Today s Northeastern Ontario Landscape and a Forecast for. Transformation-Related Capacity. December Transformation-Related Capacity

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1 Health Human Resources: Today s Northeastern Ontario Landscape and a Forecast for Transformation-Related Capacity Health Human Resources: Today s Northeastern Ontario Landscape and a Forecast for Transformation-Related Capacity December 2014 Health Human Resources 1

2 Table of Contents Executive summary... 3 Introduction... 4 Stakeholders and Available Data for the Northeastern Ontario Health Care Landscape... 4 Situational Review... 6 Health human resources forecasting models Suggestions for improving recruitment and retention of health human resources Next Steps Conclusion References Appendices Table 1. Typology of Forecasting Models Table 2. Comparison criteria of various tools of Health Human Resources Forecasting Models Table 3. Regulated Health Professions Practicing in North East LHIN (Any Practice Site), by Gender Table 4. Regulated Health Professions Practicing in North East LHIN (Any Practice Site), by 5 Year Age Categories Table 5. North East LHIN - Full-Time/Part-Time/Casual Status (Primary Practice Site), HPDB Table 6. North East LHIN - Regulated Health Professions in Select Census Subdivisions (CSDs) Table 7. Registered Nurses, Registered Practical Nurses and Nurse Practitioners Table 8. Active Physicians in Northeastern Ontario by County and Census Subdivision (2012) The North East LHIN acknowledges and thanks Behdin Nowrouzi, PhD, MPH, MSc. OT. Reg. (Ont.), for his research, writing and contribution to this report. Health Human Resources 2

3 Executive Summary Ontario s Action Plan for Health Care was released in 2012 with the goal to make Ontario the healthiest place in North America to grow up and grow old. The plan is patient-centred, focusing on providing support to all Ontarians to become healthier, have greater access and a stronger link to family health care, and ensure people receive the right care, at the right time, in the right place. Health Human Resources (HHR) plays a large part in the Action Plan, placing family and primary care at the centre of the health care system, providing faster access to care for individuals, expanding community-based services, and delivering care as close as possible to home. These are a few examples where HHR will play a huge role in the future of health care in Northeastern Ontario. Within Northeastern Ontario health care, two specific issues continually arise with HHR: the availability of health care professionals to deliver the much needed services; and the equitable distribution of professionals across the region so that Northerners can benefit from having access to care as close to where they live as possible. This report provides insight on the current state of front-line HHR across the North East Local Health Integration Network s (NE LHIN) region, an area of the province that has a dispersed population base, a high proportion of seniors, and a culturally diverse population with 23% Francophone and 11% Aboriginal, First Nation, Inuit or Métis. Early in 2013, the NE LHIN released its three-year strategic plan - Integrated Health Service Plan. The plan, which was developed further to the input of more than 4,000 Northerners, details four priorities to strengthen the continuum of care for Northerners: increase primary care coordination; enhance transitions of care; better coordinate mental health and substance abuse services; and target the needs of the region s culturally diverse population groups. In addition, the plan defines HHR as one of three enablers needed to help move the priorities forward (see Appendix A). The NE LHIN s strategic plan specifies two action items to advance HHR in the region: 1) Work with partners to develop a region-wide recruitment and retention strategy; and 2) Apply health human resource strategies to support increased capacity for community-based care. This report has been prepared to assist the NE LHIN and its partners in moving forward with HHR work in Northeastern Ontario. It outlines challenges and strategies to bolster HHR recruitment and retention and includes a review of data sources and opportunities to gain a better understanding of forecasted vacancies by sector. Data has been collected on positions for occupational therapists, physical therapists, dietitians, speech language pathologists, physicians, physician assistants, nurses, registered practical nurses and nurse practitioners. In addition, a review has been provided on the work of HHR to date. Suggestions are provided to continue HHR work, in collaboration with NE LHIN providers. Health Human Resources 3

