PART TWO: OTHER INNOVATIONS IN HEALTH CARE

During the course of its study, the Committee received testimony from witnesses about other types of innovation occurring in health care delivery, as well as the training of health care professionals and health human resource planning. Part two summarizes this testimony and presents the Committee’s findings in these areas.

The Committee heard from witnesses that many innovations are occurring in health care delivery across Canada, as well as in some other jurisdictions, in three main areas: primary health care, acute care and public health. These innovative models of health care delivery and the Committee’s observations and recommendations are presented in the sections below.

1. Innovation in the Delivery of Primary Care.

i. Multi-disciplinary Health Care Teams

The Committee heard that new models of primary health care are being established across the country. For example, with respect to multi-disciplinary health care teams delivering primary care,[237] the Committee learned about the Clinique multi-disciplinaire en santé at the Université du Québec à Trois-Rivières, which was established to provide students with multidisciplinary clinical training experiences. The clinic covers three disciplines, including occupational therapy, speech therapy and health care. The clinic provided students in these disciplines the opportunity to work in a clinical setting while being supervised by more experienced health practitioners and physicians. In addition, the Committee heard that the clinic was established to reflect and meet the needs of the local population, which included children from early childhood centres, schools and social paediatrics who often did not have access to occupational and speech therapy services.

The Committee heard from witnesses that multi-disciplinary teams and collaboration between health professionals in clinics has been found in some studies to improve quality of care, though some challenges remained, such as power struggles between different health professions.[238] They therefore recommended that the federal government support inter-professional training and education through targeted programs in collaboration with universities, as well as examine along with Canada Health Infoway Inc. how health information technology could be used to further enhance collaboration between health care providers.

ii. The Social Primary Care Model

The Committee also heard about innovative approaches for improving the health of vulnerable communities through the adoption of the “Social Primary Care Model.” According to representatives from the B.C. Healthy Living Alliance, the Social Primary Care Model is a model that delivers health care to hard‑to-reach and disadvantaged communities through the establishment of links between those communities and health care systems.[239] For example, the Social Primary Care Model embeds nurse practitioners in community settings, including schools, day cares, and community centres to act as a point of care contact between these communities and tertiary and specialist services. They also partner with Social Services Agencies/NGOs to work together to address social determinants, such as housing and food insecurity, that have an impact on the health of the community. Under the Social Primary Care Model, communities are also welcome to engage in discussions with health care providers to identify emerging health concerns, as well as ask questions and make suggestions.

The Committee heard that Dr. Judith Lynam, from the University of British Columbia School of Nursing, has conducted research evaluating this model and has found that it fosters access to health care for families facing many disadvantages and was succeeding in reaching people, including children with developmental and mental health challenges, whose health needs were not previously being addressed.[240] Dr. Lynam also found that these families were no longer going to emergency departments to receive primary care and an acute exacerbation of chronic illnesses were also being avoided, providing cost savings to the health care system.

Given the benefits of this health care model, representatives from the B.C. Healthy Living Alliance recommended that the federal government work with the provinces and territories to expand the model to other communities through the provision of research and practice grants.[241] Furthermore, they also recommended that the federal government identify best practices and lessons learned in the development and implementation of innovative primary care models across the country funded through its Health Innovation Fund, which was part of the 2004 Health Accord. According to these witnesses, an evaluation of different primary care models would help to promote their adoption across the country.

iii. The Patient’s Medical Home

The Committee also heard about Dr. Christopher Fotti’s Pritchard Farm Health Centre, which is a new family practice clinic that has nine family doctors with different specialities.[242] Consequently, patients have access to physicians with different areas of expertise in one location. Moreover, the physicians themselves are able to consult both formally and informally with their colleagues on the spot. The clinic also has diagnostic services located next door, which are linked electronically to its computer systems. The Committee heard that some of the doctors working at the clinic also worked in acute care settings, which smoothed transitions for patients between primary and acute care. Furthermore, the group practice model meant that the clinic is able to offer same day and after hour appointments.

