RURAL HEALTH SERVICES FRAMEWORK

RURAL HEALTH SERVICES FRAMEWORK June 2013 Island Health Excellent care for everyone, everywhere, every time

Table of Contents Island Health Rural Health Services Framework ISLAND HEALTH RURAL HEALTH SERVICES FRAMEWORK JUNE 2013 EXECUTIVE SUMMARY... 2 PURPOSE... 4 BACKGROUND... 5 VISION... 8 PRINCIPLES... 8 APPROACH... 9 COMMUNITY CLASSIFICATION INDEX... 11 CORE FUNCTIONS/SERVICES... 12 APPENDIX 1: MAPS... 13 APPENDIX 2: CORE FUNCTIONS/SERVICES... 15 APPENDIX 3: COMMUNITY CLASSIFICATION INDEX... 21 APPENDIX 4: COMMUNITY CLASSISICATION INDEX BY ISLAND HEALTH COMMUNITY. 28 APPENDIX 5: CORE FUNCTION MATRIX... 34 Page 1

Executive Summary Island Health Rural Health Services Framework Island Health provides health services to over 750,000 people across a varied geographic area of approximately 56,000 square kilometers, including remote, rural, extremely isolated, and island communities. The Rural Health Services Framework (Framework) is a foundational document to guide future service and system development decisions within the Island Health region. The Framework is intended to support more consistency in rural service provisions and create clarity concerning objectives and commitments with respect to health, wellness, and access to services. Access to services in rural and remote communities varies and, as a result, Island Health has found itself unable to provide transparent decision-making rationale as to why one rural community has a service while seemingly comparable communities do not. In an environment of fiscal limitations and shortages of skilled labour, the Framework will guide Island Health in Establishing consistent rural and remote service policies Considering rural and remote service investments and/or reallocations on an Authoritywide level in collaboration with health service delivery partners. The Framework is based on the key premise that an effective health care system has many providers (health authorities, physicians, First Nations, community agencies, BC Ambulance Services) and that we must work together to identify solutions to gaps in care of local populations. Access to services in rural and remote communities varies and it is a challenge across Canada. Island Health faces the same challenge around providing appropriate and accessible services. Another challenge is that available services often vary, based on historical practices and the reality of past oneoff decisions, which have resulted in real and perceived differences around services in rural/remote communities. Approximately 1 in 4 Island Health residents (approx 187,500 people) live in 54 rural or remote communities. More than 6% of Island Health s population is Aboriginal (24% of the Mt. Waddington population identified as Aboriginal) and there are 53 First Nation reserves throughout Island Health, most located in close proximity to rural and remote areas. Page 2

Why focus on rural and remote communities? Island Health Rural Health Services Framework People living in rural and remote areas on the west coast, northern areas of the island and remote islands are more likely to experience poorer health for many reasons, including housing availability, food security and steady employment. Access to services in rural and remote communities varies and, as a result, has implications when considering specialty services (both regionally and island-wide) which are appropriately accessed in larger urban centres (e.g. Nanaimo and Victoria). Within Island Health there is a need to establish clearly understood and shared organizational goals regarding rural and remote core services. What Process Have We Used? To date, the Framework has been developed in three phases: I. A literature review (2008) was conducted by Island Health Planning and Community Engagement program. This led to the development of the Community Classification Index (2009). II. III. An internal Island Health Rural Health Working Committee was formed (2010) and tasked with drafting the Framework document which included the purpose, vision, principles, classification and core services descriptions, as well as appendices outlining the specifics of definitions and maps of classified communities. Island Health s Rural Health Services program used public participation processes (2011) to engage two rural community groups for the purposes of providing: i) information about the Framework and existing work to date and ii) validation of the data to ensure accuracy and enhance local community data. The two community groups engaged were the Southern Gulf Islands Health Advisory Committee and the Mount Waddington Health Network Steering Committee, representing 13 geographic rural and remote communities. The Framework is intended to guide Island Health and our service delivery partners in Delivering health care services in rural and remote communities Establishing consistent rural and remote service policies Considering rural and remote service investments and/or reallocations Establishing a framework for engagement and discussion Page 3

Purpose Island Health Rural Health Services Framework The purpose of the Framework is to help guide Island Health and our partners in the following: Establishing consistent rural and remote service policies; Considering rural and remote service investments and/or reallocations on an Authoritywide level in collaboration with health service delivery partners; and, Carrying out community level engagement and discussions around health and wellness and appropriate services. The Framework suggests core health care functions that can be offered by health service agencies (to include, but not be limited to Island Health) in each community, based on the community s population size, distance to larger centres and unique attributes. The Framework provides information to support discussion about exploring better ways to integrate health services across the organization, to guide decisions around resource allocation in rural and remote communities and to facilitate an equitable distribution and consistent range of services for these communities. The Framework will evolve to reflect increasing integration of health service delivery, increasing technologic capabilities for remote services delivery and support and the subsequent decreasing relevance of distance between communities. As Island Health moves forward to meet its strategic priorities, we recognized the need for an overarching directional document for rural and remote health services. The need for such a Framework has been recognized throughout Health Authorities in British Columbia. Page 4

