THE WEST END NON- INSURED WALK-IN CLINIC (NIWIC)

Transcription

1 THE WEST END NON- INSURED WALK-IN CLINIC (NIWIC) Annual Report: April 2014 March 2015

2 1 Table of Contents Executive Summary... 3 Introduction... 5 Background... 5 Goal & Objectives... 5 Toronto Central Local Health Integrated Network (TC LHIN) Definition of Uninsured... 6 Non-Insured Populations Seen at the NIWIC... 6 The West End Non-Insured Walk-In Clinic (NIWIC) Services... 7 Financial Support to Clients... 7 Eligibility... 7 What to expect: Processes and Pathways... 8 Service Pathway (Non-Prenatal Clients)... 8 Service Pathway (Prenatal Clients) Client Success Stories Kathryn: Filling the gaps for people in the 3 month wait period for OHIP with chronic diseases.. 12 Melanie: Pregnant and Uninsured Results and Discussions Administrative Information Client Demographics Health Issues/Clinical Data Referrals Specialist Physicians Ongoing Prenatal Care (Midwife and Obstetrician Clinics) Primary Care Providers at Partner Community Health Centres Frontline Challenges Access to Hospital-Based Care Transitions from NIWIC to Primary Care Providers at Partner CHCs Community Outreach Eligibility Criteria Growing demand for NIWIC and service constraints... 35

3 2 Recommendations and Next Steps Revisit NIWIC Eligibility Criteria Implement Strategic Promotion of NIWIC Services Strengthen referral processes of NIWIC clients to primary care providers at partner CHCs Expand research, improve reporting protocols and promote knowledge sharing Develop NIWIC services centred on early identification Expansion of service delivery model Strategy for pre and postnatal care Appendices References Disclaimer: This report is the property of Access Alliance Multicultural Health and Community Services, and has been prepared as a quality improvement initiative for the programs and services of Access Alliance. For any questions or concerns please contact Monika Dalmacio, NIWIC Registered Nurse (RN) at mdalmacio@accessalliance.ca.

4 Executive Summary 3 Executive Summary This report provides an overview of the West End Non-Insured Walk-In Clinic (NIWIC) services from April 2014 to March It highlights client demographics, health issues, and trajectories of care to external health care providers. It also outlines key challenges and recommendations for next steps. Key Findings Demographics Total clients seen: 393 Top immigration statuses: 38.4% non-status and 23.7% permanent resident in 3-month wait period for OHIP Largest age groups: adults between years old (50.6%). Females in this age group (65.9%) were the largest sex and age group. Top languages: English, Spanish, Portuguese Top source countries and ethno-racial origins: Mexico, Portugal, Jamaica; Latin American, Black Caribbean, and White European Almost half (45%) of clients have family household incomes below $ per year Approximately 70% of clients arrived to Canada within the past five years The highest level of education attained by the majority of clients was secondary (34%) followed by post-secondary (29.8%) school Health issues Preventative health care was the top service provided (30.76%) followed by addressing of Symptoms (25.97%), and Musculoskeletal concerns (7.91%) Routine prenatal care was the top specific health issue/diagnosis addressed (5.9% of total health issues) followed by review of test results (4.33%), special screening including immunizations (4.33%), hypertension (4.33%), and joint pain (3.17%) Hypertension (4.33%) and diabetes (1.7%) were the most prevalent chronic diseases identified Mental health issues made up a small proportion (0.92%) of health issues addressed despite evidence suggesting stress and other mental health challenges are common among noninsured population Referrals 24 referrals made to specialist physicians top speciality was ophthalmology 57 referrals made for ongoing prenatal care: 12 to obstetricians and 45 to midwife clinics 25 out of 36 referrals made to primary care providers at the partner CHCs were successful. Only 33% of high risk referrals were made in the specified time frame (1-3 weeks) while 71% of medium risk referrals were made in the target time frame (4-8 weeks)

5 4 Front-Line Challenges 1. Clients face barriers accessing hospital based care due to cost and discrimination 2. There are delays transitioning clients with complex health issues (high risk needs in particular) to primary care providers at partner CHCs 3. There is suboptimal awareness of NIWIC services among local community agencies including partner CHCs 4. The eligibility criteria for the NIWIC introduced barriers for certain groups including refugee claimants with limited Interim Federal Health (IFH) 5. There are front-line service constraints to accommodating the growing demand for NIWIC services related to the current clinic flow processes and volunteer model for midwives Recommendations and Next Steps 1. Implement strategic promotion of NIWIC services 2. Strengthen referral processes of NIWIC clients to primary care providers at partner CHCs 3. Further develop research, reporting protocols, and knowledge sharing on the NIWIC 4. Revisit NIWIC eligibility criteria 5. Develop NIWIC services centred on early identification 6. Expand service delivery model 7. Strategy for pre and postnatal care

