oct 24 caphc plenary presentation - dr. maureen o'donnell

Changing the odds and finishing first:Harnessing our strengths to improve children’s health services in Canada

CAPHC October 24, 2016

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• Insert photo of child here

Objectives for today…

• What are the some of our challenges and opportunities in improving health and health services for children

• How can we move to improve health of children and youth?

• How do we improve the health service system for children and youth?

• Learning from one another

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Challenge: Proportion of children in the population as a whole

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Challenge:Proportion of children in the population as a whole

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Challenge Proportion of children in the population compared to >65

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Challenge:Geographic differences

10Accessed from www.statscan.gc.ca

Challenge:Vast geography – relatively small population

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Source: http://www.bcrobyn.com/2012/12/how-big-is-british-columbia/

Challenge: Health status of Canada’s children?

UNICEF Office of Research (2013). ‘Child Well-being in Rich Countries: A comparative overview’, Innocenti Report Card 11, UNICEF Office of Research, Florence.

ChallengeHealth care expenditures

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Challenge – describing health care expenditures for children

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Challenges

• Proportionately few children in the population

• Proportionately more children in more rural and remote areas

• Vast geography – with relatively low population and low population of children

• The health status of Canadian children remains a concern

• Health system sustainability/cost remains a concern– How well can we describe “health” related costs for children?– Health system reform, health service integration

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Strengths and opportunities

• Publically funded health care system– Multi-sectoral especially for children and youth

• Data – national and provincial

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National:•Canadian Community Health Survey•National Housing Survey•LIM –AT (Low Incomes Measures – After Tax)•Statistics Canada Labour Force Survey

Provincial:•VISTA BC Vital Statistics•Perinatal Services BC Data Base•McCreary Centre Society Adolescent Health Survey•Early Development Instrument – Human Early Learning Partnership•BEST•BC Centre for Disease Control •Ministry for Children and Family Development Data Base•Ministry of Education Data Base•Ministry of Health – Public Health Surveillance and Epidemiology, Chronic Disease Registries•Ministry of Health – HealthIdeas database

Example – BC child health status report


• Publically funded health care system– Multisectoral, especially for children and youth

• Data – national and provincial

• Data analysis, interpretation– Academic knowledge with respect to children/ excellence in health

services researchers– Partnerships e.g. CAPHC and CIHI– Emphasis on children – CIHI

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• Evidence-based policy

• Evidence-based practice, including national endeavors– E.g. TREKK, Child-Bright SPOR

• Academically strong training programs– Well trained health providers

• System innovation– Including learning from eachother

• Tremendous philanthropic support

• We collaborate rather than compete 24






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Two pronged approach to improving child health

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Improve health status Improve health services






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What makes us healthy?

Canadian Medical Association, 2013

What do we know about the health status of Canada’s children?

UNICEF Office of Research (2013). ‘Child Well-being in Rich Countries: A comparative overview’, Innocenti Report Card 11, UNICEF Office of Research, Florence.

Do you know how healthy children in your province are?

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• Ministry of Health• Ministry of Child/Family

Development• Ministry of Education

• Fraser• Interior• Island• Northern• Van-Coastal• PHSA• First Nations

• UBC Departments of Pediatrics, Surgery

• Canadian Child Health Coalition

• BC Pediatric Society• DOBC: Society of GPs• BC Principals, Vice

Principals

Government Ministries

Provincial Health

Authorities

Academic Partners

Professional Societies

Child Health BC - Steering Committee

Is “Good” Good Enough?

• A BC report

• For release November 3, 2016– “Book” version – Online version

Dimensions of Child and Youth Health & Well-being

In 2013, the PHO and the Canadian Institute for Health Information (CIHI) released a suite of 51 valid indicators

• The indicators reflect five dimensions:

THE INDICATORS: Physical Health & Well-being

• Physical health and well-being is more than the absence of disease. It includes a healthy start in life, preventive care, healthy development, safe environments, and much more.

• This dimension includes 21 indicators:

#1 Low Birth Weight#2 Smoking during Pregnancy#3 Alcohol Use during Pregnancy#4 Breastfeeding#5 Fruit & Vegetable Consumption#6 Vision Screening#7 Hearing Screening#8 Dental Caries Prevalence#9 Percentage of Children with Healthy

Weight#10 Positive Self-rated Health

#11 Youth Physical Activity Levels#12 Frequency of Tobacco Use#13 Binge Drinking#14 Marijuana Use#15 Immunization Rates#16 Asthma Prevalence#17 Serious Injury among Children & Youth#18 Chlamydia Incidence#19 Teenage Birth Rate#20 Physical Health & Well-being Skills#21 Infant Mortality Rate

THE INDICATORS: Mental & Emotional Health & Well-being

• Mental and emotional health and well-being refers to a range of personal characteristics, self-regulating abilities, capacity for connectedness, and freedom from anxiety and depression.


