Innovative solutions to a vexing issue: “social admissions”

On this episode of the CMAJ Podcast, Dr. Blair Bigham and Dr. Mojola Omole tackle the complex issue of "socially admitted" patients, sometimes uncharitably referred to as "granny dumping." They explore the factors leading to these non-acute medical admissions, the challenges faced by healthcare providers and innovative solutions to the problem.

Dr. Jasmine Mah, a geriatrics fellow at Dalhousie University, shares insights from her qualitative study published in CMAJ, titled "Managing “socially admitted” patients in hospital: a qualitative study of healthcare providers' perceptions". She provides examples of typical “social admissions”, such as patients with chronic conditions whose care circumstances have changed, and highlights the high mortality rates associated with these cases.

The discussion moves to the attitudes of healthcare providers towards “socially admitted” patients, the systemic failures leading to these admissions, and potential solutions. Dr. Mah emphasizes the need for better understanding and support for these patients, suggesting systemic changes like integrating social vulnerability into case mix indices and improving community care to prevent unnecessary hospital admissions.

Dr. Andrew Boozary, a primary care physician and executive director of the Gattuso Center for Social Medicine at University Health Network in Toronto, expands on these ideas in an editorial response. He underscores that these issues are not personal failures but policy failures, advocating for increased support roles like peer support workers and social medicine navigators. Dr. Boozary highlights the importance of innovative team-based care models to address the gaps in the current healthcare system.

Throughout the episode, the hosts and guests call for a more integrated and empathetic approach to patient care, stressing the need for systemic changes to better manage “socially admitted” patients and improve overall healthcare outcomes.

Join us as we explore medical solutions that address the urgent need to change healthcare. Reach out to us about this or any episode you hear. Or tell us about something you'd like to hear on the leading Canadian medical podcast.

You can find Blair and Mojola on X @BlairBigham and @Drmojolaomole

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Transcript

Dr. Blair Bigham:

I'm Blair Bigham.

Dr. Mojola Omole:

I'm Mojola Omole. This is the CMAJ podcast.

Dr. Mojola Omole:

So today, our topic is we're going to be discussing “socially admitted” patients,

Dr. Blair Bigham:

…also known as the granny dump.

Dr. Mojola Omole:

Oh, right, right around the holiday time.

Dr. Blair Bigham:

That's what we call it in the ER.

Dr. Mojola Omole:

Yeah, that is true.

Dr. Blair Bigham:

This is not new to any of us, Jola. But this study has looked at “social admissions”, people who are admitted to hospital without an acute medical problem, and they've gone ahead and interviewed practitioners, nurses, social workers, and physicians about these patients to figure out what's going on inside our heads. What do we really think when someone is admitted to hospital without something that I've been trained to fix?

Dr. Mojola Omole:

Yeah, it's a really great qualitative study that really tries to have a better understanding of the people who are directly involved in the care of “socially admitted” patients and then talking a little bit about what we can do for solutions.

Dr. Blair Bigham:

And it's a hot button issue. These admissions are something that I think a lot of physicians lose sleep over. These are stressful. These are viewed as a challenge, and I think that's highlighted by the fact that CMAJ chose to publish an editorial about this very topic.

Dr. Mojola Omole:

For sure. And I do think that many of us who work in acute care settings in the hospitals, it is something that we come across, and when we layer that with issues of the unhoused, this becomes a bigger topic that's not just social, but that is really crucial in our healthcare system to address.

Dr. Blair Bigham:

Absolutely. We're going to talk to the author of the qualitative study and then one of the authors of the editorial. That's coming up next on the CMAJ podcast. Dr. Jasmine Mah is a geriatrics fellow at Dalhousie University. She's the lead author of the research article in CMAJ, entitled, “Managing “socially” admitted patients in hospital: a qualitative study of healthcare providers' perceptions”. Jasmine, thanks for joining us today.

Dr. Jasmine Mah:

Thanks so much for having me.

Dr. Blair Bigham:

So let's start with the basics. Give us a typical “social admission”.

Dr. Jasmine Mah:

So let's start by defining what we mean by the “social admission” label. 

Dr. Blair Bigham:

Sure. 