4 Introduction Access to quality health care in Northeastern Ontario s rural, remote and underserviced communities is challenged by distances between communities, low population densities, inclement weather, and a small amount of health service providers. These realities, combined with a number of demographic factors such as an increasing proportion of individuals aged 65 and older, youth out-migration, higher rates of chronic disease, obesity, substance abuse and mental health issues, make it necessary to work with communities to ensure that care is provided at the right time and the right place. The NE LHIN is responsible for planning, integrating and funding health care services for more than 565,000 Northerners. With close to $1.5 billion dollars in health care invested every year, to more than 150 health service providers, who deliver more than 200 services, the NE LHIN has a vested interest in ensuring tools, information, and programs are available so that providers are able to recruit and retain the professionals needed to service the health care needs of Northerners. This report provides suggestions for building a health workforce in Northeastern Ontario that takes a more collaborative approach to enhancing patient care. Moreover, it examines the current availability of HHR workers, and the future need, given the rapid growth in the aging population. Information about the number of people working in health care today in Northeastern Ontario health care is difficult to access as there is no one source to identify current vacancies on a regional basis. There are, however, some good building blocks that help to address long-standing HHR issues. For the purposes of this document, HHR is defined as encompassing recruitment and retention, compensation and benefits, training and development, and occupational health and safety. HHR planning includes physicians, physician assistants, registered nurses, registered practical nurses, nurse practitioners, dietitians, allied health professionals (occupational therapists, physical therapists, speech language pathologists) and personal support workers. Stakeholders and Available Data for the Northeastern Ontario Health Care Landscape Local Heath Integration Network In March 2006, the Ministry of Health and Long-Term Care (MOHLTC) created 14 Local Heath Integration Networks to plan, integrate and fund local health care. As a crown agency created to work with local health care providers and community members to collectively determine the health service priorities of respective regions, the NE LHIN works with its partners to ensure health care practitioners are more accessible to Northerners and that the region s local system of care is enhanced with the help of caring professionals. Until 2011, the NE LHIN led a regional HHR steering committee that worked on regional HHR planning efforts and ensured they were well aligned with local HHR issues. The committee was subsequently dissolved and HHR became an embedded component of each NE LHIN priority. Health Human Resources 4

5 HealthForceOntario (HFO) HealthForceOntario (HFO) is the province s strategy to ensure that Ontarians have access to the right number and mix of qualified health care providers, now and in the future. HFO was created in 2006 and this provincial Health Human Resources Strategy is governed by the Health Human Resources Strategy Division of the Ministry of Health and Long-Term Care (MOHLTC). HealthForceOntario Marketing Recruitment Agency (HFO MRA) Health Force Ontario Marketing Recruitment Agency (HFO MRA) is the operational arm of the HFO strategy. It oversees several initiatives including: Access Centre for Internationally Educated Health Professionals; a recruitment and retention program and job portal; Practice Ontario; the Ontario Physician Locum Program; as well as programs supporting the introduction of several new health care professional roles such as physician assistant, surgical assistant, clinical specialist radiation therapist, and introduction of the New Nursing Graduate Guarantee. Health Human Resources Strategy Division, MOHLTC The Health Human Resources Strategy Division spearheads HHR undertakings and offers tools to support evidence-based planning across the province, including the Health Professions Database. This database provides a snapshot of the province s regulated health professions, including employment by LHIN region. The Division has also developed forecasts for physician supply and demand within the province by LHIN. Nursing Secretariat The secretariat provides strategic advice on health, the health care system and public policy issues from a nursing perspective. Created in December 1999, the Secretariat is a division of MOHLTC that supports and monitors the implementation of the Nursing Strategy for Ontario. It informs the government and external stakeholders on the status of the implementation of the Nursing Task Force recommendations, and advises on directions, activities, and strategies that impact nursing. It provides policy and administrative support to the Joint Provincial Nursing Committee and its working groups. It develops and implements recruitment and retention initiatives for the profession of nursing in Ontario. The College of Physicians and Surgeons of Ontario is the body that regulates the practice of medicine to protect and serve the public interest. By law, the college is required to maintain a public registery that includes specific information about doctors. The College of Nurses of Ontario, which is the governing body for registered nurses, registered practical nurses and nurse practitioners in Ontario, releases an annual report on membership statistics which includes information on employment by LHIN as of For example, 6,005 RNs were employed in the NE LHIN region that s 5.4 per cent of reported RN employment positions. The same report for 2013, shows 247 NPs in the NE LHIN region, or 9.4 per cent of NP employment positions. The Nurse Practitioners Association of Ontario was formed in 1973, and is the professional voice for Nurse Practitioners (NP) in Ontario. Their mission is to achieve full integration of NPs to ensure accessible, high quality health care for all. It does not provide access to their database, but provides continuing health education opportunities and research on NPs. Health Human Resources 5

