addressing the rural hhr challenge: a decade of canadian experimentation joshua tepper md, cfpc,...
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Addressing the Rural HHR Challenge: A Decade of Canadian Experimentation
Joshua Tepper MD, CFPC, MPH, MBA
Declaration of Competing Interests
Representing only myself
No COI
About Canada
Canadian Health CareNational Health System since 1964
reaffirmed in Canada Health Act 1984
Provincial/Territorial administration
Approx. 30% of costs paid by individual
Slow privatization (Diagnostics and Surgery)
1.1M employed in health care
Approx. 149,000 Nurses, 75,000+ MD
A system in crisis (HHR, Cost/Value, Access)
Distance to Specialist Care
0.52 - 14.99
15.00 - 24.99
25.00 - 49.99
50.00 - 99.99
100.00 - 2005.72
Sparsely Populated Area
(KM)
Home to 22-30% of Canadians (50%+ of Aboriginal)
More likely to be obese, smoke, drink alcohol to excessive levels, be less physically active; have a disability; die from cancer, heart disease, suicide, homicide, have traumatic injury & death
More likely to have a lower level of income, education and employment
Health status and access to health services both decline with increasing remoteness.
Chronic Maldistribution of health workforce
Rural and Remote Canada
Home to 1/3 of Australians
More likely to be obese, smoke, drink alcohol to excessive levels, be less physically active; have a disability; die from cancer, heart disease, suicide
More likely to have a lower level of income, education and employment
Health status and access to health services both decline with increasing remoteness.
Maldistribution of health workforce
Remoteness Areas in AustraliaSource: ABS (2008) Australian Social Trends.
Rural and Remote Australia
Thanks to Tanya Lehman
“The success of our health care system as a whole will be judged not by the quality or services available in the best urban facilities, but by the quality of service Canada can provide to its remote and Northern communities”
- Jose Amaujaq Kusugak
“Canada may, in fact, have a very good health care system with health outcomes that are generally among the best in the world. But there are growing signs that this is not the reality for Canadians living in smaller or more isolated communities across the country.”
- Roy Romanow, 2002
Examples of Rural HHR Initiatives
CaveatsSnapshots not a comprehensive review
Many areas have similar initiatives
Does not speak to impact
Ontario Focus
Medicine focus
Impact needs to be studied
If you have seen one rural town…If you have been to one Canadian Province/Territory….
New Educational ModelsOntario
Comprehensive Approaches
British Columbia: Rural Retention Program
Rural Continuing Medical Education Fund
Recruitment Incentive Funding
Recruitment Contingency Fund
Isolation Allowance Fund
Rural Emergency Enhancement Fund
Rural Education Action Plan
Northern and Isolation Travel Assistance Program
Rural Locum Program (GP/GP-Anaethesia/Specialist)
http://www.health.gov.bc.ca/library/publications/year/2013/rural-guide-mar2013.pdf
Rural Education Action PlanUndergraduate Rural Participation ProgramUndergraduate Teacher’s StipendCME
Advanced Skills and Training ProgramFirst Year in Practice Enhancement ProgramRural Locum Service Upgrade ProgramUrban Skills Enhancement ProgramRural GP Locum CME Program (ACLS)Specialty Training Bursary Program (FM PGY3)
Comprehensive Approaches
British Columbia:
Regionalization & Service Closures:
Pan-Canadian
Saskatchewan closed 52 of 112 hospitals; 1993-1994
Ontario major restructuring Urban and Rural hospitals 225-150; 1996-2000
Surgery, Maternity, Labs, Mental Health and Emergency Departments
19
Primary health care
Specialized Models and Programs: Ontario
Ontario Rural Northern Physician Group Agreement (RNPGA)
Groups of physicians committed to providing core primary health care services in certain rural communities
The RNPGA provides a global payment to a group of physicians and ensures patients will receive a wide range of comprehensive primary care services in 38 northern communities. The RNPGA provides physician access to all people in the defined geographic area including residents in Long Term Care Homes, patients in hospital and emergency department coverage for communities with hospitals.
More than Doctors:Newfoundland
Aboriginal Health Human Resources Initiative
Increase capacity and number of education and training programs provided by Aboriginal institutions
Improving the contribution of mainstream education and training programs to the development of Aboriginal human resources
Improve Aboriginal students’ ability to pursue education and training through financial and other supports
Improving the cultural appropriateness and effectiveness of education and training programs to meet the needs of Aboriginal students and communities
Aboriginal Health Human Resources Initiative
The Role of TechnologyNunavut:
1/5 of Canada’s land mass; 27,000 people, 25 communities (148 to 7,000); only sea and air access
Ikajuruti Inungnik Ungasiktumi (IIU) Telehealth Network - ‘a tool to help people from far away’;
More than medical services: social services, educational, public health, administration
Live and ‘store and bring forward’
Four languages, Inuktituk, Innuinaqtun, French and English
Reflections on Rural HHR
JAMA 2012
Final ThoughtsHigh degree of variation – Pros and Cons
No ‘silver bullet’
Urban context has high degree of impact on rural HHR
Definition of rural is problematic but important
Major focus of initiatives is on medicine, some in nursing and not enough elsewhere
Addressing HHR Challenge in rural areas is a chronic challenge