Canada’s coming of age: How demographic imperatives will force the redesign of acute care service delivery

Older adults represent the fastest growing age group worldwide. In Canada there were 4.3 million Canadians age 65 and older in 2002, a 66% increase over the last 20 years.[1] This demographic imperative will continue into the future with the 65-and-older population in Canada set to double in the next [2] decades while the 85-and-older population will quadruple.

The International Monetary Fund (IMF) warned in a recent report that the toll of aging on G20 nations will be 10 times that of the current financial crisis.[2] Furthermore, the IMF already considers Canada’s ratio of aging costs to be one of the highest in the world. Clearly the massive demographic transformation that is already underway will place unprecedented pressure on the Canadian health care system. 

Although some commentators have warned against “apocalyptic demography,” few have grasped the complexity of illnesses and social challenges that many older adults face and the challenges this aging demographic will pose for our current health care delivery systems.

Older adults drive health service utilization and health costs in Canada. Older adults tend to consume more expensive types of health care services, particularly in the acute care setting, when compared with younger cohorts. People age 65 and older accounted for 13.2% of the Canadian population but consumed an estimated 44% of provincial and territorial government health care spending in 2005.[3] 

Furthermore, population aging alone is increasing provincial and territorial government health care spending by an additional 1% per year.[3] In 2005, per capita health care spending was found to be highest at the beginning and at the end of life but, in general, to increase exponentially with age. 

While 65- to 74-year-olds consumed $6000 per capita, 75- to 84-year-olds consumed $11 000 per capita, and 85-year-olds (and those older) consumed $21 000 per capita, on average. In comparison, per capita health care spending among those age 1 to 65 was approximately $1700.[4]

Current provincial governments must manage resources in the face of an economic recession. This puts downstream pressures on health system administrators at the regional and provincial levels to consolidate services with the explicit agenda of reducing health care costs. In such an atmosphere, the opportunity for innovation in health service delivery becomes limited to simply “doing the same with less.” 

With annual per capita growth rates in acute care costs increasing the fastest for older adults,[3] and given that this growth rate is expected to continually increase, it is imperative that we increasingly focus our efforts on developing new cost-conscious models that are also able to meet the complex needs of older patients within acute care settings.

It has long been recognized that the way in which acute hospital services are currently resourced, organized, and delivered often disadvantages older adults with chronic health problems.[5] In addition to being costly, we are increasingly coming to understand how the quality of care provided in acute care hospitals and the loss of homeostatic reserve experienced by many older adults render many older patients particularly vulnerable to the stress of acute illness and the high-risk environment of the acute care hospital setting. 

The rates of iatrogenic complications such as falls, delirium, adverse drug events, functional decline, being discharged to a long-term care facility, and death are higher in older patients in part due to their higher rates of comorbid illness, polypharmacy, and tendency to require longer hospitalizations.[6] 

All of these factors help to explain why one in every three older adults discharged from an acute care episode currently leaves functioning at a higher level of disability than when they entered, with half of these individuals unable to ever recover what function they lost.[7]

There is need for reform in primary care, but older adults will still require hospitalization for chronic conditions and their acute exacerbations, even under the best of circumstances.[8] Therefore, there is an opportunity to reduce disease burden, promote health, and ultimately improve access and capacity through the development, linkage, and implementation of innovative care models within acute care settings. 

Early attempts made to provide guidance to hospitals on establishing geriatric services often relied more on compelling anecdotes than compelling evidence[9-11] and rarely demonstrated their efficacy. However, research over the past 2 decades has improved our understanding of risk factors for adverse outcomes and effective interventions that can prevent such outcomes.

Implementing specific point-of-care interventions and models of care in single care locations of a hospital such as the emergency department,[12-14] inpatient,[15,16] transitional, and outpatient care[17] settings can improve overall care outcomes and reduce lengths of stay, admissions, readmissions, and inappropriate resource utilization—thereby improving the overall capacity and efficiency of the system. 

However, implementing innovative models of care that challenge deeply ingrained traditional ways of providing care has proved to be a significant challenge.18 Nevertheless, now more than at any other point in Canada’s history is there an imperative, with significant social and economic implications, that will require us to develop comprehensive evidence-based care strategies to improve the care of older adults in need of acute care. And given that 60% of current hospital expenditures are directed to the older population, even small improvements can have important health, social, and economic benefits.

The way forward is to develop an innovative, evidenced-based, comprehensive, proactive, and responsive elder-friendly hospital service delivery model that integrates inpatient, outpatient, and emergency department care strategies across a single setting and promotes interprofessional collaborative practice. 

