Primary Health Care Planning Meeting, June 20, 2008

Appendix C: The Afternoon Cafe Sessions

The June 20, 2008, meeting regarding Primary Health Care on Gabriola was hosted by the BC Ministry of Health, The Vancouver Island Health Authority, and the Gabriola Health Care Society. A report of the morning sessions is included above. In the afternoon each of the participants was asked to select two topics out of nine offered, and to join a facilitated round table discussion on each of the topics. The following are the unedited participant comments in these sessions as recorded by the facilitators. While the comments will all be taken into account by the Gabriola Heath Care Society in formulating its goals and plans for the future, the views expressed are those of the participants and not necessarily those of any of the hosts. The inclusion of the comments here does not suggest that any of the hosts either endorses or supports them.

A. Community Dialogue and Engagement

  • Often people are only engaged if there is a “need” -- i.e. they are “sick”
  • Concept of a disaster training day (like earthquake preparedness)
  • A demonstration project
    • Volunteers
    • Announce that it will happen but no one knows where or what.
  • Using the press/newspapers
    • How to control the message and avoid hype
    • Press releases – regular
    • Helps with ensuring the correct or accurate message goes out
    • Expand the media circle to include Nanaimo papers.
    • In the press
      • timeline/history of the process – EACH TIME –
      • make sure everyone has the background.
  • “Central access point” for health care
    • A “building” increases this performance
    • A “magnet” for the community
    • Its more tangible
  • “Store front concept”
    • Current clinic too out of the way
    • Maybe a “central” GHCS/GHCF office.
  • People need to know where the money comes from and where it’s going.
  • Having tangible things to report
  • Put a human face on the issues – will the current doctors leave due to burnout?

  • Being clear on the facts
    • how many doctors do we have: 1, 2, 4?

  • Many “facts” require substantiation and statistics
  • Improve education of public on what happens in health care
  • Can GHCS collect statistics
    • Concerns over privacy
  • Provincial election coming this fall – ensure candidates are aware and addressing our issues.
  • Statistics – emergency – can we quantify by time of day (during office hours vs. Overnight?)

Group #2

  • How to educate and inform Gabriolans
    • Media
    • Website
    • Bulletin board
  • Newspapers – regular column and invite questions
  • We really need to “explain” what integrated health care is AND what it would provide
  • Timeline/history – how did we get to this point?

  • Be sure to focus on FACTS (not persuasion)
  • Clarify on-call funding
    • Impact on Doctors
  • All questions are valid and ensure members of the community are treated with respect.
  • Invite questions, complaints, suggestions, criticisms (positive and negative)
  • Defining the “jargon” would be helpful
  • Suggestion box
    • Allow for anonymity
  • Surveys?

    • Go out in mail
    • Mail in or drop off (Rx)
    • Survey could be picked up
  • Key Point
    • Ensure we are listening to everyone
    • Ensure we are sending out accurate, factual, information in a clear way (simple language) in a variety of ways (media, website, bulletin boards)
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B. Potential Community Vision and Partnerships


Vision

  • Need database & needs assessment – current dearth
  • Definition of which community we are trying to provide for
    • Permanent - - grossly underestimated
    • Summer residents – expansion of permanent residents not transients
  • Business planning on Island
    • Similar issue re: planning
  • Because of lack of database can’t have a hospital -- census numbers too low.
  • Vision of combining traditional and non-traditional with central location
    • close to village
    • services located together
  • Current dispersion of services – trend as well
  • The important thing is that they are integrated
    • They can be dispersed but need to communicate and integrate
  • Assisted care facilities need to be on island and need to be linked into health care
  • Census data is not telling the facts about Gabriola population – especially for health care and social services
  • Five year vision
    • Affordable housing
    • Public transportation
  • Well co-ordinated system of health and social services
    • More co-ordination
  • Lots of societies working together
  • Central area selected public health facility
  • Community land trust with cluster housing
    • When people have adequate housing they are healthier
  • Establish definitively the [number of] summer and winter residents
    • Use village market, RCMP, Post Office
    • Demographic breakdown
    • May be expensive but well worth it

Partnerships


  • All societies should be part – PHC, etc.
  • All the physicians on the island, all the health care providers, physiotherapists, etc. (alternative and traditional)
  • How can the Commons be a partner?

