CAPHC Plenary Presentation Changing the Odds and Finishing First: Harnessing Our Strengths to Improve Children’s Health Services in Canada

1. Changing the odds and finishing first:
Harnessing our strengths to improve
children’s health services in Canada
CAPHC
October 24, 2016

2. 2
• Insert photo of child here

3. Objectives for today…
• What are the some of our challenges
and opportunities in improving health
and health services for children
• How can we move to improve health
of children and youth?
• How do we improve the health
service system for children and
youth?
• Learning from one another
3

4. Objectives for today…
• What are the some of our
challenges and opportunities in
improving health and health
services for children
• How can we move to improve health
of children and youth?
• How do we improve the health
service system for children and
youth?
• Learning from one another
4

5. 5

6. Challenge:
Proportion of children in the population as a whole
6

7. Challenge:
Proportion of children in the population as a whole
7

8. Challenge
Proportion of children in the population compared to
>65
8

9. 9

10. Challenge:
Geographic differences
10Accessed from www.statscan.gc.ca

11. 11

12. 12

13. Challenge:
Vast geography – relatively small population
13

14. Source: http://www.bcrobyn.com/2012/12/how-big-is-british-columbia/

15. Challenge:
Health status
of Canada’s
children?
UNICEF Office of Research (2013). ‘Child Well-being in Rich Countries:
A comparative overview’, Innocenti Report Card 11, UNICEF Office of
Research, Florence.

16. Challenge
Health care expenditures
16

17. Challenge – describing health care expenditures for
children
17

19. Challenges
• Proportionately few children in the population
• Proportionately more children in more rural and remote areas
• Vast geography
– with relatively low population and low population of children
• The health status of Canadian children remains a concern
• Health system sustainability/cost remains a concern
– How well can we describe “health” related costs for children?
– Health system reform, health service integration
19

20. 20

21. Strengths and opportunities
• Publically funded health care system
– Multi-sectoral especially for children and youth
• Data – national and provincial
21

22. National:
•Canadian Community Health Survey
•National Housing Survey
•LIM –AT (Low Incomes Measures – After Tax)
•Statistics Canada Labour Force Survey
Provincial:
•VISTA BC Vital Statistics
•Perinatal Services BC Data Base
•McCreary Centre Society Adolescent Health Survey
•Early Development Instrument – Human Early Learning Partnership
•BEST
•BC Centre for Disease Control
•Ministry for Children and Family Development Data Base
•Ministry of Education Data Base
•Ministry of Health – Public Health Surveillance and Epidemiology, Chronic Disease
Registries
•Ministry of Health – HealthIdeas database
Example – BC child health status report

23. Strengths and opportunities
• Publically funded health care system
– Multisectoral, especially for children and youth
• Data – national and provincial
• Data analysis, interpretation
– Academic knowledge with respect to children/ excellence in health
services researchers
– Partnerships e.g. CAPHC and CIHI
– Emphasis on children – CIHI
23

24. Strengths and opportunities
• Evidence-based policy
• Evidence-based practice, including national endeavors
– E.g. TREKK, Child-Bright SPOR
• Academically strong training programs
– Well trained health providers
• System innovation
– Including learning from eachother
• Tremendous philanthropic support
• We collaborate rather than compete 24

25. Objectives for today…
• What are the some of our challenges
and opportunities in improving health
and health services for children
• How can we move to improve health
of children and youth?
• How do we improve the health
service system for children and youth?
• Learning from one another
25

26. Two pronged approach to improving child health
26
Improve health status Improve health services

27. Objectives for today…
• What are the some of our challenges
and opportunities in improving health
and health services for children
• How can we move to improve
health of children and youth?
• How do we improve the health service
system for children and youth?
• Learning from one another
27

28. 28
What makes us healthy?

29. Canadian Medical Association, 2013

30. What do we
know about
the health
status of
Canada’s
children?
UNICEF Office of Research (2013). ‘Child Well-being in Rich Countries:
A comparative overview’, Innocenti Report Card 11, UNICEF Office of
Research, Florence.