6 The Pan-Canadian Health Human Resources Network was established with development funds from Health Canada and the Canadian Institute of Health Research. It is composed of national experts, researchers and policy makers involved/interested in health human resources, policy and/or planning. A provincial body known as the Ontario Health Human Resources Research Network links health human resource researchers and community decision-makers/partners. The Ontario Physician Human Resources Data Centre is a collaborative project between the MOHLTC, College of Physicians and Surgeons of Ontario, Ontario Medical Association, and the Council of Ontario Faculties of Medicine. Housed at McMaster University in Hamilton, the data centre is the source for information on physicians and postgraduate medical trainees in Ontario. Since 1992, the centre has maintained a registry of all licensed physicians practising in Ontario, the Active Physician Registry. The centre also maintains the Ontario Postgraduate Medical Trainee Registry. Each of the Ontario medical schools transfers data on postgraduate trainees to the centre for analysis and reporting. The centre maintains Physician Hospital Appointments Listing Information for the MOHLTC and participates in the Ontario Physician Workforce Database. The Ontario PSW Registry was initiated in 2012 by the MOHLTC, and has begun collecting information on personal support workers, including demographics and employment. Situational Review According to the World Health Organization (2006), there is a shortage of 4.3 million health-care workers globally, a situation that is expected to worsen by 20% within the next two decades (World Health Organization, 2006). The shortage is most pronounced in professions that include medicine, nursing, rehabilitation, dietetics, and personal support workers. Its large geography, as well as dispersed and declining population, creates challenges in health service delivery in Northeastern Ontario. Small rural communities, some of which are only accessible by air or ice roads for months of the year, have difficulty both recruiting and retaining health care professionals. The maldistribution of doctors and other health professionals is even more significant when one considers the increased burden of illness borne by rural and remote populations (Olga Szafran et al., 2013; Rural and Northern Health Care Panel 2010; Strasser, 2003) Demographic realities of the region include: 44% of Ontario s land mass but only 4% of its total population. 19% or 109,494 people are aged 65+, compared to provincial average of 15%. Culturally diverse: 11% are Aboriginal/First Nation/Inuit/Métis; 23% are Francophone 30% live in rural and small communities compared to 14% provincially 60% of adults are overweight or obese compared to provincial average of 53% 45% of the population are living with chronic disease compared to 37% in Ontario. Health Human Resources 6

7 Maldistribution Maldistribution of the health workforce has been widely acknowledged, with urban populations having greatest access to health care (Campbell, McAllister, Eley, & Eley, 2012; WIlliams & Kulig, 2011). Worldwide, policy makers in many jurisdictions, regardless of their level of economic development, are challenged to achieve health equity and to meet the health needs of their populations (World Health Organization, 2010). Training for rural practice has become critically important in the context of continuing serious shortages of doctors (Strasser & Neusy, 2010). The World Health Organization report provides health care retention recommendations that include targeting admission policies to enrol students with a rural background, locating health professional schools outside large metropolitan areas, exposing undergraduate students of various health disciplines to rural community experiences and clinical rotations, revising curricula to include rural health topics and designing continuing education and professional development programs to meet the needs of rural health workers (Humphreys et al., 2009). The report also makes regulatory, financial, personal and professional support recommendations (Humphreys et al., 2009). In the North East region different sectors compete for the same pool of health professionals. Wages vary depending on sector, which makes retention difficult. Physician workforce Rural Canada comprises about 90% of Canada s land mass and is home to almost a quarter of the nation s population (WIlliams & Kulig, 2011). In Ontario with large metropolitan centres in the south, Northeastern Ontario contains 44% of Ontario s land mass and has close to 4% of the province s population. Overall, 21.1% of the Canadian population lives in rural and remote areas served by only 9.4% of the nation's doctors (2.4% of the specialists and 16% of the family doctors)(northern Ontario School of Medicine, 2013). In Ontario, 14% of the family doctors and 2.5% of specialists practice in rural areas covering 20% of the population - these statistics include the urban areas of Northeastern Ontario (Northern Ontario School of Medicine, 2013). An important factor in ensuring and sustaining appropriate, accessible, comprehensive, and high quality primary health care services in Northern and rural areas is the provision of an adequate, appropriately qualified health workforce (Humphreys et al., 2009). Part of the motivation behind the creation of the Northern Ontario School of Medicine (NOSM) was to address physician shortages in rural Northern Ontario. A total of 256 medical students are spread over the east campus in Sudbury and west campus in Thunder Bay. There are currently 64 students in each of the four cohorts of medical students at NOSM, with an intake of 36 students at the east campus and 28 at the west campus. Research conducted by the Centre for Rural and Northern Health Research (CRaNHR, 2014) showing data from three cohorts indicates that 63% of family physicians who had trained at NOSM for their undergraduate and/or postgraduate medical education had located their practice in Northern Ontario. Also interesting to note is that the majority (51%) of fully licensed family physicians who had trained at NOSM, located their practices in non-urban areas 23% in smaller towns and 28% in mid-sized cities. In Ontario, there are 5.6 French speaking primary care physicians for every 1,000 Francophones in communities with a French population less than 10%. This ratio is considerably greater than what was found in moderate French communities, with a French population between 10 to 24% (3.4 primary care physicians per 1,000 population) and strong French communities, with a French population of greater than Health Human Resources 7

