Enhancing Primary Health Care on the Island of Gabriola

1. Introduction

This document proposes a roadmap for the development and maintenance of a fully equipped healthcare facility which will enable integrated primary health care services to be delivered to the people of Gabriola.

Primary Health Care involves health care providers working in teams to provide a range of everyday health services on a regular, ongoing basis to help people stay healthy and prevent injury, get better, manage illness or disease, and cope with the end of life. (VIHA PHS Strategic Plan, pg. 1)

Gabriola Island is the third largest Gulf Island running about 14 km long by 4.2 km wide with a land area of 57.6 km² (22.24 sq mi). It has the second largest population of all the Gulf Islands with a population of 3,522 as of the Canada 2001 Census, however the RCMP estimate this number has risen to 5500 in 2006. The population increases significantly in July and August from seasonal visitors.

A vehicle and passenger ferry operates regularly from Nanaimo on Vancouver Island. The ferry crossing time is 20 minutes and operates between the hours of 05:45 – 22:55 on an hourly basis.

Gabriola Island is governed by the Islands' Trust. It is also represented at the Nanaimo Regional District as well as on the Nanaimo School Board.

Demographic information specific to Gabriola is difficult to obtain, however, the Nanaimo Regional District is noted for having the highest population growth in all Vancouver Island and the highest percentage of individuals > 45 years of age in the entire province. As noted in the Vancouver Island Health Authority’s (VIHA) Five-Year Strategic Plan “our increasing population of elderly people is one of the most significant challenges we face now, and will continue to face for at least the next twenty years” ( pg. 17).

In the Nanaimo Regional District ~ 9% of the people are 75 years of age or older compared to 6.7% for the province and it is estimated that the Central area of Vancouver Island will experience a 43% increase in residents aged 85 years and older by the year 2010 (VIHA Five-Year Strategic Plan, pg.18). Currently this 9% of the population account for 46% of all in-patient days on Vancouver Island (VIHA Five-Year Strategic Plan, pg.19).

A major reason for these hospital days is due to chronic ailments. Examples of these chronic diseases/health conditions include: diabetes, hypertension, congestive heart failure, renal failure, asthma and depression. As reported in the VIHA Five-Year Strategic Plan, Vancouver Island currently has the highest proportion of people in BC with a confirmed chronic condition (39%). This number will likely continue to increase as the population ages (pg. 18). A recent study done by Broemeling, et al, in 2005, found that people in BC with chronic conditions who also had another health condition used:

• 4 to 7 times more days in hospital;
• 2 to 4 times more visits to doctors;
• 4 to 5 times more home nursing and rehabilitation; and
• 2 times as many hours of home support service (pg 19).

There are no coordinated Primary Health Care services on the island. Home and Community care, Public Health, Physicians and other Health Care providers often work in isolation resulting in lost opportunities for intervention

Gabriola currently has:

• Two full time, one part time, and one occasional (every second Saturday) physician working on the island creating a ratio of about 1 physician for every 2000 residents according to the 2001 Census and about 1:2750 based on the more recent RCMP population estimates.

• The recommended ratio of family physicians and general practitioners to population is 1:995.
• An aging physician base:

• All practicing physicians are post-retirement, save one
• Younger physicians are willing to come to the island but there are limited appropriate facilities to accommodate them
• No Nurse Practitioners practicing on the island
• Limited facilities for Public Health to deliver programs such as health promotion (e.g. well baby clinics) and disease and injury prevention (e.g. immunization clinics)
• No appropriate site for Mental Health to deliver services
• No venue to provide coordinated Chronic Disease Management services (e.g. diabetes education, kidney care)

What health services exist on Gabriola are limited, resulting in Gabriolans having to leave the island to receive routine care and follow-up.

