Long-term care delays and gaps in home- and community-based care are among the “hidden drivers” of emergency department (ED) overcrowding in Canada, according to a recent statement from the Geriatric Emergency Medicine Committee of the Canadian Association of Emergency Physicians (CAEP).

The dearth of these care and support options has made the ED “the only accessible option” for many older Canadians, who now account for 20%-40% of ED visits in Canada, according to the statement.

“It’s reaching a tipping point,” emergency physician and Committee Chair Kayla Furlong, MD, told Medscape News Canada. “We’re so overcrowded, we’re worried about patient safety and outcomes down the road.”

Indeed, lives are at stake. Every 4 additional hours of ED boarding are associated with an 8.4% increase in 30-day mortality, and overnight boarding of older adults has raised in-hospital mortality by 39%, according to the statement.

‘The ED Is Not the Problem’

While the issue is playing out in EDs, CAEP, Furlong, and other experts said that EDs aren’t at fault, and neither are older patients. “Many of the drivers of ED overcrowding are factors outside the ED,” said Furlong. “It’s systemic. The ED is the receiver of all our healthcare system failures.”

“Insufficiencies in long-term care and community capacity directly drive hospital and ED overcrowding,” according to the statement. When older adults can’t access these services, they remain in hospital beds even after their acute medical issues are resolved. These patients are then designated as alternate level of care (ALC). In Canada, 10%-20% of inpatient hospital bed days are occupied by ALC-designated patients, of whom 84% are older adults.

“The ED is where you’re going to see the impacts [of system failures] first because the ED has an open-door policy,” Furlong said. “But we need to be more robust in all aspects of the system to ensure that the flow of patients from the waiting room to the ED, the hospital, and out is maintained and not backlogged.”

“People think that the solution is to fix the ED,” emergency physician Judy Morris, MD, a clinical professor at the University of Montreal, and past president of the Association des médecins d’urgence du Québec, told Medscape News Canada. “No. We need to fix primary care. We need to fix long-term care. We need to fix it all. We also have to think of other ways to give the same care to patients but move away from the idea that everything has to happen at the hospital.”

“When people don’t have access to primary care, where else are they supposed to go to receive the care they need?” asked Samir Sinha, MD, DPhil, a geriatrician and clinical scientist at Sinai Health System and University Health Network and associate professor of medicine at Toronto Metropolitan University. “When we don’t have enough home and community care, why are we surprised that hospitals can’t discharge patients back to their own homes?” 

Many acute hospital beds are occupied by people “who don’t want to be stuck in hospital, particularly in a system that hasn’t been right-sized for the needs of an aging population,” added Sinha, who is also director of health policy research at Canada’s National Institute on Ageing. 

In fact, the CAEP statement acknowledges that while 90% of older Canadians want to age in place, publicly funded home and community care can’t keep pace with the aging population. Older adults and their families frequently encounter insufficient home support hours, fragmented after-hours care, workforce shortages, and unsustainable out-of-pocket costs for private services. “As a result, many remain at home in unsafe conditions until a crisis precipitates an ED visit and hospitalization,” said Sinha.

What CAEP Is Calling For

The new statement builds on CAEP’s EM:POWER framework and calls for action on the following four fronts: recognizing long-term care and home care as essential health infrastructure; building capacity across the full continuum of care; mandating public reporting of ALC occupancy, ED boarding times, and overcrowding outcomes; and adopting a whole-system approach rather than ED-only fixes.

Asked which actions provincial governments should prioritize, Sinha called for universal access to primary care and a major increase in home care funding. “We know that about 10% of the folks who are entering our current long-term care homes across Canada could have been supported at home with formal home care supports,” he said.

He cited Denmark, which now spends more than twice what Canada spends as a share of its health budget on home, community, and long-term care, and has largely eliminated ALC bed use as a result. “They’re not asking for more money and resources for the ED,” he said. “They’re actually building smaller hospitals because they have more home and community care and supports in place.”

Morris pointed to models already operating in Canada that are solving the problem with prehospital paramedic teams that assess older adults who fall (and arrange primary care follow-up instead of an ED visit) and with home-based multidisciplinary care programs, such as one in Montreal’s Verdun borough. “Many patients prefer these options because they’re not stuck in a long-term care facility,” she said. Scaling them will take an investment in people, she added. “The greatest challenge of all of these solutions is providing more healthcare personnel in long-term care facilities, hospitals, and primary care.”

The Challenges

Change is difficult, the experts agreed. Morris pointed to the fact that hospitals “still work very much in silos.”

Sinha described “simplistic institutional responses” to overflowing EDs, such as “let’s just build more beds” or “let’s do the same things we’re doing but faster.”

Overcoming the persistent idea that older adults are to blame for overcrowding is another challenge, Furlong said. “Historically, there’s been a myth that EDs are overcrowded because of low-acuity patients who could have been seen by a family care provider, a nurse practitioner, or urgent care clinic in the community. But when we look at the data, the people who are arriving at the ED are of higher acuity. Many are older, but they’re also more complex and have more comorbidities, so they do need to be seen in the ED. It’s a matter of figuring out how to get them through the system.”

Along the same lines, she added, “the idea that once the baby boomers age out, we won’t have this issue anymore doesn’t hold up against population projections.”

Canada has only 47 long-term care beds per 1000 population, which is low compared with other countries, according to the CAEP statement. Canada overall is currently 200,000 long-term care beds short and will need an additional 200,000 beds by 2035. In Ontario, “tens of thousands await long-term care placement” and in British Columbia, the number of patients awaiting long-term care has tripled over 6 years, while provincially subsidized long-term care beds have been reduced. Data from Nova Scotia show that delays in residential and geriatric care drive recurrent ED visits and caregiver burnout, while in Saskatchewan, demand continues to outpace capacity, especially in rural and remote areas.

‘A Bit of Hope’

“We now have homegrown and international evidence that when we make better investments in the provision of home and community care, we see significant drops in ED visits and ALC visits as well,” Sinha said. “With this statement, our ED colleagues are saying, ‘This is what needs to be done, and we’re completely aligned.’ Reading this, I’m wondering if they’re geriatricians now because they really get it!”

“Patient safety is the huge issue here,” Furlong said. “Prolonged boarding means that your risk of death increases, your risk of delirium increases. Even just staying one night in the ED increases your length of stay in hospital.”

Morris sees reasons for hope. “In my region, the governments and healthcare agencies are starting to listen and acknowledge that maybe the problem is bigger than the ED,” she said. “They’re seeing the picture a little more globally.”

“Ultimately,” she said, “we want to be able to provide care to the right patient at the right place, and we’re going to keep on asking our governments to do better for us and for them.”

Furlong, Morris, and Sinha reported having no relevant financial relationships. 

Marilynn Larkin, MA, is an award-winning medical writer and editor based in New York City whose work has appeared in numerous publications, including Medscape Medical News and its sister publication MDedge, The Lancet (where she was a contributing editor), and Reuters Health.