aohc.org OPINION
Primary care transformation must focus on health equity Premier Dalton McGuinty’s departure as premier will most certainly bring change to Ontario. But one thing we hope doesn’t change is the provincial government’s commitment to transform our fragmented healthcare system. What’s required is revolutionary change – delivered in an evolutionary way. And one of the most important changes needed is for system planners to embed a health equity focus into all the new initiatives they roll out this year. As Health Quality Ontario pointed out in its latest yearly report, “one of the fundamental characteristics of a high-performing healthcare system is being equitable. Inequity in the system can increase death rates, disabilities, distress and discomfort that can prove costly to the healthcare system while jeopardizing its sustainability.”
Great health divide
Here in Ontario, we’re dealing with massive health inequities …. a great health divide that separates the poor from the prosperous, new immigrants and racialized
groups from longtime residents and European descendants, Francophones from Anglophones, and Aboriginal peoples from non-Aboriginal populations. The divide also isolates and disadvantages many populations such as lesbian, gay, bisexual and transgendered from accessing the care we need. The need for action is urgent. Consider just a few of Ontario’s current health inequities: • People living with low incomes are four times more likely to report poor or fair health as people with high incomes. The lowest income groups use the healthcare system twice as much as higher-income Canadians.
Health Links underway On December 6, the Ministry of Health and Long-Term Care announced 19 health link community projects to “improve co-ordination of care for high-needs patients such as seniors and people with complex conditions.” Four Community Health Centres will coordinate early-adopter Health Links, and a significant number of AOHC’s members are partnering with Health Links. More news in the following edition.
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Inside:
• Aboriginal centres get funding boost • Community Health Week • Talking oral care to MPPs • … and more!
HEALTH EQUITY
Health disparities ‘persistent, entrenched and relentless’ ... continued from page 1
• Those who live in northern regions lose more years to premature death than the national average. • Immigrant women find it more difficult than Canadian-born women to access the resources they need to stay healthy. • Aboriginal peoples have, on average, lower life expectancy, higher rates of serious chronic diseases such as diabetes, heart disease, cancer and asthma. • Francophones rate overall health lower than the rest of Ontarians; have a higher rate of heart disease and are less likely to visit a healthcare facility. • South Asians, the largest racialized group in Ontario, have diabetes rates of 11-14%, compared to 5-6% for non-racialized Ontarians. • Lesbian, gay, bisexual and transgendered people have larger health risks, stress and social marginalization and discrimination. Each and every one of these inequities is preventable.
Prescription needed
Given the growing consensus about the ethical and economic imperatives to promote health equity, it’s worrisome that the province’s new Action Plan for Health Care makes little mention of it. In discussions at various policy tables with the Ministry of Health and Long-Term Care (MOHLTC) and the Local Health Integration Networks (LHINs), we hear that new primary care initiatives will not be “prescriptive.” But here’s our concern: health disparities are persistent, entrenched and relentless. Unless a proactive and prescriptive approach is applied, we could easily end up with a new system that once again delivers inequitable access. Once again, those who are most vulnerable will be left behind. So it’s crucial both the MOHLTC and the LHINs embed equity considerations into their primary care plans before they start rolling them out.
The right tools are at hand
Luckily, the Ministry has a powerful tool ready and waiting to assist in equity planning. Developed in 2011 by a large team of internal and external advisors, the Health Equity December 2012
Impact Assessment tool (HEIA) is designed to assist policymakers in identifying any unintended potential impacts of new initiatives on vulnerable or marginalized groups. If negative impacts are revealed, the tool provides a process to develop strategies to mitigate those impacts. This coming year, we assume both the province and the LHINs will apply HEIA in a rigourous way as they roll out their new initiatives to transform our healthcare system. For example, with respect to any new primary care networks that are developed, it’s vital to ensure that regions and populations experiencing disparities and inequities get increased access to services from interprofessional primary care teams both willing and able to deal with their complex needs. As a start, we need interprofessional teams: • with capabilities to develop services for people living in poverty; • equipped to the many stresses faced by newcomers to Canada and racialized groups; and • that engage community members developing and delivering programs that address the root causes of the illness and injury.
