w w w . i h p m e . u t o r o n t o . c a

A. Paul Williams, PhD.

Best Brains ExchangeCIHR/Health CanadaOttawaNovember 28, 2017

Innovative Approaches and Pathways: Integrating Primary Health Care for Older Persons in Rural Canada and Beyond

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Getting the Problem Straight:Three Big Points

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Big Point 1: Shift from Health Care to Health

In Canada, primary care often defined narrowly in terms of first contact health care 2004 F/P/T Accord: “50% of Canadians having 24/7 access to

multidisciplinary teams by 2011”

WHO emphasizes health Includes, but goes beyond a “narrow offer of specialized curative

care” to embrace health promotion and the social determinants of health

Promises “better health, less disease, greater equity, and vast improvements in the performance of health systems”

Sources: A 10-year Plan to Strengthen Health Care. 2004. https://www.canada.ca/en/health-canada/services/health-care-system/health-care-system-delivery/federal-provincial-territorial-collaboration/first-ministers-meeting-year-plan-2004/10-year-plan-strengthen-health-care.html & World Health Organization. Primary Health Care: Now More than Ever, 2008. http://www.who.int/whr/2008/summary.pdf?ua=1

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Health and Wellbeing of Older Persons:Health Care Only One Factor

Source: World Health Organization. Healthy Aging. 2015. http://www.who.int/ageing/events/world-report-2015-launch/healthy-ageing-infographic.jpg?ua=1

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Big Point 2: Aging Society Not Just About Older Persons

Source: Statistics Canada 2015 http://www.statcan.gc.ca/pub/91-215-x/2013002/ct007-eng.htm

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Numerator: More Older Persons (Potential Care Recipients)

Source: OECD. Data. https://data.oecd.org/pop/elderly-population.htm#indicator-chart

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Denominator:Fewer Younger People (Potential Care Providers)

Source: OECD. Data. https://data.oecd.org/pop/young-population.htm#indicator-chart

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Speed of Aging Accelerating: Time for 60+ Population to Double from 10% to 20%

Source: WHO. Report on Aging. http://www.who.int/ageing/events/world-report-2015-launch/ageing-and-health-report.ppt?ua=1

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Aging Occurs Unevenly: Some Regions (Including Rural Areas) Age Faster

Source: Statistics Canada 2015. http://www.statcan.gc.ca/daily-quotidien/150929/cg-b004-eng.htm

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Big Point 3: Informal Carers & Support Networks Crucial

Source: Lilly. Who really cares? Caregiving intensity, labour supply and policymaking in Canada. 2011.

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Good News: Older Persons Healthier with More Gains Possible

Source: WHO. Active Aging. http://apps.who.int/iris/bitstream/10665/67215/1/WHO_NMH_NPH_02.8.pdf

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Bad News: Older Persons Still Face More Functional Challenges

Source: CIHI. Health Care in Canada, 2011. https://secure.cihi.ca/free_products/HCIC_2011_seniors_report_en.pdf

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Traditional Social Structures in Decline: Rise of One-person Households, Canada, 1951-2016

Source: Statistics Canada 2016 http://www.statcan.gc.ca/daily-quotidien/170802/cg-a001-eng.htm

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Older Persons More Likely to Live Alone: Canadians 15+ Living Alone

Source: Statistics Canada 2015 http://www12.statcan.gc.ca/census-recensement/2011/as-sa/98-312-x/2011003/fig/fig3_4-2-eng.cfm

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Generation Strain: UK

“ … a growing family care gap means that the number of older people in need of care is predicted to outstrip the number of family members able to provide it for the first time in 2017. Our plan should be to 'build' and 'adapt': to build new community institutions capable of sustaining us through the changes ahead and to adapt the social structures already in place, such as family caring, public services, workplaces and neighbourhoods.”

Source: Institute for Public Policy Research, UK, 2014. http://www.ippr.org/publications/the-generation-strain-collective-solutions-to-care-in-an-ageing-society

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Where You Want To Go: Building Supportive Communities

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Source: Ministry of Health, Labour and Welfare. Long-Term Care Insurance System of Japan. 2016. http://www.mhlw.go.jp/english/policy/care-welfare/care-welfare-elderly/dl/ltcisj_e.pdf

Supportive Communities: Japan’s Plan for Integrated Community-Based Care by 2025

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Exemplar 1: Programs of All-Inclusive Care for the Elderly (PACE), US

An international “gold standard” for integrated care for “at risk” frail older persons People to care: clients transported to adult day centre Complex health & social needs: average age of 83, 16+

medical conditions, many with cognitive impairment Inter-disciplinary teams assess & manage needs Access to a comprehensive suite of primary care,

specialty care, medications, transportation, meals, dental & vision services, mental health, emergency care

Source: Commonwealth Fund. 2016. http://www.commonwealthfund.org/publications/case-studies/2016/aug/on-lok

