Healthy Communities In Interior Health A Collaborative Approach Local governments are leaders in implementing policies and programs that promote healthier behaviours in their communities. Interior Health has an increasingly larger role in preventing chronic disease and promoting healthy behaviours. The links between improving health from a health authority and a local government perspective are very strong. This document outlines a collaborative approach to improving health and reducing risk for chronic disease. Promotion and Prevention Community Integrated Health Services August 2012

2

Acknowledgments:

This paper was inspired by the Northern Health document entitled “Position on Healthy Communities” and was written collaboratively with input from the Interior Health Healthy Communities Initiative Leadership team including Lex Baas, Kerri Wall, Betty Brown, Casey Hamilton, Pam Moore, Jenny Turco and Dr. Rob Parker. Lesley Coates provided an editorial review.

For further information about Interior Health’s Healthy Communities Initiative please contact: Lex Baas Practice Lead Promotion Prevention Community Integrated Health Services Interior Health Lex.baas@interiorhealth.ca Tel: 250 505-7239

3

1. Introduction People with chronic health conditions represent 37 per cent of the B.C. population and consume 80 per cent of total healthcare budgets. Because our population is aging, this number is projected to increase. According to the Interior Health Regional Health Area Profile, residents in the Interior region of B.C. are not as healthy as their counterparts in the Lower Mainland and the largest contributor to this disproportionate burden of illness is chronic disease. Addressing chronic disease cannot be done by any one player. Improving the health and well-being of our citizens will require sustained collaboration and partnership between Interior Health (IH), local governments, Ministry of Health, Provincial Health Services Authority and community and provincial organizations. Chronic diseases can be prevented or delayed by addressing key risk factors – IH’s Healthy Communities Initiative takes on this challenge. The purpose of this document is to outline how the Healthy Families BC Communities program is being structured and implemented in IH. The Healthy Communities Initiative in IH will use partnership, commitment and innovation to affect system change to reduce the risk factors associated with chronic disease and increase the opportunities for improved health outcomes for citizens. This represents a fundamental shift for IH and will require a new way of thinking about control, ownership, trust and collaboration. IH has committed to support local governments and communities through Goal 1 of the 2011/12-2013/14 service plan, “Improve health and wellness: Enable people to live healthier lives by working at the environmental policy and individual levels to protect the health of the population and reduce health inequities.” It is directly noted in the service plan that community efforts to support healthy living through planning, policy, constructed environments and other mechanisms are critical to decreasing the number of British Columbians who develop chronic diseases. IH also acknowledges the vital role our Healthy Communities Initiative can play in collaboration with local governments and other stakeholders to develop comprehensive strategies to address healthy living at the community level. This report outlines actions and approaches to ensure that our work with populations, organizations and governments is effective and influential. The result of these actions will be healthier public policies, reduction of inequities in social determinants of health, improved health services and a healthier population. 2. Background 2.1 An Introduction to Healthy Communities and the Population Health Approach Chronic diseases are the largest cause of death in the Interior region of British Columbia. Currently, over 80 per cent of the population report having at least one or more risk factors for chronic disease which include being a smoker, being physically inactive, eating an unhealthy diet or being overweight or obese. Healthy eating, being physically active and not smoking will significantly contribute to prevention of disease and reducing illness, but these healthy choices are not always easy to make. The neighbourhood and community environments in which people live, work and play greatly influence the ability of people to make healthy choices and to live in good health.

4

In May 2011, Healthy Families BC was launched. The Healthy Families BC (HFBC) is a four-pronged strategy that includes: 1) Healthy Lifestyles 2) Healthy Eating 3) Healthy Start 4) Healthy Communities. This strategy from the Ministry of Health, demonstrates provincial commitment to building healthy communities as an effective approach to addressing chronic disease risk factors. As a partner in HFBC, IH participated in consultations with local governments throughout the region in early 2012. Feedback from these consultations indicated the need for sustained efforts, long term commitment from IH and the Ministry of Health, and increased collaboration. Health care is more than treating disease; we have to prevent diseases before they start. HFBC Communities acknowledges that creating health is the responsibility of multiple sectors and cannot be successful by any sector working alone or in isolation. Local governments and their community partners play a pivotal role in developing health-promoting environments and communities; for example, through policies and programs for smoke-free spaces or neighbourhood planning that supports pedestrian friendly principles. Environmental changes like these promote health and the prevention of chronic diseases by encouraging physical activity and limiting tobacco use. In these environments the healthy choice becomes the easy choice. This population health approach addresses issues that affect groups of people, rather than focusing on the ailments of people individually and in isolation from their everyday lives. 2.2 A Uniform Approach to Working with Local Government One of the goals for IH’s Healthy Communities Initiative is to establish a uniform approach to working with local governments across the health region while recognizing that the initiative will need to be tailored to respond to the unique conditions each community will present. Across Interior Health there are already great examples and models for working with local government. These include:

