Championing Better Health for Fraser Region A Strategic Map for 2013–2017
Contents Message from the CEO/President and VP Public Health & Chief Medical Health Officer
1
Executive Summary 2 Introduction 9 Background 13
Strategic Priority Areas Chronic Disease Prevention Mental Health/Substance Use and Well-Being Unintentional Injury Prevention Healthy Aging
45 48 52 56 60
Data and Evaluation 65 Alignment and Opportunities
69
The Way Forward Together
74
Our Community and Challenges
21
A Strong Foundation at Fraser Health
25
Conclusion 76
Our Strategy
33
Population Health Strategic Planning Steering Committee
Overarching Approaches 35 36 Partner and Collaborate Create Supportive Environments 38 Promote Health Equity 40 Apply a Lifespan Approach 42
78
Acknowledgements 79 Appendices 80 References 82
Message from the CEO/President and VP Public Health & Chief Medical Health Officer We are pleased to present the first Strategic Map to Better Health for Fraser region. This strategic map is an outward-looking, flexible and living document with a focus on health promotion and prevention. Our region continues to be the largest in population and has the fastest growth rate in British Columbia while our health care system continues to face the challenges we are all too familiar with. Now is our time to be leading edge and to elevate our work by further integrating and working together across our programs and with our communities. Our coordinated efforts together in the four inter-connected strategic priorities areas will result in greater impact and better health outcomes for those we care about. At our health authority, we have passionate and dedicated leaders and staff producing excellent work in population health and within the core public health functions framework. The strategic map does not replace existing work but builds on the strong foundation, momentum and accomplishments of our programs. The strategic map reflects input and counsel from a broad range of partners and stakeholders. We acknowledge and thank the cross-portfolio steering committee, our key partners in the acute care sector and the Fraser Population Health Council in the development of the document. We also acknowledge the support of the Fraser Health Board and Executive team, and of the strong municipal partnerships reflected in the Fraser Health Municipal Government Advisory Council.
Dr. Nigel Murray
Dr. Paul Van Buynder
Ultimately, this is a strategic map for the next five years. It will be flexible, it will engage, it will be entrenched in partnerships and it will aim to achieve its vision of better health outcomes for our communities. We have a window of opportunity to navigate together to do amazing things.
Dr. Nigel Murray
Dr. Paul Van Buynder
President and CEO
Vice President, Public Health & Chief Medical Health Officer
A Strategic Map to Better Health for Fraser Region | 2013-2017
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Executive Summary Introduction The health challenges that we face are growing and complex. Noncommunicable diseases, such as chronic disease, injuries and other complex health issues, place a substantial burden on our families, friends and communities and the ability of our health care system to effectively meet the needs of all in our region. If the current health challenges and trends continue, our health system will be unable to meet the health needs of those we care about when they need it most. The burden of illness of these health issues, however, is largely preventable. The Strategic Map to Better Health is our opportunity to collectively champion Better Health for ourselves, our children, families and communities in the Fraser region. Fraser region not only includes the health authority but our children, parents, grandparents, friends, neighbours and our communities. This strategic map focuses on health promotion and prevention.
Partner Innovate inspire align integrate 2
Fraser Health
A Strong Foundation at Fraser Health Fraser Health (FH) is well positioned to support the Strategic Map to Better Health and the communities towards achieving better health outcomes. “Better Health” of FH’s vision is what population health aims to achieve. Population health is central to FH’s mission, which is “to improve the health of the population and the quality of life of the people we serve”. A strong foundation of critical infrastructure, existing quality population health work and progressive partnerships is already in place. Much leading edge and exemplary work towards achieving Better Health for the people of Fraser region has already been done and continues. Highlights of our quality work and progressive partnerships are provided in the main document. The strategic map will build on these strengths and complement the work that already exists within FH and our communities, across academic institutions, different levels of government and sectors.
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Our Strategy
Guiding Principles
vision
Better Health for Fraser Region.
mission
Support and strengthen champions for population health to protect, promote and improve the health and well-being of those we care about through our integrated and collective actions.
Inspire
Build on collective strengths and current efforts
Be evidence based
Align for optimal impact
We believe that prevention of disease, in conjunction with treatment of disease, is the most effective way to ensure long-term health and well-being of our communities.
Innovate
We value good quality client and public engagement in the services and programs we provide.
Respond to community needs
Be flexible and think long term
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values & beliefs
We hold true that achieving the best population health requires an ongoing commitment to innovation, best practice implementation and formation of strong partnerships.
Fraser Health
We believe everyone in Fraser region has a right to optimum health and well-being and that we must work to overcome health inequities that place a disproportionate burden of poor health on some of our most vulnerable communities.
Overarching Approaches Within each of the strategic priority areas, there are four cross-cutting approaches that are to be integrated: (1) partner and collaborate, (2) create supportive environments, (3) promote health equity, and (4) apply a lifespan approach. Together, these approaches represent an opportunity to shift the current trends affecting the health of the people of Fraser region. Great work is already happening by using these approaches. Our challenge now is to further integrate these approaches to achieve Better Health together.
pan Approac Lifes h
Mental Health/ Substance Use & Well-Being Chronic Disease Prevention
Healthy Aging
Unintentional Injury Prevention
H ea
lt h E q u it y L e
ion
• Chronic Disease Prevention • Mental Health/Substance Use and Well-being • Unintentional Injury Prevention • Healthy Aging
ion
rt Pa
nvioronm rtive E ent ppo s Su
Four inter-connected strategic priority areas were identified as offering the opportunity to have the greatest health impact for our communities for the next five years:
h in the Frase t l a rR He eg r & Collabo e ships r r a e t n
Be tt
Strategic Priority Areas
ns
Data and Evaluation Evaluation is an important part of the strategic map and needs to be developed in collaboration with our staff, key partners and our communities, including the people of Fraser region. General desired outcomes have been articulated in the strategic map but further input is required so that the overall measures of successes are meaningful, realistic, relevant, achievable and supported by the data. The strategic map will be an iterative process that will review the previous year and update the strategic map for the following five years to ensure it continues to respond to community health needs. Monitoring of all strategies and actions will be incorporated.
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Strategic Priority Areas Alignment & Opportunities The Strategic Map to Better Health aligns with national, provincial, municipal and FH mandates, priorities and strategies. Alignments and intersects are opportunities to enhance the coordination and integration of the prevention and equity activities taking place within FH and amongst our communities and partners. The strategic map’s alignment with FH’s strategic imperatives and with various levels (national, provincial and local) are noted in the document.
The Way Forward This strategic map provides the framework and a vision of population health for Fraser region over the next five years. Implementation planning is the next phase of the strategic map and will include engagement, communications and integrated action planning. Input from our frontline staff, partners, stakeholders and the people of our communities are integral to the success of the strategic map. Let’s innovate and find the solutions together on how we reach the healthy future state we all aim for. Mental Health/Substance Use and Well-being
Healthy aging
Goal
Foster healthier, more active and productive seniors (older adults) through age-friendly environments, policies and programs.
Goal
Improve the mental health and well-being of the people of Fraser region.
outcome
An increase in the number of healthy seniors in the Fraser region who enjoy independence and quality of life longer at home and in their own communities.
outcome
Increase mental health and wellness and prevent substance misuse across the lifespan.
strategies
1. Create partnerships/alignment between programs. 2. Advocate for age-friendly thinking and actions in Fraser Health and at community level. 3. Achieve an age-friendly health authority through efforts on culture, policies, care processes, physical environment.
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Fraser Health
strategies
1. Partner and collaborate to promote mental health and well-being across the lifespan and identify those at risk. 2. Apply a community setting approach to reach at-risk populations. 3. Build on Healthier Community Partnerships.
Conclusion The Strategic Map to Better Health is the first population health road map for Fraser region. The four inter-connected priority areas offer the chance to create a culture of possibilities and innovation together. We all have a role in Better Health. This flexible and living document serves as a platform to inspire champions for better health. Our collective efforts to integrate, innovate, coordinate and collaborate will result in greater impact for better health outcomes for us and those we care about.
More active and productive seniors in their own homes and communities
+
More people in our communities with positive mental health and well-being
+
Safer communities that prevent injuries from falls, motor vehicle crashes and accidental childhood injuries
+
Unintentional Injury Prevention
Goal
outcome
strategies
Create safe communities to minimize the risk of and prevent unintentional injuries.
A reduction in injury-related falls, MVCs and accidental childhood injuries.
1. Leverage both existing and emerging activity. 2. Collaborate across portfolios and sectors to develop a strategic framework. 3. Develop collaborative education targeted to Aboriginal and Youth populations.
Healthy community members living without major chronic disease or risk factors
=
better health for ourselves, our families, neighbours and communities
Chronic Disease Prevention
Goal
Prevent chronic disease through a focused and integrated population health approach on major chronic diseases and their risk factors to reduce their burden on the health care system.
outcome
An increase in daily physical activity levels, fruit and vegetable consumption and participation in recommended screening/ prevention programs, and a decrease in tobacco dependence across the lifespan.
strategies
1. Collaborate with key partners to develop a comprehensive, integrated and evidence-based framework. 2. Create a culture of proactive prevention. 3. Use existing partnerships, policy and mandates to prevent chronic disease and reduce gaps in health outcomes.
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Fraser Health
Introduction The Strategic Map to Better Health (strategic map) is our opportunity to collectively champion Better Health for ourselves, our children, families and communities in the Fraser region. Fraser region not only includes the health authority but our children, parents, grandparents, friends, neighbours and our communities.
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This is our opportunity to collectively champion Better Health for ourselves, our children, families and communities in the Fraser region.
