Concept of primary health care in canada chc dr shabon 2009

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Concept of primary health care in canada chc dr shabon 2009

  1. 1. The CHC Model of Care Prepared by the Education and Development Team, The Association of Ontario Health CentresThe information contained in this document is confidential and proprietary to the Association of OntarioHealth Centres (AOHC). Unauthorized distribution or use of this document or the information containedherein is strictly prohibited. 1 21-Aug-12 Association of Ontario Health Centres
  2. 2. 1 21-Aug-12 Association of Ontario Health Centres
  3. 3. Table of ContentsA. Acknowledgments Pg. 4B. Executive Summary Pg. 4C. Introduction Pg. 5D. Model of Care Fact Sheet – Definitions Pg. 7E. Elaboration of the Model of Care Pg. 9 (MOC) Attributes includes: A. Definition B. Elaboration C. Why this attribute is relevant to the Model of Care D. Opportunities and Challenges to Addressing this Attribute in your CHC E. Summary F. References1. Comprehensive Pg. 92. Accessible Pg. 143. Client and Community Centred Pg. 204. Interprofessional Pg. 255. Integrated Pg. 296. Community-governed Pg. 347. Inclusive of the Social Determinants of Health Pg. 398. Grounded in a Community Development Approach Pg. 44F. Glossary Pg. 492 21-Aug-12 Association of Ontario Health Centres
  4. 4. A. AcknowledgmentsThe development of the training manual and toolkit on the Model of Care involved manycommitted and passionate people whose support and contribution were vital to the production ofthis document. These include the Community Health Centre (CHC) Charter Group: Lee McKenna,Brenda McNeill, Cate Melito, Cary Milner, Hersh Sehdev, Wendy Talbot, and Adrianna Tetley,and, the invaluable expertise from the AOHC’s Education and Development Team: Sophie Bart,Keisa Campbell, Mary Chudley, Carolyn Poplak, Brian Sankarsingh, Roohullah Shabon, andSandra Wong. In addition, we would like to thank all AOHC staff for their support and the CHCrepresentatives who contributed their lived examples, experiences, opportunities and challengesthat helped bring these training tools to life. Thank you.Roohullah Shabon, Director of Education and DevelopmentThe Association of Ontario Health Centers416-236-2539 ext. 231B. OverviewThe objective of this manual, and its accompanying toolkit, is to provide information andresources on the CHC Model of Care for training purposes. The intended audience for the trainingincludes Community Health Centre staff, volunteers and Boards of Directors. This manual is anelaboration on the eight attributes of the CHC Model of Care and provides appropriate referencesand resources for a better understanding of this Model and how it is being implemented in CHCs.The eight attributes of the CHC Model of Care include: 1. Comprehensive; 2. Accessible; 3. Client and community-centred; 4. Interprofessional; 5. Integrated; 6. Community-governed; 7. Inclusive of the social determinants of health; 8. Grounded in a community development approachWhile the attributes are discussed and considered individually, they are also linked and fluidelements that do not exist in isolation from one another. For a CHC to be comprehensive, forexample, it emphasizes the interprofessional team approach. For a Centre to be grounded in acommunity development approach, it is also client and community centred, and so on.Therefore, throughout this document, you will see overlapping themes and concepts. Definingthese eight attributes emphasizes the importance of each quality independently, whilehighlighting their interconnectedness.This document is a dynamic and living resource and we will continue to add to it. For commentsand suggestions please contact:Roohullah Shabon, Director of Education and DevelopmentThe Association of Ontario Health Centres416-236-2539 ext. 230Roohullah@aohc.org3 21-Aug-12 Association of Ontario Health Centres
  5. 5. C. IntroductionPrimary health care (PHC) as defined by the World Health Organization (WHO) is essential healthcare made universally accessible to individuals and families in the community by meansacceptable to them, through their full participation and at a cost that the community and countrycan afford. It forms an integral part both of the countrys health system of which it is the nucleusand of the overall social and economic development of the community1.Primary care refers to the patients first point of contact with a health-care provider and includesbut is not limited to: disease management and prevention, disease cure, rehabilitation, palliativecare and health promotion. The greatest difference between primary care and primary healthcare is that primary health care is participatory in nature and involves the individual and theircommunity in their overall health care including prevention and management.The Ottawa Charter for Health Promotion echoes the sentiments of the WHO. It states that therole of the health sector must move increasingly in a health promotion direction, beyond itsresponsibility for providing clinical and curative services. Health services need to embrace anintegrated mandate which is sensitive and respects cultural needs. This mandate should supportthe needs of individuals and communities for a healthier life, and open channels between thehealth sector and broader social, political, economic and physical environmental components.2Canadians consistently describe Medicare as a defining feature of our identity. We are deeplyconnected to the core values of Medicare and PHC, namely a just and equitable system of healthcare equitably accessible to all Canadians. As individuals, we want to see Tommy Douglas’svision of Medicare renewed and revitalized not demolished (???). The First Stage of Medicare wasto remove the financial barriers between those who provide health-care services and those whoneed them. The Second Stage, following the path of the First, was to amend our delivery systemto reduce costs and put an emphasis on preventative medicine.The second stage of Medicare offers a vision for health that is embraced by CHCs: that asCanadians we must care for one another, and break down the barriers that prevent many fromaccessing care. With CHC Boards, management and staff on the same page about the CHCModel of Care, we can better highlight to the greater community the story of who we are andwhat we do, and further demonstrate how our Centres are champions of the Second Stage ofMedicare. We will continue to acknowledge and recognize that our CHC clients, the members ofour organizations who use our services, are at the heart of the work we do.The CHC Model of Care captures consistent principles that underlie the work of Ontario CHCs. Asa sector, we acknowledge that the differences between CHCs reflect the great diversity of thecommunities we serve. It is crucial that CHC Boards and staff share a common understanding ofthe Model and apply its principles throughout our work. These principles help to define the CHCrole in what makes a stronger – and more caring – health-care system.Based on the social determinants of health, the CHC sector provides accessible, community-governed, interprofessional, primary health-care services, including health promotion, illnessprevention and treatment, chronic disease management, and individual and community capacitybuilding. Our ultimate goal is for all Ontarians facing barriers to health to have access to qualityprimary health care within an integrated system of care.31 WHO (1978)2 Ottawa Charter for Health Promotion (1986)3 CHC Strategy Map and Balanced Scorecard (2006). Pg. 44 21-Aug-12 Association of Ontario Health Centres
  6. 6. The programs and services we offer throughout the province demonstrate our commitment toaddressing Medicare’s core values. These include: • All Canadians have timely access to health services on the basis of need, not ability to pay, regardless of where they live or move in Canada; • The health-care services available to Canadians are of high quality, effective, patient-centred and safe; and • Our health-care system is sustainable and affordable and will be here for Canadians and their children in the future.4The ultimate purpose of Medicare is to ensure Canadians: • have access to a health-care provider 24 hours a day, 7 days a week; • have timely access to diagnostic procedures and treatments; • do not have to repeat their health histories or undergo the same tests for every provider they see; • have access to quality home and community care services; • have access to the drugs they need without undue financial hardship; • are able to access quality care no matter where they live; and • see their health-care system as efficient, responsive and adapting to their changing needs, and those of their families and communities now, and in the future. 5At the heart of our Model of Care are our clients – and the communities of which they are a part.Because in CHCs Every One Matters. Every individual. Every community. Every staff person.4 Health Canada Website - http://www.hc-sc.gc.ca/hcs-sss/delivery-prestation/fptcollab/2003accord/index-eng.php5 Ibid5 21-Aug-12 Association of Ontario Health Centres
