How one hospital is dealing with Canada's aging population

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When universal health care was in its infancy, real estate agent Sharron Baker was a young woman. Now, like the health-care system itself, she is aging and in need of a refit. After cheerfully enduring a decades-long love/hate relationship with her left knee, Ms. Baker, 67, had replacement surgery at Sunnybrook's Holland Orthopedic and Arthritic Centre in downtown Toronto in November.

To a casual observer, the two-hour surgery seemed like a small construction project – retro-fitting the back porch came to mind. The amazing part was watching Ms. Baker show off her dexterity and stamina two days later as she gamely made it up and down a hospital corridor with the help of a walker.

And then she was discharged, thanks to Sunnybrook's Home on Day 3 initiative aimed at getting surgery patients in and out more quickly and freeing up beds in a hospital that, like many in urban Canada, typically runs at more than 100-per-cent capacity.

Leaving hospital so soon wasn't easy for Ms. Baker. Even though she had family support, including moving into a ground-floor bedroom with adjoining bath at her son's home, she found the aftermath gruelling. Recovering from surgery "is a slow process," she says. "They need to spend more time on that aspect."

It's not perfect, but the "day three" program is one solution for the health-care conundrum about who should get hospital beds, how long they should stay in them and who looks after patients when they are released. Sunnybrook, like all hospitals, is faced with a growing number of aging patients who are living longer than ever and coping with more and more complex needs. At the same time, it is being squeezed by budget cuts. And, just like Ms. Baker, it doesn't have much time to recover.

Ms. Baker's short hospital stay and post-operative difficulties are symptomatic of a hospital system that is only just evolving to match the country's changing demographics.

Back in the mid-1960s, when universal health care was instituted, mandatory retirement meant that people quit working at 65. Most of them conveniently died within the next decade.

Now, we never have to retire and life expectancy is heading into the stratosphere. A 60-year-old man in 2013 will live long enough to celebrate his 87th birthday, according to recent figures from the Canadian Institute of Actuaries. His female counterpart will likely reach 90. Whether either will be in robust health is not nearly so certain: Medical successes in combatting rapacious killers such as cancer, heart disease and diabetes means people are living long enough to be afflicted with dementia, depression and other chronic and complex diseases of old age.

In the 1960s, the average age in Canada was 27; now it is 47. "Our interaction with the health-care system tended to be in and out," Deb Matthews, Ontario's Minister of Health and Long-Term Care, says of the past. "If you needed your appendix out, you would go into hospital and get it out and then go home and be healthy again."

Even "getting out," though, meant staying in hospital longer, and there were more family members to help us recover when we did leave. Nowadays, a lot of those expectations have been passed on to patients. We are supposed to keep ourselves healthy and active, and to make arrangements ahead of time for post-operative care when we are briskly wheeled through the revolving hospital door.

Hospitals have no choice but to push more onto patients, because they are overloaded. A survey this week by the Commonwealth Fund ranked Canada last among 11 OECD countries for wait times to see a family physician, an issue that is forcing thousands of patients to head to emergency departments for routine complaints.

Seniors are another problem: Sunnybrook has them stuck in more than five per cent of its beds while they wait for a spot in rehab, nursing homes or community hospitals. And Sunnybrook is not unique. There are more than 2,500 patients, known as bed-blockers, clogging up hospitals across Ontario.

But if there is an escalating problem with capacity and costs now – people over 65 account for almost one-half of every health care dollar spent in Canada – imagine what will happen when baby boomers like Ms. Baker hit old age. Nearly one-quarter of all Canadians, or 7,844,309, people will be over 65 by 2030.

That may sound like a long time away, but change is hard and turning around something as creaky and as beloved as medicare is a monumental dilemma.

No time to waste

The good news scenario is that baby boomers are relatively healthy and mainly determined to stay that way, says Camille Orridge, chief executive officer of the Toronto Central Local Health Integration Network (LHIN), one of the 14 administrative bodies through which funding flows from the Ontario government to health-care providers, including Sunnybrook. "We [she includes herself in the cohort] are not all crashing at 65 the way our parents did," she says.