8 25% (1.3 primary care physicians per 1,000 population). While results of this research found that Franco- Ontarians still have less access to health services in French, the ratio of French-speaking primary care physicians to predominantly French speaking Ontarians is considerably greater than that of the general population. As part of the HFO strategy, there are government programs that support physicians going into practice, including the Northern Physician Retention Initiative program, Community Assessment Visit program, locum programs, and the Physician Outreach program. These government grant programs are designed to encourage physicians to relocate and stay in Northern Ontario. However, as the 2013 Annual Report of the Office of the Auditor General of Ontario noted, vacancy-based locum programs meant as short-term measures continued to be used for long periods of time. At the time of the audit there were about 200 specialist vacancies in Northern Ontario, and of those hospitals using locum services, one-third that had been using the Emergency Department Coverage Demonstration Project before January 2008 had been continuously using its locum services from as early as 2007, and one hospital had been using them since Additionally, HFO and municipalities offer incentive programs to recruit physicians to underserviced communities. HFO has a Northern and Rural Recruitment and Retention Initiative for physicians, which offers financial incentives to physicians who establish a full-time practice in an eligible community. Municipalities in Northeastern Ontario vary in their municipal support to newly recruited physicians. Research by Dr. EF Wenghofer, Dr. ES Grace, and Dr. EJ Korinek on the predictors of physician performance on competence found that physicians with a practice scope that matched their training were less likely to have unsafe assessment outcomes than those who did not. This suggests that recruitment efforts need to be more focused on competency skills for the community in which a vacancy is being recruited for, rather than simply recruiting a physician. Competency skills for a family physician in a rural or remote community are different from skills required in an urban centre. For instance, skills needed in a rural setting may include delivering babies, working in emergency departments, and palliative care. According to the College of Physicians and Surgeons Ontario database, about 30% of physicians in the City of Greater Sudbury have been in practice for 25 years or longer. A significant number of these physicians are at retirement age. The City of Greater Sudbury is representative of the older primary care physician workforce in NE Ontario. According to the Ontario Population Needs-Based Physician Simulation Model, created by Conference Board of Canada in partnership with the Ontario Medical Association, this model projects future supply of and need for physicians in Ontario. The NE LHIN is projected to have a surplus of 19 family medicine physicians by 2014, increasing to 279 surplus physicians by However, despite this projected surplus there are more than 13,000 Northerners from the region registered with Health Care Connect (March 2014) waiting to be connected with a primary care provider. There may be other factors impacting the model s simulations such as lower rostering rates for new physicians and the effect of maternity/ paternity leave on younger professionals starting their practice. In addition, the Auditor s Report also points to the problems with data collection. New graduates from medical schools have a high affinity for working in practice together with allied health professionals, using electronic medical records (EMR), and for work-life balance. Retiring physicians, Health Human Resources 8

9 although many have joined Family Health Organizations (FHO), Family Health Networks (FHN) and Family Health Groups (FHG), which require a level of cooperation and support for after-hours service provision, still work in stand-alone offices, many still have paper records, and often have large patient loads with many complex patients. Nursing workforce At the end of 2011, 66.7% of nurses were working full-time in Ontario, which was just slightly under the Ministry s goal of 70% of nurses working on a full-time basis. However, not all programs were equally effective in generating new full-time hires. For example, funding for the Nursing Graduate Guarantee Program is provided for up to six months with the expectation that organizations will offer permanent fulltime employment for participating new graduate nurses. However, only about one-quarter of program participants in 2010/11 and one-third in 2011/12 obtained permanent full-time positions. Examining the numbers of nurses working in rural locales across Canada, the percentages of full time employment status varied considerably amongst the major groups of the regulated nursing. In 2010, for example, the proportions of rural nurses who were employed full time included: 54% of registered nurses (RNs); 80% of nurse practitioners (NPs); and 60% of registered practical nurses (RPNs). This period of time also saw an increase in the proportions of nurses who were employed on a casual basis, rather than fulltime or part-time. Nursing workforce under-supply, recruitment challenges and low staff retention rates limit access to health services for many northern and rural residents (Canadian Nurses Association, 2012). Findings of a pilot project (Rukholm, 2005) indicated that in Northeastern Ontario, 54% of nurses who responded to the survey were over 44 years of age and 43% of these nurses were eligible for retirement within the next decade. Only 4.9% of respondents to the survey intended to work beyond the age of 60. In addition, only 10 of 88 senior nursing students intended to remain in Northeastern Ontario upon graduation. These findings emphasize the critical need for effective strategies to sustain the nursing workforce in Northeastern Ontario. Turnover intention precedes actual staff turnover. During this period, an employee will consider leaving her or his nursing position, institution, or profession. Meanwhile, decreased job satisfaction plays a vital part in the intention of an individual nurse to leave employment. Job satisfaction is in turn affected by the level of occupational stress experienced by the nurse (Zeytinoglu & Denton, 2005). Understanding more about the interrelationships between intent to leave practice, stress and job satisfaction can be used by employers to develop and institute practices designed to decrease occupational stressors, bolster job satisfaction, and mitigate nursing staff turnover in Northeastern Ontario. In 2014, the NE LHIN is actively involved in a RNAO Rural and Remote Nursing Task Force whose overall purpose was to ensure a stable and sustainable nursing workforce exists in rural, remote and underserviced areas of Ontario by bringing together policy-makers, professional and labour associations, administrators, researchers, educators and other stakeholders. The group has two objectives: (1) To identify the enablers and barriers impacting the retention and recruitment of Registered Nurses, Nurse Practitioners and Registered Practical Nurses in Ontario s rural, remote and underserviced areas; and (2) To propose short, medium and long-term strategies to ensure the retention and recruitment of Registered Nurses, Nurse Practitioners and Registered Practical Nurses in Ontario s rural, remote and underserviced areas. Health Human Resources 9