  7. 7. The CHC Model of Care Definitions6CHCs offer a range of comprehensive primary health care and health promotion programs indiverse communities across Ontario. Services within CHCs are structured and designed toeliminate system-wide barriers to accessing health-care such as poverty, geographic isolation,ethno- and cultural-centrism, racism, sexism, heterosexism, transphobia, languagediscrimination, ageism, ableism and other harmful forms of social exclusion including issues suchas complex mental health that can lead to an increased burden or risk of ill health.The CHC Model of Care focuses on five service areas: • Primary care • Illness prevention • Health promotion • Community capacity building • Service integrationThe CHC Model of Care is:Comprehensive:CHCs provide comprehensive, coordinated, primary health care for their communities,encompassing primary care, illness prevention, and health promotion, in one to one service,personal development groups, and community level interventions.Accessible:CHCs are designed to improve access, participation, equity, inclusiveness and social justice byeliminating systemic barriers to full participation. CHCs have expertise in ensuring access forpeople who encounter a diverse range of social, cultural, economic, legal or geographic barrierswhich contribute to the risk of developing health problems. This would include the provision ofculturally appropriate programs and services, programs for the non-insured, optimal location anddesign of facilities, oppression-free environments and 24 hour on-call services.Client and community centred:CHCs are continuously adapting and refining their ability to reach and to serve their clients andcommunities. CHCs plan based on population health needs and develop best practices for servingthose needs. CHCs strive to provide client-centred care.Interprofessional:CHCs build interprofessional teams working in collaborative practice. In these teams, salariedprofessionals work together in a coordinated approach to address the health needs of theirclients. Depending on the actual programs and services offered, CHC interprofessional teamsmay include physicians, nurses, nurse practitioners, dietitians, physiotherapists, occupationaltherapists, social workers, Aboriginal traditional healers, chiropodists, counsellors, healthpromoters, community development workers, and administrative staff.Integrated:CHCs develop strong connections with health system partners and community partners to ensurethe integration of CHC services with the delivery of other health and social services. Integrationimproves client care through the provision of timely services, appropriate referrals, and thedelivery of seamless care. Integration also leads to system efficiencies.Community-governed:6 Revised June, 20086 21-Aug-12 Association of Ontario Health Centres
  8. 8. CHCs are not-for-profit organizations, governed by community boards. Community governanceensures that the health of a community is enhanced by providing leadership that is reflective ofits diverse communities. Community boards and committees provide a mechanism for centres tobe responsive to the needs of their respective communities, and for communities to develop asense of ownership over “their” centres.Inclusive of the social determinants of health:The health of individuals and populations are impacted by the social determinants of healthincluding shelter, education, food, income, a stable eco-system, sustainable resources, anti-oppression, inclusion, social justice, equity and peace. CHCs strive for improvements in socialsupports and conditions that affect the long term health of their clients and community, throughparticipation in multi-sector partnerships, and the development of healthy public policy, within apopulation health framework.Grounded in a community development approach:CHC services and programs are responsive to local Community Initiatives and needs. Thecommunity development approach builds on community leadership, knowledge and lifeexperiences of community members and partners to contribute to the health of their community.CHCs increase the capacity of communities to improve community and individual healthoutcomes.7 21-Aug-12 Association of Ontario Health Centres
  9. 9. D- Elaboration of Model of Care Attributes 1. Comprehensive “Lets not forget that the ultimate goal of Medicare must be to keep people well rather than just patching them up when they get sick”7 Thomas Clement “Tommy” Douglas, father of Medicare (1904 – 1986)a. DefinitionCHCs provide comprehensive, coordinated, primary health-care for their communities,encompassing primary care, illness prevention, and health promotion in one-to-one service,personal development groups, and community level interventions.b. ElaborationThe needs of CHC clients extend beyond direct primary care services. CHCs use a variety ofstrategies including health promotion and education because the health service needs of clientsdo not occur in isolation from the broader determinants of health – including the socio-economicenvironment of the community. Anishnawbe Health’s Core Basket of CHCs work to improve the capacity of Services: individuals, families and communities. Because CHCs offer a core basket of services under one • Traditional Healing roof – a one-stop shop, so to speak – clients can • Primary Health Care access care and support in a variety of areas. • Chiropractic medicine These include: primary care, language and • Naturopathic medicine employment, settlement and shelter, the • Fetal Alcohol Spectrum Disorder Services ecological environment, family and community (FASD Services) relationships, nutrition, child development, legal • Massage Therapy aid, community development and leadership, • Traditional Counselling and the management of chronic disease. • Enaadamged Kwe (Woman’s Helper) Internal referrals (97,095 of which were made • Babishkhan across 37 CHCs in 2006/07)8 are part of our • Psychiatric services focus in providing comprehensive, barrier-free • Chiropodist services care. They can help address chronic diseases • Oral health care and manage them accordingly. According to the • Mental Health support Health Council of Canada, chronic diseases are • Community Health Worker Training the most common cause of disability and Program premature deaths in the country. The Council • Nmakaandjiiwin (Finding My Way) has also noted that most primary health-careorganizations and individual providers are not organized in ways to maximize potentialimprovements. This leaves far too many Canadians vulnerable to complications from chronicconditions. 9 CHCs respond to this with the programs and services offered. For example, a cliententers a CHC with symptoms of diabetes. In one day, that same client receives primary health-7 Tommy Douglas quoted in The Second Stage of Medicare (2007). Pg 1.8 Every One Matters (2008). Pg 159 The Second Stage of Medicare (2007).Pg 178 21-Aug-12 Association of Ontario Health Centres
  10. 10. care from a physician and is referred to a healthy cooking class for diabetes sufferers offered bya dietician as well as a low impact exercise class provided by a volunteer at the Centre. This is anexample of comprehensive services offered by CHCs that support clients’ management of theirdisease. For services that the CHC does not have at its disposal – under its own roof – it has theinformation, resources and connections to ensure the client gets additional support thoughexternal referrals.To address chronic conditions and other health needs, CHCs offer more than just individual visitsfor the client with their provider. CHCs also offer group and community supports, such asCommunity Initiatives (CIs) which are organized to affect the health of the community10 as awhole and personal development groups (PDGs) that focus on changing unhealthy attitudes orbehaviours in individuals.c. Why this Attribute is Relevant to the CHCTo make comprehensive care a reality, CHC clients receive primary health-care frominterprofessional teams under the same roof. Case consultations between health-care teamssupport the delivery of more efficient and effective health care. Improvements in primaryhealth-care are anchored in evidence-based decision making and responsiveness to health-careneeds. Through the collection of data used in conjunction with community engagementinitiatives, CHCs are able to provide relative and comprehensive services to our clients thoughthe programs and services we offer. The CHC sector uses best practices to guide the provision ofa range of prevention, early intervention and treatment programs and services.11We know that positive health outcomes for clients occur when comprehensive partnershipsamongst primary health-care stakeholders are formed. 12 These stakeholders include patients andfamilies, health-care teams and community supporters. 13 The World Health Organization (WHO)illustrates this by highlighting four essential elements for action that stakeholders shouldconsider. They include: Somerset West’s Core Basket of 1. Support a paradigm shift towards Services: integrated, preventative health care • Acupuncture services • Immigration medical examinations 2. Promote financing systems and policies • Nutrition counselling that support prevention in health-care • Mental health services 3. Equip patients with needed information, • Asthma care motivation, and skills in prevention and • Foot care services self- management • Breastfeeding information & support 4. Make prevention an element of every • Obstetrical care & prenatal health- care interaction 14 assessments • Smoking Cessation • Flu immunization clinics in theThese elements are being addressed by CHCs communityacross the province. Research tells us thatpreventative health care can take huge • Health Education workshops in the burdensoff our health-care system. In addition, early detection procedures and techniques (paps,mammograms, immunizations, smoking/alcohol cessation groups etc.) help deter many chronicdiseases that can affect not only the individual, but the family and collective health of thecommunity.10 For more information on Community Initiatives, please view Module 8.11 CHC Strategy Map and Balanced Scorecard (2006). Pg. 512 WHO (2002)13 Ibid149 21-Aug-12 Association of Ontario Health Centres