6 5 Introduction The West End Non-Insured Walk-In Clinic (NIWIC) is a partnership of seven CHCs in the west end of Toronto. The clinic was launched in March 2012 by Access Alliance Multicultural Health and Community Services (AAMHCS) to provide access to basic primary care for non-insured persons living in Toronto who do not have a primary care provider (PCP). This report provides an overview of services delivered at the NIWIC from April 2014 to March By illuminating our community health centre (CHC) partnership model, this report aims to contribute to a better understanding of the health issues faced by undocumented and certain groups of medically uninsured people living in Toronto. It also aims to highlight the challenges these individuals experience in accessing health care and advocates for a coordinated plan of action to improve medically uninsured individuals' access to healthcare services. Background It is estimated that 50% of undocumented persons living in Canada reside in Toronto i. In Toronto, undocumented and non-insured individuals have few options for accessing health care. It is not uncommon that these individuals delay seeking healthcare until their health condition becomes more complex requiring urgent treatment in an emergency department and/or admission to hospital ii. Living without health insurance is a stressful reality for people who require treatment for chronic conditions such as diabetes and for women who are pregnant iii. Non-insured people are also much less likely to access screening and health promotion services that will help them prevent illness or support them to self-manage chronic conditions iv. Toronto s Community Health Centres (CHCs) continuously voice that this is a significant health equity issue, largely affecting the most marginalized and vulnerable communities including new immigrants, refugees, racialized populations, and migrant works v. Community Health Centres recognize that precarious status is an important determinant of wellbeing and wellbeing reflects a newcomer s ability to function in and adapt to the new society. The Toronto Central Local Health Integration Network (TC LHIN) has identified that there is potential to enhance services to non-insured clients through innovative practices to manage the total non-insured funds in the sector vi. The NIWIC is one example of how the sector can coordinate to respond to the primary health care needs of the non-insured community. Goal & Objectives Our goal at the NIWIC is to collaborate with partners to serve non-insured persons by facilitating equitable access to health care services that are coordinated, consistent and comprehensive. Since the inception of the NIWIC, the following objectives have guided operations and service delivery: 1. Develop and strengthen pathways and a delivery system for health services to undocumented/non-insured residents of Toronto, 2. Increase linkages to support services and community agencies for undocumented/noninsured individuals, 3. Reduce progression to severe health outcomes,

7 Introduction 6 4. Improve self-management of health, 5. Establish evidence based practices for undocumented/non-insured persons. Toronto Central Local Health Integrated Network (TC LHIN) Definition of Uninsured In Ontario, health care is planned, integrated, and funded by Local Health Integrated Networks (LHINs). The Toronto Central (TC) LHIN guides the definition for the uninsured for all CHCs in Toronto. According to the TC LHIN, non-insured clients served at CHCs would include residents of Ontario that are in the 3-month wait period for OHIP, in the federal refugee process and health care coverage is not provided for, without OHIP due to lack of documentation (for example, homeless), and temporary foreign workers who cannot provide their own private insurance due to income status. The individual faces barriers to arranging private health care insurance and is not eligible for coverage through OHIP, IFH, the Federal Health Insurance Plans for First Nations or military personnel. Non-Insured Populations Seen at the NIWIC Recognizing the diversity within the non- insured population living in Toronto, the NIWIC has prioritized services for the following groups: Non-Status/Undocumented When someone has neither permanent nor temporary status, we refer to this person as nonstatus or undocumented. The vast majority of undocumented residents arrived in Canada through authorised channels, but lost their legal immigration status over time (i.e. Refugee Claimants, expired temporary visas, sponsorship breakdown) vii. They are persons who do not have authorization by Citizenship and Immigration Canada to reside in Canada. Because they have no legal status, they often have no health coverage. While we tend to think of non-status as a single homogeneous group, in reality it is very diverse population of people with different experiences and needs. Permanent Residents in 3-month Wait Period for OHIP New immigrants arriving with permanent residency status are eligible for OHIP three months after their arrival to Ontario. These immigrants are eligible to purchase private health insurance. However there are multiple barriers to obtaining private insurance. Private insurance is expensive, insufficient, and difficult to qualify for if the applicant has a pre-existing condition and/or if the applicant has travelled in countries with high rates of communicable diseases viii.

8 The West End Non-Insured Walk-In Clinic (NIWIC) Services 7 The West End Non-Insured Walk-In Clinic (NIWIC) Services The NIWIC is open twice per week on Mondays and Thursdays from 4:00 pm 8:00 pm at the AAMHCS Access Point on Jane clinic. The clinic offers episodic care led by registered nurses and nurse practitioners (Fig. 1). Nurse practitioners can provide medication prescriptions, requisitions for laboratory tests, and referrals to the AAMHCS consulting physician, allied health care professionals, and medical specialists as appropriate. Prenatal services are available for uninsured pregnant women once per week (Fig. 2). For clients who have urgent medical and/or social complexities, they are offered a direct referral to one of the seven partner community health centres including: 1. Access Alliance Multicultural Health and Community Services 2. Black Creek Community Health Centre 3. Davenport-Perth Neighbourhood and Community Health Centre 4. LAMP Community Health Centre 5. Rexdale Community Health Centre 6. Stonegate Community Health Centre 7. Unison Health & Community Services Clients who do not speak English have access to interpretation services from the Remote Interpretation Ontario (RIO) Network. RIO provides over-the-phone interpretation from professional interpreters and is certified by the Canadian Standards for Translation Services and the International Standards for Translation Services. Financial Support to Clients Services such as interpreters and laboratory tests are provided at no cost to clients. Clients are provided with payment letters when sent for laboratory testing and specialist referrals for medically necessary investigations. When referrals are made to specialists, specialist and diagnostic fees (at rates outlined by the OHIP Schedule of Benefits) are covered by the NIWIC and only for the first visit consultation. The exception is for women with high risk pregnancies who are referred to obstetricians for ongoing prenatal care where the NIWIC provides coverage for all visits. The NIWIC does not pay for elective procedures, facility fees charged by hospitals or Ontario Medical Association (OMA) service rates. Eligibility From April 2014 to March 2015, clients presenting to the NIWIC must have been: Living in the City of Toronto Without a primary care provider (family doctor or nurse practitioner) Medically uninsured due to the following reasons: o 3-month wait period for OHIP o Non-status and uninsured for at least six months

