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Think Tank on Equitable Access to RehabSummary and Key Messages

Date| Prepared by Name

Table of ContentsIntroduction.........................................................................................................1Build the case.....................................................................................................1

Potential of rehab........................................................................................................1Problems enhanced access to rehab could solve......................................................2Demonstrating success...............................................................................................2Specifying impact........................................................................................................2

Policy advocacy strategy....................................................................................2Need to have a clear ask............................................................................................2Focus on decision makers and institutions that can act.............................................3Focus on key system issues.......................................................................................3Look for windows of opportunity.................................................................................3

Build broad coalitions of support........................................................................3Summary............................................................................................................4Appendix: Detailed Meeting Notes.....................................................................5

June 2012 Brainstorming

IntroductionThe Canadian Working Group on HIV and Rehabilitation (CWGHR), the Wellesley Institute and, other collaborating organizations are developing a major initiative to promote discussion, awareness, and policy and program change to increase equitable access to rehabilitation across Canada. This will be a multi-pronged strategy with multi-stakeholder involvement.

To help plan out this initiative, in June 2012, we convened a smaller brainstorming meeting with people with specific expertise in health policy, programs and research. We wanted their best advice to identify strategic options, key policy opportunities and levers to enhance access to rehabilitation, and the most effective ways to engage with current partners, additional organizations, and policy makers in a broad based campaign. This document summarizes key lines of advice from the brainstorming meeting. Its advice is at a fairly high level: it identifies what needs to be done, but not necessarily how.

Build the caseAll agreed that we need a clear, solid and evidence-based case for why enhancing access tor rehab is a key issue and how it will contribute to achieving key system and patient outcomes.

Potential of rehabWe need to clearly and concisely show how improving access to comprehensive and integrated high quality rehabilitation has great potential to improve the quality of care and opportunities for good health for individuals; support an integrated and effective continuum of care; and contribute to overall system efficiency, especially through preventing avoidable deterioration of chronic conditions and reducing avoidable hospitalization and acute care.

Emphasize that fixing rehab can have positive wider system impacts. For example, improved access to rehab can support a more integrated continuum of care, patient centred care, and contribute to system priorities such as reducing avoidable hospitalization and ER use and better management of chronic conditions.

Identify a group of conditions with similar health and care trajectories (possibly also co-morbidities) and facing similar problems with current system:

Demonstrate that enhanced access to rehab is a critical component of creating common solutions, such as better care pathways and coordination that will have positive impacts.

Demonstrate how these solutions can be made actionable, for example, enhancing rehab as part of integrated continuum of coordinated care.

HIV illustrates all of this.

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Problems enhanced access to rehab could solve Demonstrate how delisting has reduced access to crucial components of a continuum of care and

weakened overall system integration Highlight the gaps in the existing continuum of care, and how this affects individual outcomes and

system integration. For example, fragmentation of care within provider institutions and the feeling that care isn’t making enough of a difference to patients demoralizes staff.

Demonstrating successWe need to marshal evidence on where and how rehab has made a significant difference and how improved access could actually be achieved. One means is to highlight specific examples or programs:

Saskatchewan Arthritis Society TC LHIN pilot project demonstrating net savings and that a better continuum of care works

Specifying impact Focus on specific conditions to better illustrate the concrete impact and potential of better access to

rehab. One powerful focus could be on seniors -- showing how rehab is such a crucial part of the continuum

of care and independence they need/want. Creating a comprehensive continuum of care for seniors will demonstrate how to do this in other parts of the system.

Policy advocacy strategyThis is best advice on how to take a strong case and get it adopted.

Need to have a clear ask Not just more rehab, but better integrated. Ask has to be concrete and specific: need to be clear about who we are asking to act and on what.

With clear goals, enhanced access to specific services It has to specify the mechanisms (“by investing in expanding program X and by enhancing

coordination across programs A-H”). This means addressing a key quandary:

Is our focus on Ontario or another province? Or is it broader (cross-country)? The challenge is that health care is provincial/territorial – but are there common themes?

Another challenge is that it’s easier to get attention by focusing on particular health conditions, but on the other hand, that can end up being too narrow.

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Focus on decision makers and institutions that can act Focus on policy makers, decisions & institutions that can act and have the levers to implement our

ask. In other words, we need to find the right landing place for demands. Show success elsewhere & demonstrate how it can work here. Show how savings can be realized. One challenge is the fragmented structure of the health care system. We need to be able to clearly

identify where and how rehab could be expanded and better integrated. For example, where would this fit within CHCs, FHTs, CCACs, hospitals?

