Senate Committee on Aging. "Canada's Aging Population: Seizing the Opportunity." (April 2009). Accessed at http://www.parl.gc.ca/Content/SEN/Committee/402/agei/rep/AgingFinalReport-e.pdf 12 CIHI 2009 13 PHAC 2010 14 Department of Finance Canada. Economic and fiscal implications of Canada's Aging Population (October 2012). Accessed at http://www.fin.gc.ca/pub/eficap-rebvpc/report-rapport-eng.asp#Toc01. 15 PHAC 2010
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It's Still About Access - Medicare Plus: CMA Policy Statement July 2007

https://policybase.cma.ca/en/permalink/policy8828
Last Reviewed
2018-03-03
Date
2007-05-29
Topics
Health systems, system funding and performance
  1 document  
Policy Type
Policy document
Last Reviewed
2018-03-03
Date
2007-05-29
Topics
Health systems, system funding and performance
Text
It's Still About Access Medicare Plus: CMA Policy Statement July 2007 Toward a Sustainable Publicly Funded Health Care System in Canada Medicare is now 40 years old in Canada, and by all accounts it continues to be highly valued by Canadians. However, there is evidence suggesting that in its present state, Medicare will not be able to effectively deliver timely access to high quality care that reflects the needs of our changing health care landscape. In order to sustain Canada's health care system for the next generation, changes need to be made to bring about a new vision for Medicare. The CMA identifies this future vision as "Medicare Plus." This policy statement expresses the views of the Canadian Medical Association (CMA) at the present time and reflects, in the CMA's opinion, a future vision of Medicare which respects the current Canadian values, legislative frameworks and commitments from government. Three key steps must be undertaken to implement this vision: a) the current Medicare program must be shored up to deliver timely access to care; b) a guarantee that provides individual recourse to timely treatment must be put in place; and c) the basket of services must be expanded along the continuum of care through a variety of means. a) The public system must commit to timely access to care according to relative need for all necessary hospital and medical services. Governments have made a good start by providing for a stable funding base and by making strategic investments in medical equipment and health information technology. They have begun to deliver on their 2004 wait-time commitments by establishing national benchmarks in 2005 and by agreeing to implement a wait-time guarantee in at least one of the five priority areas by 2010. However, the job is far from finished. Governments have yet to set out the timelines for achieving their benchmarks, and there are many other procedural areas beyond the initial five for which benchmarks need to be established. Moreover the benchmark approach now needs to be expanded beyond the specialist-patient decision to treat to include access to primary care and specialist consultation. Delivering on timely access will not be achievable without an adequate supply of doctors, nurses and other health care professionals. Canada must adopt a pan-Canadian planning approach to health human resources with a goal of national self-sufficiency that engages key stakeholders on an early, meaningful and ongoing basis. Just as the 1966 Health Resources Fund Act was instrumental in expanding the health education and research infrastructure in the 1960s and 70s, further federal and provincial/territorial investments are critical now, in light of the recent expansion of medicine, nursing and other health professional enrolment and the establishment of new health disciplines. Considerable further investment is also required in health information technology. While the establishment of the Canadian Institutes for Health Research has been a positive step, further investment is necessary, particularly in the area of knowledge transfer - from bench to bedside. b) It is essential to implement a means of guaranteeing that Canadians can obtain timely access to care. As the Supreme Court found in the Chaoulli decision, the Canada Health Act and provincial/territorial health insurance legislation provide for a virtual monopoly for public health insurance, which "on the evidence, results in delays in treatment that adversely affect the citizen's security of the person," hence it does not conform to the principles of fundamental justice. The CMA has called for a Canada Health Access Fund that would provide for a means of individual recourse to patients facing waits that exceed benchmark thresholds. When the wait time is exceeded the patient and their physician would be able to seek timely treatment where it is available, ideally close to home, but potentially in another city, another province/territory, or country. The $612 million Patient Wait Times Guarantee Trust established in the 2007 budget is a step in this direction. To the extent that the current public infrastructure constrains capacity, governments should consider contracting publicly funded services to the private sector. Failing the enactment of a publicly funded safety valve, the Chaoulli decision has established that patients cannot be denied a private sector insurance and treatment option. The Quebec government has since made provisions in its legislation to comply with the decision, however it has so narrowly circumscribed the terms and conditions under which private insurance contracts might be offered and delivered that it is highly unlikely private coverage will be offered. Nonetheless the Chaoulli decision put governments on notice, as evidenced by their progress on benchmarks and reduced wait times. Governments may be further stimulated by the fact that a case similar to Chaoulli has been filed in Alberta and another is about to be filed in Ontario. c) Medicare must be modernized to reflect the current reality of the delivery of care. In 1975, just after Medicare was fully adopted, hospital and physician expenditures represented 60% of total health expenditures; as of 2006, this share has dropped by almost one-third to 43%. Over the past two decades, prescription drugs as a