48th annual scientific assembly of family medicine skills

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48 th Annual Scientific Assembly Family Medicine Skills & Community April 6-8, 2006 PEDIATRICS: ACCESS ISSUES Dr. Cheryl R. Greenberg

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Page 1: 48th Annual Scientific Assembly of Family Medicine Skills

48th Annual Scientific Assembly Family Medicine Skills & Community

April 6-8, 2006

PEDIATRICS: ACCESS ISSUES

Dr. Cheryl R. Greenberg

Page 2: 48th Annual Scientific Assembly of Family Medicine Skills

The Child Health Program and the Dept of Pediatrics & Child

Health

Winnipeg Regional Health Authority

And University of Manitoba

Dec 2004

Page 3: 48th Annual Scientific Assembly of Family Medicine Skills

Child Health Programme- WRHA

• Vision:– Driven by a vision of a society in which all

children and their families have equal access to the full continuum of pediatric health care services. To achieve this, the Child Health programme and the Dept. of Pediatrics and Child Health will strive for highest quality, cost-effective clinical care, education, research and advocacy for children.

Page 4: 48th Annual Scientific Assembly of Family Medicine Skills

Child Health Programme- WRHA

• Mandate to provide excellence in care to children and youth throughout the province and in a collaborative way throughout western Canada

• To provide innovative care across the continuum through advocacy & empowerment

• Main site- Children’s Hospital of Winnipeg• Large outpatient pediatric service at St.

Boniface General Hospital• 2 level 3-4 intensive care nurseries serving

the province

Page 5: 48th Annual Scientific Assembly of Family Medicine Skills

Child Health Programme- WRHA

• Close linkages/services to many disciplines/programmes for children and youth: – Provincial Outreach Therapy for Children

(POTC): SMD, RCC, St. Amant Centre– Healthy Child Manitoba– Provincial Diabetes Initiative– Children’s Asthma Education Programme – Children’s Hospital Foundation of MB, Inc and

Manitoba Institute of Child Health (MICH)– MB Telehealth

Page 7: 48th Annual Scientific Assembly of Family Medicine Skills

History• 1909: 3 story home on Beaconsfield– 15 cots, 1 nurse,

volunteer doctors and surgeons

• Almost 100 years later– State –of –the –art

127 bed facility– Treats greater than

130,000 patients a year

• Committed to excellence in 3 pillars– Service, teaching

and research

Page 8: 48th Annual Scientific Assembly of Family Medicine Skills

Children’s Hospital Winnipeg• "Most paediatricians in

Canada and the United States wore bow ties. There were said to be two reasons which justified its use by paediatricians - (1) it prevented strangulation of the paediatrician by an aggressive 2 1/2 year old who caught hold of the four-in-hand [tie] and pulled with all his might and main; and (2) it kept the tie out of the diaper area."

Page 9: 48th Annual Scientific Assembly of Family Medicine Skills

Winnipeg Children’s Hospital• Only tertiary care facility for children

and youth in this province• Serves a much larger catchment area

in providing general and subspecialty care to children and youth also in– Northwest Ontario– Portions of NU

• Serves as a referral “regional”centre for tertiary care for an increasing number of subspecialties

Page 10: 48th Annual Scientific Assembly of Family Medicine Skills

Children’s Hospital • Long history of innovation and excellence• Patterns are changing in how health care is

delivered, who is delivering it and to whom– Inpatient to outpatient focus– Patient focussed to family-centred and

culturally effective care• Health care providers truly cross the

continuum and have a regional, provincial and national focus

• Improvement in health outcomes for children and their families depend on effecting change

• Interventions must be based on evidence –based quality data and strategies to implementing valid findings

Page 11: 48th Annual Scientific Assembly of Family Medicine Skills

Dept. of Pediatrics & Child Health- Univ. of Manitoba

• Mission to teach and train current and future generations of doctors and other health care professionals

• Mandate for excellence in research• Currently 84 Geographical Full Time

(GFT) and 58 “part-time” pediatricians with University appointments

• 18 Sections encompassing all (sub)specialties

• The same doctors (GFTs and PTs) that teach and do research are the ones providing the care

Page 12: 48th Annual Scientific Assembly of Family Medicine Skills

Mission and Vision• Fundamental belief in 3 pillars of Excellence

– Excellence in clinical care– Excellence in research– Excellence in teaching

• Closely related and totally interdependent• Child Health research is synonymous with

excellence in care for children and youth• Child Health research and clinical care is

fundamental to better health in adulthood• Research opportunities drive recruitment

Page 13: 48th Annual Scientific Assembly of Family Medicine Skills

Section of Allergy & Clinical Immunology

OUTPATIENTS• Last complete year

› 2555 out patients seen in consultation

• Current waiting list › 1 year or more- asthma and

allergy are increasingly exponentially!