That gives Canada some flexibility to fix the health-care system before boomers need chronic and long-term care, but there's no time to waste.

"We must identify the problems and find solutions now," Ms. Orridge warns. The next couple of decades, until the earliest boomers reach their mid-80s, offer a respite in which to build the health-care system of the future, she says, one that goes way beyond "acute hospitals" and a "sick-care system."

One potential solution that Sunnybrook is already implementing is telemedicine. It would have been a boon for Ms. Baker, who was dealing with doctors and physiotherapists in one community while recuperating in another.

Once considered a way to bring specialist services to remote communities, telemedicine is now making the patient experience better in urban areas. Who needs to trek half-way across town on a series of streetcars and buses, or fight traffic and pay exorbitant fees in hospital parking lots, to wait for hours in a clinic for a five-minute consultation about your blood tests? Telemedicine connects patients, specialists, primary doctors and home-care workers on a secure form of video conferencing without anybody leaving home or office.

Besides cutting down on the time and anxiety of travelling, telemedicine has an unexpected bonus: Patients like it because they can hear the interaction between specialists and primary-care providers and they can participate in the conversation about their own recovery or treatment.

The only remaining hitch – traditional doctors who are accustomed to billing patients per office or clinic visit and are loath to embrace a newfangled notion such as telemedicine – should be overcome with a new billing code that allows doctors to charge for electronic consultations.

Improved surgery techniques are another huge factor in cutting costs and moving patients in an out of expensive acute-care hospitals as quickly as possible. When colorectal surgeon Dr. Andy Smith began operating at Sunnybrook in the late 1990s, the typical hospital stay for a colon resection was 11 days. Now it is down to three days and it is going to get shorter, he says, because of "minimally invasive surgery, new approaches to pain management" and because "the care that those folks need is being backfilled by home care."

The Sunnybrook knee clinic, where Ms. Baker had her surgery, has cut down on waiting times to see a specialist, increased operating-room efficiencies – as many as four patients a day – and greatly enhanced mobility for a wide range of people, from fortysomething athletes with sports injuries to active boomers who want to stay that way such as Ms. Baker to seniors crippled with arthritis.

Help, at home

But the big issue remains: What happens to patients when they leave the hospital? Home care, the part that was missing from the original medicare formula, is at "the coal face of patient care," according to Barry McLellan, CEO of Sunnybrook.

Ms. Baker's post-operative problems came largely because she fell between the cracks of two regional Community Care Access Centres (CCACs), which were supposed to provide her with follow-up. She couldn't drive, she was in pain, her family doctor wasn't in the loop about her post-operative care and, because she lives outside Toronto, it wasn't convenient for her to go back to the Holland Centre.

At one of Ms. Baker's lowest points, the five-year-old daughter of a neighbour came into her bedroom for a visit. "Are you crying?" the blonde little girl with big blue eyes asked. "Don't worry," she advised. "It will heal. It just takes time."

Charmed, Ms. Baker says, "that little child came and turned my life around." But, she adds, someone should have faxed a form requesting rehabilitation to her local CCAC before surgery.

Dr. McLellan is sympathetic. As a physician he was a trauma leader; as an administrator he is diagnosing and treating a system-wide crisis. Doctors can boast of efficiencies that allow them to turnstile patients in and out of acute-care beds thanks to innovative surgical techniques and enhanced pain medications, but who is going to pick up the slack when those post-operative patients hit the streets?

"More than 50 per cent of my time is spent talking about improving the care in and around the hospital," Dr. McLellan says. "We believe we have a very major role in helping to shape and improve care that is being provided outside the walls of the hospital."

That means working closely with people like Ms. Matthews and Stacey Daub, CEO of the Toronto Central CCAC.