Background Island Health Rural Health Services Framework An important part of Island Health s mandate is to effectively serve the rural, remote and isolated communities in the region. The Framework is a foundational document, not a plan or a strategy. The Framework is intended to guide future service and system development decisions for Island Health within the broader context of always-present competing priorities as service demand increases and an ever-present reality of limited resources. The Framework provides baseline information that will help identify opportunities for appropriate services and service delivery and initiate dialogue around planning for greater consistency in rural and remote health service provision. Page 5

Challenges/Opportunities Island Health Rural Health Services Framework Many rural and remote communities across Canada, as well as in Island Health, face challenges due to a less than stable population base. One challenge is providing sustainable services with an often lean human resource/workforce for an unstable or very small population base; moreover, communities facing this challenge are more economically vulnerable due to mill closures, declining fisheries and a logging industry. Compounding these challenges in rural and remote communities is, typically, the shortage of a skilled, healthcare provider labour force and an aging population base. Additionally, individuals and families with limited income are migrating to rural and remote areas due to the rising costs of living in urban centres. Improving the health status of rural and remote populations is not a new challenge. Many organizations across Canada and in British Columbia have been facing significant challenges for years. These challenges are most effectively addressed through collaborative partnerships with communities, agencies, organizations and local governments and begin with establishing a core level of health care services/functions to be provided in communities. This Framework sets what the appropriate core level of functions/services should be in each community. This baseline of core functions/services will support decision making aimed at achieving service appropriateness and equity. In the coming years, a Rural Health Action Plan based on this Framework will outline key actions targeting priority areas with the aim to provide appropriate, timely and equitable services across communities. Page 6

Process Island Health Rural Health Services Framework In 2008, the process to develop a Framework for rural and remote communities began. Island Health s Planning and Community Engagement program undertook a literature review of rural definitions. This review showed a discrepancy around the definition of rural or remote, and the concept of varying degrees of rurality. A Community Classification Index (CCI) was developed to group like-communities together based on a number of factors including road access, ferry frequency, population size and economy base. In 2010, a project charter for the Framework was developed and approved by an Island Health-Wide Reference Group formed to support the Framework s development. In 2011, the Framework was drafted with input from all Island Health programs and services. In 2011/12, Island Health s Rural Health Services (RHS) program used public participation processes to engage two rural communities to provide information about the Framework and to validate the data and ensure accuracy. The two community groups included the Southern Gulf Islands Advisory Committee (SGIAC) - representing five south gulf islands - and the Mount Waddington Health Network Steering Committee (MWHN-SC) - representing thirteen geographic rural and remote communities. Page 7

Framework Vision Island Health Rural Health Services Framework Excellent care for everyone, everywhere, every time. Framework Principles 1. Services will be oriented towards the health needs of the community (population health approach) 2. Responsibility for supporting a healthy population is a shared responsibility between individuals, the local community, health service providers and Island Health 3. Health outcomes will be met through a sustainable range of services that are evidence-based 4. Services will be delivered in a team-oriented environment and integrated with other programs to make best use of available resources 5. Services will be person-centered, provided in a respectful and culturally-safe manner 6. Staff will be supported to do their best work in an environment that recognizes the value of flexible working conditions and allows staff to enjoy a high quality of life in their chosen communities Page 8

Approach Island Health Rural Health Services Framework This Framework will be used by communities and health service partners to develop a Rural and Remote Health Action Plan outlining priority actions. When considering creative solutions to provide comprehensive accessible services, Island Health will use the Institute of Healthcare Improvement s Triple Aim approach. improving health care in three ways Population Health Healthy People! Happy People! And we can afford it! Experience of Care The Triple Aim, www.ihi.org Per Capita Cost To optimize the health care system and take into account three key dimensions: the experiences of the individual; the health of a population; and per capita cost for the population. The evolution of health care services in rural and remote communities requires a societal shift in thinking with the public participating as active, engaged partners in their own health care plans. Island Health will collaborate with our community partners to support a population health perspective. Island Health will also develop strategies that are economically sustainable with an evidence-based cost-benefit approach. This pragmatic approach will support transformational change to improve the long-term equity of services provision in rural and remote areas. Page 9

Population Health Needs: By using a population health approach, priorities will be directed at risk populations and high needs communities that have limited resources/services. Service Analysis: By assessing the current structure of services and resources available, local innovative and collaborative solutions with primary health care providers and communities will be explored. This will include the patient s journey through the health care system to support system restructuring and new ways of delivering care that is patient focused. Building Partnerships to Improve Comprehensive Services: Where there are opportunities to improve comprehensiveness and continuity of care, Island Health will collaborate with local community government and agencies to create partnership agreements and other creative solutions. Where resources and competing priorities allow for it, funding partnerships may also be explored. Cost per Capita: Considering service shifts through redesign, restructure, realignment and community collaboration that either maintains or reduces the per capita cost to the health care system in order to achieve a sustainable, predictable and stable health care system. Page 10