10 Nurse practitioners Nurse practitioners (NPs) are advanced practice nurses, an umbrella term defined internationally as registered nurses (RNs) who have acquired the expert knowledge base, complex decision-making skills, and clinical competencies for expanded practice (International Council of Nurses, 2008). In Ontario, amendments to legislation regulating NP practice in 2007 resulted in protection of the NP title and designation of three areas of specialization: Adult, Pediatric, and Primary Health Care (Koren, Mian, & Rukholm, 2010). The workforce of primary health care NPs in Ontario is growing and changes are occurring in the distribution of NPs across primary health care environments. In 2013, the College of Nurses of Ontario (CNO) reported 1,939 NPs registered and practising in the province, with 1,635 (72.5%) of these indicating their position as a primary health care NP, 425 (18.8%) indicating their practice with adult clients, and 196 (8.7%) indicating their position in pediatrics (CNO, 2013). In the North East, there have been recruitment and retention challenges in community-based primary health care settings as these NPs have had their salaries frozen for approximately six years. In contrast their NP colleagues working in long term home care and other settings earn considerably more a year. NPs play a vital role in addressing local access to care, particularly primary care. According to the MOHLTC, as of June 2014, in Northeastern Ontario, there are: 27 Family Health Teams: 43.0 FTE NP positions, with 2 vacancies. 6 Nurse Practitioner-Led Clinics: 23.5 FTE NP positions, with 4 vacancies. 16 Nursing Stations and NP Sites: 11.9 FTE NP positions, with no vacancies. 6 Community Health Centres: 28 A better understanding is needed of the distribution of NPs across Northeastern Ontario and the environment in which they are working, as well as a better understanding of how many patients that NPs are currently providing primary care to. The NE LHIN is currently working to close this gap in available information. Allied health professionals There have been significant recruitment and retention challenges to bringing allied health professionals including occupational therapists, physiotherapists, physical therapists and speech language pathologists to rural and northern areas (Bent, 1999; O'Callaghan, McAllister, & Wilson, 2005; Solomon, Salvatori, & Berry, 2001). Allied health professionals in remote area practices operate in different working environments compared to their urban colleagues. Professional isolation, large caseloads with a limited number of service providers, and reduced access to resources, equipment and professional development, are often quoted as the major challenges associated with practising in rural areas. While a number of studies have examined the issues of recruitment and retention of health professionals in rural locations (Bourke, Humphreys, Wakerman, & Taylor, 2010; Devine, 2006), many do not provide data that is specific to Northeastern Ontario. There is a shortage of evidence examining whether factors associated with recruitment and retention among other health care professionals is also applicable to allied health professionals working in rural and northern regions. Health Human Resources 10

11 HealthForceOntario, through the Allied Health Professional Development Fund, offers to allied health professionals funding to develop skills and enhance knowledge and leadership capacity among allied health professionals. The Ministry of Health and Long Term Care has introduced new pilot projects to include more allied health professionals into Family Health Teams, Community Health Centres, Aboriginal Health Access Centres, and Nurse Practitioner-Led Clinics, such as the Medically Complex Patients pilot program and the Low Back Pain in Primary Care pilot project. A new pilot project for physician groups not affiliated with a Family Health Team was introduced in 2013 called the Inter-Health Professional pilot program, allowing physicians who would not normally have allied health professionals as part of their team, to work with them and better serve patients. Physiotherapists In the spring of 2013, the Ministry of Health and Long-Term Care announced that more than 200,000 additional seniors and patients across the province will benefit from improved access to high-quality physiotherapy, exercise and falls prevention classes. The NE LHIN has taken an active role in this important work for seniors, patients and their families by working with health care partners and health service providers to ensure enhanced access to and continuation of services within five areas of focus: 1. Exercise and falls prevention classes for seniors in community settings; 2. One-on-one physiotherapy for all long-term care residents with assessed need, in addition to group exercise classes; 3. In-home physiotherapy for seniors and people with mobility issues; 4. Clinic-based physiotherapy services across Ontario for seniors and eligible patients; and 5. Integration of physiotherapy into family health care settings, including Family Health Teams, Nurse Practitioner-Led Clinics, Aboriginal Health Access Centres, and Community Health Centres These reforms are expected to increase the demand and need for physiotherapists in the region. Other options also being explored include the feasibility of utilizing Physiotherapy Assistants in hard-to-serve areas, who would work under the supervision of a Physiotherapist and piloting OTN s Personal Video Conference Guest-Link as a possible solution for underserviced communities. The NE LHIN also encouraged small hospitals to leverage the use of technology through videoconferencing (OTN). Physician Assistants Physician Assistants are skilled members of a health-care team who provide a broad range of medical services in both primary care and speciality areas under the supervision of licensed physicians (Hooker, MacDonald, & Patterson, 2003). Although physician assistants have been working in the Canadian Forces since 1992 in Ontario, a HFO pilot project, launched in 2008, was an effort to improve access to care in the province (Jones & Hooker, 2011). There is limited empirical evidence regarding recruitment and retention strategies for physician assistants in Canada. However, the Physician Assistant Program facilitates the employment of graduates in priority clinical and geographic areas through publicly funded employment supports (HFO, 2014). As of 2010, there were 67 physician assistants in Ontario, and 65 students enrolled in physician programs (Jones & Hooker, 2011). The number of physician assistants working in Northeastern Ontario was not available at the time of this report. Health Human Resources 11