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Rural Pace Models: Northland, North Dakota Urban hub (Bismarck)/rural site (Dickinson) Shared administrative costs allow Dickinson to support

a small rural population (130 participants) PACE day centre & clinic attached to a nursing home

plus coordinated in-home services, transportation, assistance with transitions

Interdisciplinary Care Team includes doctors, nurses, social workers, physical/occupational/speech therapists, home care attendants, day/health center workers, transportation coordinators, dietitians, recreational staff, and van drivers

Source: Rural Health Information Hub. Northlands PACE. https://www.ruralhealthinfo.org/community-health/project-examples/776

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Rural Pace Models: Senior CommUnity Care, CO Two Day Centres in small towns (Eckert and

Montrose) and a satellite (in Paonia) Services provided at centres, at home, other locations Interdisciplinary team including physicians, nurses,

therapists, dieticians, drivers, social workers, recreational specialists

Range of: medical & hospital services, therapy, mental health, home modifications, supports for daily living, meals, transportation, hospice, lab services, 24 hour service to on-call nursing, caregiver supports

Partners with volunteers, disability organizations, county offices, health and human services agencies

Source: Rural Health Information Hub. Senior CommUnity Care. https://www.ruralhealthinfo.org/community-health/project-examples/784

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Exemplar 2: VON Seniors Managing Independent Living Easily (SMILE), South-East Ontario

Regional initiative (urban and rural areas) Serves “at risk” frail older persons and “at risk”

caregivers Growing numbers of older persons with assessed

needs comparable to long-stay home care clients and LTC-wait listed clients

Source: SMILE. http://www.von.ca/en/hastings/service/seniors-managing-independent-life-easily-smile

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SMILE: Supported Self-management

Specially trained care managers equipped with client budget envelopes

Work with at risk older persons & caregivers Identify & prioritize needs Create individualized care plans Provide care navigation and coordination Monitor outcomes

Care plans take into account: Client and caregiver needs Personal preferences and goals Availability of services and supports at the local level

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SMILE: Mobilizing Informal & Formal Capacity

Care plans lever local resources and capacity Formal community-based services & supports Meals-on-wheels, homemaking, transportation, respite, foot care,

assistance with shopping)

Informal and “non-traditional” providers such as neighbours, friends (but not family) Home maintenance, grocery shopping, meals, transportation

may be provided (when appropriate) by neighbors, volunteers, clubs

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Exemplar 3: Independent Living (Disability) Community

50+ years experience serving people of all ages, many of whom would have lived all or most of their lives in institutional settings Cerebral Palsy, Arthritis, Stroke, Multiple Sclerosis, Muscular

Dystrophy, Spinal Cord Injury (SCI), Spina Bifida and Huntington’s Disease; ABI; communications disabilities (e.g., non-speaking)

Persons with disabilities who are aging and who may also experience age-related health issues such as diabetes, stroke, renal failure and COPD

Growing numbers of older persons (and caregivers) at the verge of losing independence

Source: Building Capacity to Meet Ontario’s Needs. 2017. http://www.oailsp.ca/files/OAILSP%20Building%20Capacity%20Brief%20April%202017%20FINAL.PDF

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What the IL Community Provides: Non-Medical Supports for Functional Independence

Activities of daily living (ADLs) Personal hygiene (bathing and toileting), mouth & dental care,

dressing, assistance with eating, exercises, transferring/positioning/turning; bowel and bladder care

Instrumental activities of daily living (IADLs) Homemaking, laundry, assistance with appointments and groceries

Case management & system navigation Care navigation and linkages to funding, housing and other

community resources, assistance with transitions

Some medical services (often by exemption) Oxygen, ventilators, wound care

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Assisted Living Southwest Ontario (ALSO) “Layering” to Build Capacity

Phase 1: Attendant Services – Supportive Housing and Outreach

Phase 2: Addition of Mobile Services to traditional model.

Phase 3: Intra-agency integration of Services spoke and hub model.

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ALSO: Multiplying Hubs To Expand Coverage in Windsor & Rural Areas

+ 2 More in development Belle River and Leamington

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Thinking Bigger: Neighborhoods of CareSupportive Housing

Outreach

Mobile

Faith Orgs. Local Business Volunteers/Service Clubs

Transportation Parks & Rec. Post Office, LibraryMuseums, etc.

Health Agencies Social Service Agencies

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Putting the Pieces Together

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Putting the Pieces Together More Canadians living longer, better However, older persons still more likely to experience

multiple functional challenges

Healthy aging goes well beyond health care Local environments, including non-health care assets

like housing, transportation and social connectedness play key roles

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Building and Adapting In the community, informal care does the “heavy

lifting” In urban and rural areas, traditional social support

structures are in decline leaving a growing “care gap”

To fill a growing care gap, need to “build” new community institutions, “adapt” existing ones Using different approaches, all exemplars do this

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Take Away Shift the conversation from health care to health

Broaden the “unit of care” to include informal carers and social networks

Use interdisciplinary teams to provide the widest possible range of health and social supports

Engage local partners across rural and urban areas to build supportive communities Municipal services, local businesses, schools, faith

organizations, service clubs

w w w . i h p m e . u t o r o n t o . c a

paul.williams@utoronto.ca

Innovative Approaches and Pathways: Integrating Primary Health Care for Older Persons in Rural Canada and Beyond