9 The West End Non-Insured Walk-In Clinic (NIWIC) Services 8 The clinic did not see individuals with: Current visitor, student, or work visas Private health care insurance Interim Federal Health (IFH) coverage Ontario Health Insurance Program (OHIP) coverage What to expect: Processes and Pathways Using the eligibility criteria described above, medical secretaries screen potential NIWIC clients for eligibility when they present to the clinic or phone in advance (Fig 1). If the client is eligible, they are asked to complete a confidential AAMHCS paper registration form. This registration form was updated in September 2014 to include additional socio-demographic information. All fields are mandatory and interpreter support is provided where necessary. The medical secretary then opens a client chart on Nightingale on Demand (NOD) the electronic medical record (EMR) system used at all CHCs in Ontario and enters the client s contact and demographic information contained in the registration form. Service Pathway (Non-Prenatal Clients) Clients are seen by a registered nurse (RN) on a first come, first serve basis. The RN determines the chief complaint and conducts a basic health assessment. Specific issues such as immunization visits are addressed independently. Then, clients are seen by a nurse practitioner (NP) who addresses the chief complaint. After this appointment, clients may have the following: 1) Follow-up appointments booked with the NP during NIWIC hours to review test results or if further assessment is needed. 2) Referral to AAMHCS consulting physician for clients with medically complex health conditions. 3) Referral to a specialist physician as appropriate. 4) Referral to local emergency department for urgent, acute issues. The two closest hospitals are Humber River Hospital and St. Joseph s Health Centre. Clients are provided with a letter with a clinical summary explaining they were assessed by a NP who determined emergency care was deemed necessary. 5) Referral to NIWIC midwife if client was not identified earlier as needing prenatal care. 6) Referral to allied health professionals, community services, and settlement workers 7) Referral to a partner CHC for a primary care provider, for clients with complex medical and/or social health concerns (see Appendix A). This process is coordinated by the NIWIC nurse coordinator.

10 The West End Non-Insured Walk-In Clinic (NIWIC) Services 9 Non-insured patient Walk-in Reception Registration Open Chart Midwife Assessments RN Triage/Assessment Determines presenting health issue Basic health history & vitals Identifies risk factors Settlement Services Community & Allied Health Services Nurse Practitioner Addresses chief complaint Diagnoses/Treatment Reviews diagnostics Specialist referrals Patient follow-up Physician Consult RN Primary Care Coordinator Patient follow-up CHC referrals Medical Specialist Figure 1. NIWIC Pathway

11 The West End Non-Insured Walk-In Clinic (NIWIC) Services 10 Service Pathway (Prenatal Clients) When the NIWIC prenatal services ( Midwife Mondays ) are available, clients who have confirmed or suspected pregnancies are booked directly with a midwife (Fig. 2). These midwives are rotating volunteers from local midwife clinics in Toronto. As a result, the clinic is not set up to provide ongoing prenatal care. Instead, it serves as an entry point to the health care system for uninsured pregnant women in need of prenatal care. Midwives conduct prenatal assessments using a standardized health and obstetric history form that combines parts of the Ontario Ministry of Health and Long Term Care Antenatal Records 1 and 2. Clients are sent for routine prenatal bloodwork, ultrasounds, and genetic screening as appropriate. Once the test results are available, clients are asked to return to the NIWIC to review their results with a midwife. The midwife is responsible for determining whether the woman is appropriate for midwifery or obstetrical care. Then, a referral is initiated to an external midwife clinic or obstetrician for ongoing prenatal care. Clients have access to the NIWIC prenatal services until they are connected to a midwife or obstetrician. They are encouraged to return to the NIWIC for non-pregnancy related health issues. Clients can be referred to settlement workers and allied health professionals at AAMHCS to help address social issues including financial barriers, safe housing, food security, and domestic violence. If the client has co-existing medical or social complexities, they are also referred to a primary care provider at a partner CHC.

12 The West End Non-Insured Walk-In Clinic (NIWIC) Services 11 Uninsured pregnant woman presents to Obstetrician for Ongoing Care High Risk Referral NIWIC Secretary 1. Establish eligibility 2. Confirm demographic information 3. Add woman to client list 4. Prepare a prenatal package for client (includes lab/imaging requisitions, prenatal resources & template referral letters) NIWIC Midwife 1 st Visit 1. Routine prenatal assessment 2. Brief history & physical assessment 3. Order blood work, U/S, genetic screens 4. Discussion of referral options 5. Inform on availability of prenatal classes 6. Initiate referral through secretary to Midwife Clinic or Obstetrician Low Risk Referral Midwife Clinic for Ongoing Care Secretary follows up on pending referral to OB or midwife clinic Midwife 2 nd Visit 1. Review test results 2. Conduct brief physical assessment 3. Confirm prenatal care referral to Midwife or Obstetrician 4. Encourage continued use of the NIWIC for non-pregnancy related issues 5. Refer to Settlement, Allied Health & RN for other community, social & health resources. Other referral options Client leaves with package including lab test/imaging reports and assessment notes to bring to OB or midwife appointment Allied health Settlement Workers RN Case Manager - referral to partner CHC for primary care provider Figure 2. NIWIC Prenatal Pathway Current service details and eligibility criteria can be found on the NIWIC website:

