Winnipeg Free Press - PRINT EDITION
Virtual ward, real results
Doctor, nurse, home-care co-ordinator team up in year-long project keeping elderly, chronic patients in their homes instead of hospital beds
A few years ago, before a series of mini-strokes and Alzheimer's disease robbed her of the ability to speak, Terry Miller pleaded with her husband, Don, to let her live out her remaining years in their North Kildonan bungalow.
"I just love it here," the former army sergeant told her husband, a retired Lutheran pastor.
Don, still spry at 82, has gone to great lengths to grant his 89-year-old wife's wish. With the help of the Winnipeg Regional Health Authority, he's installed an overhead track-lift system and an electric hospital-style bed for Terry, who cannot walk on her own.
His wife receives intensive home care, giving Don 12 hours of respite each week. Occasionally, Terry is placed for brief periods in a personal-care home to give her husband a longer break.
But for the most part, this fragile elderly woman is getting her wish, spending her remaining years in her sunny suburban home -- thanks, in part, to a new medical outreach program being piloted in northeast Winnipeg. The program's early results have been very favourable.
And soon, hundreds of severely and chronically ill Winnipeggers like Terry Miller could live out their remaining days at home, avoiding frequent trips to the hospital and a move to a personal care home. It's an approach to health care that not only holds the promise of better care, but also savings -- a critical consideration given provincial spending on health care topped $5 billion for the first time in this week's budget.
-- -- --
Dr. Paul Sawchuk's old brown leather case looks as though it could have once been used by the avuncular Dr. Marcus Welby, MD of 1960s-1970s TV fame.
Sawchuk, who has practised medicine for 20 years, bought the bag at a second-hand shop to carry his lunch. Now, he uses it when making house calls.
For more than a year, Sawchuk, along with registered nurse Jan Williams and home care co-ordinator Arle Jones, have formed a team that has provided care for 10 chronically ill patients in northeast Winnipeg. The patients, ranging in age from their early 60s to late 80s, suffer from chronic lung or cardiovascular disease or other complex medical conditions. Some have mental-health issues. All have been heavy users of the health-care system.
During a year-long pilot project that ended in February, the team, supported by other staff from the Access River East medical and social services centre on Henderson Highway, created a virtual hospital ward for the 10 clients. Often, Sawchuk and Williams would call on a patient together; at other times, one or the other would visit alone; sometimes all three team members would come calling. The visits usually occurred during regular business hours, Monday to Friday.
The idea, borrowed from the United Kingdom, is that providing medical care alongside home care to certain chronically ill patients can keep them in their own homes longer, improve their quality of life and reduce the need for expensive hospital visits.
The results of the pilot project were so positive, the province and WRHA are looking at forming virtual wards with up to 100 clients each in three yet-to-be-disclosed areas of the city.
During the pilot project, the 10 patients needed to be conveyed to hospital emergency rooms 27 times compared to 64 ER trips for the same patients in the previous 12 months. The results were similarly positive for hospital admissions (10 compared with 25 the previous year) and days spent in hospital (138 compared to 319).
"When those people have medical issues, it's very difficult for them to get to a hospital. They phone ambulances. It can be very challenging for them to access even basic care," said Sawchuk.
Patients and family members were given phone numbers for all three team members as well as the phone number for the Access River East centre. Families were told not to hesitate to call 911 if they felt there was an emergency.
But team members found they could often prevent their patients going to hospital simply by intervening before medical conditions worsened or assuring a client a doctor and/or a nurse would visit them later in the day or the next day.
Sawchuk said a patient with chronic respiratory problems might need fairly urgent, but not necessarily emergency, care. "They would wake up in the morning, feel unusually short of breath, feel that they need something to change. And historically the group of people that we looked at... would go to the emergency department," he said. "Our commitment to them was that if you need an ambulance, phone an ambulance. But if you don't think you need an ambulance quite yet, phone us first and we will see whether we can get you what you need. And if that means a home visit or antibiotics or some sort of other treatment then we will work to provide that for you within an hour or two."
-- -- --
Elderly people suffering from lung disease, heart disease and other chronic illnesses use a disproportionate amount of health-care money. They are big users of hospital emergency departments and often take up hospital beds for long periods while waiting for a vacancy in a personal care home. Given that the population is aging, this group is only going to grow larger.