Mapping needs
Detailed province-wide mapping and analysis of population needs must be conducted to assess where these types of services should be extended. This will require strong stewardship from the provincial government to ensure a consistent approach throughout all 14 LHINs. AOHC intends to play a facilitating role. The next edition of Synergy will include news of a report which will reveal which parts of the province have the greatest need for interprofessional primary healthcare services designed for those populations whose health is most at risk. It is that kind of evidence that drives AOHC’s conviction on health equity as an integral part of primary care transformation in this province.
by Adrianna Tetley, Executive Director Association of Ontario Health Centres
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Funding for Aboriginal centres a vital step forward The province’s 10 Aboriginal Health Access Centres (AHACs) received good news in September when they learned their base funding was getting a boost to the tune of about three per cent. The enhanced funding was a positive response by the Ministry of Health and Long-term Care to core funding inequities experienced by the AHACs over an extended period of time. The funds are designated to: improve health outcomes in Aboriginal populations; improve access to mental health and addictions services; provide physician services; and ensure access to primary health care services. While the spending priorities of each AHAC differ in response to the needs of their communities, common goals include being able to pay staff fairly, fill existing gaps in program support and other service complements, moving forward in implementing a new electronic medical record, and becoming accredited. Two years ago the AHACs moved to the Ministry of Health and Long-term Care from the Aboriginal Healing and Wellness Strategy and that has made a tremendous difference in their sustainability. Says AOHC executive director Adrianna Tetley:“This permanent funding increase is an important step towards equity, but it is only a first step and we encourage the Minister to complete the journey towards equity.“
Equity has the backing of all members of the Association of Ontario Health Centres, she adds. Tetley refers to the unanimous support of AOHC members, expressed in a letter to Health Minister Deb Matthews, to put equitable funding for AHACs as the number one funding priority of the organization, ahead of the needs of the other members. As co-chair of the AHAC circle, Pamela Williamson, executive director of the Noojmowin Teg Health Centre on Manitoulin Island, has thanked her AOHC colleagues for their “consistent support.” AHAC leaders, clients, and many First Nations bodies had a hand in advocating for this funding, she recounts, but gives “recognition to the association and its members for their significant role.” She also recognizes Minister Matthews’ commitment to community health and for recognizing the health needs of First Nations and Aboriginal persons.
CHCs feeling impact of cuts to federal refugee health care Four months after changes were made by the federal government to the Interim Federal Health (IFH) program, Community Health Centres (CHCs) are seeing the effects on the ground. There has been considerable concern about the cuts to refugee health coverage among many health care professionals, including physicians providing care to refugees, hospitals, specialized clinics, midwives and public health agencies. CHCs have a budget allocation prioritized for people who are non-
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status and uninsured. A number of CHCs in the Greater Toronto Area are reporting increased pressure on these funds as they are seeing more people who were previously covered by the IFH program. Many fee-for-service doctors are no longer seeing refugees because of the administrative time and burden it takes to determine if they have health coverage under the new rules. Instead refugees are being sent to CHCs. As uninsured funds are drawn down, CHCs may require additional funding to ensure that
refugees who are no longer supported by the IFH program are not denied the health care they need.
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ORAL HEALTH
‘Why am I living with pain and infection?’ A recent study by Public Health Ontario found that 20 per cent of Ontarians do not visit a dentist because they cannot afford it. That leaves thousands of people in Ontario to suffer with pain and infection from poor oral health. If you have low income you are at higher risk of oral illness and most likely do not have dental insurance. Many people have no choice but to go to the local emergency room of their hospital where they can get painkillers – but no dental treatment for the problem. In 2006, 26,000 people in Ontario used acute care hospitals for dental problems. Poor oral health affects a person’s overall health and wellbeing. Research has shown links between poor oral health and diabetes, cardiovascular disease, pneumonia and Alzheimer’s. If you have missing or rotten teeth it affects your self-esteem and can make it difficult to find employment. Public programs to address oral health in Ontario are a fragmented patchwork – there are programs for low income children, social assistance clients, and a federal reimbursement program for Aboriginal peoples, but none for uninsured low-income adults and seniors.
What are AOHC members doing to tackle this problem?
Providing services: 34 Community Health Centres, one communitygoverned Family Health Team and one Aboriginal Health Access Centre are providing oral health care services to low-income individuals December 2012
campaign calling for the extension of oral health programs to include adults who cannot afford emergency treatment. AOHC members are active partners in this campaign – they are meeting with MPPs this fall to deliver the signed postcards and call for all parties to include commitment to oral health programs for low-income adults in their election platforms. Here are actions to consider.