Focus on key system issues The chances of success will be enhanced if the demand for improved rehab is well aligned with key

system priorities and drivers. Pick a condition or opportunity that could be a key lever for change and is ready for reform. For

example, showing how enhanced access to rehab will support provincial objectives of reducing avoidable hospital admissions.

Focusing on a key issue and demonstrating its potential for a year or so could be powerful way to build awareness and support.

Alternatively, could pitch this kind of issue/opportunity as a promising pilot project. Ensure that any pilot project doesn’t just show specific impact, but demonstrates how enhanced access to rehab will be integrated into the broader continuum of care.

Look for windows of opportunity Look for windows of policy opportunity where the case for enhanced access to rehab could be

particularly influential. Current review of seniors in Ontario Council of the Federation working group As FHTs are brought into the LHINs, could rehab be integrated/required? Within MOHLTC, the revitalizing rehab pilot project.

Build broad coalitions of support Build broad coalitions so that similar messages are getting through to policy makers through many

sources E.g. homecare, provincial LHIN & CCAC coordinating bodies, APACTS, Ontario Hospital

Association Put together a strong story line

With common core messages

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That can be adapted by/for particular audiences, opportunities, coalitions.

Summary Our strategy has to be multi-pronged: policy advocacy, pilot projects & building awareness/support Build a strong case that demonstrates the improved outcomes that enhanced rehab can achieve. Develop a focused policy advocacy campaign with asks/cases tailored to particular contexts, decision

makers and conditions. Get the key message in front of as many people and coalitions as possible

Build coalitions promoting similar messages Find key champions across these many coalitions and conditions; Map the landscape of possible stakeholders and partners.

Put together a strong story line: with common core messages plus adaptations by/for particular audiences, opportunities, coalitions.

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Appendix: Detailed Meeting NotesPresent: Bob Gardner (chair), Elisse Zack, Marg McAlister, Genevieve Obarski, Kelly O’Brien,

Chris Sulway, Steini Brown, Steve Barnes

Elisse provided background on the work undertaken to date.

CWGHR has been working on access issues for several years; issues that have been discussed are not specific to HIV

The meeting participants introduced themselves. Jennifer Verma of the Canadian Health Services Research Foundation sent regrets; she is

interested in being involved as the work moves forward Other key players have signed on to be part of the steering committee, such as the MS

society, CAOT, CPA, community health centres This meeting will inform the steering committee and is being before the steering committee

is convened in order to strategize first at a higher level

Bob initiated the discussion and reviewed the key questions circulated for the meeting.

How does this issue align with your work? how do we build a good case? What is the “request ()” beyond this meeting? – determining the “ask” is part of the purpose

of the meeting Who is the target of the request – provincial or regional? – different jurisdictions may be

targeted; timing may be right to reach the “innovation group” (ministry of health?) is there a specific CCAC that deals with these issues – yes, for specific populations but

rehab is not high on the list to interest the LHIN CEO the issue would need to be narrowed down to physical and mental

health Sick Kids has a patient navigators program; there is no model that is doing a great job out

there, though there are some individual programs if championed, need a saleable deal framed the philosophy to attract stakeholder with so many issues, should we selectively focus on a model Arthritis Society - historically has had access to physio that is paid for by provincial health

program health outcomes? show to be improvement with no additional costs what outcome is sought? access, health work quality What is “quality”?

- live longer – - increase ability to participate (work / life), - labour force participation, - stay at work

-- health outcome – continue on the “plateau” and delay decline (need to articulate that response)- mitigate the impact: e.g. people not on ODSP with no insurance cannot access so

decline until they do need to go on ODSP5


what happened to the Fair Benefits Program? there was a “whole minister” assigned to it; it is in the budget repeatedly;

don’t have an advocate – need a champion get evidence?

- nurse practitioners group- institute at St Mikes – CRICH; hosted 1st international conference on inner city health- research at Bridgepoint- research by Mike Landry

also from the home care side – like frail elderly – same types of outcomes; do have champions; CCAC driving it in Toronto

Saskatchewan is accelerating person-centred (Seattle) model (Dan Florizone is Deputy Minister responsible)

rehab as prevention is a major topic --- prevent acute care need Possible ways – 2 major ways – to approach?