Community Classification Index (CCI) The CCI classifies communities into a limited number of mutually exclusive categories (see Appendix 1). This will assist to identify and understand where there are opportunities for improvement to service and achieve service equity. Rural and remote towns are grouped as like-communities, based on population size, travel time to larger centres and unique attributes such as transportation links, economy/employment, commercial and community services and education availability (see Appendix 2). Island Health recognizes that there is a difference in rural definitions between our CCI and the Province s Physician Master Agreement Rural Subsidiary Agreement (RSA). The RSA provides the payment mechanism for physicians practicing in rural and remote areas of British Columbia. The points system in the RSA focuses on the access to basic and advanced health services, while the CCI also considers other variables such as transportation, population, etc. This gives Island Health s CCI more flexibility to classify communities and determine appropriate and equitable service levels. Page 11

Core Functions/Services In Appendix 3, core functions/services are defined and arranged in bundles by type of service. This will form the basis of an inventory of current service levels during the development of a Rural and Remote Health Action Plan. Appendix 5 sets out an equitable future state of service levels to be provided in each category of rural or remote community. The intent is that services will be provided by the broader health care system which includes both Island Health and non-island Health providers and that these are delivered in a cost-effective manner. The Framework and inventory of services will be used to identify areas of new service priorities for the Rural and Remote Health Action Plan. Page 12

Appendix 1: Maps Island Health Rural Health Services Framework Community Classification Index for Northern Vancouver Island Kingcome Inlet VIHA Communities Rural Health Services Community Classification Index Large Urban Centre Urban Centre Holberg Coal Harbour/New Quatsino Winter Harbour Quatsino Port Hardy Port McNeill Port Alice Sointula Cormorant Island Guilford Island Tlowitsis Sayward Suburban Subdivision Rural Centre Outlying Rural Remote Rural Accessible Island Very Remote Rural Isolated Island Woss Quadra Island Kyuquot Cortes Island R.H.S. Community Population Coal Harbour/New Quatsino 176 Cormorant Island 737 Cortes Island 1,116 Denman Island 1,095 Ehattesaht 85 Gold River 1,362 Guilford Island - Holberg 169 Hornby Island 1,074 Kingcome Inlet - Kyuquot 300 Port Alice 821 Port Hardy 4,525 Port McNeill 2,623 Quadra Island 2,187 New Quatsino 70 Sayward 341 Sointula 886 Tahsis 366 Tlowitsis - Woss 401 Zeballos 268 Ehattesaht Zeballos Tahsis Gold River Hesquiaht Ahousat Tla-o-qui-aht Tofino Campbell River Merville Courtenay Comox Royston Cumberland Union Bay Denman Island Hornby Island La Fanny Bay Bowser Qualicum Beach Coombs Park Port Alberni N Community Classification Index for Central Vancouver Island Quadra Island aht Zeballos Tahsis R.H.S. Community Gold River Hesquiaht Tla-o-qui-aht Ahousat Tofino Population Ahousat (Flores Island) 661 Bamfield 200 Bowser 1,840 Chemainus First Nation 636 Coombs 3,419 Ditidaht 199 Gabriola Island 4,050 Hesquiath 100 Penelakut (Kuper) Island - Lasqueti Island 355 Malahat First Nation 674 Mudge Island 60 Parksville/Qualicum 26,518 Beach Port Alberni 22,374 Thetis Island 350 Tla-o-qui-aht 300 Tofino 1,655 Uchucklesaht 200 Ucluelet 1,687 Valdes Island - Youbou 734 Ucluelet Cortes Island VIHA Communities Campbell River Rural Health Services Community Classification Index Large Urban Centre Merville Urban Centre Courtenay Comox Suburban Subdivision Royston Rural Centre Cumberland Union Bay Outlying Rural Denman Island Hornby Island Fanny Bay Lasqueti Island Remote Rural Bowser Accessible Island Qualicum Beach Very Remote Rural Coombs Parksville Port Alberni Isolated Island Nanaimo Gabriola Island Mudge Island Toquaht Uchucklesaht Chemainus First Nation Valdes Island Ladysmith Thetis Island Penelakut Island Galiano Island Bamfield Youbou Ditidaht North Cowichan Mayne Island Lake Cowichan Duncan Pender Island Saturna Island Saltspring Island Mill Bay Malahat First Nation Sidney Port Renfrew Highlands Saanich Peninsula View Royal Langford Jordan River Victoria Shirley Sooke Colwood Metchosin Otter Point Page 13

Community Classification Index for Southern Vancouver Island Island Health Rural Health Services Framework VIHA Communities Rural Health Services Community Classification Index Port Alberni Large Urban Centre Urban Centre Suburban Subdivision Rural Centre Outlying Rural Uchucklesaht Remote Rural Accessible Island Very Remote Rural Isolated Island Ditidaht Qualicum Beach Coombs Parksville Gabriola Island Nanaimo Mudge Island Valdes Island Chemainus First Nation Thetis Island Ladysmith Penelakut Island Galiano Island Youbou Mayne Island North Cowichan Lake Cowichan Duncan Pender Island Saturna Island Saltspring Island Mill Bay Malahat First Nation Sidney R.H.S. Community Population Galiano Island 1,278 Mayne Island 1,112 Pender Island 2,200 Port Renfrew 291 Saltspring Island 9,640 Saturna Island 359 Shirley, Otter Point, Jordan River 2,096 Sooke 14,163 Port Renfrew Jordan River Shirley Otter Point Saanich Peninsula Highlands View Royal Langford Victoria Colwood Sooke Metchosin Page 14

