Primary Care and Public Health Collaboration: Perspectives from Public Health in British Columbia
and Ontario Presenters: Ruta Valaitis
Anita Kothari
Panelists: Michael Green
Victoria Lee Carol Timmings
Disclosure of Commercial Support
CFPC Conflict of Interest
Presenter Disclosure Presenter: Ruta Valaitis; Anita Kothari, Victoria Lee, Mike Green, Carol Timmings Relationships with commercial interests: • Grants/Research Support: CIHR • Speakers Bureau/Honoraria: None • Consulting Fees: None • Other: None
Program of Research
Purpose: To examine the implementation of public health renewal processes using 2 public health programs - across British Columbia (BC) and Ontario (ON)
Chronic disease prevention/Healthy living (CDP) Sexually transmitted infection prevention (STIP)
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Program of Research Goals
To inform public health systems renewal in Canada and, in turn, contribute to improving population health and reducing health inequities
To advance the field of public health services research in Canada by implementing a consensus-based research agenda and applying/ developing innovative research methodologies
To inform integration and linkage of public/ population health and primary care services
To train expert public health services and population health researchers
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The Research Team
Principal Investigators: Marjorie MacDonald, Trevor Hancock, Bernie Pauly, and Ruta Valaitis
ON Academic Researchers: Linda O’Mara, Anita Kothari, Sandra Regan, John Garcia, Ruta Valaitis (Co-PI)
ON Decision-maker Researchers: Heather Manson (ON Lead), Gayle Bursey, Vera Etches, Betty Ann Horbul, Doaa Saddek/Eva Stewart-Bindernagel, Nancy Peroff-Johnston, Jenifer Pritchard, Renée St. Onge, Carol Timmings, Deanna White/Marina Stegne
BC Academic Researchers: Marjorie MacDonald (Co- PI), Allan Best, Anne George, Trevor Hancock, Esther Sangster Gormley, Joan Wharf Higgins, Craig Mitton, Bernie Pauly (Co-PI), Roger Wheeler, Sabrina Wong
BC Decision-maker Researchers: Warren O’Briain (Lead), Ted Bruce, Veronica Clair, Karen Dickenson, Lydia Drasic, Amanda Parks, Michael Pennock, Jennifer Scarr, Lorna Storbakken, Peggy Strass
Research Coordinators: Diane Allan (BC), Nancy Murray (ON) Funder: Canadian Institutes of Health Research (CIHR)
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Research Questions and Cross-cutting Themes
Question 1: What factors/contexts influence or affect the implementation of these policy interventions?
Question 2: What have been the impacts/effects of these policy interventions on: staff, the organization, the populations served, other organizations, and communities?
Cross-cutting Themes: a) Equity b) Public health human resources
c) Primary Care/Public Health Collaboration
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Methods
• Case studies involving – 6 ON health units, – 4 regional health authorities – A provincial health authority in BC, – And, provincial ministries.
• Focus groups and interviews (n=75) including front line staff, managers, directors, MOHs/MHOs and others serving urban, rural/remote regions, as well as ministry staff.
• Data collected between late 2010 up to 2012
Methods
• Case Studies • Themes identified using
inductive/ deductive coding (main research questions to frame)
• Nvivo 9/ 10 • Team approach to coding
and second reviewer for all coding
RESULTS
• the nature of collaborations; • factors influencing collaboration; and • influence of PH policies on collaboration • perceived outcomes
Interpreting results
• BC+++ ON+++ Many reported in BC or ON • BC++ ON++ Some reported in BC or ON • BC+ ON+ A few reported in BC or ON
NATURE OF COLLABORATIONS
What activities are being done?
CDP/ HL • Tobacco reduction (BC+++; ON+++) • Diet, nutrition, obesity prevention (BC +:
ON+++) • * Maternal Child Health (BC+++) (did not
interview HBHC teams in ON) • Diabetes care & prevention (ON++) • General information sharing (ON+)
What activities are being done?
STIP • STI treatment and care management and clinic
work (BC++; ON+++) • Hep C program (ON++) • Education, inservices, consults (BC+; ON+)
What PC settings?