  11. 11. d. Opportunities & Challenges to Addressing this Attribute in your CHCSometimes the contribution of individuals and organizations is not always deemed of equal‘value’ and this can lead to conflict and dissatisfaction. In addition, people come to the table withdifferent skills, experiences, motivations, and prejudices. Furthermore, a collaborative effortinvolving individuals from different walks of life can often magnify personal conflicts anddifferences. There are often different power dynamics at play between clients, families andservice providers which can affect true collaboration amongst these stakeholders. This can havea further impact on the health outcome of our clients and we need to bring them back to thecentre of our focus and decision making. Four Villages’ Core Basket of Services: An additional challenge to addressing comprehensive care in CHCs is to find and • Treatment of acute illnesses &chronic balance the resources needed to really conditions support the provision of a comprehensive • Mental health counselling basket of services. Also, health promotion and illness prevention sit on the sidelines of • Physiotherapy & Occupational therapy our health-care system and are not • Care & support for healthy children & adults integrated or embedded as a primary focus. • Diabetes management and support There is still a focus on the hierarchy of care. • Nutrition counselling and education Many strategies to address burdens on our • Arthritis self-management health-care system are clinically focused and • Social connection do not take into account the broader • Active living and healthy eating determinants of health • Foot care / Shoe clinic • New mothers and families with children Mary Berglund’s Core Basket of Services: • Pregnancy care and education • Healthy child development • Food Bank • Support and education for parents • Physiotherapy • OHIP applications/document assistance • Chiropodist services • Community kitchens • Dietician ser vices • OrthopedicsDivision between clinical and health promotion • Mobile Eye-Care Unit (Partner)teams arises from different payment structures • Mobile Breast Screening Unit (Partner)(funding and salaries) and different prestige in • Diabetic Educationthe health-care discourse between clinical and • Chronic Disease Follow-up Programsocial service/health promotion services • Lab Specimen Collectionfurthering the hierarchy of care. • Immunization Program • Health Promotion ServicesThe challenges to comprehensive care can • Focus/Core Program (Lead Agency)particularly resonate with rural communities. • Men’s & Women’s Wellness Clinic’sPublic health has limited presence/activity in rural • Blood Sugar Screening Programstownships and this leads rural residents traveling • Blood Pressure Screening Programsto the city for both their comprehensive health care as well as employment in the health-carefield. Also, both rural and urban physicians have too many patients to engage in preventive workand due to work overload have very limited involvement with other providers.Another challenge presents itself when health-care teams need to refer a client to an externalprovider. If a client needs to attend cooking classes for diabetes at another institution becausethe CHC is not offering that service, in what way can we ensure it is accessible for the client.10 21-Aug-12 Association of Ontario Health Centres
  12. 12. CHCs might also want expand services to address additional health needs, but have limitedphysical space. This hinders CHCs’ abilities to expand services, to enhance existing services andmeet the demands and rising needs of the community.e. SummaryCHCs are addressing these challenges, not only one-by-one through innovative programs andservices designed to support the needs of particular communities, but as a unified sector. CHCsare providing comprehensive services that are effectively addressing the key attributes ofprimary health care such as accessibility, coordination, continuity of services, and accountability.In short, we are providing interprofessional care, flexible service approaches, programs thatbuild community capacity to address the social determinants of health, accountability to ourcommunities through community-governed Boards of Directors, partnerships with othercommunity stakeholders, and infrastructure that supports the integration of primary care withthe delivery of other health and social services.1515 Strategic Review of the CHC Program (2001). Pg. v.11 21-Aug-12 Association of Ontario Health Centres
  13. 13. f. ReferencesAssociation of Ontario Health Centres. (July 2006) CHC Sector Strategy Map Project: StrategyMap and Balanced Scorecard.Association of Ontario Health Centres. (March 2008). Everyone Matters: Who We are and WhatWe Do.Association of Ontario Health Centres. (March 2007). Second Stage of Medicare: ConferenceReport.Shah P. Chandrakant & Moloughney W. Brent. A Strategic Review of the CHC Program. (May2001). Community and Health Promotion Branch Ontario Ministry of Health and Long-Term Care.The Ottawa Charter for Health Promotion: An International Conference on Health Promotion.(November 1986).[Online] Available: http://www.who.int/hpr/NPH/docs/ottawa_charter_hp.pdf [1986, November17-21] Page 4World Health Organization: Integrating Prevention into Health-care. (October 2002). [Online]Available: http://www.who.int/mediacentre/factsheets/fs172/en/[2008, April 14].12 21-Aug-12 Association of Ontario Health Centres
  14. 14. 2. Accessible“Access is the ability or right to approach, enter, exit, communicate with, or make use of health services.”16a. DefinitionCHCs are designed to improve access, participation, equity, inclusiveness and social justice byeliminating systemic barriers to full participation. CHCs have expertise in ensuring access forpeople who encounter a diverse range of social, cultural, economic, legal or geographic barrierswhich contribute to the risk of developing health problems. This would include the provision ofculturally appropriate programs and services, programs for the non-insured, optimal location anddesign of facilities, oppression-free environments and 24-hour on-call services.b. ElaborationIn CHCs, access is about eliminating barriers and providing equitable17 health care to our clientsand our communities. While this may seem obvious, we must remember that clients often haveneeds that are not adequately provided for by the existing health and social service system. Hamilton Urban Core OralThere are generally two aspects to access18. Firstly, client Health Programaccess is the extent to which our clients are able to attainneeded services. For example, if a parent The goal of the Oral Health Program needs tobring her children in for immunizations but is to increase levels of good oral she worksfrom 8:00am-6:00pm then accessing health (Oral Health enhancement) services thatare only available from 9am-5pm will be and prevent and reduce oral health very difficult.Also, if a client cannot speak the language problems (health promotion and of herprovider and has serious symptoms that she risk reduction). The Oral Health needs toexpress to her providers, having someone Program aims to promote oral that can health among individuals andtranslate and interpret will be very useful to her. groups that are underserved and lack access to adequate oral healthThe second aspect to access is care. In addition to servicesorganizational. Organizational access is the provided to individuals such as extent towhich our clients are represented and cleaning, fluoridation, pits and involved inthe design, development, implementation, fissure sealants, check-ups and so delivery andadministration of CHC services. As on, the Oral Heath Coordinator discussed inthe third Module, the integrity of the care provides oral health education that CHCsprovide is based on client and community sessions to schools, ESL programs, needs. and a variety of communityClients identify their health-care needs, and CHCs support agencies and community groups.the delivery of care to address these needs.Below is a Chart of both Client andOrganizational Barriers:16 A Cultural Competence Guide for Primary Health-care Professionals in Nova Scotia (2005). Pg 4.17 For more discussion on ‘equity’, please view Module 318 Equal Access Pilot Project.13 21-Aug-12 Association of Ontario Health Centres
