Gardner changing face of ont conf june 16 2010

Bob Gardner Changing Face of Ontario Conference June 16, 2010 © The Wellesley Institute June 17, 2010 www.wellesleyinstitute.com 1

• scale of health disparities → importance of health equity • how health disparities can be addressed through comprehensive health equity strategy • acting on health equity within the health system • building equity into all planning and delivery – highlighting some frameworks and resources for equity-focused planning • targeting some % of programs and resources for equity impact • part of this is equity-focused planning: • exercise on using Health Equity Impact Assessment • back to driving health equity strategy into action • including addressing underlying social determinants through community-based initiatives and cross-sectoral collaborations © The Wellesley Institute June 17, 2010 www.wellesleyinstitute.com

• If all Ontarians had the same health as Ontarians with higher incomes, the POWER project has estimated that: • 318,000 fewer people (166,000 women and 152,000 men) would be in fair or poor health • 231,000 fewer people (110,000 women and 121,000 men) would be disabled • 3,373 fewer deaths each year (947 women and 2,426 men) among Ontarians living in metropolitan areas © The Wellesley Institute www.wellesleyinstitute.com 8

inequality in how long people live • difference btwn life expectancy of top and bottom income decile = 7.4 years for men and 4.5 for women + inequality in how well people live: • more sophisticated analyses add the pronounced gradient in morbidity to mortality → taking account of quality of life and developing data on health adjusted life expectancy • even higher disparities btwn top and bottom = 11.4 years for men and 9.7 for women Statistics Canada Health Reports Dec 09 © The Wellesley Institute www.wellesleyinstitute.com 10

• clear research consensus that roots of health disparities lie in broader social and economic inequality and exclusion • impact of inadequate early childhood development, poverty, precarious employment, social exclusion, inadequate housing and decaying social safety nets on health outcomes is well established here and internationally • real problem is differential access to these determinants – many analysts are focusing more specifically on social determinants of health inequalities www.welleseyinstitute.com 11

•Determinants interact and intersect with each other •In constantly changing and dynamic system •In fact, through multiple interacting and inter- dependent economic, social and health systems •Determinants have a reinforcing and cumulative effect on individual and population health © The Wellesley Institute www.wellesleyinstitute.com

POWER Study Gender and Equity Health Indicator Framework 14

• Health disparities or inequities are differences in health outcomes that are avoidable, unfair and systematically related to social inequality and disadvantage • This concept: • is clear, understandable and actionable • identifies the problem that policies will try to solve • is also tied to widely accepted notions of fairness and social justice • The goal of health equity strategy is to reduce or eliminate socially and institutionally structured health inequalities and differential outcomes © The Wellesley Institute www.wellesleyinstitute.com

• A positive and forward-looking definition = equal opportunities for good health • Health equity is a broad concept that also prioritizes diversity: • reflecting the increasing diversity of Ontario society and the fact that racism and ethno-cultural differences are important determinants of health disparities • recognizing that services that reflect and speak to the diversity of cultures are essential to an equitable system • Impact of achieving health equity would • extend far beyond enhancing individual and collective well being • also contribute to overall social cohesion, shared values of fairness and equality, economic productivity, and community strength and resilience © The Wellesley Institute www.wellesleyinstitute.com

• the point of all this analysis is to be able to identify policy and program changes needed to reduce health disparities • but health disparities can seem so overwhelming and their underlying social determinants so intractable → can be paralyzing • think big and think strategically, but get going • everything can’t be tackled at once --need to split strategy into actionable components and phase them in • make best judgment from evidence and experience • identify actionable and manageable initiatives that can make a difference • experiment and innovate • learn lessons and adjust – why evaluation is so crucial • gradually build up coherent sets of policy and program actions – and keep evaluating • need to start somewhere – and focus here is on health system © The Wellesley Institute 17 www.wellesleyinstitute.com

