ReviewofVCHTransSpecialtyCareServices

1

ExecutiveSummary

SummaryIn winter 2018, a review of VCH’s Trans Specialty Care serviceswas completed to identify strengths in the current system,strategiestoreducewaittimes,andopportunitiestoenhancethecurrentservices.Informationwasgatheredthroughattendanceatmeetings,reviewofdocuments,individualandgroupdiscussionswith staff, and supportedwithEMRdata.The reviewwas led incollaboration by a VCH project manager and contracted peeradvisor.

In spring, a second phase of the review was completed with afocus on client engagement as an opportunity to obtain directfeedback on experiencesof care.Anonline surveyand three in-person focus group sessions were held with clients who hadpreviously accessed Trans Specialty Care services at Raven SongorThreeBridges.

Recommendations fromboth the reviewand client engagementprocesswereanalyzedandgroupedintothefollowingcategories:

A. PrograminfrastructureandleadershipB. ServicedeliveryimprovementsC. Capacitybuilding&educationD. Increasingclientaccesstoservices,education&supports

Our immediate next steps are to build the necessary programinfrastructure needed to address the recommendations anddevelopanactionplan.Somerecommendationscanbeaddressedin the short-term and many are already underway. Otherrecommendationswilltakelongertoplanandimplement.

A number of themes and recommendationsweremade that gobeyond themandate and scope of the TSC program.While theprogram cannot commit to delivering recommendations beyonditsscope,itiscommittedtoadvocacyandexploringpartnershipswithotherstakeholderstoaddressthem.

September2018

• HeldindividualandgroupmeetingswithstaffatRavenSongandThreeBridges

• Onlinesurvey(N=13)andfocusgroupsessions(N=8)wereconductedtoobtainclientfeedback

• ReviewofEMRdataandrelevantdocuments

• Analysisofkeyrecommendationsandthemesfrombothprocesses

ReviewMethods

BackgroundVancouver CoastalHealth is recognized as an international leader in deliveringcareandsupporting transpeoplethroughmedical transition. Since the closure of the provincial gender clinic in 2002, Trans Specialty Care (TSC)servicesatVancouverCoastalHealthhaveevolvedovertimeandarebasedattwoVancouverCommunityHealthCentres (CHCs),RavenSongandThreeBridges.Today, there is increasingdemand forservicesevidencedby longwaittimesandagrowingwaitlistofpatientsacrosstheprovince.

Context• WaitlistandwaittimesforTSC

servicesaregrowing~4-5monthsforhormoneassessmentand2monthsforsurgicalassessmentasofAug2018

• Over25%ofclientscomefromotherhealthauthorityregions

• ThereisaneedtodevelopstrategiestobuildcapacitywithinVCHandexternally

• Opportunitytoobtainclientfeedbackontheirexperiencesaccessingcare

2

ProgramInfrastructureandLeadershipInordertocarryoutthefullrecommendationsfromthereviewand client engagement process, itwas important to begin byimplementing the recommendations below that provide thenecessary infrastructureand foundation fordevelopmentofaprogram:

Short-term(0–3months)1. Formally assign program leadership and secure projectsupport2. Establish a steering committee to provide programleadership,oversightandgovernance3. Establish working groups to review and amend currentworkflowsandprocedurestoimprovetheclientjourney

Ø Host a planning workshop to understand currentstateanddefinefuturestate

Medium-term(3–6months)

4.CentralizeservicesandcreateadefinedcoreteambasedoutofThreeBridges

Ø Developspecific jobrequirementsandcompetenciesforteammemberstomeettheneedsofclients

5. Provide ongoing opportunities for client engagement andfeedbackonprogram

Peer advisors will be engaged throughout the programplanningand implementationphasesof theproject. Twopeeradvisors will sit on the TSC Steering Committee and peeradvisors will also be asked to participate in specific workinggroup activities to offer insight and to help create newprocesses,workflows,andpolicies.

