Homecare, Part 1: “Alone on the Train”
When I woke up in a sweat, I realised why I had this dream. I have been thinking a lot about the gaps we face to provide homecare to a population increasing in need. As a result, these patients, mostly elderly, are institutionalized at high rates (1), separated and isolated from their families and communities, often despite their will. They must feel like I did in my dream: alone, powerless, and scared.
A lot has been written on the importance of homecare to meet the demographic changes facing Canada. As each province has to reform its health system somewhat in ways to meet these demands, the Federal Ministry has appropriately tied some cash transfers to progress made on reforms, thereby setting homecare as a federal priority (2).
Implementation of this agenda has thus far been highly variable, despite the time pressures at hand. In Ontario, responsibility for homecare has recently been transferred to Local Health Integration Networks (LHINs) to address ongoing problems with coordination of care. This has been controversial but has promise at least for one reason: LHINs (and sub-LHINs especially) are by definition interested in linking patients and providers geographically.
This is important. I currently have patients who drive an hour or more to see me, a result of years of difficulty finding a family physician. Unfortunately, I cannot return the favor as they age and need care at home. Thus, continuity of care is interrupted in a dimension that we do not think about often enough in Canada, that of geographic continuity, or the ability to provide service across geographic locations (clinic, hospital, and home) (3). This is surprising, given that Canada is defined by geography.
When I moved my family to London, UK (to study medical geography), we were immediately assigned a clinic within walking distance of our flat. Some may think this is too prescriptive, but we could still choose from a number of providers within that clinic. Certainly, the sheer density of providers in the UK makes this more attainable, but there is no reason that patients in Canada should drive across the city for care. Especially as they age and need services closer to home.
In Ottawa, we have run a number of models using Geographic Information Systems to show that rates of home visits drop off markedly when a patient lives more than five kilometers from their provider. That doesn’t sound like much does it? But considering that we often do home visits first thing in the morning or after clinic in rush hour traffic, those five kilometers may explain a lot. And because, with rare exceptions (Community Health Centres in the province have a geographic mandate, perhaps explaining in part their better outcomes), we may be driving in different directions during an afternoon booked with home visits, those kilometers add up quickly.
We are trying to study this pattern provincially, knowing that even one home visit by a physician makes it much more likely for patients who want to die at home to do so (4). There are probably many other factors at play, but the role of geography cannot be understated.
We are also interested in the role the physician’s home address may have in providing home visits to their patients, but these data are much more difficult to obtain. (If any readers are interested in how one may be able to study this, it would be great to hear from you.)
For now, I have been asking more of my patients (from Hawkesbury, or Carleton Place, or even Kanata—20 kilometers away) what they would want should they need home visits. It hadn’t occurred to them that distance might be such a barrier. We talk about what may be possible (Ottawa is getting a light rail next year, and that will help, but it will still involve getting on a train), and what may lie ahead. Often, older patients talk about wanting to be closer to loved ones. Some have moved away.
Perhaps Ian McWhnney inherently understood all this when he advised us to “share the same habitat as [our] patients” (5). And perhaps the LHINs are listening too: it is very rare for me to be referred a new patient who lives more than that magical five kilometers away.
References:
1. http://www12.statcan.gc.ca/census-recensement/2011/as-sa/98-312-x/98-312-x2011003_4-eng.cfm
2. https://www.canada.ca/en/health-canada/news/2017/04/minister_philpotthighlightssignificantinvestmentstoimproveaccess.html?=undefined&wbdisable=true
3. Kerr J et al. Two new aspects of continuity of care. Can Fam Physician. 2012 Aug; 58(8): e442–e449.
4. Tanuseputro P, Beach S, Chalifoux M, Wodchis W, Hsu A, Seow H, Manuel D. Associations between Physician Home Visits for the Dying and Place of Death: A population-based retrospective cohort study. In press.
5. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2305997/pdf/canfamphys00254-0081.pdf
Photo Credit: Couvrette/Ottawa