Dr. Jasmine Mah:

It's someone without a medical condition. It's a label that we use in healthcare to describe people who end up in hospital for predominantly social reasons. And I'll give you a couple of examples. These are patients that I've seen or similar cases. Somebody with vision impairment who is cared for by his wife his entire life, lived in a three-story home, and then his wife dies, and he can't stay in that home without her support. They don't have children nearby or other friends. So his health hasn't changed, but the circumstances have changed, and he's brought in by ambulance to the hospital until some sort of alternative can be reached. Another example that I saw was someone who was living with mobility issues who drank a lot of alcohol, but he was living in his garage because he couldn't afford to live in a new apartment that was accessible by wheelchair. So the neighbor of the garage called the police who brought him into hospital because it was an unsafe living environment. There was no running water. And then probably the most prevalent scenario that we see, at least over here in Nova Scotia, is that older adult with cognitive impairment is getting progressively worse. Their family has tried to do everything long-term care is not available for their type of care, and then they're brought into hospital awaiting long-term home care, home placement.

Dr. Blair Bigham:

So this sounds a lot like what some people might call failure to cope, failure to thrive, caregiver burnout. Are these terms sort of all related to the same idea around the “social admission”?

Dr. Jasmine Mah:

Exactly. They're all synonymous. They're all used by different centers. And I think that's one of the challenges of this population is every place, every region has a different way of trying to help this patient population.

Dr. Blair Bigham:

So socially admitted patients come to the hospital, they don't have any acute medical issues. Why are they being admitted if they don't have a medical problem?

Dr. Jasmine Mah:

Yeah, I think that's one of the most interesting things about this patient population. One thing that really didn't make sense to me and the research team. So the way that we actually use it in practice as a paradox, right? Because if someone truly has no medical conditions, if they have no physical or mental or cognitive problems, then why can't they live alone in the community? So it's inevitable that these patients do have medical conditions, but it's often chronic, it's often degenerative, and we can't immediately solve them in our healthcare system that's focused on acute medical issues. And because of that, we're the ones who are labeling it “social”.

Dr. Blair Bigham:

Interesting. I feel a bit guilty here as an emergency doctor because my job at the end of the day is pretty simple. My job is to determine if you can go home safely or do you need to be admitted? And if you can't go home safely, to whom will you be admitted under? That's the basics of emergency medicine. Let's just acknowledge that many papers have found that the mortality rate for these socially admitted patients who are being admitted without an acute medical concern is Dr. Blair Bigham%. What's going on there? Why is the mortality rate so high if I'm just admitting you because you've got no place safe to go?

Dr. Jasmine Mah:

So I will actually one up that and say one of the better conducted, and the evidence is actually really poor in this area, was a study done out of Australia. They use acopia instead of failure to thrive and failure to cope. Mortality in the hospital was 22.2%.

 Dr. Mojola Omole:

That's insane.

Dr. Jasmine Mah:

And they're not palliative care.

Dr. Mojola Omole:

Why is this happening? Why are we having high mortalities? What is going on?

Dr. Jasmine Mah:

So great question. And I think that's one of the things that we really wanted to try and understand from the perspective of the healthcare providers when we started our study. So was there something that we were doing? Are there things that we could do better to try and prevent these high mortalities? And we can really kind of break it down into, first of all, are we missing acute presentations? Are people coming in, and because they don't have that family member, we don't actually know what their baseline is? Are they always like this or is this an acute change? And in our findings, sometimes that label propagated itself all the way up from the paramedics would come into the emergency department and tell the triage nurses that, oh, this person, we come to their house every week, and this is just someone who's going to need a social admission. And that actually gets propagated right up to the physicians and then right up to the floors. And it's not until day two or three when you're like, oh, this person actually has an infection or a new stroke. So we miss people that way, and that might be contributing to the mortality. And then the other side of that is are we doing things once they're admitted in hospital that might increase their complication rate? And of course we are, we know that for certain types of populations, functional decline happens, hospital nosocomial infections, and in this population that is we found on the last priority of everybody's list. Those things will just be caught a lot later. If at all,

Dr. Blair Bigham:

Who should be responsible for “social admissions”? Do we need almost a special service or what do you think the solution might be to this?

Dr. Jasmine Mah:

Solutions…

Dr. Blair Bigham:

Should we put them all under gerontology? 

Dr. Mojola Omole:

I'm sure they would not love that. 

