The West End

Non-Insured Walk-in Clinic (NIWIC)

Sideeka Narayan, RN, MPH

March 16, 2013

West End - Non-Insured Walk in Clinic

(NIWIC)

Background

– Official number of persons living without recognized status in Canada unknown.

– Estimates say: 200,000 and 500,000 persons without status, majority living in major urban centres.

– Increasing awareness of health issues affecting the non-status/non-insured (poor access to perinatal care, unmanaged chronic disease, mental health problems)

– Non-status newcomers are at High Risk for poor access to preventive care

– Toronto LHIN: CHCs have identified there is an opportunity to enhance services to non-insured clients.

The NIWIC

Partnership of 7 Community Health Centers in West Toronto:

1. Black Creek CHC

2. Unison HCS

3. Access Alliance MHCS

4. LAMP CHC

5. Rodale CHC

6. Stonegate CHC

7. Davenport-Perth NCHC

Goal: To improve access to basic primary care (episodic) for unattached non-status/non-insured people living in the city of Toronto.

NIWIC Proposed Outcomes

1. Increased linkage between service providers with shared concerns;

2. Effective matching of need with resources;

3. Develop and strengthen pathways and a delivery system for services to unattached non-

status/non-insured population;

4. Reduced unnecessary visits to the Emergency Department for unattached non-status/non-

insured persons;

5. Reduced progression to severe health outcomes;

6. Increased linkages to support services and community agencies for unattached non-

status/non-insured people;

7. Improved self-management of health;

8. Joint strategizing, project planning and initiation;

9. Evidence-based practices established for unattached non-status/non-insured persons.

Eligibility Criteria

– Anyone matching these criteria can use the NIWIC during open hours;

• People with no-status/the non-insured

• People who are in the 3 month wait period for their OHIP

• People who do not have a primary care provider (i.e.. no doctor or nurse practitioner)

• People who live west of Yonge Street in the City of Toronto

– People who cannot use the NIWIC include:

• Anyone who already has a doctor/nurse practitioner,

• Anyone who already has OHIP or who covered by government insurance including IFH,

• Anyone who has private insurance

• Anyone who is a visitor or a student

NIWIC Services

What service can a person expect to receive at the NIWIC:

1. Episodic : Care for a specific medical problem, without an ongoing relationship being established between the person and health care professionals – if medically required there will be follow-up;

2. No cost to patient

3. Telephone interpretation

4. Referral to medical specialists as appropriate

5. Referral to community services (Diabetes Education, Midwives)

6. Referral to Settlement Services (housing, food insecurity, health costs, etc.)

7. People identified with chronic and/or unstable conditions referred to one of the partner CHCs

RN Case Manager

• Patient care coordination • Urgent CHC Partner referral

RN Triage/Assessment • Confirms eligibility • Determines presenting issue • Basic health hx & vitals • Identifies other risk factors

Practitioner

• Deals with chief complaint • Diagnoses/Treatment • Consults • Reviews labs • Patient follow-up

Physician Consult

Settlement • Information provision • Support service referral

Community & Allied Health Services

NIWIC: March 12th - November 30th 2012

Hours of Operation Monday, 4:00pm-7:30pm;

Wednesday, 1:00pm-4:30pm

Location Access Point on Jane, 761 Jane St.

2nd Floor

Total # of clinics 71

Total # of hours 248.5 (7 hours per week)

Staff Involved 1 Secretary, 1 Triage RN, 1-2 NPs, 1

Settlement Worker

Total # of Patients 113

Total # of Encounters 533

Total # Male 44

Total # Female 69

Total # < 5 yrs. 14

Average Patient Age 29

Hours and Staff Patient Statistics

Patient Demographics – Age & Gender

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5

10

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0 - 3 04 - 9 10 - 17 18 - 29 30 - 39 40 - 44 45 - 64 65 - 74 75 - 84

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Age Group

Male

Female

Preferred Languages of Patients

• Medical interpretation

available over the phone

through RIO services

Immigration Status

• Non-status/non-insured “undocumented”: lack official documentation, (i.e. PR card, student visa, work permit or IFH (61%)

• Permanent Resident in 3 month wait period for OHIP (26%)

• Refugee Claimant: Denied refugee status by Immigration & Refugee Board of Canada