  15. 15. Questions to consider in identifying barriers to Barriers accessing care at a CHC - Is the facility designed in a way that creates or reduces physical barriers for clients? - Does the facility meet the physical needs of clients who have Physical mobility restrictions, are deaf or hard-of-hearing or are blind or have vision problems? - Are CHC programs and services available outside of regular business hours? Geographic - Is the CHC accessible by car or public transit? - If the CHC has a large geographic catchment area, how does it enable clients to access services? - Do appropriate outreach programs exist to support the care of those who are immobile or cannot reach services by transportation? Communications - Are services and resources available in the language needed? - Are interpreters available, when needed and of the gender preferred by clients? - Are clients informed of changes or plans to their programs and services? - Are signs written in plain language? Cultural - Do CHC staff understand the implications of how a client’s culture impacts their health and access to care? - Are CHC programs respectful of clients’ cultural needs? Economic - Are CHC programs responsive to the needs of clients who cannot afford health-related costs (e.g. medications, healthy foods, oral care, cost to get to the CHC, time off work or childcare needed when accessing care, etc.)? - Do CHCs programs and services provide support for clients living in abject poverty? - Do CHCs programs and services take into account the class realities experienced by clients? - Does the CHC provide care for non-insured clients (e.g. recent immigrants, people without health cards, people who do not want to enrol)? Social - Are CHC programs designed to respond to the realities of different social situations (e.g. being addicted to drugs, living on the street, choosing to stay with an abusive spouse, etc.)? - Are CHC programs designed to support the needs of the LGBTTQQ community?C. Why this Attribute is Relevant to the CHC14 21-Aug-12 Association of Ontario Health Centres
  16. 16. When CHCs strive to provide accessible care, their work is informed by an anti-oppressioncommitment. The Board of Directors of the Association of Ontario Health Centres (AOHC) iscommitted to embedding anti-oppression in all aspects of its governance policies, processes andpractices. The Board seeks to:  increase access, participation, equity, Centre de santé communautaire inclusiveness and social justice by eliminating de Sudbury program for Franco- systemic barriers to full participation; Ontarian youth  Promote positive relations and attitudinal change by creating a climate where discriminatory or Fifty young Francophones participate oppressive behaviours are not tolerated; in the program, which connects  Foster an AOHC Board that is reflective of its students in high school and post- membership and inclusive of racialized and secondary institutions to their rich minoritized groups French heritage. More than 8,000 students have joined in the St. Jean Some CHCs are at the forefront of anti-oppression Baptiste musical shows as organizers, work. As explained in the anti-oppression statement performers or enthusiastic audience of Access Alliance Multicultural Health and Community members. The young people also Services: organize a homeless supper and, on Ste. Catherine’s Day, conduct a mass “ Racism, xenophobia, classism, sexism, collection of personal-care products homophobia and heterosexism, ableism, and for people living on the street. ageism cause pain and humiliation and have far- The youth programming reminds reaching consequences. Each one in its own way, young Franco-Ontarians that their prevents equality in opportunity, access to asylum, roots run deep and that they are part immigration opportunities, education, jobs, of a vital and connected community. housing, health-care and social services, and limits And it also familiarizes young participation in decision-making bodies.19 Francophones with other local Francophone agencies and services.” CHCs prioritize offering services to those clients who face challenges in finding appropriate care within themainstream health-care system. Forexample, in the 2006 / 07 fiscal year: Regent Park CHC Responding to religious and spiritual diversity In just 37 CHCs across the province, 18,466 non-insured and 8,253 Regent Park Community Health Centre has adapted its homeless clients were served services to respond better to diabetic Muslim clients when they are fasting during the holy month of 49.5% of CHC clients across the Ramadan. Potential health complications include province had annual family incomes altered nutritional levels, prescription medication issues of less than $20,000 per year and mental and emotional health issues stemming from the intensity of the month’s devotions. 9,454 CHC clients received service in 15 languages other than English or Physicians, nurses and other providers have worked French.20 with community and religious leaders to develop guidelines for better care and treatment. They also actively encourage clients to “have the conversationWhen working to provide accessible care about fasting” with their health-care providers. This isto our clients, CHCs recognize that our supported through educational materials endorsed byclients face numerous and diverse religious leaders and distributed at the local mosque.barriers that affect if and how they19 Access Alliance, Anti-Oppression Policy & Practice20 Everyone Matters (2008)15 21-Aug-12 Association of Ontario Health Centres
  17. 17. access care. CHCs strive to reduce these barriers. Furthermore, when we view accessibilityunder the lens of the social determinants of health, we are better able to provide relevantservices and improve overall health outcomes.d. Opportunities & Challenges to Addressing this Attribute in your CHCA key challenge to providing an accessible The NorWest CHCs:environment is to acknowledge that some Reaching out to isolatedpopulations and communities face communities barriers.The Ontario Healthy Communities Of all Ontario’s Community HealthCoalition states: Centres, the NorWest Community Health Centres has the largest“People do not necessarily choose to catchment area: 24,567 hectares,deliberately discriminate against those approximately the size of the entirewho are different from themselves. Many province of New Brunswick.of the barriers to participation within Its newest CHC satellite is ancommunity organizations exist because of innovative mobile unit that travelsa lack of awareness of differing wants or around the vast catchment area withneeds… There is no simple formula for a nurse practitioner, an RN foot-carealleviating all barriers, as each person’s nurse and a community healthneeds are unique.” 21 worker. Clients receive primary health-care like Pap smears, The [AOHC] Board understands that there physicals and the identification and When are similarities, intersections and monitoring of chronic illnesses. The differences between forms of oppression unit is also a platform for health- and the ways in which they manifest themselves. There is also recognition of promotion programs on healthy the issues of power and privilege and how eating, effective parenting and they inform organizational dynamics. The alcohol and substance- abuse [AOHC] Board acknowledges the particular prevention. pervasiveness and impact of racism in society at large even after decades of considering how to make an environment more legislation and initiatives. accessible to an individual or a group of individuals, it is important to hear from the person or people Board Governance and Anti-Oppression involved as to what the real barriers are. However, Framework, the AOHC. it is not always simple for individuals to identify their needs or fully grasp the systemic barriers that arehindering their access to care.Another challenge for CHCs can be balancing the implementation of a particular solution with theimpact the change can have on the organization itself. Sometimes answers to problems cannotbe immediately implemented. For example, if a CHC needs to apply physical changes to itsinfrastructure, this is a long process that can often require resources (financial or otherwise) thatthe organization does not have at its disposal.e. Summary Anne Johnston HealthIn summary, to demonstrate respect for lived experiences Stationand to ensure that solutions make sense to clients we need to Women/Youth withengage “people who experience barriers to access in Disabilities Programsdiscussions on how to remove those barriers”22. This kind ofdialogue can also help CHCs find solutions that work for both Anne Johnston is a uniquethe organization and the person/people experiencing the CHC at it provides services to clients who experience21 Ontario Healthy Communities Coalition (2004) various forms of disabilities.16 21-Aug-12 Association of Ontario Health Centres This CHC also offers specific programs and services for women and youth with disabilities.