Dr. Blair Bigham

I mean, I'm going to put it back on you. What is the better way, if not to just throw our hands up in the air and have a label that says, we don't know what we can do for you essentially?

Dr. Jasmine Mah:

I actually think that's so funny because one of the reasons you might notice that most of the research team are the geriatricians, and it's because inevitably we would always get consulted on this patient population.

Dr. Blair Bigham:

But that's inevitably right. It takes time before someone says, okay, let's involve geriatrics. I'm wondering, should the emerg doc, should we just be calling geriatrics to say, ”Hey, we can't find an acute medical problem, but I don't have a disposition other than to fill a hospital bed?”

Dr. Jasmine Mah:

And I, that's the really difficult part about this is fundamentally, I think it's a matter of philosophy. When we are looking after people who don't fit into our boxes, first of all, we have to recognize that we have boxes and we have alternative goals on the physician side. So that's number one. And then I think the second thing is it's a principle of how you want to use your resources as a division, as the geriatric division, as the emergency department, as a hospital. So often what I hear in this patient population is, oh, they're taking up a bed that could be better used for someone else. And that is a utilitarian way of approaching medicine, right? The idea that we are taking from one to help another in order to make the best use of all our resources.

Dr. Blair Bigham:

This is fascinating. Let's dig into what you found more. What were the attitudes of physicians around these patients?

Dr. Jasmine Mah:

They were positive in that every person we interviewed actually felt that this patient population deserved good care, just not the care that was provided by them on their unit or their service.

Dr. Blair Bigham:

Interesting. Almost like they were orphaned.

Dr. Jasmine Mah:

They were. And that is the name of our “social admission” pathway, the Orphan Patient Policy.

Dr. Blair Bigham:

Oh, interesting. Okay. Tell us more about that policy.

Dr. Jasmine Mah:

So our policy is that each patient admitted under this pathway is assessed by an MD. So whether that's the emergency physician or whether they'll consult someone else. They're deemed to have no acute medical or surgical problem. They have to be seen in the emergency department by the extended healthcare team, either the social work, continuing care. They have to have maxed out social supports, and then they actually get moved to the first available bed in the hospital.

Dr. Blair Bigham:

Anywhere in the hospital.

Dr. Jasmine Mah:

Anywhere in the hospital. 

Dr. Mojola Omole:

Like a surgical floor.

Dr. Jasmine Mah:

Correct. And this was a principle of fairness.

Dr. Blair Bigham: Oh Jola.

Dr. Mojola Omole: Oh, we don't like that.

Dr. Blair Bigham: 

But if we just establish that Dr. Blair Bigham% of these patients will die, shouldn't they be under no disrespect to Jola and her surgical colleagues, but they're not dying of a GI bleed or mesenteric ischemia, right? They're dying of a medical problem and not a surgical problem.

Dr. Jasmine Mah:

So to be honest, we don't really know. So those are results of our chart review, which we are still in the process of publishing, and we are going to be looking into how these patients passed away in hospital. Some things that come to the top of my mind is I've actually been called to codes on these patients who, for example, had a UTI and the ciprofloxacin interacted with their warfarin, and all of a sudden you've got a massive GI bleed.

Dr. Mojola Omole:

Is someone rounding on them on a daily basis or q 2 days.

Dr. Jasmine Mah:

The expectation is that they are seen by a medical physician only if something changes. So first when they're admitted to the floor, and then when something changes. In practice, teams do seem, we documented whether they were writing notes on them and they were seen at least once a week or at least sometimes twice a week by all services, which was great, but how in-depth those notes were, if it was just continuing current management, that's more the speed that we saw.

Dr. Blair Bigham:

Interesting. So what else did participants reveal to you in your interviews? Did they have any solutions? Were they angry? Did they blame somebody for this system?

Dr. Jasmine Mah:

One of the things that I thought was really interesting is the idea that once somebody is labeled in this way, no other services really wanted to get involved. And it was actually really hard to get the right type of care once things did change. So, for example, that person had a GI bleed, you might want to get GI involved, but no, they were just admitted under the orphan patient policy, there's someone who's not supposed to be sick. There was someone who was admitted and continuing care was like, oh no, they must have too many behaviors. So it took a lot for the healthcare providers to advocate to make sure that these patients did get the right care, which that label prevented them from doing that.

