This is the second of two Community Dispatches which have discussed the important work of the System-Linked Unit on Health and Social Service Utilization at McMaster University. Their cumulative research documents what many service providers know in practice: that is, services that produce better outcomes are part of a continuum of interlinked and comprehensive services that treat the whole person, not just an isolated part of the individual.
The Council feels it is important for agency managers, staff and boards to be aware of this important research and its implications for our work in our community and, most importantly its significance for the development of public policy and future programs.
There is much debate in Canada about how to "heal" our public health care system, especially about how to ensure there is enough funding to provide good care to Canadians when they need it.
I would like to make the case that we can reduce some of the costs of health care by helping people get the services they need. The most expensive services we provide are those that have not been tailored to people's needs.
Over the past 10 years, the System-Linked Research Unit on Health and Social Service Utilization at McMaster University has been studying how to improve health and contain costs through community-based services to people who have some health problems.
With the active participation of our community partners who provide services in the Regions of Halton and Hamilton-Wentworth, investigators with the System-Linked Research Unit were able to conduct studies on a variety of samples, settings, sectors and services.
What we found is both simple and profound - giving people the help they need to feel and function better usually costs the same as or less than not doing anything to make sure they get the support that will help them.
Why? Because people who are hurting will usually try to find a remedy, but the services they use are not necessarily going to be the ones that will solve their problem. A piecemeal approach to helping them can be expensive, while also missing the cause of the problem. It can be difficult, even for a trained professional, to sort out the difference between a person's condition (that they have severe diabetes), their circumstance (they lost their job), and their problem (which may be depression).
The savings are achieved, not because the service that solves the problem is cheap, but because making people healthier and better able to cope with their lives creates savings elsewhere. The biggest cost savings in health care tend to accrue where people are high users of the health system.
What may seem unlikely on the surface - better health outcomes for the same or less money - actually makes practical sense.
Consider someone who has chronic illness, lives alone, and is having trouble coping. Without any concerted effort to help them with problem-solving and adjustment to their particular circumstances, this person will probably spend a lot of time seeking medical help. When we compared a group who received counselling and support to a group who were left to cope on their own, the people who struggled with depression and loneliness on their own were half as well adjusted, and cost the health system 10 times more ($40,000 per year per person vs. $4,000).
We found a similar pattern in other areas. There were studies that revealed better outcomes for a higher cost, but they were in areas in which the clients were from an under-served group, such as caregivers of family members who were losing their mental capacities to Alzheimer's or other conditions. (This is an area where we, as a society, have not yet come to grips with; that is, the need to provide the necessary social supports to keep both cared-for and care-giver as healthy as possible).
The System-Linked Research Unit on Health and Social Service Utilization received core funding from the Ontario Ministry of Health, and also raised research funding for projects from other sources, including the federal government. We approached the comparative costing of services on a much broader scale than usual. We did not just look at the cost of providing the service to achieve a certain outcome, we looked at what other services the person used to cope with their chronic illness or mental health problem. We used an inventory that tracked direct and indirect costs, including how often they went to the doctor or the hospital, and what medications they used.
A study of a program for seniors living alone, that proactively screened and treated them if they were suffering from loneliness and isolation, found that seniors over 75 years of age and living alone who received support showed some social/emotional improvement and consumed less than a third of the health care resources used by untreated seniors over 75 years of age living alone.
People who attended a specialty pain clinic for chronic pain generated proportionately less cost in use of other health services compared to people who did not go to a pain clinic. Clients treated at a mental health clinic had similar states of mental health compared to those who were referred to the clinic but did not use the service, and yet those who were treated consumed far less health care service.
We also learned a lot through this research about what kinds of services work best to produce improved health at the same or lower cost.
Our health system is geared to providing services one provider at a time, one problem at a time, and on-demand. The most successful strategies in the System-Linked Research Unit's research were those that exhibited the following characteristics:
The services that produced better health outcomes were not necessarily medical. Some were delivered in a doctor's office. Others were provided with a nurse in a person's home, or by a volunteer at a seniors' centre, or a therapist at the mental health clinic, or a children's recreation coach at a neighbourhood park, or a psychologist in a school.
The cost savings we found were not always in the health care budget, but they often were. People who had been relying heavily on health services used fewer of them or fewer expensive ones when their needs were met appropriately. Sometimes, the savings were in the social services, or in the tax system when people became well enough to go back to work.
Another of our studies looked at the cost of a program for very troubled adolescents provided by an alliance of health, social and educational service providers in a school setting, compared to the cost of hospital and specialist care for teens who were waiting for the program. Over the same period of time, those waiting had twice the per-person cost ($10,000 per year) compared to similar students enrolled in the comprehensive, school-based program.
A 1998 study of single parents on social assistance, found that those who were offered a coordinated package of services - child care and recreation for their children, employment training, and visits by a public health nurse - were more likely to leave welfare for work than those offered one piece of the package or those left to fend for themselves.
The cost of the package of services - that helped the kids as well their parents - was no more expensive that the services consumed by those fending for themselves and was associated with a $300,000 savings within one year for every one hundred mothers served. The savings were from reduced social assistance payments. Recreation for the children paid for itself in the reduced use of professional and probationary services and resulted in mental health benefits for mothers on welfare. A number of Ontario municipalities are improving their services to families on welfare, based on these findings.
In summary, Canadians are proud and protective of our health care system, and so they should be. I would argue, however, that investments in other services that support health and well-being will take pressure off the health care system and help the medical community do what they do best.
One suggestion would be to invest in more social workers for hospital emergency rooms. Emergency doctors do not have time to figure out what is troubling people who arrive in the middle of the night. Their job is to deal with medical crises. But someone who is battling cancer may be there mainly because they are frightened and alone. A social worker who would arrange an assessment at home for a community counselling and support service could make a major difference to that person's recovery. Based on our research, community service would pay for itself through cost savings elsewhere in the system. But we have to fund the hospitals and the community agencies to provide these services that will save money for the system as a whole.
Moreover, the most serious barrier to delivering cooperative, holistic, proactive community-based services is the way in which the different sectors are funded (separately) now. We have to work out how to reward alliances that bring health, social, education, recreation and corrections sectors together in communities.
I am not saying that developing these strategies and alliances will be easy. What I am saying is that if we can develop innovative, intersectoral approaches, there is potential to save precious public resources, not only in health care but across publicly-funded systems, and at the same time improve the quality of people's lives.
Gina Browne, Ph.D., Reg. N., is founder and director of the System-Linked Research Unit, and professor of nursing and clinical epidemiology and biostatistics, Faculty of Health Sciences, McMaster University. For 23 years who has also worked as a family therapist in Halton Region. Contact Dr. Brown at the System-Linked Research Unit of McMaster University, Hamilton, Ontario. 1-905-525-9140 ext 22293 or e-mail firstname.lastname@example.org
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