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Fraser Health
The health challenges that we face in the Fraser Region1 are growing and complex. Non-communicable diseases, such as chronic disease, injuries and other complex health issues, place a significant burden on our families, friends and communities as well as our health care system. For example, as our parents and grandparents grow older, they will likely have multiple and complex medical health care needs. At the other end of the spectrum, chronic disease is becoming more prevalent in our children. Today’s generation of children could be the first in history to live less healthful and shorter lives than their parents.2 The burden of illness of these health issues, however, is largely preventable. The strategic map is a flexible and living document that focuses on health promotion and prevention in four interconnected strategic areas that together, provide the greatest impact. Comprehensive and integrated approaches to prevention are needed. This strategic map serves as a platform to engage and inspire people and partners to be champions for Better Health. The strategic map will build on these strengths and complement the work that already exists within FH and our communities, across academic institutions, different levels of government and sectors.
In this document, Fraser region will be used to refer to Fraser Health Authority and the communities we serve while Fraser Health (FH) or Fraser Health Authority will refer to the health authority itself. 2 Olshansky et al., “A potential decline in life expectancy,� p. 1143 1
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Fraser Health
Background The development of the strategic map was guided by a population health approach. While this strategic map will not cover every aspect of population health, every effort was made to ensure alignment with municipal, provincial and internal priorities to enable broader reach to more people and amplify positive health impacts. The following sections provide background information on key terms.
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What is Population Health? In our health care system, a range of services is provided to the people who live, learn, work and play in the Fraser region. Some services are provided to the individual through diagnosis, treatment and rehabilitation. Other services look for ways that larger numbers of people can benefit and improve their health. This approach is known as the population health approach. Rather than finding solutions to improve or protect the health of one person at a time, population health strategies look to improve the health of groups of people or the health of people in a region, community, province, country or even part of the world. One example is immunizations. By having a large number of people in our communities and workplaces vaccinated against certain diseases that can be transmitted from one person to another, people not only protect themselves but also protect others who may not be able to have the vaccination (e.g., our children and grandparents) from the spread of disease. Population health strategies focus on prevention as well as ensuring everyone has an equal chance at better health.
What affects our health? Access to high-quality health care services is essential to good health. Even with the best health care system, different groups of people within the Fraser region will experience health differently from other groups, and this will vary across their lifetime. Research shows that age, gender, FACTORS IMPACTING BETTER HEALTH race, income, social and cultural factors, working conditions and many other factors (determinants of health) affect a person’s health. Other factors include (1) social status, (2) social support networks, (3) education and literacy, (4) social environments, (5) physical environments, (6) personal health practices and coping skills, (7) healthy development in childhood, (8) biology and genetic endowment, and (9) health services. Figure 1. Relationship between individual and broad factors affecting health The larger the concentric circle, the broader the influence and the more people can be affected. It is important to note that all the factors that affect one’s health are linked—within, between and across spheres. (Adapted from the Sudbury Public Health Unit with permission)
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Fraser Health
Why are there differences in our health? Differences in our health are influenced by the relationship between the person, his or her community, and the socio-economic, political, cultural and environmental factors that he or she is exposed to. Everyone in our society is exposed to these factors at some level; it is the differences in exposure and levels of exposure that play a role in our health outcomes. When members in a society feel the burden of these factors more heavily, poorer health outcomes are inevitable. For example, hospitalization rates for chronic disease are three to four times higher in the most disadvantaged groups.
Norwegian Ministry of Health and Care Services, “National strategy to reduce social inequalities in health�, p. 11. Reproduced with permission.
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We all have a role in Better Health
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Fraser Health
Health Inequities Health inequities are avoidable and unfair differences in health outcomes. The main contributors to health inequities are the external environment and conditions mainly outside the control of the individuals concerned. An example of a common health inequity is the difference in mortality rates between people from different social classes. Most health inequities can be prevented or reduced. Determining whether a health difference is unfair involves a value judgment. Health inequality, on the other hand, is when there is a difference in health outcomes without the value judgment (e.g., biological differences between men and women; differences in mobility between young and elderly people).
Who is responsible for population health? Everyone at all levels across all sectors has a role in Better Health. Within the Fraser region, all FH programs and services, frontline staff, management, executive and Board, and all our communities are a part of the prevention solution. Important to the sustainability of any strategy is FH’s partnership with local governments, community agencies, schools, businesses, other stakeholders and the people of our region. Prevention efforts, however, need integration, collaboration, partnership and collective innovation.
What strategies does the population health approach use? Population health strategies use broad approaches to prevent potential health problems before they affect the health care system.3 Population health approaches share common key elements such as: focusing on the health of populations; involving the public; basing decisions on evidence; using multiple strategies; collaborating across different sectors and levels; addressing the individual and broad factors that affect health; and investing in the broad areas that affect people’s health (e.g., education, safe communities, jobs). To see some of the strategies that different levels across the Fraser region can influence within their own spheres, please see Appendix 1. One other key aspect of the population health approach is to demonstrate accountability for health outcomes. This calls for an increased focus on health outcomes (versus inputs, processes and products) and involves an examination of changes in health status, determinants of health and health status inequities between population sub-groups. Different types of evaluations are used to assess these changes. Results are shared and reported in a timely manner to all partners and citizens. 3
For more information on the population health approach, please visit the Public Health Agency of Canada’s website: http://www.phac-aspc.gc.ca/ph-sp/approach-approche/ index-eng.php A Strategic Map to Better Health for Fraser Region | 2013-2017
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Levels of Prevention There are four levels of prevention, three of which are highlighted. 4 The first two levels target populations who are well and healthy whereas the third level of prevention starts to focus on groups of people who are at-risk of developing disease, illness or disability. An example of childhood obesity is used to illustrate the types of prevention activities at each level.
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Primordial Prevention – Strategies at this level aim to prevent disease and illness or the risk factors that lead to disease (in the example, childhood obesity) from happening in the first place. The focus of primordial prevention is to: (1) positively change the social and environmental conditions so that risks factors have a less likely chance of developing (e.g., communities that promote walking; early childhood health education); and (2) advocate for and the development of policies where everyone or selected groups benefit (e.g., school vending machines limiting unhealthy snacks; policies that limit the density of fast food establishments in residential communities), health examinations (e.g., monitoring early childhood weight and development) and controlling risk factors (e.g., high cholesterol through medication and diet).
2
Primary Prevention – This type of prevention focuses more on reducing the specific causes/risk factors of disease and illness. Strategies focus on health promotion (e.g., healthy lifestyles that include physical activity in schools, limiting screen time, healthy diets) and the protection against disease and disability (e.g., exclusive breastfeeding up to six months). Universal or targeted (e.g., gender specific, culturally appropriate) approaches are used.
3
Early Secondary/Early Detection – This level of prevention is more targeted and focuses on at-risk populations through promoting early detection or screening and early treatment of disease and limitation of disability. Some strategies for the example of childhood obesity would include periodic health examinations (e.g., monitoring early childhood weight and development) and controlling risk factors (e.g., high cholesterol through medication and diet). 4
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Tertiary prevention is the fourth level of prevention, where the disease has developed and been treated. Key goals are to reduce the impact of the disease on a person's function, longevity and quality of life.
Fraser Health
Partner Innovate inspire align integrate
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Fraser Health
Our Community and Challenges Fraser Health Authority serves the largest population and is the fastest growing health authority region in BC. Covering an area that stretches from Burnaby to White Rock to Boston Bar, FH serves over 1.6 million people. The Fraser region has the highest birth rate in BC and is expected to have BC’s largest increase in population.
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We are diverse, culturally and geographically: 5 • Over 40% of all BC immigrants = 1/3rd of our region’s population • More than 80% of BC’s government-assisted refugees • Over 35 languages spoken • 32 First Nations communities • Ranging urban-rural population sizes (e.g., ~8,300 in Hope to over 403,000 in Surrey) The health status and behaviours of the people in our communities are likewise diverse, varying between municipalities and even within the same municipality. Overall, some 45% of people in the Fraser region are physically inactive. Over 55% of people do not consume the recommended intake of daily fruit and vegetables. Individuals living in rural areas are more likely to suffer from poor health than those living in urban areas. Health status declines in the further eastern areas of the Fraser region. 6 Like many other regions, our communities and our health care system face the following current trends and challenges 6, 7:
Chronic conditions and injuries are responsible for over $22 billion per year in economic burden in BC. 6 Increasing costs of medical technologies and pharmaceuticals.7 A growing and aging population with multiple and complex health care needs.7 Many competing health care priorities for funding. The increasing gap in health status across socioeconomic status levels in the Fraser region.
Fraser Health Authority, “Health Profile 2011” Kendall, “Provincial Health Officer’s annual report” 7 Canadian Institute for Health Information (CIHI), “National health expenditure trends” 5
6
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Fraser Health
Figure 2. Revenue/Spending Scenario in British Columbia, 2004-2017
100%
Total
90% 80%
Health
70%
Percent
41.6%
40% 30% 20%
28.4%
Public Health Agency of Canada (PHAC), “The Case of ActNowBC in British Columbia” 27.0% 8
27.0%
Education
27.0%
16.6% Other
10% 0% -10%
71.3%
53.6%
60% 50%
100.0%
-0.6% 04/05 05/06 06/07 07/08 08/09 09/10 10/11 11/12 12/13 13/14 14/15 15/16 16/17 17/18
Year Adapted from “The Case of ActNowBC,” by Public Health Agency of Canada (p. 40), Copyright 2009 by the Public Health Agency of Canada. Retrieved from http://www.phac-aspc.gc.ca/publicat/2009/ActNowBC/pdf/anbc-eng.pdf
These health challenges do not recognize boundaries or areas of responsibility. If the status quo of current activity is maintained and no new actions to promote health and prevent disease occur, it is estimated that by 2017 that the BC Ministry of Health would require 71.3% of the total budget of the government, increased from 41.6% in 2005-2006 8 (see Figure 2). If this holds true, spending in other areas would reach zero by 2017/2018 while health care make up most of the provincial budget. From the perspective of achieving Better Health for ourselves, our families and our communities and to ensure that we can access quality social and education services when we need them, more action must be taken to prevent disease and promote health. Multifaceted solutions and strategies using a population health approach across multiple sectors and levels of government are required. 8
Public Health Agency of Canada (PHAC), “The Case of ActNowBC in British Columbia”
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Fraser Health
A Strong Foundation at Fraser Health Fraser Health is well positioned to support the strategic map and the communities towards achieving better health outcomes.