The Committee heard that the clinic had been established following a model developed by the College of Family Physicians of Canada called “The Patient’s Medical Home.”[243] According to the College of Family Physicians of Canada, this model is a family practice defined by its patients as the place they feel most comfortable to present and discuss their personal and family health and medical concerns.[244] It serves as a central hub for the timely provision and coordination of a broad range of health services provided by a team or network of providers, including nurses, physician assistants located in the same physical site or linked virtually through different sites in the community.

iv. Integrating Complementary and Conventional Medicine

The Committee heard about another model of care seeking to integrate complementary and conventional medicine within a community clinic setting.[245] Approximately 40% to 80% of cancer patients, particularly breast cancer patients, seek the services of complementary practitioners to improve their quality of life as they undergo conventional therapies such as chemotherapy and radiation. The Committee heard that the Ottawa Integrative Cancer Centre is a multidisciplinary community clinic that includes: naturopathic doctors, medical doctors, acupuncturists, physiotherapists, counsellors and a nutritionist that was established to provide treatment and support for patients undergoing conventional cancer treatments at the Ottawa Hospital Cancer Centre. These treatments and supports include facilitating post-operative healing and controlling the side effects associated with chemotherapy and radiation. Supported by the Ottawa Regional Cancer Centre, as well as CIHR, the Committee heard that the Ottawa Integrative Cancer Centre is also working with the Ottawa Hospital Research Institute to evaluate the benefits of complementary medicine in relation to cancer patient outcomes, including recurrence and mortality rates.

v. Health Co-operatives[246]

Witnesses also highlighted the establishment of health co-operatives across Canada. The Committee heard that there are approximately 120 health cooperatives in Canada, which are located primarily in Quebec, but also in Manitoba, Saskatchewan, British Columbia, New Brunswick and Nova Scotia. Witnesses from the Conseil canadien de la coopération et de la mutualité explained that health care co-operatives are collective enterprises that provide infrastructure and resources for the provision of services, which promote, maintain and improve the health and living conditions of communities. Its members are involved in both the organization and management of these services. Members agree to fund the co-operative’s operations through qualifying shares, annual contributions and donations. These witnesses explained that health co-operatives had been established to ensure that communities have on-going access to health care in their communities. Located in mostly rural and remote communities, 46% of health co-ops were established because the local community health clinic was closing, while 54% of new health co-ops were established to bring new services to the community, such as home care, telehealth and prevention services to targeted populations such as First Nations and Inuit communities. In order to promote the establishment of health co-ops across Canada, these witnesses recommended that the rules regarding contributions to co-operatives be clarified, as well as allow these contributions to be claimed as medical expenses.

2. Innovations in the Delivery of Acute Care

i. Use of Physician Assistants

The Committee also heard from witnesses about different efforts to improve the efficiency and performance of acute care settings. For example, surgery wait times for hip and knee surgeries are being addressed by the Concordia Joint Replacement Group by increasing the productivity of surgeons through the employment of physician assistants. The assistants help with the positioning, prepping, draping and closure during hip and knee surgeries.[247] The use of physician assistants frees up the surgeon earlier, in turn allowing the surgeons to begin surgery in an adjacent room that was already prepared for surgery by other physician assistants. The Committee heard that the employment of physician assistants has resulted in a 42% increase in the volume of surgeries and an associated drop in wait times from 44 weeks to 30 weeks. Dr. Rob Ballagh, a surgeon appearing before the Committee as an individual, also explained that the Canadian military is also using physician assistants, called physician extenders, who have specialized medic training and work under the supervision of physicians.[248] The use of physician extenders is helping to address the shortages of physicians in the military.[249]