Dr. Blair Bigham:

Earlier you used the term utilitarian to sort of describe how sometimes these patients are viewed as taking up a resource. I think that's, maybe the NHS folks would agree with that as well, but certainly it would contrast with maybe an American viewpoint where these patients might be viewed as income generators, but in Canada, we have no income for our hospitals. We're not making money off of anybody. What is the scale of this at a system level? What does this cost when we have socially admitted patients who are not able to access easily the services that can help get them out of hospital? You can see where I'm going with this. Is it cheaper to just deliver the service they need rather than stick them on a floor, call them an orphan and hope they don't suffer a complication in their purgatory? 

Dr. Mojola Omole:

But isn't there services that sometimes need, is long-term care, like finding a permanent home?

Dr. Blair Bigham:

Yeah, in Ontario, we have alternate level of care, which in some hospitals is taking up to 30% of the beds.

Dr. Mojola Omole:

Because they're waiting for long-term care. 

Dr. Blair Bigham:

They're waiting. But a lot of these patients who get socially admitted in the ER, if someone said there's a nursing home bed available, I'd be like, great, you're discharged. You don't need to come into the hospital.

Dr. Jasmine Mah:

That's exactly where all this research leads to. So I'll say the counter of that, Jola, is that CIHI and the National Institute of Aging estimate that between one in five and one in nine patients in nursing homes today or long-term care facilities have the same medical conditions as people living outside who may not actually need long-term care. And we know that from Scandinavian countries like Denmark, if you shift the percentage of your long-term care budget from, ours is predominantly going to long-term care homes instead of home care and community care, you can actually prevent those admissions, you can improve the quality of life, and we can decant acute care facilities.

Dr. Blair Bigham:

By decanting the nursing homes into the community, you can then decant your ALC patients from the hospital into the nursing home.

Dr. Jasmine Mah:

By swapping the proportion of long-term care funds that are going to the community instead of nursing homes. I do want to answer your question about the cost.

Dr. Blair Bigham:

Sure. Yeah.

Dr. Jasmine Mah:

So I can just speak to our center and prior to the pandemic, they're really small absolute numbers. Prior to the pandemic, we were seeing maybe 30, 40 a year. And then since the pandemic, it's been like one every two to three weeks actually. But the actual relative impact of these patients on our bed system. So in 2020, we estimated it was about 7% of our bed days.

Dr. Blair Bigham:

So there are not a lot of them, but they stay for a long time. And so the bed days are high,

Dr. Jasmine Mah:

Some of them more than a year. And there is a lot of potential cost savings by caring for people where they should be cared for, which is not our hospital systems for this patient population. But I think that's a small piece of it because what about the people who lose function in the hospital or who get hospital-related complications? We're just pushing that cost to a different part of the system down the line.

Dr. Blair Bigham:

This is such a systemic failure it seems. What are some of the system-level changes that could improve the situation?

Dr. Jasmine Mah:

So I have two or three. My master's was in health financing. So I'm really big into financial incentives. And as you chatted, what if we built social vulnerability into our case mix indices because often our hospitals are penalized for keeping patients in hospital. So why would you provide them better care if you're losing money for the same patient with the same chronic medical condition? Another way to think about it is in Scandinavian countries, as soon as the acute care part is over, the municipality takes over that care. So they place it on that community to then be incentivized, who also control the nursing homes. And again, it's a system, a better functioning system, but then those communities are incentivized to actually move the patient to where they need to be in order to balance their budget. So that's one of my thoughts on how we can, instead of physicians are so busy on a day-to-day basis, let's make it easy on us to provide that right type of care. And then my second one is just recognizing, thinking about frailty at the front door of all healthcare interactions because we're doing a marvel in medicine by keeping people alive. But now the biggest problem is not mortality anymore, it's frailty and especially for the patient population I serve.

Dr. Blair Bigham:

That was fantastic. Thank you so much for your time, Jasmine.

Dr. Jasmine Mah:

Yeah, thanks for the lovely banter.

Dr. Blair Bigham:

Dr. Jasmine Mah is a geriatrics fellow at Dalhousie University in Halifax.