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Critical Infrastructure in Place Fraser Health is well positioned to support the strategic map and the communities towards achieving better health outcomes. Fraser Health has adopted a population health orientation or approach to respond to the health needs of its resident population in an optimal manner. 9 Population health is central to FH’s mission, which is “to improve the health of the population and the quality of life of the people we serve.” “Better health” of FH’s vision is what population health aims to achieve. In addition to FH’s vision and mission being linked with this approach, FH has structures already in place that position and support the strategic map. There are key elements within FH that support Better Health: FH strategic imperatives, program management, leadership support and support services (see Figure 3). The key result or output of each of these key elements is described briefly. Figure 3. Key Elements that Position Fraser Health to Support Population Health and the Strategic Map to Better Health.
Better Health
FH Strategic Imperatives
Synergies with population health approach
Program Management
Population health activity across portfolios
Leadership Support
High Priority Initiative - Better Health
Support Services
Population Health Observatory
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Fraser Health
Key Result/ Output
FH, “Fraser Health Authority Service Plan”
Partnerships
Population Health
Key Element
1. FH Strategic Imperatives: Linkages with the Population Health Approach There are strong linkages between FH’s strategic imperatives and the population health approach.10 For example, the Progressive Partnerships Strategic Imperative focuses on engaging citizens as partners and creating collaborative partnerships internally within FH and externally with municipalities and community agencies. See the ‘Foundational Partnerships & Work – Highlights’ section for details of key partnerships that can help move the strategic map forward. 2. Program Management: Population Health Activity across FH Portfolios Program management is a model adopted by FH aimed at integrating and coordinating activities as well as the population health approach across portfolio areas. All program portfolios in FH incorporate elements of prevention into their current work and have established some innovative partnerships. Opportunities exist to improve sustainability through cross-portfolio collaboration, shared facilities, resources, and information. An example is the Seamless Perinatal Care Program along with the Infant Mortality Review Committee, which comprises leaders across different programs coming together to better understand infant mortality and its causes and evaluate effective interventions that minimize such deaths. 3. Leadership Support: High Priority Initiative – Population Health
is linked with FH’s strategic imperative of Progressive Partnerships. As we are all aware, partnerships are critical to the success and sustainability of population health strategies, which require multiple sectors and levels of government. Building on the excellent ground work laid by the Healthier Community Partnerships with our municipalities and community partners, FH partnerships will broaden over time to include businesses, health professional groups, and community agencies. Another arm of this high priority initiative is prevention and equity in programs. The objective is to support programs to develop and implement prevention strategies and apply an equity lens in their service planning. This work aims to enhance existing programmatic activities or develop new activities and to ensure that these are accompanied by meaningful indicators and reflected in service plans. 4. Support Services: Emerging Population Health Observatory The Population Health Observatory was recently revitalized. It has an integral role in population health and provides support in the areas of health assessment/disease surveillance, research, program evaluation, performance measurement, and knowledge translation. The observatory works with health planners to provide them with needed population health information to inform decision making and action.
Population health is embedded in one of the high priority initiatives that FH Executive has prioritized to be the focus for the organization. This high priority initiative
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Contact us for more information on how FH’s strategic imperatives align with the population health approach.
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Foundational Partnerships & Work – Highlights Progressive Partnerships Fraser Health’s strategic imperative to advance strategic alliances and progressive partnerships is an important element of the strong foundation supporting Better Health. Engaging “citizens as partners” For us to truly respond to the health needs of our communities, we need to listen and partner with the people who live, learn, work and play in the Fraser region. An example of building these critical partnerships is the Primary Health Care initiative, Patients as Partners, which focuses on “nothing about me without me.” This integration of patients as partners in the development of system redesign has resulted in the creation of the Patient Advisory Council for patients to have a stronger voice in policy setting and decision-making. A member of this council sits on the Fraser Population Health Council, which was created as an advisory body to the development of the strategic map and ongoing public health activity. Another example of emerging work in public engagement is the research being conducted by FH Women’s Health team. The goal of this research is to develop and implement a model of patient engagement that supports marginalized women to have a voice in program planning.
Partner Innovate inspire align integrate 28
Fraser Health
Creating collaborative partnerships internally Some of the many internal partnerships created by our programs: • Emergency Medicine: Clinical partnerships have been developed to provide care that better meets the needs of specific populations. Geriatric Emergency Nurses, Psychiatric Liaison Nurses, and social workers partner to help with reintegration into the community. These partnerships support more equitable and better outcomes for patients and help reduce readmission rates. • Trauma: This program is partnering on a research project with the Insurance Corporation of BC and RoadSafe BC to learn about ways to prevent traumatic injury due to motor vehicle accidents. • Surgery: Linkages with the Older Adult Program have been made to look at ways to reduce falls in our elderly family members after they have had surgery. • Aboriginal Health: Numerous internal and external partnerships have been formed to support better health for the Aboriginal population across the life course. These range from support groups for pregnant women and new moms to memory health workshops for seniors.
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Creating collaborative partnerships externally with municipalities and community agencies At FH, the Board and Executive can help to carry forward the strategic map within their own respective spheres of influence and linkages to other networks. The strong municipal partnerships in the Fraser Health Municipal Government Advisory Council and the successful Healthier Community Partnerships provide the forum to ensure that the dialogue on Better Health is a two-way communication. The Fraser Population Health Council has membership from internal and external partners (e.g., academia, local government). Various programs at FH have established partnerships with academic institutions, including universities and local colleges. These partnerships include research, program evaluation, community projects and the development of tools and resources for use within programs while contributing to the professional development of future leaders and decision-makers in health care and related support services.
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Fraser Health
Foundational Work Fraser Health’s leaders and staff with population health responsibilities continue to produce quality work that contributes to the foundation needed for the strategic map and to elevate our population health activity to another level. Some examples are provided below. Public Health provides much of the day-to-day work in core public health functions; this work needs to continue. Traditional public health roles in health protection and communicable diseases are needed to improve, maintain or protect the health of the people of Fraser region while meeting provincial and legislative requirements. Likewise, ongoing monitoring of and response to potential emerging communicable disease outbreaks enables people to visit community spaces (e.g., restaurants, community centres, parks) without fear of infection. Natural disasters are unpredictable and require coordinated emergency response and management across different sectors. There is excellent work that is being done to address the broader factors that affect our health. For example, teams within Public Health working in the Maternal Child Health area have dedicated their efforts to creating supportive FH environments for early childhood development. The Healthier Community Partnerships are successful partnerships with FH local governments and communities that bring together multiple stakeholders across different sectors and agencies that commit to working towards a common goal of creating healthier communities through policy and collective action.
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The Mental Health and Substance Use Program has leveraged partnerships with key community and provincial stakeholders to promote mental health and prevent mental disorders. For example, it partners with the school districts in the Fraser region to provide primary and secondary mental health promotion and prevention targeted towards our children and youth in elementary, middle and high schools. In partnership with the Provincial Health Services Authority, the mindcheck website11 has been created to target mental health prevention and early intervention for youth 13 to 25 years old. The Older Adult Program leads population health planning and healthy aging for our seniors. It has established a model program on falls prevention in seniors and works with clinical programs across the continuum of care and across settings (e.g., home, community, schools). This model includes standard setting and monitoring, emphasizing evidencebased approaches, and developing and applying new knowledge. Falls prevention activities are also delivered in partnership at our schools, residential care facilities and Parks and Recreation community settings. Prevention activity across the Fraser region is increasing, and great things are already happening. Now is the time to create stronger relationships built on trust and collaboration to innovate and integrate activity.
This is a youth and young adult website (www.mindcheck.ca), an existing program in the Mental Health and Substance Use program. A Strategic Map to Better Health for Fraser Region | 2013-2017
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vision
Better Health for Fraser Region.
mission
Support and strengthen champions for population health to protect, promote and improve the health and well-being of those we care about through our integrated and collective actions.
values & beliefs
We hold true that achieving the best population health requires an ongoing commitment to innovation, best practice implementation and formation of strong partnerships. We believe that prevention of disease, in conjunction with treatment of disease, is the most effective way to ensure long-term health and well-being of our communities. We value good quality client and public engagement in the services and programs we provide. We believe everyone in Fraser region has a right to optimum health and well-being and that we must work to overcome health inequities that place a disproportionate burden of poor health on some of our most vulnerable communities.
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Fraser Health
Our Strategy GUIDING PRINCIPLES Inspire We aim to listen to our partners, stakeholders and the public and inspire them to promote better health. Build on our collective strengths and current efforts We will build on the exemplary and innovative work in population health that is already being done within FH and our communities. Be evidence based The best available evidence will be used to inform and highlight where investment of resources will succeed. Where we are doing something new and leading edge, we contribute to the evidence base. Align for optimal impact Maximize impact through integration, coordination, collaboration and partnerships. Innovate This is our opportunity to create stronger connections that build trust and collaboration and promote innovation. Respond to community needs Promote the right service to the right population group or community at the right time while influencing the trends and challenges that impact health. Be flexible and think long term There is a need to remain flexible to changing circumstances and for sustainable disease prevention within our healthcare system.