ii. Adoption of Lean Approaches

The Committee heard that acute care settings are adopting “lean” practices to improve the efficiency and performance of acute care settings. Lean is defined as a “patient/client-focused approach to identifying and eliminating all non-value adding activities and reducing waste within an organization.”[250] Value-adding activities are those the client/patient is willing to pay for, either directly or indirectly through taxes, as in the case of the health care system. “Lean” is a philosophy or mindset that has been borrowed from the manufacturing sector. For example, the Committee heard that in its adoption of “lean” thinking, St. Boniface Hospital had focused on narrowing its strategic priorities from 15 to 4 in order achieve better results in those areas.[251] The hospital holds multiple improvement events per month, in which frontline staff and managers get together to develop ways to solve a particular problem. These applications of “lean” thinking have increased patient satisfaction, increased the engagement of staff, as well as reduced its hospital standardized mortality ratio by 30%. The Committee heard that St. Boniface Hospital had succeeded in improving their financial performance by 1%, which resulted in $3 million worth of savings.

The Committee also heard that the Concordia Joint Replacement Group had also adopted “lean” thinking to improve hip fracture care by tracking where the delays in surgery were and identifying solutions to address bottle necks in the system.[252] These efforts have reduced surgery wait times for hip fracture patients to 1.8 days, the length of stay has decreased to 25 days and the in-hospital mortality ratio has declined to 5%. Because of the increases in efficiency and performance of acute care settings associated with the adoption of “lean” practices, one witness recommended that a learning centre for the use of “lean” thinking in health care be established in Canada for health care leaders. Another witness suggested that different hospitals or health regions could focus on developing models in their areas of expertise, such as chronic disease management or emergency department management, which could then be shared across jurisdictions. One witness identified the importance of tracking and measuring outcomes through the use of databases to both identify problems within the system, as well as ensure that changes in the system were having an impact.

iii. A Virtual Hospital Ward[253]

The Committee heard from Dr. Danyaal Raza from the Canadian Doctors for Medicare about a virtual ward project in Toronto that is allowing patients to receive hospital care and supervision at home. Patients who are at high risk for being readmitted to a hospital are virtually admitted into the hospital while they are at home. They are provided with around the clock care at home, which is similar to that found in a hospital. As virtually admitted patients, they are able to call their care team with any concerns until they are transitioned over to their regular doctor. This system helps keep patients physically out of the hospital, while connecting them to community care and preventing them from falling through the cracks. In order to promote these types of innovations in the delivery of care, Dr. Raza also recommended that the federal government play a leadership role by sharing best practices in new models of care. He further explained that this sharing could be done by establishing a national body that looks at innovation from a national perspective. He suggested that the Health Council of Canada, which is currently tracking some best practices in health care delivery through its innovation portal, could be given a broader mandate and funding to help identify and scale up best practices and innovations across the country.

iv. Out-of-Hospital Surgery Clinics[254]

Dr. Emad Guirguis from the Lakeview Surgery Centre described to the Committee how acute care could be delivered outside a hospital setting, including the performance of surgeries and general anesthetic procedures. Dr. Guirguis explained that his accredited facility provides services that are considered medically necessary services under the Canada Health Act, such as hernia operations and breast cancer surgery, as well as those that may not be covered, such as laparoscopic gastric banding surgery for persons who are obese. The Committee heard from Dr. Guirguis that some jurisdictions, including Ontario, are currently considering contracting-out some types of surgeries (that do not require patients to be fully hospitalized) to out-of-hospital surgery facilities, which could conduct them safely and efficiently and reduce pressures on hospital operating rooms.

v. Use of Funding Models to Improve Access to Care[255]