12 Dietitians Dietitians are health care professionals who have earned a bachelor s degree specializing in food and nutrition and have completed supervised practical training through a university program or an approved hospital or community setting (Dietitians Canada, 2014). The current dietitian shortage in Northeastern Ontario is anticipated to worsen given that about half of Canada s dietitian workforce plans to retire within the next ten years (Wyatt, Dietrich, & Vanderkooy, 2012). If implemented, a number of directions can help to minimize this impact, among them: improve and increase training capacity in accredited universities and practicum programs; more promotion of workforce mobility through bridging programs for international educated dietitians (Wyatt et al., 2012); greater participation of Aboriginal and Francophone populations in dietetic training (e.g., through the Northern Ontario Dietetic Internship Program at the Northern Ontario School of Medicine); and a centralized collection of labour market information for dietitians. Personal Support Workers Unlike most other health-care workers in Ontario, personal support workers (PSW) are not a regulated health care profession, meaning there is no governing body which sets standards for the skills and knowledge needed to practice as a PSW, and the services they can provide (Born & Laupacis, 2012). However, PSWs have a role standard which says personal support workers do for a person the things that the person would do for themselves, if they were physically or cognitively able (Born & Laupacis, 2012). There is great variability in the roles of PSWs. For example, some PSWs provide medical care such as changing wound dressings and administering medication, and others provide only personal care such as bathing, transfers from bed and housework. A PSW s training experience, supervision and workplace policies dictate their role and responsibilities. An estimated 57,000 PSWs in Ontario work in the long-term care sector, 26,000 work for agencies that provide community and home care, and about 7,000 provide care in hospitals (Born & Laupacis, 2012). With PSWs being the largest group of workers in Ontario s long-term care and home care sector, many recommend that once more is known about the scope of their work through the provincial registry, further steps can be taken to ensure that they are equipped to provide high quality care (Born & Laupacis, 2012). The limited PSW workforce data presents challenges for planning and forecasting regarding this type of health worker in Northeastern Ontario. Differences in pay, with community care being the lowest at just over minimum wage, also creates problems in terms of recruitment and retention of PSWs amongst the health care sectors (hospital, long term care, and community care). However, as announced in the 2014 provincial budget, PSWs working in publicly funded agencies (i.e. CSS and CCAC) will be allocated an additional $1.50 per hour. This move will help to increase recruitment and retention rates for PSWs working in the growing community-based health care sector. Home and Community Care Services Act Recent changes to the Home and Community Care Services Act (HCCA) indicate potential increase in demand for PSW staff providing services in the community support service sector (CSS). MOHLTC has concluded development of a policy guideline that will allow for the provision of personal support services (PSS) by community support service (CSS) organizations to seniors who require moderate care (those individuals not eligible to receive services under the Assisted Living Services for High Risk Seniors Policy - ALS-HRS). To coincide with the completion of the policy guideline, the required changes to the regulation under the Home and Community Services Act, 2004 were finalized and came into effect on July 1, Health Human Resources 12

13 Health Human Resources forecasting models Four types of forecasting models have been recognized in the literature based on how they develop estimates, what is estimated and the theoretical underpinnings of the models. The basic types of models include: supply projection, utilization or demand projection, needs-based planning and benchmarking (Table 1). A forecasting study may combine different modelling approaches to varying degrees (Timony & Hogenbirk, 2010). There is no single model that is available to fulfil all forecasting requirements. Different models appear to be suitable for different spatial and temporal scales. Models typically employ statistical or mathematical relationships and there is considerable variability among and within models. For instance, models may vary in their complexity of relationships, time period, geographic coverage, type of institution (e.g., hospital, nursing home), type of health professional, nature of input data (i.e., fixed or variable data values), type of output data (e.g., demand, supply, gap), headcounts, full time equivalents, and vacancies). Models also vary in the extent to which they project past trends into the future (with or without adjustments for changing demographics) or simulate future conditions based on known or assumed causal relationships or correlations (See Table 2). Suggestions for improving recruitment and retention of HHR in Northeastern Ontario Ontario s vision for health care embraces a goal that there will be the right number and mix of health care professionals, when and where they are needed. The shortage of health human resources is especially pronounced in rural and Northern regions. The following suggestions are designed to help address this shortage and ensure the right mix of professionals is available to Northerners. Leverage existing data repositories developed by provincial regulatory bodies in order to accurately determine the current landscape and continue to work to develop a regional recruitment and retention strategy. The development of a recruitment and retention plan targeting the North East requires the best available data and evidence-based practice tools. Existing databases should be leveraged with policies supporting the ability to manipulate and analyze provincial level data. Health care partners should continue to collaborate and utilize tools and resources to assist health service providers in their recruitment and retention efforts (for example, posting vacancies to the NE LHIN website, facilitating the implementation of new HHR programs i.e. Grow your Own Nurse Practitioners, etc.). Revitalize the NE LHIN s Inventory Snapshot Tool to capture regional and community level data for current and forecasted vacancies. Launched in 2010, the tool provided a picture of the workforce complement of health human resources across various sectors that receive funding from the NE LHIN. Results not only may be used to provide an evaluation of the current workforce, but also to anticipate future health human resource needs for the region. The tool also provides a central data repository that can be accessed across the region and serve as a model for other LHINs. Currently, no centralized data is available to provide an accurate evaluation of the health human resources workforce, or for it to be used in forecasting analysis. The creation and implementation of this data repository provides statistics and makes forecasting feasible and reliable. Health Human Resources 13