1. its in the health system that the most disadvantaged in SDoH terms end up sicker and needing care • equitable healthcare can help to mediate the harshest impact of the wider social determinants of health on health disadvantaged populations and communities 2. in addition, there are systemic disparities in access and quality of healthcare that need to be redressed • people lower down the social hierarchy tend to have poorer access to health services, even though they may have more complex needs and require more care • unless we address inequitable access and quality, healthcare could make overall disparities even worse • at the least, the goal is to ensure equitable access to care for all who need it, regardless of their social position © The Wellesley Institute www.wellesleyinstitute.com

Toronto Central: Lower Income, More Physician Visits For Arthritis % With Physicia n Visits for Arthritis, Age 45-64, TC LHIN 2001-03 25 20 20 14 15 13 11 10 5 0 Low Income High Income Males Females Proportion of Residents with physician visits for Arthritis is higher in Lower Income neighbourhoods, especially females. Neighbourhood Income Quintiles Toronto Community Health Profiles Partnership, www.torontohealthprofiles.ca © The Wellesley Institute www.wellesleyinstitute.com 19

Toronto Central: Lower Income, Lower Hip Replacement Rate Hip Replacement Rate, TC LHIN, 2004/05 144 150 #/100,000 100 68 50 0 Lowest Income Highest Income Age Standardized Rates. Total Hip Replacements per 100,000 Population by Neighbourhood Income Quintiles. Source: Institute for Clinical Evaluative Sciences (ICES) November 2006 © The Wellesley Institute © The Wellesley Institute www.wellesleyinstitute.com www.wellesleyinstitute.com 20

• broad social and healthcare provider consensus that discrimination between women and men is no longer acceptable • but research has shown that women are less likely than men to receive: • standard heart medication • dialysis treatment • admission to intensive care units • certain surgical procedures – cardiac catherization, kidney transplants, knee arthroplasty (replacement) • surgeons and referring physicians respond in surveys that sex of patient has no effect on their clinical decisions • so….. © The Wellesley Institute www.wellesleyinstitute.com 21

• to see if there were differences by gender in clinical practice • standardized male and female patients went to family physicians and orthopaedic surgeons • presented with the same scripted clinical scenario • found striking differences: • orthopaedic surgeons were 22X more likely to recommend male for total knee arthroplasty than female • family physicians were 2X more likely for male Source: Borkhoff et al, CMAJ, March 11, 2008 © The Wellesley Institute www.wellesleyinstitute.com 22

• POWER data indicates that because of our universal system, access to primary healthcare is high, but… • the % of recent immigrants who were satisfied with • being able to get a routine check up and • with care from their doctor for an urgent problem was about 1/3 less than for Canadian-born • in both these cases, immigrants here for over ten years had only slightly lower or about the same rates as Canadian-born • the % of people who speak neither English or French who were satisfied with care from their doctor for an urgent problem was also about 1/3 less • Wellesley research in St James Town in Toronto highlighted quality of care dimensions – it found that recent immigrants preferred to go to providers who were able to speak their own language and understand their culture © The Wellesley Institute www.wellesleyinstitute.com 23

•while health disparities are pervasive and deep-rooted, they can be changed through policy and program action •comprehensive strategy developed in 2008 for Toronto Central LHIN – 50> recommendations •many recommendations have been acted on •other LHINs are also prioritizing and moving to address health disparities © The Wellesley Institute www.wellesleyinstitute.com 24

• goal is to ensure equitable access to high quality healthcare regardless of social position and that all individuals and communities get the care they need • can do this through a two pronged strategy : 1. building health equity into all health planning and delivery • doesn’t mean all programs are all about equity • but all take equity into account in planning their services and outreach 2. targeting some resources or programs specifically to addressing disadvantaged populations or key access barriers • looking for investments and interventions that will have the highest impact on reducing health disparities or enhancing the opportunities for good health of the most vulnerable © The Wellesley Institute www.wellesleyinstitute.com

Drive health equity into health system through: • making equity core to strategic Priorities and ongoing Planning • using Levers to hand – requiring plans from providers, building equity into performance management • Aligning equity with system priorities and drivers • Targeting some resources and investment to maximize equity impact • Evaluating impact and building a cycle of learning and innovation © The Wellesley Institute June 17, 2010 www.wellesleyinstitute.com 26