The Committee heard from Dr. Jason Sutherland from the Centre of Health Services and Policy Research at the University of British Columbia that adopting new models for the funding of health care delivery could create incentives for hospitals to improve access to care and decrease wait times for surgeries. The Committee heard that British Columbia has begun to implement activity-based funding for elective procedures. Activity-based funding is funding that is provided to hospitals to target certain areas such as increasing the volume of elective surgeries in particular areas (e.g., cataract or knee surgery). Dr. Sutherland explained that Ontario is adopting a model that provides financial incentives to providers that are implementing evidence-based practice for the care of chronic conditions. Tying financial incentives to the quality of health care is known as quality-based procedures. The Committee also learned about bundle payment schemes being implemented in the United States, which focus on bundling payments for combined services offered by different health care settings, such as home and acute care, to promote seamless transitions between these different delivery systems for patients. In addition to calling for a national clearing house for best-practices in health care delivery, Dr. Sutherland also recommended that the Canadian Institute for Health Information develop data sets to evaluate innovations in the delivery of health care, in particular data sets that focus on patient outcomes. From his perspective, these data are necessary to evaluate innovations in health care delivery.

3. Innovations in Public Health[256]

The Committee also heard about an innovative public health strategy to address the HIV epidemic in Canada. According to research conducted by the B.C. Centre for Excellence in HIV/AIDS, the use of antiretroviral therapies, which are used in the treatment of HIV/AIDS, could be used to help prevent the transmission of the disease because they reduce the amount of the virus circulating in the blood to undetectable levels. The Committee heard that the use of antiretroviral therapies in the treatment of HIV/AIDS has reduced the number of new HIV infections in British Columbia by 40%. Similarly, the Centre also found that the treatment of mothers with antiretrovirals prevents the transmission of HIV to their babies by nearly 100%. Consequently, the Government of British Columbia has adopted a new strategy called “seek and treat,” which seeks to facilitate and normalize the testing of individuals for HIV, as well as provide them with antiretrovirals to prevent further spread of the disease. As a result of these efforts, the Committee heard that HIV morbidity and mortality have decreased in the province by more than 90% and the number of new HIV infections has been reduced by more than 66%. By reducing the number of new cases of HIV, this strategy is also providing cost savings to the health care system, as the average cost of HIV treatment per patient is $15,000. As the incidence of HIV is increasing rapidly in other parts of the country, including Manitoba, Saskatchewan and Newfoundland and Labrador, there is a need to adopt a national strategy focusing on HIV testing for the general population.

The Committee also heard from Dr. Thomas Kerr from the B.C. Centre for Excellence in HIV/AIDS that other public health measures could be adopted to address the HIV epidemic in Canada, including abstinence-based and harm reduction programs for injection drug users, who represent the highest proportion of new cases of HIV/AIDS. The Committee heard that these programs have reduced the HIV infection rate among injection drug users in Vancouver from 19% to 1%.

4. Innovations in Health Care Delivery in other Jurisdictions[257]

In his appearance before the Committee, Mr. Ray Racette from the Canadian College of Health Leaders articulated that Canada could look to other jurisdictions to identify ways in which it could improve the overall efficiency and performance of its health care system. He suggested that Canada examine Sweden’s health care model. He explained that the Swedish health care system prioritizes primary care; adopts lean practices to improve backlogs in hospitals; undertakes major efforts to promote care for the elderly in the home rather than in institutions; includes patient safety and quality in national priorities; and makes efforts to engage consumers in the health care system by providing them with choices. Furthermore, the Committee heard that Sweden’s health care system also insures a broader basket of goods, including dental care for the young and elderly, home care and a national pharmacare program. In order to gain insight into health care delivery in another federal state, Mr. Racette suggested that Australia’s health care model be examined, in particular its decision-making structure, which includes a Standing Council on Health which is made up of federal and state ministers of health and Health Ministers Advisory Committee, which works collaboratively to develop national health care priorities.

5. Committee Observations and Recommendations

The Committee’s study revealed that many innovative models of health care delivery are occurring across the country, many of which focus on the collaboration among different health professionals, as well as the integration of different sectors of the health care system. Witnesses felt that the federal government has a role to play in identifying, evaluating and sharing best practices in health care delivery from both Canada and other jurisdictions. Based upon these observations, the Committee therefore recommends that:

22. The Government of Canada take note of the innovative models of health care delivery outlined in this section of the report.