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Fraser Health
Overarching Approaches Within each of the strategic priority areas, there are four cross-cutting approaches that are to be integrated: (1) partner and collaborate, (2) create supportive environments, (3) promote health equity, and (4) apply a lifespan approach. Together, these approaches represent an opportunity to shift the current direction of the trends affecting the health of the people of Fraser region. Great work is already happening by using these approaches. Our challenge now is to further integrate these approaches to achieve Better Health.
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Approach #1 Partner and Collaborate We all have expertise, skills and perspectives to contribute towards better health. This is an opportunity to continue to strengthen existing partnerships and to garner new ones, across sectors, levels of government and within our own organization. Better health outcomes are achieved with coordinated strategies and consistent messaging across all levels in the Fraser region. Our impact is amplified through partnerships. A key opportunity to achieve positive health outcomes is through enhanced collaboration between primary care physicians and public health. The primary care physicians of our communities are an important link to the people we serve, and it is crucial that we explore and strengthen this partnership further, while ensuring that population health outcomes are aligned with other initiatives linking clinical programs at FH. For example, the Integration of Primary and Community Care12 is strongly focussed on the integration of primary care (physicians) with FH’s community programs, including Mental Health and Substance Use, Home Health, Older Adult and Public Health programs. The work of this initiative is important for population health outcomes. Other areas for expanding progressive partnerships are the community, voluntary, publicly-funded (e.g., schools), religious and private sectors. There is untapped potential for influencing positive health impacts with these groups championing Better Health, due to the respect and credibility they garner in their communities.
12
The Integration of Primary and Community Care (IPCC) is a Key Result Area (KRA) #3 of the provincial Ministry of Health’s Triple Aim core initiative, Integrated and Targeted Primary and Community Health Care, and aligns with FH’s Better Health High Priority Initiative.
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Approach #2 Create Supportive Environments Where we live, learn, work and play influences our health. Influencing and creating supportive environments for positive health outcomes at the individual, community and population levels are needed. Supportive environments that make the healthy choice the easy choice will allow people, communities and all of Fraser region to have better health outcomes. Creating such supportive environments requires partnerships and collaboration amongst many key groups across sectors (e.g., local governments, community agencies, schools, businesses and FH) to develop the needed policies, strategies and community-based programs. Fraser Health already champions its ongoing work within the organization and with communities to create supportive environments. An example is a new FH policy currently in the prototype phase that endorses a Baby Friendly13 approach, promoting environments that support breast feeding and nutrition practices for young childbearing families in all FH hospitals, all health units and community settings. The Healthier Community Partnerships initiative includes strategies that focus on improving the health of individuals and communities in the Fraser region through collective action involving community stakeholders and the public. Actions such as healthy eating policies and development of official community plans are just some examples of current work. The communities of Fraser region are also leading in developing policies that create the supportive environments that promote health for their citizens. In 2011, Chilliwack created an aged-friendly bylaw that required developers of municipal buildings to be aged friendly. This policy also extends to aged housing. These are only some examples of how FH and its communities are creating the supportive environments that make the healthy choice the easy choice. Current successful strategies and policies need to be shared across FH to further build and expand upon what’s already working. Where there is limited activity, policies and strategies warrant identification and implementation.
13
“Baby Friendly� is an international policy with 10 best practice steps to promote, support and protect breastfeeding.
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Approach #3 Promote Health Equity Healthy communities are the foundation for good health. Health equity is not about treating everyone the same but about recognizing that different groups of people have varying needs to achieve good health. Providing equal levels of services to all populations does not lead to equal outcomes. While providing universal services to our population is important, these services need to be complemented by targeted services for those who face significant barriers to health. The strategic opportunity here is for us to ensure everyone has an equal chance to better health through our actions (e.g., policy, planning, research and leadership). There are pockets of FH communities where people experience greater barriers to achieve good health.14 Research shows that individuals in lower income households are more likely to have difficulty accessing healthy living options, to have chronic disease, to have higher utilization of our health care services, and to have worse outcomes. Being deprived of the goods and conveniences that are part of modern life (e.g., access to nutritious food, affordable transportation, adequate housing, neighbourhoods with recreational areas, etc.) is associated with higher rates of death and hospitalization.15 Reducing health inequities between different groups and communities in society remains one of the most effective ways of improving a populations’ health. Strategies can include developing policies that are culturally appropriate and applying a health equity lens to program planning and evaluation. An example of program re-design that responded to inequities within populations is the Public Health Best Beginnings program that has developed strategies to identify vulnerable pregnant women, new mothers, children and families and to provide enhanced services to improve health outcomes.
To see a map of the areas of Fraser region where people from the most deprived to least deprived areas (based on socio-economic status), please see Appendix 2. 15 Pampalon et al., “A deprivation index for health planning in Canada�
14
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An example of community level work is the city of Langley’s Healthier Community Partnership, where one of its partners, Aldergrove Neighbourhood Services works with homeless youth. The largest barrier for homeless youth is affordable housing. Aldergrove Neighbourhood Services has established partnerships with local community agencies, the youth wellness clinic and local landlords to provide a multitude of services to homeless youth in Langley, including financial literacy, simple housing services, and friendly landlord programming, and referral to health services. Homeless youth who have their housing and health needs met are then able to focus on their future (e.g., education, employment).
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Approach #4 Apply a Lifespan Approach Many risks for hospitalization can effectively be minimized or prevented and protective health factors optimized. Fraser Health can be more proactive and examine its health promotion and prevention services16 to identify and mitigate the risks across the lifespan and reduce demand for acute care services. There are opportunities for prevention and promotion at sensitive developmental points across the lifespan, especially when particular health risks or concerns become more prevalent at certain times of life. An opportunity for prevention and promotion is the linkages between childhood experiences and positive mental health. Supportive community environments for children as well as mental health promotion and prevention activities can have the most effective impact on mental health outcomes. Fraser Health is part of an initiative that improves client outcomes in not only positive mental health but also in preventing unintentional injuries and chronic disease. The BC Healthy Connections Project is implementing and evaluating the Nurse Family Partnership program. The program is an evidence-based program for young, first-time low income mothers that has shown significant client outcomes including improved prenatal health and parenting, reduction of child maltreatment, improved children’s mental health and development and improved maternal life course and mental health. Applying a lifespan approach to our work includes enhancing our knowledge of risk and protective factors, early signs and symptoms of illness as well as the application of effective ways to promote health and intervene early. For example, “Start Young� messaging can be applied consistently across the four strategic priority areas and across all levels within FH and by our communities.
16
While early intervention is out of the scope of health promotion and prevention, it is important to be aware of when early intervention may be needed so that referral to appropriate services can be made, be it to FH, community or private services. Early intervention is effective and costs less than when an illness or disease has progressed further.
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Strategic Priority Areas The selection of the priority areas was designed to help shape the first integrated population health strategic map to Better Health for Fraser Region. These areas do not replace the already outstanding and ongoing work that FH continues to do in population health, however, they are intended to enhance or address gaps in potential opportunities for growth, integration, and maximizing better health outcomes for our communities. The four strategic priority areas are: • Chronic Disease Prevention • Mental Health/Substance Use and Well-being • Unintentional Injury Prevention • Healthy Aging
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Everything is Connected
pan Approac Lifes h
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In the following sections, further detail on the priority areas is provided, including a summary on the next page. Each priority area starts with a definition and broad overview of strategic area with some health statistics of the population of Fraser region. The goals, desired outcomes, strategies and recommended actions for each of the priority areas are outlined. The recommended actions were identified by the Population Health Strategic Planning Steering Committee with input from our partner programs and Fraser Population Health Council. These actions include work that is currently ongoing as well as opportunities to further build on or expand existing work. Working groups will be established to review these recommended actions along with other activities suggested by working group members and our communities to determine which will have the greatest impact. The goal is to ensure that the workplans developed will be meaningful, realistic and achievable in the current context. Year 1 will be mostly directed to organizing integrated planning but some actions are still mentioned as they need to meet provincial requirements. Years 2 to 5 contain more of the recommended actions. 46
Fraser Health
Well-Being Chronic Disease Prevention
Healthy Aging
Unintentional Injury Prevention
H ea
lt h E q u it y L e
ns
nvioronm rtive E ent ppo s Su
Everyone at FH and in our communities has an opportunity to positively contribute to these four priority areas. For example, the Maternal, Child, Infant and Youth program can influence early childhood development to reduce the risk of chronic disease later in life. Residential Care and Assisted Living’s introduction of the vitamin D protocol for all senior residents at care facilities enables these senior residents to maximize their quality of life through mobility and safety of care.
ion
Be tt
These four priority areas are inter-related with initiatives that cross the boundaries. Helping our senior residents to stay healthy and in the Fras h t l a er physically active for as long as possible, policies that minimize e Re H or deter the drinking or limit the availability of alcohol in r C & o g s l labo ip e rati ersh communities, and addressing the mental health and n t on r Pa wellness of youth all contribute to the health and wellMental Health/ being of our communities. Substance Use &
The Strategic Map to Better Health is a guide for everyone to build on current efforts to innovate, coordinate and work together towards the common goal of better health for people of the Fraser Region. Mental Health/Substance Use and Well-being
Healthy aging
Goal
Foster healthier, more active and productive seniors (older adults) through age-friendly environments, policies and programs.
Goal
Improve the mental health and well-being of the people of Fraser region.
outcome
An increase in the number of healthy seniors in the Fraser region who enjoy independence and quality of life longer at home and in their own communities.
outcome
Increase mental health and wellness and prevent substance misuse across the lifespan.
strategies
1. Create partnerships/alignment between programs.
strategies
2. Advocate for age-friendly thinking and actions in Fraser Health and at community level.
2. Apply a community setting approach to reach at-risk populations.
3. Achieve an age-friendly health authority through efforts on culture, policies, care processes, physical environment.
3. Build on Healthier Community Partnerships.
Chronic Disease Prevention
Unintentional Injury Prevention
Goal
outcome
strategies
Create safe communities to minimize the risk of and prevent unintentional injuries.