• need to make equity one of driving priorities for health system and reform • equity and a population health focus are among key principles enshrined in new Excellent Care for All Act = opening and context • need clear provincial strategy for equity: • implicit from MOHLTC, but promised ten year strategy has not been released • Ministry of Health Promotion is moving towards a healthy community planning approach – potentially more equity-orientated • need strategic coherence across health system in approach to equity • LHINs and other coordinating agencies need to prioritize equity • cascading down to clear prioritization from providers for their service delivery and resource allocation © The Wellesley Institute June 17, 2010 www.wellesleyinstitute.com 27

• greater chance of success for equity strategy if aligned with provincial priorities: • diabetes, wait times, mental health • mental health and diabetes are particularly sensitive to social conditions • chronic disease prevention and management programs cannot be successful unless they take account of social conditions and constraints • critical to enabling people with mental health challenges to recover , manage condition or live in the community are a continuum of community supports that take into account the social exclusion, poverty and other challenges people face • these priorities will not be achieved unless planning/delivery takes equity into account © The Wellesley Institute www.wellesleyinstitute.com 28

• equity also supports other system drivers • better access to primary care is key to reducing pressure on ER wait times and ALC • reducing language barriers to good care through better interpretation can reduce mis-diagnoses and over- prescriptions → enhanced quality and cost effectiveness • taking lived conditions/experience into account – meaning equity and diversity → essential to high quality patient- centred care • reducing higher expenditures on vulnerable populations due to health disparities → can contribute to overall sustainability © The Wellesley Institute www.wellesleyinstitute.com 29

• addressing health disparities in service delivery and planning requires a solid understanding of: • key barriers to equitable access to high quality care • the specific needs of health-disadvantaged populations • gaps in available services for these populations and kids • need to understand roots of disparities: • i.e. is the main problem language barriers, lack of coordination among providers, sheer lack of services in particular neighbourhoods, etc. • which requires good local research and detailed information – speaks to great potential of community-based research • involvement of local communities and stakeholders in planning and priority setting is critical to understanding the real local problems • requires an array of effective and practical equity-focused planning tools © The Wellesley Institute www.wellesleyinstitute.com 30

1. quick check to ensure equity is 1. simple equity lens considered in all service delivery/planning 2. Health Equity Impact 2. take account of disadvantaged Assessment populations, access barriers and related equity issues in program planning and service delivery 3. assess current state of provider 3. equity audits and/or HEIA organization 4. determine needs of communities 4. equity-focused needs facing health disparities assessment 5. assess impact of programs/interventions on 5. equity-focused evaluation health disparities and disadvantaged populations © The Wellesley Institute 31 www.wellesleyinstitute.com

• planning tool that analyzes potential impact of program or policy change on health disparities and/or health disadvantaged populations • can help to plan new services, policy development or other initiatives • can also be used to assess/realign existing programs • intended to be relatively easy-to-use tool • essentially prospective • piloted in Toronto in 2009 by MOHTLC, Toronto Central LHIN and WI • refined template and developed a new workbook • HEIA is being used in Toronto Central and other LHINs and providers across the province • HEIA is being incorporated into a “health in all policies’ framework by MOHLTC • increasing attention to potential – from WHO, through most European strategies, PHAC, to MOHLTC and LHINs © The Wellesley Institute www.wellesleyinstitute.com 32

prior step: • screening – identifying projects where HEIA would be useful – where there could be differential impact or outcomes 1. template asks how the planned program or initiative affects health equity for particular populations • list of health disadvantaged populations – not meant to be exhaustive • potential impact on social determinants of health 2. then assess potential positive and negative impacts of the initiative on the population(s) based on best available evidence -- and indicate where more information is needed 3. develop means to build on positive and mitigate negative impacts 4. planners indicate how implementation of the initiative will be monitored to assess its impact 34

• generally designed for planning forward: • easy-to-use tool to ensure equity factors are taken into account in planning • more generally, can be a means to ensure equity is incorporated into routine planning throughout an organization • but providers in pilot phases – and experience from other jurisdictions -- identified other uses: • for strategic and operational planning • for assessing whether programs should be re-aligned or continued • to build principles into evaluation and quality improvement © The Wellesley Institute June 17, 2010 www.wellesleyinstitute.com 35