  • Provide land for assisted living and other projects (i.e. home support, food, clinic)
  • Need to figure out how to do it
    • Costs
    • Regulations
    • Etc.
  • The island health centre
    • Financial manager
    • Public, private funds
    • Local management.
  • Council of societies to create co-ordination of societies
    • Needs
    • Focus
    • Sharing of information
    • Actions
  • Consensus on vision – soul stirring!
  • Government – they should be involved as much as we can drag them in
  • Foundations – lots in the United States – can we access
  • Grant to access funds
    • Data
    • Council
  • Some individual or group that can make decisions
  • Moral persuasion makes it happen – not a government body
  • Mechanism to translate decisions into actions
  • Need funds to make things happen after goals, vision, soul stirring occurs.
  • Visioning brings funds – and people who can make it happen
  • Vision
    • Database – current census data don’t work – we need this information for planning
    • Full coordination & integration of traditional and non-traditional
      • Health
      • Social services
      • Societies
      • Etc.
    • Focus on assisted living is crucial
    • Council/coalition of groups
      • Vision
      • Sharing
      • Implementation
      • Funding
      • Skilled people


Group two


Vision

  • We will all be so healthy that we won’t need health care:
    • No smoking
    • No addictions
    • Riding scooters & bikes
  • Reality – That health officials will recognize the uniqueness of geography & population
  • It is happening today – exciting
  • It is a start
  • Establish relationships so that it is ongoing – not just a one day wonder.
  • Not only aging population that we need to focus on – we had an issue with a seven year old –
    • Now that we have ETR the [greater the number of patients] that can be treated here the better.
  • Immediate response to emergencies has made a big difference vs. going to Nanaimo.
  • Comes out in dollars – especially when you count ambulances, etc.
  • Vision – Reduction in risk
    • If you are healthy you don’t feel the risk but when something happens you feel the risk
    • Identifying potential risks and using that information to start moving toward a vision
    • One concern for people as they age is access to health care
      • Some have moved off the island as a result.
    • Turn the risks into a to-do list
    • Chronic Disease management
      • Education re various risks
      • Responses to mitigate risks
  • We do not have the population base for an operating room – our vision is really about all the emergency services on the other side of the line
    • Enough physicians and other medical practitioners on the Island tp provide emergency services (other than operations)
      • Maternity?

        May need C-sec.


Partnerships

  • Don’t like the term – suggests commercial arrangement..
  • Health care providers should be co-ordinated and integrated.
    • Groups like
      • Hope Centre
        • Children, teens preventative support
      • School
      • Home and community care
      • Partner with walking groups, recreation, etc.
  • Need co-ordinator
    • To help get groups together
      • Might need funding
    • To increase relationships outside of narrow bands
    • Co-ordination and communication is the key
    • Certain funds are allocated for specific activities – when you put them all together you increase impact.
    • Need certain types of people to co-ordinate and bring groups together.
    • GHCS should provide at least an information transfer to assist co-ordination
    • Access to information in information system
      • Need to ensure privacy while ensuring information is available to the relevant health care provider

Summary

  • Prevention is the key
    • Identifying risks
    • Turn assessment of risks into a vision
  • Integration and co-ordination of various components of health care system
    • Include voluntary groups (i.e. GESS, Walking Group)
  • Emergency Care
    • Operating line
    • Standards of care
  • Issue –available resources
    • Physicians and health care practitioners and volume
  • Partnerships – many groups on the island provide support
  • Need good co-ordination to increase relationships outside of current bands.
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C. Prevention and Self Care

  • Opportunity – trails and walking path creation and maintenance
    • Elderly and others enjoy experience “off road” and “mental health promotion”
    • Barriers to trails
      • Highways and transportation
      • Island Trust & Ministry of Transportation report/paper (Plan for Community) not being implemented
    • Issue – Accessibility of trails
      • For all
      • Shorter walks
      • “Wheel friendly”
  • Opportunity – Seniors gardens
    • Accessible to seniors with canes
  • Opportunity - Rollo Centre
    • Address social and recreational opportunities
    • Barrier – Rollo doesn’t do health based programmes. Mandate to do volunteer programming.
  • Opportunity – Gathering place
    • Outstanding youth health prevention services
      • Mentoring
    • Keeps active focus
    • Kids
    • Assistance in rural setting for positive creativity
  • Issue:
    • Substance abuse and addiction
      • Opportunity – AA programme
      • Disclosure is an issue in small town
    • Smoking – Policy of smoke free in community programmes
  • Opportunity: Programme proposal: “Keep Well”
    • Volunteer driven programme
      • RN
      • Pharmacist
      • RD
      • Etc.
    • Keep people out of doctors offices
    • Senior programme
    • Model from North Vancouver
    • SFU evaluation of programme
  • Opportunity: Information on internet
  • Barrier: Provincial/VIHA chronic disease programme not available
    • No programme run on Gabriola
    • No Nanaimo programme lead
  • Barrier: Public health focus is on Child and youth
    • No funding for adults and seniors
    • No dietician services provided on the Island
    • Conflict between access to food and food safety
      • Opportunity: Farmers are engaged in a dialogue
  • Opportunity: People for a Health Community
    • Offers programmes for high risk groups
      • Women’s issues
      • Food bank
      • Employment support/transition
      • Disability applications
        • Lots of disability interests
    • Barrier: Not enough mental health support and service
  • Mental health
    • Confidentially and privacy issue
    • Safe house?

