concept of primary health care in canada chc dr shabon 2009

The CHC Model of Care

Prepared by the Education and Development Team,

The Association of Ontario Health Centres

The information contained in this document is confidential and proprietary to the Association of Ontario Health Centres (AOHC). Unauthorized distribution or use of this document or the information contained herein is strictly prohibited.

12-Apr-23 Association of Ontario Health Centres1

Table of Contents

A. Acknowledgments Pg. 4

B. Executive Summary Pg. 4

C. Introduction Pg. 5

D. Model of Care Fact Sheet – Definitions Pg. 7

E. Elaboration of the Model of Care (MOC) Attributes includes:

A. DefinitionB. ElaborationC. Why this attribute is relevant to the Model of CareD. Opportunities and Challenges to Addressing this

Attribute in your CHCE. SummaryF. References

Pg. 9

1. Comprehensive Pg. 9

2. Accessible Pg. 14

3. Client and Community Centred Pg. 20

4. Interprofessional Pg. 25

5. Integrated Pg. 29

6. Community-governed Pg. 34

7. Inclusive of the Social Determinants of Health Pg. 39

8. Grounded in a Community Development Approach Pg. 44

F. Glossary Pg. 49


A. Acknowledgments

The development of the training manual and toolkit on the Model of Care involved many committed and passionate people whose support and contribution were vital to the production of this document. These include the Community Health Centre (CHC) Charter Group: Lee McKenna, Brenda McNeill, Cate Melito, Cary Milner, Hersh Sehdev, Wendy Talbot, and Adrianna Tetley, and, the invaluable expertise from the AOHC’s Education and Development Team: Sophie Bart, Keisa Campbell, Mary Chudley, Carolyn Poplak, Brian Sankarsingh, Roohullah Shabon, and Sandra Wong. In addition, we would like to thank all AOHC staff for their support and the CHC representatives who contributed their lived examples, experiences, opportunities and challenges that helped bring these training tools to life. Thank you. Roohullah Shabon, Director of Education and DevelopmentThe Association of Ontario Health Centers416-236-2539 ext. 231

B. Overview

The objective of this manual, and its accompanying toolkit, is to provide information and resources on the CHC Model of Care for training purposes. The intended audience for the training includes Community Health Centre staff, volunteers and Boards of Directors. This manual is an elaboration on the eight attributes of the CHC Model of Care and provides appropriate references and resources for a better understanding of this Model and how it is being implemented in CHCs.

The eight attributes of the CHC Model of Care include:

1. Comprehensive;2. Accessible; 3. Client and community-centred; 4. Interprofessional;5. Integrated; 6. Community-governed;7. Inclusive of the social determinants of health; 8. Grounded in a community development approach

While the attributes are discussed and considered individually, they are also linked and fluid elements that do not exist in isolation from one another. For a CHC to be comprehensive, for example, it emphasizes the interprofessional team approach. For a Centre to be grounded in a community development approach, it is also client and community centred, and so on. Therefore, throughout this document, you will see overlapping themes and concepts. Defining these eight attributes emphasizes the importance of each quality independently, while highlighting their interconnectedness.

This document is a dynamic and living resource and we will continue to add to it. For comments and suggestions please contact:Roohullah Shabon, Director of Education and DevelopmentThe Association of Ontario Health Centres

416-236-2539 ext. [email protected]


C. Introduction

Primary health care (PHC) as defined by the World Health Organization (WHO) is essential health care made universally accessible to individuals and families in the community by means acceptable to them, through their full participation and at a cost that the community and country can afford. It forms an integral part both of the country's health system of which it is the nucleus and of the overall social and economic development of the community1.

Primary care refers to the patient's first point of contact with a health-care provider and includes but is not limited to: disease management and prevention, disease cure, rehabilitation, palliative care and health promotion. The greatest difference between primary care and primary health care is that primary health care is participatory in nature and involves the individual and their community in their overall health care including prevention and management.

The Ottawa Charter for Health Promotion echoes the sentiments of the WHO. It states that the role of the health sector must move increasingly in a health promotion direction, beyond its responsibility for providing clinical and curative services. Health services need to embrace an integrated mandate which is sensitive and respects cultural needs. This mandate should support the needs of individuals and communities for a healthier life, and open channels between the health sector and broader social, political, economic and physical environmental components.2

Canadians consistently describe Medicare as a defining feature of our identity. We are deeply connected to the core values of Medicare and PHC, namely a just and equitable system of health care equitably accessible to all Canadians. As individuals, we want to see Tommy Douglas’s vision of Medicare renewed and revitalized not demolished (???). The First Stage of Medicare was to remove the financial barriers between those who provide health-care services and those who need them. The Second Stage, following the path of the First, was to amend our delivery system to reduce costs and put an emphasis on preventative medicine.

The second stage of Medicare offers a vision for health that is embraced by CHCs: that as Canadians we must care for one another, and break down the barriers that prevent many from accessing care. With CHC Boards, management and staff on the same page about the CHC Model of Care, we can better highlight to the greater community the story of who we are and what we do, and further demonstrate how our Centres are champions of the Second Stage of Medicare. We will continue to acknowledge and recognize that our CHC clients, the members of our organizations who use our services, are at the heart of the work we do.

The CHC Model of Care captures consistent principles that underlie the work of Ontario CHCs. As a sector, we acknowledge that the differences between CHCs reflect the great diversity of the communities we serve. It is crucial that CHC Boards and staff share a common understanding of the Model and apply its principles throughout our work. These principles help to define the CHC role in what makes a stronger – and more caring – health-care system.

Based on the social determinants of health, the CHC sector provides accessible, community-governed, interprofessional, primary health-care services, including health promotion, illness prevention and treatment, chronic disease management, and individual and community capacity building. Our ultimate goal is for all Ontarians facing barriers to health to have access to quality primary health care within an integrated system of care.3

The programs and services we offer throughout the province demonstrate our commitment to addressing Medicare’s core values. These include:

1 WHO (1978) 2 Ottawa Charter for Health Promotion (1986)3 CHC Strategy Map and Balanced Scorecard (2006). Pg. 4


All Canadians have timely access to health services on the basis of need, not ability to pay, regardless of where they live or move in Canada; The health-care services available to Canadians are of high quality, effective, patient-centred and safe; and Our health-care system is sustainable and affordable and will be here for Canadians and their

children in the future.4

The ultimate purpose of Medicare is to ensure Canadians:

have access to a health-care provider 24 hours a day, 7 days a week; have timely access to diagnostic procedures and treatments; do not have to repeat their health histories or undergo the same tests for every

provider they see; have access to quality home and community care services; have access to the drugs they need without undue financial hardship; are able to access quality care no matter where they live; and see their health-care system as efficient, responsive and adapting to their

changing needs, and those of their families and communities now, and in the future. 5

At the heart of our Model of Care are our clients – and the communities of which they are a part. Because in CHCs Every One Matters. Every individual. Every community. Every staff person.

4 Health Canada Website - http://www.hc-sc.gc.ca/hcs-sss/delivery-prestation/fptcollab/2003accord/index-eng.php5 Ibid


The CHC Model of Care Definitions6

CHCs offer a range of comprehensive primary health care and health promotion programs in diverse communities across Ontario. Services within CHCs are structured and designed to eliminate system-wide barriers to accessing health-care such as poverty, geographic isolation, ethno- and cultural-centrism, racism, sexism, heterosexism, transphobia, language discrimination, ageism, ableism and other harmful forms of social exclusion including issues such as complex mental health that can lead to an increased burden or risk of ill health.

The CHC Model of Care focuses on five service areas:

Primary care Illness prevention Health promotion Community capacity building Service integration

The CHC Model of Care is:

Comprehensive:CHCs provide comprehensive, coordinated, primary health care for their communities, encompassing primary care, illness prevention, and health promotion, in one to one service, personal development groups, and community level interventions.

Accessible:CHCs are designed to improve access, participation, equity, inclusiveness and social justice by eliminating systemic barriers to full participation. CHCs have expertise in ensuring access for people who encounter a diverse range of social, cultural, economic, legal or geographic barriers which contribute to the risk of developing health problems. This would include the provision of culturally appropriate programs and services, programs for the non-insured, optimal location and design of facilities, oppression-free environments and 24 hour on-call services.

Client and community centred:CHCs are continuously adapting and refining their ability to reach and to serve their clients and communities. CHCs plan based on population health needs and develop best practices for serving those needs. CHCs strive to provide client-centred care.

Interprofessional:CHCs build interprofessional teams working in collaborative practice. In these teams, salaried professionals work together in a coordinated approach to address the health needs of their clients. Depending on the actual programs and services offered, CHC interprofessional teams may include physicians, nurses, nurse practitioners, dietitians, physiotherapists, occupational therapists, social workers, Aboriginal traditional healers, chiropodists, counsellors, health promoters, community development workers, and administrative staff.

Integrated:CHCs develop strong connections with health system partners and community partners to ensure the integration of CHC services with the delivery of other health and social services. Integration improves client care through the provision of timely services, appropriate referrals, and the delivery of seamless care. Integration also leads to system efficiencies.

Community-governed:CHCs are not-for-profit organizations, governed by community boards. Community governance ensures that the health of a community is enhanced by providing leadership that is reflective of

6 Revised June, 200812-Apr-23 Association of Ontario Health Centres6

its diverse communities. Community boards and committees provide a mechanism for centres to be responsive to the needs of their respective communities, and for communities to develop a sense of ownership over “their” centres.

Inclusive of the social determinants of health:The health of individuals and populations are impacted by the social determinants of health including shelter, education, food, income, a stable eco-system, sustainable resources, anti-oppression, inclusion, social justice, equity and peace. CHCs strive for improvements in social supports and conditions that affect the long term health of their clients and community, through participation in multi-sector partnerships, and the development of healthy public policy, within a population health framework.

Grounded in a community development approach:CHC services and programs are responsive to local Community Initiatives and needs. The community development approach builds on community leadership, knowledge and life experiences of community members and partners to contribute to the health of their community. CHCs increase the capacity of communities to improve community and individual health outcomes.


Anishnawbe Health’s Core Basket of Services:

Traditional Healing Primary Health Care Chiropractic medicine Naturopathic medicine Fetal Alcohol Spectrum Disorder Services

(FASD Services) Massage Therapy Traditional Counselling Enaadamged Kwe (Woman’s Helper) Babishkhan Psychiatric services Chiropodist services Oral health care Mental Health support Community Health Worker Training Program Nmakaandjiiwin (Finding My Way)

D- Elaboration of Model of Care Attributes

1. Comprehensive

“Let's not forget that the ultimate goal of Medicare must be to keep people well rather than just patching them up when they get sick”7

Thomas Clement “Tommy” Douglas, father of Medicare (1904 – 1986)

a. Definition

CHCs provide comprehensive, coordinated, primary health-care for their communities, encompassing primary care, illness prevention, and health promotion in one-to-one service, personal development groups, and community level interventions.

b. Elaboration

The needs of CHC clients extend beyond direct primary care services. CHCs use a variety of strategies including health promotion and education because the health service needs of clients do not occur in isolation from the broader determinants of health – including the socio-economic environment of the community.

CHCs work to improve the capacity of individuals, families and communities. Because CHCs offer a core basket of services under one roof – a one-stop shop, so to speak – clients can access care and support in a variety of areas. These include: primary care, language and employment, settlement and shelter, the ecological environment, family and community relationships, nutrition, child development, legal aid, community development and leadership, and the management of chronic disease.