13 Client Success Stories 12 Client Success Stories The NIWIC provides individuals without medical insurance with access to health care services. This access is critical to preventing worsening health conditions, development of new illnesses, and medical emergencies. The client stories below illustrate two examples of individuals who have used the NIWIC and were supported with their health needs. Kathryn: Filling the gaps for people in the 3 month wait period for OHIP with chronic diseases Kathryn is a female in her late 50s and newcomer permanent resident from the Caribbean. She was sponsored by her husband who has been living and working on his own in Canada for several years. In her home country, Kathryn enjoyed working as a classroom assistant, which helped to support her children and grandchildren. Kathryn was diagnosed with diabetes and high blood pressure (hypertension) 20 years ago. She was receiving regular health care in her home country but still struggled to take control of her diabetes. She faced diabetes complications leading to a toe amputation and foot ulcer. Before leaving the Caribbean, she made sure to see her doctor and nurses for a final visit. She had her foot ulcer cleaned and bandaged. Her doctor provided Kathryn with a one month supply of medication for her diabetes and high blood pressure. Five days after arriving to Canada, Kathryn and her husband were relieved to learn about the West End Non-Insured Walk-In Clinic (NIWIC) from a local community agency. At the NIWIC, she was assessed by a nurse and nurse practitioner. Her foot ulcer was cleaned and assessed for signs of infection. Her blood pressure and sugar levels were high even though Kathryn had been taking her prescribed medications. The nurse practitioner informed Kathryn and her husband of local hospitals in case of medical emergencies. The nurse case manager/coordinator sent an urgent referral to a partner community health centre where Kathryn could be connected to a family doctor, foot care clinic, and diabetes education team, without needing to wait for her OHIP. While Kathryn waited to be connected to a family doctor, she continued to use the NIWIC. The NIWIC consulting doctor saw Kathryn and changed her medications to better manage her blood pressure and sugar levels. The nurses cleaned and changed the dressings for Kathryn s foot ulcer twice per week. In less than two weeks after her first visit to NIWIC, Kathryn had her first appointment booked with her family doctor. She was quickly connected with foot care specialists in addition to a diabetes nurse and dietician. Months later, Kathryn calls the NIWIC expressing her thanks for the support provided to her and her husband. They did not know they could have access to extensive health care services without OHIP. Kathryn continues to see her health care team at the community health centre.

14 13 Melanie: Pregnant and Uninsured Melanie, is a young woman from the Americas. She presented alone to the walk-in clinic on a Monday evening at 32 weeks of pregnancy. She was timid, emotional and fearful. On social and health history she disclosed that she had come to Canada on a visitor s visa to be with her partner. Her visitor s visa had expired during this time. Her partner was emotionally and physically abusive. She ended up needing to leave him and in the process he withheld all of her documents (passport, visa). The client divulged that she was HIV+, she was aware of the importance of anti-retroviral therapy but had discontinued use 4 months earlier due to financial constraints and lack of information about resources available to her. At the time of her appointment she was living with a friend and had little to no financial means. The volunteer midwife assessed her and made an urgent referral to a midwifery colleague operating at a collaborative HIV program for pregnant women in Toronto. The NIWIC Nurse Practitioner ordered all of the required tests to determine her HIV viral load and general health status. Through the NIWIC the client was linked up with a midwife, obstetrician, neonatologist and HIV specialist.. It was identified that the client s viral load was quite high, however her specialist health care team was able to respond by providing the appropriate medication prior to delivery. While final status will not be known for some time, a healthy child was delivered at term, and early tests indicate that the child will likely be HIV negative. The risk of delivering an HIV+ Canadian baby would have been much higher had she not presented to the clinic and received the appropriate follow up, including long-term HIV care. After delivery the client was followed by an HIV specialist and the NIWIC nurse referred her and her baby to a partner CHC for ongoing care. However, due to difficulties contacting Melanie after the birth, she was lost to followup.

15 Results and Discussions 14 Results and Discussions Administrative Information The NIWIC was open twice weekly on Mondays and Thursdays from 4:00 pm to 8:00 pm (Table 1). The prenatal services were available once per week on Mondays. The clinic was primarily serviced by paid AAMHCS staff including medical secretaries, a registered nurse, and nurse practitioners. In addition, the clinic received invaluable support from volunteer Registered Midwives who saw all of the pregnant women presenting to the NIWIC for prenatal care. Up to June 2014, a Toronto Public Health nurse worked at the clinic each Monday as a triage nurse. The AAMHCS nurse worked at the NIWIC on Thursdays as a triage nurse and otherwise provided support as the NIWIC nurse coordinator (Fig 1). From September 2014 to March 2015 the NIWIC piloted the use of a volunteer registered nurse who provided triage support alongside the AAMHCS registered nurse coordinator (Table 1). Table 1. Clinic Hours of Operation and Staffing Requirements Hours of Operation Mondays and Thursdays 4:00 pm 8:00 pm (Midwives available on Mondays) Location Access Alliance Multicultural Health and Community Services Access Point on Jane 761 Jane Street, 2 nd Floor Toronto ON M6N 4B4 Staffing per Clinic 1 Secretary 1 Registered Nurse (RN) 1 Nurse Practitioner (NP) 1 Registered Midwife (Volunteer) Mondays only Total Staffing and Support 2 Secretaries 3 Registered Nurses Access Alliance RN Toronto Public Health RN April to June 2014 Clinic Volunteer September 2014 to March Nurse Practitioners 2 Part-Time Access Alliance NPs 1 Locum Access Alliance NP 1 Consulting Physician 21 Registered Midwives (Volunteer)