• each table will go thorough the HEIA for a concrete specific example • use the template and workbook • we will see if participants have examples they want to pursue • and/or some tables will work up a hypothetical case • we will then report back and collectively discuss lessons learned © The Wellesley Institute June 17, 2010 www.wellesleyinstitute.com 36

You are planning to develop diabetes outreach in a specific neighborhood or area. You want to improve people’s ability to monitor and manage their own care, and to get residents hooked into primary care for ongoing support and monitoring. Use the HEIA tool to help plan this programme. © The Wellesley Institute June 17, 2010 www.wellesleyinstitute.com 37

1. was the template useful for analyzing the potential impact of the planned program? 2. what kinds of potential positive and negative impacts did you find? 3. what means to build on positive and mitigate negative impacts did you identify? 4. how would you monitor impact other lessons learned? © The Wellesley Institute June 17, 2010 www.wellesleyinstitute.com 38

• a promising direction several LHINs have taken up is to require providers to develop equity plans • these plans are designed to: • identify access barriers, disadvantaged populations, service gaps and opportunities in their catchement areas and spheres • develop programs and services to address those gaps and better meet healthcare needs of disadvantaged communities • these provider plans have the potential to: • raise awareness of equity within the organizations • build equity into planning, resource allocation and routine delivery • pull their many existing initiatives together into a coherent overall equity strategy • build connections among providers for addressing common equity issues • hospitals in Toronto Central and Central LHINs developed equity plans broadly meeting those objectives • and other providers in Central have done plans © The Wellesley Institute www.wellesleyinstitute.com 39

http://www.torontoevaluation.ca/tclhin/index.html © The Wellesley Institute www.wellesleyinstitute.com

• these plans were seen to achieve their objectives of building awareness of equity within the organizations and beginning to embed equity in planning and decision- making • in Central: issues identified in the hospital plans were incorporated into individual hospital deliverables → they report quarterly on progress • in Toronto Central: • the hospitals are required to refresh their plans under their current HSAAs • commitments and priorities identified in the refreshed plans will be built into next HSAAs • three immediate key issues identified in many of the 18 plans were moved on by the LHIN © The Wellesley Institute www.wellesleyinstitute.com

1. language is key barrier to access • cross-sectoral project analyzing how to enhance and streamline interpretation services • building on comparative international research 2. when hospitals in Toronto Central began working on their equity plans it became very clear that they simply did not have the necessary data to do equity-driven planning • project with several Toronto hospitals to see how to collect patient SDoH data 3. huge barriers faced by people without health insurance • project led by GTA CHCs to analyze how to streamline available funds and practice © The Wellesley Institute www.wellesleyinstitute.com 42

• clear in new Excellent Care for All Act that priorities will be driven through performance management and guidelines • all hospitals, agencies and CHCs sign Service Accountability Agreements with LHINs that govern flow of funds • can build in specific expectations and deliverables • will vary by community and provider -- but could include: • undertaking appropriate equity-focused planning • providing sufficient services in languages of community and appropriate interpretation • identifying areas where access to services is inequitable and developing plans to address barriers and gaps • ensuring service utilization matches appropriately with demography and needs of their catchment profile • developing specific services or outreach to particular disadvantaged populations – homeless, isolated immigrant seniors, etc. © The Wellesley Institute www.wellesleyinstitute.com

• vital part of comprehensive policy on health equity • setting targets or defining indicators – that build on available reliable data and make the most sense in the particular context • closely monitoring progress against the indicators or targets • disseminating the results widely for public scrutiny • another result of TC LHIN hospital equity plans = development of hospital clinical equity indicators by CRICH • need to build these equity targets and objectives into routine performance management and routine provider planning © The Wellesley Institute 44 www.wellesleyinstitute.com