A reduction in injury-related falls, MVCs and accidental childhood injuries.
1. Leverage both existing and emerging activity. 2. Collaborate across portfolios and sectors to develop a strategic framework. 3. Develop collaborative education targeted to Aboriginal and Youth populations.
1. Partner and collaborate to promote mental health and well-being across the lifespan and identify those at risk.
Goal
Prevent chronic disease through a focused and integrated population health approach on major chronic diseases and their risk factors to reduce their burden on the health care system.
outcome
An increase in daily physical activity levels, fruit and vegetable consumption and participation in recommended screening/ prevention programs, and a decrease in tobacco dependence across the lifespan.
strategies
1. Collaborate with key partners to develop a comprehensive, integrated and evidence-based framework. 2. Create a culture of proactive prevention. 3. Use existing partnerships, policy and mandates to prevent chronic disease and reduce gaps in health outcomes.
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Chronic Disease Prevention Chronic disease is disease that persists for a long time, progresses slowly, cannot be cured by vaccines or medication, and is common with aging. Some of the leading chronic diseases include: obesity, oral health problems, cancer, cardiovascular disease and diabetes. Chronic diseases share modifiable risk factors, such as smoking, physical inactivity, alcohol misuse and unhealthy diets. Chronic disease, although largely preventable, is becoming more and more prevalent: • Dental caries and periodontal disease are the most prevalent chronic diseases in Canada 17 and early childhood caries is the most common chronic disease in childhood. 18 • In BC, 27% of British Columbian children and youth were classified as overweight or obese in 2004.19 What is alarming is that the proportion of obese children has nearly tripled in the last 25 years. • More than 50% of cancers are preventable. Chronic disease is the largest contributor to the health-care cost burden in B.C. with $22 billion each year on both direct and indirect costs.20 This is an underestimate based on 1998 data since 80% of morbidity and mortality in our health care system are due to chronic disease. Obesity alone costs up to $830 million a year to the BC economy. 21
17 18 19 20 21
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Health Canada, “Summary report: oral health” Canadian Dental Association, “CDA Position Paper” Health Canada, “Healthy Living” Health Canada, “Economic burden of illness” Colman, “Cost of obesity”
Some health statistics of the Fraser region: 5 • Lung cancer is the greatest cause of Potential Years of Life Lost (PYLL) in women in BC and FH. • Ischemic heart disease is the greatest cause of PYLL in men in FH. • In 2005, only 50% of FH residents aged 18 years and over had a healthy weight; 45% were overweight/obese. • In 2009/10, about 204,000 FH residents aged 12 and older smoked. • FH has the highest age standardized prevalence rates of diabetes mellitus in BC.
• Prevalence of asthma is increasing, and FH has the second highest rate among BC health authorities. • Generally, the eastern areas of Fraser region have higher prevalence rates of cardiovascular disease than western areas. The burden of chronic disease is distributed unevenly across the Fraser region. Figure 4 shows that people who are most deprived of the resources (Q4 and Q5) for good health (e.g., access to nutritious food, affordable transportation, adequate housing, education, income, etc.) have higher rates of death resulting from chronic disease than those who are in the least deprived category (Q1). The same trend holds true for hospitalization rates due to chronic disease.
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Figure 4. Chronic disease mortality rate by level of material deprivation Chronic Disease Mortality Rate by Quintile of Material Deprivation in Fraser Health, 2004 -2008 1,450
1428.2
1,400
Age-Standardized Rate per 100,000
1,350
1327.9
1327.7
1,300 1,250 1,200
1230.0 1192.7
1,150 1,100 1,050 Q1 Low
Q2
Q3
Q4
Material Deprivation
Q5 High
Goal
Strategies
Prevent chronic disease through a focussed and integrated population health approach on major chronic diseases and their risk factors to reduce their burden on the health care system.
In collaboration and partnerships with municipalities, schools, community agencies and other key stakeholders:
Desired Outcome An increase in daily physical activity levels, fruit and vegetable consumption and participation in recommended screening/prevention programs, and a decrease in tobacco dependence across the lifespan.
• Develop an evidence-based framework for integrated, comprehensive chronic disease prevention for the Fraser region. • Transform the culture from reactive to a proactive mindset (in our language and actions) with respect to prevention and promotion. • Leverage the existing policies, partnerships and mandates for chronic disease prevention, reducing the gaps in health outcomes across FH and its communities.
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Recommended Actions Year 1 – To organize integrated planning and: • Implement a Healthy Families BC initiative. Healthy Start and Healthy Schools are part of the Ministry of Health’s initiative. • Healthy Start’s standardized services promote the health of all pregnant women and their children and families and focuses resources on those most in need to ensure that all new families have a healthy start in life. • Healthy Schools use the school setting to promote healthy living amongst school children. Surrey has been identified as the municipality to pilot the implementation of this strategy. • Extend implementation of the Baby Friendly Policy in FH. • Implement a healthy food policy for FH. • Conduct an environmental scan on existing policies, partnerships and mandates.
Within 2 years: • Create a stakeholder forum to review data profile (see the Data and Evaluation section) and the environmental scan. • Develop a framework for integrated and comprehensive chronic disease prevention across the life span reflecting a “start young” principle. • Utilize the Plan, Do, Study, Act (PDSA) framework for rapid continual service improvement. • Initiate /table / governance: targeted and universal chronic disease prevention initiatives Fraser-wide (internal and external). • Develop, in collaboration with key partners and stakeholders, integrated education for chronic disease in all communities. • Initiate a healthy food policy implementation in municipalities. • Achieve a smoke-free environment in FH and align with municipal smoke-free policies. • Expansion of the integration of healthy living initiatives across FH programs.
Within 3 to 5 years: • • • • •
Develop resources and tools to reach wider audiences and enable sustainability. Coordinate a social marketing program for health promotion activities across FH region. Achieve a baby-friendly status for every hospital and public health unit in FH. Develop a plan for Fraser region, in collaboration with key partners in FH and its communities. Collaborate with community general practitioners to: • improve primary prevention strategies. • increase prescription to prevention interventions to patients. • increase awareness and knowledge of available services. A Strategic Map to Better Health for Fraser Region | 2013-2017
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Mental Health/ Substance Use and Well-Being
Mental health is “a state of well-being in which an individual realizes his or her own abilities, can cope with the normal stresses of life, can work productively and is able to make a contribution to his or her community”22 In essence, mental health and wellbeing is an essential part to overall health and wellbeing and effective community functioning across the lifespan. The impact of mental illness in BC is significant. People of all ages and all walks of life can be affected by mental illness. The broad factors that affect our health, including social relationships and income, are related to mental health. Those with a strong sense of community belonging are more likely to rate their own mental health as very good/excellent compared to those with a weak sense of community. Those with low income are less likely to rate their own mental health as very good/excellent compared to those with high income. Mental illness has been estimated to cost the Canadian economy $51 billion annually in lost productivity. 23 The economic burden in BC of mental health and problematic substance use is more than $6.6 billion each year. The proportion of indirect costs resulting from lost productivity related to alcohol use alone is estimated at $1.1 billion. 24
22 23
24
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World Health Organization, “Mental health” Lim et al., “A new population-based measure of the economic burden of mental illness” BC Ministry of Health, “Healthy minds, healthy people”
Some health statistics of the Fraser region: 5 • Prevalence of depression/anxiety between 2000 and 2010 increased in BC and FH; one in five people will experience depression in their lifetime. • Alcohol is the most problematic drug and has the highest prevalence rate of problematic drug use amongst those who use alcohol or any illicit drug. • Eastern areas of Fraser region have the highest percentage of residents with depression. In absolute numbers, however, the southern and northern areas have more people diagnosed with depression. • Dementia prevalence in FH is similar to the overall BC prevalence but the FH rate is increasing and ranges from 0.6% in Chilliwack to 0.9% in Mission.
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Goal
Strategies
Improve the mental health and well-being of the people of Fraser region.
• Partner and collaborate with partners in the promotion of mental wellness and identification of clients at risk for mental illness across life span.
Desired Outcome Increase mental health and wellness and prevent substance misuse across the lifespan.
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• Use settings approach (e.g., home, neighbourhood, schools) to reach at-risk populations. • Leverage Healthier Community Partnerships to expand partnerships and collaborations to promote mental health and well-being.
Recommended Actions Year 1 – To organize integrated planning and: • Expand and promote mindcheck. • Promote low-risk drinking guidelines (municipal alcohol project). • Promote Speak Up, a mental health literacy program to be implemented across FH high schools, colleges and universities over the next three years. • Continue to roll-out Promoting Wellness, Reducing Harms forums to focus on anti-stigma and harm reduction messaging to mixed professional audiences (e.g., police, city councillors, clinicians, physicians). • Implement a BC Healthy Connections Project—an evaluation of the Nurse Family Partnership intervention that is dependent on collaborative work across primary care, community agencies and Public Health.
Within 2 years: • Review evidence / approaches to promote mental health and reduce stigma. • Review effective interventions/approaches, emerging and promising practices, mindcheck, Nursing Family Partnership, and others as relevant. • Review organizational ability to effectively increase and deliver mental health promotion and prevention, overcome challenges (e.g., cultural influences), and to support staff training where needed. • Develop a reliable tool to appropriately identify mental health promotion target audiences. • Identify and mitigate barriers to target audience participation in mental health promotion programs. • Building on existing initiatives that work with high-risk populations. • e.g., promote the Practice Support Program for mental health promotion to the general practitioner community. Currently, this is a voluntary training program for general practitioners in independent practice within the Collaborative Care program and Integrated Health Network initiatives. • Promote dialogue on mental health awareness/knowledge transfer. • Link brain health to other chronic disease prevention initiatives. What is good for other diseases (e.g., heart health, diabetes, chronic conditions or Healthy Aging) is also important for brain health. • Identify actions from the BC 10-year Mental Health Plan for implementation. The plan includes some actions on mental health, smoking, and alcohol.