Signed dental postcards advocating improved support programs for adults were presented recently to MPP Laurie Scott, centre. From left, Loretta Fernandes-Heaslip, of the Brock Community Health Centre, Anna Rusak, of the Health Unit, Jennifer Gill and Ryan Alexander, both of Community Care City of Kawartha Lakes Community Health Centre, make the presentation.
and families in their communities. Many of these centres have new dental suites as a result of the Healthy Smiles Ontario program initiated in 2010. Staff are finding that over 80 per cent of their oral health clients have chronic diseases. These clients are often referred to other clinicians or programs within the centre to promote improved health. The majority of AOHC members are working with local public health units on oral health care issues. Advocating to eliminate barriers to oral health care: This summer over 50,000 people across the province signed postcards as part of the Ontario Oral Health Alliance ASSOCIATION OF ONTARIO HEALTH CENTRES
Promoting healthy public policy: AOHC joined other oral health stakeholders in a new report entitled, Staying Ahead of the Curve: a unified public oral health program for Ontario? Released in October, the report calls on the Ontario government to replace the current patchwork of programs with a more efficient unified program. In the report, AOHC Executive Director Adrianna Tetley notes that CHCs and AHACs are well positioned to play a stronger role in delivering a more cohesive program for people in need given their strength and experience in working with marginalized populations.
It’s a strange truth of Canadian public policy: the care of our lips, tongues and throats is fully covered by public funding, but not our teeth and gums. - Armine Yalnizyan, Canadian Centre for Policy Alternatives
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INFORMATION MANAGEMENT
AOHC facilitates fast-pace EMR deployment A year after a contract was signed to adopt a common up-to-date electronic medical record (EMR), already a dozen of the 86 scheduled member centres have gone live, learnings abound, and the dedicated AOHC team is working to meet the 2014 deadline to complete all implementations. A dozen Community Health Centres (CHCs) and communitygoverned Nurse Practitioner-led clinics (NPLCs) have deployed the new EMR: Nightingale on Demand, developed by Nightingale Informatix Corporation. Ontario’s 10 Aboriginal Health Access Centres (AHAC) will also adopt the EMR. It’s a huge undertaking with so many AOHC members involved, two languages, and the different starting places of different centres. Some still use paper records and a huge scanning job is underway to ensure the transfer of information (or “data migration.”) Other centres have been fully electronic for years and are cleaning up their electronic data before it is migrated. It’s a complex piece of coordination. “The data migration phase is a hugely complicated one, but we have an experienced team and we will ensure that all critical data is migrated without incident. During and after the data migration process, centres will be able to continue providing care to their clients,” says AOHC’s EMR director Nolan Yearwood. Throughout the two-year process, quality improvement is a key driver. At a recent meeting of executive directors of many centres involved, early adopters shared December 2012
development group categories reflecting health prevention and community development • It includes decision-support platforms
Benefits
Pat Chilton, executive director of Missiway Milopemahtesewin Community Health Centre in Timmins, receives a plaque October 24 from Michelle Hurtubuise in recognition that the centre acted as an early adopter in AOHC’s 2-year EMR roll-out
their lessons learned with those still waiting in the queue. “Our staff was keen to implement the EMR. Some had prior EMR experience, most did not … We are upbeat and positive about our new tool,” says Ron Ballantyne, executive director of Brock CHC that has already “gone live.”
About the EMR:
• Bilingual interface • Certified by OntarioMD physicians’ group • Uses an ASP or application service provider model to cut down on software and technical support costs • Enhancements include: the system of clinical terminology ENCODE-FM • and the addition of personal ASSOCIATION OF ONTARIO HEALTH CENTRES
• Improved client safety through the reduction of handwritten notes; improved quality of care via automated alerts/reminders. • Ready access for care providers to new eHealth offerings such as electronic access to hospital reports; data sharing with other healthcare service providers. • More client information captured and managed according to accepted standards; improved data quality over time; lower healthcare system costs.
MSAA reporting
When data is the topic, it’s key to sort out what numbers to trust – to establish what AOHC chief information officer Rod Burns likes to call “the source of truth.” In October, at the start of fiscal Q2, for the first time CHCs were able to use BIRT, their new source of truth, to produce their MSAA (multi-sectorial accountability agreement) reports. BIRT is a business intelligence and reporting tool developed by AOHC’s not-for-profit partner Connex Ontario. It will act as the new authoritative data source for community health centres and can submit data for reporting and analysis.