16 Results and Discussions 15 Between April 2014 and March 2015, the clinic served 393 clients over 1200 encounters (Table 2). Each client had an average of 3 encounters at the NIWIC. Given the procedural NIWIC pathway (Fig 1), three encounters per client may involve assessments performed by a registered nurse and nurse practitioner on their first visit (two encounters) followed by a follow-up assessment by the nurse practitioner on another date (one encounter). Prenatal clients are typically seen twice by a NIWIC midwife before being referred to a midwife clinic or obstetrician for ongoing prenatal care (Fig 2). Table 2. NIWIC Clients and Visits Total # of Clients Seen 393 Total # of Client Encounters 1200 Average # of Encounters per Client 3 Client Demographics The majority of individuals seen at the NIWIC are non-status (38.4%) followed by permanent residents in the 3-month wait period for their Ontario Health Insurance Program (OHIP) (23.7%) (Table 3). The third largest category was Other (21.6%). The current AAMHCS registration form does not provide clients an opportunity to specify their "other" immigration status. It is possible that individuals opting for the "other" category belong to immigration statuses available on the registration form, leading to underestimates of percentages for the listed immigration status categories, especially for non-status and non-insured groups. The NIWIC also saw a handful of refugee claimants (4.6%) who experienced barriers to accessing health care. Some refugees had very limited Interim Federal Health (IFH) coverage (Public Health or Public Safety Health-Care Coverage). This is a consequence of the significant reduction to the Interim Federal Health Plan (IFHP) enacted by the federal government in The other main challenge that these clients experienced in accessing health care included lack of awareness that their Interim Federal Health (IFH) coverage needed to be renewed annually. For clients who were unaware of the annual renewal process for IFH, they were referred to AAMHCS settlement workers to facilitate clients with the IFH renewal process.

17 Results and Discussions 16 Table 3. Immigration status of NIWIC Clients Immigration Status Count Percentage (%) Non-Status Permanent Resident Other Refugee Claimant Humanitarian or Compassionate Process Prefer not to answer Government Assisted Refugee Data Unavailable Do not know Temporary Foreign Worker Canadian Citizen Work Permit Total The largest age group served at the NIWIC was adults between years old (50.6%) and the average client age was 34 years old (Fig. 3). Female adults in this age range, which largely encompasses the childbearing ages, represented the largest sex and age group (33.8%) of all clients seen at the NIWIC. This is consistent with previous NIWIC data. It coincides with the fact that routine prenatal care is the top health issue addressed at the NIWIC (see the Health Issues/Clinical Data section below for further details). More females (259, 65.9%) sought healthcare services over males (133, 33.8%) among adults and child/youth groups (Fig. 3 and Fig. 4).

18 Number of Clients Number of Clients Results and Discussions < Age Groups (Years) Female Male Unknown Figure 3. Age groups and sex of NIWIC clients Female Male Age Groups (Years) Figure 4. Child and youth age groups and sex of NIWIC clients The most common languages spoken by NIWIC clients was English (159, 40.5%) followed by Spanish (98, 24.9%) and Portuguese (51, 13.0%) (Fig. 5). The top three countries of origin were Mexico, Portugal, and Jamaica, which coincides with previous years (Fig. 6). Designated countries of origin (DCO) are considered by the conservative federal government as countries that do not typically produce refugees, respect human rights and offer state protection ix. It is interesting to note

19 Number of Clients Number of Clients Results and Discussions 18 that the Mexico and Portugal the top two countries of origin are DCOs, which may coincide with limited immigration pathways to Canada from these countries including applying for refugee claimant status. The top racial-ethnic groups were Latin American, Black-Caribbean, and White- European (Fig. 7) Language Figure 5. Top 10 preferred languages of NIWIC clients (n=393) Country of Origin Figure 6. Top 12 countries of origin of NIWIC clients (n=393). Citizenship and Immigration Canada Designated Countries of Origin (DCO) are circled.

20 Racial/Ethnic Group Results and Discussions 19 Latin American Black - Caribbean White - European Black - African Asian - South East Middle Eastern Asian - South Asian - East Indian - Caribbean White - North American Black - North American Number of Clients Figure 7. Racial-ethnic groups of NIWIC clients (n=273) The highest level of education completed by NIWIC clients was secondary (34%) followed by postsecondary (29.8%) and primary (19.8%) education (Fig. 8).