A number of residents are forced to seek care off island because Gabriola doctors can’t take more patients (a visit to a doctor in Nanaimo takes a minimum 4-5 hours because of ferries, etc).
Gabriola residents often delay accessing medical care because:

• No 24 hour primary health care facility available on the island

• When Gabriolans access care off the island they are often forced to pay for accommodation in Nanaimo because of the ferry schedule
• No facilities to provide urgent care

• No emergency cardiac drugs (e.g. thrombolytics) on island because no emergency facilities exist
• Public Health to give child immunizations on island infrequently
• Lab work is only available three half days a week
• No x-ray or ultrasound services are available on island

Patient’s either opt out of follow-up, or delay treatment to avoid traveling to and from Nanaimo

Emergencies that occur after ferry hours require the port authority boat in Nanaimo to be sent or the medivac helicopter.

• In bad weather, patients cannot be transferred off island and there is nowhere to house a patient on Gabriola

Ambulances are required to transfer a patient to hospital if they are requested to do so by a patient. If there was a facility on the island to assess these patients than physicians could intervene when a hospital transfer was not necessary.

The number of ambulance calls between Jan 1 and October 2006 was 339. With a number of ambulance transfers:

• The ferry service is delayed, and
• Gabriola is left without its one and only LifePack and other resuscitation equipment (available in only one ambulance).
• An ambulance call off island takes a minimum 4-5 hours.

What health services exist on Gabriola are limited, resulting in Gabriolans having to leave the island to receive urgent care and follow-up.

In 2000, the Government of Canada established the Primary Health Care Transition Fund to support provinces and territories in their efforts to reform the primary health care system. The province of British Columbia received 74 million dollars and 49 million of that money was transferred to the Health Authorities for renewal projects.

The Vancouver Island Health Authority (VIHA) reviewed its Primary Health Care System and identified the following three key issues:

• Lack of organization in primary health care has resulted in a fragmented delivery system
• Need to develop alternatives to hospital care for everyday care and chronic disease management
• Need to provide Vancouver Island residents with equitable access to quality care, no matter where they live

In April 2006, VIHA identified primary health care as a priority in its Five-Year Strategic Plan: “A comprehensive primary health care system will help us prepare for, and provide more appropriate health services to our growing and aging population, and help us manage the increasing number of residents with chronic conditions” (VIHA PHC Strategic Plan, pg 4). In June 2006, the Vancouver Island Health Authority (VIHA) issued a press release in which the Minister of Health, George Abbott remarked: “Enhancing access to timely, high quality health care services for all British Columbians is a top priority for this government.” VIHA”s Vice-President and Chief Medical Officer, Glen Lowther stated: “We know that many of the people who present at our emergency departments could be treated more quickly, and just as well, in a clinic setting.”

VIHA’s strategic objectives for Primary Health Care are as follows:

• Increase the proportion of our population who have access to primary health care services, by working with communities to enable the creation of interdisciplinary teams tailored to the needs of the community and increasing the availability of telehealth services
• Increase the emphasis on health promotion, disease and injury prevention, and chronic disease management, by providing better access to information
• Expand 24 – hour access to essential primary health care services
• Establish interdisciplinary teams, so that the most appropriate care is provided by the most appropriate provider; and
• Facilitate better coordination with other health services such as specialist, hospital, community health services, and other social services that effect health, and foster improved communication and collaboration between physicians and other health care providers (VIHA PHC Strategic Plan, pg. 16)

VIHA has stated that it wishes to build partnerships to provide better care and in order to manage scarce healthcare resources will give priority to:

• Groups that focus on reducing health inequities in communities by providing full-service family practice
• Communities that are actively planning to meet their own health needs and demonstrate the capacity to move towards enhanced primary health care
• Provide flexible compensation packages such as blending fee-for-service models with contracted services
• Have sustainable operational funding requirements such as co-locating existing services (e.g. family practice offices with urgent care and diagnostic services) and other VIHA and/or community services
• Make better use of existing capital and infrastructure such as working with private investors to build new primary health care centres (VIHA PHC Strategic Plan, pg. 17)

The Vancouver Island Health Authority funds and operates only a small number of primary health care services directly. The majority are funded and operated by other levels of government, other agencies and organizations, private practices and Aboriginal peoples.