proportion of total health spending have doubled from 7% in 1986 to an estimated 14.2% in 2006. While a majority of Canadians have prescription drug coverage from either private or public plans, it is estimated that some 3.5 million are either uninsured or underinsured for prescription drug costs. Looking ahead, we can expect to continue to see a mix of public and private plans and out-of-pocket payments (e.g., co-payments) and greater use of tax policy. This is the experience of most European and other industrialized countries. In Canada and internationally, the prospects for additional health programs funded on a first-dollar basis out of general taxation revenues are slim. However, there is a clear consensus as reflected in the Romanow and Kirby reports on the need for catastrophic prescription drug coverage and a growing concern about how to address the issue of very costly "orphan" drugs for rare diseases, and expensive treatments for common diseases such as breast cancer. In 2003, first ministers committed to having catastrophic drug coverage in place by the end of 2005-06, and while this is one of the elements of the National Pharmaceutical Strategy, little collective action has taken place beyond further study. Similarly a 2003 commitment by first ministers to first-dollar coverage for a basket of short-term acute home care, community mental health and end-of-life care services remains unmet. The issue of long-term care (LTC) of the elderly looms on the horizon as the first cohort of the baby boom generation turns 65 in 2011. Indeed hospitals are already feeling the pinch of a lack of alternative level of care beds. International experience suggests that LTC cannot nor should not be financed on the same pay-as-you-go basis as medical/hospital insurance. Germany has implemented a social insurance approach to pre-funding LTC. In its 2007 budget, the federal government introduced a Registered Disability Savings Plan (RDSP) to help parents of children with a severe disability to ensure their children's future financial security by investing after-tax income on which the investment income will accumulate tax-free. Consideration should be given to implementing a similar program for LTC. (NOTE - to see "Medicare Plus" table -- see PDF) In summary, we must first ensure that the current Medicare system is on sustainable footing for future generations. Second, Canadians must have a measure of certainty that not only will they receive quality care, but that they will receive it in a timely fashion. Third, recognizing the boundaries of our current Medicare program, we must address the terms and conditions under which Canadians will be able to access the broader continuum of care. Finally, it must be recognized that the health policy landscape is not static, a fact of which governments are aware. For example, in its 2007 budget, Quebec announced that former health minister Claude Castonguay will chair a task force to address sustainable health funding. In addition, British Columbia has been holding a "Conversation on Health" with its citizens that will wrap up in the fall of 2007. As the debate on the future of Medicare changes over time, the CMA's policy will continue to be redeveloped and redefined. CMA Board of Directors May 2007
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Policy Summary: Managing the Public-Private Interface to Improve Access to Quality Health Care

https://policybase.cma.ca/en/permalink/policy8826
Last Reviewed
2018-03-03
Date
2007-05-29
Topics
Health systems, system funding and performance
  1 document  
Policy Type
Policy document
Last Reviewed
2018-03-03
Date
2007-05-29
Topics
Health systems, system funding and performance
Text
The Canadian Medical Association (CMA) supports the concept of a strong publicly funded health care system where access to medical care is based on need and not on the ability to pay. Health care services in Canada have historically been funded and delivered by a mix of the public and private sectors. At the present time, approximately 70% of health expenditures are publicly funded from general tax revenues; the remaining 30% are privately funded either through private insurance or out-of-pocket payment. The public-private interface occurs in two key areas: the private delivery of publicly funded services, and the delivery of privately funded services in publicly owned facilities. Drawing on the key issues raised in the CMA's June 2006 discussion paper, It's About Access, this policy summary sets out guidelines for decision-making and policy development for managing the public-private interface within Canada's health care system in order to optimize timely access to high-quality care. Policy Principles The following principles provide a framework for guiding future strategies for managing the public-private interface. 1. Timely access: Canadians should have timely access to medically necessary care and individual recourse should wait times be unreasonably long. 2. Equity: Access to medically necessary care must be based on need and not on ability to pay. 3. Choice: Canadians should have choice of physician; and physicians should have choice with respect to their practice environment. 4. Comprehensiveness: Canadians should have access to a full spectrum of medically necessary care. 5. Clinical autonomy: Any care model should respect the autonomous decision-making within the patient-physician relationship. Physicians must be free to advocate on behalf of their patients. 6. Quality: The public and private health care sectors must be held to the same high quality standards and be independently monitored. To ensure professional accountability, any facility providing medical services must be subject to medical supervision. 7. Professional responsibility: The medical profession has a responsibility to promote the strongest possible health care system that best meets patients' needs. Both public and private sectors have a responsibility to train the next generation of health professionals and to advance knowledge through teaching and research. 