Internal referrals (97,095 of which were made across 37 CHCs in 2006/07)8 are part of our focus in providing comprehensive, barrier-free care. They can help address chronic diseases and manage them accordingly. According to the Health Council of Canada, chronic diseases are the most common cause of disability and premature deaths in the country. The Council has also noted that most primary health-care organizations and individual providers are not

organized in ways to maximize potential improvements. This leaves far too many Canadians vulnerable to complications from chronic conditions. 9 CHCs respond to this with the programs and services offered. For example, a client enters a CHC with symptoms of diabetes. In one day, that same client receives primary health-care from a physician and is referred to a healthy cooking class for diabetes sufferers offered by a dietician as well as a low impact exercise class

7 Tommy Douglas quoted in The Second Stage of Medicare (2007). Pg 1. 8 Every One Matters (2008). Pg 159 The Second Stage of Medicare (2007).Pg 17


http://www.aht.ca/services/traditional_healers_elders_and_medicine_people

http://www.aht.ca/services/nmakaandjiiwin_finding_my_way

http://www.aht.ca/services/community_health_worker_training_program

http://www.aht.ca/services/mental_health

http://www.aht.ca/services/dentist

http://www.aht.ca/services/chiropodist

http://www.aht.ca/services/psychiatrist

http://www.aht.ca/services/babishkhan

http://www.aht.ca/services/enaadamged_kwe_woman_s_helper

http://www.aht.ca/services/traditional_counsellors

http://www.aht.ca/services/massage_therapists

http://www.aht.ca/services/fetal_alcohol_spectrum_disorder_services_fasd_services

http://www.aht.ca/services/fetal_alcohol_spectrum_disorder_services_fasd_services

http://www.aht.ca/services/naturopaths

http://www.aht.ca/services/chiropractors

http://www.aht.ca/services/physicians_and_nurses

Somerset West’s Core Basket of Services:

Acupuncture services Immigration medical examinations Nutrition counselling Mental health services Asthma care Foot care services Breastfeeding information &

support Obstetrical care & prenatal

assessments Smoking Cessation Flu immunization clinics in the

community Health Education workshops in the

community

provided by a volunteer at the Centre. This is an example of comprehensive services offered by CHCs that support clients’ management of their disease. For services that the CHC does not have at its disposal – under its own roof – it has the information, resources and connections to ensure the client gets additional support though external referrals.

To address chronic conditions and other health needs, CHCs offer more than just individual visits for the client with their provider. CHCs also offer group and community supports, such as Community Initiatives (CIs) which are organized to affect the health of the community10 as a whole and personal development groups (PDGs) that focus on changing unhealthy attitudes or behaviours in individuals. c. Why this Attribute is Relevant to the CHC

To make comprehensive care a reality, CHC clients receive primary health-care from interprofessional teams under the same roof. Case consultations between health-care teams support the delivery of more efficient and effective health care. Improvements in primary health-care are anchored in evidence-based decision making and responsiveness to health-care needs. Through the collection of data used in conjunction with community engagement initiatives, CHCs are able to provide relative and comprehensive services to our clients though the programs and services we offer. The CHC sector uses best practices to guide the provision of a range of prevention, early intervention and treatment programs and services.11

We know that positive health outcomes for clients occur when comprehensive partnerships amongst primary health-care stakeholders are formed. 12 These stakeholders include patients and families, health-care teams and community supporters. 13 The World Health Organization (WHO) illustrates this by highlighting four essential elements for action that stakeholders should consider. They include:

1. Support a paradigm shift towards integrated, preventative health care

2. Promote financing systems and policies that support prevention in health-care

3. Equip patients with needed information, motivation, and skills in prevention and self-management

4. Make prevention an element of every health-care interaction 14

These elements are being addressed by CHCs across the province. Research tells us that preventative health care can take huge burdens off our health-care system. In addition, early detection procedures and techniques (paps, mammograms, immunizations, smoking/alcohol cessation groups etc.) help deter many chronic diseases that can affect not only the individual, but the family and collective health of the community.

d. Opportunities & Challenges to Addressing this Attribute in your CHC

10 For more information on Community Initiatives, please view Module 8. 11 CHC Strategy Map and Balanced Scorecard (2006). Pg. 512 WHO (2002)13 Ibid14


Four Villages’ Core Basket of Services:

Treatment of acute illnesses &chronic conditions Mental health counselling Physiotherapy & Occupational therapy Care & support for healthy children & adults Diabetes management and support Nutrition counselling and education Arthritis self-management Social connection Active living and healthy eating Foot care / Shoe clinic New mothers and families with children Pregnancy care and education Healthy child development Support and education for parents OHIP applications/document assistance Community kitchens Legal advice / Interpretation

Mary Berglund’s Core Basket of Services:

Food Bank Physiotherapy Chiropodist services Dietician ser vices Orthopedics Mobile Eye-Care Unit (Partner) Mobile Breast Screening Unit (Partner) Diabetic Education Chronic Disease Follow-up Program Lab Specimen Collection Immunization Program Health Promotion Services Focus/Core Program (Lead Agency) Men’s & Women’s Wellness Clinic’s Blood Sugar Screening Programs Blood Pressure Screening Programs Ontario Telehealth Network

Sometimes the contribution of individuals and organizations is not always deemed of equal ‘value’ and this can lead to conflict and dissatisfaction. In addition, people come to the table with different skills, experiences, motivations, and prejudices. Furthermore, a collaborative effort involving individuals from different walks of life can often magnify personal conflicts and differences. There are often different power dynamics at play between clients, families and service providers which can affect true collaboration amongst these stakeholders. This can have a further impact on the health outcome of our clients and we need to bring them back to the centre of our focus and decision making.

An additional challenge to addressing comprehensive care in CHCs is to find and balance the resources needed to really support the provision of a comprehensive basket of services. Also, health promotion and illness prevention sit on the sidelines of our health-care system and are not integrated or embedded as a primary focus. There is still a focus on the hierarchy of care. Many strategies to address burdens on our health-care system are clinically focused and do not take into account the broader determinants of health

Division between clinical and health promotion teams arises from different payment structures (funding and salaries) and different prestige in the health-care discourse between clinical and social service/health promotion services furthering the hierarchy of care.

The challenges to comprehensive care can particularly resonate with rural communities. Public health has limited presence/activity in rural townships and this leads rural residents traveling to the city for both their comprehensive health care as well as employment in the health-care field. Also, both rural and urban physicians have too many patients to engage in preventive work and due to work overload have very limited involvement with other providers.

Another challenge presents itself when health-care teams need to refer a client to an external provider. If a client needs to attend cooking classes for diabetes at another institution because the CHC is not offering that service, in what way can we ensure it is accessible for the client.


CHCs might also want expand services to address additional health needs, but have limited physical space. This hinders CHCs’ abilities to expand services, to enhance existing services and meet the demands and rising needs of the community.

e. Summary

CHCs are addressing these challenges, not only one-by-one through innovative programs and services designed to support the needs of particular communities, but as a unified sector. CHCs are providing comprehensive services that are effectively addressing the key attributes of primary health care such as accessibility, coordination, continuity of services, and accountability. In short, we are providing interprofessional care, flexible service approaches, programs that build community capacity to address the social determinants of health, accountability to our communities through community-governed Boards of Directors, partnerships with other community stakeholders, and infrastructure that supports the integration of primary care with the delivery of other health and social services.15

15 Strategic Review of the CHC Program (2001). Pg. v. 12-Apr-23 Association of Ontario Health Centres11

f. References Association of Ontario Health Centres. (July 2006) CHC Sector Strategy Map Project: Strategy Map and Balanced Scorecard.

Association of Ontario Health Centres. (March 2008). Everyone Matters: Who We are and What We Do.

Association of Ontario Health Centres. (March 2007). Second Stage of Medicare: Conference Report.

Shah P. Chandrakant & Moloughney W. Brent. A Strategic Review of the CHC Program. (May 2001). Community and Health Promotion Branch Ontario Ministry of Health and Long-Term Care.

The Ottawa Charter for Health Promotion: An International Conference on Health Promotion. (November 1986). [Online] Available: http://www.who.int/hpr/NPH/docs/ottawa_charter_hp.pdf [1986, November 17-21] Page 4

World Health Organization: Integrating Prevention into Health-care. (October 2002). [Online] Available: http://www.who.int/mediacentre/factsheets/fs172/en/[2008, April 14].


http://www.who.int/mediacentre/factsheets/fs172/en/

http://www.who.int/hpr/NPH/docs/ottawa_charter_hp.pdf

Hamilton Urban Core Oral Health Program

The goal of the Oral Health Program is to increase levels of good oral health (Oral Health enhancement) and prevent and reduce oral health problems (health promotion and risk reduction). The Oral Health Program aims to promote oral health among individuals and groups that are underserved and lack access to adequate oral health care. In addition to services provided to individuals such as cleaning, fluoridation, pits and fissure sealants, check-ups and so on, the Oral Heath Coordinator provides oral health education sessions to schools, ESL programs, and a variety of community agencies and community groups.

2. Accessible

“Access is the ability or right to approach, enter, exit, communicate with, or make use of health services.”16

a. Definition

CHCs are designed to improve access, participation, equity, inclusiveness and social justice by eliminating systemic barriers to full participation. CHCs have expertise in ensuring access for people who encounter a diverse range of social, cultural, economic, legal or geographic barriers which contribute to the risk of developing health problems. This would include the provision of culturally appropriate programs and services, programs for the non-insured, optimal location and design of facilities, oppression-free environments and 24-hour on-call services.

b. Elaboration

In CHCs, access is about eliminating barriers and providing equitable17 health care to our clients and our communities. While this may seem obvious, we must remember that clients often have needs that are not adequately provided for by the existing health and social service system.

There are generally two aspects to access18. Firstly, client access is the extent to which our clients are able to attain needed services. For example, if a parent needs to bring her children in for immunizations but she works from 8:00am-6:00pm then accessing services that are only available from 9am-5pm will be very difficult. Also, if a client cannot speak the language of her provider and has serious symptoms that she needs to express to her providers, having someone that can translate and interpret will be very useful to her.

The second aspect to access is organizational. Organizational access is the extent to which our clients are represented and involved in the design, development, implementation, delivery and administration of CHC services. As discussed in the third Module, the integrity of the care that CHCs provide is based on client and community needs. Clients identify their health-care needs, and CHCs support the delivery of care to address these needs.

Below is a Chart of both Client and Organizational Barriers:

16 A Cultural Competence Guide for Primary Health-care Professionals in Nova Scotia (2005). Pg 4.

17 For more discussion on ‘equity’, please view Module 318 Equal Access Pilot Project.


Centre de santé communautaire de Sudbury program for Franco-

Ontarian youth

Fifty young Francophones participate in the program, which connects students in high school and post-secondary institutions to their rich French heritage. More than 8,000 students have joined in the St. Jean Baptiste musical shows as organizers, performers or enthusiastic audience members. The young people also organize a homeless supper and, on Ste. Catherine’s Day, conduct a mass collection of personal-care products for people living on the street. The youth programming reminds young Franco-Ontarians that their roots run deep and that they are part of a vital and connected community. And it also familiarizes young Francophones with other local Francophone agencies and services.”

C.

Why this Attribute is Relevant to the CHC

When CHCs strive to provide accessible care, their work is informed by an anti-oppression commitment.

12-Apr-23 Association of Ontario Health Centres

BarriersQuestions to consider in identifying barriers to

accessing care at a CHC

Physical

- Is the facility designed in a way that creates or reduces physical barriers for clients?

- Does the facility meet the physical needs of clients who have mobility restrictions, are deaf or hard-of-hearing or are blind or have vision problems?

