Care at Home: Progress (?)

The last sentence of my previous post in October scares me because I really meant to show progress on getting practical home care of frailty going on the Sunshine Coast in a few weeks. It’s a few months and most of the progress is clarification of the significant barriers we face. But I remain doggedly, guardedly optimistic.

I think the most important problem is one shared all over healthcare: not enough doctors. This could seem a bit paradoxical since I believe in many ways we have too many doctors, but until we change how doctors’ time is used and what patients consider “medical”, finding a family physician – let alone seeing a specialist when you could really benefit from one – is still virtually impossible. The good doctors on the Coast who unlike me are working full time are most of them working way more than full time, and are involved in important outside-office tasks like anaesthesia, ER, maternity, and looking after patients in the hospital. It’s no surprise that a lot of these people feel overworked and burnt out and resist anyone looking for more on-call commitment or taking on new, difficult, patients.

Part of our service if it ever gets going will involve a particular extremely effective nurse practitioner who will finish her maternity leave sometime in the summer. We’ve been told by the local administrator there is “no money” to hire anyone, but the current panacea for “attachment” to physicians (and source of funds to cure a variety of other ills that dog the system) called Patient Care Network has a fat budget. This overarching clinical administration is funded by the BC government, but is very limited in its probable practical impact. It looks for the Sunshine Coast like it may after sententious consideration of its woolly goals hire three or four full-time people, available gradually over three or four years. We hope that our wonderful nurse practitioner will be one of those few people, but her employment may be subject to limitations, at best.

We need to share an electronic medical record for our group members to be on-call for one another outside office hours. There is within the health information world an irresolvable conflict of values crying out for compromise but mostly peopled by fundamentalists on one side or the other: confidentiality versus access to information. The several clinics on the Coast have not been allowed to share health information outside their walls, so far.

There’s another irresolvable conflict, and an old one, within family practice which is “We should all be across-the-board generalists” versus “I want to do mainly my special interest: developmental disability, critical care, indigenous health, hospitalism, frailty, mental health, hair transplants” – you name it. Generally speaking with notable exceptions the more rural a family practice environment is the more “generalist” doctors need to be and here on the Coast, with maybe 30 family physicians and situated a helicopter-hop away from a big city we are partly rural partly not. But some doctors arguably legitimately insist that everyone do everything, or a little bit of everything anyway. This fits not-too-badly with what I envision as the eventual care of frailty program, but I’m afraid I’m seen as one of those pseudo-specialist GPs and therefore probably viewed with some suspicion.

Then there’s the pandemic. Enough said.

At the moment we are gearing up to submit an application to a tangle of agencies local and provincial which may give us $100,000 or more to “study” the program we are proposing. Presuming success at that (and there is plenty of money around) the idea of shifting homebound frailty’s priorities from rescue and prevention to comfort and function by offering an alternative to the 911 panic button in crisis might remain alive for maybe another year at least.

I’m not promising an update in a few weeks but will keep my avid readership informed one way or another about all this.

About John Sloan

John Sloan is a senior academic physician in the Department of Family Practice at the University of British Columbia, and has spent most of his 40 years' practice caring for the frail elderly in Vancouver. He is the author of "A Bitter Pill: How the Medical System is Failing the Elderly", published in 2009 by Greystone Books. His innovative primary care practice for the frail elderly has been adopted by Vancouver Coastal Health and is expanding. Dr. Sloan lectures throughout North America on care of the elderly.
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