Long-term care patients in hospitals partly blamed for Horizon deficit as well as bed shortage

Patients who should be in long-term care but are instead taking up hospital beds were a major topic of Horizon Health's board meeting Thursday and were blamed in part for the network's projected deficit of more than $64 million this year.

Board chair Susan Harley said New Brunswick's rapid population growth and the province's aging population continue to put extreme pressure on the health-care system with "inadequate" placement options for long-term care patients.

"In some hospitals, we're seeing levels of over 35 per cent of hospital beds occupied by elderly patients who do not require acute hospital care," Harley told the board.

With so many of these patients, known as alternate level of care, or ALC, patients, in hospital, the number of people who can be admitted through emergency departments is drastically reduced, she said.

Greg Doiron, vice-president of clinical operations, said the goal is to reduce ALC numbers to below 330, or 20 per cent of total hospital beds, by January 2026. 

But the province needs to accelerate growth in nursing homes, he said.

A graph provided by Horizon has 652 acute care beds in network hospitals now being used by ALC patients, or 39 per cent of the total. The numbers have shown "substantive and consecutive" increases since the pandemic, Doiron said.

The number of people aged 65 or older New Brunswick increased 78 per cent between 2004 and 2022, he said, but new nursing home beds only increased 21 per cent in the same period.

"As you creep beyond 20 per cent, you start to really have meaningful impact on our ability to provide acute care," he said. 

The nursing home waiting list has also grown and now stands at more than 1,000 people, "because there's no new capacity."

And the longer that ALC patients stay in hospitals, the worse off they become, he said.

"What we see is a decompensation of these patients due to the lack of those resources, which actually makes their situation worse, makes their ability to be placed more challenging, and ultimately leads to a longer and longer stay in hospitals."

Stephen Bolton, chair of patient safety and quality improvement, said a solution to the bed shortage created by ALC patients is challenging because nursing homes fall under the Department of Social Development, not Health.

"We look after people from when they're in cradle until they need long-term care, and then that responsibility is given to someone else," Bolton said.

"So in a real sense, Horizon is not master of its own house, and we really are critically dependent upon their co-operation and the ability of our partners to solve this problem."

When asked if Horizon was advocating the province change this jurisdiction, Harley said Horizon is meeting soon with John Dornan, the new health minister and former head of Horizon.

"We either need to have everything under one department, or a very tight relationship where we have the same goals of that business if it does span two departments," Harley said.

"There's a bit of a disconnect," she said, between both departments.

Horizon projected to have large deficit

Horizon CEO Margaret Melanson said the network is headed for a deficit, "which unfortunately we may not be able to recover prior to the end of March," but possibly can be righted by next year, she said.

Vice-chair Mike Walton said the deficit is in part due to increased ALC patients and about 200 more patients receiving care than the funded capacity for the network. Inflation has also increased most costs, he added.

Walton commended the end of travel nurse contracts, a controversial response to the nursing shortage during COVID.

"However, this has resulted in inflated overtime costs for nursing because as you've heard from management previously, our workloads are still very high," he said.

High hopes for community care clinics

Much of the meeting saw discussion of community care clinics, which the new Susan Holt government has made a  priority.

"So it's nice to see the alignment of something that we have said is key to success, and they also are supporting it," Harley said.

Natasha Lemieux, vice-president of community, said some physicians who work in solo practices have expressed that up to half the patients they see don't necessarily need to be seen by a physician.

"There are a number of other care providers from nurse practitioners, nurses, physiotherapists, social workers, mental health clinicians, as examples, who all might have been able to see that individual and address their care needs," she said.

Lemieux said physicians have said they're becoming isolated at their solo practice and spend too much time on paperwork. Retirements have also created issues where patients are suddenly orphaned without a doctor.

Community care clinics are the solution to all these problems, she said.

Horizon has been working with 70 physicians and feels comfortable to start by launching 17 of the community care clinics, Lemieux said.

Horizon will look at its 47 sites and existing buildings and staff to consider where clinics will be. Fifteen per cent of Horizon's current providers will be shifted to the team-based model, she added.

"We know we need to scale and spread rapidly in order to get everyone connected."

In an interview with reporters, Melanson said Horizon is just waiting for funding for collaborative care clinics to "activate" the goal of 30 of them by 2028, the plan put forward by Holt during the recent election campaign.

The goal is to make local collaborative care clinics "the hub" of care for a patient.

"Primary care becomes the place that you start your journey when you're born and you end your journey at end of life and everything in between," Lemieux said.

"And that as you need different levels in the continuum of care, you might step out for a moment to get surgery and then come back into primary care."

Performance metrics show Horizon in the red

The board shared Horizon's monthly performance dashboard, tracking 13 goals the health network has to improve care.

Coded by colours of a traffic light to show progress, seven of the 13 are red. Among the reds is the non-urgent MRI wait time. The target is 30 days, but the average wait is currently nearly a full year, at 363 days.

Horizon's goal is to do 95 per cent of surgeries within target time frames, but it's currently at 60.3 per cent. But Doiron said the wait has been shortened, from 20,305 in March to 17,729 in September, because of the newly opened cataract clinics and increased surgical capacity in Moncton.