Community Services Workers: Addressing an Equity Need in Primary Care Organizations

Transcription

1 Community Services Workers: Addressing an Equity Need in Primary Care Organizations AFHTO Conference October 18, 2016 Presented by: Francine Janiuk RN, BScN, MPA, Nursing Manager, Queen s Family Health Team Laura Cassidy, B.Comm, Quality Improvement Decision Support Specialist Linda Robb Blenderman, RN, BScN, MSc, Kingston Health Link Project Coordinator

2 Disclaimer of Commercial Support Presenters: Laura Cassidy, Linda Robb Blenderman Francine Janiuk This program has not received financial support or in kind support from any commercial organization Potential for conflict(s) of interest: None No potential sources of bias to mitigate

3 Agenda Background information Social determinants and their importance to overall health Community Services Workers (CSW): Embedded in Primary Care Outcomes Pearls, challenges and mitigation strategies

4 City of Kingston POPULATION: 123, % Growth Since % Age 65 + Highest Proportion of Immigrants (approx. 13%) 29.9% Seniors Live Alone High Prevalence of Cancer, COPD, Heart Disease, Arthritis, Mental Health and Addictions 3.6% French as Mother Tongue Source: Statistics Canada Focus on Geography Series, 2011 Census. Statistics Canada Catalogue no XWE Ottawa, Ontario. Analytical products, 2011 Census. Last updated October 24, Source: IHSP4, SE LHIN, April Available at:

5 Health Care Infrastructure Primary Care 4 Family Health Teams 2 Family Health Groups 2 Family Health Organizations 1 Community Health Centre & Street Health Solo Physician Practices Community: Hospitals (3): Community Care Access Centre Addictions & Mental Health Public Health Other Community & Social Services Tertiary and secondary 5

6 What determines health?

7 Why is this important? Everyone deserves the opportunity to have a safe, healthy place to live, work, eat, sleep, learn and play. Problems or stress in these areas can affect health. We ask our patients about these issues because we may be able to help. 1 Growing up in poverty is associated with increased adult morbidity and mortality from causes including diabetes, mental illness, stroke, cardiovascular disease, gastrointestinal disease, central nervous system disease, cirrhosis, injuries, and homicide. 1 We all regularly screen for diabetes, hyperlipidemia, cancer; when the evidence exists, hypertension, depression, smoking, and addiction, yet how many of us screen for the overarching condition of poverty one of the most important risk factors for ill health and death? 2 Family doctors and their primary care teams, as front-line health care providers, are in the ideal position to screen for and address poverty when possible. 3 Sources: 1-Wilkins R, Berthelot JM, Ng E.. Trends in mortality by neighbourhood income in urban Canada from 1971 to Ottawa, ON: Statistics Canada; Screening for poverty in family practice. Sandy Buchman, MD CCFP FCFP. Available at: 3- Brcic V, Eberdt C, Kaczorowski J. Development of a tool to identify poverty in a family practice setting: a pilot study. Int J Family Med 2011;2011: Epub 2011 May 26.

8 Why is this important? Consistently in Ontario, the poorer you are, the poorer your health, the less likely you are to have quality health care, and, overall, the worse you fare in your health outcomes. Source: Income and Health, Health Quality Ontario, 2016, p. 32

9 Video

10 Material Deprivation Associated with differences in education, income, and employment Source: KFL&A Social Determinants of Health Mapper.

11 Deprivation Index (DI) Source: Understanding Health Inequities and Access to Primary Health Care in South Eastern Ontario, Page 5

12 ED Visit Characteristics: Utilization Frequencies by DI Source: Understanding Health Inequities and Access to Primary Health Care in South Eastern Ontario, Page 6

13 Inpatient Care Resource Intensity by DI Source: Understanding Health Inequities and Access to Primary Health Care in South Eastern Ontario, Page 7

14 Kingston Health Link Primary Care Led Virtual Program Communities of Practice

15 Profile of HealthLink Complex Patients: n=239 Avg Age: 67 60% Female 4 + Chronic Conditions 55% Mental Health 8% Addictions 27% Referred to CSW Avg # of Medications: 17

16 Community Services Workers Assist and advocate for/with individuals in meeting their practical, short-term needs by focusing on solutions. We navigate on the ground We do the ground work

17 How did we get started? Built from Kingston CHC model Located in primary care organizations- shared resource Initiated for Health Link complex patients only Available to FHTs/FHGs/FHOs/FHNs/solo physician practices Now available to unattached patients