      Is it still in the works?

  • Future: Building on services by sharing
    • Interagency sharing
    • Think tanks for funding, support, resources.
    • Need VIHA at the table
    • Need all service providers at table
  • Opportunity: Home and community care environmental risk assessments being provided VIHA in ___________
    • Medication assessment being done
      • Enhanced communication with pharmacist and MD
    • Food security part of environmental assessment
  • Food bank – Monday and Tuesday
    • Approximately 40 people for services
    • Soup kitchen is only available Monday and Tuesday
    • Emergency food cupboard
  • Barrier: Transportation is an issue
    • Barrier to access to Nanaimo and Gabriola
    • Opportunity: Small town mentality is a benefit to “taking care” of at risk groups.
    • Opportunity: New transportation society
      • Ride share programmes
      • Bus
  • Issue: Access to pool for exercise
  • Opportunity: Local business support
    • Gymnastics
    • Yoga
    • Sports commission
      • Access to sports
      • Need to ask if subsidy is required to pay for sports opportunities
  • Opportunity: Health information is available from pharmacist
    • Barrier: Prenatal classes
      • Available?

      • Awareness of service and topics/information available
  • Required: Public education of services that are available across the age span
    • Need strategy to access information
      • Media
      • Word of mouth
      • Updates
      • Challenges to keep information up to date/current
  • Opportunity: Hire a co-ordinator for all volunteer services


Group two

  • Opportunity: Exercise
    • Swimming pool
      • Warm
      • Cost – needs to be accessible
    • Walking group
      • Needs variety of pace – active vs. less active
    • Yoga and other exercise options
      • Cost
  • Barrier: Access to dietician
    • How to access needs to be communicated
  • Opportunity: Senior friendly community
    • People for a Health Community gathering information and sharing
  • Opportunity: Need to get to everybody
    • Mail
    • Newspapers do not get to everyone
    • Pharmacy is a good location
  • Barrier: Transportation
    • To services
    • To fitness
    • To food
  • Barrier: No services for special learning
    • Special needs services limited
      • Should be ongoing in adult population
    • Adult education -- no focus
  • Opportunity: Family, friends, support to increase participation, support
    • ?

      Special education in school.
  • Barrier: Music opportunities for children and adults
  • Barrier: Expense to Connect/access associations in Nanaimo
    • i.e. Diabetes
    • i.e. Cancer
  • Opportunity: Alzheimer group on Island
  • Opportunity: Alternate therapy exposure
    • Acupuncture
    • Homeopathic medicine
    • Physiotherapy
    • Barrier: the cost.
  • Pool
    • Home care
    • Supports programming exercise
  • Opportunity: Youth group – “Gathering Place”
    • Prevention focus
    • Youth – preschool, middle, teen
      • Mentorship
  • Opportunity: Commons support of
    • Seniors gardening
    • School garden club
  • Access to
    • Therapy dog programme
    • Music therapy
  • Companionship
    • Visiting programme
    • Awareness of where services would benefit
    • Solutions to isolation
  • Barrier: No parish nurses
    • Provides information and resource connectivity
  • Future:
    • Support People for a Health Community to enhance independence through awareness of services and access to services
    • Volunteer registration
    • Support for volunteers
      • Prevent burnout
    • Commons working on assisted living
      • Need to get the “team” together (including business community) to share strengths and assets
    • Education
      • Pharmacy
      • AA
      • Tobacco
      • Alcohol
      • Drugs
      • Barriers:
        • Privacy, confidentiality
        • Alanon – off island
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D. Medical Emergency services

