By John Muscedere and Fred Horne
When a frail older patient has an acute health crisis in Canada, our health system usually delivers excellent service. That's good news. But health -- and quality health care -- is determined by more than just response to medical emergencies.
The truth is, our health system often fails when it comes to addressing the complex care needs of frail patients between urgent health events. We rarely deliver quality chronic care, comprehensive home care or continuous care, and in particular, poorly handle transitions between care settings and providers.
We also often neglect more cost-effective interventions with proven health and quality of life benefits, such as social supports that can help people age in place.
Our over-emphasis on acute care needs to the consequent neglect of other aspects of the health system has serious consequences -- especially for those who are frail. These consequences include both worsened health outcomes and increased health costs.
The burden of "frailty" in Canada is steadily growing. Today, approximately 25 per cent of those over age 65, and 50 per cent of those over 85 -- over one million Canadians -- are medically frail. In 10 years, well over two million Canadians may be living with frailty.
It's time we improved the quality and quantity of care delivered for frail Canadians.
Frailty is specifically defined as a state of increased vulnerability, with reduced reserve and loss of function across multiple body systems. Frailty reduces the ability to cope with normal or minor stresses, such as infections, which can cause rapid and dramatic changes in health.
Frail people are at higher risk for worsened health outcomes and death than we would expect based on their age alone. Frailty isn't simply about getting older. The risk of becoming frail increases with age, but the two are not the same.
Why does the concept of frailty matter?
Frail Canadians are the major consumers of health care in all settings. Of the $220 billion spent on health care annually in Canada (11 per cent of GDP), 45 per cent is spent on those over 65 years old, although they only represent 15 per cent of the population.
In spite of higher utilization of health-care resources for those who are frail, many current therapies have not been evaluated in this population and we don't know if they are beneﬁcial, cause harm, are cost-eﬀective or waste scarce health-care resources.
Are we over-treating frailty in some instances with ineffective, burdensome therapies and tests, yet not providing adequate social and medical supports in other areas? The evidence suggests the answer is almost certainly yes.
It's time we improved the quality and quantity of care delivered for frail Canadians -- and improve the health system for everyone in the process. Here's how it can be done.
First, we need to break down silos of care based on single diseases, single organ failure, settings of care or clinical disciplines. Addressing frailty requires a coordinated, multidisciplinary approach. Instead of having multiple specialist appointments and replicating tests across different facilities, we could have "one-stop shops" that cater to the needs of patients, not providers.
Secondly, we need to address the needs of Canada's frail elderly in a more equitable health-care system across the country. As we outlined in our recent brief submitted to the Finance Committee 2017 pre-budget consultations, this can be accomplished by establishing a Health Accord funding model based on age and considering frailty instead of the current per capita funding model.
Funding enhancements should be directed towards strengthening primary health care along with social and economic supports. Most frail adults live in the community; strengthening primary care and community supports are crucial to help them age in their preferred settings.
Thirdly, we need to provide patients, clinicians and health-care system decision makers with high-quality evidence on the effectiveness of treatments in those who are frail. Most clinical research systematically excludes both the very sick and the elderly. Without evidence, aggressive and expensive therapies are often over-used without improvement in outcomes resulting in poor quality of life and wasted health-care resources.
Finally, we also need to improve the recognition and assessment of frailty in our health-care system to aid in the implementation of more appropriate care plans including better medication management and advance care planning.
To better address the health care needs of our aging population, we need to recognize that not all aging is the same. By identifying the most vulnerable of our aging population or those who are frail, we can institute appropriate care plans along with improved supports thereby improving outcomes, quality of life and health-care resource utilization.
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