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CONGRATULATIONS
Order of Canada for Pathways to Education founder In September, Carolyn Acker was made a member of the Order of Canada “for her contributions to increasing access to education for thousands of disadvantaged students across Canada.” It was while she was executive director of Regent Park Community Health Centre that Carolyn Acker founded the innovative Pathways to Education program that helps youth in low-income areas graduate from high school and transition to post-secondary school. Carolyn remains on the board of Pathways to Education in the role of founder. Community Health Centres continue to be a natural partner for the program and, as one of dozens of community initiatives, partner with Pathways not only at Regent Park but also at North Hamilton, Kitchener, Pinecrest-Queensway, Unison and Rexdale CHCs.
Carolyn Acker, centre, pictured with a Pathways to Education current student and a graduate
Bright lights!
Jubliee medal recipients
In October, the Association of Family Health Teams of Ontario presented its Access and Quality award to Marina Hodgson, Executive Director of North Kawartha Family Health Team, an AOHC member. Hodgson won the “Bright Lights” award for her work with the team over the last four years, growing from one location that served 900 patients to locations in both Fenelon Falls and Bobcaygeon that offer primary care to over 5,500 in the large rural area where 19 per cent of the population are senior citizens, many in lower income brackets and less mobile than the provincial average. Competing against 554 other applicants, in November AOHC member Community and Primary Health Care – Lanark, Leeds, and Grenville of Brockville won the $20,000 William H. Donner Award for Excellence in the Delivery of Social Services, the award for the highest-performing agency overall. And for the fifth time, CPHC won the Services for Seniors award and its $5,000 prize. CPHC is underway with plans to develop a $9.5 million Community and Primary Health Care Health and Wellness Centre of Excellence in Brockville, to open as early as next summer.
Executive directors of four community health centres have been awarded the Queen’s Diamond Jubilee medal in recognition of their contributions to their communities: • Michael Birmingham, Carlington CHC • Denise Brooks, Hamilton Urban Core CHC • Marcel Castonguay, Centre de santé communautaire Hamilton/Niagara • Jocelyne Maxwell, Centre de santé communautaire du Témiskaming
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Other recipients connected to AOHC members we know about include: • 23-year-old Amber Morley, director of the South Etobicoke Youth Assembly that operates out of the Lamp CHC in Mississauga. See article; • Merton Baird, a member of the Seniors Advisory Committee at The Four Villages Community Health Centre in Toronto; and • Marg Hennig, recognized for her many community roles including as a volunteer with Kitchener Downtown Community Health Centre
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Quality improvement: beyond the checklist Improving health care, the patient experience and reducing wait times are just some of the reasons quality improvement has become such a watchword for healthcare in Ontario. Quality improvement became a commitment for AOHC members first five years ago. And the initial work has put our community-governed primary care centres in good shape prior to changing provincial requirements. Work is currently underway by the Ministry of Health and Long-Term Care and Health Quality Ontario to expand the strategy building out of the 2010 Excellent Care for All Act (ECFAA) to Ontario’s primary care sector, which includes AOHC members. This will begin with the development of quality improvement plans. The purpose of this work is to ensure there are uniform commitment and a consistent approach to improving the quality of care delivered to Ontarians. Community Health Centres are largely ahead of the curve in meeting most of the expectations under the Act. A recent maturity assessment survey has revealed that 77% of the centres have a quality committee, 69% have quality improvement plans, 94% do client and caregiver surveys, 87% do employee satisfaction surveys, 77% have a client relations process and 80% have a declaration of values. Aboriginal health access centres as well as community-governed family health teams and nurse practitioner-led clinics are earlier in the process but also preparing to meet quality improvement requirements. So compliance with ECFAA will not be a problem, says consultant Lorri Zagar. But that’s not the end of the line for AOHC members. Their intention is to truly adopt the spirit of quality improvement and Zagar and others are working with AOHC member centres to “get beyond a checklist” of requirements to improve care and access. “For organizations that are really successful in quality improvement, QI (quality improvement) is not an add-on,” she says, “but integrated into all of the everyday problem solving that they do.” She assesses that community health centres have come “light years” in this in the five years since it has become a priority and that probably organizations aren’t yet aware of how much knowledge they’ve built up. Now it’s time to share that knowledge on quality, says Zagar. She notes the example of Rideau Community December 2012
Health Services that, as part of their Better Health Project, organized group medical visits in Smith Falls and Merrickville to improve access for their community. That project provides excellent lessons that other centres can learn from, says Zagar, especially those looking to increase their panel size (the number of patients seen by a physician or physician/healthcare group). Looking at the big picture, Zagar says that: “Being ECFAA-compliant and moving along the quality improvement journey allows CHCs to align with the LHIN priorities and meet the goals of the Ministry of Health and Long-Term Care’s primary care plan. However, more importantly, creating a culture of quality in everything CHCs do enable them to continue the great work they do for clients within the health care environment facing organizations today.”