Appendix 2: Core Health Care Functions/Services FUNCTION / SERVICE DESCRIPTION A. EMERGENCY TRANSPORTATION A1. Remote Evacuation Emergency evacuation from locations beyond reach of traditional 911 services by any means available including, Search and Rescue, Canadian Coast Guard, or volunteer or ad hoc peer rescue and transportation. A2. Emergency 911 Transport A3. Critical Care Transportation 911 Emergency Response pre-hospital care and transport to nearest and most appropriate facility, generally to include BCAS Primary Care Paramedic / Basic Life Support services. Emergency Transportation between facilities or to site of injury/illness provided by Advanced Cardiac Life support or higher trained providers via air or ground. Includes BCAS Autolaunch, Early Fixed Wing Activation, Ground Based Critical Care Transportation, Infant, Pediatric, and Maternity specialized transportation. B. ELECTIVE TRANSPORTATION B1. Elective Transportation for Ambulatory Services B2. Elective Transportation for Inpatient Services Travel by usual public methods including Public Transportation, Wheels for Wellness, HandiDart, Private Vehicle, BC Ferries, Private Vessel or Water Taxi, etc. Usually paid for by client or their 3 rd party insurer. Inter-facility inpatient transfer services provided at public expense by BCAS or other contracted provider. C. HEALTH INFORMATION C1. BC Health Guide Handbook Hard copy manual with comprehensive information on how to recognize and cope with common health concerns. Available at pharmacies and government agency offices. BC First Nations Health Handbook is available online as a companion document. C2. HealthLink BC Telephone or online access 24/7 to non-emergent health information. C3. Island Health Public Website Internet access to Island Health health information, services and facilities plus links to other health resources. D. CHILD, YOUTH, FAMILY & PUBLIC HEALTH SERVICES D1. Health Promotion, Screening, Education D2. Youth and Family Substance Use Services Process of enabling individuals and communities to increase control over and improve their health throughout the life continuum. Includes: - Healthy Child Development: speech therapy, audiology, nutrition, dental, physiotherapy, and occupational therapy. - Infant Development and Supported Child Development Community-based services that include withdrawal management, supported residential services coordination, individualized planning, counseling and outreach services. D3. Communicable Disease Prevention & Control Immunization programs (vaccine for preventable communicable diseases). Prevention, management and control of communicable diseases (i.e. investigation, screening, treatment, follow-up, education and contact tracking, etc.). Page 15

D4. Environmental Health Protection D5. Health Emergency Management D6. Disease, Injury & Disability Prevention D7. Reproductive Health, Pregnancy/Childbirth & Parenting Services that contribute to healthy natural and built environments by providing risk reduction activities to protect public health. Response to severe outbreaks of communicable diseases, natural or human-induced disasters, major accidents, etc. Includes emergency health response services, such as disaster preparedness. Programs that focus on the prevention of specific disease, disabilities and injuries that contributes significantly to the burden of disease, including harm reduction. Reproductive health, pregnancy/childbirth and parenting services encompass counseling, education, outreach and clinical services to support women, men and families at all stages of life cycle. E. URGENT AND EMERGENT HEALTH CARE E1. Rural Emergency Health Care Facilities (REHCF) Level 1: First Aid E2. REHCF Rural Level 2 Basic Medical Clinic Industrial site health office staffed with First Aid providers, Emergency Medical Technicians or Registered Nurses, depending on local regulations. Initial triage of all outpatients. Definitive care for minor conditions. Stabilization and transfer to another facility where required. Usually not open 24 hrs/day, but providers might be on call. Initial triage of all outpatients. Definitive care for minor outpatient conditions. Stabilization and transfer to a hospital facility where required. Usually not open 24 hrs/day, but providers might be on call. Services may be provided by RNs, NPs, or physicians, with telehealth backup. E3. REHCF Rural Level 3 Diagnostic and Treatment Centre Initial triage of all outpatients. Definitive care for appropriate inpatient and outpatient conditions. Stabilization and transfer to another hospital facility where required. Usually not open 24 hrs/day, but providers might be on call. Usually equipped with at least minimal diagnostic testing. Highest usual level of provider is that of General Practitioner, but may not be continuous. E4. REHCF Rural Level 4 Rural Hospital (Basic Rural Acute Care Hospital with ED) Initial triage of all outpatients. Definitive care for appropriate inpatient and outpatient conditions. Stabilization and transfer to another hospital facility where required. Open 24 hrs/day and highest usual level of provider is that of a General Practitioner. E5. REHCF Rural Level 5 Rural Hospital (Regional Rural Acute Care Hospital with ED) Initial triage of all outpatients. Definitive care for appropriate inpatient and outpatient conditions. Stabilization and transfer to another hospital facility where required. Open 24 hrs/day and highest usual level of provider would be a medical specialist within core specialties and a General Practitioner for all other services. Page 16