Within 3 to 5 years: • Develop and implement mental health and wellness strategies. • Develop and implement—in collaboration with key partners, including patients—a patient engagement framework to guide decision-making and policies for mental health promotion that builds on and integrates with current patient engagement initiatives (e.g., Family Visiting Program, Advancing Women’s Equity through a Strategy of Meaningful Engagement [AWESOME] project). • Support the development and implementation of municipal alcohol policy. • Implement actions identified from the BC 10-year Mental Health Plan. A Strategic Map to Better Health for Fraser Region | 2013-2017
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Unintentional Injury Prevention
The field of unintentional injury prevention is relatively new and addresses motor vehicle crashes (MVCs), occupational and industrial injuries, drowning, unintentional poisoning, falls, bicycle and pedestrian injury, choking, foreign body aspiration and suffocation, burns and scalds and sports and recreational injuries. 25 From 2001–2010, falls, transport-related injuries and unintentional poisoning were amongst the top leading causes of injury-related deaths in BC and account for 60% of these deaths.26 The estimated direct costs for unintentional injury in FH were about $381 million in 2004; falls accounted for 36% of these costs ($137 million), followed by MVCs at 21% ($80 million) and poisonings at 11% ($42 million). 27 In FH, this is not an established area of practice and the coordination of activities internally and with community stakeholders is limited.25 Currently, some FH programs are undertaking aspects of unintentional injury prevention. As part of the provincial plan requirements to strengthen public health across all health authorities, FH completed its performance improvement plan (PIP) on unintentional injury prevention. The resulting gap analyses identified that there was a significant need to coordinate existing efforts and establish clear direction and leadership for unintentional injury prevention in FH. Two of the recommended priorities for this area of prevention mirror the overall intent of the strategic map: • Creating a coordinated, health authority-wide structure with clearly defined accountabilities • Establishing health authority-wide strategies, priorities, and data collection and evaluation processes that take equity considerations into account
25 26 27
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FH, “Unintentional injury prevention” BC Injury Prevention and Research Unit, “Quick facts” FH, “Injury Profile”
Some health statistics of the Fraser region: 27 • Falls and MVCs were two of the three leading causes of hospitalization in FH. • The leading factors contributing to collisions, injuries and vehicle-related deaths were speeding, alcohol, following too closely and driving without car restraints.
• Residents in the eastern parts of Fraser region had higher risk of deaths and hospitalizations from injury than residents to the west. • From 2006 to 2010, the rate of accidental childhood poisoning, although low, was higher in FH than compared to that in BC, with over 50% of the deaths occurring in FH.
• MVCs is the third highest category of PYLL among men in FH (tenth in women).
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Goal
Strategies
Create safe communities to minimize the risk of and prevent unintentional injuries.
• Leverage emerging and existing activity (e.g., healthy public policy, partnerships, education and local interests) to advocate for and promote unintentional injury prevention.
Desired Outcome A reduction in injury-related falls, MVCs and accidental childhood injuries.28
• Collaborate with cross-portfolio and cross-sector partners/stakeholders to develop a strategic framework for unintentional injury prevention. • Partner to develop a collaborative education campaign to prevent injuries (e.g., accidental childhood poisoning, pool safety, bicycle/vehicle safety) in Aboriginal and child and youth populations.
28
Dependant on provincial mandates/activities
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Recommended Actions Year 1 – To organize integrated planning and: • Conduct an environmental scan of existing FH and community policies on unintentional injury prevention. • Identify membership for a cross-portfolio and cross-sector unintentional injury prevention coalition.
Within 2 years: • Form a cross-portfolio and cross-sector unintentional injury prevention coalition to identify gaps and synergies/opportunities for alignment: • Update the Unintentional Injury Performance Improvement Plan (2009), which includes conducting an environmental scan/inventory and reviewing priorities and reviewing the previously drafted strategic framework for Unintentional Injury Prevention in FH. • Review existing reports, guidelines, recommendations and strategies regarding injury from external organizations (e.g. World Health Organization's Safe Cities, Northern Health Authority’s position statement on injury prevention and resources, BC 10-year Mental Health Plan). • Explore effective settings approaches (e.g., home and schools). • Update evidence papers on unintentional injury prevention. • Expand falls risk assessment in the community and medication management to reduce risk of falls in seniors.
Within 3 to 5 years: • Implement prevention strategies based on Year 2 review evidence and other reports (e.g., BC Road Safety Strategy) for implementation of strategies at FH and support municipalities with their implementation of their selected strategies. • Reprioritize areas of focus based on the unintentional injury data profile. • Create—in collaboration with key stakeholders—a five-year implementation strategy for unintentional injury prevention. • Work in partnership with municipalities to ensure that official community plans include considerations to reduce unintentional injuries. • Provide support by providing injury profiles to municipalities to identify priority areas and action plans.
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Healthy Aging Healthy Aging has been defined as the process of optimizing opportunities for physical, social and mental health to enable seniors to take an active part in society without discrimination, and to enjoy independence and quality of life.29 Fraser Health’s senior population is expected to increase over the next 20 years. The projected change in the 65+ group is significantly higher than the other age groups at 46.2% increase between 2011 to 2021; 40.1% for 2021 to 2031.5 The over 85+ age group also has a similar picture. In the youths to adults age 64 group, the average annual health care spending is less than $3,809 per person whereas those in the 65 to 69, 70 to 74 and 80+ age groups spend approximately $7,732, $10,470 and $17,469, respectively.7 A growing and aging population with complex health care requires effective health promotion and disease prevention to complement the current strategies, such as home-is-best, to manage chronic conditions and improve quality of life. The latter is cross-cutting amongst FH’s programs.
29
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Health Canada, “Healthy aging in Canada”
Some health statistics of the Fraser region: 5 • Socially isolated seniors are more likely to suffer poor physical or mental health than are seniors with active social lives. Over 60% of FH seniors reported high levels of social support. • Despite ongoing efforts to support and encourage cessation and prevention, some seniors continue to smoke cigarettes. However, each of our health service delivery areas has lower smoking prevalence than BC overall. • In 2009, between 43% and 56% of FH seniors reported being active to moderately physically active during their leisure time. This was below the provincial average of 55%.
• The prevalence of diabetes has increased steadily over the last nine years, with 25% of FH seniors living with this disease in 2008/09. • Leading causes of death (2003 to 2007) included ischaemic heart disease, digestive organ cancer, lung cancer, cerebrovascular disease, chronic obstructive pulmonary disease, diabetes, pneumonia/influenza, and dementia. • Among external causes of death, accidental falls was the leading cause of death for FH seniors. • The leading cause of hospitalization of seniors in FH is heart disease and chronic lower respiratory disease.
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Goal
Strategies
Foster healthier, more active and productive seniors through age-friendly environments, policies and programs.
• Create partnerships / alignment between programs (e.g., Home Health, Public Health, Older Adult, End of Life, Residential Care and Assisted Living) to promote, support and enable seniors’ health and healthy aging in the Fraser region.
Desired Outcome An increase in the number of healthy seniors in the Fraser region who enjoy independence and quality of life longer at home and in their own communities.
• Advocate for an age-friendly lens for policies and programs internally and within communities. • Use the following strategic areas to achieve an age-friendly health authority: culture, policies, care processes, and environment (physical).
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Recommended Actions Year 1 – To organize integrated planning and: • Identify priorities for focus in Healthy Aging. • Align with any existing work on mobility and unintentional injury prevention strategies. • For example, identify opportunities (e.g., healthy eating practices, smoking cessation, early detection of chronic disease & vaccine preventable diseases) within the Older Adult Healthy Aging Framework developed by Older Adult Program in order to leverage work internally and with communities. • Establish linkages with the chronic disease prevention framework that will be developed under the priority area of chronic disease prevention. • Expand the use of innovative preventions including vaccines (e.g., pneumococcal) in seniors.
Within 2 years: • Identify and review appropriate FH policies and programs with an age-friendly lens. • Establish FH-wide policy for all new policies to include this lens. • Develop internal guiding documents for healthy aging policies at FH. • Explore and develop linkages with Alzheimer’s society (e.g., Healthy Brain Program), United Way and other external organizations, e.g., to garner capacity (e.g., volunteers), engage in data collection/research and information sharing, and to align/coordinate strategies. • Align with the work of the Healthier Community Partnerships initiative in promoting healthy aging in the communities. • Develop and implement a Healthy Aging education module for FH leaders and staff.
Within 3 to 5 years: • Link promotion of brain health to other chronic disease prevention initiatives (e.g., Healthy Heart) in order to address chronic conditions and healthy aging comprehensively. • In collaboration with key acute care sector partners and other key FH programs and services, change seniors’ care planning processes to reduce length of stay and in-hospital complications. • Implement age-friendly policies and strategies in FH and support Fraser region communities to do the same.
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Data and Evaluation This section briefly outlines the key data and evaluation needs for the strategic map.
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Data Chronic Disease Prevention This section outlines some of the key data needs that have been identified for potential use in each of the strategic priority areas. Specific data needs and linkages will be flushed out further with our staff, partners and communities.