"They're high users of the health-care system, but they're high users because that's the only option that we've given them," said Réal Cloutier, a senior executive with the Winnipeg Regional Health Authority.
So the province and the WRHA have been looking for new ways to care for chronically ill patients so they can remain at home longer. In a recently negotiated contract with doctors, the province offered financial incentives for family physicians to spend more time with chronically ill patients.
And now, the province is testing the use of multidisciplinary health teams to treat such patients in their own homes.
Cloutier is unsure, at this point, about the precise financial trade-offs in expanding the use of medical/home-care teams. But the current overcrowded state of hospital emergency rooms and wards tells him something needs to be done. "The intent behind (the virtual hospital ward) is a rebalancing of the health-care system," Cloutier said.
While the teams may not save a lot of money, they might prevent hospital and emergency room costs from rising as quickly as they might otherwise. That's especially important as the population continues to age. "Our belief is we can actually improve the quality of care and reduce the dependency on emergency departments and hospital beds," Cloutier said.
-- -- --
A Free Press reporter and photographer tag along as Sawchuk, Williams and Jones pay a visit to the Millers' home.
Don greets the team members like they're old friends. Pointing to Jones, the octogenarian announces: "This young lady, I tell you, I wouldn't mind having her for a daughter!"
Terry is reclining in a special wheelchair in a sitting room. Suffering from late-stage Alzheimer's, she utters a brief distressed cry as Sawchuk approaches her. She is unable to process what his presence means. In a personal care home, with several different people coming and going, that distress would be multiplied many times daily.
Terry has trouble moving herself. She can only walk if aided. She also has trouble swallowing. Her skin is fragile and prone to bed ulcers. She's at risk of various infections. She requires a great deal of care -- both from her husband and from home care workers.
Despite his advanced age, Don is still able occasionally to walk Terry to the bathroom or to a sitting room.
"In a personal care home, she would never walk. That's one of the benefits of his care," Sawchuk said.
Despite the fact she cannot speak, she can still express contentment with her familiar surroundings. Don said when his wife has to spend a short time in a personal care home to give him a longer respite, she is always happy to come home.
"There really is a joy, and she can still express that," he said.
Don said having medical and home care workers come to his home has been a godsend.
"It relaxes me to know I can call them," he said, adding that his wife is traumatized by trips to emergency rooms.
Jones said if the couple didn't have the support of a doctor, nurse and home care system, Terry would likely be in a personal care home. Keeping her at home improves both Terry's and Don's quality of life, she said.
"She's still in her own home. She's still seeing the same yard she saw when she was able to enjoy it," Jones said.
"I think it also improves Mr. Miller's quality of life because of his pride in being able to take care of her. It shows every day."
-- -- --
Sawchuk, Williams and Jones used to work pretty much in separate silos at the Access River East health and social service centre on Henderson Highway.
That was before they were asked to be guinea pigs for a new way of caring for chronically ill people. Since then, they've learned to work together as a team. During their year-long pilot project, they met weekly to compare notes on the 10 patients in their virtual ward.
They met over lunch as the project was something they fitted in around their regular jobs at the clinic. Their regular noon-hour meetings were augmented by impromptu hallway discussions about patients and brief telephone conversations. The collaborative process has meant more work. But the three say it's been rewarding, particularly as they witnessed the positive effect it's had on their patients. (The project is officially over, but the three continue to care for the 10 patients.)
"It's been a very positive experience. It's been really valuable to work as a team because we all kind of bring our different perspectives and approaches," said Williams.
She said the team has gained valuable information about its clients through the home visits.
"The difference of seeing someone actually in their own home... gives us a whole different view of how they function and what their living arrangements are like. It gives you a whole different appreciation for what their challenges are and their successes or supports," she said.
All of the patients in the Winnipeg pilot project had been receiving home care, which is where Jones fits in. As a home care co-ordinator with 130 clients, she's known many of the patients on the virtual ward longer than have her two colleagues. "I loved it," she said of the year-long project. "We need more (virtual wards)."
Republished from the Winnipeg Free Press print edition April 21, 2012 A6
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