31. Do you know how healthy children in your province
are?
•
31

32. • UBC Departments
of Pediatrics,
Surgery
• Canadian Child
Health Coalition
• BC Pediatric
Society
• DOBC: Society of
GPs
• BC Principals, Vice
Principals
• Fraser
• Interior
• Island
• Northern
• Van-Coastal
• PHSA
• First Nations
• Ministry of Health
• Ministry of
Child/Family
Development
• Ministry of
Education
Government
Ministries
Provincial
Health
Authorities
Academic
Partners
Professional
Societies
Child Health BC - Steering Committee

33. Is “Good” Good Enough?
• A BC report
• For release November 3, 2016
– “Book” version
– Online version

34. Dimensions of Child and Youth Health &
Well-being
In 2013, the PHO and the
Canadian Institute for Health
Information (CIHI) released a
suite of 51 valid indicators
• The indicators reflect five
dimensions:

35. THE INDICATORS:
Physical Health & Well-being
• Physical health and well-being is more than the absence of
disease. It includes a healthy start in life, preventive care, healthy
development, safe environments, and much more.
• This dimension includes 21 indicators:
#1 Low Birth Weight
#2 Smoking during Pregnancy
#3 Alcohol Use during Pregnancy
#4 Breastfeeding
#5 Fruit & Vegetable Consumption
#6 Vision Screening
#7 Hearing Screening
#8 Dental Caries Prevalence
#9 Percentage of Children with Healthy
Weight
#10 Positive Self-rated Health
#11 Youth Physical Activity Levels
#12 Frequency of Tobacco Use
#13 Binge Drinking
#14 Marijuana Use
#15 Immunization Rates
#16 Asthma Prevalence
#17 Serious Injury among Children & Youth
#18 Chlamydia Incidence
#19 Teenage Birth Rate
#20 Physical Health & Well-being Skills
#21 Infant Mortality Rate

36. THE INDICATORS:
Mental & Emotional Health & Well-being
• Mental and emotional health and well-being refers to a range of
personal characteristics, self-regulating abilities, capacity for
connectedness, and freedom from anxiety and depression.
• This dimension includes 7 indicators:
#22 Incidence & Prevalence of Most Common
Mental Health Disorders
#23 Positive Self-esteem
#24 Positive Self-rated Mental Health
#25 Positive Life Satisfaction
#26 Considered Suicide
#27 Suicide Rate
#28 Most Common Prescription Mental
Health Drugs

37. THE INDICATORS:
Social Relationships
• Social relationships are key components of child and youth health
and well-being, and includes having relationships that are close,
trusted, accepting, affirming and reciprocal with peers, parents,
teachers, coaches and others.
• This dimension includes 11 indicators:
#29 Positive Parent Relationship
#30 Trusting Adult Relationship
#31 School Connectedness Rate
#32 Community Connectedness Rate
#33 Incidence of Abuse/Neglect
#34 Incidence of Sexual Abuse
#35 Rate of Children in Care
#36 Discrimination Rate
#37 Bullying Rate
#38 Youth Conviction Rate
#39 After-school Activities

38. Advisory Committee members include representatives:
– Health Officer’s Council
– Ministry of Health
– Ministry of Education
– Ministry for Children and Family Development
– First Nations Health Authority
– Health Authorities
– Doctors of BC
– BC Pediatric Society
– BC Children’s Hospital
– BC Centre for Disease Control
– Perinatal Services BC
– BC Representative for Children and Youth
– UBC
– Researchers from McCreary Centre Society, HELP
A collaborative effort

39. Some indicators demonstrate improvement over time
Language and Cognitive Development Domain – Vulnerability on EDI

40. Some indicators show stability over time
Physical Health domain – Immunization rates

41. Some indicators showed decline over time
Social Relationships

42. Disparities by sex/gender in many indicators

45. Some examples of how we are responding in BC
• Trying to deliver the “critical messages” about health status of our children
– Including through work of our Healthy Child Development Alliance
45

46. Some examples of how we are responding in BC
• Trying to deliver the “critical messages” about health status of our children
– Including through work of our Healthy Child Development Alliance
• Measured health status – so we have the knowledge of health status to work
with
• Worked with the Ministry of Health’s so ensure their “Lifetime Prevention
Schedule” has a focus on evidence-based interventions for children. E.g
flouride varnish for prevention of caries
46

47. Some examples of how we are responding in BC
• Trying to deliver the “critical messages” about health status of our children
– Including through work of our Healthy Child Development Alliance
• Measured health status – so we have the knowledge of health status to work
with
• Worked with the Ministry of Health’s so ensure their “Lifetime Prevention
Schedule” has a focus on evidence-based interventions for children e.g.
flouride varnish for the prevention of caries
• Working on implementation strategy for flouride varnish for children
• Continuing/ renewed immunization efforts
• Reinforcing efforts regarding mental health promotion/health literacy
• Linkages with First Nations Health Authority
• Province standards and resources for healthy physical activity and healthy
eating in child care settings (Ministry grant)
47

