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What are Canadians seeking in the client experience How Can Health Professionals Embrace Patients, C


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Title: What are Canadians seeking in the client experience How Can Health Professionals Embrace Patients, C

What are Canadians seeking in the client
experience?How Can Health Professionals Embrace
Patients, Clients and Families?
  • Dr. Judith Shamian
  • President CEO
  • VON Canada
  • WHIN Symposium
  • May 22nd, 2008
  • Richmond, BC

What do Canadians Want?
  • Equitable and timely access to reliable service
  • Effective treatments and high quality care
  • Partnerships - involvement in decision-making
  • Support for family friend caregivers
  • Flexibility and choice
  • Information support for self-care
  • Seamless, integrated care
  • Emotional support and respect
  • Live, heal, and age at home

What do Canadians Want?
  • What initiatives would you support to improve the
    health system?
  • more home and community care programs 80
  • electronic patient records 60
  • more use of non-physician health providers 59
  • allowing the delivery of publicly covered
    services to be contracted out 51
  • paying to promote wellness and prevent disease,
    even if this means higher costs in the short
    term 51
  • Health Care in Canada Survey 2006

What do Canadians Want and Need?
  • Increase in demand for home care
  • Aging population
  • 4.3 million Canadians are 65 or older
    (Statistics Canada)
  • Re-structuring of health care system
  • Technology
  • Increased consumer demand
  • Between 1996 and 2046, the number of people
    needing home care is expected to double (CHCA,
  • 53 of Canadians prefer to recover at home
    (Health Care in Canada Survey, 2006).
  • Similar findings for end-of-life care.

Canadians Have a Health Care System That is.
  • Fragmented
  • Little coordination between providers or across
  • Inequitable
  • Access to care and services is not consistent
    across the country. Access is dependant on many
    things, such as geography, income (e.g. user
    fees), eligibility criteria, language, etc.
  • Reactive and illness-based
  • Reactive system that is good at treating illness
    but does a poor job at prevention and management
    (e.g. chronic disease)
  • Acute-care focused
  • Hospitals are very well-resourced in comparison
    to other sectors of health care.
  • Hierarchical, provider-centred

Hierarchy of the Health Care System
  • Often very little communication from top to
  • Clients and their families left feeling disengaged

Interprofessional Collaboration
  • Work is being done across the country, in both
    education and practice settings to create a
    cultural shift and encourage interprofessional
  • Interprofessional Network of BC (In-BC)
  • Institute of Interprofessional Health Sciences
  • The majority of work being done is targeted at
    health professionals.
  • Clients are involved in projects, but their level
    of involvement varies according to the project.

Patient-Centred Care
  • In some areas of the country, patients and their
    families are starting to be included as part of
    the care team. For example
  • Seamless Care - An Interprofessional Education
    Project for Innovative Team Based Transition Care
    (Dalhousie University)
  • Student teams from medicine, nursing, pharmacy,
    and dentistry/dental hygiene are helping patients
    develop the skills and knowledge necessary to
    manage their illness in consultation with the
    health care team as they transition from acute
    care to home or continuing care settings.
    (Project Website)

There are Gaps Between What We Know and What We
  • We say that we
  • Deliver client family-centred care
  • Work with patients as equal partners in care
  • Make evidence-based decisions
  • Deliver integrated seamless care
  • Want right person, right place, right time
  • but we dont
  • Develop providers skills
  • Help them develop confidence/skills
  • Have easy access to evidence at Point of Care
  • Bridge barriers between sectors
  • Provide appropriate funding mechanisms

Why Interprofessional Collaboration and
Patient-Centred Practice?
  • It is what Canadians want
  • Improves
  • patient outcomes
  • access to care and services
  • patient safety and communications among providers
  • efficiency of the system
  • recruitment and retention of HHR
  • (Adapted from Health Canada)

Self Managed Care
Wagner EH. Chronic disease management What will
it take to improve care for chronic illness?
Effective Clinical Practice. 19981(1)2-4.
Canadians Want Self Managed Care
  • Should Canadians take responsibility for their
    own health?
  • Canadians should take care of their own health,
    prevent illnesses and injuries, and by lead a
    healthy lifestyle 85
  • Canadians should work in partnership with
    healthcare providers to manage their health care
  • Canadians who live a healthy lifestyle should be
    rewarded, for example by tax incentives 50
  • Health Care in Canada Survey 2006