21 Number of Clients Results and Discussions Figure 8. Level of education of NIWIC clients Level of Education Over half of NIWIC clients are living below the low income cut-off, which is $ according to Statistics Canada (2013). Forty-five percent of clients have family household incomes below $ per year (Fig. 9). These may even be underestimates since 42% of clients did not specify their household income. Low socioeconomic status (SES) significantly limits clients access to adequate health care. When combined with a lack of health insurance, the detrimental effects of low SES on clients health are exacerbated. Clients frequently report avoiding seeking health care because they are unable to afford the fees at local walk-in clinics and hospitals. Having limited financial means also makes it difficult to afford medications and medical supplies. This is especially true for individuals with chronic diseases who are faced with the challenge of needing life-long treatment. For example, an individual with diabetes may need to pay for medications, a glucometer, glucose test strips, and lancets.

22 Number of Clients Results and Discussions 21 Uninsured individuals needing hospital care for acute conditions, pregnancy, or hospital-based procedures are faced with costly facility and physician fees. These fees are not regulated and can vary from hospital to hospital depending on the service(s) provided. Uninsured pregnant women may be charged $500 to $3000 per day for hospital births x. Clients have presented hospital bills to NIWIC healthcare providers ranging from approximately $500 to $ The NIWIC attempts to mitigate the impact of financial constraints and poverty on clients health (see Financial Support) through CHC/midwife clinic partnerships, interprofessional collaboration, and knowledge of free and low-cost community resources. Nevertheless, these supports are limited. The clinic has some medication samples or stock medications (common antibiotics and over the counter pain relievers) available to dispense at no cost to clients. A limited amount of contraceptives, purchased by AAMHCS from Planned Parenthood Toronto, are also available for clients to purchase at-cost. Settlement workers assist clients with negotiating payment plans with hospitals. However, this strategy is more successful when arranged in advance and is not possible for clients with emergent health concerns needing immediate medical attention. Referrals to CHCs provide clients with access to primary care providers, counsellors, diabetes education teams, and programming that would otherwise be unaffordable Income Level Figure 9. Total family income levels of NIWIC clients (before taxes)

23 Number of Clients Results and Discussions 22 The NIWIC provides a means of improving access to preventative care and early acute care for medically uninsured residents in Toronto. When evaluating groups of NIWIC clients according to year of arrival to Canada, the largest group was newcomers arriving in 2014 (20.6%) (Fig. 10). This likely corresponds to the 23.7% of NIWIC clients who were newcomer permanent residents in the 3-month wait period for OHIP (Table 3). Approximately 70% of clients arrived to Canada within the past five years (from 2010 to 2015) of accessing the NIWIC. The healthy immigrant effect is a phenomenon where immigrants who typically have better overall health compared to Canadian-born residents when arriving to Canada, lose this health advantage over time. After several years of living in Canada, their likelihood of acquiring poor health conditions may equal or surpass the rates seen in Canadian-born individuals. However, this phenomenon mainly applies to adult economic immigrants and is less applicable to other categories of immigrants, children xi, seniors, prenatal clients. The NIWIC helps support newcomer permanent residents in the 3-month wait period to maintain good health by providing early access to care. Twenty-three percent of clients arrived to Canada before 2010 (Fig 10). This likely corresponds to undocumented residents and those with pending applications for permanent residency (for example, humanitarian and compassionate consideration). Individuals are eligible for the NIWIC if they do not have a primary care provider. Therefore, these NIWIC clients who are longer-term immigrants to Canada have been without regular primary and preventative health care such as cancer screening. They are at higher risk of presenting to the NIWIC with advanced chronic conditions and undetected illnesses Date of Arrival to Canada Figure 10. Date of arrival to Canada (n=393)

24 Number of Health Issues Addressed Results and Discussions 23 Health Issues/Clinical Data To analyze the categories of health issues and diagnoses made at the NIWIC, we collected the health assessment codes from the Nightingale on Demand (NOD) electronic medical records for all NIWIC clients (n=393) presenting to the NIWIC between April 2014-March There were 1733 assessments and diagnoses made in this time period (Fig. 11). At the NIWIC, health assessments and diagnoses are recorded using the Electronic Nomenclature and Classification of Disorders and Encounters for Family Medicine (ENCODE-FM). However, since the International Classification of Diseases (ICD) is a diagnostic tool that is more widely used for epidemiological and health management purposes (World Health Organization, 2015), we converted the ENCODE-FM assessments to ICD-10 codes and organized them according to the ICD-10 chapters (Appendix B) Health Issues Figure 11. Categories of all health issues (N=1733) addressed at the NIWIC

25 Results and Discussions 24 The clinic saw clients with preventative, acute, and chronic health care needs. Figure 11 summarizes the categories of health issues addressed at the NIWIC. The top three health issue categories addressed were Preventative Health Care (30.8%), Symptoms (without a medical diagnosis) (26%), and Musculoskeletal (7.9%) (Fig. 11 and Table 4). The top specific health issues/diagnosis addressed overall were routine prenatal care (5.9% of total health issues) followed by review of test results (4.33%), special screening including immunizations (4.33%), hypertension (4.33%), and joint pain (3.17%) Table 4. Health issues addressed with top 3 subcategories of health concerns addressed at the NIWIC (n=1733) Categories of Health Issues Specific health issues/diagnoses addressed Count of Health Issues Addressed Percentage (%) of Total Health Issues Preventive Health Care Routine prenatal care Review of test results Special screening & immunizations Symptoms Headache Cough Musculoskeletal Musculoskeletal Joint pain Low back pain Neck pain Genitourinary Breast lump Urinary tract infection Non-inflammatory disorder of vagina Endocrine Type 2 diabetes mellitus Hyperlipidaemia (high cholesterol and fats in blood) Hypothyroidism, unspecified Circulatory Essential (primary) hypertension Phlebitis and thrombophlebitis of other deep vessels of lower extremities Angina pectoris, unspecified Respiratory Acute pharyngitis Asthma Acute upper respiratory infection Skin