• there are broad targets for priorities such as diabetes or encouraging healthy behaviours → build equity into these targets: • a number of LHINs have identified areas where diabetes incidence is highest → equity target = reduce differences in incidence, complications and rates of hospitalization between populations or areas • a good service target has been proposed for diabetes = high/increasing % of people who get best standard care → equity target = reduce differences by gender, income, ethno-cultural background • need to drill down in specific areas that have high equity impact: • ensuring access and use of primary health care does not vary inequitably by income level, immigration status, neigbourhood, gender, race, etc. • in fact, concentrate services in most disadvantaged communities with greatest needs • many programs assess their services through client satisfaction surveys and similar methods • providers look for high and improving satisfaction → equity target = reduce any differences in satisfaction by gender, income, ethno-cultural background, etc. © The Wellesley Institute www.wellesleyinstitute.com 45

• precondition for all this planning, monitoring indicators, and assessing progress against objectives and targets is reliable data on: • health outcomes and behaviour, differentiated by population, neighbourhood and income, education, ethno-cultural background and other determinants of health • service use patterns, also stratified • how well service use reflects catchment and community make-up • trends in all of this – to monitor impact and progress • when hospitals in Toronto Central began working on their equity plans it became very clear that they simply did not have the necessary data to do equity-driven planning • a workshop was held on what kinds of data on equity and diversity are available, how the existing data sets can be effectively used, and what further types of data are needed • presentations and resources from the day and report from working group to Collaborative were published on partner sites including http://www.healthequitycouncil.ca/dev © The Wellesley Institute www.wellesleyinstitute.com 46

• target services to specific areas or populations: • those facing the harshest disparities – to raise the worst off fastest • or most in need of specific services • or the worst barriers to equitable access to high-quality services • this requires sophisticated analyses of the bases of disparities: • i.e. is the main problem language barriers, lack of coordination among providers, sheer lack of services in particular neighbourhoods, etc. • which requires good local research and detailed information – speaks to great potential of community-based research to provide rich local needs assessments and evaluation data • involvement of local communities and stakeholders in planning and priority setting is critical to understanding the real local problems © The Wellesley Institute © The Wellesley Institute www.wellesleyinstitute.com 47 www.wellesleyinstitute.com

• North York West region has been identified as high need – diverse population, high % of racialized population, high risk factors, lack of access to primary care • problems include concentrated poverty and inadequate services and infrastructure • highlights the need for local cross-sectoral planning and collaboration beyond boundaries • need to link up with local social services, community service agencies, residents, public health, other LHINs in area • in Toronto and other cities: people without health insurance – primarily immigrant/refugees: • many community initiatives to provide access • Women’s College Network on Noninsured is forum for coordination • recently held research conference showing critical barriers to access and good care and resulting adverse health outcomes for vulnerable people © The Wellesley Institute June 17, 2010 www.wellesleyinstitute.com

• one of identified equity challenges for North York General hospital was language: • identified as critical issue in hospital equity plans and other Toronto Central planning → major project to develop more systematic coordinated approach to interpretation in downtown hospitals • could hook up to this – or at least keep it on horizon • could also link into Healthcare Interpreters Network • another critical barrier to equitable access in parts of Central – and other LHINs – is remoteness and transportation • have been innovative community-based and volunteer transportation • highlights key role of LHINs in enabling such critical supports for health and in supporting cross-sectoral collaborations © The Wellesley Institute www.wellesleyinstitute.com 49

• LHINs are all about integration and coordination: • will be experimenting and innovating with enhanced coordination and partnerships • with different kinds of community-based service delivery and on-the- ground coordination → locate in high-need areas • solid evidence that enhancing primary care is one of key ways to improve care of disadvantaged • lack of access to primary care has been identified as a key issue for Prov and LHINs • recognizing that most of primary care levers are outside LHIN mandate → need to collaborate • concentrate new investments or coordination initiatives in particular regions or neighbourhoods, or in particular populations such as refugees or uninsured © The Wellesley Institute www.wellesleyinstitute.com

• assessing the potential equity impact of initiatives on particular populations requires solid understanding of that population's health situation, needs and context → need ongoing engagement with the population and/or specific community-based research or needs assessment • analyzing how to design services to meet specific barriers or population needs will also benefit from engaging the affected population • similarly, monitoring and assessing the impact of service initiatives also needs: • research and input from the affected population • health outcome data stratified by population and determinants © The Wellesley Institute 51 www.wellesleyinstitute.com