F. PRIMARY HEALTH CARE F1. Primary Health Care A clinic providing a patient with primary care throughout their life span and events; coordinating care through varying health and medical conditions and maintaining a longitudinal comprehensive patient record. Usually provided by a physician, sometimes provided by a nurse practitioner, often collaborating with other health professionals and utilizing consultation or referral as appropriate. Promotes effective communication with patients and encourages the role of the patient as a partner in health care. May be itinerant or continuously available in the community. F2. Chronic Disease Resource Service G. NUTRITION THERAPY An ambulatory service focused on newly-diagnosed patients, group education and exacerbation management and care plans within the community. G.1 Nutrition Therapy Dietitians support development and maintenance of optimal nutritional health through assessment, consultation and education. H. ACUTE AMBULATORY AND INPATIENT FUNCTIONS H1. Acute D&T A clinic providing all services in F1 above, usually staffed by a physician, which in addition is co-located with access to basic diagnostic and laboratory services, and which has sufficient capability to offer basic treatment services including intravenous medication, analgesia, and initial stabilization of medical conditions. Diagnostic, laboratory and treatment services may not be continuously available. H2. Acute Inpatient Services Short-term medical treatment, usually in a hospital, for patients having an acute illness or injury or recovering from surgery. Is capable of providing diagnostic, laboratory and treatment services on a continuous or almost continuous basis, utilizing on-call providers, if necessary. H3. Acute Inpatient and Procedural Sedation All services of H2. above, and procedures requiring sedation, including endoscopy, closed reduction, or cardio version and usually all provided by a General Practitioner. May include basic low risk obstetrical services without caesarian section capability. I. DIAGNOSTIC I1. Lab Collection Services Services that provides specimen collection and basic ECGs. May only be offered on a scheduled itinerant basis. No on-site analysis. I2. Lab Collection & Point of Care Analysis Facilities that provide collection and analysis of specimens using point of care devices operated by lab or non-lab staff such as RNs or MDs. Also serves as collection site for a wider range of off-site lab investigations. I3. On Site Laboratory Facilities that provide on-site lab collection and analysis including basic chemistry, hematology, and blood bank services. Analysis conducted by dedicated lab personnel. Page 17

I4. Imaging Services: Basic X-Ray I5. Imaging Services: X-Ray & Ultrasound A facility with basic x-ray capability to create images of internal body organs, tissues, or cavities using X-rays for diagnostic purposes. Under current service model, usually a site will not have this capability unless I2 or I3 services are also present. Same as I4. above, with the addition of ultrasound. I6. Full Imaging Services Same as I5. above, with the addition of CT scanning or MRI. J. HOME & COMMUNITY CARE J1. Home Care Nursing (Direct Care Nursing) J2. HCC-Physiotherapy & Occupational Therapy J3. HCC-Case Management Nurses assist individuals to manage their own care at home by providing nursing assessment, education, counseling and medical/surgical care. Physiotherapists & Occupational Therapists promote and help maintain independence and safety at home through assessment, treatment, consultation and education. Community-based service to assist clients with supported care at home. Hospital-based service to assist clients in their transition from hospital to home or care facility with assessment; care planning and health teaching. Authorization of various services and programs such as: Choice Support for Independent Living; Regional Resources for Adults with Disabilities Living; Residential Care; Adult Day Programs; Assisted Living; Subsidized Home Support Services; and Supportive Housing. J4. HCC-Social Work Counseling and social work services to promote the safety and well being of clients and/or significant others. The focus is on short-term health care crisis intervention. This includes adult guardianship. J5. Home Support To supplement rather than replace clients efforts to care for themselves, with the assistance of family, friends and community. Community health workers provide personal assistance with services such as medications, bathing, dressing and caregiver support. J6. Quick Response Crisis Intervention J7. HCC-Discharge Facilitation K. REHABILITATION Interdisciplinary team that provides crisis intervention at home to eligible clients when required. This is an emergency response service. To facilitate transition from the hospital into the community by referring complex clients to appropriate community support services; such as Long Term Care, Home Care Nursing, Rehabilitation Services, Aboriginal Health, etc., so that clients are able to live at home. K1. Rehab-Physiotherapy Help patients reach the highest level of function by: - preventing complications K2. Rehab-Occupational Therapy - maintaining or improving independence, and K3. Audiology & Speech - reducing disability. Services K4. Rehab-Social Work Counseling and social work services to promote the safety and well being of clients and/or significant others. Page 18

