Dr. Ruby Alvi couldn’t shake the thought of the patient she had seen earlier in the day. The woman had suffered a miscarriage in October. Things got even worse for her after that. Alvi doesn’t know if she was sent home from the hospital with proper care instructions or her patient was too traumatized by the miscarriage to have comprehended any instructions at all. There was no follow up with the patient. The woman went home, bled profusely and became severely anemic. When she fainted, her family called 911.
Today, Alvi, a family health specialist with the Trillium Summerville Family Medicine Teaching Unit in Mississauga, says her patient is coping with depression from what she went through. A miscarriage is rather common, says Alvi, but the impact it’s had on this woman’s whole life has been particularly devastating.
“This is a high-functioning person who can no longer work,” Alvi says. “She’s dealing with profound sadness and the trauma of profuse bleeding afterwards. Her side effects were considerable.”
Alvi’s patient is trying to recover physically from her miscarriage while also struggling with a mental illness. She is part of a growing cohort, referred to as complex patients, which is increasingly becoming the focus of health policy analysts and physicians alike.
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“Year over year, we found a population who were continually high users of the health care system,” says Dr. Paul Kurdyak, director of health systems research at the Centre for Addiction and Mental Health in Toronto. “When we looked further into these patients, they were getting the furthest thing from coordinated care.”
Complex patients have co-morbidity – more than one medical condition. The Ontario health care system isn’t really set up to treat them: a complex patient might have to visit one specialist for one condition and a second specialist for another, even if the two conditions are in some way related.
This inability to help patients in a coordinated way is one reason behind the provincial government’s “Proposal to Strengthen Patient-Centred Health Care in Ontario,” released today. The government says the proposal contains ideas to “improve communication and connections between primary health care providers, hospitals and community care.” The province is seeking feedback on the proposal from the public and the health care sector.
“People always had multiple medical illnesses,” says Dr. Kymm Feldman, who teaches family and community medicine at the University of Toronto. “An aging population means we are seeing more of it.”
But as Alvi’s patient illustrates, it’s not only seniors who tend to have more than one medical condition. Many antipsychotic medications lead people with mental illness to be obese and have metabolic problems.
“One in five individuals with schizophrenia also has diabetes,” says Kurdyak. “You can imagine managing the complexities of diabetes, the measuring of blood sugar and making sure you get proper care. It’s a tall order for anyone.”
In Ontario’s $50.8 billion health care system, complex patients come at a huge cost: frequent medical appointments and lab tests, and different specialists addressing each specific health need. Treating them better could help keep health expenditures down.
Complex patients often find themselves going to the emergency room and then being admitted to the hospital -- and these admissions are the most costly interactions a patient has with the health care system, says Dr. Walter Wodchis, a health economist at the University of Toronto. It’s the “high care, high cost patients” who are the top five per cent most active users of the health care system, he says.
But it’s not just dollars and cents. “We don’t necessarily produce good outcomes for these patients,” Kurdyak says.
When people living with schizophrenia go to the ER for a cardiac event, only 50 per cent of them are likely to get follow-up care and 50 per cent of them are more likely to die after discharge than other cardiac patients.
A patient with complex care needs shouldn’t have to work so hard to get the care they need, says Kurdyak, who is also director of health outcomes with the Medical Psychiatry Alliance. The system should come to them.
Alvi doesn’t know how to help her patient. The woman has an appointment to see a counsellor for her depression, but that’s not until the end of February. Ideally, she should have had follow-up psychiatric attention at the time of the miscarriage.
“Her miscarriage was in October. She’s the walking wounded. She will not be able to see someone for her depression unless she’s suicidal.”
Clarification: This article originally stated that ER visits were among the most costly interactions in the health care system. But ER visits in and of themselves are not that expensive; it's the inpatient admissions that can follow ER visits that are. The text has been updated to reflect this.