  18. 18. barrier. While CHCs work to address barriers to health care, we can still be limited by the greaterbarriers and prejudices that exist in our social system. Nevertheless, CHCs are acknowledgingthese barriers and working towards providing equitable health care to all Ontarians. This isevident from the relevant programs and services offered throughout our organizations. Anishnawbe Health Toronto Providing culturally competent care Anishnawbe Health Toronto is an Aboriginal-focused CHC. Its mission is to “improve the health and well being of Aboriginal People in spirit, mind, emotion and body by providing Traditional Healing within an interprofessional health-care model.” The mission is put into practice through programs and services based on Aboriginal Traditional Healing. As well, in this environment, physicians and nurses work together with traditional healers, elders, medicine people and traditional counselors to meet the health-care needs of their clients.22 Building Inclusive Communities Tips Tool (2003)17 21-Aug-12 Association of Ontario Health Centres
  19. 19. f. ReferencesA Cultural Competence Guide for Primary Health-care Professionals in Nova Scotia.(2005). [Online]. Available:http://www.gov.ns.ca/psc/pdf/Diversity/toolkit/Cultural%20Competence%20Guidelines.pdf[2005] Page 4.Access Alliance: Anti-Oppression Principles & Practice. [Online]. Available:http://www.accessalliance.ca/index.php?option=com_content&task=view&id=35&Itemid=12Association of Ontario Health Centres. (May 2006). Anti-Racism andAnti-Discrimination Working Group Report: Advice and recommendations to theBoard for policy changes and/or development to reflect AOHC’s commitment to theprinciples of anti-racism and anti-discriminationAssociation of Ontario Health Centres. (February 2007). Board Governance AntiOppression Framework.Association of Ontario Health Centres. (March 2008). Everyone Matters: Who We are and WhatWe Do.Building Inclusive Communities Tips Tool. (2003). [Online]Available: http://whiwh.com/BIC_tips.pdf [2003]Ontario Healthy Communities Coalition: Inclusive Community Organizations: A Tool Kit. (2004).[Online]. Available http://www.healthycommunities.on.ca/publications/ICO/ICO_1.pdf [2004October]18 21-Aug-12 Association of Ontario Health Centres
  20. 20. 3. Client & Community Centered “Nothing about me without me”23a. DefinitionCHCs are continuously adapting and refining their ability to reach and to serve their clients andcommunities. CHCs plan based on population health needs and develop best practices forserving those needs. CHCs strive to provide client-centered care.b. ElaborationThe CHC sector develops individual and community capacity through the lens of the socialdeterminants of health. This perspective allows for the identification of root causes of healthissues, and for a strategic response to community needs. We will continue to be community led,provide community infrastructure, and assist communities to develop their own uniquesolutions.24 Examples and Experiences from CHCsClient and community-centered care includes Woolwich essentialelements25. These are: Mennonite children leave school1. Superb access to care earlier than most other students (age2. Respect for patients’ values, preferences, 14) and are engaged in farming/shop and expressed needs activities while at home on the farm. Local teachers and WCHC recognized3. Clinical management systems that support the need for specialized instruction in high- quality care, practice-based learning, and the area of safety and injury quality improvement prevention. The Rural Community4. Emotional support to relieve fear and Health Worker provides this anxiety5. Involvement of family and friends education with volunteer support to6. Integration of health care and health-care many public, catholic and parochial settings7. Physical comfort schools on a rotating basis. The education covers topics such as:8. Ongoing routine patient feedback to a practice chemicals, tractors, chainsaws, silo9. Publicly available information on practices gases, shop safety, animals,10. Increased patient education lawnmowers, as well as buggy road safety, first aid, food safety andIn CHCs, we often use the term ‘client’ rather babysitting. than‘patient’. ‘Patient’ implies that the provider is the all-knowing expert and the patient is thepassive receiver of care26. In CHCs, ‘clients’ are active contributors to the care we receive. Also,a CHC ‘client’ uses many other services that are not focused on primary health care. Forexample, a client that participates in a personal development group that focuses onbreastfeeding, nutrition, literacy, environmental health, or employment skills.23 Health-care in a land called People Power: nothing about me without me (2001)24 CHC Strategy Map and Balanced Scorecard (2006) Pg 5.25 Adapted from Audet et al (2006)26 Neuberger, Julia (1999).19 21-Aug-12 Association of Ontario Health Centres
  21. 21. The use of the terms ‘equity’ and Examples and Experiences from CHCs Women’s Health in Women’s Hands ‘equality’ also need to be clarified when talking about client and Many WHIWH clients come from all over the globe. community-centred care. “They’ve often lived through the unthinkable,” says According to Competence Eunadie Johnson, former Executive Director. “They Consultants & Associates27, may have survived the trauma of genital ‘equality’ is defined as treating mutilation, the horror of war or the oppression of a people the same based on the police state. In their quest for immigrant status assumption that everyone is the they’re at the mercy of their sponsors – often the same and has the same needs. very men who are abusing them. HIV/AIDS may be a pervasive foe for themselves and their loved ‘Equity’, on the other hand, refers ones”. to treating people differently based on our different needs in order to “We give health and social service professionals ensure we can access the same information that comes directly from the women services as others who are not themselves,” says Johnson. “It helps them challenged with the same needs. understand that women have special needs; they When it comes to client and can’t use the regular medical model to assess community-centered care, we them.” Indeed, with all its advocacy initiatives, WHIWH is guided by the conviction that every Examples and Experiences from CHCs woman has an inherent ability to advocate on her LAMP own behalf and that she is ultimately the best judge of her own needs. All of the centre’s advocacy Historically a highly industrialized neighbourhood, LAMP’s (Lakeshore Area Multi-Service Project) catchment area had a large population of workers seeking help with occupational health and safety concerns. LAMPS community is less geographical and more occupational. The work has taken them into every environment, from soft rock mines to day care centers. The centre only serves workplaces with less than 200 employees. Special projects take staff out into the Greater Toronto Area investigating workplace issues brought to their attention by employees, their unions and companies themselves. The centre’s research on occupational illnesses appears in professional journals and sparks worldwide demand for speakers from among its staff. emphasize that not everyone requires the same kind of care, in the same manner, at the same time. For a service and/or organization to be truly community and client- centered, it must have an equitable foundation. c. Why this Attribute is Relevant to the CHC According to a 2004 paper published by the Health Network28, almost 80% of Canadians believe that it is important for individuals to be involved in major decisions about our health-care system. Responding to population health needs is essential when providing client and community-centered care. Often when focusing on a27 Competence Consultants & Associates (2005).28 Abelson, Julia and Francois-Pierre Gauvin (2004)20 21-Aug-12 Association of Ontario Health Centres
  22. 22. priority population, the expertise developed is sought after by other academic and health-care institutions around the world. To adequately respond to the local population health needs, CHCs conduct community health needs assessments, which involve reviewing both quantitative and qualitative information from the local community. Quantitative data include statistics, current health and social research, socio-demographic and -economic data and health status reports. Qualitative data can be gathered by engaging with community members to hear directly from them as to what the local health priorities are. This information is used to help define a Centre’s priority populations, what programs and services should be offered, what staff are needed and what community partnerships should be developed. d. Opportunities & Challenges to Addressing this Attribute in your CHC Examples and Experiences from CHCs One of the challenges in Centre Francophone de Toronto addressing community-centred care at a CHC is servicing all Francophone individuals or families who have those in the community who immigrated to Toronto or who are newcomers to experience barriers to Toronto can receive services that will facilitate their accessing care. Due to limited entry into Canadian society and help them get adjusted financial and human resources, in their daily lives. The Centre francophone offers a sometimes it is not always considerable number of services to newcomers, including: feasible for a CHC to satisfy the • Social services (emergency housing, financial needs of every priority assistance) population in the community. • Immigration services Furthermore, some CHCs have a wide variance in the • Government services demographics of their clients. • Community services Some CHCs serve mixed The counselors may also offer assistance with filling in forms managing budgets. In one-on-one meetings, income populations and it is a they can determine each person’s specific needs and challenge to ensure each guide the client to those programs at the Centre that populations gets the best meet his or her needs. There is also an outreach appropriate service at the service to support the Francophone community. appropriate time. An additional challenge in addressing client-centred care is that there can be a real diversity of needs among individual clients and meeting everyone’s unique needs can be challenging. Also, social needs are experienced as greater than medical needs. However, dollars are primarily available for clinical services. The challenge is for funders to understand the broader picture of health, as Examples and Experiences from CHCs well as comprehend the available West Elgin Community Health Centre capacities and resources that extend beyond medical services Farmers and rural farm families are one of West Elgin that could be made available to Community Health Centre’s priority populations. In the the community. summer of 2005 over 400 farmers from Western Elgin County participated in a “Farm Family Survey” that looked In addition, providing ongoing at Occupational Illness and the Health and Safety of the needs assessments of individual farming community. As a result of this, CPR classes were client services and community conducted for farm families in the community and a subsequent Asthma Program was developed. An21 21-Aug-12 Association of Ontario Health Illness screening questionnaire was developed Occupational Centres and continues to be used by West Elgin Physicians and Nurse Practitioners to identify and help manage individuals who have work related illnesses.