• Community Health Centres (BC++; ON +++) • Family Health Teams (ON +++) • Interdisciplinary PC Clinics (BC++) • Divisions of Family Practice (BC++) • Integrated primary health networks (BC ++) • Hospital programming focused on primary care
(ON ++) • Others such as walk in clinics, jails, local
addictions centres, STI partnership clinics (ON +)
Strength of Ties to PC
• Strong links (BC+; ON++) • Planning underway/seen as important by
stakeholders (BC+; ON+) • Weak ties (BC+; ON+)
No or very little collaboration
• ON + BC ++ – Discussions at higher levels (BC):
• … primary care is within our umbrella of community integrated health services. So I do understand they’re in our department now, under our portfolio. I haven’t personally, have not had any interaction with primary care. [ ]I believe at a level higher than myself, so my practice leads, my manager, is looking at having those interactions and that, and they’re more working with staff or leads or primary care. So my interaction has been none. Being truthfully honest, zero. (2011)
– Little to no collaboration (ON) • I would say with physical activity or even healthy eating, for that matter, there’s no
collaboration. We’ll promote each other’s programs, each other’s initiatives or stuff like that.
BARRIERS AND FACILITATORS
Intrapersonal Factors
Values beliefs attitudes • MD Negative – time pressures, lots of competing issues (BC ++; ON ++) • MD Positive attitudes; MDs belief it is worthwhile (BC ++; ON +)
– “We’ve done flyers, we’ve done communications, we’ve invited them to come and sit on
our steering committee as we were developing the program but it’s really hard to engage [MDs] because for one, we didn’t have the resources to pay them, so engaging physicians means also paying them to participate so that has been a challenge. … [ ] and I don’t know if it’s because they’re really busy seeing the clients or they’re not aware of what we do.
– So we have a partnership. Two local female physicians, approached us in public health to partner with them to offer a connecting pregnancy, a model of care for at-risk maternity patients. So we were very receptive to doing that because of course that’s our bread and butter, that is a vulnerable population and we certainly want to improve our relationships in partnering with physicians around maternal child population and so we took the chance and that’s been going very well. We’re just in the process of evaluating that because we’ve been doing it for about a year now. It’s rubbed with a bit of the other GP’s that are not involved in the connecting pregnancy because they don’t deliver enough babies themselves.
Interpersonal Factors
• Approaches differ between PC and PH (BC+++; ON ++) for all professionals – “if you think of an example of youth which is a vulnerable
population, they need primary care and public health services and attention and if public health and primary care aren’t working together then youth can fall through the cracks and be underserviced. And there’s many other populations like that where yes, primary care is taking more of the medical approach and public health is taking a more public health approach but you need both.” (BC)
• Effective communication (BC +++; ON +) – “We roll out a new program, the nurse family partnership, is a
perfect example of this. One of our docs didn’t even know we weren’t visiting every woman.” (BC)
Interpersonal Factors
• Role Clarity – understanding the role and work of the other (BC++; ON+) – “The gap might be probably primary care providers not
knowing […] what we do and citing us as a valuable resource for their patients. (ON)
– “No they don’t know the work we do, they don’t understand the work we do, they don’t understand the length of time it takes to get results, right. They could understand discontinue the STI clinics because it was this number of people treated and this number of people right. But to actually have that bigger broader picture of it, you know, that healthy living involves poverty and how many people you have living in poverty? And how many, you know like community gardens do you have, some of them don’t get that.” (BC)
Organizational Factors
• Organizational communication and coordination mechanisms (BC +++++; ON +++) – “What I have witnessed is that the public health folks feel like
the docs are not communicating like they should be, they aren’t listening to what they need them to listen to, are not willing to look at things outside of what their box is. That is what I hear from the public health side. Then when I put my primary care hat on, what I hear from the primary docs is public health doesn’t tell us, they ask us for stuff but they never report, we never hear back what is going on with our patients if they go do something with public health. There is too much information, I don’t really know what they are asking of me, they don’t talk to us.