• Discussions are underway between the City of Kelowna Parks and Recreation program staff and IH’s Healthy Communities Initiative staff to develop a strategic direction for improving physical activity opportunities for identified priority populations - children and seniors with chronic conditions. The discussions have focused on creating a working partnership to evaluate and implement community based physical activity programming.

• Health Protection is working with the Vernon Transportation Demand Management committee to identify and promote active travel options for the general population, specifically targeting seniors and children

• A community nutritionist is facilitating a partnership agreement between IH, the Kamloops Food Policy Council and the City of Kamloops for the expansion of a public produce project established with a Community Food Action Initiative grant.

We can learn from these examples, and through IH’s Healthy Communities Initiative we will be able to examine how effective they are, how they can be further developed to address

“The worst thing for a physician to do is to help someone get well and then send them back into the situation that got them sick in the first place”.

Sir Michael Marmot (WHO)

5

common risk factors and how they can be adapted for other communities. 3. IH Healthy Communities Initiative in the larger context Interior Health’s strategic direction 2012/13-2014/15 envisions a health care system across the interior of British Columbia that includes all activities and services in the community and in the health care system that improve population health and reduce the costs of providing health care. The IH mission to “promote healthy lifestyles” is addressed in all four goal areas of the strategic direction, making IH’s Healthy Communities Initiative not only an essential part of IH’s commitment to the full spectrum of wellness for people in the region but also integral to aligning with initiatives at the provincial level. Table 1 below illustrates the other links between IH’s Healthy Communities Initiative and the Goals of the IH strategic direction. Alignment with Interior Health’s Strategic Direction

1. Improve Health and Wellness

• “Support communities, including schools, businesses, and municipalities to strengthen healthy living opportunities to reduce obesity and the prevalence of chronic disease”– a shared commitment between IH and local governments is the best approach.

• “Redirect health promotion and prevention initiatives” – using an ‘upstream’ approach to combat cancer and chronic disease is the most effective model.

• “Meet the needs of First Nations and Aboriginal communities by collaborating with them to plan and deliver culturally sensitive health care services” – as part of a ‘priority population’, Aboriginal people are recognized by those working with a population health lens.

• “Assess, recommend, and implement actions to improve the health of Interior Health’s population” – working with local governments provides direct access to our IH population

2. Deliver High Quality Care

• “Develop and implement chronic disease prevention and management strategies” – Healthy Communities initiative

3. Ensure Sustainable Health Care by Improving Innovation, Productivity, and Efficiency

• “Engage in community consultations and partner with community stakeholders to actively meet population health needs” – consistent efforts must be made to collaborate with local governments and non-profit organizations that also have the health of IH residents foremost in their minds.

4. Cultivate an Engaged Workforce and a Healthy Workplace

• “Create healthy and safe work environments” – IH must ‘walk the talk’ in efforts to support a population health approach. What’s good for people in IH communities is good for IH staff.