L. MENTAL HEALTH & ADDICTIONS SERVICES L1. Acute-Care Treatment Provides specific therapy to deal with acute mental health issues. Clients are first assessed by a clinician and then receive treatment through counseling or other services. L2. Crisis Response Emergency services aimed at the assessment and rapid stabilization of acute symptoms of mental illness and/or emotional distress. Includes mobile intervention services. L3. Crisis Stabilization A facility/residence/household providing residential response to crisis. L4. Crisis Line 24/7/365 risk management triage, support, and referral. L5. Community Support Services (Case Management) L6. Psychosocial Rehabilitation Case management supporting people with severe and persistent mental illness. Clients receive support and/or treatment in their own environment, such as: assessment and intake services; care planning and linking clients to appropriate services; repatriation and authorization of various services and programs such as: Assertive Community Treatment, Residential Services, Early Psychosis Intervention etc. Psychosocial rehabilitation may include illness education and management; skills for daily living; health promotion; occupational therapy and return to meaningful activity, including leisure and employment. L7. Counseling Services A supportive counseling environment to resolve mild to moderate problems, improve understanding and learn new skills. L8. Addiction Services Provide information, education, support and treatment for people affected by or at risk of developing alcohol and other drug-related dependencies. L9. Withdrawal Management M. SENIORS HEALTH M1. Geriatric Medical Services Continuum of support of daytox, supported withdrawal at home, short-stay beds and access to medical detox and designated beds for rural clients. In-home/facility assessments and treatment recommendations such as: consultation, liaison, education and support; capacity building; and Advanced Directives. M2. End of life Care Consultation Services and Education, such as: in-patient Services, Hospice Support and Standards and Guidelines. M3. Complex Care Home Residential facility providing accommodation, care and supervision for adults who are no longer capable of directing their own day-to-day activities. Page 19

N. ABORIGINAL HEALTH SERVICES N1. Aboriginal Health Nursing N2. Aboriginal Health Full Service Primary Care N3. Aboriginal Health Patient Navigator Services N4. Cultural Competency Education Provide liaison between Aboriginal clients, families, communities and Island Health/community health care services, individual client/family consultation, health and wellness planning, support for cultural and spiritual practices and may include first aid or first responder services. Primary Care Services equivalent to F1 above, but delivered in a culturally appropriate manner within a community by an integrated team of providers. May be itinerant or continuous. Likely includes: - Maternal child health services - Infectious / Communicable / Disease Services - Chronic Disease Management and, - Mental Health and Addictions. Support of Aboriginal clients through the transition from community to a health facility and back again to help integrate within appropriate community support services. Acts as a cultural and educational resource to other health care providers and acts as a liaison between clients and health care providers where barriers to communication or services exist. Generally provided within an acute care hospital and community. Train, educate and facilitate service providers to develop the skills to deliver culturally safe programs and services. Page 20

Appendix 3: Community Classification Index ISLAND HEALTH COMMUNITY CLASSIFICATION INDEX Page 21

Description The Community Classification Index groups like-communities into a limited number of mutually exclusive categories based on population size, travel time to larger centres and unique attributes. Purpose The community classification index is intended to serve several interlinked functions: To act as a method for identifying and classifying rural areas, in a coherent, logical and defensible manner; To assist with the community engagement by classifying rural areas in a way that local governments and community residents can identify with and support; To improve our understanding and appreciation of the wide range of rural and remote communities within Island Health; To help identify and understand areas where services may not be available or may not be consistently accessible or provided across communities; and To act as a practical guide to help determine suitable and consistent service delivery models, service levels, and access to services for each community classification. Rural is not an absolute term; there are varying degrees of rurality, just as there are different levels of urban development. Therefore, the index uses a scale to assess the different degree of rurality for a community based on two factors: population size; and travel time to larger centres. Population Size There is a correlation between population size and level of rurality. Although far from exact, population size indicates the likely demand for community services. In terms of service planning, population provides an indication of the ability of a community to be able to sustain services, given that a critical mass of residents who need service is required. Travel Time There is a correlation between travel time and level of quality. How quickly residents can access larger centres is a key consideration for the products and services that should be appropriately provided in or to an area. A community that can easily access a larger nearby centre for basic (daily) goods and services is less isolated. Index Continuum The index has been developed as a continuum, so that as a community changes, it might shift up or down a category in the index. While this makes the index clearer to understand, but there is a danger of this not reflecting reality. The different classifications in the index should be seen as broad banding, where different levels of rurality may be present within the same classification. More importantly, at their current level of development, the healthcare services required within each classification will be similar. Page 22

Practical application The model is designed to be applied practically. Population size and access are being used as methods to evaluate rurality. Ultimately, it is not the size of a community, or its proximity to larger centres, but the health needs of the population and the ability of the overall population to support and sustain health services that will influence planning. This relies on people being willing to move there, having schools for their children, employment opportunities for partners and access to recreation and leisure activities. Additional Thoughts and Considerations The areas of transportation infrastructure, economy and employment, commercial and community services and education have been provided with the index to help describe their level of development for each community classification. These are general observed patterns but there will almost always be one-off exceptions. N.B. The following descriptions use some specific terminology please see the Definitions section. Transportation Infrastructure Areas that are more developed generally have better access links with other areas. This includes both travel time and the available transportation infrastructure (roads, highways, trains, buses, bridges, ferries, etc.). Together, these give an indication of the accessibility of an area. Economy and Employment Rural areas usually have primary industry or tourism-based economies. One or two industries usually dominate the local economy and often one or two companies dominate the industry. Local authorities/municipalities often employ a considerable proportion of the working population. Urban areas rely more on secondary or tertiary sector businesses; commercial businesses are generally more prolific than industrial businesses. Media companies, financial organizations and/or professional service companies will often play a considerable role in the local economy, whereas they are non-existent in rural areas. Page 23