  23. 23. needs assessments to ensure that programs and services continue to meet changing needs requires certain resources and capacity. The CHC workload can often be more than employees can handle and community health worker and health promoter positions are often under funded. This can lead to CHC team members being asked to do jobs that are not part of their job description. This can lead to employee dissatisfaction. e. Summary Ontario CHCs ensure our clients are engaged meaningfully in decisions about our health and health care in our communities. Case studies and research reviews suggest that meaningful community engagement, with community members actually involved in decision making, improves health and health care. 29 In the CHC sector, we are taking the opportunities to engage our clients and communities in the development of programs and services to foster and encourage better health outcomes.29 Everyone Matters (2008). Pg. 34.22 21-Aug-12 Association of Ontario Health Centres
  24. 24. f. References Abelson, Julia and Francois-Pierre Gauvin. (2004 April). Engaging Individuals: One Route to Health Care Accountability. Health-care Accountability Papers – No/2. Health Network. Adapted from World Health Organization (1985) as cited in J. Abelson and B. Hutchison. (1994) Primary health-care delivery models: a review of the international literature. McMaster University Centre for Health Economics and Policy Analysis. Paper. 94-15. Association of Ontario Health Centres. (March 2008). Everyone Matters: Who We are and What We Do. Association of Ontario Health Centres. (July 2006). CHC Sector Strategy Map Project: Strategy Map and Balanced Scorecard. Audet, A. et al. Adoption of Patient Centered Care Practices by Physicians. (2006). [Online]. Available: http://www.commonwealthfund.org/publications/publications_show.htm? doc_id=365654 (2006, April 10) Competence Consultants & Associates. (2005). Tool Kit: Tool #1: What we mean by some words. Community Organizational Health Inc. (2008). [Online]. Available: http://www.cohi- soci.ca/index.php?page=e1403 Delbanco, Tom. MD et al. (2001, September). From Health-care in a land called People Power: nothing about me without me. Health Expectations. Blackwell Science Ltd. Volume 4, 144-150. Neuberger, Julia. (1999) Do we need a new word for patients? BMJ. Volume 318: 1756-823 21-Aug-12 Association of Ontario Health Centres
  25. 25. 4. Interprofessional “The right care, by the right provider, at the right time”30 a. Definition CHCs build interprofessional teams working in collaborative practice. In these teams, salaried professionals work together in a coordinated approach to address the health needs of their clients. Depending on the actual programs and services offered, CHC interprofessional teams may include physicians, nurses, nurse practitioners, dietitians, physiotherapists, occupational therapists, social workers, Aboriginal traditional healers, chiropodists, counsellors, health promoters, community development workers, and administrative staff. b. Elaboration Many CHC clients have complex health conditions and need to see multiple providers. In 2006/07, 37 CHCs made over 200,000 referrals either internally to other health- care providers on the team or to external health-care providers.31 Clients were internally referred to child-care workers, chiropodists, counsellors, cultural interpreters, oral health-care workers, dietitians, physical therapists, surgeons, and traditional healers. Also in 2006/07, over 8,000 CHC An interprofessional process for communication and decision making that enables the separate clients saw more than four health- and shared knowledge and skills of care providers care providers during a single visit; to synergistically influence the client care almost 20,000 clients saw more than provided. A foundational component of three health-care providers; and collaborative practice is ‘equality’ within the team almost 35,000 saw more than two. 32 framework and not hierarchy. This improves the effectiveness of case consultation which has a Building Better Teams pg.27 positive impact on the delivery of care. Furthermore, coordination and continuity of care improve when clients’ needs are met through provider collaboration and teamwork. Teamwork improves access to primary health-care especially in under- serviced areas of the province, which ultimately results in more cost-effective care. The effective use of all health-care professionals will enable them to maximize their skills and work to the full extent of their qualifications, training, and scope of practice. Evidence demonstrates that a substantial proportion of the current activities of family physicians could be done equitably well by nurse practitioners, for example. In Ontario, the top five physician billing codes that accounted for approximately 69% of the total amount billed by primary care physicians in 1996/97 ($1.2 billion) included intermediate assessments/well-baby care, general assessments, minor assessments, individual psychotherapy and counselling. There is a great deal of evidence from other jurisdictions that demonstrate that these services can be done by other qualified practitioners at a much lower cost to the system.30 AOHC Fact Sheet CHCs and the “Three Rs”31 Everyone Matters (2008).32 Ibid.24 21-Aug-12 Association of Ontario Health Centres
  26. 26. The benefits to the client in engaging in a collaborative practice model include: seamless access to a wide variety of health-care services; options when one’s primary provider is absent; and more choice of appropriate providers to meet one’s needs. c. Why this Attribute is Relevant to the CHC Interprofessional teams mirror (on the provider side) the complexity Experiences and Examples from CHCs of the health issues experienced by Teen Health CHC Eating Disorders Program the client. The inter-disciplinary Serving 12-to-24-year-old Windsor and Essex County team approach acknowledges that youth for the past 15 years, the centre takes teamwork the health of an individual is to heart. Once every other week, the centre’s eating intricate and multi-dimensional. disorders team meets to review every file in its When community health workers caseload. Working in conjunction with the Bulimia and and health promoters are part of Anorexia Nervosa Association (of Essex County), the the team, preventative health gathering draws together everyone from every issues as well as mental and discipline within the centre who is, or has, worked on psycho-social issues are active files. Social workers, nutritionists, physicians – addressed.33 three people from the agency and four from outside – touch base on "everything everyone is doing with each client," says primary care services manager Tom Ontario’s Community Health Groulx. "The clients get ‘unidirectional’ help," says Centres acknowledge the Groulx. That is, "we don’t have several different people importance of collaboration not giving clients contradictory and therefore confusing only in healing but also in advice. If we decide on a course of action in a unified preventative care and overall front, it makes more sense for everyone." health promotion. As communities and as a sector, we are working towards building an understanding of health as more than simply patching up the ill, but keeping people well. This work entails the commitment of more than one person, and more than one profession. It takes the passion and time of a wide range of health service providers. In Ontario, most private physicians are paid on a fee for service model. Ontario CHC physicians are paid a salary as are other providers. CHC physicians are therefore able to see clients with complex care needs because they can address more than one issue in a single service event and provide more time to their clients. More time with clients allows for more counselling and preventative care by primary care providers which leads to better health outcomes. d. Opportunities & Challenges to Addressing this Attribute in your CHC Despite the tremendous benefits of collaborative practice models, there are still significant barriers to surmount. “…we’re still educating health professionals in silos…formal education of health-care professionals around collaborative patient-centred practice as well as informal education to help team members understand the scope of practice of their colleagues is essential”34.33 AOHC Fact Sheet. What does it mean to work in Collaborative Practice?34 AOHC Fact Sheet. What does it mean to work in Collaborative Practice?25 21-Aug-12 Association of Ontario Health Centres
  27. 27. In addition, the elements that help and encourage team work and collaboration (regular meetings, activities, and communiqués among staff) require time, energy, commitment, and financial resources. When providers and front-line staff are stressed and overworked, they often cannot attend regular meetings and participate in staff activities. York Community Service Legal Clinic Furthermore, issues of liability are frequently raised The clinic launched in 1978, just five years after the centre opened. "This kind of interprofessional structure concerning the roles of helps us help people with complex, multiple problems providers and their legal because of the wide system of support available," says responsibilities and Francie Kendal, director, communications and accountabilities. According to a development. For instance, a client may come in for joint document released by the primary health-care treatment. The health-care Canadian Medical Protective professional may then find out the client is about to be Association and the Canadian evicted — and the distress may be a factor in his or her Nurses Protective Society35, ill health. So they may refer the client to the legal there are steps that team, or even the eviction prevention program, and other support programs the centre offers. collaborative teams can take “Having professionals from other disciplines on-site (including purchasing liability enhances the quality of care that staff can offer by way insurance) that will protect of their quick access to others. For instance, a providers should an issue arise. counselor who needs