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Feb 29, 2016
On February 29, the Ontario Lung Association sent the following letter to the attention of Ontario’s Minister of Health and Long-Term Care.
The Honorable Dr. Eric Hoskins
Minister of Health and Long-Term Care
80 Grosvenor Street
10th Floor, Hepburn Block
Toronto, Ontario M7A 2C4
Re: Patients First: A proposal to strengthen patient-centred health care in Ontario
Dear Dr. Hoskins,
Lung disease is accountable for a high proportion of costly hospitalizations, emergency department visits, and other rising health care costs. It would benefit the Government of Ontario to invest further in lung health to support individuals who are affected by lung disease, and to change the trajectory of rising health and economic costs related to lung disease. As such, we are pleased to have the opportunity to respond to the Ministry of Health and Long-Term Care’s discussion paper, Patients First. We applaud the Ministry for taking the time to seek feedback from patients to care providers and stakeholders.
As noted in The Lung Association’s report “Your Lungs, Your Life,” more than 2.4 million people in Ontario are affected by a serious lung disease and this figure is expected to increase to 3.6 million over the next 30 years.i In 2011, direct and indirect costs of lung disease were estimated at $4 billion with the expectation that they will rise to more than $300 billion in 30 years. After cancer and heart disease, it is the third most common reason for mortality in this province and the only chronic disease where mortality is on the rise. Sadly, it is also the only one of the top four chronic diseases without a provincial strategy. Your proposal to address gaps in care and put “Patients First” provides an excellent opportunity to right this wrong.
The Ontario Lung Association supports your proposal to further integrate services at a regional level, however, cautions that a strong provincial framework will be required to ensure evidence-based care is implemented effectively and efficiently throughout the province. The Ontario Lung Health Action Plan, developed by more than 60 stakeholder organizations, provides consistent, evidence-based guidelines that all LHINs can follow ranging from prevention to early identification to treatment and care.
One of the primary recommendations within the Ontario Lung Health Action Plan which will demonstrate immediate results to both patient care and health-care costs, is the addition of Certified Respiratory Educators (CREs) throughout the health-care system. Building on existing infrastructure, our research indicates that a modest investment of $200 per patient, will yield a savings of $1000 per person. CREs are highly trained professionals from a wide range of registered disciplines including nurses, nurse practitioners, respiratory therapists, physiotherapists and pharmacists.
Minister, I would be pleased to meet with you to discuss your priorities and how we might help to fill the existing gaps in health care as they relate to lung health. Only together can we help all Ontarians breathe with ease, because, When you can’t breathe, nothing else matters.™
Thank you for your consideration.
President and CEO, Ontario Lung Association
Ontario Lung Association
The Ontario Lung Association is one of Canada’s longest standing, most respected not-for-profit health promotion organizations and a leader in the prevention and management of chronic lung disease, tobacco cessation and prevention, and air quality and its effects on lung health. We provide education and support to the more than 2.4 million Ontarians who live with lung disease, as well as all Ontarians to help them breathe with ease.
The Ontario Lung Association works with many partners to improve lung health. We are stronger because of the integral involvement of the Ontario Thoracic Society and of the Ontario Respiratory Care Society that both function within the Ontario Lung Association. Together they represent more than 900 health-care providers, including respirologists, family physicians, registered nurses, nurse practitioners, respiratory therapists, pharmacists, physiotherapists, and others. We have worked with these professionals to produce the attached submission. Our response reviews each of the four proposals in the discussion paper and identifies how the Ontario Lung Health Action Plan aligns with the directions presented by the Ministry of Health and Long-term Care.
February 29, 2016
Putting Patients First and Addressing Gaps in Care
In Ontario, approximately 2.4 million people, or 1 in 5, have a serious lung disease. While the largest proportion suffer from asthma, the largest gap in care is likely related to the 870,000 people who are currently living with chronic obstructive pulmonary disease (COPD).ii This number is expected to escalate to more than 1.2 million by 2041. The estimated cost of COPD to the health-care system is more than $3.3 billion. Data published this year by Dr. Walter Wodchis show that in Ontario, COPD is one of the top five reasons for hospitalization of adults between the ages of 18-64.iii
For those over the age of 65, COPD and pneumonia are two of the top five reasons for hospitalizations. Lung disease accounts for a large portion of the pressure on emergency departments and admission to hospitals, particularly during recurrent viral epidemics, such as influenza. Obstructive sleep apnea is also a common, and growing problem in Ontario. Respiratory disease is particularly common in underprivileged segments of our population, including First Nations individuals and people with language barriers. All these people will benefit greatly from an integrated system of care as proposed by the Ministry of Health and Long-Term Care.
1. More Effective Integration of Services and Greater Equity
The proposal to provide care that is more integrated and responsive to local needs by identifying sub-LHIN regions provides an opportunity to more effectively integrate Certified Respiratory Educators within care teams to maintain and enhance evidence-based standards of care, improve access to early diagnosis, and improve patient education, which is essential for effective utilization of respiratory medications, home oxygen, and respiratory devices provided by the Ministry of Health and Long-term Care. The Ontario Lung Association (OLA) has the capacity to make available to local health organizations several such standards, such as the Health Quality Ontario Quality-Based Procedures for COPD, and the Primary Care Asthma Program (PCAP), which was originally funded by the Ministry of Health and Long-Term Care as a pilot project. The latter was proven effective in providing standardized, evidence-based care by utilizing guideline-based tools such as care maps, algorithms and action plans while responding to local needs. PCAP can easily be replicated across all regions of Ontario to provide consistent and non-fragmented care. Quality-based incentive programs could also be introduced to enhance respiratory care at a local level.