• Modifiable risk factors (e.g., fruit and vegetable consumption, physical activity) • Prevalence of chronic diseases (e.g., diabetes, dental diseases) • Diabetes management (A1c tests) • Mortality from chronic disease
Mental Health/Substance Use and Well-being • Prevalence of depression/anxiety and dementia • Mental health literacy rate30 • Alcohol attributable deaths (annual average number) • Hospitalization rates for major mental illness/substance use
Unintentional Injury Prevention • Hospitalization • Mortality related to unintentional injuries • Emergency room visits
Healthy Aging • Data on effective prevention strategies that have known positive impacts on seniors’ health 30 • Hospital admission rates for falls and related injuries • Vaccination rates for seniors (influenza, pneumococcal,30 herpes zoster 30) • Pharmacy counselling fee usage 30 • Modifiable risk factors (e.g., fruit and vegetable consumption, physical activity) as well as chronic disease prevalence in seniors Note: The data is available unless otherwise noted. 30
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Population Health Observatory is exploring whether this type of data is available and/or feasible for collection.
Evaluation Evaluation is an important part of the strategic map and needs to be established in collaboration with our staff, key partners and communities, including the people of Fraser region. General desired outcomes have been articulated but further input is required so that the overall measures of successes are realistic, relevant, achievable and supported by the data. The strategic map will be an iterative process that will review the previous year and update the strategic map for the following five years to ensure it continues to respond to community health needs. Key steps to develop the data and evaluation for the strategic map:
1
Develop an evaluation framework for the strategic map, including measures of success.
The types, quality, accessibility, level and sources of data currently available are variable for each of the priority areas. An analysis of the available data is needed to ensure that the strategies and actions demonstrate effect. Where data does not currently exist, innovative ways to collect the data is needed so that we contribute to the evidence base on interventions, especially new and different ones. Measures should also incorporate the four overarching approaches.
2
Produce health data profiles for each priority area.
Health data profiles are needed to identify further areas of focus and establish a baseline of the health status of our communities. Baseline health status data will allow for comparisons of whether current efforts are going in the desired direction (e.g., target indicators) towards the articulated health outcomes. The data profiles will include top diseases/illnesses based on burden of disease (e.g., mortality, hospitalizations, economic), risk factors, and health inequities/deprivation data. If appropriate and required, the data profiles can also be completed for each community.
3
Monitor and evaluate the strategic map.
Once the evaluation framework (measures, processes and timeline) is established, the strategic map will be monitored and evaluated. Data will be collected and analyzed on a regular basis, according to the established timelines for the outputs, indicators and outcomes identified for the strategic priority areas.
4
Showcase work through research.
The innovative work that we do represent unique opportunities for us to demonstrate and showcase the work through research. For example, the FH Women’s Health team is conducting research on patient engagement with the goal of developing and implementing a model of patient engagement that supports marginalized women to have a voice in program planning (AWESOME project).
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Alignment and Opportunities The Strategic Map to Better Health aligns with national, provincial, municipal and FH mandates, priorities and strategies. Alignments and intersects are opportunities to enhance the coordination and integration of the prevention and equity activities taking place within FH and amongst our communities and partners. Alignment with FH’s strategic imperatives and programs has been noted earlier throughout this document. Highlights of alignment by national, provincial and local levels are noted in this section.
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Overarching Approaches (General) The values and guiding principles of the BC Provincial Public Health Plan (draft) also identify the four overarching approaches of our strategic map (i.e., partner & collaborate, create supportive environments, promote health equity and apply a lifespan approach). The Provincial Health Services Authority (PHSA) released the “Reducing Health Inequities in Health Care” report last year and is currently working on developing health equity indicators appropriate for use across all health authorities in BC. The work of these health equity projects at PHSA will inform the integration of health equity within the strategic map work. The strategic map aligns with Fraser Health’s Medical Makeover Innovation Laboratory through its orientation to the provincial Triple Aim Plan,31 which aims to improve the health of the population of BC as one of its outcomes 32 and has health equity as one of its values. This is an opportunity to test innovative population health initiatives. The Innovation Laboratory takes the best ideas about health care delivery—whether they originate locally, are from other highperforming health systems or are based on scientific evidence—and tests them. FH is the lead in BC for this testing. Initiatives that pursue the Triple Aim tend to encourage health promotion and disease prevention, improved system integration, and reduction of health disparities. The goal is to find ways to leverage greater value from health care resources while managing the rising demand for care and improving healthcare.
31 32
BC Ministry of Health, “Triple Aim Plan” The three outcomes of the Triple Aim Plan are (1) improve population health, (2) enhance quality clinical services, and (3) a sustainable publicly-funded health care system.
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Partner Innovate inspire align integrate
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Strategic Priority Areas The following table highlights some of the alignments of the strategic priority areas with priorities at the national, provincial and local levels.
Priority Area Chronic Disease Prevention
National
Provincial
• The Federal-
Regional
Fraser Health
• The Provincial Territorial-Provincial Public Health Plan (draft) (FTP) agreement • The Healthy on the Framework Families BC for Achieving Initiatives/ Healthy Weights Key Result Area #1 • Canadian Cancer Society • Heart & Stroke Foundation
• Healthy Living Initiatives and Healthier Community Partnerships
• Canada-India Networking Initiative on cardiovascular health for South Asians
Mental Health/ Substance Use and Well-Being
• The 1st pan Canadian mental health strategy (FTP, in development)
• The 10-year Mental Health Plan, “Healthy Minds, Healthy People” • Ministry of Health’s Triple Aim Plan
• A priority identified by some of our Fraser region communities
• FH Mental Health and Substance Use program (health promotion and prevention goals)
Unintentional Injury Prevention
• The Canadian Collaborating Centres on Injury Prevention (vision and mandate)
• A provincial road safety strategy currently safety developed strategy being beingResearch and Prevention • currently The BC Injury developed Unit’s injury surveillance and research • The BC Injury Research and Prevention Unit’s injury surveillance
• FH position statement on transportation from the Office of the Medical Health Officers (in development)
Healthy Aging
• The Public Health Agency of Canada’s strategic plan for 2007-2012
• The BC Ministry of Health’s Seniors Action Plan • The Provincial Public Health Plan
• Healthy Aging Framework developed by the Older Adult program
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• A priority identified by some of our Fraser region communities
Canada-India Networking Initiative on cardiovascular health This unique collaboration between Fraser Health, academic and other institutions in Canada/BC and India has led to the emerging Centre of Excellence for South Asian health. The Centre’s vision is to reduce the burden of cardiovascular disease in South Asians, both in India and Canada.
Provincial road safety strategy The development of this strategy is led by the Ministry of Public Works collaborating with multiple ministries (e.g., Health, Transportation), the health authorities and communities.
Healthy Aging – a community priority Through the Healthier Community Partnerships, working groups in various municipalities have been established to examine how best to promote and enable healthy aging for their seniors.
The first pan Canadian mental health strategy This is being developed by the Mental Health Commission of Canada, which is currently reviewing key background documents on mental health and exploring FTP collaboration in this area. A key piece of work is the national anti-stigma initiative.
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The Way Forward Together Implementation planning is the next phase of the strategic map. Input from our frontline staff, partners, stakeholders and the people of our communities are integral to the success of the strategic map. Our staff, stakeholders and partners understand the realities and challenges facing the people we serve as well as help to ensure that health needs of the communities are met. Let’s innovate and find the solutions together on how we reach the healthy future state we all aim for.
Integrated Action Planning
Alignment Opportunities
Structures
Organizing integrated planning will form a major part of the first year of the strategic map to ensure we determine the most appropriate approach to integration. Engagement and level of involvement of our stakeholders and partners will vary depending on the stakeholder or partner. People, such as our frontline staff and managers, will have the opportunity to shape and influence the direction of this work in multiple ways. At a high level, work plans will be developed by cross-portfolio working groups that will work in collaboration with key stakeholders/partners to identify specific indicators, objectives, outcomes and integrated action plans for implementation. Some of the activities will include mapping outcomes, reviewing data profiles and developing evidence review papers of best practices. Evaluation will be a key component of these working groups.
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Resources
Action
Accountability
Partnership
Local Goal Setting
Evaluation
Long-term Planning
Sustainability
Innovation and Resources In an environment of scarce resources for competing priorities, we need innovative solutions to build capacity, expand our reach and garner financial support. Some of the emerging work for the strategic map will expand reach through creative partnerships (e.g., volunteers, students) that don’t require more financial resources. Some initiatives may require dedicated resources—what can we do within our spheres of influence to make this happen?
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Conclusion The Strategic Map to Better Health is the first population health road map for Fraser region. The four inter-connected priority areas offer the chance to create a culture of possibilities and innovation together. We all have a role in Better Health. This flexible and living document serves as a platform to inspire everyone to be champions for better health. Our collective efforts to integrate, innovate, coordinate and collaborate will result in greater impact for better health outcomes for us and those we care about.
Be tt
Mental Health/ Substance Use & Well-Being Chronic Disease Prevention
Healthy Aging
Unintentional Injury Prevention
H ea
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lt h E q u it y L e
ns
nvioronm rtive E ent ppo s Su
pan Approac Lifes h
tio n
rtn Pa
ion
in the Fras alth er e Re H & Collabo g s p i er h ra ers
More active and productive seniors in their own homes and communities
+
More people in our communities with positive mental health and well-being
+
Safer communities that prevent injuries from falls, motor vehicle crashes and accidental childhood injuries
+
Healthy community members living without major chronic disease or risk factors
=
Better health for ourselves, our families, neighbours and communities.
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Population Health Strategic Planning Steering Committee The strategic map was developed under the leadership of the Population Health Strategic Planning Steering Committee with membership from the Older Adult, Primary Health Care, Public Health and Mental Health and Substance Use programs.