Targeted training AOHC will coordinate governance training on quality improvement for 295 primary healthcare centres including our member centres as well as family health teams and nurse practitioner-led clinics. AOHC is partnering with the Association of Family Health Teams of Ontario and the Canadian Patient Safety Institute to adapt the training they provided to hospitals in 2011. Seven workshops will be offered across the province between January and April for board chairs, board quality leads and executive directors. Workshop attendance will be organized to ensure that participation represents approximately half of the available centres from each primary care model. A limited number of spaces will be available on a first come first served basis. It is very likely that AOHC will deliver similar governance training to our member centres that are unable to participate in the first seven workshops.
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COMMUNITY HEALTH WEEK
Health and Long-Term Care Minister Deb Matthews kicked off Community Health Week on October 1 at the provincial legislature with members from four Community Health Centres: Rexdale, Scarborough, Access Alliance and Regent Park.
Community Health Week 2012 Celebrating the local
Dental day at Woodstock and Area CHC December 2012
Chigamik takes it to the street in Midland ASSOCIATION OF ONTARIO HEALTH CENTRES
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Calls grow for comprehensive network of CHCs Opinion leaders across Ontario are endorsing the recent recommendation of the Canadian Index of Wellbeing (CIW) that many more people should have access to comprehensive and coordinated services provided by Ontario’s Community Health Centres. “The CIW is very much on the mark with its prescription for a comprehensive network of CHCs. A comprehensive network will benefit the long-term health of people living in Ontario and strengthen our overall health system,” said Bill MacLeod, CEO of the Mississauga Halton Local Health Integration Network. He continued that his LHIN, “is very interested in establishing a network of CHCs to meet the high needs in this region.” Others healthcare leaders were also in agreement with the CIW’s report, its second annual, which said that such a network of CHCs would deliver “a better start for children, fewer avoidable hospital visits, better prevention and management of mental illness and complex chronic disease, and improved chances for seniors to age at home.” According to Alex Munter, CEO of the Children’s Hospital of Eastern Ontario, “CHCs are highly effective at easing pressures on hospitals and helping people in the community more easily access the services they need to stay healthy.” Doris Grinspun of the Registered Nurses Association of Ontario (RNAO) had equal praise. “CHCs, as well as other interprofessional models like nurse practitioner-led clinics and family health teams, are the key to improving health and wellbeing.” The RNAO CEO also noted a
new report from her association to expand access to interprofessional teams and assign them the mandate of handling care coordination and system navigation. Meanwhile, Ontario communities advocating with the provincial government and their LHINs for access to CHC services are hoping the CIW recommendation will prompt a quick response to their calls... Following release of the CIW report, Mayor Frank Scarpitti applauded community members’ efforts to bring a CHC to Markham, saying his city would greatly benefit from “having tailor-made health and wellness related services, fully able to meet cultural and linguistic needs.” In a Toronto Star article written by MarkhamRichmond Hill’s Dr. Naila Butt, the community leader wrote that “with rising rates of chronic disease and depression, especially in AOHC’s Adrianna Tetley with Dr. Naila Butt newcomer communities, we of Social Services Network of Markham desperately need access to the CHC comprehensive approach. “ The CIW‘s recommendation to expand access to CHCs was one of several made in its second annual report to improve the wellbeing status of Canadians which has declined since last year. For a copy of the full report visit www.ciw.ca.
Retiring premier Dalton McGuinty was overheard in a summer visit to Vaughan Community Health Centre telling centre staff: “You are saving us money.” The focus of Vaughan CHC is youth, seniors and people who have mental health and addiction issues. Health promotion and community programming are strengths of the centre. December 2012
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