Commercial and Community Services Economy and employment can be generally considered as the supply side of the economic equation. Commercial and community services can be considered the demand side of the equation: what services are available to residents, and how far do they have to travel to get them. However, it is also an indicator of the ability of a community to supply and sustain required services; for example, a community with a single small grocery store cannot typically support anything more. Commercial and community services includes services such as: Basic, discretionary and luxury goods (as defined below). Recreation, social, cultural and entertainment opportunities, including the diversity and range. (Rural areas might offer a bar/ restaurant and lots of walking trails; urban areas offer cinema multiplexes and theatres). Religious facilities (and number of religions and denominations). Emergency services: the type of service provided and cover (e.g. no continual police presence, volunteer fire service, air ambulance access only) is a good indicator of rurality. As with education, these can be seen as basic, necessary services. Services, such as water supply systems, sewerage systems, electricity, garbage disposal. Generally, one would expect these only to be an issue in separating the more extreme categories of rural; the lack of any of these is a good indication that a community is rural. However, this should include consideration not just about whether service is provided, but also the reliability of that service. Urban areas occasionally have blackouts; more rural areas may have semi-regular interruptions (and generators!). Education Similar to healthcare, the provision of education is a fairly reliable indicator of rurality. It is a basic community need, and a basic human right (e.g. UN Children s charter, if not always enshrined in individual countries legislation), and the ability to fill and maintain that need can be a predictor of the community s ability to provide and sustain other community services. It should also consider access to education and learning facilities for adults: libraries, refresher training courses, post-graduation or college courses, and computer/internet access, etc. Definitions The index uses definitions to describe the level of goods and services available within an area, and the predominant types of industry and employment. Page 24

Goods and Services Staple Basic requirements of daily living: basic groceries, personal care, cleaning products and fuel. Discretionary General, less frequent purchases, such as clothing, basic household appliances and furnishings, personal and professional services such as hairdresser, plumber, lawyer, and car mechanic. Luxury Selective, high-value items, such as certain clothing, jewelry, sophisticated household appliances and furnishings. Possibly includes, cars and computers. Note on nomenclature: several sources were consulted, including the Global Industry Classification Standard (GICS), North American Industry Classification System, and certain marketing textbooks and websites. The 3 levels are a basic marketing categorization, although no common terminology can be identified. The nomenclature is therefore invented, based on the terms used by the above sources. Types of Industry Primary Secondary Tertiary Government & Tourism Areas working collecting and processing raw materials: logging and mining; farming, fishing and agriculture. Manufacturing and processing industries: car and ship building and food processing factories etc. Arguably includes call centres. Service sector: includes areas such as finance, insurance, investment and banking, architecture and design and customer service. Regarded as separate categories. Page 25

Community Classification General Description Pop. Size Distance/ travel time (personal transport) Transportation Links, Access and Type Economy/Employment Commercial & Community Services Available Education 1 Metropolitan 500,000+ 2 Large Urban Centre Large cities, and surrounding zone of influence, including commuter belt. 75,000+ Access to most products & services within 30 min. Local & regional public transport and multiple highways. Provides (Inter) national access e.g. airport. Diversified economy/ multiple employment opportunities. Service sector well developed. Provides specialty and luxury consumer products Post Secondary Education - University 3 Urban Centre Cities and larger towns. 75,000 30,000 Access to most products & services within 30 min. Local & regional public transport. Provides national access e.g. train, coach. Diversified economy; predominantly service sector and secondary industry. Provides diversified general social/ economic services. Post Secondary Education - Colleges 4 Suburban District Commuting areas that predominantly rely on urban centres. N/A Access to urban centre within 30 min. Strong transport links to local urban areas, including local public transport and multiple highways. Economy integrated with local urban areas. Population largely employed in secondary/ tertiary services, and may commute to urban areas on a regular basis. Inhabitants willing to travel to urban centre for discretionary goods and services. Staple goods and services available locally. K-12 school available. Postsecondary within traveling distance. 5 Rural Centre Regional towns, often serve as a focus point for surrounding area 30,000 5,000 Access to urban centre within 3 hours. Public transport available. Limited regional access e.g. bus service. Single highway entry in and out of centre. Heavy primary industry, fishing or agricultural reliance. Tourism and/ or local authority likely to be major employers. Staple and basic discretionary services provided locally. K-12 school available. 6 Outlying Rural Smaller rural communities/areas that rely on rural centres. May be outlying areas of rural centre, or detached community. 5,000 500 Access to rural centre within 60 min and urban centre in 3 hours. Limited/ no public transport; limited roads linking communities. Single industry dominated - impact - hard for partners to find jobs when families move to area. Limited emergency service presence. Have to travel to rural centre for discretionary goods or services. Elementary available, have to travel to high school. Page 26