- Are CHC programs and services available outside of regular business hours?

Geographic

- Is the CHC accessible by car or public transit?- If the CHC has a large geographic catchment area, how does

it enable clients to access services?- Do appropriate outreach programs exist to support the

care of those who are immobile or cannot reach services by transportation?

Communications

- Are services and resources available in the language needed?

- Are interpreters available, when needed and of the gender preferred by clients?

- Are clients informed of changes or plans to their programs and services?

- Are signs written in plain language?

Cultural- Do CHC staff understand the implications of how a client’s

culture impacts their health and access to care?- Are CHC programs respectful of clients’ cultural needs?

Economic

- Are CHC programs responsive to the needs of clients who cannot afford health-related costs (e.g. medications, healthy foods, oral care, cost to get to the CHC, time off work or childcare needed when accessing care, etc.)?

- Do CHCs programs and services provide support for clients living in abject poverty?

- Do CHCs programs and services take into account the class realities experienced by clients?

- Does the CHC provide care for non-insured clients (e.g. recent immigrants, people without health cards, people who do not want to enrol)?

Social

- Are CHC programs designed to respond to the realities of different social situations (e.g. being addicted to drugs, living on the street, choosing to stay with an abusive spouse, etc.)?

- Are CHC programs designed to support the needs of the LGBTTQQ community?

14

Regent Park CHCResponding to religious and spiritual diversity

Regent Park Community Health Centre has adapted its services to respond better to diabetic Muslim clients when they are fasting during the holy month of Ramadan. Potential health complications include altered nutritional levels, prescription medication issues and mental and emotional health issues stemming from the intensity of the month’s devotions.

Physicians, nurses and other providers have worked with community and religious leaders to develop guidelines for better care and treatment. They also actively encourage clients to “have the conversation about fasting” with their health-care providers. This is supported through educational materials endorsed by religious leaders and distributed at the local mosque.

The Board of Directors of the Association of Ontario Health Centres (AOHC) is committed to embedding anti-oppression in all aspects of its governance policies, processes and practices. The Board seeks to:

increase access, participation, equity, inclusiveness and social justice by eliminating systemic barriers to full participation;

Promote positive relations and attitudinal change by creating a climate where discriminatory or oppressive behaviours are not tolerated;

Foster an AOHC Board that is reflective of its membership and inclusive of racialized and minoritized groups

Some CHCs are at the forefront of anti-oppression work. As explained in the anti-oppression statement of Access Alliance Multicultural Health and Community Services:

“ Racism, xenophobia, classism, sexism, homophobia and heterosexism, ableism, and ageism cause pain and humiliation and have far-reaching consequences. Each one in its own way, prevents equality in opportunity, access to asylum, immigration opportunities, education, jobs, housing, health-care and social services, and limits participation in decision-making bodies.19

CHCs prioritize offering services to those clients who face challenges in finding appropriate care within the mainstream health-care system. For example, in the 2006 / 07 fiscal year:

In just 37 CHCs across the province, 18,466 non-insured and 8,253 homeless clients were served

49.5% of CHC clients across the province had annual family incomes of less than $20,000 per year

9,454 CHC clients received service in 15 languages other than English or French.20

When working to provide accessible care to our clients, CHCs recognize that our clients face numerous and diverse barriers that affect if and how they access care. CHCs strive to

reduce these barriers. Furthermore, when we view accessibility under the lens of the social determinants of health, we are better able to provide relevant services and improve overall health outcomes.


19 Access Alliance, Anti-Oppression Policy & Practice

20 Everyone Matters (2008)12-Apr-23 Association of Ontario Health Centres15

The [AOHC] Board understands that there are similarities, intersections and differences between forms of oppression and the ways in which they manifest themselves. There is also recognition of the issues of power and privilege and how they inform organizational dynamics. The [AOHC] Board acknowledges the particular pervasiveness and impact of racism in society at large even after decades of legislation and initiatives.

Board Governance and Anti-Oppression Framework, the AOHC.

Anne Johnston Health Station

Women/Youth with Disabilities Programs

Anne Johnston is a unique CHC at it provides services to clients who experience various forms of disabilities. This CHC also offers specific programs and services for women and youth with disabilities.

A key challenge to providing an accessible environment is to acknowledge that some populations and communities face barriers.

The Ontario Healthy Communities Coalition states:

“People do not necessarily choose to deliberately discriminate against those who are different from themselves. Many of the barriers to participation within community organizations exist because of a lack of awareness of differing wants or needs… There is no simple formula for alleviating all barriers, as each person’s needs are unique.” 21

When

considering how to make an environment more accessible to an individual or a group of individuals, it is important to hear from the person or people involved as to what the real barriers are. However, it is not always simple for individuals to identify their

needs or fully grasp the systemic barriers that are hindering their access to care. Another challenge for CHCs can be balancing the implementation of a particular solution with the impact the change can have on the organization itself. Sometimes answers to problems cannot be immediately implemented. For example, if a CHC needs to apply physical changes to its infrastructure, this is a long process that can often require resources (financial or otherwise) that the organization does not have at its disposal.

e. Summary

In summary, to demonstrate respect for lived experiences and to ensure that solutions make sense to clients we need to engage “people who experience barriers to access in discussions on how to remove those barriers”22. This kind of dialogue can also help CHCs find solutions that work for both the organization and the person/people experiencing the barrier. While CHCs work to address barriers to health care, we can still be limited by the greater barriers and prejudices that exist in our social system. Nevertheless, CHCs are acknowledging these barriers and working towards providing equitable health care to all Ontarians. This is evident from the relevant programs and services offered throughout our organizations.

21 Ontario Healthy Communities Coalition (2004)22

Building Inclusive Communities Tips Tool (2003)


The NorWest CHCs:Reaching out to isolated

communities

Of all Ontario’s Community Health Centres, the NorWest Community Health Centres has the largest catchment area: 24,567 hectares, approximately the size of the entire province of New Brunswick. Its newest CHC satellite is an innovative mobile unit that travels around the vast catchment area with a nurse practitioner, an RN foot-care nurse and a community health worker. Clients receive primary health-care like Pap smears, physicals and the identification and monitoring of chronic illnesses. The unit is also a platform for health-promotion programs on healthy eating, effective parenting and alcohol and substance- abuse prevention.

16

Anishnawbe Health TorontoProviding culturally competent care

Anishnawbe Health Toronto is an Aboriginal-focused CHC. Its mission is to “improve the health and well being of Aboriginal People in spirit, mind, emotion and body by providing Traditional Healing within an interprofessional health-care model.” The mission is put into practice through programs and services based on Aboriginal Traditional Healing. As well, in this environment, physicians and nurses work together with traditional healers, elders, medicine people and traditional counselors to meet the health-care needs of their clients.


f. References

A Cultural Competence Guide for Primary Health-care Professionals in Nova Scotia. (2005). [Online]. Available: http://www.gov.ns.ca/psc/pdf/Diversity/toolkit/Cultural%20Competence%20Guidelines.pdf [2005] Page 4.

Access Alliance: Anti-Oppression Principles & Practice. [Online]. Available:http://www.accessalliance.ca/index.php?option=com_content&task=view&id=35&Itemid=12

Association of Ontario Health Centres. (May 2006). Anti-Racism and Anti-Discrimination Working Group Report: Advice and recommendations to the Board for policy changes and/or development to reflect AOHC’s commitment to the principles of anti-racism and anti-discrimination

Association of Ontario Health Centres. (February 2007). Board Governance Anti Oppression Framework.


Building Inclusive Communities Tips Tool. (2003). [Online]Available: http://whiwh.com/BIC_tips.pdf [2003]

Ontario Healthy Communities Coalition: Inclusive Community Organizations: A Tool Kit. (2004). [Online]. Available http://www.healthycommunities.on.ca/publications/ICO/ICO_1.pdf [2004 October]


http://www.healthycommunities.on.ca/publications/ICO/ICO_1.pdf

http://whiwh.com/BIC_tips.pdf

http://www.accessalliance.ca/index.php?option=com_content&task=view&id=35&Itemid=12

http://www.gov.ns.ca/psc/pdf/Diversity/toolkit/Cultural%20Competence%20Guidelines.pdf

Examples and Experiences from CHCs

Woolwich

Mennonite children leave school earlier than most other students (age 14) and are engaged in farming/shop activities while at home on the farm. Local teachers and WCHC recognized the need for specialized instruction in the area of safety and injury prevention. The Rural Community Health Worker provides this education with volunteer support to many public, catholic and parochial schools on a rotating basis. The education covers topics such as: chemicals, tractors, chainsaws, silo gases, shop safety, animals, lawnmowers, as well as buggy road safety, first aid, food safety and babysitting.

3. Client & Community Centered

“Nothing about me without me”23

a. Definition

CHCs are continuously adapting and refining their ability to reach and to serve their clients and communities. CHCs plan based on population health needs and develop best practices for serving those needs. CHCs strive to provide client-centered care.

b. Elaboration

The CHC sector develops individual and community capacity through the lens of the social determinants of health. This perspective allows for the identification of root causes of health issues, and for a strategic response to community needs. We will continue to be community led, provide community infrastructure, and assist communities to develop their own unique solutions.24

Client and community-centered care includes essential elements25. These are:

1. Superb access to care2. Respect for patients’ values, preferences, and

expressed needs3. Clinical management systems that support high-

quality care, practice-based learning, and quality improvement

4. Emotional support to relieve fear and anxiety5. Involvement of family and friends6. Integration of health care and health-care settings7. Physical comfort8. Ongoing routine patient feedback to a practice9. Publicly available information on practices10. Increased patient education

In CHCs, we often use the term ‘client’ rather than ‘patient’. ‘Patient’ implies that the provider is the all-knowing expert and the patient is the passive receiver of care26. In CHCs, ‘clients’ are active contributors to the care we receive. Also, a CHC ‘client’ uses many other services that are not focused on primary health care. For example, a client that participates in a personal development group that focuses on breastfeeding, nutrition, literacy, environmental health, or employment skills.

23 Health-care in a land called People Power: nothing about me without me (2001) 24 CHC Strategy Map and Balanced Scorecard (2006) Pg 5.25 Adapted from Audet et al (2006)26 Neuberger, Julia (1999).


The use of the terms ‘equity’ and ‘equality’ also need to be clarified when talking about client and community-centred care. According to Competence Consultants & Associates27, ‘equality’ is defined as treating people the same based on the assumption that everyone is the same and has the same needs. ‘Equity’, on the other hand, refers to treating people differently based on our different needs in order to ensure we can access the same services as others who are not challenged with the same needs. When it comes to client and community-centered care, we emphasize that not everyone requires the same kind of care, in the same manner, at the same time. For a

service and/or organization to be truly community and client-centered, it must have an equitable foundation.

c. Why this Attribute is Relevant to the CHC

According to a 2004 paper published by the Health Network28, almost 80% of Canadians believe that it is important for individuals to be involved in major decisions about our health-care system. Responding to population health needs is essential when providing client and community-centered care. Often when focusing on a priority population, the expertise developed is sought after by other academic and health-care institutions around the world.

27 Competence Consultants & Associates (2005). 28 Abelson, Julia and Francois-Pierre Gauvin (2004)


Examples and Experiences from CHCsWomen’s Health in Women’s Hands

Many WHIWH clients come from all over the globe. “They’ve often lived through the unthinkable,” says Eunadie Johnson, former Executive Director. “They may have survived the trauma of genital mutilation, the horror of war or the oppression of a police state. In their quest for immigrant status they’re at the mercy of their sponsors – often the very men who are abusing them. HIV/AIDS may be a pervasive foe for themselves and their loved ones”.