- Focus on one region / program / issue- incrementally – embed where possible

may have fertile ground for:- 1 disease group? - simplify? focus on problems such as delisting?- better care?- better coordination?- or different care? save costs down the road

pick a lever for change and focus for a year or so, also longer term timeline reducing costs --- “if only got rehab”

is rehab part of “team care”? need to educate -- another gap? CMA connections Not just rehab but a continuum of care; avoidable hospitalization - still a goal? for HQO,

ministry group --- “revitalization of rehab” LHIN is looking at a best practice of care; focusing on frail elderly

- 3 populations- net savings to system- all is done around “events”, not looking at prevention

Study by Toronto Central CCAC: 1-5% of group is major cost to system. Is there a danger of a focus on the 1% vs the next 25% and below? Need a simple story; with a way to recoup cost/ realize the benefit. Savings happen in different places [than where cost of care is incurred] Maybe look at a more integrated system e.g. St Joseph’s Hamilton or somewhere outside

Ontario? Winnipeg - community health centre has an OT on staff in Ontario (?) PTs are not allowed on family health teams but OTs are Need to show a working model? Need a story - St Paul’s in Vancouver for examples? how to focus – one group? had more impact with EDN numbers than HIV numbers eg. on

CPP- D changes for rapid reinstatement of CPP-D benefits if health failed again after return to work

stroke is an “event” -- not in and out like episodic – get back to optimal level people are also living with multiple morbidities prevention of chronic situation -- easy to put a face on the story common set of actionable solutions for similar trajectory

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reaches a broad group hard sell? add seniors? also have episodes, do not fully recover but improve to new

“plateau” a review over the summer on senior strategy; aging – brings in HIV related conditions Ministers like to announce “more” -- who should be gotten “onside” i.e. the “choir” behind

the minister; who is part of the mobilization strategy and becomes the “choir”? involve deputy ministers; Health Care Innovation working group, working with CMA(?) need to focus at a local level; provincial jurisdiction inner city health group in Toronto deals only with disadvantaged populations; have rehab –

referred by family health team, links to other groups PT, Ryerson psych; captures hard to serve populations

champion group could integrate CRICH – FHT –CCAC use to tackle multi-morbidities CCAC is doing group visits (rather than 1 on 1) smaller hospitals have closed or restricted outpatient care FHT only about 1 year old – it is integrating into LHIN; they are trying to figure it out now should there be research undertaken while conducting campaign? “pilot” in downtown Toronto? Community Health Centres have a national association; very small percentage served

across the province; created to serve hard-to-reach populations; A few CHC’s (e.g. East End CHC in Toronto) have PTs or OTs on staff

FHT Doctors cannot be paid by LHINs: admin and non-doctor staff can should be talking to these groups put together a story line

- what outcome- who champions- what approach- where to pitch- what vehicles (all)

success conditions:- clear outcome- focused- tailored case- get in front of many people / coalition

to be successful -- understand why policy is what it is in order not to pitch in wrong place / way: may need re-framing

Next steps:- who is coalition – on same message- what is case / message (2 paragraphs)- win for all

Success stories:

- Toronto Central LHIN- Winnipeg Community health centre (Nine Circles)- Arthritis Society

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- BCCAA (?) / HQO- North End Community Health Centre, Halifax

emphasis on patient-centred care could also involve a palliative care group? have worked with Canadian Hospice-Palliative

Care

Others to talk to?- key stakeholder groups - often don’t think about rehab- Canadian Home Care- (orthopedic?) hospital - get group of rehab together - APACTS – rehab coalition, community based- provincial association of CCWCs - Pamela Fralick – Canadian Healthcare association- Steering group and other interested groups (eg Change Foundation)- family health – association of Family Health teams- CFPC- Women’s College – ambulatory care focus – looking at new model- Bridgepoint- Caregiver coalition- groups have a different reason for being there than the professional associations- bring stakeholders and practitioners together

Other contacts from meeting group?- LHIN group (think tank) driving change – chair: Bob Morton- asked that others be forwarded

Existing partners are national – may want to focus more locally but with representation from the national groups

consider HIV lens - complex- has a face- people are living / aging

Which buttons are ready to be pushed? HIV?

Understand the “end game” to build coalition; define key question -- with own wording for groups

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