Community Classification General Description Pop. Size Distance/ travel time (personal transport) Transportation Links, Access and Type Economy/ Employment Commercial & Community Services Available Education 7 Accessible Island Island communities accessible via regularly scheduled ferries. < 5,000 More than 5 trips per day from island to urban centre. Frequent and regularly scheduled ferry service. Limited/ no public transport. Minimal industry. Work often seasonal. Economy likely focused around tourism, arts and basic community services. Limited emergency service presence. Basic staple goods only. May have Elementary 8 Isolated Island Small, isolated island communities with occasional ferry or no ferry services available. < 2,000 Must take two ferries or a water taxi, or fewer than 6 trips per day, or ferry service not near urban centre. Infrequent ferry service, may or may not have many paved roads. Typically no public transport. Minimal industry. Work often seasonal. Economy likely focused around tourism, arts and basic community services. Minimal access to social/ economic services. No permanent police. May have Elementary 9 Remote Rural Small communities. Significant barriers to accessing other communities. < 2,000 Access to rural or urban centre within 90 minutes, and urban centre within 5 hours Need personal transport; single road access to town (potentially unpaved). Single industry dominated. Often multiple jobs per person due to population size. Reliance on volunteers for emergency services. Basic staple goods only. Elementary available, travel to high school. 10 Very Remote Rural Small, isolated communities with restricted access. < 1000 Potentially >24 hours depending on weather Air and/or sea transport often required Minimal industry. Work often seasonal. Economy likely to be focused around tourism and basic community services. Minimal access to social/ economic services. No permanent police. Minimal/ no school available 11 Wilderness No established community. Individuals living in wilderness. < 100 Varies Varies Most often self-employed or subsistence living. None None Page 27

Appendix 4: Community Classification Index By Island Health Community Island Health Rural Health Services Framework Name Classification Population (2011) Communities Nearest Rural Centre Nearest Urban Centre Nanaimo Large Urban Centre 101,030 Nanaimo, Lantzville, Cedar, Cassidy, South Wellington, East Wellington four Snuneymuxw First Nation reserves, and Nanoose First Nation Victoria Large Urban Centre 225,671 Victoria, Esquimalt, Oak Bay, Saanich, Songhees Nation, and Esquimalt Nation Courtenay/Comox Urban Centre 45,880 Courtenay, Comox, two Comox First Nation reserves, Surrounding Area Cowichan Urban Centre 43,252 Duncan, North Cowichan (Including Chemainus, Crofton, Maple Bay), Cowichan Bay, Halalt First Nations, and Cowichan First Nations Reserves (except one near Dougan Lake) Westshore Urban Centre 61,949 Langford, View Royal, Colwood, Highlands, Metchosin, and Beecher Bay reserve (Scia'new) Campbell River Urban Centre 35,608 Campbell River, three First Nation reserves (Homalco, Cape Mudge, Campbell River), Surrounding Area to south Saanich Peninsula Urban Centre 41,168 North Saanich, Central Saanich, Sidney, Tseycum, Pauquachin, Tsartlip, and Tsawout Mill Bay Suburban District 14,077 Cobble Hill, Mill Bay, Shawnigan Lake, one Cowichan First Nation Reserve near Dougan Lake See Urban Centre Cowichan, 15-30mins Ladysmith Suburban District 9,467 Ladysmith, Saltair See Urban Centre Cowichan, 15-30mins Port Alberni Rural Centre 22,820 Port Alberni, Surrounding Area including Hupacasath and Tseshaht First Nation See Urban Centre Comox Valley, 60-90mins Oceanside Rural Centre 27,822 Qualicum, Parksville, Dashwood, French Creek See Urban Centre Comox Valley, 45-60mins Page 28

Name Classification Population (2011) Communities Nearest Rural Centre Nearest Urban Centre Sooke Rural Centre 13,089 Sooke, East Sooke, and the two T'Sou-ke Nation reserves See Urban Centre Westshore, 15-30mins Jordan River, Shirley, Otter Point 2,194 Jordan River, Shirley, Otter Point Saltspring Island Rural Centre 10,234 See Urban Centre Saanich Peninsula and Cowichan, 45-60mins Port McNeill Rural Centre 2,505 Port Hardy, 30-45mins Port Hardy Rural Centre 4,756 Port Hardy, two Kwakiutl reserves and one Gwa'sala-'Nakwaxda'xw Band reserve See Urban Centre Campbell River, 120-180mins Campbell River, 120-180mins Coombs Outlying Rural 3,924 Coombs, Errington, and surrounding area Oceanside, 0-15mins Comox Valley, 45-60mins Merville Outlying Rural 5,186 Black Creek, Merville, Headquarters See Urban Centre Comox Valley, 15-30mins Royston Outlying Rural 2,181 Royston See Urban Centre Comox Valley, 0-15mins Cumberland Outlying Rural 3,398 Cumberland See Urban Centre Comox Valley, 0-15mins Malahat First Nation Outlying Rural 692 Cowichan Valley A (RDA) CSD Malahat First Nation 102 Malahat First Nation Chemainus First Nation Outlying Rural 683 Chemainus 13 Census SubDivision Union Bay Outlying Rural 1,048 Union Bay Oceanside, 30-45mins Comox Valley, 15-30mins Fanny Bay Outlying Rural 1,171 Fanny Bay, Buckley Bay, Mud Bay Oceanside, 15-30mins Comox Valley, 15-30mins Bowser Outlying Rural 1,969 Bowser, Deep Bay, Qualicum Bay, Qualicum First Nation Oceanside, 15-30mins Comox Valley, 30-45mins Page 29