“We give health and social service professionals information that comes directly from the women themselves,” says Johnson. “It helps them understand that women have special needs; they can’t use the regular medical model to assess them.” Indeed, with all its advocacy initiatives, WHIWH is guided by the conviction that every woman has an inherent ability to advocate on her own behalf and that she is ultimately the best judge of her own needs. All of the centre’s advocacy efforts aim to enhance self-determination.

Examples and Experiences from CHCsLAMP

Historically a highly industrialized neighbourhood, LAMP’s (Lakeshore Area Multi-Service Project) catchment area had a large population of workers seeking help with occupational health and safety concerns. LAMPS community is less geographical and more occupational. The work has taken them into every environment, from soft rock mines to day care centers. The centre only serves workplaces with less than 200 employees.Special projects take staff out into the Greater Toronto Area investigating workplace issues brought to their attention by employees, their unions and companies themselves.The centre’s research on occupational illnesses appears in professional journals and sparks worldwide demand for speakers from among its staff.

20

Examples and Experiences from CHCsCentre Francophone de Toronto

Francophone individuals or families who have immigrated to Toronto or who are newcomers to Toronto can receive services that will facilitate their entry into Canadian society and help them get adjusted in their daily lives. The Centre francophone offers a considerable number of services to newcomers, including:

Social services (emergency housing, financial assistance)

Immigration services Government services Community services

The counselors may also offer assistance with filling in forms managing budgets. In one-on-one meetings, they can determine each person’s specific needs and guide the client to those programs at the Centre that best meet his or her needs. There is also an outreach service to support the Francophone community.

Examples and Experiences from CHCsWest Elgin Community Health Centre

Farmers and rural farm families are one of West Elgin Community Health Centre’s priority populations. In the summer of 2005 over 400 farmers from Western Elgin County participated in a “Farm Family Survey” that looked at Occupational Illness and the Health and Safety of the farming community. As a result of this, CPR classes were conducted for farm families in the community and a subsequent Asthma Program was developed. An Occupational Illness screening questionnaire was developed and continues to be used by West Elgin Physicians and Nurse Practitioners to identify and help manage individuals who have work related illnesses.

To adequately respond to the local population health needs, CHCs conduct community health needs assessments, which involve reviewing both quantitative and qualitative information from the local community. Quantitative data include statistics, current health and social research, socio-demographic and -economic data and health status reports. Qualitative data can be gathered by engaging with community members to hear directly from them as to what the local health priorities are. This information is used to help define a Centre’s priority populations, what

programs and services should be offered, what staff are needed and what community partnerships should be developed.


One of the challenges in addressing community-centred care at a CHC is servicing all those in the community who experience barriers to accessing care. Due to limited financial and human resources, sometimes it is not always feasible for a CHC to satisfy the needs of every priority population in the community. Furthermore, some CHCs have a wide variance in the demographics of their clients. Some CHCs serve mixed income populations and it is a challenge to ensure each populations gets the appropriate service at the appropriate time.

An additional challenge in addressing client-centred care is that there can be a real diversity of needs among individual clients and

meeting everyone’s unique needs can be challenging.

Also, social needs are experienced as greater than medical needs. However, dollars are primarily available for clinical services. The challenge is for funders to understand the broader picture of health, as well as comprehend the available capacities and resources that extend beyond medical services that could be made available to the community.

In addition, providing ongoing needs assessments of individual client services and community needs assessments to ensure that programs and services continue to meet changing needs requires certain resources and capacity. The CHC workload can often be more than employees can handle and community


http://www.wechc.on.ca/content.asp?id=117

health worker and health promoter positions are often under funded. This can lead to CHC team members

being asked to do jobs that are not part of their job description. This can lead to employee dissatisfaction.

e. Summary

Ontario CHCs ensure our clients are engaged meaningfully in decisions about our health and health care in our communities. Case studies and research reviews suggest that meaningful community engagement, with community members actually involved in decision making, improves health and health care. 29 In the CHC sector, we are taking the opportunities to engage our clients and communities in the development of programs and services to foster and encourage better health outcomes.

29 Everyone Matters (2008). Pg. 34.12-Apr-23 Association of Ontario Health Centres22

f. References

Abelson, Julia and Francois-Pierre Gauvin. (2004 April). Engaging Individuals: One Route to Health Care Accountability. Health-care Accountability Papers – No/2. Health Network.

Adapted from World Health Organization (1985) as cited in J. Abelson and B. Hutchison. (1994) Primary health-care delivery models: a review of the international literature. McMaster University Centre for Health Economics and Policy Analysis. Paper. 94-15.


Association of Ontario Health Centres. (July 2006). CHC Sector Strategy Map Project: Strategy Map and Balanced Scorecard.

Audet, A. et al. Adoption of Patient Centered Care Practices by Physicians. (2006). [Online].Available: http://www.commonwealthfund.org/publications/publications_show.htm?doc_id=365654(2006, April 10)

Competence Consultants & Associates. (2005). Tool Kit: Tool #1: What we mean by some words.

Community Organizational Health Inc. (2008). [Online]. Available: http://www.cohi-soci.ca/index.php?page=e1403

Delbanco, Tom. MD et al. (2001, September). From Health-care in a land called People Power: nothing about me without me. Health Expectations. Blackwell Science Ltd. Volume 4, 144-150.

Neuberger, Julia. (1999) Do we need a new word for patients? BMJ. Volume 318: 1756-8


http://www.cohi-soci.ca/index.php?page=e1403

An interprofessional process for communication and decision making that enables the separate and shared knowledge and skills of care providers to synergistically influence the client care provided. A foundational component of collaborative practice is ‘equality’ within the team framework and not hierarchy.

Building Better Teams pg.27

4. Interprofessional

“The right care, by the right provider, at the right time”30

a. Definition

CHCs build interprofessional teams working in collaborative practice. In these teams, salaried professionals work together in a coordinated approach to address the health needs of their clients. Depending on the actual programs and services offered, CHC interprofessional teams may include physicians, nurses, nurse practitioners, dietitians, physiotherapists, occupational therapists, social workers, Aboriginal traditional healers, chiropodists, counsellors, health promoters, community development workers, and administrative staff.

b. Elaboration

Many CHC clients have complex health conditions and need to see multiple providers. In 2006/07, 37 CHCs made over 200,000 referrals either internally to other health-care providers on the team or to external health-care providers.31 Clients were internally referred to child-care workers, chiropodists, counsellors, cultural interpreters, oral health-care workers, dietitians, physical therapists, surgeons, and traditional healers.

Also in 2006/07, over 8,000 CHC clients saw more than four health-care providers during a single visit; almost 20,000 clients saw more than three health-care providers; and almost 35,000 saw more than two. 32 This improves the effectiveness of case consultation which has a positive impact on the delivery of care. Furthermore, coordination and continuity of care improve when clients’

needs are met through provider collaboration and teamwork. Teamwork improves access to primary health-care especially in under-serviced areas of the province, which ultimately results in more cost-effective care.

The effective use of all health-care professionals will enable them to maximize their skills and work to the full extent of their qualifications, training, and scope of practice. Evidence demonstrates that a substantial proportion of the current activities of family physicians could be done equitably well by nurse practitioners, for example. In Ontario, the top five physician billing codes that accounted for approximately 69% of the total amount billed by primary care physicians in 1996/97 ($1.2 billion) included intermediate assessments/well-baby care, general assessments, minor assessments, individual psychotherapy and counselling. There is a great deal of evidence from other jurisdictions that demonstrate that these services can be done by other qualified practitioners at a much lower cost to the system.

30 AOHC Fact Sheet CHCs and the “Three Rs”31 Everyone Matters (2008).32 Ibid.


Experiences and Examples from CHCsTeen Health CHC Eating Disorders Program

Serving 12-to-24-year-old Windsor and Essex County youth for the past 15 years, the centre takes teamwork to heart. Once every other week, the centre’s eating disorders team meets to review every file in its caseload. Working in conjunction with the Bulimia and Anorexia Nervosa Association (of Essex County), the gathering draws together everyone from every discipline within the centre who is, or has, worked on active files. Social workers, nutritionists, physicians – three people from the agency and four from outside – touch base on "everything everyone is doing with each client," says primary care services manager Tom Groulx. "The clients get ‘unidirectional’ help," says Groulx. That is, "we don’t have several different people giving clients contradictory and therefore confusing advice. If we decide on a course of action in a unified front, it makes more sense for everyone."

The benefits to the client in engaging in a collaborative practice model include: seamless access to a wide variety of health-care services; options when one’s primary provider is absent; and more choice of appropriate providers to meet one’s needs.

c. Why this Attribute is Relevant to the CHC

Interprofessional teams mirror (on the provider side) the complexity of the health issues experienced by the client. The inter-disciplinary team approach acknowledges that the health of an individual is intricate and multi-dimensional. When community health workers and health promoters are part of the team, preventative health issues as well as mental and psycho-social issues are addressed.33

Ontario’s Community Health Centres acknowledge the importance of collaboration not only in healing but also in preventative care and overall health promotion. As communities and as a sector, we are working towards building an understanding of health as more than simply patching up the ill, but keeping people well. This work entails the commitment of more than one person, and more than one profession. It takes the passion and time of a wide range of health service providers.

In Ontario, most private physicians are paid on a fee for service model. Ontario CHC physicians are paid a salary as are other providers. CHC physicians are therefore able to see clients with complex care needs because they can address more than one issue in a single service event and provide more time to their clients. More time with clients allows for more counselling and preventative care by primary care providers which leads to better health outcomes.


Despite the tremendous benefits of collaborative practice models, there are still significant barriers to surmount.

“…we’re still educating health professionals in silos…formal education of health-care professionals around collaborative patient-centred practice as well as informal education to help team members understand the scope of practice of their colleagues is essential”34.

In addition, the elements that help and encourage team work and collaboration (regular meetings, activities, and communiqués among staff) require time, energy, commitment, and financial resources. When providers and front-line staff are stressed and overworked, they often cannot attend regular meetings and participate in staff activities.

33 AOHC Fact Sheet. What does it mean to work in Collaborative Practice? 34 AOHC Fact Sheet. What does it mean to work in Collaborative Practice?


York Community Service Legal Clinic

The clinic launched in 1978, just five years after the centre opened. "This kind of interprofessional structure helps us help people with complex, multiple problems because of the wide system of support available," says Francie Kendal, director, communications and development. For instance, a client may come in for primary health-care treatment. The health-care professional may then find out the client is about to be evicted — and the distress may be a factor in his or her ill health. So they may refer the client to the legal team, or even the eviction prevention program, and other support programs the centre offers.“Having professionals from other disciplines on-site enhances the quality of care that staff can offer by way of their quick access to others. For instance, a counselor who needs to find some legal information need not go outside the centre – the expert is just down the hall”.

Furthermore, issues of liability are frequently raised concerning the roles of providers and their legal responsibilities and accountabilities. According to a joint document released by the Canadian Medical Protective Association and the Canadian Nurses Protective Society35, there are steps that collaborative teams can take (including purchasing liability insurance) that will protect providers should an issue arise. While these issues are infrequent, it does concern physicians as to how much of their work can be shared with nurse practitioners, nurses and other CHC staff. Through education, open discussion and knowledge sharing, this concern will be diminished.