8. Transparency: Decisions affecting the mix of public-private funding and delivery must be made through an open and transparent process. Providers faced with potential conflicts of interest have a duty to recognize and disclose them and to resolve them in the best interest of patients. 9. Accountability: The public and private health sectors should be held to the same high accountability standards including clinical outcomes, full cost accounting and value-for-money. 10. Efficiency: The public and private sectors should be structured to optimize the use of human and all other resources. Public-Private Interface Issues In light of the foregoing principles, the CMA has identified several key issues where improved management of the public-private interface could lead to better access to high-quality health care services for Canadians. Implementing a wait-time care guarantee Canadians face increasingly long wait times for necessary medical care, frequently beyond recommended maximum wait times. In the 2004 first ministers' agreement, wait time benchmarks were established for five priority areas in the publicly funded system: cardiac care, cancer care, diagnostic imaging, joint replacement and sight restoration. When care is not delivered within benchmarks, there is no effective "safety valve" to provide recourse. Patients are forced to wait for care in Canada or seek it within the private sector or in other jurisdictions at their own expense. A safety valve is needed to enable Canadians to obtain required care where wait time guarantees cannot be met. Ideally, Canadians would never have to use the safety valve, but its inclusion in Canadian health policy would help restore confidence in the public health system and focus governments upon meeting commitments to provide timely access to care. The Patient Wait Times Guarantee Trust announced in the 2007 federal budget is a positive first step. The CMA recommends that: * Governments work with the CMA and other medical organizations to establish clinically appropriate wait-time benchmarks for all major diagnostic, therapeutic, surgical and emergency services. * Where wait-time benchmarks can be established, governments implement them nationally. * If national wait-time benchmarks are not met, Canadians should be entitled to a publicly funded safety valve whereby the government would reimburse payment for treatment, travel and other appropriate costs if the service is provided outside the home jurisdiction or within the private sector. * When access to timely care cannot be provided in the publicly funded system, Canadians should be able to use private health insurance to reimburse the cost of care obtained in the private sector. Private insurance contracts are now permissible in Quebec for hip replacement and cataract surgery, with the stipulation that the insurer must fund all aspects of the treatment including rehabilitation. At present, it is not clear how this could work in practice in terms of risk rating of either the patient or on the performance of the public system. * In the interest of providing timely care within the publicly funded system, governments must ensure that Canada has sufficient health professionals and infrastructure to meet need. Improving performance measurement, quality assurance and accountability in the public-private interface It is essential that the health care system be accountable to Canadians, in particular with respect to the roles and responsibilities of different levels of government and their delegated agents, such as regional health authorities and specialty boards. Accountability becomes all the more pressing as public-private collaboration expands. There may be a growing role for the private sector in the delivery of publicly funded health care provided that it delivers services in a cost-effective manner. As with the public sector, any private sector involvement in health care must be patient-centered as well as transparent and accountable. Health care services in both sectors must be delivered to the same high standards of quality. In order to achieve this, solid means of quality assurance must be in place to ensure that value-for-money is being received where public funds are used to contract for service delivery in public and private settings and to monitor the impact of privately funded services on the public system. There are currently a number of data gaps that need attention. For example, there is a lack of formal comparative studies of the cost-effectiveness and quality of public and private delivery in Canada based on primary data; there is confusion surrounding the monitoring of quality for uninsured services; and there is uncertainty about the extent of voluntary accreditation of health care facilities in the public and private sectors. The CMA recommends that: * Governments establish uniform requirements and regulation where appropriate for measuring quality of care in both public and private settings, including: a) collection of data on process and outcomes of care; b) reporting of such data on all publicly insured services to regulatory bodies; c) accreditation standards for both public and private service delivery equivalent to those of the Canadian Council on Health Services Accreditation; and d) protection of health information privacy. * Governments and regional health authorities that enter into public-private partnerships do so through an open and transparent tendering process. * Where governments include public-private delivery mechanisms to expand system capacity, they do so with regulation to evaluate quality and cost-effectiveness. * Governments conduct ongoing evaluation of the quality and cost-effectiveness of public-private delivery options. Defining the public health care system and the basket of publicly insured services The delineation of publicly insured services is a fundamental policy issue for governments, health care providers and patients. The publicly-funded health system cannot be expected to meet all needs for all patients; choices must be made and trade-offs negotiated. However, decisions about the basket of insured services have typically been ad hoc and made behind closed doors. The system has also been slow to respond to emerging