"We are set up to provide specialized care for people who have unique and special needs – be it trauma, cancer, heart, high risk maternal and neonatal – but we also need to be sure that our complex patients are transferred with a really good care plan to another organization, say rehab, or home," Dr. Mclellan says. "That part is incredibly important to our functioning as a hospital."

What we also need, says Ms. Orridge, "are more retirement homes and more assisted-living homes on Main Street, so you can go out with your walker and get your milk and go back home." She didn't add, and be safe and well cared for, but that is the warning coming out of the horrific tragedy in L'Isle-Verte, Que., where a fire early Thursday morning ravaged a senior's home, leaving five people dead and another 30 missing. That "is the other piece about how we address the numbers thing – not just with hospitals."

Ontario hospitals' operating budgets are in the deep freeze – from an era when they were growing at six per cent annually, they are now at zero, even though labour costs are rising by two per cent a year. Home and community care are the only parts of health care in Ontario that are getting an increase in funding because, says Ms. Matthews, "we know that people recover more quickly at home." The top-up this year, including meals on wheels and other community supports, is six per cent, or $260-million in an overall provincial health-care budget of more than $45-billion.

Still, every penny that goes to home care is money that isn't going to hospitals. You'd think that Sunnybrook's CEO would resent that. Not so. The days of hospitals as temples in which august male physicians held court have vanished, if they ever existed.

"We need to make better use of our resources because this wave is coming," says Dr. McLellan.

A future in its past

At Sunnybrook, that wave is already lashing the shoals.

On a cold January morning, Michael Graydon arrives for his music therapy session. Trim in his long-sleeved pewter T-shirt and trousers, he's 91, but with his chiselled profile and slate grey hair, he looks a dozen years younger – a candidate for a Grecian Formula commercial.

But, Mr. Graydon, a retired dentist and a jazz lover, has dementia. When he's agitated, he can't sleep and works out obsessively, doing crunches, planks and sit-ups by the hour; when he's confused, he gets angry and can be verbally and physically abusive, especially if wartime memories – experiences that he never shared with his family – roar to the surface of his damaged brain.

(Michael Gradyon is not the patient's real name. His family requested anonymity because he is unable to give consent.)

Because he's a Second World War veteran who served in a combat zone, Mr. Graydon is entitled to live at Sunnybrook in the Dorothy Macham Home (DMH), a special 10-bed unit that is part of Sunnybrook's veterans' centre and a national model for treating people with severe behavioural issues.

Nobody wants to have dementia – least of all me – but the Alzheimer's Society projects that more than a million of us will suffer from the devastating disease by 2030, the same year that one in four Canadians will be over 65. Watching the sensitivity and kindness with which Mr. Graydon and other veterans are treated makes the prospect so many of us face almost bearable – if we could be so fortunate to find a spot in a place like the veterans' centre.

Mr. Graydon is one of more than 500 veterans living in nursing-home rooms and long-term-care beds at Sunnybrook. They pay less than $1,000 a month for food and accommodation, with the rest supported by an annual grant of $25-million from Veterans Affairs Canada (VAC). Their average age is 91, half of them have dementia and more than 200 are plagued with complex conditions needing continuing medical care. Some, like Mr. Graydon, require constant supervision on a locked ward.

Ironically, Sunnybrook's past may be the nkey not only to its future, but to how all of us should care for an increasingly elderly and infirm population. Founded after the Second World War as a soldier's hospital, Sunnybrook has morphed over the decades into a specialized regional hospital in trauma, stroke, burns, cancer and neonatology, but the geriatrics practised over the decades in the veterans' centre is an important part of its ongoing role as a teaching hospital.

"There is an interesting thing that happens when you care for a cohort," says Jocelyn Charles, medical director of the veterans' centre. A former family physician, she has worked at the centre since 1990. "As they age, their care needs change," she says. "That is different from being a facility in the community caring only for older people."