Population Health Strategic Planning Steering Committee - Linda Bachmann, Director, Public Health - Jami Brown, Manager, Healthy Living/Healthier Communities - Kathleen Friesen, Director, Population Health, Older Adult - Christine Halpert, Interim Director, Public Health - Dr. Victoria Lee, Medical Health Officer - Meryl McDowell, Director, Mental Health and Substance Use - Diane Miller, Executive Director, Primary Health Care & Aboriginal Health, Chilliwack, Mission & Agassiz Communities, Chilliwack Hospital and Mission Hospital - David Portesi, Acting Executive Director, Public Health & Maternal, Infant, Child & Youth - Tim Shum, Regional Director, Health Protection, Public Health - Dr. Helena Swinkels, Medical Health Officer Previous member: Rowena Rizzotti, Executive Director, Surrey Memorial Hospital and Surrey Community [previously also Executive Director for Public Health and Maternal, Infant, Child & Youth]
Support Team Lisa Bournelis, Senior Consultant, Strategic Transformation Team Alex Dabrowski, Consultant, Alex Dabrowski Communications Jennifer Reed Lewis, Consultant, Organizational Development Vicki Swan, Director of Community Relations and Public Engagement, Communications and Public Affairs Pam Theriault, Managing Consultant, Organizational Development Samantha Tong, Consultant, Population Health Strategy, Office of the Medical Health Officers
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Acknowledgements Several key partners and stakeholders provided their advice and guidance to the work:
Fraser Population Health Council Dr. Paul Van Buynder, VP, Public Health and Chief Medical Health Officer (Chair) Dr. Ellen Balka, Professor, School of Communication, Simon Fraser University (SFU) Mayor Peter Fassbender, City of Langley Dr. Jim Frankish, Professor, School of Population & Public Health, University of British Columbia Eduardo Garza, Director, Health and Business Analytics Dr. John Hamilton, Program Medical Director, Primary Health Care and General Practice Cathie Heritage, Executive Director, Cardiac Program Dr. Bashir Jiwani, Director, Ethics Services Andy Libbiter, Interim Executive Director, Mental Health and Substance Use Dr. Victoria Lee, Medical Health Officer Val Leblanc, Patient representative, Fraser Health Regional Patient Advisory Council Councilor Mary Martin, Councilor, City of Surrey Diane Miller, Executive Director, Primary Health Care & Aboriginal Health, Chilliwack, Mission & Agassiz Communities, Chilliwack Hospital and Mission Hospital David Portesi, Interim Executive Director, Public Health & Maternal, Infant, Child & Youth Dr. Malcolm Steinberg, Clinical Assistant Professor and Program Director, Public Health Practice, SFU Vicki Swan, Director of Community Relations and Public Engagement, Communications and Public Affairs Dr. Helena Swinkels, Medical Health Officer Previous member: Dr. John O’Neil, Professor and Dean, Faculty of Health Sciences, SFU
Medical Health Officers: Dr. Gillian Arsenault; Dr. Mark Bigham; Dr. Elizabeth Brodkin (also Executive Medical Director, Infection Control); Dr. Larry Gustafson (also Program Medical Director, Residential Care and Assisted Living); Dr. Marcus Lem; Dr. Nadine Loewen; Previous MHO: Dr. Veronic Clair Mental Health and Substance Use (MHSU): Andy Libbiter, interim Executive Director; MHSU Leadership team; Dr. Karen Tee, Manager, MSHU Child and Youth Services; Dr. Sherry Mumford, Director, Clinical Programs – MHSU Services Maple Ridge and Langley; Karen Bunner, Director, Clinical Programs Older Adult: Valerie Spurrell, Executive Director; Dr. Peter O’Connor, Program Medical Director; Dr. Fabio Feldman, Manager Falls & Injury Prevention Primary Health Care: Paula Young, Director, Primary Health Care Infrastructure The steering committee would like to thank the following people, programs and services for their support and/or contribution to the development and/or review of the population health strategic map: Stephanie Bale Rahul Chhokar Karen Dickenson Rachel Douglas Judith Hockney Cecelia Holling Ruth Hellerud-Brown Pamela Munro Trudy Reid Ellison Richmond Sally Ruan Beth Snow Population Health Assessment Team – Stephanie Konrad, Geoffrey Ramler, Ruth Whiteway Population Health Observatory Public Health Managers (Promotion and Prevention, Health Protection)
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Appendices 1. Examples of Population Health Strategies within different levels across the Fraser region 2. Deprivation Map for Fraser region
APPENDIX 1 – Examples of Population Health Strategies across the Fraser region
FRASER HEALTH COMMUNITIES Economic Policies
FRASER HEALTH
Social Services
FH PROGRAM Advocacy Outreach/ Education Housing Policies
Lifestyle decisions I make
Income I earn Healthy Public Policy
Service Delivery
Our community policy choices
Education I have
Health Literacy
Housing and food I can afford Where I work
Community connectedness I Social stressors experience I face Collaboration/ Co-ordination between programs Staff Training & Development Environmental Policies
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Investment In Better Health
Planning
External Partnerships Strategic Alignment
Advocacy
Workplace Health & Wellness
Municipal Planning
APPENDIX 2 – Deprivation Map for Fraser Region
The map below shows the socio-economic status of the Fraser region from most deprived to least deprived. Figure 3 Proportion of deprived population by municipality, based on Pampalon index, 2006 HIgh
Low
Hope
L ow
Social Deprivation
Hi g h
New Westminster
Material Deprivation
Surrey White Rock Abbotsford Burnaby Mission Chilliwack Coquitlam Port Coquitlam Langley
H igh
Maple Ridge Delta Port Moody Pitt Meadows 0%
20%
40%
60%
80%
100%
Hope
Maple Ridge
surrey
From “Fraser Health Population Health Analysis” by M. Hayes & O. Amram, p. 8.
Source(s): Pampalon and Raymond, 2000
ethnicity The FHA region contains significant numbers of ethnic minority groups. A large First Nations population is scattered throughout the FHA area, mostly from the Sto:lo First Nation. Figure 4 shows the distribution of the Aboriginal population in the FHA region.
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Fraser Health. (2012). The medical makeover innovation laboratory framework [Internal document]. Surrey, BC: Author. Fraser Health Population Health Strategic Planning Steering Committee. (2012, April). Guiding framework for the development of the population health strategic map [Internal document]. Surrey, BC: Author. Fraser Health Population Health Strategic Planning Steering Committee. (2012, April). Summary of approach for the development of the population health strategic map [Internal document]. Surrey, BC: Author. Hayes, M.V. & Amram, O. (2012). Fraser Health Population Health Analysis. Retrieved from http:// ihsts.ca/wp-content/uploads/2012/11/FraserHealthReport-Population-Hayes-EN.sflb_.pdf Health Canada. (2005). Healthy aging in Canada: A new vision: A vital investment [Discussion brief]. Retrieved from http://www.phac-aspc.gc.ca/seniors-aines/publications/public/healthy- sante/vision/vision-bref/index-eng.php Kendall, P. (2006). Provincial health officer’s annual report: An ounce of prevention. Retrieved from http://www.health.gov.bc.ca/pho/pdf/phoannual2006.pdf Lim, K. L., Jacobs, P., Ohinmaa, A., Schopflocher, D., & Dewa, C. S. (2008). A new population based measure of the economic burden of mental illness in Canada. Chronic Diseases in Canada, 28(3), 92–98. Retrieved from http://www.phac-aspc.gc.ca/publicat/cdic-mcbc/28-3/ pdf/cdic28-3-2eng.pdf Olshansky, J. S., Passaro, D. J., Hershow, R. C., Layden, J., Carnes, B.A., Brody, J., Hayflick, . . . & Ludwig, D.S. (2012). A potential decline in life expectancy in the United States in the 21st century. New England Journal of Medicine. 352(11), 1138--1145, 2005. Retrieved from http:// www.nejm.org/doi/pdf/10.1056 /NEJMsr043743 Norwegian Ministry of Health and Care Services (2006). Report No. 20 (2006-2007) to the Sorting. National strategy to reduce social inequalities in health. Retrieved from http:// www.regjeringen.no/en/dep/hod/documents/regpubl/stmeld/2006-2007/Report-No-20 2006-2007-to-the-Storting.html?id=466505 Mental Health Commission of Canada. (2012). Mental health strategy for Canada. Retrieved from http://www.mentalhealthcommission.ca/English/Pages/Strategy.aspx
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Pampalon, R., Hamel, D., Gamache, P., & Raymond, G. (2009). A deprivation index for health planning in Canada. Chronic Diseases in Canada. 29(4), 178–191. Retrieved from http://www. phac-aspc.gc.ca/publicat/cdic-mcbc/29-4/pdf/CDIC_MCC_Vol29_4_ar_05-eng.pdf Public Health Agency of Canada. (2007). PHAC strategic plan: 2007–2012. Retrieved from http://www.phac-aspc.gc.ca/publicat/2007/sp-ps/index-eng.php Public Health Agency of Canada. (2009). The case of ActNowBC in British Columbia, Canada. Retrieved from http://www.phac-aspc.gc.ca/publicat/2009/ActNowBC/pdf/anbc-eng.pdf Public Health Agency of Canada. (2011). A federal, provincial and territorial framework for action to promote healthy weights. Retrieved from http://www.phac-aspc.gc.ca/hp-ps/ hl-mvs/framework-cadre/intro-eng.php Public Health Agency of Canada. (2012). Population health approach. Retrieved from http://www.phac-aspc.gc.ca/ph-sp/approach-approche/index-eng.php Sudbury Public Health Unit. (2012). Let's start a conversation about health...and not talk about health care at all (video). Retrieved from http://www.sdhu.com/content/healthy_living/doc. asp?folder=3225&parent=3225&lang=0&doc=11749 World Health Organization. (2012). Mental health: Strengthening our response (Fact Sheet No. 220). Retrieved from http://www.who.int/mediacentre/factsheets/fs220/en/
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Contact Us Fraser Health Authority Suite 400, Central City Tower 13450 – 102nd Avenue Surrey, BC V3T 0H1
www.fraserhealth.ca betterhealth@fraserhealth.ca
November 2012