Primary Care and Public Health Collaboration: British Columbia and Ontario Compared CPHA 2014 Toronto Valaitis, R., Easton, K., Dickenson, K., Kothari, A., O Mara, L., MacDonald, M., Manson, H., Murray, N., Sangster-Gormley, E., Turner, S., Tyler, I., Wong, S.
Program of Research Purpose: To examine the implementation of public health renewal processes using 2 public health programs - across British Columbia (BC) and Ontario (ON) Chronic disease prevention/healthy living (CDP) Sexually transmitted infection prevention (STIP) 2
Program of Research Goals To inform public health systems renewal in Canada and, in turn, contribute to improving population health and reducing health inequities To advance the field of public health services research in Canada by implementing a consensus-based research agenda and applying/ developing innovative research methodologies To inform integration and linkage of public/ population health and primary care services To train expert public health services and population health researchers 3
The Research Team Principal Investigators: Marjorie MacDonald, Trevor Hancock and Bernie Pauly ON Academic Researchers: Ruta Valaitis (ON Lead), Linda O Mara, Anita Kothari, Sandra Regan, John Garcia ON Decision-maker Researchers: Heather Manson (ON Lead), Gayle Bursey, Vera Etches, Betty Ann Horbul, Doaa Saddek, Nancy Peroff-Johnston, Jenifer Pritchard, Renée St. Onge, Carol Timmings, Deanna White BC Academic Researchers: Marjorie MacDonald (Co- PI), Allan Best, Anne George, Trevor Hancock, Esther Sangster Gormley, Joan Wharf Higgins, Craig Mitton, Bernie Pauly (Co-PI), Roger Wheeler, Sabrina Wong BC Decision-maker Researchers: Warren O Briain (Lead), Ted Bruce, Veronica Clair, Karen Dickenson, Lydia Drasic, Amanda Parks, Michael Pennock, Jennifer Scarr, Lorna Storbakken, Peggy Strass Research Coordinators: Diane Allan (BC), Nancy Murray (ON) Funder: Canadian Institutes of Health Research (CIHR) 4
Research Questions and Cross-cutting Themes Question 1: What factors/contexts influence or affect the implementation of these policy interventions? Question 2: What have been the impacts/effects of these policy interventions on: staff, the organization, the populations served, other organizations, and communities? Cross-cutting Themes: a) Equity b) Public health human resources c) Primary Care/Public Health Collaboration 5
Methods Case studies involving 6 ON health units, 4 regional health authorities A provincial health authority in BC, And, provincial ministries. Focus groups and interviews (n=75) including front line staff, managers, directors, and others serving urban, rural/remote regions, as well as ministry staff. Data collected between late 2010 up to 2012
Methods Case Studies Themes identified using inductive/ deductive coding (main research questions to frame) Nvivo 9/ 10 Team approach to coding and second reviewer for all coding
the nature of collaborations; factors influencing collaboration; influence of PH policies on collaboration; perceived outcomes RESULTS
Interpreting results BC+++ ON+++ Many reported in BC or ON BC++ ON++ Some reported in BC or ON BC+ ON+ A few reported in BC or ON
NATURE OF COLLABORATIONS
CDP/ HL What activities are being done? Tobacco reduction (BC+++; ON+++) Diet, nutrition, obesity prevention (BC +: ON+++) *Maternal Child Health (BC+++) (did not interview HBHC teams in ON) Diabetes care & prevention (ON++) General information sharing (ON+)
STIP What activities are being done? STI treatment and care management and clinic work (BC++; ON+++) Hep C program (ON++) Education, inservices, consults (BC+; ON+)
What PC settings? Community Health Centres (BC++; ON +++) Family Health Teams (ON +++) Interdisciplinary PC Clinics (BC++) Divisions of Family Practice (BC++) Integrated primary health networks (BC ++) Hospital programming focused on primary care (ON ++) Others such as walk in clinics, jails, local addictions centres, STI partnership clinics (ON+ all STIP)
Strength of Ties to PC Strong links (BC+; ON++) Planning underway / seen as important stakeholders (BC+; ON+) Weak ties (BC+; ON+)
No or very little collaboration ON + BC ++ Discussions at higher levels (BC): So, it s not a new concept but it s been around again for years, and primary care is within our umbrella of community integrated health services. So I do understand they re in our department now, under our portfolio. I haven t personally, have not had any interaction with primary care. [ ]I believe at a level higher than myself, so my practice leads, my manager, is looking at having those interactions and that, and they re more working with staff or leads or primary care. So my interaction has been none. (2011) Little to no collaboration (ON) I would say with Physical Activity or even Healthy Eating for that matter there s no collaboration. We ll promote each other s programs, each other s initiatives...