› urgent consults prioritizedINPATIENTS• Hospital consultations seen

immediately

Page 14: 48th Annual Scientific Assembly of Family Medicine Skills

Section Resources

• 3 consultant allergists + 1 community ped

• 1 nurse practitioner• 1 clinic nurse• 4 part-time asthma educators• 2 full time secretaries• Excluding research support staff

Page 15: 48th Annual Scientific Assembly of Family Medicine Skills

Children's Hospital Asthma Admissions

1993-2003

0

100

200

300

400

500

600

1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003

Year of Admissions*Children's Asthma Education Project Began **CAEC Offically Launched

Nu

mb

er o

f A

dm

issi

on

s

Totals

*

517

22

Page 16: 48th Annual Scientific Assembly of Family Medicine Skills

Section of Allergy & Clinical Immunology

– “Made in Manitoba” research• Leaders in the translation between research and

practice –ie “BEST PRACTICE” based on locally gathered evidence-based quality data– Eg. MB Health supported a 4 yr Demonstration

Project which showed the impact of education on decreasing health services utilization and enhanced quality of life of children and youth with asthma

– Simultaneously supported by Industry (Merck Frosst; AZ)to allow the project to move forward- $200,000 p.a for all research costs (Research nurses; data analysis; laboratory measurements)

– Programme has ongoing continuous evaluation and since 2002 in a province-wide programme (CAEC), total operating budget $120,000 pa

Page 17: 48th Annual Scientific Assembly of Family Medicine Skills

Asthma Educator Intervention

0

100

200

300

400

500

600

1:1 Education Class Participants

Num

ber o

f Par

ticip

ants

Totals

Page 18: 48th Annual Scientific Assembly of Family Medicine Skills

CAEC WebsiteApril 2003 to March 2004

www.asthma-education.com

0

5000

10000

15000

20000

25000

30000

35000

40000

45000

50000

12 Month Period From Launch April 2003 to March 2004

Hits

/Mon

th

Totals

Page 19: 48th Annual Scientific Assembly of Family Medicine Skills

Section of Allergy- Impact of Research

• Top quality research goes hand in hand with top quality care- current research $ > $3 million pa operating costs not medical remuneration

• Industry supports research now• Active fellowship programme

– 2 members are co-mentors in the CIHR- funded National Training programme in Allergy and Clinical Immunology

• Clinical load continues to grow- needs unmet– 3 GFTs supplemented by community ped but

clinical and research commitments not being met

Page 20: 48th Annual Scientific Assembly of Family Medicine Skills

The Child Health Program and the Dept of Pediatrics & Child

Health• Our deliverables are care, research & teaching

excellence• The only reason we have excellent tertiary care

here is because people chose to come here because of the research potential

• Only have excellent care if there is excellent research

• Current system is leading to crisis in all Sections– Increasingly difficult to fulfill its committment

to clinical and academic missions

Page 21: 48th Annual Scientific Assembly of Family Medicine Skills

Al Aynsley-Green

National Clinical Director for Children for England

Bridging the gap between politics, policy and practice!

Page 22: 48th Annual Scientific Assembly of Family Medicine Skills

Children should be our nation’s most precious asset!

• Nothing matters more to families than the health and welfare of their children

• They are a living message to a time we will not see• They are vital for our national economic survival• Healthy mothers produce healthy children who

become healthy adults• Much adult ill health has its roots in childhood

Page 23: 48th Annual Scientific Assembly of Family Medicine Skills

‘Children’s services were described in the 1970s as a Cinderella service. Cinderella has never been to the ball. It’s still a Cinderella service after 25 years. This can’t be right.’

Ian Kennedy on the Bristol Inquiry.BMJ 2001;323:183

Page 24: 48th Annual Scientific Assembly of Family Medicine Skills

The systems failures exposed by Kennedy and Laming:

• care always subordinated to demands of adults

• lack of concern for vulnerable individuals

• failure to listen to patients and caregivers

• quality of care less than it should be

• lack of effective planning

• fragmentation and lack of responsibility

• lack of effective leadership

• (Ability to admit a sick child is a major success!)