Organizational Factors
• Importance of PH in relation to other parts of the health system (BC+++++) – … the whole primary care and our integrated health networks and all that. I
think that’s cool and a movement forward but it doesn’t include population health concepts and I don’t think they’ve made that connection yet. (BC)
– You know we recognize that you’re over there but they’re not really paying a lot of attention I think to this population health type of work that we do. We’re just kind of on the back burner right now. (BC)
• Organizational changes (BC +++) – “How are we going to work with physicians? And if, we were just struggling to
understand how would we work with physicians? Like we’re all at this population health are working with the determinants of health and what not. Like physicians are working at their care delivery to a client right? So they were trying to make this system a community integrated health services all wrapped around patient care and with the physician at the center. And were struggling to fit into that model.”
Organizational Factors
• Structures and Models (BC++; ON++) – “I mean the CHCs and there’s a network of them in [city], the Family
Health Teams, there’s some network of that I believe. […] they are all kind of independently can work on their own thing so there’s not … although we have the Standards it doesn’t require anything. It doesn’t require them to partner with us.” (ON)
– ‘If there’s no established other clinic or something like that, you’re needing to deal with new people [docs on locums] all the time.’ (ON)
Organizational Factors
• Structures and Models Continued…(BC++; ON++) – “…within the development of our community integration portfolio
because it puts primary care and promotion and prevention, a.k.a. our public health nurses, in that same portfolio area. So they are in the same leadership team having those conversations and then hopefully it can work more closely with our physicians. And there’s some new structures that are set up to help the health authority work more closely with physicians in the community because they don’t report to us right, but they have such a huge role… And so hopefully there will be a role for public health to work with some of those structures.” (BC)
Organizational Factors
• Resources and funding issues (BC +++; ON ++) – I just think it’s a very expensive way to sometimes
deliver some of the, some of the programs or pay physicians to deliver some of the programs. So as far as collaboration I think there is pretty good collaboration. I think sometimes the health authority thinks that they can support physicians, and I think they can to a certain degree; I just sometimes worry about the, the erosion of say public health to focus on primary care prevention. (BC)
Organizational Factors
• Leaders/ champions – to liaise with PC (ON+) – “we also have a physician outreach specialist that we’ve been working
with to kind of outline the strategies with communication with these external partners.” (ON)
– I’m actually the designated champion in our senior management team for liaison with primary care for this. (ON)
– VP of community integration from within her portfolio is promotion and prevention, but she also has home and community care, primary care, and so any links with our physicians. It is just huge right now. Aboriginal health, mental health and addictions, so she has all of those underneath her, and part of public health is only a small piece of that…..[ ] so they had to figure out how core functions fit into that and, you know, so we are just in the process of that right now basically. And all of those VPs, I don’t know how much understanding they have of core functions. (BC)
Systemic Level
• Public Health Policy influences – ON: OPHS (Ontario Public Health Standards,
Protocols, Guidance Documents, indicators and accountability agreements)
– BC: Core Functions Framework and Model Core Program Papers
Province Name of Document Type of Document
BC (n = 8)
1. BC Core Functions Resource Document Core document 1. Healthy Living
Model Core Program Papers
1. Reproductive Health and Prevention of Disabilities
1. Healthy Infant and Early Child Development 1. Healthy Communities 1. Prevention of Unintentional Injury 1. Health Assessment and Disease Surveillance 1. Communicable Disease
ON (n = 5)
1. Ontario Public Health Standards 2008* Core document 1. Sexual Health and Sexually Transmitted Infection
Prevention and Control* Protocols 1. Population Health Assessment*
1. Infectious Diseases* 1. Smoke-Free Ontario Act – Tobacco Compliance*
[m1]Some aspects of communicable disease control are legislated under the Public Health Act.
Policy Influence on Collaboration
• Stimulated actual PC / PH collaborations [ON++ (CDP/ STIP)]: – “I’ve noticed an emphasis on [smoking] cessation at
the primary care level and public health role in that.” (ON)
– “I think there’s always more collaboration at the local level for that. And from my experience in [HU] last year…there is ongoing collaboration for either specific areas or programs or specific attempts to do a more concerted strategic planning towards the collaboration.” (ON)
Policy Influence on Collaboration
• Increase in planning/building strategy for collaboration [ON+ (STIP & CDP)]: – “It needs, it needs a bit more leadership, …a bit more
work to have more joint planning and integration and that’s happened since the public health standards were adopted. There has been more deliberate work to think about how do we integrate.”