• investing in better chronic care prevention and management are vital elements of health reform • up-stream initiatives need to be planned and implemented through an equity lens • very clear gradient in incidence – and impact – of chronic conditions • some populations and communities need greater support to prevent and manage chronic conditions • need to build these specific needs into CDPM planning and resource allocation • a very interesting primer has been developed by Health Nexus, Ontario Chronic Disease Prevention Alliance and other partners to help incorporate social determinants into chronic care management and support http://www.ocdpa.on.ca/docs/Primer%20to%20Action%20SDOH%20F inal.pdf © The Wellesley Institute 52 www.wellesleyinstitute.com

• more emphasis on health promotion is vital to long-term sustainability of system and individual health • consistent data on variations of risk factors along the social gradient • anti-smoking, exercise and other health promotion programmes need to explicitly foreground the particular social, cultural and economic factors that shape risky behaviour in poorer communities– not just the usual focus on individual behaviour and lifestyle • need to customize and concentrate health promotion programs especially for most disadvantaged • if this isn’t done → can unintentionally widen disparities as better off take up programs more • the Ministry of Health Promotion is starting to take a healthy communities approach to planning health promotion • opportunity to get beyond individual behavioural approaches © The Wellesley Institute www.wellesleyinstitute.com 54

• Ministry and LHINs need to fund and enable evaluation – not just as a tacked-on expectation and not ties to accountability regimes • need to figure our what interventions and approaches work, in what contexts and why • can’t just measure activity – number or % of pop’n that participated in a program • need to measure health outcomes – even when impact only shows up in long-term • need to assess reach -- who isn’t signing up? • need to differentiate those with greatest need = who programs most need to reach and keep to have an impact → develop funding and evaluation weighting that recognizes more complex needs and challenges of most disadvantaged, and builds this into incentive system → investment in policy directions and program interventions that will have the strongest equity impact © The Wellesley Institute www.wellesleyinstitute.com 55

• cross-sectoral coordination and planning are key ways to put wider SDoH into action • many European national strategies emphasize local adaptation and cross-sectoral collaboration: • British Health Action Zones were examples of concentrated local investments in community economic development and targeted healthcare and social service improvements • potential of comprehensive community initiatives: • collaborative cross sectoral efforts – for poverty reduction, community development, health disparities • Vibrant Communities, Social Planning Councils and others are developing cross-sectoral planning forums and processes in many communities around poverty and inequality – with clear implications for health © The Wellesley Institute www.wellesleyinstitute.com 57

• in Canada, some Regional Health Authorities have developed service and planning links with local social services or emphasized community capacity building: • Saskatoon began from local research documenting shocking disparities among neighbourhoods • focusing interventions in the poorest neighbourhoods – locating services in schools, relying on First Nations elders to guide programming, etc. • wide collaboration among public health, municipality, school board, business, community, Aboriginal and other leaders • in Ontario public health are key players in addressing health disparities on the ground • a number of public health units have been pioneering social determinants approaches -- Sudbury, Waterloo, Toronto • often involved in community collaborations © The Wellesley Institute www.wellesleyinstitute.com 58

• hub-style multi-service centres in which a range of health and employment, child care, language, literacy, training and social services are provided out of single ‘one stop' locations • Winnipeg Regional Health Authority and Manitoba Family Services and Housing have partnered on a new model to integrate health and social service delivery – one-stop access models in various communities to deliver a broad range of health and social services directly and to refer on to other agencies when services aren’t available • some new satellite CHCs are being developed in designated high-need areas in Toronto will involve the CHCs delivering primary and preventive care and other agencies providing complementary social services out of the same location • Ontario provincial associations representing CHCs, mental health and community service agencies have been promoting idea -- including to LHIN CEO provincial planning table © The Wellesley Institute 59 www.wellesleyinstitute.com

• huge number of community and front-line initiatives already addressing equity across province • CHCs especially, community organizations based out of specific ethno- cultural communities • many community providers have established ‘peer health ambassadors’ to provide system navigation, outreach and health promotion services to particular communities • for homeless people: • CAISI database so records are accessible from many providers • travelling psychiatrists, nurses and other providers • Baby and Me passport • Street Health report as CBR into action • but • experience and lessons learned are not being shared systematically • potential of promising interventions is not being realized © The Wellesley Institute 60 www.wellesleyinstitute.com