Over the years, Dr. Charles and her staff have acquired a vast depth of knowledge and experience about geriatrics, skills that could provide a primer in treating an aging population with chronic complex diseases in a changing health-care system.

'Go with the flow'

From the outside, DMH looks like a suburban brick bungalow with gardens and a cedar hedge – which camouflages a fence that keeps patients from wandering away. Dr. Charles likes to tell a story about the veteran who obsessively dug up perennials in the freshly planted gardens; when the landscapers complained, a staff member replied, "but it is his garden."

Instead of restraints and heavy medication, care in the DMH is based on the mantras "go with the flow," and "anticipate the unmet need, whether it is physical, social, emotional, or related to a past experience." These patients may not be here by choice, but we should all be so lucky if we have to be incarcerated – think of Francesco Greco, who was charged with murdering his 87-year-old roommate Francisco DaSilva in a Toronto nursing home in November. There have been 60 such homicides involving seniors in nursing homes across Canada in the past dozen years, according to a CTV W5 investigation.

In the home-like atmosphere of DMH, by contrast, there's a stone fireplace and a nurse's station outfitted like a den, staff adhere to a patient-driven schedule under which veterans eat when they are hungry and sleep when they are tired; the television is controlled so that news of insurgent attacks or suicide bombers won't trigger buried memories and activate post-traumatic stress episodes.

Down the corridor I hear a discordant and low-pitched chanting from a patient's room. "He started singing when we put up the Christmas tree a month ago, and he hasn't stopped yet," explains patient manager Sylvia Buchanan.

"That must be annoying," I say.

The deadpan look on her face is an essay in patience as she steers me back to the dining room. A few of the other patients, oblivious to the man who is stuck like a broken record in the middle of a song, are eating lunch. One of them, a lanky fellow with a shock of white hair tells me at least 10 times in as many minutes how he jumped out of planes behind enemy lines during the D-Day invasion of Normandy. Each repetition is climaxed by a proud flash of his wrist watch, which has Juno Beach 1944 imprinted on its face. I find the performance both haunting and charming because I am awed by his bravery and he reminds me of Matthew Cuthbert in Anne of Green Gables, but I don't have to live with him.

What's next

Few people outside the higher echelons of Sunnybrook and VAC realize that the last of these veterans of the Second World War and the Korean War will die within the next few years. The spacious veteran's facility, with its Inuit art collection, comfortable reception areas, concerts, barbershop and dentist's chair, will no longer be needed and the money will stop flowing from VAC for their care.

"We will continue to support war veterans for as long as they need to be cared for at Sunnybrook," says Sandra Williamson, VAC's director of long-term care and disability benefits. But, "it is not a federal facility, so the future of what happens will be determined by Sunnybrook in consultation with the Ontario Ministry of Health."

Will the lessons learned caring for the veterans be applied to ordinary folk in a rapidly aging country? Could Sunnybrook be a model for other hospitals with veterans' beds across the country? Or will the doors be locked, turning once vibrant facilities into expensive artifacts?

Health Minister Deb Matthews says it is Sunnybrook's responsibility to get together with the LHIN and put together a proposal. And that includes a pitch to cover the $25-million annual shortfall that Sunnybrook currently receives from VAC.

"Is there a fixed plan?" Dr. McLellan asks rhetorically sitting across from me at a meeting table in his sun dappled office. Not yet.

"The worst thing we would want to see are plans to build a new facility because [the government] thinks it will be needed in three, five, 10 years down the road, when we have a facility like that," Dr. McLellan says, nodding his head to indicate the veterans' centre that most of us only know from watching Remembrance Day services on television.

He understands better than anybody that there will be beds open in 2016 unless VAC changes its admission criteria.

The clock is ticking, as it is for the rest of the health-care system.

Follow me on Twitter: @semartin71

We want to hear about health care in your community: What works, what doesn't, and what you think we should do about it. Share your experiences – and ideas for change. Follow @Globe_Health, tweet with #thehospital or email thehospital@globeandmail.com to join the conversation.