26 Results and Discussions 25 Pruritus vulvae Cutaneous abscess, furuncle and carbuncle Follicular cyst of skin and subcutaneous tissue Injury Allergy, unspecified Sprain and strain of ankle Injury of adductor muscle and tendon of thigh Infectious Disease Chlamydial infection Tinea inguinalis [Tinea cruris] Acute hepatitis B without delta-agent and without hepatic coma Digestive Constipation Gastro-oesophageal reflux disease with oesophagitis Unilateral or unspecified inguinal hernia, without obstruction or gangrene Pregnancy and childbirth Vomiting of pregnancy, unspecified Spontaneous abortion Haemorrhage in early pregnancy, unspecified Eye Other specified disorders of eye and adnexa Subjective visual disturbances Pterygium Nervous System Cluster headache syndrome Tension-type headache Disorders of initiating and maintaining sleep [insomnias] Blood and immunology Iron deficiency anaemia, unspecified Vitamin B12 deficiency anaemia due to intrinsic factor deficiency Anaemia, unspecified Mental Health Depressive episode, unspecified Unspecified sexual dysfunction, not caused by organic disorder or disease Unspecified mood [affective] disorder Ear Disorder of ear, unspecified Otitis media, unspecified Otalgia Cancer Leiomyoma of uterus, unspecified Benign neoplasm of breast Congenital Disorders

27 Results and Discussions 26 Polyostotic fibrous dysplasia External Causes of Disease and Death Agent primarily affecting the gastrointestinal system, unspecified Antithyroid drugs Antihyperlipidaemic and antiarteriosclerotic drugs Total Health Issues Preventative Health Care Preventative health care issues (30.8%) was the number one health issue category addressed (Table 4 and Fig. 12). It included routine prenatal care (5.9%), screening and immunizations (4.3%), review of test results (4.3%), and medical care (3.1%). Routine prenatal care was the top health issue addressed at the NIWIC. This coincides with local reports that identify reproductive health care as the most common health need for uninsured residents xii. The NIWIC prenatal services (see Fig 2 and Ongoing Prenatal Care (Midwife and Obstetrician Clinics) for further details) is an important health promotion initiative for vulnerable uninsured pregnant women. The services aim to improve mother and child health outcomes, preventing poor and potentially life-long health conditions. Considering the children born to these women will become Canadian citizens, offering accessible health care services to all pregnant women would reasonably be a cost-saving measure for the health care system and a benefit to Canadian society. The clinic administers publicly funded vaccines according to the Publicly Funded Immunization Schedule for Ontario, primarily to school-aged children. Newcomer children in the 3-month wait period for OHIP often bring immunization records from their home country to identify any outstanding immunizations needed prior to starting school in Canada. On the other hand, children who have been longer-term residents, often visit the NIWIC for immunizations after receiving a letter from Toronto Public Health notifying them they are due for immunization(s) in accordance to the Ontario Immunization School Pupils Act. Some families reported going to walk-in clinics and being told they would have to pay over $100 for their child to receive the needed immunizations. Other families had language barriers to understanding the instructions outlined on their children's school letters. They did not know how to book appointments at TPH community clinics and how to self-report that the immunizations were received to prevent school suspensions. As a result, the NIWIC serves as an important public health initiative for clients facing barriers to obtaining mandatory immunizations.

28 Routine Prenatal Care Special Screening & Immunizations Review of Test Results Medical Care Addressing Fear of Illness Administrative Procedures Pregnancy Testing Birth Control Blood Pressure Check Laboratory Testing Number of Health Issues Addessed Results and Discussions 27 ` Preventive Health Care Preventive Health Care Issues Figure 12. Top 10 health issues of Preventive Health Care category (n=533) addressed at NIWIC Symptoms The second most common health issue category addressed was symptoms without diagnoses (26%) (Table 4 and Fig. 13). The top symptoms of clients presenting to the clinic were headache (2%), cough (1.7%), and musculoskeletal issues (1.6%). Other symptoms addressed include abdominal masses, pelvic/abdominal/throat pain, rash, localized masses, urinary symptoms (Fig. 13). Most of these symptoms are adequately managed at the NIWIC and prevents unnecessary hospital emergency department visits. However, for urgent and acute conditions that are beyond the capacity of the NIWIC, assessments by nurse practitioners allows for appropriate referrals to the emergency department. It is common for uninsured individuals to delay seeking the needed