Current VIHA Funded clinics include:

• Health Point
• Health Point Luther Court
• Ladysmith Health Centre
• Comox Valley Nursing Centre

Current VIHA Supported clinics:

• Cool Aid Family Practice Clinic,
• University of Victoria Student Health Services
• James Bay Community Project

Other examples of clinics are listed in the table below:

Cortes – pop’n 1000	Cortes Community Health Centre is owned by Cortes Community Health Association. It is on land leased to them for $1 per year by the Cortes Seniors Association who plan to build retirement units on the rest of the land. Cost was $250,000 plus $100,000 in donated labor. Urgent care facility is equipped and supplied with drugs by the government to treat/evaluate/stabilize primary care patients. 1 doctor 3 days per week, child and adult mental health services, public health nurse, receptionist, part time manager (1 day week). Operating expenses mostly covered by rents and government.
Denman – pop’n 1200	Until recently, health care was provided via a private doctor’s office. However the Denman Health Centre Society have leased a residential house and renovated it into a clinic. Urgent care room is equipped and supplied with drugs by the government to treat/evaluate/stabilize primary health care patients. 1 full time doctor plus a 2nd doctor 1 day per week. Mental health counselor, family counselor, chiropractor, massage therapist, reception area, medical supply lending program. Building rented for 5 years. 1800 sq ft was completely renovated with $30,000 donated funds plus extensive donations of labor and materials. Done in 3 months and managed gratis by a local contractor. Operating expenses largely funded by rents and government. A now retired doctor still provides a woman’s clinic and palliative care out of her home.
Galiano – pop’n 1100	Galiano Health Care Society owns and runs Galiano Health Care Centre Urgent care facility is equipped and supplied with drugs by the government to treat/evaluate/stabilize primary health care patients. Clinic also offers a child clinic, chiropractor, foot clinic, ½ day a week Lab, and medical equipment loan cupboard. Society raised $285,000 beginning in 1985 to buy land and build centre in 1991. Operating expenses largely funded by rents and government.
Hornby – pop’n 1000	Hornby Island Ratepayers Association owns and Hornby/Denman Health Care Society runs a clinic. Urgent care facility is equipped and supplied with drugs by government. Clinic has space for 1 doctor (presently one FT equivalent shared by 2 doctors, 2-3 weeks at a time.) A second building run by Hornby/Denman Health Care Society offers a mental health counselor, drug counselor, coordinator of homemakers, pt office manager, and storage for lending out medical equipment. Operating expenses largely paid by rents and government.
Mayne – pop’n 900	Mayne Island Health Care Clinic is operated by Mayne Island Health Care Association and owned by Mayne Island Improvement District. Urgent care facility is equipped and supplied with drugs by the government to treat/evaluate/stabilize primary health care clinics. Clinic has 1 doctor 3 days per week, a public health nurse & a RN who communicates with doctors off island when doctors are not there. Operating expenses are mostly covered by rents and government.
Pender – pop’n 1800	Pender Island Health Care Centre is community owned and operated by a society. Originally built in 1980 by the Lions Club who paid ½ the cost. Government paid the other ½. Urgent care facility is equipped and supplied with drugs by the government to treat/evaluate/stabilize primary care patients. Clinic has 2 doctors, a dentist, chiropractor, massage therapist, physiotherapist, common health nurse office (3 part time nurses), coordinator of volunteer services, part time Office Manager. They are seeking a 3rd doctor. Present plans are to double the size of the building and $500,000 has been raised so far from donations and grants from foundations. Cost will be $700,000 and they hope the government will come up with $200,000. Operating expenses largely funded by rents and government and they are “more or less self-sufficient”.
Quadra – pop’n 4000	Medical clinic is a private practice. No urgent care facility. 2 doctors split a 5 day week. One lives on the island. Ambulance takes primary health care patients by ferry or medivac to Campbell River.
Saturna – pop’n 350	Saturna Recreation Centre Society owns the property and the Saturna Medical Clinic is in a wing of the Community Centre. The clinic is run by Saturna Community Club Society. Urgent care facility is equipped and supplied with drugs by the government to treat/evaluate/stabilize primary care patients. Clinic has 1 doctor every other week, 1 retired doctor ½ day a week, and other doctors who have homes there and will take calls when in residence. Clinic was built with funds raised and labor and materials donated. Geothermal heating and advanced septic systems were part of the Recreation Centre keeping costs down to about $140,000. An annual BBQ pays the operating costs.

