Building an effective Primary Health Care

system with and for First Nations / Aboriginal communities

Presentation to Quality Forum February 28, 2014

Carol Park & Mara Andrews

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OVERVIEW OF PRESENTATION

VCH’s focus on Aboriginal / First Nations involvement in “Integrated Primary & Community Care” (IPCC) work across the region (since April 2012) – the “Aboriginal / First Nations IPCC Initiative”

First Nations / Aboriginal Primary Health Care Model and mapping services to the model – informing health planning

The Aboriginal / First Nations IPCC

Initiative by VCH How we are supporting the development of an

effective primary health care system with and for First Nations / Aboriginal communities

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The Process of Integration

Knowing one another

Building trust Sharing

knowledge & information Learning

Identify opportunities Finding and

implementing solutions to

problems (gaps) Sharing resources

to make it work

Working together respectfully & transparently

Working to benefit patients &

community & providers

RELATIONSHIPS COLLABORATIVE SOLUTIONS INTEGRATION

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VCH Integration Model

Priority Areas of Integration

1. Inter-Professional

Collaborative Practice Teams

2. Coordinated Processes of Care between Providers and Organizations.

3. Patients as Partners 4. Shared Care GP-Specialist 5. Care Management 6. Expanded Chronic Care

Model

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VCH’s 14 First Nations communities that we are engaging in IPCC

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Collaboration toward Integration FORMAL INTEGRATION TABLES ARE ACTIVE: • North Shore (Squamish & Tsleil-Waututh) • Pemberton (Mt Currie & Southern Stlìtlìmx) • Powell River (Sliammon) RELATIONSHIPS IN OTHER AREAS BETWEEN NATIONS & VCH & PHYSICIANS : • Central Coast (Nuxalk, Heiltsuk, Owekeeno, Kitasoo) • Sunshine Coast (Sechelt) • Southern Vancouver (Musqueam) • Squamish Valley (Squamish Nation – north)

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Example: Pemberton IPCC Steering Committee

• SSHS (Southern Stl’atl’imx Health Society) – 4 First Nations communities

• Mt Currie / Lil’Wat Health Centre • VCH Pemberton Health Centre • Physicians working in Pemberton • Community partners • “Coming Together” hosted at Mt

Currie October 2012 • Focus = Transport +

Communications + new Health Services (e.g. Nurse Practitioner)

• Tele-health into Stl’atl’imx remote communities

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Example Initiatives that the partners work together on

• Tele-health implementation • Referrals and Discharges between VCH Discharge Coordinators and

First Nations health centers • Information Sheets for Physician offices (describing services provided

on-reserve and how to access them) • Nurse Practitioner Proposals (NP4BC) • Improving processes within emergency departments • Improving access to maternity services and retaining women in pre-

natal care • Orientation of new health practitioners into communities • Home Health Re-design

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Evaluation of this Work EVALUATION ACTIVITIES: • Aboriginal / First Nations IPCC initiative – what has

changed since we increased our capacity to work with First Nations / Aboriginal communities?

• Baseline measure April 2012 • 6 monthly evaluation for changes • Seeing improvement across 6 indicators measuring partnership,

cultural awareness, collaborative solutions, cultural shifts • Specific events

– “Coming Together” event run by Pemberton IPCC members

• Reflective Sessions – Surveys and focus groups with Regional IPCC members

• Best Practices – Telling the stories of best practice relationships, gains, efficiencies

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LOGIC MODEL FOR ABORIGINAL / FIRST NATIONS INTEGRATED PRIMARY & COMMUNITY CARE

INITIATVE

Service & Cultural

Awareness

Coordination & opportunities for

improvement

MEDIUM TERM:

Cultural shifts - new ways of doing things

MEDIUM TERM:

Improved patient, client and provider experiences

LONG TERM: Improved health

Relationship & Trust Building

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EVALUATION RESULTS: Cultural Shifts

AFTER 6 MONTHS

APRIL 2012 Over 90% of participants felt at the beginning that “nothing had begun yet” in relation to specific First Nations projects AFTER 6 MONTHS 90% rating for `nothing has begun` reduced to 11% 33% felt good progress was being made. 91% previously stated no progress on having FN lens on IPCC work now over 33% stating good or very good progress.

BASELINE: April 2012

91.7%

8.3%

Projects that impact First Nations communities

91.7%

8.3%

First Nations lens on IPCC work

Very good progress being made Good progress being made Initiated but still a lot to do Not Begun Yet Unsure

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Some key lessons – Successes & challenges SUCCESSES: • The foundation Is being built – we need to sustain it • Innovative changes are occurring • Stakeholders (Providers) are reporting improved experiences • We have an operational focus on IPCC-Aboriginal-FN work • Coordination with FNHA / FNHDA through Partnership Accord CHALLENGES: • Building relationships, trust building & engagement takes time (VCH + physicians +

First Nations) • Changing organizational culture / ways of doing things takes time (resistance to

change) • Competing priorities and resources (doing day to day work while participating in

change / transformation / planning / meetings / engagement) • Changes in leadership and staff (VCH, physicians, FNs) • Patients and populations are diverse (poor data on FN / Aboriginal populations) • Technology system challenges (no EMRs in FN health centers)

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VCH Region: Aboriginal / First Nations Primary Health Care

Service Model

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Why the need for a Primary Health Care “model”? • DEFINING WHAT IS PHC FOR THIS WORK?: IPCC engagement

demonstrated a general lack of understanding of “Primary Health Care” in the broader sense among First Nations communities – needed to define it