The current Ontario Medical Association’s incentives that have been rolled out to CHCs in an attempt to increase compensation to physicians require CHC clients to be enrolled to an ‘assigned physician’. Clients are enrolled to physicians and not the CHC, which does not take into account that other providers (nurse practitioners, nurses etc.) often provide primary care to clients. Also, clients go to their CHCs for programs and services that do not require a physician and so enrolment figures do not adequately present the work that all health-care providers are doing at their CHC.

The design and infrastructure of CHCs also provides challenges to interprofessional work. Specifically when clinical teams and health promotion teams are separated. This decreases the potential for case conferencing and discussion as well as developing social relationships with colleagues.

Also, funders have very different pay scales for different types of work. Members of the clinical team are better supported by funding than members of the social team. Furthermore, different providers offering the same services get paid differently. Nurse practitioners, for example, performing pap smears are paid differently to a physician performing the same task.

e. Summary

Strong teams ensure there is a shared philosophy and vision and involve participatory leadership where every member on the team has a formal/informal leadership role. We know that collaborative and interprofessional team work can develop trusting and respectful working environments which serve the client better as health outcomes are improved. When we adopt an integrated teamwork approach that values different professional approaches and perspectives that create well-defined roles and role expectations and develop leadership as a core competency then the environment for both staff and clients improves. Working towards integrating clinical teams with the non-clinical teams develops an environment of continuous learning and improvement which further serves to benefit our clients.36

35 CMPA/CNPS Joint Statement (2005)

36 Building Better Teams (2007)


f. References

A. Mitchell et al. (1993). Utilization of Nurse Practitioners in Ontario. A Discussion Paper Requested by the Ontario Ministry of Health. Nursing Effectiveness, Utilization and Outcomes Research Unit. Paper 93-4.

Association of Ontario Health Centres (2007). Building Better Teams: A Toolkit for Strengthening Teamwork in Community Health Centres. Resources, Tips, and Activities you can Use to Enhance Collaboration.

Association of Ontario Health Centres (June, 2007). Building Better Teams: Learning from Ontario’s Community Health Centres. A Report of Research Findings.

Association of Ontario Health Centres Fact Sheet. CHCs and the Three Rs: The right care, by the right provider, at the right time.

Association of Ontario Health Centres (March 2008). Everyone Matters: Who We are and What We Do.


Association of Ontario Health Centres Fact Sheet. What does it mean to work in Collaborative Practice?

CMPA/CNPS. (2005). Joint Statement on Liability Protection for Nurse Practitioners and Physicians in Collaborative Practice. [Online]. Available: http://www.cnps.ca/joint_statement/English_CMPA_CNPS_joint_stmt.pdf (2005 March).




http://www.cnps.ca/joint_statement/English_CMPA_CNPS_joint_stmt.pdf

Linkages across sectors and between providers support clients to successfully transition, with due respect for the barriers that they may face and the complexity of their care issues.

Every Door Leads to Service. http://www.aohc.org/app/wa/doc?docId=168

Experiences and Examples from CHCsGayZoneGaie

A partnership of organizations in Ottawa have come together using existing resources to provide a service that includes HIV and STD testing as well as offering a variety of wellness programming for gay men and ‘guys into guys’. Partners include: Sommerset West Community Health Centre, Centretown Community Health Centre, Ottawa Public Health, the Youth Services Bureau of Ottawa; the AIDS Committee of Ottawa, Pink Triangle Services, and Ottawa Gay Men’s Wellness Initiative.

5. Integrated

“Every door leads to service.”37

a. Definition

CHCs develop strong connections with health system partners and community partners to ensure the integration of CHC services with the delivery of other health and social services. Integration improves client care through the provision of timely services, appropriate referrals, and the delivery of seamless care. Integration also leads to system efficiencies.

b. Elaboration

Integration involves cross-sectoral partnerships with organizations and institutions that provide both direct client care (such as community organizations) and indirect client care (such as universities and municipal and/or provincial governments). When we work in partnership with others to solve problems by using common resources, we are more likely to support clients and provide accessible and comprehensive care. Integrated care is not about passing the responsibility of care to someone else, but rather its about unifying goals

and resources across organizations to improve the overall quality of care.

CHCs integrate with partners in a number of different ways, from physical integration, such as co-locating in the same building, to functional integration, such as sharing resources, to program integration. In 2006-07 alone, 54 CHCs were part of 1,275

partnerships, an average of 24 partnerships per CHC.38

Within the CHC accreditation process, Building Healthy Organizations39, working with partners (defined as “organizations that CHCs work closely with to jointly operate programs and services or work on joint planning or advocacy initiatives to benefit their communities”) is an essential criterion for accreditation.

As outlined in the 2006 CHC Strategy Map, CHCs are an entry point to the health-care system for people facing barriers to health. Benefits to integration affect our clients in profound and meaningful ways. If certain services and sectors are not connected, people accessing health-care services can fall through the cracks. CHCs have established the expertise in developing partnerships enabling us to provide integrated primary health care both within the sector and beyond. CHCs continue to develop partnerships and to enhance cross-sectoral service coordination that complements the programs and

37 Every Door Leads to Service (2006)

38 Everyone Matters (2008) 39 Building Healthy Organizations (2008)


http://www.aohc.org/app/wa/doc?docId=168

Woolwich CHC Hospice Programs

Woolwich and Wellesley Hospice programs have an advisory committee made up of WCHC staff, clergy, hospice volunteers, and Community Care Access Centres (CCAC) The advisory committee and staff implement hospice programs and services collaborating with CCAC, KW Alzheimers Society and other hospices in South West Ontario. These include the Association for Community Living, Community Care Concepts, Canadian Cancer Society and Long Term Care facilities to meet the hospice and long-term care needs of the community.

Service Integration is most usefully defined as an on-going process whereby localagencies engage in progressively greater degrees of joint service activities along anintegration continuum.

Ryans & Robinson 2005

services of other service providers, leads to appropriate use of resources, and increases the sustainability of the health-care system.40 C. Why this Attribute is Relevant to the CHC

Working in an integrated way with community members and service providers is a natural and fundamental component of the CHC Model. Integrated work helps prevent clients from falling through the cracks and is effective in reducing costs to the entire health-care system.

With the establishment of the Local Health Integration Networks (LHINs), CHCs are expected to continue and increase integration with other providers in the community for the purpose of “maintaining and sustaining a world-class health-care system that will help keep people healthy, deliver good care when they are sick and will be there for their children and grandchildren”.41


Integration and working in partnerships makes it possible to leverage resources and often produces cost effective approaches to the provision of services and programs, but working with partners is challenging in the best of times and requires resources. This is often an overlooked or neglected aspect of integration and partnership work. It is challenging to balance program needs with the need to focus on policy change and community capacity building. In addition, many programs need a lot of administrative support and it sometimes is a challenge to identify on whose shoulders this responsibility should fall.

Also, some organizations serve particular priority populations and are isolated from integration because other institutions and agencies within the same geographic community serve different clients and address different health-care issues.

Integration requires perseverance and commitment to address issues when they arise. Respect and acknowledgement of the contribution of all parties are essential.

In summary, successfully partnering can present some challenges for the various partners involved. They are:

Differences in funding and accountability to government

Organizational and professional cultures that may work against integrated models

Differing ‘frameworks for practice’ Inequitable power amongst potential partners Histories of unsuccessful partnerships42

Successful integration requires that the autonomy of each organization remains intact. Organizations develop common goals related to the integration, and identify the strategies and inputs each organization will implement

40 CHC Strategy Map and Balanced Scorecard (2006). Pg 541 Ontario Local Health Integration Networks (2006)


Experiences and Examples from CHCsCentretown CHC

Since 1998, a community-based program for type 2 diabetes education has operated in Ottawa out of Centretown Community Health Centre. The Diabetes Network serves all of the community health and resource Centres across the city, co-ordinating services among community members, hospital-based programs, public health, CCAC, the Canadian Diabetes Association and, more recently, local family health teams. From April 1, 2007, to June 30, 2007, the program served 592 new clients in groups and individually, in addition to offering almost 800 follow-up visits. Services are available in 11 different languages. In addition, a dietician designed an award-winning diabetes food guide that is now available across Canada in many languages.”

individually and collaboratively. This ensures that organizations remain autonomous and partner rather than merge completely.

At the 2007 AOHC conference43, Guelph CHC put on a workshop entitled Partnership Supporting Healthy Childhood Development. They also identified ways that agencies should work together across sectors. These include: 1. Find a legitimating agent to call the community of service providers together.2. Define the range of services to be included at the table.3. Insist that those attending the committee meetings will be executive directors or very

senior management staff who have an appropriate degree of decision making power.4. The initial meetings of the inter-agency committee should be spent coming to an

agreement on the concepts and language of service integration.

5. Set realistic goals and meet as often as the work requires.

6. Provide a modest amount of funding to support administrative expenses associated with inter-agency activity.

7. Devise and pursue a rigorous progress evaluation and continuous quality improvement strategy.

e. Summary

CHCs have integrated in a meaningful way with other organizations as well as other CHCs to ensure our clients get the most appropriate service by the organization/staff with the best expertise to provide this service. Our Centres have partnered with the Centre for Addiction and Mental Health, Community Care Access Centres, the Canadian Diabetes Association, various hospitals, numerous universities, Legal Aid Ontario, family service organizations, and many more. We have a proven willingness and commitment to address challenges; an evolutionary approach to change; an ability to respect the views and opinions of others; and accountable governance structures 44 to ensure our clients remain at the heart of what we do.

42 Integrated Primary Health-care. (2007) 43 www.aohc.org44

? Integrated Primary Health-care. May 23, 200712-Apr-23 Association of Ontario Health Centres31

f. References

AOHC, OCSA and OFCMHAP. Every Door Leads to Service: Enhancing Access And Building a Culture of Service Integration for a Made in Ontario Health System. (2006). [Online]Available: http://www.aohc.org/app/wa/doc?docId=168 [2006, July]


Association of Ontario Health Centres. (July 2006). CHC Sector Strategy Map Project: Strategy Map and Balanced Scorecard.

Community Organizational Health Inc. (March 2008). Building Healthier Organizations. www.cohi-soci.ca

Edwards, Karen. Integrated Primary Health-care. (2007). NSW Health. [Online].Available: http://www.achse.org.au/nsw/seminars/23may07_edwards.ppt (2007, May 23).

Local Health System Integration Act. (2006). Ministry of Health and Long-Term Care. [Online].Available: http://www.e-laws.gov.on.ca/html/statutes/english/elaws_statutes_06l04_e.htm (2006).

Local Health Integration Network / Health Service Provider Governance Resource and Toolkit for Voluntary Integration Initiatives. (2008). [Online].Available: http://www.centrallhin.on.ca/page.aspx?id=3860 (2008, Sept 8).

Ontario’s Local Health Integration Networks (2006). [Online]. Available: www.lhins.on.ca/legislation.aspx

Ryan B., Robinson R. Service Integration in Ontario: Critical Insights from the Service Community. (2005). [Online] Available: http://www. tns-global.com

.


http://www.lhins.on.ca/legislation.aspx

http://www.centrallhin.on.ca/page.aspx?id=3860

http://www.e-laws.gov.on.ca/html/statutes/english/elaws_statutes_06l04_e.htm

http://www.achse.org.au/nsw/seminars/23may07_edwards.ppt

http://www.cohi-soci.ca/

http://www.aohc.org/app/wa/doc?docId=168

[The Board shall consist of] active members who collectively demonstrate a broad range of relevant skills and experience and reflect the community being served.

MOHLTC (2001)

When governance Boards shift from representing their silos, to representing the best interests of the ‘owners’, the system will begin to truly transform.