Recommendation#2:TSCSteeringCommittee

A key recommendation from the reviewwasto create a more formalized structure forprogram implementation.This fall, a steeringcommittee will be launched and its purposewill be toprovide operational leadershipandspearhead implementation of therecommendationsfromthe reviewandclientengagement process. The committee will becomprisedofoperational,medicalandprojectleadership aswell as two peer advisors.Oneof the first tasks of the committeewill be tohostaplanningworkshoptohelpinformhowserviceswillbedeliveredinfuturestate.

Two working groups, a Service DeliveryWorking Group and a Capacity BuildingWorkingGroupwillalsobeformedtoaddressprogram recommendations and tasked withproducingspecificdeliverables.

Recommendation#4:CentralizeServicesSincetheclosureoftheprovincialgenderclinicin2002,transspecialtycareserviceshaveevolvedattwodifferentVancouverCommunityHealthCentres(CHCs),RavenSongandThreeBridges,withdifferingmodelsofservice.TherecommendationtocentralizeservicesatThreeBridgeswasmadetosupportthedevelopmentofaspecializedteamunderasinglemodelofcare,whileensuringadequateservicevolumestomaintainclinicalskills,competencyandexpertise.ThetransitionofservicestoThreeBridgesalsomeansthatclientswouldhaveincreasedaccesstotransspecialtycareservicesthroughouttheweekandaccesstothesamewraparoundsupportsforalltransspecialtycareclientssuchascounseling.Hostingservicesunderthesameclinicalmodelwillbetterfacilitatethecreationofclearworkflowsforteammembersandallowustoprovidebetterstaffsupportstomeetthegoalofensuringamoreconsistentclientexperienceforalltransspecialtycareclients.

BoththereviewandclientengagementprocessesrevealedthattheTSCprogram’sgreateststrengthisitspeople.Reviewersandclientfeedbackhaveobservedthattheprogram’scareprovidersarededicatedtotheirworkandarecaring,compassionateandkindtoclients.

Inabsenceofformaltraining,staffhavedevelopedexpertise inthis area over time and are recognized both locally andinternationallyas leaders indelivering carefor transclients.Asdedicatedchampions,staffhavebeengenerousinsharingtheirknowledge and have mentored other providers new to thiswork. Also, while there are improvements to be made todecreaseprogramwaittimes,theTSCprogramreportssomeoftheshortestwaittimescomparedtoothercitiesandprovincesacrossCanada.

The review process also found a number of opportunities toenhancetheclientjourneyinfuturestate:

Mediumtolongterm(3to6months+)10.Createasaferandmorewelcomingspaceforclients:

Ø Develop&supportnon-oppressivecultureØ Hirepeersinclient-facingrolesØ Reviewguidelinesandprocedurestohelpcreateasafe

andwelcomingspaceØ Review existing policies and develop action plan to

addressclient-on-clientharassmentØ Create physical space that is warm, welcoming and

visuallyshowsclientsthatitisasafespacetobeinØ ExploredevelopmentofclientcharterofrightsØ Implement evaluation of clinic culture and staff

wellness11. Review and streamline current processes and policies toeliminateunnecessarystepsintheclientjourney12.Pairclientswithaspecificteamofclinicianswhoarefamiliarwiththeircareasawaytofacilitatetrustbuilding,createasaferexperience,andminimizeexcessiveinformationgathering13.Aspartofateamapproachtocare,increaseroleofnursingwherepossibletoprovidemoreclinicalservicesincollaborationwithaTSCphysician14. Develop a standardized process and workflow for clientreferralstosocialwork15.Evaluate current filing andbooking systems andworkflowsto minimize errors in misgendering or addressing clients bywrongname16.Createadditionaloptionsforhowtobookappointments

CapacityBuilding&Education

Short-term(0to3months)

What’shappeningalready?• Prismhasadjusteditsworkplantofocusmore

oninternaleducationacrossVCH;atrainingdaywiththeemergencydepartmentatVancouverGeneralHospitalisplannedthisfall

• CapacitybuildingactivitiescurrentlyunderwayatseveralVCHCHCsincludingReach,Heatley,andDowntownCommunityHealthCentre

• Atemporarynursingrolehasbeenestablishedtohelpmanagethewaitlist,improvepatientflowfromTSCservicestoprimarycare.AsofSeptember,73clientshavebeensuccessfullymatchedwithserviceprovidersinthecommunity.