Page 25: 48th Annual Scientific Assembly of Family Medicine Skills

                                           

       

                                                                                                                           

                                  

      

Map of Manitoba's Regional Health Authorities

Page 26: 48th Annual Scientific Assembly of Family Medicine Skills

• • •

• MANITOBA CHILD HEALTH ATLAS 2004•  • Inequalities in Child Health: • Assessing the Roles of Family, Community, Education and Health CareMarni Brownell, PhD

Noralou Roos, PhDRandy Fransoo, MScAnne Guevremont, BSc, MEdNorman Frohlich, PhDAnita Kozyrskyj, BScPhm, PhDRuth Bond, MAJennifer Bodnarchuk, MA Shelley Derksen, MScLeonard MacWilliam, MSc, MNRMMatt Dahl, BScNatalia Dik, MScBogdan Bogdanovic, BComm, BAMonica Sirski, MMathHeather Prior, MSc

• Acknowledgements• This is the website for The Manitoba Child Health Atlas 2004, published solely on the World Wide Web. The Atlas comes out of

a 3-year project funded by the Canadian Population Health Initiative focusing on factors that contribute to inequalities in child health and well-being. The Atlas provides descriptive, population-based analyses of the health and educational outcomes of Manitoba children, at the level of health regions and sub-regions.

• Graphs and maps of variations in child health and educational achievement at various stages of development and by family circumstances and community characteristics are provided on this website. Excel files with the data used to develop these graphs and maps are also provided so users can develop their own output.

• • Winnipeg Report

(20-page pdf) Figures from Report * SummaryNon-Winnipeg Rural and Northern Health Care Meeting Presentation * * PowerPoint file can be downloaded for notes.

• © 2004 University of ManitobaLast modified on Tuesday, 05-Jul-2005 22:37:17 CDT  

Page 27: 48th Annual Scientific Assembly of Family Medicine Skills

Figure 3.3.3a: Age Profile of Brandon, 2000Population: 47,337

7% 6% 5% 4% 3% 2% 1% 0% 1% 2% 3% 4% 5% 6% 7%

0-4

10-14

20-24

30-34

40-44

50-54

60-64

70-74

80-84

90 +Brandon 2000

Manitoba 2000

Males Females

Page 28: 48th Annual Scientific Assembly of Family Medicine Skills

Figure 3.3.9a: Age Profile of Burntwood, 2000Population: 45,051

7% 6% 5% 4% 3% 2% 1% 0% 1% 2% 3% 4% 5% 6% 7%

0-4

10-14

20-24

30-34

40-44

50-54

60-64

70-74

80-84

90 +Burntwood 2000

Manitoba 2000

Male Female

Page 29: 48th Annual Scientific Assembly of Family Medicine Skills

Infant Mortality Rates for Liveborn Infants Under 1 Year of Ageby Manitoba RHA, 1997-2001

0 2 4 6 8 10 12

South Eastman

Central

Brandon

Assiniboine

Winnipeg

Interlake

North Eastman (1)

Parkland

Churchill (s)

Nor-Man

Burntwood (1)

Manitoba

Rate per 1000

Manitoba RHA

Manitoba Average

'1' indicates rate signifi cantly diff erent f rom the Manitoba mean

's' indicates data suppressed due to small numbers

Page 30: 48th Annual Scientific Assembly of Family Medicine Skills

Child Mortality Rates for Children Aged 1-19 Years by Manitoba RHA, 1997-2001

0 2 4 6 8 10 12

South Eastman

Central

Brandon

Assiniboine

Winnipeg (1)

Interlake

North Eastman (1)

Parkland

Churchill (s)

Nor-Man (1)

Burntwood (1)

Manitoba

Adjusted Rate per 10000

Manitoba RHA

Manitoba Average

'1' indicates rate signifi cantly diff erent f rom the Manitoba mean

's' indicates data suppressed due to small numbers

Page 31: 48th Annual Scientific Assembly of Family Medicine Skills

Low Birth Weight Rates by Manitoba RHA, 1997-2001

0 10 20 30 40 50 60 70 80

South Eastman

Central

Brandon

Assiniboine

Winnipeg (1)