• KNOWLEDGE BUILDING: Knowledge in many communities oriented to Federal / Health Canada programs they are funded for – but hard for them to see where these “fit” within the PHC scope

• ENSURING A PHC ‘FIT’ WITH FIRST NATIONS LENS: Provided a means of engaging FNs on what PHC means to them and how culture, tradition and spirituality fits in

• COMMON LANGUAGE: Creating a common language between First Nations Health Directors & staff – and VCH Service Managers & Physicians so everyone understands the PHC scope (level playing field)

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Example of Glossary for each cluster

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Example of Glossary for each cluster

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Working toward achieving the ‘ideal model’ in VCH region’s 14 First Nations communities

(on reserve)

• Mapped current services against the model in each community to identify what is working well (including integration between FN & VCH & local health practitioners), gaps & improvements needed

• Production of 14 individual “maps” and regional analysis of trends • Many examples of best practice and innovative arrangements by First

Nations with local health practitioners and with VCH services • Gaps are most evident in:

– Mental Health and Substance Use (treatment beds +counsellors + psychology / counselling for trauma + social workers)

– Sustainable prevention programs (all areas except communicable disease prevention)

– Traditional, Cultural and Spiritual Wellness programs and activities (integration into health) due to lack of resources to cover costs

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DASHBOARD (15 FN communities) • 69 service lines

assessed (7 clusters) • Green – means good

access to the service in the model

• Orange – means there is access but quality issues

• Light red – means there is an ‘insufficient’ service to meet demand

• Red – means there is no service (outright gap)

There is a narrative behind each service line & rating for each community

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DASHBOARD (14 FN communities) • 69 service lines

assessed (7 clusters) • Green – means good

access to the service in the model

• Orange – means there is access but quality issues

• Light red – means there is an ‘insufficient’ service to meet demand

• Red – means there is no service (outright gap)

There is a narrative behind each service line & rating for each community

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Working toward achieving this vision for urban Aboriginal populations

• Greater Vancouver (North Shore + Vancouver + Richmond) = 16,585 Aboriginal population (1.6% of over 1m people)

• Gathered data on current services for Aboriginal populations in these areas from service providers including: – Specific Aboriginal organizations delivering services – VCH services:

– Services that are targeted for Aboriginal populations – Services that are not ‘targeted’ but accessed by significant % of Aboriginal

population

• Mapped these services using same model but using LHAs (and “neighbourhoods” as defined by each Municipality)

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OVERALL GAPS IDENTIFIED IN URBAN AREA

LHA Traditional / Cultural

Prevention Programs

Family Health Home & Community Care

Mental Wellness & Substance use

Health Practitioners

Richmond Gaps in VCH services

Suicide & Injury prevention

Parenting, womens, mens, elders

Service available but no data

Social work, clin. Psychology, suicide

response

Cost & Transport to dental and

optometrists

City Centre - Smoking cessation, suicide prevention,

A&D prevention

- - Counselling, social work and suicide

response

-

North East Gaps in VCH services

Smoking cessation, suicide prevention,

A&D prevention

- - Counselling, social work and suicide

response

Improve referrals to specialists;

accessing dental

Westside Gaps in VCH services

Injury, A&D and violence prevention

- - - Dental

Midtown Some gaps in VCH services and NGOs

Suicide, violence & A&D prevention

- Case management and adult day

programs

Counselling, social work, clinical psychology

-

South Gaps in VCH services

Not provided locally Not provided locally Not provided locally Not provided locally Not provided locally

DTES Some gaps in VCH services

Physical activity, smoking, injury, suicide and A&D

prevention

Elders programs Adult Day support Counselling, social work, clinical psychology

Dental

North Shore Some gaps in VCH services

Injury prevention - Adult Day support Accessing treatment beds

Dental

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IMPACTS OF THE CURRENT STATE MAPPING WORK

• The results of the current state mapping have enabled us to: – Identify what services are provided; who delivers them on and off reserve;

what gaps exist – Work with Health Directors to prioritize areas to focus on together at a

regional level and individually at IPCC tables for locally-specific issues – Provide information to VCH ‘teams” wanting to extend / deliver services to

Aboriginal communities (e.g. HIV/AIDs, mental health & addictions, home health) and to inform them on perceived gaps for their planning

– Provide a current state baseline for engagement with the new First Nations Health Authority on priorities for strategic investment of resources

– Help to plan and implement tele-health / EMR implementation with FNHA – Engage Practice Support Program (PSP) to work with specific Nations – Engage Divisions to work with First Nations on “GP4ME” (attachment) – Ensure we are all working from the same information base

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• Taking time to build relationships is key – Sharing information on who provides what: This is key to getting everyone on

the same page and avoiding assumptions – Ensuring everyone understands each others ‘drivers’ and ‘pressures’ – Ensuring people respect and acknowledge differences – Creating a willingness to learn more about their own populations (e.g. Cultural

Days on reserve for all service providers) – Regular (IPCC) meetings and discussions helps to build trust and

understanding, and confidence in the process of working together respectfully

• Establishing this foundation has enabled the improvement work to

happen: – Current state mapping information of services for First Nations / Aboriginal

people – Rollout of service initiatives (discharge protocols, tele-health, Stop HIV

expansion, Nurse Practitioners, shared training opportunities, new clinics etc) – Strengthen partnerships and supports (e.g. Divisions, PSP)

Lessons