Many Gabriolans have long desired an enhanced, seamless and locally accessible primary health care system. In light of the Vancouver Island Health Authority’s primary health care initiative and after examining health care systems on the other Gulf Islands, Gabriolans realized now was the time to act. In November 2006, the Island of Gabriola created “The Gabriola Health Care Society”. The Vision of the Society is to: The Society’s immediate Goal is to: The Society aims to work towards this vision by:

• Assessing and responding to community healthcare needs.
• Working with the health professionals and VIHA to develop programs that address those needs.
• Providing facilities to licensed health care practitioners in a way that fosters integrated team care and accessibility wherever possible.
• Working in partnership with other community agencies to improve conditions affecting health.

The Guiding Principles for the Gabriola Health Care Society are:

• Community based - Goals are defined by the community. There must be strong public participation in each phase of planning and delivery.
• Locally Accessible - Health services will be delivered as close to home, on island and by island providers (e.g. physicians, nurse practitioners) wherever possible and accessible in emergencies 24 hours a day, every day of the year.
• Interdisciplinary - Access to complementary treatments and support programs in conjunction with basic medical care (e.g. physiotherapy and public health promotion activities such as tobacco cessation and healthy baby initiatives).
• Integrated Team Approach - Coordination of case management, health and other services to ensure that residents can easily access a range of “seamless” care from one intake point (e.g. mental health/addiction services).
• Innovative - The ever-changing needs of a small, rural population requires that programs are flexible and that new approaches such as enhanced nursing & telehealth are evaluated as means to better serve the communities.
• Illness and Disease Prevention based – need to ensure the ability to provide immunization and treatment for infectious diseases. Plus, deliver Chronic Disease Management services which have significant cost savings in preventing illness and reducing use of hospital and more costly medical treatments.

The benefits of developing a coordinated approach to delivering primary health care on Gabriola are:

• Allows for integration of healthcare services;
• Improves communication and sharing of information and data;
• Allows for some level of surge capacity and response support for emergencies;
• Facilitates better access to expertise;
• Increases efficiency of use of scarce resources;
• Improves alignment of practices;
• Enhances emergency response capabilities;
• Creates a society which can identify system gaps and advocate for improvements on an ongoing basis.

6. Proposed Solution

The Gabriola Health Care Society has developed a three phased approach to achieve its goal:

PHASE 1:

• Hold informal consultations with and provide information to Gabriolans regarding the Society’s goals & objectives;
• Facilitate a Town Hall meeting to provide a project overview, gather feedback and plan next steps;
• Investigate other Primary Health Care models currently in practice provincially and beyond;
• Investigate various funding opportunities;
• Legally formalize Gabriola Health Care Society;
• Investigate possible building sites (consider zoning, water, septic); and
• Meet with Vancouver Island Health Authority to identify options/opportunities for partnerships/funding.

PHASE 2:

• Establish Society Board of Directors and Officers;
• Secure necessary funding;
• Formalize building requirements:

• Trauma room
• Patient rooms X 6
• Physiotherapy room
• Public Health/Mental Health/Home Care nurses offices
• Meeting room
• Admin office
• Waiting room
• Kitchen
• Shower and laundry
• X-ray
• Lab equipment

• Acquire, construct, and/or lease real estate, and manage such real estate; and
• Acquire medical and other equipment for use in the facility.

PHASE 3:

• Lease or otherwise provide the facility and related equipment to physicians, government health agencies and other appropriate users;
• Provide administrative and other services that may be required in connection with the administration and use of the facility; and
• Establish the Society’s next goals.