Interlake

North Eastman

Parkland

Churchill

Nor-Man

Burntwood

Manitoba

Rate per 1000

Manitoba RHA

Manitoba Average

'1' indicates rate signifi cantly diff erent f rom the Manitoba mean

Page 32: 48th Annual Scientific Assembly of Family Medicine Skills

Aboriginal People

• First Nations (Indian); Inuit; Metis• 10% of Winnipeg is aboriginal- children 17-18%• Much poorer health status

– 52% of teen pregnancy aboriginal

– 83% of children in care are aboriginal

– Severe trauma overrepresented• “Eagle’s Eye View”, United Way Wpg

• MCHP/Centres/Reports

• Statistics Canada, Aboriginal People’s Survey 2001

Page 33: 48th Annual Scientific Assembly of Family Medicine Skills

Canadian Hospitals that Specialize in Pediatric Care

Hospital No. of BedsMost Recent Annual

Budget Budget/Bed

Winnipeg Children's Hospital 120 $46.0 million $0.38

Montreal Children's Hospital 180 $77.3 million $0.43

McMaster Children's Hospital, Hamilton 117 $55.0 million $0.47

Children's Hospital of Western Ontario, London 70 $45.0 million $0.64

Children's Hospital of Eastern Ontario, Ottawa 150 $130.0 million $0.87

Alberta Children's Hospital, Calgary 107 $130.0 million $1.21

Source: The Medical Post/Special Report: Pediatric Hospitals/March 7, 2006

Page 34: 48th Annual Scientific Assembly of Family Medicine Skills

Context now:• Population base with every circumstance, condition and

disease affecting children• Best opportunity to improve children’s lives and health

for 50 years!• The way we think about things and do them need to

change• Outstanding opportunities for staff - esprit de corps,

pride, valued; training, teaching, evidence & research• Innovative approaches to care to improve the patient’s

experience• We must see ourselves as co-drivers in the driving seat!

Page 35: 48th Annual Scientific Assembly of Family Medicine Skills

Guiding Principles- organized integrated approach

• Ownership /Commitment/Will– Shared between community/clinicians/leadership

• Data and Scope– Listing and Coordination of existing services

– Preventative vs crisis care

• Communication• Knowledge translation

– Monitor outcomes

Page 36: 48th Annual Scientific Assembly of Family Medicine Skills

Clinical Scenarios- Refer or Not?

• 1 month old below birth weight and respiratory difficulties

• 5 year old with abdominal pain

• 2 year old with buckle fracture

• ADHD?• Learning problems

Page 37: 48th Annual Scientific Assembly of Family Medicine Skills

If Refer, to whom , how, when?

• To consultant pediatrician or subspecialist?– Pediatrician – refer to community pediatrician in Wpg

• ? “private clinic” or St Boniface ambulatory group• Ambulatory clinic group at Children’s• Consultant pediatricians in Portage, Brandon, Thompson

– Subspecialist• Most common- cardiology, allergy, neurology, GI, ped surgery

( and subspec surgery), plastics, ortho, diabetes, respirology, neonatology, child development, CADEC, Hemat/oncol

• Phone? Every service has on call physician 24/7 204-787-2071• FAX 787-4807

Page 38: 48th Annual Scientific Assembly of Family Medicine Skills

If Refer, to whom , how, when?

• Develop core group of consultant general pediatricians to triage consults, offer rapid feedback as required

• 24 hour “Hot Line”

• Increase use of TeleHealth

• Outreach clinics

Page 39: 48th Annual Scientific Assembly of Family Medicine Skills

Provincial Child Health Strategy

• Regional networks of family physicians with designated individuals with enhanced skills in pediatrics– To achieve this: implement enhanced skills training for 3rd year

now, CME/ upgrade for current family physicians- rotations in Winnipeg; Telehealth case conferences; PALS; NALS, ACORN; CLIPP ( www.dartmouth.edu/~clipp); Healthy ABC’s ; Can. Ped. Soc. website

• Consultant general pediatricians available 24/7– Onsite +/- off –site

• Enhance recruitment to Family Medicine and General Pediatrics

Page 40: 48th Annual Scientific Assembly of Family Medicine Skills

Every Child Matters 5 key objectives:

• Being healthy• Staying safe• Enjoying and achieving• Making a positive contribution• Securing economic well-being

delivered by:

- Supporting parents and carers

- Early interventions and effective protection

- Accountability and integration

- Workforce reform

Page 41: 48th Annual Scientific Assembly of Family Medicine Skills