  • How and who defines an emergency
    • Patient driven
    • Has to respond to call
  • Risk in our community
    • Overwork
    • Underequipped
    • MDs underpaid for emergency call during office hours
  • ** Our “clinic” is not recognized as emergency dynamic
    • No way to bill
  • Lack of effort between rural physicians, BCMA, and Ministry of Health to resolve MOCAP gap
    • Lack of co-ordination
    • Lack of responsibility to resolve problems
    • This is a retention issue for rural doctors
    • No voice
    • No statistics
    • Not on political agenda of BCMA
    • Not linked to other doctors
    • Community voice is key
  • Key message
    • Community voice is key in making and “supporting doctors” which leads to successful service provision, retention, and recruitment
    • Greater communication between parties involved in emergency services
    • Clarify roles and obligations of VIHA in emergency service provision
    • Public information
      • What is available
        • Seniors
        • Others
      • Who to call. When.
      • One piece of paper covering both clinic hours and off island numbers
    • Need to balance burn-out vs. 24 hour on-call
    • Need to look at other community on-call models.
    • Clarify VIHA’s obligations to community
    • Better Ambulance Society care role.

Group two

  • Challenges
    • Community resistance to expanded clinic
    • Need another physician/resources
    • What do “we” mean by emergency services?

      • Population growth
      • Ferry constraints
      • 24/7/365 availability and coverage
    • Walk-in traffic
    • Physician retention
      • Practice size
    • Connection/Privileges at NRGH
      • Access to patient care data
      • Continuity of care
    • How do we respond to emergencies in a marine/coastal world?

    • Dynamic and transitional population
    • Attracting physicians
    • Range of services provided is limited.
  • Solutions
    • Stable full service family practice would help with capacity to respond to episodic care needs.
    • Practice support programme/Integrated Health Network
    • Remove 50 person per day limit on FFS billings
  • Key message
    • Focus on ways to create a sustainable practice for local physicians including shared on-call (sharing the pager)

Group 3

  • What do we have
    • No 24 hour emergency c are unit on the island
    • Emergency boat
    • Need inventory of what is available on the Island
    • Ambulance service
    • First responders
    • Uncertainty as what to do in case of emergency
  • Challenges
    • Little control of changes in health system
      • Set up response
      • Change
      • Poor communication
      • Confusion
      • Setup
      • Change
      • Etc.
    • Public unclear as to what or who to call
  • Opportunities
    • If we had additional doctors we could have a pager system
    • Challenges of providing on-call
    • Setup of emergency room
      • Equipment
      • “over night” capacity
    • Link between island and Nanaimo emergency room to circumvent delay
      • Need to strengthen two-way communication
    • Goal is to not forward emergency to Nanaimo, but t stabilize, treat on the Island where possible
      • 75% stabilized
      • Need to create trackable statistics for reporting
    • Location of clinic
      • Where are doctors (Silva Bay)
      • Population concentrated
      • Central
      • Ferry/Village
    • Educate people about how it works now
    • First aid
  • Personnel needs of clinic
    • Doctor
    • Nurse practitioner
    • Mix of skills and scheduled
    • “Remote backup”
    • Links to nurse and home care
    • 6/12/24 hour observation bays with nurse care
    • “Observation Hospital”
      • Tumbler Ridge
    • Set goals for diversion of patients from Nanaimo and track the savings.
  • Key message – Emergency services goal:
    • Small “observation hospital” staffed with a mix of doctors and nurses which is centrally located with our growing population knowing how to access it.
    • Trackable statistics
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E. Chronic Health Care and Education


Considering that chronic conditions include diabetes, hypertension, arthritis, heart disease, asthma, COPD and depression, a significant proportion of the residents of Gabriola will at some time require chronic health care and education:

  • Some of the challenges facing those with a chronic condition include
  • Limited diabetes services
  • Inadequate communication regarding lab testing
  • No rehabilitation program e.g. for heart disease
  • Transport problems
  • Acute exacerbations of chronic conditions often require admission to NRGH and with appropriate facilities the patient could be stabilized and remain at home
  • Follow-up of treatment often involves the cost of leaving the island
  • Lack of day programs and respite for patients with severe chronic conditions
  • Patients with more that one chronic condition can present with some complex health problems

Some of the solutions discussed:

  • Glucometers serviced and checked on Gabriola for diabetics
  • Educators as part of a team to visit Gabriola
  • Integrated services; doctors, nurses, public health, home care etc
  • Patients becoming pro-active in their own health care
  • Health care providers have a responsibility to encourage patients to participate in managing their chronic condition
  • Follow-up offered locally, either one to one or group support