EnsureallThreeBridgesandTSCstaffcompletePrism101Training6.

7.

8. Buildcapacityfordeliveryoftier2and3acrossprimarycareforclients

ServiceDelivery

9. Establishandimplementaworkplanformanagingclientwaitlistsandattachingnon-mandateclientstocareprovidersinthecommunity

Ø Establishanevaluationframeworkforconnectingclients

Mediumtolongterm(3to6months+)

ReviewtheroleofPrismanditsmandatetofocusoninternaleducationandtraining

Increaseclientaccesstoservices,education&supportsMediumtolongterm(3to6months+)

17.Beginhostingaonce-monthlysurgicalreadinessassessmentsession

18.FacilitateadditionalcohortsofGenderJourneysinthe2018/19fiscalyear

19.Explorethefeasibilityofpilotinghormoneandsurgicalreadinesssupportgroups

20.Beginevaluationofwaystoreallocateresourcestowardsmorepsychosocialfocusedapproach

Ø E.g.accesstocounsellingandexplorecapacityforteamapproachtovisits

21.Increaseaccesstoprograminformationthough

comprehensiveprintandonlineeducationmaterialsand/or

regularin-personclienteducationsessions

22.Explorefeasibilitytodeliverservicesoneveningsand

weekendsandtoprovidetransonlyclinictimes

Keythemes&recommendationsoutsideTSCprogramscopeWhilerecognizedasimportantareasofwork,thefollowingrecommendationsarebeyondtheprogramscopeandmandateoftheTSCprogram.Thisfollowingsetofrecommendationswillrequireleadershipandcollaborationfromand/orwithotherVCHprogramsandexternalpartners:

Ø Exploreopportunitiestopromoteincreasedsafetyandaccessibilityforessentialclinicalservicescurrentlyavoided

bytransclients(suchasbloodwork,mammogram,sexualhealthcheck-ups,etc)

Ø Seekoutopportunitiestosupportthecreationofarobustnetworkofpeersupportgroupsandpeereducation

Ø Seekoutopportunitiestoincreaseaccesstoessentialnon-

clinicalservicessuchasphysiotherapyandmedical

tattooingpost-oppatients,andelectrolysistopre-op

patients

Ø Exploreopportunitiestosupportbetterresourcesfor

clinicianssuchasattheRACElineorthecreationofonline

resources

Ø Promotetrans101trainingasanessentialskillforallVCH

staff,beyondtheTSCprogram

Ø Exploreopportunitiestoprovidemoreflexibleoptionsfor

accesstocare,suchassatelliteclinicsstaffedbyTSC

cliniciansorcontractedserviceproviders

• PartnershipandcollaborationwithotherkeystakeholderssuchasTransCareBC,theMinistryofHealthandcommunityagenciesisrequiredtoaddresstheserecommendations

• Someworkisalreadyinprogress,suchasaprovincial101trainingmoduleledbyTransCareBCandcompetencytraininginitiatedbyLifelabs

• OurnextstepswillbetofollowupwithpartnerstounderstandwhatworkhasbeendoneandwhatroletheTSCprogramcanplaytohelpadvocateandsupporttheserecommendations

What’shappeningalready?

• Monthlysurgicalreadinesssessionsarehappeningmonthly+

• FundingforGenderJourneyshasbeensecuredandwillbeofferedin2019