• to drive equity-focused innovation and effective interventions, we need to be able to: • collate and analyze all the useful intelligence gained from equity-focused planning • capture and share information on local initiatives, and build on local front-line insights • share the resulting knowledge across regions – and beyond • assess the most promising initiatives or directions rigorously • scale up promising initiatives across the province where appropriate • need to create forums and infrastructure for this innovation knowledge management • and need to build equity-focused innovation into incentives and drivers - - cascading from Prov to LHINs to providers • expectation that X% of budget will be devoted to equity-orientated innovation • ear-marked funds for equity innovation © The Wellesley Institute www.wellesleyinstitute.com 61

• sophisticated strategy, solid equity-focused research, planning and innovation, and well-targeted investments and services are key • but in the long run also need fundamental changes in over- arching state social policy and underlying structures of economic and social inequality • these kinds of huge changes come about not just because of good analysis, but through widespread community mobilization and social pressure • key to equity-driven reform will also be empowering communities to imagine their alternative health futures and to organize to achieve them © The Wellesley Institute www.wellesleyinstitute.com 62

• health disparities are pervasive and deep-seated – but can’t let that paralyze us • do need a comprehensive and coherent health equity strategy – but don’t wait for perfect strategy • think big and think strategically – but get going • there is a solid base of healthcare provider experience, commitment and community connections to build on • a great deal of equity-focused planning and innovative delivery is already going on – challenge is to build on this potential • have set out overall strategic approaches, principles and tools to drive equity into action → experiment and innovate • many within the health system have long experience and strong commitment to equity → build on this to drive coordinated and coherent system-wide equity agenda into action © The Wellesley Institute www.wellesleyinstitute.com 63

• hypothetical case study used in HEIA exercise in major Toronto academic hospital © The Wellesley Institute June 17, 2010 www.wellesleyinstitute.com 64

• much monitored and incorporated into performance mgmt and quality improvement • clear pressure to reduce re-admissions – ties to ALC, ER and other priorities • are there equity implications? • can assume people on operating table are treated equitably depending upon their immediate situation • but are there variations in outcomes – immediate success of operations, mortality, complications, re-admissions? • by gender • by social and economic situation • by ethno-cultural or immigration status • by comfort/facility with English © The Wellesley Institute June 17, 2010 www.wellesleyinstitute.com 65

• whether there are inequitable variations in re-admissions is a research question: • hospitals don’t usually collect such data • so use proxy data from postal code = neighbourhood characteristics from census data • can use case studies and small-scale interview/chart review studies • highlights importance of project underway to collect better equity-relevant data • if evidence is yes – or if practitioners experience leads them to conclude that there are inequitable variations • then need to drill down using HEIA template to analyze why particular populations might have higher re-admissions – two examples to illustrate • patients from poor neighbourhoods • patients who do not speak or understand English well • and need to drill down to different stages of care process © The Wellesley Institute June 17, 2010 www.wellesleyinstitute.com 66

•population health and •not much hospitals can do epidemiological data indicate about social conditions? that they may have poorer overall health •take poorer situations/higher → greater risk risks into account: + less capacity to cope well with • at least, ensure no differential effects of surgery or inequitable treatment • equitable care = more intensive pre-admission planning and support • even broader = including child care, transportation and other assistance to support coming in for pre-surgery • nutritional and other support to help prepare © The Wellesley Institute June 17, 2010 www.wellesleyinstitute.com 67

•population health and •take poorer situations/higher epidemiological data indicate risks into account that they may face: •as previous + • SES challenges as above • cultural competence lens reflecting more unequal or precarious position in labour • interpretation at pre-surgery market • translation of all material • plus effects of immigration • more intensive follow-up to status, social exclusion and confirm/support – possibly other social determinants peer health ambassadors shaping poorer overall health → greater risk + less capacity to cope well with effects of surgery + might not understand pre-op instructions and prep © The Wellesley Institute June 17, 2010 www.wellesleyinstitute.com 68