Chronic Disease Noncommunicable Disease
  • The global burden of noncommunicable diseases
    continues to grow tackling it constitutes one of
    the major challenges for development in the
    twenty-first century. Noncommunicable diseases,
    principally cardiovascular diseases, diabetes,
    cancers, and chronic respiratory diseases, caused
    an estimated 35 million deaths in 2005.
    DISEASES, 2008
  • WHO Department of Chronic Disease and Health
  • Promote healthy living (better diet, more
    physical activity and tobacco cessation) and
    healthy societies, especially for the poor and
    those living in disadvantaged populations.
  • Prevent premature deaths and avoid unnecessary
    disability due to chronic diseases. The solutions
    exist now, and many are simple, cheap and cost
  • Treat chronic diseases effectively, using latest
    available knowledge. Make treatment available to
    all, especially those in the poorest settings.
  • CARE
  • Help provide appropriate care by facilitating
    equitable and good quality health care for major
    chronic diseases.

1. Stay_at_Home with VONChronic Disease Self
Managed Care
Stay _at_ Homes Case Management and System
Delivery System Design Decision Support
Continuing Care/VON
Primary Care/FHT/PCI/Family Doctor
Case Management Care Coordination
Self-Care Portal
Care Planning Tx
Advocacy referral
Care Coordination and Case Management
Assessment, referral, liaison with health care
community Patient Monitoring - Pro-active calls
to client for assessment, care planning, follow
up Education provide Phone education/resource
and portal access. System Navigation. Resources
guidance and routine care calls, referral, long
term follow up. Portal for Client Information
Connectivity to patient information from an
integrated primary, secondary, etc.
sources Interventions timely support, Nursing
assessments, Nutrition /Education , Medication
Therapy, CDSMP classes Community Support Meals
Programs, Transportation, Visiting companions,
Respite etc.
Chronic Disease Self-Management Classes
  • First class JanuaryFebruary 2008 with 15
  • the first week, I met someone and thats what
    made me go back. She had the same diagnosis as
    me and felt no one was paying attention to her
    either. Its so good to find someone from my
    planet because sometimes you feel like a total
    idiot complaining about pain that cant seem to
    be fixed.
  • Things changed in little bits and pieces during
    the program. I listened to the voice in me that
    I hadnt been paying attention to by listening to
    others in the room. I realized I had to stop
    thinking about how I got here and start thinking
    about how I get out. I needed to take back the
    control I had given away to everyone else.
  • Its like being active again.

2. Self-Managed CareAging at Home
  • Seniors Managing Independent Living Easily
  • Part of Aging at Home Strategy (Ontario Ministry
    of Health and Long-term Care)
  • The model is designed to maximize local access to
    services through multiple access portals at
    points in the system where people traditionally
    seek care or have contact with their community,
    as well as assistance with service navigation, if
    wanted or needed.
  • More importantly, it provides seniors with the
    choice of self-managing services through
    traditional and non-traditional service
    providers, and/or of selecting care from
    traditional community support agencies.

Betty SMILE Participant
  • Betty is 91 and lives in a house that overlooks
    Picton Harbour. It has a front porch, a balcony
    and a deck at the back. The deck is where she
    likes to be in the summer, because it looks out
    on her flower garden.
  • These days, shes only able to putter around in
    the garden. I hire someone to take care of the
    heavy gardening work, explains Betty. She also
    likes to knit, and shows us a blue shrug that she
    is making for one of the residents of a nearby
    nursing home. It helps to keep them warm, she
  • Betty cant do as much as she used to, so she
    pays her neighbour, Bob, to do maintenance work
    in and around the house. Because she doesnt own
    a car, he sometimes drives her to appointments or
    her nephew does, and she covers their gas.
  • Last year, Betty was diagnosed with cancer and
    now needs to go to Kingston General Hospital for
    treatment. She says that the Cancer Society
    covers her transportation, but she is on her own
    for other appointments. So thats difficult,
    she adds.
  • Betty is proud to have reached 90 and to be
    living at home still. There are a few of us on
    this street who are in our 90s and still living
    in our own homes, says Betty. Its a real

Why Self-Managed Care?
  • The SMILE program will make it possible for more
    seniors who are frail and elderly, and most at
    risk of premature institutionalization, to
    receive help with activities that are essential
    to daily living, so they can remain in their
  • Because dignity is a matter of choice, SMILE will
    offer them options in managing their care, in
    selecting services, in choosing who comes into
    their home and when.