Dr. Mojola Omole:

Dr. Mah's research and social admissions prompted an editorial in the CMAJ titled, “Social admissions to hospitals or not personal failures, policy ones.” Dr. Andrew Boozary is one of the co-authors. He's a primary care physician and executive director of the Gattuso Center for Social Medicine at University Health Network in Toronto. Thank you so much for joining us today, Andrew.

Dr. Andrew Boozary:

Thank you both for having me. I really appreciate it.

Dr. Mojola Omole:

So our first question I have for you is that not every research article in the CMAJ prompts an editorial. What about this paper from Dr. Mah made you say, you know what? Let me address this and write an editorial for it.

Dr. Andrew Boozary:

I think that this paper just hit on so many cross-cutting issues that people in the healthcare system are feeling. I think it was also telling that the authors use the unquote “social admissions” throughout the paper in terms of addressing this issue that I think has been talked about for a really long time and maybe skated around a bit in terms of how we even address or talk about these patient admissions and these patient stories and caregiver stories that are pouring into hospitals across the country. And it's not entirely clear about what we should do.

Dr. Mojola Omole:

Dr. Mah's research found that physicians that they had spoken to were not blaming individual patients. In your editorial, you also really emphasized this point that this is not a personal failure, but it's actually a policy failure. Why did you feel like this was really important to emphasize and bring forward?

Dr. Andrew Boozary:

I think it was a really important finding that health workers did not feel that the onus was on patients. But in my experience, and I think coming through the last few decades of training, I think we've seen this shift, which I think is towards a much more grounded and truthful experience that the onus is actually on our system and structural policy than it is on individuals or patient failures. But I can very much remember being in an emergency department and it was very common to be referring to people as frequent flyers. We talk about failure to cope, I think, are other things that we've seen in medical notation and that has been codified for a very long time. I also remember in my last year of medical school, in the last class actually, that a student had asked, do we have to see patients who are homeless because they don't pay taxes or they're housed? So that was not all that long ago. And so I think we're seeing more of this shift. And so I think all of that, it's something that we have to keep pushing towards and understanding that the onus is actually with us in not writing and codifying loss to follow up, failure to cope or social admission, to scrub our own hands clean of what the structural determinants and the policy failures are outside the hospital or clinical setting.

Dr. Blair Bigham:

I was a little surprised that Dr. Mah didn't find comments that were sort of pejorative towards patients. I don't know, maybe people were on their best behavior for a research interview, but I work in a busy community hospital, work in a lot of busy community hospitals right now, and I don't know there's cultural differences between them all, and I think some are worse than others when it comes to victim blaming or patient blaming for this.

Dr. Andrew Boozary:

I agree. I think there's different experiences and approaches or maybe clinical cultures that I think we've been working in various spots would say can be better than others. I think the other element on this is the paper did capture the moral distress aspect. And I think that's an important area where it's clear that we have a health system that's also under a lot of strain. We have colleagues working in really challenging environments and being pushed beyond their own limits and their own real boundaries to try to do the best that they can. And so I can also understand that when you see this sort of burnout, you see this moral distress. There can be attitudes and behaviors and approaches that none of us as healthcare workers want in the system. And so I think, again, it's another system lens around you having people pushed to the brink. You have people pushed to the brink to the hospital as the last resort. And in many ways, it's been a perfect storm for a very long time. For far too long, I would argue. And yeah, I think you'd probably capture different things if you had a hot mic in an emergency department or various parts of the clinic. But I do think there was a lot of truth that was able to be picked up by Dr. Mah and colleagues that were, people do not want to see people come here with no other option. They also, in many ways, don't know what to do. And there's also this growing divide I think that we've seen between people, between neighborhoods with these widening social inequities that are also probably driving some of these different behaviors and attitudes towards patients or people without housing, without home care, people who use drugs. We know these are very serious areas of stigma and discrimination.

Dr. Blair Bigham:

In your editorial, you talk about a few different job positions or work positions that can help offer a novel solution to some of these problems. Because when I think about it, I mean, if physicians think they have it bad, the nurses have it so much worse. When a nurse comes to me and says, this patient doesn't have a ride home, I say, okay, well go figure it out. It's not my problem. And so I do feel like in these busy environments, as hard as it is on physicians, it's so much harder on everybody else. But you have some team members who seem to help, and one of them is a peer support worker. Tell me about that role.