14 The tool generates a summary of the health care workforce in Northeastern Ontario at regular points in time locally, by community and at the regional level. The tool is intended to capture a cross-sectional snapshot of the current FTEs and provide HHR information by age, gender and employment type. It also provides a socio-cultural breakdown in terms of health service specifics related to French Language Health Services and Aboriginal, First Nations, Inuit, Métis. The tool was last populated by participating health service providers in June Revitalizing the tool would help to meet a gap in HHR information at the NE LHIN level. Previously, the tool was sent to NE LHIN-funded health service providers to complete. In order to be most useful to a wider range of stakeholders, it is recommended that a plan be developed to approach LHIN-funded health service providers first to complete the tool, and then broaden the request for all providers. The tool is a key asset, providing annual statistics on health human resources. In order for it to work, health service providers need to complete and submit health workforce templates and surveys on an agreed upon time basis. The first step to re-introduce the tool would be to conduct a pilot study to test the tool s logistics, psychometric properties, and gather information prior to a larger roll-out of the instrument. This will enhance the existing tool and provide additional information to the changing health human resource landscape in the region. The pilot stage would be followed by full implementation and dissemination of the inventory tool to increase participation rates and sustain its use into the future. Local providers and academic institutions, research centres and researchers could also use this information to support research and disseminate best practices of models of care, community engagement and improve health services delivery. The use of the inventory would play a crucial role in workforce planning and sustainability, as well as build partnerships with post-secondary institutions, and provide tools for succession planning. It would also apply a Northeastern perspective to validate the relevancy of provincial HHR plans, and set relevant targets for access to care in the region. Work with partners to develop and implement health human resources strategies to increase capacity for community-based care. The Community Support Sector provides services to older adults, adults and children with disabilities, and individuals requiring professional services while at home or following hospitalization. Reinvigorating and strengthening the NE LHIN s community support services system is a priority and will continue to be a focus for years to come (as per the current governments Vision for Home and Community based Care, April 2014). As the average age of residents in the NE LHIN is increasing, making access to quality care and support through the provincial long-term care and support services system is crucial. The North East LHIN can play an important role in providing leadership in creating opportunities to bring together funding across health and social services. This may be accomplished by breaking down organizational barriers and incorporating local communities in the decision-making process. The roll out of Health Links and Community Networks are a first step in ensuring all health care professionals are working together for the benefit of the patient. Initiatives supported by the LHIN such as the Grow Your Own Nurse Practitioner Program, PSW Fast Track Program developed at Lakeland Long-Term Care Home in Parry Sound, and the PSW Training Program Health Human Resources 14