Why Self-Managed Care?
  • Canadians want control over their chronic illness
  • 16 million Canadians live with chronic illness
  • 80 of adults over age 65 have a chronic disease
  • 25 of Aboriginal people over age 45 have
  • Chronic Disease is responsible for
  • 60 of hospitalizations
  • 70 of all deaths in Canada
  • 2/3 of medical admissions via emergency
  • 80 of family doctor visits
  • 60-80 of total medical costs
  • Source Rapoport, J. et al Chronic Diseases in
    Canada, 2004 in CDM for the SIMS partnership.
    Phase 2 CDM Program Design. CDM working group,
    April 12, 2006.

Why Self-Managed Care?Lifestyle Changes Reduce
Health Care Costs
3. Family/Caregiver Engagement and Support
  • 2.85 million Canadians are caregivers
  • Caregivers in Canada provide more than 2 billion
    hours of caregiving, saving the health care
    system an estimated 5 billion per year
  • Predominantly female (77), typically older
  • Male caregivers also play an important role
  • Emerging trend of teen and young adult caregivers
  • Many are employed outside the home

Who is Providing Care in the Community?
sources Canadian Home Care Human Resources
Sector Study, 2003 National Population Health
Survey, (NPHS), 1996 Statistics Canada,
General Social Survey, 1996
What caregivers need?
Caregivers need to be informed regarding what
support is available to them not only to support
the family member but also to meet their own
needs. This information is not readily evident,
you really have to dig for it or the list of
helpful organizations is so long you dont know
where to look it needs to be organized such that
you can contact the organization quickly. There
is so much searching required it is a real
challenge. Caregiver, VON Canada Learning to
Listen Listening to Learn Project participant,
  • What caregivers need
  • Easy to understand information about caregiving
    health, financial, emotional information
  • Access to respite information and opportunities
    for themselves
  • Connection with the health care system

(No Transcript)
Purpose of the portal
  • The Caregiver Connect provides caregivers with
    information, resources and supports they need
  • to care for themselves
  • to provide better quality care to their family
    members and/or friends and
  • to connect and share with other caregivers.

Who will Benefit from this Portal?
  • Caregivers
  • access to information
  • a space to learn, share and seek support for
  • reduces the feeling of isolation
  • Care recipients
  • will improve care from their informed and
    supported caregiver
  • Health professionals
  • access to up to date community specific
  • The health care system
  • caregivers save the system an estimated 5B a
  • they need to be supported to be sustained in
    their work

Building a Community of Practice
  • Caregiver Portal Communities of Practice (CoP)
    are distributed groups of people who share a
    common concern and sense of purpose about the
    care of a family member or friend. The concept of
    community binds them together
  • The Caregiver Portal will serve as the virtual
    meeting place for these Communities of Practice
  • Caregivers will connect online with peers and
    other experts via the Caregiver Portal CoP

Caregiver Portal Community of Practice
a circle of caring
Other Health Care Professionals
Health Care Provider
Family/ Friend Caregiver
Care Recipient
Other Caregivers
Caregiving network
Concluding Remarks
  • Approaches to health care must include patients
    and their families in meaningful ways for the
    benefit of patients and caregivers as well as
    the health care system.
  • Patient and caregiver engagement improves health
    outcomes and overall well-being.
  • There are not enough resources (HHR, beds, money,
    etc.) to provide comprehensive care and support
    to everyone if we continue with our current
    acute-care focused approach. There is no other
    option, luckily it happens to be the right
    thing to do!

Concluding Remarks
  • Time to move from rhetoric to action
  • Philosophy must be embedded across sectors and
    vertically throughout work settings (i.e.
    frontline ?management).
  • All approaches, policies, programs and services
    must centre on the needs of clients and their
    families. Mechanisms must be put in place along
    with targets and incentives to make sure that
    progress is made.
  • Collective accountability

  • Health professionals have a moral and
    professional obligation to embrace patients,
    clients and families.

Thank you
Judith.Shamian_at_von.ca www.von.ca
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