While this may sound logical and obvious, we are not aware of any studies that demonstrate the implementation and cumulative effect of an integrated strategy across all the care settings within an acute care hospital. Finally, few studies have attempted to consider the model of care as an important element of elder-care transformation. These are all gaps that need to be addressed.

So how are we moving this agenda forward? The Care of Older Adults with Acutely Compromised Health Research Network (COACHNet) is a newly formed national network of health and social care researchers from five provinces (British Columbia, Alberta, Ontario, Quebec, and Nova Scotia) that have committed to work together to address the complexities of caring for older adults in acute care settings and across the continuum of care. 

Through the network’s multifaceted 10-year research program we plan to transform current traditional paradigms of hospital care by developing, implementing, and demonstrating the wide-ranging benefits that an elder-friendly hospital integrated service delivery model can contribute toward optimizing the outcomes of hospitalization for older adults. 

In this manner, COACHNet will be the long-awaited but necessary step that can help ensure the greater efficiency and capacity that is needed and that can be developed and sustained within the existing acute care system to meet current and future demands for hospital care by all Canadians.

Acknowledgments
The authors would like to thank Bruce Leff, MD, for his thoughtful review of the manuscript.

References

1.    Statistics Canada. A Portrait of Seniors in Canada. 2007.
2.    Milner B, Scoffield H. The growing cost of an aging world. The Globe and Mail. 8 July 2009.
3.    Canadian Institute for Health Information. The Cost of Hospital Stays: Why Costs Vary. Ottawa: CHI; 2008.
4.    Canadian Institute for Health Information. Hospital trends in Canada—Results of a Project to Create a Historical Series of Statistical and Financial Data for Canadian Hospitals Over Twenty-Seven Years. Ottawa: CHI; 2005.
5.    Thorne, SE. Negotiating Health Care: The Social Context of Chronic Illness. London: Sage Publications, Inc; 1993.
6.    Brennan TA, Leape LL, Laird NM, et al. Incidence of adverse events and negligence in hospitalized patients. Results of the Harvard Medical Practice Study I. N Engl J Med 1991;324:370-376.
7.    Covinsky KE, Palmer RM, Fortinsky RH, et al. Loss of independence in activities of daily living in older adults hospitalized with medical illnesses: Increased vulnerability with age. J Am Geriatr Soc 2003;51:451-458.
8.    Siu AL, Spragens LH, Inouye SK, et al. The ironic business case for chronic care in the acute care setting. Health Aff (Millwood) 2009;28:113-125.
9.    Coakley D (ed). Establishing a Geriatric Service. London: Croom Helm; 1982.
10.    Eisdorfer C, Maddox, GL. The Role of Hospitals in Geriatric Care. New York: Springer; 1988.
11.    Persily NA (ed). Eldercare: Positioning Your Hospital for the Future. Chicago, IL: American Hospital Publishing, Inc; 1991.
12.    McCusker J, Verdon J, Tousignant P, et al. Rapid emergency department intervention for older people reduces risk of functional decline: Results of a multicenter randomized trial. J Am Geriatr Soc 2001;49:1272-1281.
13.    Mion LC, Palmer RM, Meldon SW, et al. Case finding and referral model for emergency department elders: A randomized clinical trial. Ann Emerg Med 2003;41:57-68.
14.    Leff B, Burton L, Mader SL, et al. Hospital at home: Feasibility and outcomes of a program to provide hospital-level care at home for acutely ill older patients. Ann Intern Med 2005;143:798-808.
15.    Inouye SK, Bogardus ST Jr, Baker DI, et al. The Hospital Elder Life Program: A model of care to prevent cognitive and functional decline in older hospitalized patients. J Am Geriatr Soc 2000;48:1697-1706.
16.    Landefeld CS, Palmer RM, Kresevic DM, et al. A randomized trial of care in a hospital medical unit especially designed to improve the functional outcomes of acutely ill older patients. N Engl J Med 1995;332:1338-1344.
17.    Naylor M, Brooten D, Campbell R, et al. Comprehensive discharge planning and home follow-up of hospitalized elders: A randomized clinical trial. JAMA 1999;281:613-620.
18.    Rockwood K. What Does an ACE Unit Trump? Can J Geriatr 2006;9:192.

hidden

Dr Sinha is the Erickson/Reynolds fellow in Clinical Geriatrics, Education, and Leadership at the Johns Hopkins University School of Medicine. Dr McElhaney is the Allan M. McGavin chair in geriatrics research and chair of the Division of Geriatric Medicine at the University of British Columbia. Dr Rockwood is the Kathryn Allen Weldon professor of Alzheimer Research and the chair of the Division of Geriatric Medicine at Dalhousie University.