6

As with IH, the other health authorities in B.C. agree that to effectively address the underlying risk factors resulting in chronic disease we must work in concert with larger multi-sector and interdisciplinary teams. Fraser Health’s Healthier Communities program has seen excellent success and was recently recognized by the Minister of Health as a preferred practice. This approach advocates for improved collaborative relationships with local governments and key to the Fraser model is the importance of locally designed, locally driven efforts that match methods and intentions with local reality. Additionally, the flexibility of the Fraser model, with its emphasis on local leadership, allows for adaptation to the unique geography and demographics of the Interior region. Northern Health has also made great strides with their Integrated Population Health Approach by making adaptations for the urban/rural differences as well as contexts of climate and geographic dispersion. Within IH we have the unique challenge of working with 59 different communities, many with low populations and limited resources,scattered across a broad geography. Interior Health’s Healthy Communities Initiative can be successful in addressing this challenge if the commitment to partnership and collaboration is there for the long haul. 4. Components and Strategies The details of IH’s Healthy Communities Initiative are presented here in three sections: our work within Interior Health; our work with communities; and our work with the larger provincial HFBC Communities program. While these sections are outlined separately, in practice many parts of them intersect and will function simultaneously. A genuine and effective community-led process requires that communities enter into partnership when they are ready to do so and that the work proceeds at a pace acceptable to each community. For example, IH’s Healthy Communities Initiative will share health reports, other relevant inventories of resources and related data with local communities to inform about their health status. In some cases this knowledge will inspire a readiness to take action. In cases where a community is already engaged with IH this information may help to focus strategic efforts on healthy living initiatives.

4.1 Internal Development of Interior Health’s Healthy Communities Initiative

a) An Interior Health Healthy Communities Team IH has established a team to guide, oversee and ensure effective organization of its Healthy Communities Initiative. Currently the team consists of community health facilitators, a medical health officer, an environmental health officer, the promotion and prevention practice lead, a community integrated health services (CIHS) operations leader, a geographic information system analyst and will expand to include communications and an Aboriginal health practice lead. This team will develop the strategic direction for the initiative and be accountable to director of promotion & prevention and the vice president for CIHS. Although IH’s Healthy Communities Initiative is CIHS led, it must be emphasised that this is a health authority-wide initiative with active participation from many portfolios.

7

b) The Community Health Facilitators The community health facilitator positions have been created as part of the required reallocation of resources to support Healthy Families BC. The community health facilitators are expected to:

• Support cross-portfolio capacity for collaborative work with communities; • Facilitate collaborative multi-sectoral partnerships; • Support local governments and communities to mobilize around healthy communities

initiatives aimed at addressing risk factors for chronic disease; • Identify a baseline of current local actions that promote health; • Facilitate the development of future actions; • Assist local government to access and interpret health data; • Illustrate relevant evidence-based strategies based on the five pillars of HFBC

Communities for improving specific chronic disease risk factors; • Support communities in program/action evaluation planning; and • Ensure good relationships are developed and sustained with local governments.

c) Inventories of IH Staff Active in Community Work

Central to the Interior Health Healthy Communities Initiative is the connection between IH’s Healthy Communities Initiative staff and IH operations staff who provide consultation and services in communities. With IH’s Healthy Communities Initiative goal of reducing chronic disease by targeted promotion and prevention activities, the knowledge and experience of operations staff is crucial. To this end IH’s Healthy Communities Initiative team will develop inventories of Interior Health staff and services that already support local governments in promoting healthy living. This inventory will be matched to external inventories of programs and services available at the community level to provide a complete picture of IH involvement and resources geared to health promoting activities.

d) Lead by Example

While it is important for health authorities to encourage healthy community development, it is also important to remember that often actions speak louder than words. Through consultation and consideration of an integrated program with Interior Health’s Employee Wellness Initiative it may be possible to align internal health and safety initiatives with IH’s Healthy Communities Initiative to include the development of a healthier organization through workplace policies and incentives.

8

4.2 Working with Communities

a) Initial Engagement and Partnership Agreements

There are multiple ways that communities may be introduced to IH’s Healthy Communities Initiative. The first introduction for most communities was through participation in one of the four Healthy Communities consultations hosted by the Ministry of Health in conjunction with IH and supported by the Union of British Columbia Municipalities. These consultations, held in early 2012, gave local governments a chance to hear about the provincial initiative and discuss how an integrated healthy communities approach could be developed in partnership with health authorities. Following the consultations communities learned about their options to move to next steps: a local government could approach IH for assistance with a community health project, triggering a dialogue and perhaps agreement to work in partnership or local governments may be referred by other IH staff or programs based on pre-existing work such as the healthy built environment work led by Health Protection. The key to success is a timely response, respectful dialogue, and a commitment from IH and the local government to develop and maintain a long term relationship geared towards improving the health of citizens. Given our vast health region and the large number and diversity of communities that we serve, IH’s Healthy Communities Initiative needs to be phased in over a number of years based on community readiness and need. By proactively balancing community readiness with principles of equity, IH will be better able to manage expectations and ensure we work within the limited resources available. Partnership agreements are intended to demonstrate commitment to work together to achieve the goals of IH’s Healthy Community Initiative including the development of healthy living strategic plans (explained below). These agreements can take many forms; from a simple motion in council agreeing to work in collaboration with IH to improve the health of the community to a more inclusive letter with local government and other key partners (e.g., school districts, First Nations, community agencies). Regardless of the form, the agreements should make it clear that the partners agree to work collaboratively, over an extended period of time to improve the health of the community by addressing movable barriers to good health.