BARRIERS AND FACILITATORS
Toolkit2collaborate.ca
Intrapersonal Factors Values beliefs attitudes MD Negative time pressures, lots of competing issues (BC ++; ON ++) MD Positive attitudes; MDs belief it is worthwhile (BC ++; ON +)
Interpersonal Factors Approaches differ between PC and PH (BC+++; ON ++) for all professionals if you think of an example of youth which is a vulnerable population, they need primary care and public health services and attention and if public health and primary care aren t working together then youth can fall through the cracks and be underserviced. And there s many other populations like that where yes, primary care is taking more of the medical approach and public health is taking a more public health approach but you need both. (BC) Effective communication (BC +++; ON +) We roll out a new program, the nurse family partnership, is a perfect example of this. One of our docs didn t even know we weren t visiting every woman. (BC)
Interpersonal Factors Role Clarity understanding the role and work of the other (BC++; ON+) No they don t know the work we do, they don t understand the work we do, they don t understand the length of time it takes to get results, right. They could understand discontinue the STI clinics because it was this number of people treated.[ ] But to actually have that bigger broader picture of it, you know, that healthy living involves poverty: And how many people you have living in poverty? And how many community gardens do you have. Some of them don t get that. (BC)
Organizational Factors Organizational communication and coordination mechanisms (BC +++++; ON +++) What I have witnessed is that the public health folks feel like the docs are not communicating like they should be, they aren t listening to what they need them to listen to, are not willing to look at things outside of what their box is. That is what I hear from the public health side. Then when I put my primary care hat on, what I hear from the primary docs is public health doesn t tell us, they ask us for stuff but they never report, we never hear back what is going on with our patients if they go do something with public health. There is too much information, I don t really know what they are asking of me, they don t talk to us.
Organizational Factors Importance of PH in relation to other parts of the health system (BC+++++) the whole primary care and our integrated health networks and all that. I think that s cool and a movement forward but it doesn t include population health concepts and I don t think they ve made that connection yet. But I don t foresee that happening still for another 10 years or 20 or who knows how long it s going to take right? It s too far ahead, like this, right now, this primary care concept is still so fresh. (BC) Organizational changes (BC +++) How are we going to work with physicians? And if, we were just struggling to understand how would we work with physicians? Like we re all at this population health are working with the determinants of health and what not. Like physicians are working at their care delivery to a client right? So they were trying to make this system a community integrated health services all wrapped around patient care and with the physician at the center. And were struggling to fit into that model.
