This document outlines priorities and focus areas for community health and care work in Island Health, which serves over 767,000 people in British Columbia. It discusses the Ministry of Health context, including initiatives like patient medical homes and specialized community programs. It then provides an overview of Island Health, noting the aging population and higher rates of chronic conditions compared to the rest of BC. The priorities for community health and care work are establishing primary care homes, strengthening community health services, enrolling those at risk or rising risk, and strengthening linkages across the system. Areas of focus under each priority are described in detail.

1. Page 1
Areas of Focus
• Ministry of Health Context
• Island Health Context
• Examples of Community Health and Care
work

2. Page 2
Ministry of Health
Context
• Patient Medical Homes &
Primary Care Homes
• Specialized Community Service
Programs: Complex Medical,
Frail & MHSU
• System attributes include:
Case finding; Coordinated
access; Standardized intake;
System Responsiveness;
Technology enabled
• Strengthening population
health

3. Page 3
Island Health
Overview
Composite Index for Health Problems by Local
Health Areas
• 767,000 people
• Life expectancy of 82 years
• 10% of population are 75+;
this is expected to double by
2041
• Island Health has higher
prevalence for most chronic
conditions compared to BC
• 79% of the population has
strong ties to a family
physician

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5. Vision
Integrated health care services delivered through team based approach

6. Shared Work

7. Page 7
Priorities for CHC Work
1. Establish Primary Care Homes
2. Strengthen Community Health Services
3. Enroll those at Risk and Rising Risk
4. Strengthen and establish linkages across
the Community Health and Care System

8. 2. Strengthen Community
Health Services• Areas of Focus:
1. Realigning
Existing Staff to
work in Team
Based Care
2. Standardized
Coordinated
Access
[Photo credit: Susan Young Photography]
Areas of Focus:
1. Strengthen Team
Based Care
2. Standardized
Coordinated
Access
3. Neighbourhood
Model for Home
Support

9. 3. Enroll those at Risk/Rising Risk
• Areas of Focus:
1. Proactive Case
Finding
2. Rapid
Mobilization of
Services
3. Expanding
Hours of Service
Areas of Focus:
1. Proactive Case
Finding
2. Rapid
Mobilization of
Services
3. Expanding
Hours of Service

10. 4. Strengthen and establish
linkages across CHC System• Areas of Focus:
1. Technology
Enabled
Primary Care
Services
2. Work on the
Social
Determinants of
Health
Areas of Focus:
1. Improved Care
Transitions
to/from Hospital
2. Technology
Enabled Primary
Care Services
3. Work on Social
Determinants of
Health

11. “If you want to travel fast, travel alone. If
you want to travel far, travel together.”
- N'gambai African Proverb

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What will be different?
Service Focus Client Needs Focus
Passive Referral Proactive Case Finding High Risk People
Focus on Eligibility/Interventions Services designed based on Client Needs
Single Discipline Multi-Professional, Aides & Community Partners
Care Management as Defined Role Care Management Accountability of all Professionals
Individual Focus Population Focused
Reactive Proactive
Single Sector/Silo Services/Programs Integrated Systems/Teams
Broker Model of Care Management Clinical Care Coordination/Navigation
Access 5 days/week - multi programs Access 7 days/week – single access

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Community Health & Care Strategy
Questions
Phil.Lawrence@viha.ca
SAtkinson@cihi.ca