48. Some examples of how we are responding in BC
• Trying to deliver the “critical messages” about health status of our children
– Including through work of our Healthy Child Development Alliance
• Measured health status – so we have the knowledge of health status to work
with
• Worked with the Ministry of Health’s so ensure their “Lifetime Prevention
Schedule” has a focus on evidence-based interventions for children e.g.
flouride varnish for the prevention of caries
• Working on implementation strategy for flouride varnish for children
• Continuing/ renewed immunization efforts
• Reinforcing efforts regarding mental health promotion/health literacy
• Linkages with First Nations Health Authority
• Province standards and resources for healthy physical activity and healthy
eating in child care settings (Ministry grant)
• Must link with and support youth! 48

49. A call to action
49

50. How do we respond as health care providers and
managers?
• Deliver the critical messaging
• But does it influence…
– What services we provide?
– How we provide our services?
– For example, how do geographic disparities/inequities influence what
you provide?
50

51. Our call to action: I’ll hope you’ll join in thinking
about…
• What do you know about the health/health status of children in your
province?
• What is your province measuring about the health of its children?
• What population health initiatives are supporting child health?
• How are pediatric/child health experts involved in
supporting/influencing child health (promotion) programs and policy?
• For those of us delivering health services, how do we consider
health status and social vulnerabilities in our hospitals?
51

52. Two pronged approach to improving child health
52
Improve health status Improve health services

53. Objectives for today…
• What are the some of our challenges
and opportunities in improving health
and health services for children
• How can we move to improve health
of children and youth?
• How do we improve the health
service system for children and
youth?
• Learning from one another
53

54. How do support the system of health services for
children? And do we even need a “system?”
54

57. • Challenges service planning given relatively
low volumes & large geography
(Rural/remote and small urban needs)
• Desire to ensure primary care is optimized
while simplifying referral paths and access to
specialty and sub-specialty services.
• Build a foundational to quality and the
development of appropriate:
– Practice guidelines/care pathways
– Care pathways
– Team-based practice models (on-site & via
outreach/telehealth)
– Provincial health human resource strategy
• Sustainability of quality services
What issues did we need to tackle?
57

58. 58
Literature
and
Jurisdictional
review

59. Why tiered approach?
Australia’s Queensland Health: “Clinical Services Capability Framework”
Bundaberg Regional
59

61. Tiers at a Glance (All Services)
61

62. Tiers at a Glance (All Services)
62

63. What does each module “outline?”
• Responsibilities:
– Clinical
– Knowledge Sharing and Transfer
– Quality Improvement and Research
• Requirements:
– Providers
– Equipment and Supplies
– Facilities
– Medications
– Interdependencies
63

64. • key individuals – across
disciplines & geography
• Use outcome evidence
• Use service utilization data
• Guided consensus meetings
(series)
• Broad stakeholder feedback on
draft, including provincial
councils/committees,
• Acceptance by provincial ministry
councils/committees
How do we develop a Tiers of Service Module?
64

65. Each module has three components
65

66. Completed modules
66

67. • Clinical Services:
– Emergency Department
– Medicine
– Medical Subspecialties
– Surgery (Adult & Pediatric Surgical Specialists)
– Intensive Care for children
– Child Development & Rehabilitation
– Mental Health & Substance Use
– Home-based Services
• Clinical Diagnostic & Therapeutic Services:
– Laboratory, Pathology & Transfusion Medicine (in conjunction with
PSBC and the Provincial Lab Agency)
– Diagnostic imaging
– Pharmacy
A series of Tiers of Service Modules (for child health)
67

68. Sample page– Surgery
Example of one area of clinical responsibilities
68
Refer to details in “Surgical Tiers “in brief”
and/or “in full””

69. • Clinical Services:
– Emergency Department
– Medicine
– Medical Subspecialties
– Surgery (Adult & Pediatric Surgical Specialists)
– Intensive Care
– Child Development & Rehabilitation
– Home-based Services
– Mental Health & Substance Use
• Clinical Diagnostic & Therapeutic Services:
– Laboratory, Pathology & Transfusion Medicine (in conjunction with
PSBC)
– Diagnostic imaging
– Pharmacy
Where are we at with the child health tiers?
69

70. 109/109 ED’s in BC completed self-assessment
Module developed, self-assessments completed
70