Dr. Andrew Boozary:

That's a role that I really believe is the future, and the now I think of healthcare delivery in many various centers or cities in the country. So the peer support worker is usually a person who has had lived experience with homelessness, or there are people who use drugs and have had various traumas that have led them to wanting to be able to provide this work. They are paid positions. And I have to commend the neighborhood group that we partnered with at University Health Network that have a training program for peer support workers that are able to provide the kind of supports and education that people need. And I have to tell you, Blair, this is probably the role that I get some of the most emails about at the hospital saying we can never lose peer workers now as part of the healthcare team. This is from nurses, social workers, physicians. And so they work alongside the staff, as I mentioned, and are able to sit and care for patients who come in who are either without housing or people who use drugs. They may not have as much of an acute medical need in the emergency department, but they can help work with them to connect them to a more humane discharge, try to connect them to various community services and supports or income supports, and just be with them in the journey where we've talked about in the beginning of the conversation, there is stigma. There is poor treatment towards people who use drugs towards people who are unhoused towards racialized populations in emergency departments. And I think this is a tangible way for hospitals to try to better care for people who are there, but also partner instead of us as hospitals saying, well, we can recreate these peer support worker roles. I think partnering with TNG was a major shift and a major learning for us in how we can start to provide this care.

Dr. Blair Bigham:

In contrast, that role with a more, I'll use the term professional role, a regulated role like a social worker.

Dr. Andrew Boozary:

So there are, again, some differences and nuances. And I also want to take the opportunity to really shout out to social workers. They've really embraced peer support workers. And so I have to really commend them in terms of how they did not see peer support workers as a threat, but actually a welcome addition to how they could work together to better provide supports. And so I think with peer support workers, they're able to provide and sometimes unconventional options for people of, is it to go outside and have a smoke together? Is it trying to find different options or taxis to get people to a safe setting? How can they also provide some of the connection out in the community where I think social workers provide so much great care in the hospital, the peer support workers a little bit more at this intersection of hospital and community. And they work really closely with another role that we've developed with community leadership and support and other funders is  around social medicine navigators. So those folks are not embedded in the emergency department or the hospital ward, but they're there with them for the accompaniment when they are discharged from hospital or they're back in the hospital to come. So you could sort of start to hopefully see, as I'm painting this picture, that there are these real connection points with different roles, but they work really as a team. And I think that as we continue to hear, the solution is team-based care. I fully agree. I think the point that I would keep pushing on is we just need new teams in 2024, not the teams that we were talking about in these reports 30 or 35 years ago.

Dr. Mojola Omole:

So how do the social medicine navigators differ in terms of their scope of work from the social workers who you traditionally would see in the emergency trying to help connect people with supports?

Dr. Andrew Boozary:

So there's also a lived experience piece with the social medicine navigators that builds upon what we've seen with peer support workers, Jola. The other piece is that they're fully mobile, so the real element of accompaniment. So they're not really tethered to one space. They are with them, accompanying them to medical appointments, being able to work with them or come meet with them wherever they are to try to either address issues like loneliness, which is a major issue in terms of the ill effects on health, all the way to trying to help connect them with primary care providers, whether that's a nurse practitioner or income supports with some of the support agencies and community groups I've mentioned.

Dr. Blair Bigham:

How have you guys been able to fund them and recruit them?

Dr. Blair Bigham:

I can tell that you're a believer in their return on investment. How do you convince people to make it a line item?

Dr. Andrew Boozary:

Yeah, so this is not just some evangelical belief in terms of their value. There's some really great randomized trials that have been done in North America that really do show the value. I think as Blair, you're mentioning around the ROI. So one, I think the wellbeing and the human dignity piece, in almost every evaluation we've seen around social medicine navigators, community health workers, peer workers has been significantly positive. And the other part is when you look at some of these randomized control trials, they've actually seen for every dollar spent on a community health worker, there is a two and a half dollar return back to the hospital and system by the way of savings. So I think there's both really powerful cost-effective analyses. There's some really important patient-reported outcome, patient-reported experience analyses that have been published in this area. And we're continuing to try to build the evidence base here at UHN, but I know many different healthcare settings are doing this in Canada, trying to do these evaluations, try to continue to build this case. And for those of us who are involved with it, I think there is consensus that there's no going back. We can't revert these healthcare teams now that we've seen peer support workers and social medicine navigators becoming part of the healthcare delivery team. 

