Riding the Grey Wave
How U of T Medicine is helping Ontario prepare for an aging population with complex health needs.
BY PIPPA WYSONG
Ontarians are getting older, faster.
By 2016, for the first time, there will be more seniors in Ontario than children. By 2036, the number of seniors in the province will have more than doubled from 2 million in 2012 to almost 4.2 million.
Canada’s biggest province isn’t alone. In many industrialized countries, an aging and growing population is putting strain on economies, pension plans and public health programs.
Health care professionals are doing their part to ensure that elderly people have what they need to live long, healthy lives, but it’s a tremendous challenge — one that faculties of medicine, in-cluding ours at the University of Toronto are working hard to address.
As we age, many of us will develop complex conditions. For instance, we may find ourselves facing diabetes, mobility issues due from arthritis and heart disease at the same time. Complex diseases require more complex care, so people struggling with a variety of conditions need care from a variety of services —ranging from treatments from specialist physicians to rehabilitation specialists to nurses. They may also need help at home, and transportation around town.
Making sure that people get this kind of integrated care is one of the goals of Building Bridges to Integrate Care (BRIDGES) established and co-led by the Departments of Medicine and Family and Community Medicine with support from the Ontario Ministry of Health and Long Term Care. The series of evaluative projects are seeking new ways to help integrate existing programs and services to give people seamless access to health care and provide the evidence to support these new directions. They’re conducting nine different multidisciplinary and multi-agency studies addressing different aspects of care and services for people with complex diseases.
“All the various health and community services that people need have evolved independently to address specific needs and work under separate organizations and institutions. Services are fragmented making them inefficient and more costly overall than they need to be,” says Onil Bhattacharyya (PhD ’07), Associate Professor in the Department of Family and Community Medicine and co-Principal Im-plementer of BRIDGES.
“The best estimates we have say that Ontario could save between $4 and $6 billion a year by eliminating redundant services, improving coordination and providing more appropriate services.”
There are gaps in the system as well as overlap. For example, some people may cycle between inpatient and outpatient care as well as support from community services. BRIDGES helps correct these problems by integrating services, which reduces costs in the health care system and makes the system work better for patients and providers alike.
“The best estimates we have say that Ontario could save between $4 and $6 billion a year by eliminating redundant services, improving coordination and providing more appropriate services,” says Bhattacharyya.
“Our goal is to develop and test different models of care to help these higher-risk patients so we can reduce their need for hospitalization and improve their overall quality of care,” he said. Once the evidence shows which models work best, they can be scaled-up and rolled-out across the province. This is where Samir Sinha, an Assistant Professor of Medicine and Director of Geriatrics at Mount Sinai Hospital, comes in.
Sinha has been testing alternative ways of integrating services and care in different communities as part of an overall Acute Care for Elders (ACE) strategy at Mount Sinai. One new approach he is lead-ing is the 24-bed ACE Unit, which opened its doors in 2011.
Through ACE, patients are treated for their medical problems in the hospital where a team of specialists and caregivers work together to determine their social and functional needs — and ensure they get the right supports and services when they are discharged. Hospital staff work closely with community partners such as the Community Care Access Centre, House Calls and other agencies to deliver the care patients need.
“The approach is working,” says Sinha. “By linking all these systems together with technology and better communication, we are seeing better outcomes for our patients.” The approach also saves money. In 2012–2013, ACE saved the hospital $6.4 million by supporting shorter hospital stays and reducing repeat admissions — all while serving even more patients than before.
The success of these projects led to Sinha becoming the Provincial Lead of Ontario’s Seniors Strategy. He authored the “Living Longer, Living Well” report, which is being used by the Ministry to integrate services and care throughout the province. It’s part of Ontario’s Action Plan for Health Care, which outlines a new direction for revamping the health care system.
Sinha’s recommendations — developed after broad consultation — address financial security, finding primary care physicians and ensuring that community support agencies and family doctors can com-municate better. The report suggests developing more assisted living and supportive housing units so that people with needs can live independently for longer and diversifying the scope of care that can be provided by paramedics — especially in rural communities. The report also recommends allowing long-term care facilities to offer out-patient care to people in the community.
Finally, the report says that geriatrics needs to be a core part of training programs for all health professionals.
“Canada has a shortage of geriatricians, and part of that is because people are not exposed to working with older people in their training,” Sinha says.
So far, the province has already taken action on two-thirds of the recommendations.
“As a result of the programs enhanced by that investment, there was a 26 per cent drop in people aged 75 and over being placed into long-term care facilities,” Sinha says. Waiting lists for long-term care facilities are shorter than they were just three years ago.
Reducing Elderly people’s need for health care services is also an important part of the solution.
Geoff Fernie and Alex Mihailidis (B.AS ’96, MASc ’98) from the iDAPT (Intelligent Design for Adaptation, Participation and Technology) Centre at the University Health Network, Toronto Rehabilitation In-stitute (TRI) are working on doing just that. Researchers at the centre are creating innovative technologies to help people with daily tasks, mobility issues and communication.
Hidden away on University Avenue, iDAPT is a series of labs, workshops and offices located two-and-a-half stories above ground and five storeys underground. The facility has a series of rooms that allow researchers to model everything from someone’s apartment to a hospital room to an outdoor environment. The rooms and equipment allow researchers to mimic everyday environmental challenges faced by older people.
“For the aging person, we are working on three fronts,” says Fernie, who is a Professor in the Department of Surgery and the Institute of Biomaterials and Biomedical Engineering and Vice-President Research at TRI. “Prevention, rehabilitation and independent living.”
One example of prevention is a new method researchers have developed to rate the safety of footwear on ice. After testing various boots and shoes on an icy surface in one of their labs, they discovered the key to staying upright in winter is the material used for a shoe’s sole, not the tread.
The team is now inviting shoe manufacturers to send shoes for testing so they can offer labels with ratings of how well the shoes grip ice. This ensures consumers can look for shoes that are safer on ice — and prevent falls, says Fernie. He notes that falls account for huge surges of emergency room visits in the winter.
Falls on household stairs are another big source of injuries. Fernie’s team discovered that the standard length of each step is too short and can lead to an increased risk for falls. The Canadian building code will be changed as a result, which should result in three times fewer falls.
Alex Mihailidis is leading a project that will use a small ceiling-mounted device combining a motion sensor, communications system and a computer vision. The system can detect if you fall, and will ask if you need assistance. If you say yes or don’t respond at all), it will call or text family members or neighbours to help — or call 911 directly.
“Together these projects will make the smart home of the future. The technology can be fitted into anyone’s home, will be affordable and will help older people live independently for much longer,” says Mihailidis.
Policy makers worry that the oncoming grey wave — the rapid growth of the number of seniors in the coming years — has the potential to swamp the health care system. Clinicians and researchers at U of T Medicine are doing their part to ensure Ontario can ride that wave by improving the delivery of care — and ensuring care is needed less frequently.
These lessons are not only having an impact in Ontario but are also informing responses in other parts of the world. Sinha’s report has been downloaded over 25,000 times from countries around the globe and has been reviewed across Canada as well as in New Zealand and Singapore.
“Last December, I was invited to present the strategy to the World Health Organization. I’m honoured that they’ve taken such an interest in the report and its principles,” says Sinha.
In Toronto, Sinha and others at U of T continue to influence policy and solve serious problems related to aging.