Adamson et al (2007)

6. Community-governed

“The CHC Board’s role is not just to reflect the community but to reflect the community that it serves!”45

a. Definition

CHCs are not-for-profit organizations, governed by community boards. Community boards and committees provide a mechanism for Centres to be responsible to the needs of their respective communities, and for communities to develop a sense of ownership over “their” Centres.

b. Elaboration

CHCs participate in democratic governance of health-care delivery through locally-elected community-based boards to ensure health care remains responsive and customized to the priority needs of our clients46. Therefore, our Boards remain accountable to CHC clients by ensuring relevant programs and services.

CHC Boards are composed of the community, by the community and or the community, and have governance guidelines. Examples of guidelines include:

Improving upon the quality and relevance of services provided. Ensuring transparency and accountability of the services provided and the intended

populations. Empowering the communities by reinforcing authentic participation. Understanding community governance as a determinant of health. Encouraging sustainability through community ownership and community participation. Improving individual and community health outcomes as the representatives elicit local

knowledge and expertise. Being more cost effective as genuine community ties are built and more appropriate

services are delivered to the right people at the right time. 47

As Karen Patzer outlines in her research project Review of the Trends and Benefits of Community Engagement and Local Community Governance in Health Care, “The most significant value added of community governance inhealth appears to be related to its ability to achieve better health outcomes for both individuals and communities by increasing empowerment and social capital. A research review undertaken by Health Canada (2003) indicated that “research associating social capital with health shows that the higher the level of social capitalin a community, the better the health status and that strengthening the social capitalof communities would consequently constitute a promising means of reducinginequality in the area of health”. Recent studies of social capital also see it as adeterminant of certain diseases”48

45 AOHC Fact Sheet. Community Governance as a Determinant of Health. 46 AOHC conference report (2007). Pg 447 Adamson et al (2007) 48 Page 5


Four Villages CHCCommunity Representation

We work to ensure that the board is representative of the community, the clients served as well as the skills required to move the center along. We ensure that board members are fully integrated and part of every process and not just ‘token representatives’.

Community involvement and representation is important when deciding the priority populations of our CHCs and the health and social issues to be addressed. Public involvement can be very powerful and can restore citizen power over our lives by addressing health needs and improving outcomes. However, public involvement can be mere manipulation and non-participatory in nature. Sherry Arnstein49 outlines eight levels of public involvement. These eight levels are distributed into three tiers. The three tiers include: nonparticipation, tokenism, and citizen power. Her ladder of public involvement is illustrated below:

8. Citizen Control7. Delegate Power Citizen Power50

6. Partnership

5. Placation4. Consultation Tokenism3. Informing

2. Therapy1. Manipulation Nonparticipation

Arnstein’s general idea is simple. There are areas of public involvement which require no authentic input by the individuals or the community. On the other hand, there are also areas of public involvement which are based on citizen decision making and influence. The following discusses the ladder of public involvement in more detail:

Manipulation is when individuals are ‘participating’ in something where they have no legitimate power. Their real input is not considered.

Therapy is a way of ‘pacifying the masses’ to the real issues that are facing them. For example, if a community is experiencing violence among its youth instead of addressing the root causes of this violence such as low incomes, inadequate education, and insufficient support, the community ‘leaders’ may show you how to ‘deal with troublesome youth’. Therapy is also a form of manipulation.

Informing is where individuals are told what is to happen, why and how. However, it is one-way communication and is, therefore, false participation or tokenism.

Consultation is when individuals are asked their opinions but the information gathered does not necessarily lead to action, change or progress.

Placation involves populations being underrepresented in Boards of Directors and on committees and councils. If two of the 12 decision makers are representatives of that community, then it is not adequate representation.

Partnership is the first step on the ladder of Citizen Power. This is when power is elaborated on through negotiation between individuals and power holders. There is constant discussion and feedback which is open to cooperation and compromise.

49 Arnstein, Sherry R. July (1969) 50 In CHCs, we need to consider that many of our clients and members may not be ‘citizens’ of Canada but are still active and contributing members to their communities.


Gateway CHCStrategic Directions Committee

The Board has implemented a committee called the Strategic Directions Committee to support the long-term planning of services to ensure that they meet the needs of the local community while being aligned to changes in the health system. The Board reports back to the Gateway Membership twice a year for feedback which also provides an opportunity for Board Member recruitment.

Delegate Power goes one step beyond partnership in that negotiations between individuals and public officials can also result in individuals achieving dominant decision-making authority over a particular plan or program.

Citizen Control is when community members are making decisions about their lives and the power holders implement these decisions and support the public’s right to choose. 51

c. Why this Attribute is Relevant to the Model of Care

Because our Centres are sponsored and managed by incorporated boards of directors (which include our clients, community leaders, health and social service providers), we can advocate for ourselves and our community. In addition, we are held accountable to our clients because CHC Boards are responsible for ensuring the services we provide are accessible, comprehensive and integrated, as well as working to improve the health outcomes of clients.

The World Health Organization considers certain essential elements that connect local governance to empowerment which are particularly evident in CHCs. These are:

While participatory processes make up the base of empowerment, participation alone is insufficient if strategies do not also build capacity of community organizations and individuals in decision-making and advocacy

Successful empowering interventions cannot be fully shared or ‘standardized’ across multiple populations, but must be created within or adapted to local contexts

The most effective empowerment strategies are those that build on and reinforce authentic participation ensuring autonomy in decision making, sense of community, and local bonding, and psychological empowerment of the community members themselves

Structure barriers and facilitators to empowerment interventions need to be identified locally

Effective empowerment strategies are needed for socially excluded populations52


Holding a position on a Board of Directors is completely voluntary. In fact, it is illegal to compensate a Board member financially (or otherwise) for their participation in a non profit organization. While some CHCs do opt to have staff members on their Boards, these staff members are non-voting members and cannot make up a quorum (voting majority).Often Board members have full-time jobs, families, and other commitments and responsibilities.

51 Ibid52 WHO (2006)


Experiences and Examples from CHCsSouth-East Ottawa Tune-Up Kit

South-East Ottawa Centre for a Healthy Community has produced a Tune-Up Kit that has its 12-member board of directors running like a well-oiled machine. The evaluation tools in the kit are used to monitor directors’ goals and skills and their understanding of the crucial issues they face.

"We place a high value on being community directed," says executive director David Hole. "We start and finish with the community. We take our direction from it and are accountable to it. Having the right people doing the right stuff relies on having the right information," he says.

Hole acknowledges "a CHC must deliberately make time for this sort of activity in the midst of the daily grind. Often we just lack resources," he says. "Everyone is busy”.

It can be a challenge for non profit organizations to recruit and retain board members. In the recruitment process, it can be difficult to promote Board recruitment in a way

that ensures that various populations are aware of the process and are represented in a meaningful way (skilled as governors as well as representative of the community).

Another challenge facing CHCs occurs when satellite CHCs are formed. Satellites do not have a separate Board of Directors. Often satellites have different priority populations than the main organization and therefore they may not be equitably represented on the Board.

There exists another challenge when ensuring that members of priority populations are on the Board. If, for example, a CHC’s priority population is youth age 12-18, this can involve some liability issues. Another example might be if a CHC populations that speak different languages. If the CHC Board commits to ensuring it is reflective of its priority populations, considerations for these types of barriers must be made and strategies to reducing barriers be implemented.

e. Summary

Community governance ensures that the health of a community is enhanced by providing leadership through effective partnerships between individuals, community and staff of Community Health Centres. Not only are the professional skills, expertise, and knowledge brought to the table of community-governed Boards, but so are the lived experiences of Board members that make their contribution to the governance of CHCs all the more relevant. How an organization chooses to govern often depends on the maturity of the organization as well as its lifecycle. Regardless of where CHCs are on this spectrum, having input from clients ensures relevance of programs and services. These relevant services lead to improved health outcomes.


f. References

Adamson, Bonnie & Ted Ball, Elinor Caplan, Gordon Cheesbrough, Ken Moore and Gabriel Sekaly. (2007). How Can Local Health-care Governance Survive? Instistute of Public Administration of Canada.

Arnstein, Sherry R. (1969). A Ladder of Citizen Participation. [Online]. JAIP, Vol. 35, No. 4, July 1969, pp. 216-224.Available: http://lithgow-schmidt.dk/sherry-arnstein/ladder-of-citizen-participation.html#d0e75Originally published as Arnstein, Sherry R. "A Ladder of Citizen Participation," JAIP, Vol. 35, No. 4, July 1969, pp. 216-224. I do not claim any copyrights.

Association of Ontario Health Centres Fact Sheet. Community Governance as a Determinant of Health.

Association of Ontario Health Centres. (March 2007). Second Stage of Medicare: Conference Report.


Ministry of Health and Long Term Care. Community Health Centre Policy and Procedure Manual (December 2001).

Patzer, K.T. A Review of the Trends and Benefits of Community Engagement and Local Community Governance in Health Care (June 2006). Association of Ontario Health Centres.

World Health Organization. What is the Evidence on the Effectiveness of Empowerment to Improve Health (February 2006). [Online] Available: http://www.euro.who.int/Document/E88086.pdf . Health Evidence Network.



Pathways to EducationRegent Park CHC

Ensuring that young people get to school, graduate, and move on to post-secondary programs is the focus of this program.The program uses a multi-layered approach to tackle huge drop-out rates and a 60% reduction in the number of students who are considered to be “academically at risk.”Numbers have shown a 75% five-year graduation rate and a 90% acceptance rate for those having applied to colleges and universities. Also, more than twice the number of Regent Park youth will not attend post-secondary institutions

7. The Social Determinants of Health (SDOH).

“[health is] created and lived by people within the settings of their everyday life; where they learn, work, play and love”.53

a. Definition

The health of individuals and populations are impacted by the social determinants of health including shelter, education, food, income, a stable eco-system, sustainable resources, anti-oppression, inclusion, social justice, equity and peace. CHCs strive for improvements in social supports and conditions that affect the long term health of their clients and community, through participation in multi-sector partnerships, and the development of healthy public policy, within a population health framework.

b. Elaboration

Many social inequities can determine the health of the individual and community including income, employment, environment, housing, education and many others. These inequities affect the health outcomes of individuals and in CHCs we recognize that what determines the overall health of an individual goes far beyond their bio-physical condition. In 1998, Health Canada expanded on their list of conditions which they termed ‘Determinants of Health’. These determinants are outlined as follows:

i. Income ii. Social supportiii. Education and literacyiv. Employment and working conditions v. Social environmentsvi. Physical environmentsvii. Personal health practices and coping skillsviii. Healthy child developmentix. Biology and genetic endowment x. Health servicesxi. Gender xii. Culture

When

barriers exist to addressing the aforementioned determinants, individuals and communities are less likely to achieve optimal health. When support systems are in place like Ontario’s Community Health Centres that understand and address these issues, then the collective health of the community and individuals is more likely to improve. While the opinions of academics and health researchers may vary on the exact number and names of the

53 Ottawa Charter for Health Promotion (1996)


Avoidable health inequalities arise because of the circumstances in which people grow, live, work, and age, and the systems put in place to deal with illness. The conditions in which people live and die are, in turn, shaped by political, social, and economic forces

The WHO’s Commission on the Social Determinants of Health (2008) Page 9.