Policy Influence on Collaboration
• Policy reminds us to collaborate with Primary care (BC+; ON+): – “…there was always a desire to collaborate, but I
think [the policy] has made the need to collaborate more visible.” (BC)
– “So I think it’s we’re well aware from the Standards … I think it’s important that it’s there and I think that the Standards do help to remind again that we need to be working with this area, this sector..” (ON)
Policy Influence on Collaboration
• Unclear if Policies have influenced [ON+ (STIP)] – “It’s hard to know. It’s hard to attribute it to the
OPHS, because primary care has been identified as a key partner for a long time.”
Policy Influence on Collaboration
• Many felt the Policy did not make any impact on PC PH collaboration; [ON (CDP & STIP)] – “…but before then we had a physician’s newsletter
that went out. It’s not something …public health in general hasn’t been tapping into. It just might not be CDP has not been tapping strongly into that opportunity because of our differing perspectives…. or the OPHS Standards don’t direct us to focus on primary care.”
RECEPTIVITY AND STRATEGIES TO IMPROVE COLLABORATIONS
Receptivity
• All over the map (ON)
Strategies
• Improve communication mechanisms (BC+++) (transparent, organized, social inclusion)
• Create a physician engagement strategy (BC++; ON++); Rapid reviews, connections, positions – e.g., peers, outreach)
• Increase knowledge and understanding of each others’ worlds (BC+; ON+)
• Improve planning for partnerships with PC (BC+) and look for opportunities to collaborate (BC+; ON+)
• Improve accountability mechanisms for PC and PH (BC+) • Related to approaches – responsiveness, work with not at
(BC++) • Unsure how (BC++)
PERCEIVED OUTCOMES OF COLLABORATION
Perceived Outcomes of PC PH collaboration
• Strengthened relationships between PH and PC sectors (BC+++) • Benefits are minimal, not yet realized, or expected to come (BC+++; ON +) • Help in assessments - Data gathering (BC +++; ON +) • Improved or New Services and Programs (BC+; ON+) • Increasing Access to Programs and Services (BC ++; ON++) • New approaches established for provision of services programs (BC++) • Better Reach Attainment of PH Goals And Objectives (BC++; ON+) • Improved Health Behaviours (BC +; ON++) • Improved inclusivity - engagement of partners in planning (BC+; ON+) • Increase in Diagnoses (BC+) • New programs or services established (ON+; BC+) • Program Sustainability (ON+) • Reduced duplication of services (BC+) • Related to Efficiencies Gained (BC+; ON+)
Limitations/ Next Steps
Limitations Difficult to attribute association between PC PH
collaboration to PH Policies Was left to the end of long list of focus group
questions – rushed
Recommendations
• FHTs and CHCs are the most natural PC partners for PH and should be encouraged; – need to explore how to engage with and overcome
barriers to work with other PC partners in the future [HU]; – need to work with PC Branch at the Ministry to look for
solutions to better identify list of PC practices (in ON)
• Need more education for PC & PH to understand each other; joint conferences should be encouraged
• Engage with other PC team members as well as MDs to build stronger communication
Recommendations
• Collaborations with PC which reduce MD workload, cost PC no time or resources, or provide PC with resources are more likely to succeed
• Designated leaders/champions who work with PC need to be supported
• OPHS should be revised to explicitly name PC as a partner to encourage stronger collaborations on relevant issues that are important to each local community and a natural fit for the two sectors
Recommendations
• Topics that are the most natural fit for collaboration seem to be: tobacco cessation, well child, obesity prevention, diabetes prevention)
• Initiatives that address common goals should be the first place to start building collaborations
• STI work to be continued as in the past as per Policies
Please visit: http://www.toolkit2collaborate.ca/