29 Headache Cough Musculoskeletal Abdominal/Pelvic Mass or Swelling Pelvic/Perineal Pain Lower Abdominal Pain Rash Localized Swelling or Mass Number of Health Issues Addressed Throat Pain Urinary Results and Discussions 28 medical care because of costs, fear of deportation, and fear of discrimination xiii. As a result, the health education provided by health care providers at the NIWIC is often crucial to encouraging clients to go to the hospital to address their emergent health needs in spite of these reservations Symptoms Symptoms Figure 13. Top 10 health issues of Symptoms (n=450) category addressed at NIWIC Musculoskeletal Issues and Link to Working Conditions The third most common health issue category addressed was musculoskeletal issues (7.9%) including joint pain, low back pain, and neck pain (Table 4). Many clients report pain is related to poor working conditions. It is common to hear of clients working long hours at physically demanding jobs. The demands of clients' jobs often aggravate their health conditions. Yet, given their financial constraints (Fig. 9) and the lack of job security, clients have little choice but to continue working. Studies linking the effects of precarious work on health have also found that individuals in low-paying and precarious jobs commonly develop pain due to long periods standing, heavy lifting, injuries, and pressures to work harder and faster xiv. When advising rest is not realistic, other common recommendations for clients include education on proper body mechanics, over the counter pain medications, and referrals to low-cost massage and physical therapy clinics.

30 Results and Discussions 29 Chronic Disease: Diabetes and Hypertension The two most prevalent chronic diseases addressed at the clinic were diabetes (1.7% of total health issues addressed) and hypertension (4.3%). This finding is in line with national studies that identified immigrants as being significantly more likely to develop diabetes over Canadian-born counterparts with shorter and longer term immigrants being 20% and 70% more likely to develop diabetes, respectively xv. Data from the Ontario Diabetes Database studying the link between ethnoracial origin on diabetes identified immigrants from Latin America, the Caribbean, South Asia, and Sub-Saharan Africa--significant client groups at the NIWIC--to be at high risk for developing diabetes xvi. The risk of developing heart disease including high blood pressure also increases with length of stay in Canada. In addition to immigration status and ethno-racial origin, environmental and social factors contribute to the development of chronic conditions among newcomers. For instance, new immigrants living in low-income neighbourhoods in Toronto that are less walking and cyclingfriendly are 50% more likely to develop diabetes than longer-term residents xvii. Yet, most interventions to address type 2 diabetes are specific to conditions and symptoms rather than upstream policies that improve social and economic conditions xviii. For NIWIC clients experiencing a multitude of poor psychosocial living conditions that increase their risk of developing chronic conditions such as diabetes, episodic medical care such as those provided at the NIWIC, is only one part of a multi-approach needed to address the needs of medically uninsured populations. Using the evidence gathered from the NIWIC, broader advocacy efforts need to be made to improve living conditions and access to health for uninsured clients. Cancer There were minimal cancer-related health concerns seen at the NIWIC (0.46%). Immigrants tend to have lower incidences and mortality rates of most cancers compared to Canadian-born residents xix. Nonetheless, cancer care is an important health issue to consider for uninsured clients as it can pose a significant challenge in the future. There are limited non-insured funds distributed from the Toronto Central LHIN to CHCs that are meant to cover fees for physicians and diagnostic tests. The costs associated with cancer care for one individual would exceed the funds available to an individual CHC. Collaboration between community health centres for funding support would be necessary to sustain the advanced needs for cancer care. The cancer care needed for cancer clients with advanced medical conditions is beyond the scope of CHCs that are equipped to provide primary health care. In fact, health care providers at organizations serving non-status and noninsured populations often feel like they are burdened with a disproportionate responsibility for this group's health care xx. Therefore, additional support from community care agencies and hospitals would be needed to ensure clients receive the comprehensive care that they need.

31 Results and Discussions 30 Mental Health Non-insured and underinsured individuals are at higher risk of having mental health challenges xxi. Individuals without recognized immigration status frequently experience high stress levels related to their precarious immigration status and limited access to health and community services. Refugee claimants experience stress due to the application process, family separation, precarious immigration status and settlement-related stressors. Newcomers living with low income, which comprises most NIWIC clients, are also more likely to report emotional problems and declines in health status compared to higher income newcomers. Studies have also suggested that women from Central and South America are more likely to experience emotional challenges related to immigration. In spite of this research on mental health conditions faced by non-insured and immigrant populations that NIWIC serves, only 0.92% of health issues addressed were related to mental health conditions. It is possible that clients' mental health challenges manifested as somatic (physical) symptoms. However, given the discrepancy between the research literature and NIWIC findings, the NIWIC may need to take a more deliberate approach to screening for mental health conditions. Improving mental standardized health screening would allow for enhanced detection of mental health conditions that may be difficult for clients to report due to stigma, for example. Impact of NIWIC By providing preventative health care and addressing client's immediate concerning symptoms, the NIWIC aims to prevent the progression to severe and negative health outcomes. Early interventions offer significant benefits such as access to diagnostic testing for early detection of disease and connections to a wide array of health care providers to reduce the impact of complex physical, mental, and social health conditions. With the supports of partner community health centres, the NIWIC has been well-equipped to address these primary care needs. The results suggest the feasibility of other community health centres to offer similar services for medically uninsured clients. Referrals Specialist Physicians Between April 2014 to March 2015, twenty four clients were referred to specialist physicians (Table 5). The top three medical specialties sought were ophthalmology, gastroenterology, and gynecology. Patterns in health issues were noted from ophthalmology and gynecology referrals. Three out of five ophthalmology referrals were related to symptoms of advanced diabetes diagnoses. All referrals to gynecology were related to a combination of uterine fibroids, dysmenorrhea and heavy menstrual bleeding. Table 5. Referrals to specialist physicians Number of Referrals Ophthalmology 5 Gastroenterology 3 Gynecology 3