b) Healthy Living Strategic Plans Partnership agreements between local governments and IH signal a commitment to work together to develop a healthy living strategic plan. The plan will outline the barriers to health that the community has identified as priorities to address and will also articulate the actions that will be taken to address them. These plans should focus on the five pillars of the HFBC Communities program — physical activity, healthy eating, tobacco reduction, healthy environments and priority populations - since there is strong evidence that actions in these areas can reduce the risk factors for chronic disease and obesity. The action strategies in the healthy living strategic plans will vary from community to community but actions should be measurable over time. Health authorities are required to report on the number of healthy living strategic plans completed with local governments and will also be required to report on the actions that have been undertaken and completed. In recognition of the long time frame required to effect change when undertaking upstream health promotion work, the healthy living strategic plans will be sustained over a five year time frame.

9

c) Community Recognition

Success, innovation, and achievements need to be celebrated and shared. Communities have made it clear that recognition and celebration of reaching milestones is a must. Recognition of significant accomplishments builds community pride, enhances commitment and shares the innovations which expands the range of possibilities available for all to use. A recognition program is under development for IH’s Healthy Communities Initiative to distinguish those communities that have taken the lead in healthy community action through collaborative work. Recognition will happen within IH and at a provincial level with through HFBC Communities.

4.3 Participation with Healthy Families BC Communities

IH is a participant in the development of the provincial Healthy Families BC Communities program and is actively engaged in the following areas:

a) Development of provincial Healthy Community Tools and Resources b) Development of a provincial Healthy Communities Model to Support Aboriginal

Communities c) Participation in provincial Evaluation and Reporting

5. Evaluation and Indicators of Progress The overall goal is to improve the health outcomes of our communities. It is expected that measurable improvements will be noted in the long-term mortality and morbidity rates as indicated in our local health area reports. This will ultimately reduce the burden on the health care system.

5.1 Provincial Indicators of Progress IH is required to report on the number of partnership agreements it has in place with local governments to develop healthy living strategic plans. The province has acknowledged that the completion of a healthy living strategic plan could take as long as a year once the parnership agreement is in place. IH is also be required to report on the number of strategic healthy living plans that are completed and has specific targets to meet. In addition to reporting on the completed plans, health authorities are required to submit quarterly updates to the Ministy of Health about achievements in the HFBC Communities program including collaborative actions as outlined in the plans. The Ministry of Health has identified short-medium and long term outcomes for the provincial HFBC Communities program. These outcomes will guide the Interior Health evaluation process:

10

Short-Medium Term Outcomes: • Increased knowledge and use of healthy community resources • Enhanced healthy living policies • Increased availability and improved accessibility to healthy living programs and

services • Increased adoption of smart growth principles in community plans

Longer Term Outcomes:

• Communities in B.C. are using a healthy communities approach • Improved healthy eating, physical activity and tobacco reduction levels in the

population • Improved health status and reduced preventable health care costs

5.2 Evaluation

The IH Healthy Communities Initiative has begun to consult with IH Planning and Strategic Services to create a developmental evaluation model. The evaluation process will incorporate such short-term measures as community feedback about general progress, collaborations and healthy built environment infrastructure in addition to longer-term performance measures of improved population health outcomes. Of prime importance is the input and insights of community members who will be able to address what goals were met, why or why not, and which goals changed or became irrelevant. While the number of communities engaged is a required performance measure, the level of engagement and the scale of partnership experienced will be a strong indicator of progress. 6. Conclusion Interior Health’s Healthy Communities Initiative is an innovative way of working at a population health level to address risk factors and conditions for chronic disease. This work will require a significant shift for IH in terms of working collaboratively across government sectors and within our health authority. Improving the health of residents living in the region is our business, the business of local governments and the business of individuals who live here.