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15

20

25

SouthAmerica

Africa Carribean SouthAsia

NorthAmerica

East Asia CentralAmerica

Europe Unknown

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Region of Origin

Region of Origin

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14

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Country of Origin

Country of Origin

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40

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Year of Arrival

Arrival to Canada

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60

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Income Level

Average Income

Distribution of NIWIC patients in GTA by

postal code and CHC Partners

Client by postal code

Access Alliance CHC

Unison CHC

Stonegate CHC

Lamp CHC

Rexdale CHC

Davenport-Perth NCHC

Black Creek CHC

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100

150

200

250

300

350

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Reason for Visit

Reasons for Visit: Broad Categories

Frequency of Medical Reasons for Visit

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Reason for Visit

Frequency of Medical Issues Addressed by a

Practitioner

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Health Issues Addressed

Category Count % of Health Issues

Addressed

Pain 68 20.8%

Pain - Other 49 15.0%

Back Pain 13 4.0%

Headache/Migraine 6 1.8%

Sexual and Reproductive Health Issues 63 19.3%

Pregnancy Related Issues 31 9.5%

Contraception Advice/Issues 15 4.7%

Other Reproductive Health Issues 11 3.4%

Sexually Transmitted Diseases

(excl. HIV/AIDS & Hepatitis) 6 1.8%

Respiratory/E.N.T. Issues 39 11.9%

Throat 22 6.7%

Cough 11 3.4%

URI/Colds 5 1.5%

Ear Infection/Inflammation 1 0.3%

Gastrointestinal Issues 26 8.0%

Stomach Pain/Discomfort 19 5.8%

Constipation 4 1.2%

Diarrhea 2 0.6%

GERD and Gastritis 1 0.3%

Reasons for Visit – Major Categories & Subcategories

Category Count % of Health Issues

Addressed

Sexual and Reproductive Health Issues 84 20.7%

Pregnancy Related Issues 36 8.9%

Contraception Advice/Issues 18 4.4%

Other Reproductive Health Issues 17 4.2%

Sexually Transmitted Diseases

(excl. HIV/AIDS & Hepatitis) 13 3.2%

Pain 51 12.6%

Pain - Other 32 3.0%

Back Pain 12 3.0%

Headache/Migraine 8 2.0%

Respiratory/E.N.T. Issues 39 9.6%

Throat 16 4.0%

Ear Infection/Inflammation 11 2.7%

Cough 7 1.7%

URI/Colds 4 1.0%

Allergic Rhinitis 1 0.2%

Chronic Disease Risk Factors 29 7.1%

Hypertension/High Blood Pressure 18 4.4%

Smoking 6 1.5%

High Cholesterol 3 0.7%

Overweight and Obesity 2 0.5%

Health Issues Addressed – Major Categories & Subcategories

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Issues Addressed

Settlement Support

Frontline Challenges

• Access to hospital based

care

• Access to perinatal care for

High Risk pregnancies

• Unmanaged chronic

disease

Key Developments

• CHC Referral Pathway

• Prenatal Care Pathway

- Midwifery partnership

• Toronto Public Health

Partnership

CHC Referral Process 1. NIWIC NP to identify level of urgency

– Medium Risk (PCP in 4-8 weeks)

– High Risk (PCP in 1-3 weeks)

2. NIWIC RN identifies partner CHC closest to patient’s home & contacts

CHC/NIWIC liaison by phone/email

3. NIWIC RN to send NIWIC Referral Form

4. CHC/NIWIC liaison to respond by email:

– PCP Name, Title

– Date, time, of initial appointment with PCP

5. NIWIC RN to inform patient & patient to sign AA consent form for release of

health info.

6. NIWIC Secretary to fax Health Records to CHC & close patient’s NIWIC chart

NIWIC - Partner CHC Referrals

CHC Name # of NIWIC Patient

Referral

Unison 5

Access Alliance 4

Black Creek 2

LAMP 1

Rexdale 1

Davenpoort-Perth 1

Stonegate 1

Total 15

Prenatal Pathway

NIWIC - Midwifery Referrals

(August-December 2012)

Midwifery Group # of NIWIC Patient Referral

West End Midwives 12

Diversity Midwives 1

Midwives Collective of Toronto 2

Total 15

Next Steps

• Implement onsite midwifery

• Continue to build new partnerships that facilitate a

system of support for the non-status/non-insured.

• Increase NIWIC promotion and outreach to the

community

• Strengthen NIWIC reporting to enhance evidenced-

based research

• Based on evidence, promote the uptake of service model

at other urban based CHCs

References

1. Access Alliance Multicultural Health & Community Services & Toronto Public Health.

(2011). The Global City: Newcomer Health in Toronto. Retrieved from

http://www.toronto.ca/health/map/newcomer.htm

2. Caulford, P. & D’Andrade, J. (2012). Health care for Canada’s medically uninsured

immigrants and refugees. Whose problem is it? Canadian Family Physician, 58, 725-

727.

3. Shirane, R. (2009). Inequity in access to Canada’s health-care system: Medically

uninsured, legal residents of Canada suffer from preventable and manageable

conditions. (unpublished report).

4. TC LHIN Community Health Centres. (2010). Examining the issue of non-insured in

community health centres within the Toronto Central Local Health Integration Network

catchment. Final report submitted to the Toronto Central LHIN. Toronto, ON: TC LHIN

Community Health Centres.

Questions?

For more information about

the NIWIC please contact me:

snarayan@accessalliance.ca

Synthesis of Recommendations

1. Promote progressive policies for ‘regularization’ of non-status groups

2. Remove restrictions to accessing early and timely healthcare services

3. Promote ‘Access without Fear’ model nationally (as opposed to Don’t Ask

Don’t Tell)

4. Expand ministry funding to increase and expand services to non-status/non-

insured groups

5. Need urgent action, particularly for priority groups/issues

a. Pregnant women

b. Children

c. Mental health services

d. Urgent care

6. Promote partnerships and collaboration within healthcare sector and across

sectors

7. Expand research, improve reporting protocols, and promote knowledge

sharing