technologies and shifts in the delivery of care. At the present time the national medicare basket includes hospital and medical services. The provinces/territories also fund additional services at their discretion (e.g., seniors' drug coverage, home care). While this widens the scope of public coverage, it creates disparities in access across jurisdictions, and Canada is often referred to as a "patchwork quilt" in this regard. The CMA recommends that: * There should be ongoing periodic monitoring and reporting of the comparability of Canadians' access to a full range of medically necessary health services across the country. * In keeping with the CMA's 1994 document Core and Comprehensive Health Services: A Framework for Decision-making, there is a need to define a set of nationally comparable, publicly funded core services. The nature of these services should be continually assessed in an evidence-based and transparent manner. The mode of delivery for these services should be at the discretion of local jurisdictions and may involve both the public and private sectors. * Government health insurance plans should give adequate notice when services are to be delisted. Transparency and accountability in the regulation of physician activity within the public-private interface The ability of physicians to choose whether or not to participate in the public health insurance plan has been a key feature of Medicare since its inception. Physicians are willing to accept reasonable limits on their ability to opt in or out of the public health plan to ensure that adequate access to medical services is maintained. In order to achieve this, an effective regulatory framework is required to govern the intersection of public and private health care and there must be concerted effort on the part of stakeholders to investigate the implications of and opportunities to minimize conflicts of interest. When considering options for the delivery of publicly insured services by the private sector, it is critical that the integrity of the public system is maintained and that Medicare remain the cornerstone of Canadian health care. The reality for many physicians is that they must concurrently deal with multiple payers - patients covered by provincial/territorial health insurance plans, injured workers covered by workers' compensation boards and various groups of individuals covered by third-party insurers. Whatever the funding arrangement, the following fundamental characteristics of the physician-patient relationship cannot be altered: * Patients should be able to choose their physician. * Physicians must have freedom to advocate on behalf of their patients. * Physicians should be allowed to have choice in their practice environments, including the right to opt out of the publicly funded system. * It is the duty of providers to recognize and disclose potential conflicts of interest and to resolve them in the best interests of patients. The CMA will work with its divisions and affiliates to develop a code of conduct for physicians who provide services in the private sphere and for those who provide services in both sectors. The CMA recommends that: * Governments should allow physicians to have choice in their practice environments, including the right to opt out of the public health insurance program provided that patient access to publicly funded care is not compromised. This is presently permitted in all jurisdictions except Ontario. * Governments should examine practice arrangements where physicians are able to work in both the public and private sectors so as to maximize the availability of medical services, particularly in situations where there are budget constraints resulting in inefficient use of health human resources and physical infrastructure. * Governments should remove bans preventing physicians from opting out or preventing them from practising in both the public and private sectors where it can be shown that this would improve access to services for the entire population, increase the capacity of the health care system and reduce wait times. Medical education and training Physicians collectively have a responsibility to train future generations. Looking ahead, we may expect to see a continued trend toward the delivery of diagnostic, medical and surgical procedures in specialized facilities that are privately owned and operated. From the standpoint of medical education and training, this raises two issues. First, a significant number of the current complement of clinical teachers may perform an increasing proportion of their work in such facilities, which may have implications for public teaching hospitals. Second, to the extent that the delivery of services may migrate from teaching hospitals to specialized facilities, this may potentially limit the education and training exposure of medical residents. The CMA recommends that: * Physicians must be appropriately trained for the scope of practice in which they are engaged, whether in the public or private sector. * Medical trainees need exposure to all types of practice arrangements across the public-private interface. * Medical trainees need exposure to all areas of clinical medicine, including those areas predominately delivered by either the public or private sectors. * Governments that choose to contract out services to private delivery must ensure that training opportunities include exposure to both sectors. * The CMA, in partnership with medical student organizations, will promote education about the public-private interface and health care funding and delivery issues. Conclusion Canada's health care system is the product of a long-standing partnership between public and private funding and delivery. The interaction between both sectors will continue to be an important dimension of medicare that must be carefully managed. The framework of decision-making principles and recommendations set out in this policy will hopefully enhance debate among stakeholders and the public about future directions for how to best manage the public-private interface. CMA Board of Directors May 2007
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