Another initiative aimed at health-care integration and implementation of standard, guideline-based care is the Value Demonstrating Initiative on COPD. This demonstration project is a unique collaboration between the Ministry of Health and Long-term Care, the Ontario Lung Association and Innovative Medicines Canada. Three sites are involved in the pilot: an urban centre (Toronto Western Family Health Team), a rural setting (Temiskaming Health Link) and another diverse urban centre (Wise Elephant Family Health Team in Brampton). Early feedback indicates increased use of spirometry for proper diagnosis, increased patient education and improved care coordination.
The Primary Care Asthma Program and the Value Demonstrating Initiative on COPD are but two examples of programs that can:
2. Timely Access to Primary Care and Seamless Links between Primary Care and Other Services
The OLA strongly recommends that adequate human resources be provided to strengthen health care teams. Specifically, we advocate for the addition of a Certified Respiratory Educator (CRE) to each of the sub-regions working with either an existing team or with solo primary care practitioners. The CRE can support a wide range of preventative (e.g., smoking cessation) and complex (e.g., education in management of disease and development of a self-management action plan) care needs, and help be the conduit between patients and other community services.
It is also essential that primary care teams have access to spirometry. Spirometry, a simple breathing test, is used as an important lung health diagnostic tool. This will require the appropriate human resources to perform the test and interpret the results. The CRE’s can perform these tests, and the OLA has a knowledge translation program called the Provider Education Program (PEP) that provides free, accredited workshops on spirometry interpretation.
Increased access to pulmonary rehabilitation is another element that will support lung health patients in the community and address some of the challenges of keeping people out of the hospital. Research shows that less than two per cent of patients have access to pulmonary rehabilitation services in Ontario, despite the fact that Health Quality Ontario has declared it the most effective treatment option for people with COPD, along with smoking cessation.iv
The recommendations highlighted for the integration of the primary care sector within the sub-regions (addition of CREs, spirometry as an essential diagnostic tool, and access to pulmonary rehabilitation) are all an integral part of the Ontario Lung Health Action Plan. We believe these interventions can:
3. More Consistent and Accessible Home and Community Care
The number of people with lung health disease living at home and wishing to stay home for as long as possible is increasing as our population ages. These include people with complex airway and invasive/non-invasive ventilation care needs (for example people with neuromuscular diseases of all ages) as well as persons needing long-term oxygen at home. The need for standardized care and community teams that can respond to and care for people living at home with lung disease is essential, and will allow for more of these patients to stay at home rather than requiring hospital beds.
In some LHINs, there are examples of integrated community care teams that are able to transition people from hospital to home care in a safe and effective manner. For example the London Health Sciences Centre has invested in a registered respiratory therapist as a case navigator to ensure the implementation of the Health Quality Ontario Quality-based Procedures for patients with COPD, and guides patients through the transition from hospital to home.
Establishing adequately resourced teams to support patients transitioning from hospital to home care can:
4. Stronger Links between Public Health and Other Health Services
The proposal to better integrate population and public health planning with other health services and formalizing linkages between LHINs and public health units can have a positive impact, as long as expertise in health promotion and health prevention is not lost or diminished. One challenge of integrating public health more closely with the LHINs is to ensure that at the LHIN Board level the expertise and experience of public health are maintained.
The Ontario Lung Association recognizes the importance of health promotion and prevention, and advocates for the adoption of the Ontario Lung Health Action Plan, a road map that would provide LHINs with strategies that can be adapted to their local areas and would address prevention, health promotion, early identification, treatment and care. The OLA also supports the need for a strong surveillance system related to all lung diseases. The OLHAP recommends prioritizing such a system and ensuring that it is linked to existing provincial and national databases and surveillance systems.
The Ontario Lung Association supports the Ministry of Health and Long-Term in their efforts to put patients first, and integrate health care at the local level. We hope that the involvement of stakeholders will be an integral part of the implementation.
The Ontario Lung Association will continue to work with our government and community partners to provide essential tools, such as evidence-based guidelines, to support changes and improvement in the health-care system. We believe that the Ontario Lung Health Action Plan is a key tool that could support the work ahead for all the LHINs.
Our team would be pleased to meet with the Ministry or LHIN representatives to discuss our response further in an effort to ensure that lung health issues, which affect more than 2.4 million Ontarians, remain at the forefront of the integration efforts proposed to improve our health care system. The Ontario Lung Association will continue to support not only lung health patients, their families and caregivers, but all Ontarians as they strive to breathe easily!
i “Your Lungs, Your Life: Insight and Solutions to Lung Health in Ontario” has been produced by the Ontario Lung Association, based on data from: Smetanin, P., Stiff, D., Briante, C., Ahmad, S., Ler, A., Wong, L. Life and Economic Burden of Lung Disease in Ontario: 2011 to 2041. RiskAnalytica, on behalf of the Ontario Lung Association, 2011.
ii Gershon AS, Guan J, Victor JC, Goldstein R, To T. Quantifying health services use for chronic obstructive pulmonary disease. Am J Respir Crit Care Med. 2013 Mar 15;187(6):596-601.
iii Wodchis WP, Austin PC, Henry DA. A 3-year study of high-cost users of health care. CMAJ. 2016; Jan 11.
iv Brooks D., Sottana R., Bell B., Hanna M., Laframboise L., Selvanayagararajah S., Goldstein R, Characterization of pulmonary rehabilitation programs in Canada in 2005. Can Respir. J. 2007, Mar; 14(2):87-92