Key message:

  • Locally accessible chronic health care to focus on education, prevention, monitoring, patient self-management and peer support.
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F. Primary Health Care throughout the Lifecycle

  • Lack of knowledge re services available
    • Solution: pamphlet describing/listing services
    • Make pamphlet /information available locally
    • Need access to information for patients and caregivers re diagnoses/what to expect.
  • Challenge –home care changed from comprehensive to narrow and services were lost
    • Home care needs more people, increased hours to be willing to do more
    • Need for respite care
  • Better & timely information /coordination to improve transition home from hospital
  • Timely access to home care
  • Solution to home care – move administration/management back to Gabriola
  • Need to co-ordinate agencies offering services/equipment to ensure not wasting/duplicating resources
  • Solution to home care – increase staff & make use of nurse practitioners
  • Need for meals on wheels/transportation to support people to stay in homes
  • Support for public transportation including $$$ from government.
  • Explore alternatives to public transport
    • Jack Bell Foundation
    • Dedicated local vehicle adaptable to needs of community (transport to events, appointments, shopping)
  • Provide access for other needs (social contact, reading material) to prevent isolation for seniors and care givers.
Key message: Need to support people and caregivers at home through increasing home care services, transportation, co-ordination of available services and education.
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G. Mental Health and Addictions

  • Local coordinator (on island?

    )
  • Role for nurse practitioner and home support.
  • Better integration.
  • Possibility of legalization of “drugs” combined with education – “decriminalize”
  • Support on island NA&AA – more information in public domain.
  • ** integrated health care
    • All professionals working together
    • “Patient centred”
  • Reach-out to “the out of the loop”

Group two

  • Providing an outreach capacity
    • Proactive case finding
  • In-office counselling on regular/consistent basis
  • Awareness and education on mental health and addiction
  • 30 homeless
  • Housing for mental/disability clients with appropriate support.
  • **Partnerships (Hope Centre, etc.)
    • Teens and seniors
    • VIHA & community wisdom
  • **One point of access for all VIHA services
    • A broker
  • Paid peer support
    • Self-help
    • Social, vocational, educational
  • Increase self-worth of individuals.
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H. Health Care Worker and Physician Retention

  • Number of physicians?

    • Minimum of five (VIHA)
    • Need to attract 3 more
    • One physician per 1,500 population (per VIHA)
    • However, that ratio may not apply on Gabriola
    • Older population, on average, so more visits per patient per year
    • Possibly lower overhead than a city practice
    • Maternity leave and sickness coverage?

      • Locums?

  • Attract physicians – don’t like on-call
  • Contract teamwork
  • Electronic conferencing
  • Adequate numbers
  • Lifestyle of physician
  • Family practice training programme
  • Housing
    • To attract and retain
    • Incentives by community
  • Recruiting fairs?

  • Who to contact at VIHA?

    ?

  • Nurse practitioners?

    • Insurance issues?

  • Fee for service vs. Salary?

    • Other methods?

      • Ladysmith model?

  • Comprehensive payment arrangements
    • “Hybrid” model (ref. Tofino?

      )
    • Nurse practitioners take income away from fee-for-service doctors?

  • Doctors still need to be on call even if nurse practitioner.
  • Other models?

    Pender Island?

  • Paid on Call $$
  • First responders are fantastic
  • Recruitment fair?

    Gabriola style?

    • Retention – teamwork
    • Society – designated group - - Welcome Wagon style.
  • Physician sabbaticals?

    • Student doctors
    • Locum trials
      • purpose built apartment as a part of the final clinic
  • Limited licenses
  • Continuing permanent family practice physician preferable
  • Navigating the system
    • Simplified, accessible, understandable.
  • Demonstrate excellence on Island
    • Patient and doctor retention go hand in hand.
  • Special needs, multiple illnesses
    • How to co-ordinate treatment
  • Bring Home Support back to Gabriola
  • Quarterback/co-ordination/direction
    • How
    • Who

Key message

  • Health Care team with co-ordination which will attract and retain permanent physicians
  • Supportive information technology
  • Home care integration/co-ordination/communication
  • Understanding the process
    • Navigating the system
      • Both patient and care-giver
  • Recruitment and retention off all staff across the board
  • Assisted living Incorporating
    • Tele-health
    • Tele-medicine
    • Information technology
  • Accessing timely information
    • Nurseline?

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