Dr. Blair Bigham:

So where's the disconnect? Why isn't this in every emergency department, in every medicine ward? Why is it just, it seems to be sort of a few hospitals that have been able to scrounge this together.

Dr. Andrew Boozary:

There's probably a myriad of challenges, Blair. I mean, it's hard to speak to all of them or to context-specific ones. I think you mentioned it in your past question, and this is not me ducking it. I think the funding issue, to come to it head on, is important. There's not really conventional funding budgets or allocations for these kinds of roles. And I think that's something we can hopefully work on across the country to see funders start to recognize peer support workers and community health workers as really part of healthcare teams, not just community sector teams where they're providing, again, really important and valuable work. So in many of the cases, I know for us, we really benefited from philanthropy being able to pilot this. So to the Gattuso Foundation to be able to say, we believe in this pilot around peer support workers to help with navigation. And then really trying to make that case to the province and other funders where we've been really fortunate that they've been able to see the value of this. And now I think, Blair, the question is how can we scale it to your point? And so whether it's a funding issue, whether, again, it's in some ways just a requirement to see teams differently and it's just not been something that maybe has been top of mind in various parts of the country because just the proximity to these models may not be as close. But that's something I hope given some of this research, some of these editorials, some of this work in various domains can start to seep into hospital settings across the country. And so that's why I think, again, even being able to have this conversation together, I hope is important to try to get more and more of the word out of the really great experience that various hospitals and emergency departments have with these new and innovative models of care.

Dr. Mojola Omole:

I think that's a great place to leave it. Thank you so much for spending part of your day with us.

Dr. Andrew Boozary:

Thank you so much to you both. I really appreciate the invite, and it's been amazing to be following the podcast for the last year especially.

Dr. Blair Bigham:

Oh, thank you for that. 

Dr. Mojola Omole:

Dr. Andrew Boozary is a primary care physician and executive director of the Gattuso Center for Social Medicine at University Health Network in Toronto. 

Dr. Blair Bigham: 

So, Jola, we have hospitals that are supposedly full of patients who don't need to be in hospital. We have, I'll use the pejorative frequent flyers, people who are coming into the hospital over and over again because of issues that arise from outside of the hospital. And I don't know, I just feel like, why don't we have the money for something as simple as a peer navigator or another social worker to help keep people out of hospital and patch together some of these individualized solutions that benefit health?

Dr. Mojola Omole:

My answer is that I find that often hospital administrators lack imagination. And we go for the simple solution, which is hire nurses, agency nurses, and pay them triple the amount of the nurses that you already have. Whereas everybody would be happier with their job if there were peer support workers in the hospital, if there were social medicine navigators helping them. Because what causes burnout and frustrations to leave the healthcare system, especially for allied health and our nurses, is the overburden of all of these things that are happening. People want to work, people enjoy their job, they want to serve, but not under these conditions. But it takes imagination to say, hey, let's improve this environment for people and for people who work here and improve it for our patients so that they have the support as they're navigating the system because they also don't want to be there. It's the last resort when you're there. It's, as Andrew said, it's the last social safety net. 

Dr. Blair Bigham:

And Jasmine also brought up that idea of incentives, and I feel like our healthcare system has such fragmented accountability where the purses are controlled by so many different people that it's hard to make those line-of-sight connections to say, wait, if we spend money out of purse A, we will save double the money in purse B. Everyone's just protecting their own little domains, and the silos really have to be broken down because none of what we're doing is making any sense.

Dr. Mojola Omole:

A hundred percent. And I think that that's a huge issue. 

Dr. Blair Bigham:

Spend the money better. Well, no. I mean, everybody always says that. We do need more money. There's so many structural problems. 

Dr. Mojola Omole: 

We always need more money, but the money that we have, let's invest it upstream. Instead of being reactive with how we spend the money on healthcare, let's prevent.

Dr. Blair Bigham:

That's it for this week on the CMAJ podcast. Thank you so much for listening. Solutions were tough to find this week, but help us out, spread the message, get the word out. Please like or share wherever you download your audio. The CMAJ podcast is produced by PodCraft Productions for the CMAJ. I'm Blair Bigham.

Dr. Mojola Omole:

I'm Mojola Omole. Until next time, be well.