•poor living conditions, food, •take poorer situations/higher anxiety → less able to cope → risks into account: poorer recovery • at least, ensure no differential •can’t take as much time off or inequitable treatment in post-surgical (length of stay) work or discharge planning •can’t afford dressings and • equitable care = more other requirements intensive case mgmt and assessment •can’t afford meds • send home with more •don’t have equitable access supplies, meds, etc. to home and community- • more intensive follow-up to based support those in greatest need – not • research question for CCAC just medically defined • is access and utilization equitable? © The Wellesley Institute June 17, 2010 www.wellesleyinstitute.com 69

•social determinants + cultural competence related challenges as lens previous • interpretation for + may not understand discharge planning how to take meds or • translation of all post- surgical materials follow-up care • more intensive follow up may not be able to in language/culture contact professional for • potential of peer health advice ambassadors © The Wellesley Institute June 17, 2010 www.wellesleyinstitute.com 70

• demonstrated value of equity lens on this issue – and most? • can identify inequitable constraints and barriers: • in this case, some seem outside of hospital’s control → but can take into account in care planning • can identify mediating actions that can be taken and make recommendations: • to senior mgmt team • to appropriate surgical, nursing and other care teams • then need to monitor impact: • indicators and stats • patient satisfaction – by these equity variables • can assess lessons learned → incorporate into ongoing quality improvement © The Wellesley Institute June 17, 2010 www.wellesleyinstitute.com 71

• back to bigger picture • following is a roadmap for comprehensive integrated policy action on determinants of health and health inequality © The Wellesley Institute www.wellesleyinstitute.com

1. look widely for ideas and inspiration from jurisdictions with comprehensive health equity policies, and adapt flexibly to Canadian, provincial and local needs and opportunities; 2. address the fundamental social determinants of health inequality – macro policy is crucial, reducing overall social and economic inequality and enhancing social mobility are the pre-conditions for reducing health disparities over the long- term; 3. develop a coherent overall strategy, but split it into actionable and manageable components that can be moved on; 4. act across silos – inter-sectoral and cross-government collaboration and coordination are vital; 5. set and monitor targets and incentives – cascading through all levels of government and programme action; © The Wellesley Institute 73 www.wellesleyinstitute.com

6 rigorously evaluate the outcomes and potential of programme initiatives and investments – to build on successes and scale up what is working; 7 act on equity within the health system: • making equity a core objective and driver of health system reform – every bit as important as quality and sustainability; • eliminating unfair and inefficient barriers to access to the care people need; • targeting interventions and enhanced services to the most health disadvantaged populations; 8 invest in those levers and spheres that have the most impact on health disparities such as: • enhanced primary care for the most under-served or disadvantaged populations; • integrated health, child development, language, settlement, employment, and other community-based social services; © The Wellesley Institute 74 www.wellesleyinstitute.com

9 act locally – through well-focussed regional, local or neighbourhood cross- sectoral collaborations and integrated initiatives; 10 invest up-stream through an equity lens – in health promotion, chronic care prevention and management, and tackling the roots of health disparities; 11 build on the enormous amount of local imagination and innovation going on among service providers and communities across the country; 12 pull all this innovation, experience and learning together into a continually evolving repertoire of effective programme and policy instruments, and into a coherent and coordinated overall strategy for health equity. © The Wellesley Institute 75 www.wellesleyinstitute.com

• these speaking notes and further resources on policy directions to enhance health equity, health reform and the social determinants of health are available on our site at http://wellesleyinstitute.com • my email is bob@wellesleyinstitute.com • I would be interested in any comments on the ideas in this presentation and any information or analysis on initiatives or experience that address health equity © The Wellesley Institute www.wellesleyinstitute.com

The Wellesley Institute advances urban health through rigorous research, pragmatic policy solutions, social innovation, and community action. © The Wellesley Institute June 17, 2010 www.wellesleyinstitute.com 77

Gardner changing face of ont conf june 16 2010

by Wellesley Institute

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Gardner changing face of ont conf june 16 2010 Presentation Transcript