15 along the James Bay and Hudson Bay Coasts, are locally implemented solutions to increase Northerners access to primary health care and to support the recruitment and retention of health care professionals who are key to ensuring a successful transition to more community-based care. There is a need to address the wider social determinants of health through interdisplinary collaborations, comprehensive community-based care that reflects the lived experience of disadvantaged communities, and policy advocacy that meets the needs of the aging population. Fortifying this approach is continuous service and system-level innovation through an equity. Health disparities are a major public health and social justice concern in the North East where less affluent members of the population suffer from a disproportionate amount of morbidity and live shorter lives. Capture cultural diverse HHR needs (Francophone and Aboriginal) and implement strategies to minimize the gap in meeting those needs. Through the NE LHIN s Local Aboriginal Health Committee and work with, the Réseau du mieux-être francophone du Nord de l'ontario, the North East LHIN is supporting strategies to meet the HHR needs of Francophone and Aboriginal/First Nations/Métis community, and to address health inequities. There is a need to build equity into community-based care for Aboriginal and Francophone populations to reduce health disparities. In consultation with Aboriginal and Francophone stakeholders in the region, gaps are being identified and efforts are made to narrow them. Efforts can extend to enhanced navigation, culturally competent care, expanded community-based delivery in disadvantaged neighbourhoods, enhanced primary care and health promotion. Use existing partnerships to leverage existing strategic and data based plans that address HHR needs in the North East region at the community level. Pan-Northern organizations like the NE LHIN, HFO and NOSM can use their system level leadership role to gather existing strategic plans and databases from its partners and leverage work that has already been achieved on HHR to fill gaps and address shortages. It is important to have a discussion on how to better engage and involve health regulatory bodies in recruitment and retention. Review government recruitment incentive programs and municipal recruitment incentive programs to develop a larger plan, where all programs align. Current recruitment incentive programs are not functioning as a seamless strategy, with some municipalities offering large incentives to physicians to move to their community without requirements for residency or practice, which may delay physicians from starting a practice. Improve retention strategies While recruitment efforts have shown some success, particularly with the introduction of the Northern Ontario School of Medicine, effort needs to be made in the area of retention, including ensuring the right person with the right skills are recruited to the right community, and creating systems that allows better support to health care professionals across Northeastern Ontario. Health Human Resources 15

16 Continue to implement new ways of using technology to deliver care The NE LHIN is a leader in the use of the Ontario Telemedicine Network (OTN). Some programs already in place to support areas that are underserviced by health care professionals include access to physician specialists in dermatology and psychiatry, and OTN nurses at hospitals to support patients accessing specialist services via OTN. Another example is the NE LHIN s work to create an econsult program, which will allow physicians access to a variety of specialists through OTN, to answer questions about referrals and care. With a cultural comfort in using this technology, NE Ontario should continue to look for opportunities to use technology to assist with access to health care professionals. Explore barriers to salaried health professionals Organizations such as CHCs and AHACs, which have salaried health care professionals, have a difficult time recruiting and retaining physicians, yet these organizations, which provide health care to underserviced communities, have great value in the system. Physicians, in particular, choose not to work in these settings. Determining the reasons why and working to resolve these barriers will assist many people in getting access to health care near their home. Next Steps The NE LHIN s goals to bolster HHR initiatives across the region require an increased use of transdisciplinary collaborative care models and innovative practices. By expanding its labour market data collection initiatives, broadening its role in optimizing the skills of the existing HHR labour force, and sound planning, the NE LHIN can continue to be a key partner in enhancing resources across the region. The NE LHIN s HHR goals require data that will allow projection models that estimate the number of the broad range of health care professionals. Such a forecast will examine the current workforce, project a future demand, and estimate attrition and retirement rates in the near and intermediate future for Northeastern Ontario. Having readily available data for the region is especially important for health care professions that continue to be in demand and are comprised of an aging workforce. Regardless of the forecasting model used, its assumptions and factors incorporated will require re-examination over time. The NE LHIN s strategies to support increased capacity for community-based care requires collaboration with multiple stakeholders. In addressing health disparities in health care service delivery and planning, the NE LHIN can identify key barriers to equitable access to high quality care and the specific needs of health-disadvantaged populations. Particular needs of Aboriginal people and communities must be taken into account in planning all equity initiatives such as enhanced navigation, culturally competent care, expanding community-based delivery in disadvantaged regions, enhanced primary care and health promotion. Equity in health must also represent equal opportunity to be healthy, for all population groups, including improved community-based access to services. Health Human Resources 16

17 Conclusion HHR planning is bolstered by bringing together the many stakeholders and organizations that play a vital role in maintaining the labour force in Northeastern Ontario. These include government, communities, employers, post-secondary institutions, professional associations, unions, and others that represent patients and the public. The benefit of such collaboration is a better mutual understanding of the issues affecting the patient and our regional workforce. Developing and sustaining a stable HHR workforce and avoiding previous cycles of under-supply and oversupply, will require a number of strategies to be implemented. A data collection shortfall persists, as well as deficits in implementing and promoting a healthy work environment and other health promotion strategies. There is a need to establish a Northeastern Ontario central repository for data on HHR. This will benefit all Northerners by providing reliable information for forecasting predictions regarding HHR. Moreover, it will provide health service providers in Northeastern Ontario with current data and allow them to make informed decisions about their recruitment and retention policies. Work settings and the quality of work life of HHR workers is also important and must be addressed in order to meet the region s HHR needs. Documenting and improving the North East LHIN s understanding of these health care workplaces may lead to better recruitment and retention strategies in rural and northern regions. By identifying what comprises a healthy work environment for professionals such as nurses in northern and rural communities, recruitment and retention strategies can be implemented at the personal, community, and organizational levels. As the North East LHIN works to improve the health of the communities in Northeastern Ontario, it is vital that the region s supply and mix of health care professionals ensures ready health access for all residents, regardless of their place of residence. Health Human Resources 17

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22 Appendix A NE LHIN IHSP Summary, Health Human Resources 22