71. © Child Health BC | November 27, 20154
Data management and analyses completed for
109/109 ED’s
71

72. To what tier are sites aligned?
18
© Child Health BC | January 19, 2016
Given their tier alignment,
what are the strengths and
“opportunities”?
For each site, each HA, the province

73. 73
Hospitals providing ED
care to children, with
ED Tier designation

74. Example – HA map putting tier alignment in context of driving time
74

75. Emergency Tiers
What action has happened since the self-assessment
• Close collaboration between CHBC and the
MOH’s Committee (ESAC)
• Sites and regional action:
– Received their reports
– Site and regional “opportunities”
• Province wide action:
– ESAC and CHBC have created provincial
working group
– Agreed to a common work plan on
September 8, 2016 – heavily T1 and T2.
– Links to academic health network and
mental health services
– Links to national endeavours (e.g. TREKK) 75

76. Received agreement to proceed, in face of other
priority areas
76

77. Even now…
77

78. What is the value in proceeding?
Why is Tiers of Service work of assistance?
Clinical Services:
• Planning and standardization of appropriate services: To reduce
risk/improve quality. To improve efficiency within and across sites.
• Standardization of appropriate care: To set the stage for layering
on clinical standards which are appropriate to tier of service offered
• Rural and Remote focus: Useful across province, especially in
rural and remote settings.
• Capital planning: To focus capital projects to the service needs
appropriate to the community and volumes served – the Tiers
necessary.
• Health human resource planning/Credentialing: To assist in
predicting the nature of the services and subsequent HHR needs at
a given Tier.
78

79. What is the value in proceeding?
Why is Tiers of Service work of assistance?
Quality Improvement/CQI:
• Self-assessment identifies themes for QI and leads to QI action that
is appropriate by tier - enhances focus and efficiency of QI efforts
with less duplication across sites and regions.
Health provide learning/KT
• Educational competencies are identified for each Tier with then
suitable educational content and deliver methods (“Tiers of
Learning”)
Formal Education and Research roles
• Supports the academic mandate/health science network concept in
clear and appropriate ways.
79

80. Tier by tier improvement opportunities
80

81. Linked with Doctors of BC, MOH and “BC Guidelines”
Mary Lou Matthews, Jennifer Scarr, Dr. C Yang (and advisory
group)
Supporting Tiers 1 (Primary Care)
Asthma Guideline and Tool Kit

82. Provincial childhood diabetes planning
Involves Provincial Advisory Committee and 4 working groups
-multi-disciplinary including schools
- all HA’s involved
– Care guidelines for BC (based on review of international standards)
– Service plan for BC (aligned with Tiers of Service)
– Education and resources – for parents and providers
– Information and data
– Research and Evaluation
Pediatric early warning system – PEWS – for inpatient care
– Large scale provincial implementation with research project and embedded QI
– >30 hospitals in BC by end of 2016
Tier 4- leaders and impacted on both
Supporting Tiers 2 and 3

83. • Outreach
• Tele-health – Technology-enhanced access
To care for children
– 19 community sites in BC are now
“pediatric-enhanced”
Telehealth sites
– Surgical patient Journey
– Pediatric medicine subspecialties
– Tele-PICU now live!
– Tele-ED under very early development
Supporting Tiers 2 and 3

84. Cross-Tier Priorities
Delivered at every tier – unique role/capacity of each
tier must be considered
• Child and youth mental health
• Complex care – “frail children”
• Home care for children…
84

85. 85

86. Two pronged approach to improving child health
86
Improve health status Improve health services

88. Enablers of success so far - examples
• Legacy of Dr. Clyde Hertzman
– Long standing awareness of child health and development issues – HELP
• Child Health BC table
– Key players affecting policy, accountable for delivery, training and influence
– Cohesive network with collaborative spirit
– Expansion from focus on health services to cross continuum
– Strong trusting relationships being built
• Focus on tiers has helped us
– Generate improvement activities across tiers
– Understand data – different meaning at different tiers
– Have a common language
– Understand the relationship between volume and quality
88

89. Enablers of success
• BC Children’s Hospital Foundation and its donors
• Leveraging
89

90. Much more to do
• Evaluate all initiatives
– Process measures
– Outcomes measures
– Health status
• Learn from others
90

91. Objectives for today…
• What are the some of our challenges
and opportunities in improving health
and health services for children
• How can we move to improve health
of children and youth?
• How do we improve the health service
system for children and youth?
• Learning from one another
91

92. Questions? Thoughts?
92