38

Examples & Experiences from CHCsCentretown Laundry Co-op

The co-op was developed in the late nineties when provincial cuts to welfare programs had made things difficult for people with lower incomes living in Ottawa. Most programs responding to these changes were focused on food and shelter, and neglected the people's needs for belonging, for self-esteem building, and for a community. A public consultation was called to determine what the imminent needs of the affected community were, and what gaps were not being filled by existing programs. One of the key needs identified was affordable laundry. The co-op is a facility that permits low-income and street-cultured residents to do laundry at low cost. Its environment involves member-centred mentoring built on member assets. Members are becoming progressively more involved in operations and eventual management of the organization".

determinants of health, all agree that factors outside of our control have a great impact on our health and wellbeing.For example, if an individual comes for medical care because he fell down the stairs of his building and broke his leg, the physician might enquire how that happened. The man responds that he was drunk and that’s why he fell down the stairs. When the physician asks why he was drinking, the man responds that he is depressed. When asked why he is depressed, the man responds that he lost his job and is about to lose his apartment if he cannot bring in any income. In this example, we can see how a clinical injury occurred because of many non-clinical factors. Often health problems occur because of events spiraling out of control.

C. Why this Attribute is Relevant to the CHC

CHC clients and communities are much more complex and diverse than those of many other health-care organizations. For example, over 11 per cent of CHC clients are homeless or have no health insurance. This percentage is 12.5 per cent in urban CHCs54. In addition, our clients come from 209 different countries and we provide services in more than 56 languages. In three Centres alone services are offered in more than 40 languages55. Our CHCs identify priority populations and include those who have traditionally had difficulty accessing primary health-care such as: rural and/or northern isolated communities, immigrants, refugees, homeless people, at-risk youth, seniors and people living in poverty. 56

In developing our health-promotion and illness-prevention programs and services, Community Health Centres take these social determinants into account. Ottawa Charter for Health Promotion has identified five areas for action which are already being implemented in CHCs. They are:

1. building healthy public policy2. creating supportive environments3. strengthening community action4. developing personal skills5. reorienting health services 57

Many of the programs and services we offer include: legal aid; environmental initiatives; settlement and new immigrant support; employment and skill development; English as a Second Language classes; cooking and nutrition lessons; well baby and healthy childhood development support; coping skills instruction; anti-oppression initiatives and many more

54 Everyone Matters (2008). Page 12.55 Ibid.56 Ibid. Page 9.57 Ibid. Page 17.


Cooking on a ShoestringWest Lambton CHC

This program is a four-week cooking series on healthy, low cost, simple recipes, and a fifth-week grocery store tour. Food is enjoyed in group settings with friendly educational discussions about health eating, including fat content, and serving sizes.

ommunity. All these initiatives address the social determinants of health and support the overall health outcomes of CHC clients.


In the environment of decreased government funding coupled with the rise in living costs, it becomes increasingly difficult to improve the daily living conditions of Ontarians.

Even though CHCs focus on addressing issues of inequity, individuals have our own biases and prejudices which can promote oppressive behaviour or what is referred to as being “culturally incompetent”. Ontario is also home to many different cultures, races, religions, and sects and we

cannot assume that the resources and support that everyone needs will be the same. The power of the CHC is its local focus and grassroots emphasis. However, even in these communities we are dealing with a wide range of cultures and ethnicities.

In addition, current definitions of the SDOH have been criticized for excluding key concepts such as health literacy, race, and sexual orientation. Some of our Centres, for example, provide excellent services and support for our clients of the GLBTTQQ58 community. When important factors like race and sexual orientation are not considered, it is a challenge to show their validity when talking about health determinants and equity.

The Evaluation Framework59, has been designed to ask particular questions of our CHCs (at a broad organization, socio-demographic, individual service events, personal development group, and community initiative level), to ensure we are addressing the intended populations and tackling the appropriate health issues of our communities. However, certain things are a challenge to measure. For example, it is hard to measure the number of clients receiving mental health support when they choose to remain anonymous.

Another note of concern when addressing the SDOH is the political context in which it is discussed. In other words, can we separate a discussion on the SDOH from the municipal, provincial or federal political status of our government? The quality of public policy can have a direct impact on our income, education, environment etc.

Thus, to what extent can communities and organizations have control over what determines the health of its members?

In addition, addressing social factors and making significant progress requires resources and work of many sectors. It is often difficult to pull these sectors together.

Furthermore, working towards achieving outcomes can be a challenge when addressing a particular determinant of health. For example, CHCs who work to assist their clients in job skills and recruitment are limited by external barriers such as limited job opportunities.

e. Summary

58 Gay, Lesbian, Bi-sexual, Transgendered, Two-Spirited, Queer, Questioning59 Evaluating the CHC Program (2006)


As identified by the WHO, addressing the social determinants of health includes improving daily living conditions; tackling the inequitable distribution of power, money and resources and; measuring and understanding the problem and accessing the impact of action 60. CHCs recognize that effective primary health care addresses these determinants. May of our clients have experienced social exclusion, barriers to accessing shelter, education, income and employment security, food and stable eco-systems. Our programs and services work to address these issues by encompassing primary care, illness prevention and health promotion, and use a community development approach to building healthy public policy in supportive environments.

60 WHO (2008) Pg. 1012-Apr-23 Association of Ontario Health Centres41

f. References

Association of Ontario Health Centres. Evaluating the CHC Program: CHC Evaluation Framework and Data Entry Manual (2006).


The Ottawa Charter for Health Promotion: An International Conference on Health Promotion. (November 1986). [Online]Available: http://www.who.int/hpr/NPH/docs/ottawa_charter_hp.pdf [1986, November 17-21]

The World Health Organization’s Commission on the Social Determinants of Health. Final Report. Closing a Gap in a Generation: Health Equity through Action on the Social Determinants of Health. (2008). Page 9


http://www.who.int/hpr/NPH/docs/ottawa_charter_hp.pdf

Examples and Experiences from CHCsWomen of the World Project (WOW)

London InterCommunity Health Centre

WOW has been increasing community capacity, overcoming social isolation and building local leadership from the ground up. The project has trained scores of local immigrant women to navigate the health and social system. Graduates often go on to do additional training in order to become volunteer peer support workers. Many volunteers have, in turn, being able to translate their experience into well-paying employment with community agencies.

8. Community Development Approach

“a democratic process that involves the active participation of a variety of people”61

a. Definition

CHC services and programs are responsive to local community needs. The community development approach builds on community leadership, knowledge and life experiences of community members and partners to contribute to the health of their community. CHCs increase the capacity of communities to improve community and individual health outcomes.

b. Elaboration

Community development supposes that progress and change in the community can be achieved through public participation. The involvement of community members, and their partnerships with governments and other institutions, is the best way to address social and economic issues facing a community and to find probable, sustainable, and viable solutions. The principles of democracy, voluntary involvement, self-help, planning, and community education are important in this model62.

While different literature struggles with how to define Community Development, we have summarized several important principles relevant to the context of CHCs63.They include:

1. Holistic Approach

Community development includes natural, human, financial or infrastructure resources.64 Communities go well beyond the geographic location of its members to include shared interests, health needs, language, culture and belief systems. How we identify ourselves is as essential as to where we identify ourselves. Community development initiatives consider the social determinants of health.

2. Empowerment

Development works at harnessing our knowledge, skills and experience. When we organize and plan initiatives together, and have a role in identifying what is at stake

61 Frank, Flo et al (1999)62

Community Capacity Building Facilitator’s Handbook (2008)63 Healthy Communities (2008), CedResources (2008) 64 Frank, Flo et al. (1999) Pg. 17


Examples and Experiences from CHCsNo Community Left Behind, South East Ottawa

Since July 2005, centre staff have been collaborating with a wide range of community-development specialist, community-policing professionals, and neighbourhood activists to address factors that lead to crime, victimization, fear for safety and social exclusion.Intergenerational tension and fears of vandalism and loitering have been reduced with a youth centre, a skating park, weekly movie and sports nights, dances and other programming initiated and directed by young people themselves

in our communities, we are more likely to feel empowered by the process. This empowerment leads to greater responsibility and accountability which promotes healthier lifestyles and more sustainable resources.

3. Process

Community Development takes time, commitment, planning, organizing, and implementing. Developing a mutual vision with multiple partnerships and accumulating resources takes time and energy. However, it is in this process that real capacity building: the power, skills, knowledge and experience of people can be enhanced.

4. Sustainability

Community Development is not about finding short-term solutions to long-term issues. Conservation and preservation should be key elements to any form of sustainable community development. Any misuse of natural, human, financial or infrastructure can often cause long-term degradation.

5. Partnerships

Community Development involves partnerships. While community members might initiate the vision of a particular development project, this work cannot be done in isolation. Partnerships might involve community leaders, other community-based organizations, other CHCs, governments, business, educational institutions etc. Collaborative efforts are essential to building stronger, healthier, and more empowered communities.

C. Why this Attribute is Relevant to the CHC

Community Health Centres often partner with other social service sectors and utilize the expertise of local community members.

One of our most effective tools is what we call Community Initiatives (CIs). Community Initiatives are often dramatic change makers because they tackle the root causes of problems that are harming people’s health. And they engage community members in developing solutions. Community Initiatives are flexible, and they use whatever approaches work, employing advocacy, community organizing, political action and other group strategies.65

Involvement in Community Initiatives implies a shift in thinking along the following lines66:

1. from a focus on individual health to an emphasis on collective health;2. from foreground (close-up detail) to summary (big picture, context);3. from concentrating on behaviour change to considering the influence of

environmental change (i.e., in structures, systems, policies, services and the social and physical environments) on the community's health;

65 Everyone Matters (2008).66 E. Rajkumar (1999)


Examples and Experiences from CHCsCreating Healthy Communities for

YouthGateway CHC

Community members turned to Gateway over concerns of loitering and vandalism in Tweed’s small downtown core. Gateway sought Human Resources and Social Development funding for a youth events co-coordinator. This led to the formation of a Youth Action Committee and weekly meetings to address local concerns. In 2007, the Youth Action Committee was recognized as a committee of City Council.

4. where the focus does remain on behaviour change, from the health/lifestyle behaviour and skills of individuals, to community/civic behavioural norms and skills development in such areas as conflict resolution and group process;

5. from downstream thinking (how to solve problems after they appear) to upstream thinking (how to prevent problems by addressing them at their roots);

6. from top down (or organizationally determined) issues and approaches to bottom up (community-identified) issues and approaches, given that changes resulting from active, genuine community involvement tend to be more lasting and meaningful;

7. from practitioner as expert (lead role) to practitioner as resource (support role);8. from a needs/deficit orientation (which emphasizes problems and shortcomings --

glass half-empty) to a capacity orientation (which views the community in terms of its strengths and potential -- as a glass half-full)67

Through these initiatives, we can see sustainable and viable actions to improve the overall health of our communities. Therefore, community development is an essential attribute to our Model of Care.

d. Challenges to Addressing this Attribute in your CHC

The Centre for Addiction and Mental Health68 has outlined challenges they have experienced with community development endeavours. One key challenge is honest representation of marginalized communities having a genuine voice. It is one thing to say that community development must take on a holistic approach that includes sustainable actions and empowerment of communities. It is quite another to ensure disenfranchised communities are adequately representing their communities and having their voices heard.