18 Role of CSW Work closely with the patients CSWs collaborate with each other and with community partners i.e. OW, ODSP, DSO Services Provide a health equity lens The Community Service Worker role has also been invaluable. Their expertise, whether involved in a full consult for social supports, or simply faxing back a quick reply to my questions is a huge asset to a physician in a FHO model who does not have a social worker on site. Physician in a FHO

19 Social Determinants Addressed by CSWs Total Referrals: 2015/16: /17 Q1&Q2: 200

20 Case Study 1 Elderly female (80 s); raising teenage grandson Housing: 2 bedroom apartment with mold growing inside and around the balcony Income: CPP & OAS equaling about $1300 a month Non-discretionary expenses: Rent $980 + utilities Role of the CSW: social system navigation, housing, food security, employment Food voucher KCHC Food bank information Facilitating affordable housing Facilitating application for social housing Engage grandson in conversation about employment

21 Case Study 2 Woman in her 40 s lives alone; owns her home Income: ODSP Issue: Water pipe burst in basement Client was unable to follow through on getting her water turned off, was using a wet vac instead Client also did not have funds to pay for the repairs Family Doctor referred to CSW for support Role of CSW: system navigation, advocacy, accessing resources Accessed City program to help low income homeowners to complete emergency repairs and renovations Facilitated conversation with Utilities Kingston to shut water off so the work could be done Provided support

22 Pearls Embedding CSWs into the team Promoting the role with Primary Care teams Raising organizational awareness of the importance of the social determinants of health Creating community supports and community services networks Starting where the doors are openidentifying early adopters

23 Challenges Role boundaries Driving/transportation Multiple documentation systems Various policies Lack of funding Circle of Care Duplication of service

24 Mitigation Strategies Data Communication with Executive Directors/Physician Leads and others Addressing barriers related to the health care culture CSWs participating in case conferences Participation in the Primary Care Forum and other healthcare training initiatives Marketing materials Referral sources

25 Next Steps Patient health outcomes short/long term Health system outcomes

26 Upstream Risks Screening Tool Pilot: Sample Screening Questions

27 Social Determinants Identified Using the Screening Tool During the Pilot

28 Loyalist FHT Screening Tool Outcomes and Next Steps: n=30 13 people (45%) selected that they wanted this information stored in their chart and 3 people (1%) wanted a follow-up telephone call Facilitated relationships with patients and families Transportation results skewed everyone was onsite People expressed lack of food knowledge vs food security Reconfirms why some of our programs/ displays/ education opportunities exist A resource is required to screen on an ongoing basis

29 Questions

30 Contact Info Francine Janiuk, RN, BScN, MPA, Nursing Manager, Queen s Family Health Team, francine.janiuk@dfm.queensu.ca Linda Robb Blenderman, RN, BScN, MSc., Kingston Health Link Project Coordinator, lrb@maplefht.ca Laura Cassidy, B.Comm, Quality Improvement Decision Support Specialist, lcassidy@maplefht.ca

31 References Brcic V, Eberdt C, Kaczorowski J.(2011). Development of a tool to identify poverty in a family practice setting: a pilot study. Int J Family Med 2011;2011: Epub Buchman, S. Screening for poverty in family practice. Available at: Health Quality Ontario. (2016). Income and Health. Available at: Kingston, Frontenac, Lennox & Addington Health Unit. Understanding Health Inequities and Access to Primary Health Care in South Eastern Ontario Report, Available at: Lalonde, M. (1974). A New Perspective on the Health of Canadians, Government of Canada. Available at: Mikkonen, J. & Raphael, D. (2010). Social Determinants of Health: The Canadian facts. Toronto: York University School of Health Policy and Management

32 References Continued Murray, S. (2006). Poverty and Health. CMAJ, 174: 7 doi: /cmaj Southeast LHIN. (2016). IHSP4. Available at: Statistics Canada. (2012). Focus on Geography Series, 2011 Census. Statistics Canada Catalogue no XWE Ottawa, Ontario. Analytical products, 2011 Census. Last updated October 24, 2012 Wellesley Institute. (2012). Housing and Health: Examining the links. Available at: Wilkins R, Berthelot JM, Ng E. (2002). Trends in mortality by neighbourhood income in urban Canada from 1971 to Ottawa, ON: Statistics Canada Images and graphic art taken from Google Images and Bing Images