to find some legal information While these issues are need not go outside the centre – the expert is just infrequent, it does concern down the hall”. physicians as to how much of their work can be shared with nurse practitioners, nurses and other CHC staff. Through education, open discussion and knowledge sharing, this concern will be diminished. The current Ontario Medical Association’s incentives that have been rolled out to CHCs in an attempt to increase compensation to physicians require CHC clients to be enrolled to an ‘assigned physician’. Clients are enrolled to physicians and not the CHC, which does not take into account that other providers (nurse practitioners, nurses etc.) often provide primary care to clients. Also, clients go to their CHCs for programs and services that do not require a physician and so enrolment figures do not adequately present the work that all health-care providers are doing at their CHC. The design and infrastructure of CHCs also provides challenges to interprofessional work. Specifically when clinical teams and health promotion teams are separated. This decreases the potential for case conferencing and discussion as well as developing social relationships with colleagues. Also, funders have very different pay scales for different types of work. Members of the clinical team are better supported by funding than members of the social team. Furthermore, different providers offering the same services get paid differently. Nurse practitioners, for example, performing pap smears are paid differently to a physician performing the same task. e. Summary Strong teams ensure there is a shared philosophy and vision and involve participatory leadership where every member on the team has a formal/informal leadership role.35 CMPA/CNPS Joint Statement (2005)26 21-Aug-12 Association of Ontario Health Centres
  28. 28. We know that collaborative and interprofessional team work can develop trusting and respectful working environments which serve the client better as health outcomes are improved. When we adopt an integrated teamwork approach that values different professional approaches and perspectives that create well-defined roles and role expectations and develop leadership as a core competency then the environment for both staff and clients improves. Working towards integrating clinical teams with the non-clinical teams develops an environment of continuous learning and improvement which further serves to benefit our clients.36 f. References A. Mitchell et al. (1993). Utilization of Nurse Practitioners in Ontario. A Discussion Paper Requested by the Ontario Ministry of Health. Nursing Effectiveness, Utilization and Outcomes Research Unit. Paper 93-4.36 Building Better Teams (2007)27 21-Aug-12 Association of Ontario Health Centres
  29. 29. Association of Ontario Health Centres (2007). Building Better Teams: A Toolkit for Strengthening Teamwork in Community Health Centres. Resources, Tips, and Activities you can Use to Enhance Collaboration. Association of Ontario Health Centres (June, 2007). Building Better Teams: Learning from Ontario’s Community Health Centres. A Report of Research Findings. Association of Ontario Health Centres Fact Sheet. CHCs and the Three Rs: The right care, by the right provider, at the right time. Association of Ontario Health Centres (March 2008). Everyone Matters: Who We are and What We Do. Association of Ontario Health Centres Fact Sheet. What does it mean to work in Collaborative Practice? CMPA/CNPS. (2005). Joint Statement on Liability Protection for Nurse Practitioners and Physicians in Collaborative Practice. [Online]. Available: http://www.cnps.ca/joint_statement/English_CMPA_CNPS_joint_stmt.pdf (2005 March). Community Organizational Health Inc. (2008). [Online]. Available: http://www.cohi- soci.ca/index.php?page=e140328 21-Aug-12 Association of Ontario Health Centres
  30. 30. 5. Integrated “Every door leads to service.”37 a. Definition CHCs develop strong connections with health system partners and community partners to ensure the integration of CHC services with the delivery of other health and social services. Integration improves client care through the provision of timely services, appropriate referrals, and the delivery of seamless care. Integration also leads to system efficiencies. b. Elaboration Integration involves cross-sectoral partnerships with organizations and institutions that provide both direct client care (such as community organizations) and indirect client care (such as universities and municipal and/or provincial governments). When we work in partnership with others to solve problems by using common resources, we are more likely to support clients and provide accessible and comprehensive care. Integrated care is not about passing the Linkages across sectors and between responsibility of care to someone else, providers support clients to successfully but rather its about unifying goals and transition, with due respect for the barriers resources across organizations to that they may face and the complexity of improve the overall quality of care. their care issues. CHCs integrate with partners in a http://www.aohc.org/app/wa/doc?docId=168 number of different ways, from physical integration, such as co-locating in the same building, to functional integration, such as sharing resources, to program integration. In 2006-07 alone, 54 CHCs were part of 1,275 partnerships, an average of 24 partnerships per CHC.38 Within the CHC accreditation process, Building Healthy Experiences and Examples from CHCs Organizations39, working with partners (defined as GayZoneGaie “organizations that CHCs work closely with to jointly operate programs and services or work on joint A partnership of organizations in Ottawa planning or advocacy initiatives to benefit their have come together using existing resources to provide a service that includes communities”) is an essential criterion for HIV and STD testing as well as offering a accreditation. variety of wellness programming for gay men and ‘guys into guys’. As outlined in the 2006 CHC Strategy Map, CHCs are Partners include: Sommerset West an entry point to the health-care system for people Community Health Centre, Centretown facing barriers to health. Benefits to integration affect Community Health Centre, Ottawa Public our clients in profound and meaningful ways. If certain Health, the Youth Services Bureau of services and sectors are not connected, people Ottawa; the AIDS Committee of Ottawa, accessing health-care services can fall through the Pink Triangle Services, and Ottawa Gay Men’s Wellness Initiative. cracks. CHCs have established the expertise in developing partnerships enabling us to provide integrated primary health care both within the sector37 Every Door Leads to Service (2006)38 Everyone Matters (2008)39 Building Healthy Organizations (2008)29 21-Aug-12 Association of Ontario Health Centres
  31. 31. and beyond. CHCs continue to develop partnerships and to enhance cross-sectoral service coordination that complements the programs and services of other service providers, leads to appropriate use of resources, and increases the sustainability of the health-care system.40 C. Why this Attribute is Relevant to the CHC Working in an integrated way with community members and service providers is a natural and fundamental component of the CHC Model. Integrated work helps prevent clients from falling through the cracks and is effective in reducing costs to the entire health-care system. With the establishment of the Local Health Integration Networks (LHINs), CHCs are expected to continue and increase integration with other providers in the community for the purpose of “maintaining and sustaining a world-class health-care system that will help keep people healthy, deliver good care when they are sick and will be there for their children and grandchildren”.41 d. Opportunities & Challenges to Addressing this Attribute in your CHC Integration and working in partnerships makes it possible to leverage resources and often produces cost effective approaches to the provision of services and programs, but working with partners is challenging in the best of times and requires resources. This is often an overlooked or neglected aspect of integration and partnership Service Integration is most usefully defined work. It is challenging to balance program as an on-going process whereby local needs with the need to focus on policy agencies engage in progressively greater change and community capacity building. degrees of joint service activities along an In addition, many programs need a lot of integration continuum. administrative support and it sometimes is a challenge to identify on whose shoulders Ryans & Robinson 2005 this responsibility should fall. Also, some organizations serve particular priority populations and are isolated from integration because other institutions and agencies within the same geographic community serve different clients and address different health-care issues. Integration requires perseverance and commitment to address issues when they arise. Respect and acknowledgement of the contribution of all parties are essential. In summary, successfully partnering can present some Woolwich CHC Hospice Programs challenges for the various partners involved. They are: Woolwich and Wellesley Hospice  Differences in funding and accountability to programs have an advisory government committee made up of WCHC staff,  Organizational and professional cultures that may clergy, hospice volunteers, and work against integrated models Community Care Access Centres  Differing ‘frameworks for practice’ (CCAC) The advisory committee and staff implement hospice programs  Inequitable power amongst potential partners and services collaborating with CCAC, KW Alzheimers Society and other hospices in South West Ontario.40 These include the Association for CHC Strategy Map and Balanced Scorecard (2006). Pg 5 Community Living, Community Care41 Ontario Local Health Integration Networks (2006) Concepts, Canadian Cancer Society30 21-Aug-12 Association of Ontario Health Centres and Long Term Care facilities to meet the hospice and long-term care needs of the community.