Organizational Factors Resources and funding issues (BC +++; ON ++) I just think it s a very expensive way to sometimes deliver some of the, some of the programs or pay physicians to deliver some of the programs. So as far as collaboration I think there is pretty good collaboration. I think sometimes the health authority thinks that they can support physicians, and I think they can to a certain degree; I just sometimes worry about the, the erosion of say public health to focus on primary care prevention. (BC)
Organizational Factors Leaders/ champions to liaise with PC (ON+) we also have a physician outreach specialist that we ve been working with to outline the strategies with communication with these external partners. (ON) I m actually the designated champion in our senior management team for liaison with primary care for this. (ON) the VP of community integration from within her portfolio is promotion and prevention, but she also has home and community care, primary care, and so any links with our physicians. It is just huge right now. Aboriginal health, mental health and addictions, so she has all of those underneath her, and part of public health is only a small piece of that..[ ] so they had to figure out how core functions fit into that and, you know, so we are just in the process of that right now basically. And all of those VPs, I don t know how much understanding they have of core functions. (BC)
Organizational Factors Structures and Models of PC (BC ++; ON ++) I mean the CHCs and there s a network of them in [city], the Family Health Teams, there s some network of that I believe. [ ] they are all kind of independently can work on their own thing so there s not although we have the Standards it doesn t require anything. It doesn t require them to partner with us. (ON)
Policy influence Systemic Level
Policy Influence on Collaboration Stimulated actual PC / PH collaborations [ON++ (CDP/ STIP)]: I ve noticed an emphasis on cessation at the primary care level and public health role in that. (ON) I think there s always more collaboration at the local level for that. And from my experience in [HU] last year there is ongoing collaboration for either specific areas or programs or specific attempts to do a more concerted strategic planning towards the collaboration. (ON)
Policy Influence on Collaboration Increase in planning/building strategy for collaboration (ON+) It needs, it needs a bit more leadership, a bit more work to have more joint planning and integration and that s happened since the public health standards were adopted. There has been more deliberate work to think about how do we integrate.
Policy Influence on Collaboration Policy reminds us to collaborate with Primary care (BC+; ON+): there was always a desire to collaborate, but I think [the policy] has made the need to collaborate more visible. (BC) So I think it s we re well aware from the Standards I think it s important that it s there and I think that the Standards do help to remind again that we need to be working with this area, this sector.. (ON)
Policy Influence on Collaboration Unclear if Policies have influenced [ON+ (STIP)] It s hard to know. It s hard to attribute it to the OPHS, because primary care has been identified as a key partner for a long time.
Policy Influence on Collaboration Many felt the Policy did not make any impact on PC PH collaboration (ON++) but before then we had a physician s newsletter that went out. It s not something public health in general hasn t been tapping into. It just might not be CDP has not been tapping strongly into that opportunity because of our differing perspectives in the. or the OPHS Standards don t direct us to focus on primary care.
STRATEGIES TO IMPROVE COLLABORATIONS
Strategies Improve communication mechanisms (BC+++) (transparent, organized, social inclusion) Create a physician engagement strategy (BC++; ON++); Rapid reviews, connections, positions e.g., peers, outreach) Increase knowledge and understanding of each others worlds (BC+; ON+) Improve planning for partnerships with PC (BC+) and look for opportunities to collaborate (BC+; ON+) Improve accountability mechanisms for PC and PH (BC+) Related to approaches responsiveness, work with not at (BC++) Unsure how (BC++)
PERCEIVED OUTCOMES OF COLLABORATION
Perceived Outcomes of PC PH collaboration Strengthened relationships between PH and PC sectors (BC+++) Benefits are minimal, not yet realized, or expected to come (BC+++; ON +) Help in assessments - Data gathering (BC +++; ON +) Improved or New Services and Programs (BC+; ON+) Increasing Access to Programs and Services (BC ++; ON++) New approaches established for provision of services programs (BC++) Better Reach Attainment of PH Goals And Objectives (BC++; ON+) Improved Health Behaviours (BC +; ON++) Improved inclusivity - engagement of partners in planning (BC+; ON+) Increase in Diagnoses (BC+) New programs or services established (ON+; BC+) Program Sustainability (ON+) Reduced duplication of services (BC+) Related to Efficiencies Gained (BC+; ON+) +++ Many reported ++ Some reported + A few reported
Limitations/ Next Steps Limitations Difficult to attribute associations to Policies Was left to the end of long list of focus group questions not as much time spent on this question
Implications Policy has had an impact on partnerships in general, although not clear in relation to PC Types of partnerships with PC are context dependent Inconsistencies in results across and between health units
Thank you! Contacts: Ruta Valaitis Valaitis@mcmaster.ca