An additional challenge considers the extent to which government agencies and donors actually approach communities for their input and expertise. Funders often do a poor job of explaining and promoting their community development role and the concept of community capacity69. In terms of Community Initiatives70, one of the greatest challenges we have in legitimizing them to funders is that they often have no clear beginning or end and evolve out of ongoing activities and discussions. In addition, partners and participants may come and go and because CIs are fluid and dynamic in nature, their original intention might have formed into

something quite different. The goals and objectives might change which makes milestones a challenge to measure and evaluate.

e. Summary

Building capacity of clients and community in a holistic and sustainable way is at the heart of the work that CHCs do. Strengthening partnerships with other organizations contributes to addressing the social determinants of health which in turn leads to community

67 Community Initiatives Manual (1999)68

CAMH (2002)69 Ibid.70 Community Initiatives Manual (1999)


development and improved health outcomes. An organization that works in isolation mirrors the challenges and struggles that individuals working in isolation experience. This includes lack of knowledge transfer, insufficient resources, inadequate leadership and collaboration and authentic public participation. Fortunately, funders are realizing the importance of cross-sectoral partnership and grassroots initiatives. In addition, CHCs are able to access more clients and provide more effective support through an overall focus on community development and capacity building.


f. References

Adapted from The TENETS: TEN Eternal Truths! Training workshop materials prepared by E. Rajkumar, Toronto: March, 1999. Taken directly from the AOHC Community Initiatives Manual. AOHC. 1999

Association of Ontario Health Centres (March 2008). Everyone Matters: Who We are and What We Do.

Centre for Addiction and Mental Health. (2002). Strategies and Principles for Community Development. Module 7.

Community Development. [Online]Available: http://maaori.com/develop/commwhat.html

Community Development: What is it? Working Statement on Community Development. [Online]. Available: http://maaori.com/develop/commwhat.html

Community Development: Principles and Practices. [Online]Available: http://www.cedresources.ca/docs/modules/cd.pdf

Frank, Flo and Anne Smith. (2008). Community Capacity Building Facilitator’s Handbook: Community Development. [Online]. Regional Economic Development Board. Available: http://www.cedresources.ca/docs/modules/cd.pdf (2008, September 8)

Healthy Communities. [Online]Available: http://www.healthycommunities.on.ca/publications/ground/index.html

Ontario Healthy Communities Coalition. (2008). From the Ground Up: An Organizing Handbook for Healthy Communities. [Online]. Available: http://www.healthycommunities.on.ca/publications/ground/index.html (2008, September 10).

Ravitz, Mel. (1982). Community Development: Challenge of the Eighties. Journal of Community Development Society. V13 N1 Pg.1-10.

Sustainable Community Development: Principles and Concepts. (1997).Delray Beach, Florida: St. Lucie Press. Xix, 257 p.

Conclusion:


http://www.healthycommunities.on.ca/publications/ground/index.html

http://www.healthycommunities.on.ca/publications/ground/index.html

http://www.cedresources.ca/docs/modules/cd.pdf

http://www.cedresources.ca/docs/modules/cd.pdf

http://maaori.com/develop/commwhat.html

http://maaori.com/develop/commwhat.html

The CHC Model of Care is a standard of care that works for everyone, particularly CHCs. The CHC Model identifies comprehensive; accessible; client and community-centred; interprofessional; integrated; community-governed care that is based on a community development approach and focuses on addressing the social determinants of health. All these attributes are part of the bigger picture of the Second Stage of Medicare: to reduce costs and put an emphasis on preventative medicine.

Tommy Douglas’s original vision of Medicare includes: preventing Canadians from developing disease; preventing Canadians from complications after experiencing illness; and using early interventions to treat acute illness to prevent long-term health troubles. The First Stage of Medicare –removing financial barriers to accessing care – has supported many Canadians and has put Canada on the map as a leader in ensuring accessible and inclusive health care. However, many larger issues relating to this Stage are still evident in our health-care system today. These are:

Health services are not funded and organized in ways to best enable and encourage timely, equitable access to high quality health care and in ways that encourage individuals, or communities to be active participants in their own care;

Far too many Canadians experience preventable injury, illness or complications from illness. Health promotion and illness prevention sit on the sidelines of the healthcare system;

Some Canadians are less healthy than others due to social and economic factors that cause illness and injury. This is because we have not adopted a comprehensive planning process to improve population health and reduce health inequities. Also absent is adequate coordination of healthcare planning with other sectors such as housing and employment, to address factors which directly impact on people’s health.71

The Second Stage of Medicare is focused on essential changes to the delivery of health care to ensure more equitable and easier access to care as well as placing health promotion and education as pivotal components to the delivery of health care and improved health outcomes. The AOHC, in coordination with the Canadian Alliance of Community Health Centres has developed a list of essential changes and steps that would characterize the Second Stage of Medicare72. These include:

Increased focus on population health Care is delivered more equitably Health promotion and illness prevention are integrated across the continuum of care More timely, accessible, and client-centred care Canadians are more actively engaged in managing and making decisions about our

care Canadians enjoy continuously improving quality of care

The CHC Model of Care addresses these changes in profound and meaningful ways. Our CHCs focus on population health needs, barrier free care, health promotion and illness prevention and chronic disease management. Through the examples and experiences of programs and services by CHCs outlined in this manual we are able to show what excellent work CHCs are doing in this arena. The good news is these examples are just a small taste of the work that all Centres are doing to support our clients and to improve health outcomes. However, we cannot rest easy and assume health outcomes will automatically improve. As CHCs, we have to continuously ask ourselves, “are we addressing all eight attributes and, if not, how do we progress?” This is a continued effort to support our clients and our communities to achieve optimal health. Because at the very core of the work we do Every One Matters.

71 http://www.aohc.org/aohc/index.aspx?ArticleID=229&lang=en-CA72 Ibid


Glossary

Ableism: discrimination or prejudice against individuals with disabilities (1)

Ageism: The cultural, institutional and individual set of practices and beliefs that assign different values to people based on assumptions or stereotypes according to their age, thereby resulting in differential treatment. (2)

Anti-oppression: concerned with eradicating social injustice perpetuated by societal inequalities, particularly along the lines of race, gender, sexual orientation and identity, age, class, ability and religion (3)

Classism: The systematic oppression of subordinated class groups to advantage and strengthen the dominant class groups (3)

Clinical management systems: computer software products that coordinate and integrate all the inherent activities involved in the management and running of a healthcare facility. Clinical Management Systems include Electronic Medical Records (EMRs), patient registration, billing, and scheduling. (4)

Collaboration / collaborative practice: “An interprofessional process for communication and decision making that enables the separate and shared knowledge and skills of health care providers to synergistically influence the client/patientcare provided…” (5)

Community engagement: encompasses a wide variety of activities from consultations with the public to community development and community capacity building. The goal of Community Engagement is to develop and enhance public participation in health service planning and decision-making, and raise awareness within the health system about community issues and concerns that may not otherwise be apparent. (6)

Community Initiatives: sets of activities that strengthen and, in many cases, transform the entire community by addressing factors affecting individual, family and collective health. (7)

Cultural competence: Is a set of “congruent behaviors, attitudes, and policies that come together in a system, agency, or among professionals that enables the system or professionals to work effectively in cross–cultural situations” (8)

Equality: treating people the same based on the assumption that everyone is the same and has the same needs. (9)

Equity: treating people differently based on our different needs in order to ensure we can access the same services as others who are not challenged with the same needs. (9)

Ethno/culturo centrism: The tendency to view others, using one’s own group and customs as the standard for judgement and seeing one’s group and customs as the best.

Ethno/culturo centrism usually includes overgeneralizations about others' or one's own cultures and their inhabitants, on the basis of limited or skewed, if any, evidence. It usually leaves little room for the possibilities of other ways of thinking, seeing, understanding and interpreting the world. (2)

Genderism: Holding people to traditional expectations based on gender, or punishing or excluding those who don't conform to traditional gender expectations. (11)


Health promotion: Health promotion is the process of enabling people to increase control over, and to improve, their health. (12)

Heterosexism: Assuming every person to be heterosexual therefore marginalizing persons who do not identify as heterosexual. It is also believing heterosexuality to be superior to homosexuality and all other sexual orientations. (11)

Homophobia: The irrational fear and intolerance of people who are homosexual or of homosexual feelings within one's self. This assumes that heterosexuality is superior. (11)

Inclusion: An inclusive society creates both the feeling and the reality of belonging and helps each of us reach our full potential. The feeling of belonging comes through caring, cooperation, and trust. We build the feeling of belonging together. The reality of belonging comes through equity and fairness, social and economic justice, and cultural as well as spiritual respect. We make belonging real by ensuring that it is accepted and practiced by society. (12)

Local Health Integration Network: Not-for-profit corporations created by the Ontario government in 2006 to plan, integrate and fund local health services.

Medicare: Canada’s national health insurance program, composed of 13 interlocking provincial and territorial health insurance plans, framed by the Canada Health Act.

Ottawa Charter for Health Promotion: 1986 document produced by the World Health Organization. It was launched at the first international conference for health promotion that was held in Ottawa.

Primary Health Care as defined by the World Health Organization in 1978 is: Essential health care; based on practical, scientifically sound, and socially acceptable method and technology; universally accessible to all in the community through their full participation; at an affordable cost; and geared toward self-reliance and self-determination (WHO & Unicef, 1978).

Primary Care: Primary care refers to the patient's first point of contact with a doctor or a health care team. Primary care includes but is not limited to : disease management and prevention, disease cure, rehabilitation, palliative care and health promotion.

The greatest difference between primary care and primary health care is that primary health care is fully participatory and as such involves the community in all aspects of health and its subsequent action (Anderson & McFarlane, 2000; Wass, 2000; WHO, 1999). (2)

Population health: an approach to health that aims to improve the health of the entire population and to reduce health disparities among population groups.

Racism: The belief that race accounts for differences in human character or ability and that a particular race is superior to others. (8)

Sexism: The assumption that one sex is superior to the other and the resultant discrimination practiced against members of the supposed inferior sex, esp. by men against women. (3)

Transphobia. Describes oppression based on Gender Identity and experienced by Trans Identified people including transgender, transsexual, cross dressers, gender queer,

and transvestite. Transphobia refers to the irrational fear, hatred, prejudice or negative attitudes towards trans identified people. Another term Genderism refers to the assumption that all people must conform to society’s gender norms and, specifically to the


binary construct of only two genders (male and female). (Asking the Right Questions 2 by CAMH 2004). (2)

Xenophobia: fear and hatred of strangers or foreigners or of anything that is strange or foreign (1)

References: 1. Merriam-Webster Online Dictionary . 2009. Merriam-Webster Online. 2 February 2009

http://www.merriam-webster.com/dictionary/ableism

2. CHC Model of Care . AOHC Fact Sheet. June 2008.

3. OPIRG McMaster Anti-Oppression Web Based Tool www.opirg.ca/antioppression

4. OntarioMD.ca

5. Primary Health Care, A Framework that Fits. (2006) EICP-ACIS. www.eicp-acis.ca.

6. Vancouver Coast Health. http://www.vch.ca/ce/

7. Who We Are and What We Do . AOHC.

8. From A Cultural Competence Guide for Primary Health Care Professionals in Nova Scotia . Diversity and Social Inclusion Initiative. Primary Health Care Section, Nova Scotia Department of Health

9. Competence Consultants & Associates (2005).

10. Carleton University Equity Services Definitions. http://www.carleton.ca/equity/sexual_orientation/definition.htm.

11. The Ottawa Charter for Health Promotion . First International Conference on Health Promotion, Ottawa, 21 November 1986. http://www.who.int/healthpromotion/conferences/previous/ottawa/en/

12. Inclusion: Societies that Foster Belonging Improve Health Ontario Prevention Clearinghouse


http://www.who.int/healthpromotion/conferences/previous/ottawa/en/

http://www.carleton.ca/equity/sexual_orientation/definition.htm

http://www.vch.ca/ce/

http://www.eicp-acis.ca/

http://www.opirg.ca/antioppression

http://www.merriam-webster.com/dictionary/ableism

concept of primary health care in canada chc dr shabon 2009

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