  32. 32.  Histories of unsuccessful partnerships42 Successful integration requires that the autonomy of each organization remains intact. Organizations develop common goals related to the integration, and identify the strategies and inputs each organization will implement individually and collaboratively. This ensures that organizations remain autonomous and partner rather than merge completely. At the 2007 AOHC conference43, Guelph CHC put on a workshop entitled Partnership Supporting Healthy Childhood Development. They also identified ways that agencies should work together across sectors. These include: 1. Find a legitimating agent to call the community of service providers together. 2. Define the range of services to be included at the table. 3. Insist that those attending the committee meetings will be executive directors or very senior management staff who have an appropriate degree of decision making power. 4. The initial meetings of the inter-agency Experiences and Examples from CHCs Centretown CHC committee should be spent coming to an agreement on the concepts and language of Since 1998, a community-based program for type service integration. 2 diabetes education has operated in Ottawa out 5. Set realistic goals and meet as often as the work of Centretown Community Health Centre. The requires. Diabetes Network serves all of the community 6. Provide a modest amount of funding to support health and resource Centres across the city, co- administrative expenses associated with inter- ordinating services among community members, agency activity. hospital-based programs, public health, CCAC, the Canadian Diabetes Association and, more 7. Devise and pursue a rigorous progress evaluation recently, local family health teams. From April 1, and continuous quality improvement strategy. 2007, to June 30, 2007, the program served 592 new clients in groups and individually, in addition e. Summary to offering almost 800 follow-up visits. Services are available in 11 different languages. CHCs have integrated in a meaningful way with other In addition, a dietician designed an award- winning diabetes food guide that is now available organizations as well as other CHCs to ensure our across Canada in many languages.” clients get the most appropriate service by the organization/staff with the best expertise to provide this service. Our Centres have partnered with the Centre for Addiction and Mental Health, Community Care Access Centres, the Canadian Diabetes Association, various hospitals, numerous universities, Legal Aid Ontario, family service organizations, and many more. We have a proven willingness and commitment to address challenges; an evolutionary approach to change; an ability to respect the views and opinions of others; and accountable governance structures 44 to ensure our clients remain at the heart of what we do.42 Integrated Primary Health-care. (2007)43 www.aohc.org44Integrated Primary Health-care. May 23, 200731 21-Aug-12 Association of Ontario Health Centres
  33. 33. f. References AOHC, OCSA and OFCMHAP. Every Door Leads to Service: Enhancing Access And Building a Culture of Service Integration for a Made in Ontario Health System. (2006). [Online] Available: http://www.aohc.org/app/wa/doc?docId=168 [2006, July] Association of Ontario Health Centres. (March 2008). Everyone Matters: Who We are and What We Do. Association of Ontario Health Centres. (July 2006). CHC Sector Strategy Map Project: Strategy Map and Balanced Scorecard. Community Organizational Health Inc. (March 2008). Building Healthier Organizations. www.cohi-soci.ca Edwards, Karen. Integrated Primary Health-care. (2007). NSW Health. [Online]. Available: http://www.achse.org.au/nsw/seminars/23may07_edwards.ppt (2007, May 23). Local Health System Integration Act. (2006). Ministry of Health and Long-Term Care. [Online]. Available: http://www.e- laws.gov.on.ca/html/statutes/english/elaws_statutes_06l04_e.htm (2006). Local Health Integration Network / Health Service Provider Governance Resource and Toolkit for Voluntary Integration Initiatives. (2008). [Online]. Available: http://www.centrallhin.on.ca/page.aspx?id=3860 (2008, Sept 8). Ontario’s Local Health Integration Networks (2006). [Online]. Available: www.lhins.on.ca/legislation.aspx Ryan B., Robinson R. Service Integration in Ontario: Critical Insights from the Service Community. (2005). [Online] Available: http://www. tns-global.com .32 21-Aug-12 Association of Ontario Health Centres
  34. 34. 6. Community-governed “The CHC Board’s role is not just to reflect the community but to reflect the community that it serves!”45 a. Definition CHCs are not-for-profit organizations, governed by community boards. Community boards and committees provide a mechanism for Centres to be responsible to the needs of their respective communities, and for communities to develop a sense of ownership over “their” Centres. b. Elaboration CHCs participate in democratic governance of health-care delivery [The Board shall consist through locally-elected community-based boards to ensure health of] active members who care remains responsive and customized to the priority needs of our collectively demonstrate clients46. Therefore, our Boards remain accountable to CHC clients by a broad range of ensuring relevant programs and services. relevant skills and experience and reflect CHC Boards are composed of the community, by the community and the community being or the community, and have governance guidelines. Examples of served. guidelines include: MOHLTC (2001)  Improving upon the quality and relevance of services provided.  Ensuring transparency and accountability of the services provided and the intended populations.  Empowering the communities by reinforcing authentic participation.  Understanding community governance as a determinant of health.  Encouraging sustainability through community ownership and community participation.  Improving individual and community health outcomes as the representatives elicit local knowledge and expertise.  Being more cost effective as genuine community ties are built and more appropriate services are delivered to the right people at the right time. 47 As Karen Patzer outlines in her research project Review of the When governance Boards shift from representing Trends and Benefits of Community Engagement and Local their silos, to representing Community Governance in Health Care, the best interests of the “The most significant value added of community governance in ‘owners’, the system will health appears to be related to its ability to achieve better health begin to truly transform. outcomes for both individuals and communities by increasing empowerment and social capital. A research review undertaken by Adamson et al (2007) Health Canada (2003) indicated that “research associating social capital with health shows that the higher the level of social capital in a community, the better the health status and that strengthening the social capital of communities would consequently constitute a promising means of reducing45 AOHC Fact Sheet. Community Governance as a Determinant of Health.46 AOHC conference report (2007). Pg 447 Adamson et al (2007)33 21-Aug-12 Association of Ontario Health Centres

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