#22 Incidence & Prevalence of Most Common Mental Health Disorders

#23 Positive Self-esteem#24 Positive Self-rated Mental Health#25 Positive Life Satisfaction#26 Considered Suicide#27 Suicide Rate#28 Most Common Prescription Mental

Health Drugs

THE INDICATORS: Social Relationships

• Social relationships are key components of child and youth health and well-being, and includes having relationships that are close, trusted, accepting, affirming and reciprocal with peers, parents, teachers, coaches and others.


#29 Positive Parent Relationship#30 Trusting Adult Relationship#31 School Connectedness Rate#32 Community Connectedness Rate#33 Incidence of Abuse/Neglect#34 Incidence of Sexual Abuse

#35 Rate of Children in Care#36 Discrimination Rate#37 Bullying Rate#38 Youth Conviction Rate#39 After-school Activities

Advisory Committee members include representatives:– Health Officer’s Council– Ministry of Health– Ministry of Education– Ministry for Children and Family Development– First Nations Health Authority– Health Authorities – Doctors of BC– BC Pediatric Society– BC Children’s Hospital– BC Centre for Disease Control– Perinatal Services BC – BC Representative for Children and Youth – UBC– Researchers from McCreary Centre Society, HELP

A collaborative effort

Some indicators demonstrate improvement over time

Language and Cognitive Development Domain – Vulnerability on EDI

Some indicators show stability over time Physical Health domain – Immunization rates

Some indicators showed decline over timeSocial Relationships

Disparities by sex/gender in many indicators

Some examples of how we are responding in BC

• Trying to deliver the “critical messages” about health status of our children– Including through work of our Healthy Child Development Alliance

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• Measured health status – so we have the knowledge of health status to work with

• Worked with the Ministry of Health’s so ensure their “Lifetime Prevention Schedule” has a focus on evidence-based interventions for children. E.g flouride varnish for prevention of caries

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• Worked with the Ministry of Health’s so ensure their “Lifetime Prevention Schedule” has a focus on evidence-based interventions for children e.g. flouride varnish for the prevention of caries

• Working on implementation strategy for flouride varnish for children• Continuing/ renewed immunization efforts• Reinforcing efforts regarding mental health promotion/health literacy• Linkages with First Nations Health Authority

• Province standards and resources for healthy physical activity and healthy eating in child care settings (Ministry grant)

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• Worked with the Ministry of Health’s so ensure their “Lifetime Prevention Schedule” has a focus on evidence-based interventions for children e.g. flouride varnish for the prevention of caries

• Working on implementation strategy for flouride varnish for children• Continuing/ renewed immunization efforts• Reinforcing efforts regarding mental health promotion/health literacy• Linkages with First Nations Health Authority

• Province standards and resources for healthy physical activity and healthy eating in child care settings (Ministry grant)

• Must link with and support youth! 48

A call to action

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How do we respond as health care providers and managers?

• Deliver the critical messaging

• But does it influence…– What services we provide?– How we provide our services?

– For example, how do geographic disparities/inequities influence what you provide?

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Our call to action: I’ll hope you’ll join in thinking about…

• What do you know about the health/health status of children in your province?

• What is your province measuring about the health of its children?

• What population health initiatives are supporting child health?

• How are pediatric/child health experts involved in supporting/influencing child health (promotion) programs and policy?

• For those of us delivering health services, how do we consider health status and social vulnerabilities in our hospitals?

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How do support the system of health services for children? And do we even need a “system?”

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109 hospitals/HC’s see children in ED

73 hospitals admit for medical

reasons

43 admit for surgical reasons

• Challenges service planning given relatively low volumes & large geography (Rural/remote and small urban needs)

• Desire to ensure primary care is optimized while simplifying referral paths and access to specialty and sub-specialty services.

• Build a foundational to quality and the development of appropriate: – Practice guidelines/care pathways– Care pathways – Team-based practice models (on-site & via

outreach/telehealth) – Provincial health human resource strategy

• Sustainability of quality services

What issues did we need to tackle?

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Literature and Jurisdictional review

Why tiered approach?

Australia’s Queensland Health: “Clinical Services Capability Framework”

Bundaberg Regional

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Tiers at a Glance (All Services)

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Tiers at a Glance (All Services)

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What does each module “outline?”

• Responsibilities:– Clinical – Knowledge Sharing and Transfer – Quality Improvement and Research

• Requirements:– Providers– Equipment and Supplies– Facilities– Medications– Interdependencies

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• key individuals – across disciplines & geography

• Use outcome evidence

• Use service utilization data

• Guided consensus meetings (series)

• Broad stakeholder feedback on draft, including provincial councils/committees,

• Acceptance by provincial ministry councils/committees

How do we develop a Tiers of Service Module?

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Each module has three components

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Completed modules

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• Clinical Services:– Emergency Department– Medicine– Medical Subspecialties– Surgery (Adult & Pediatric Surgical Specialists)– Intensive Care for children– Child Development & Rehabilitation– Mental Health & Substance Use– Home-based Services

• Clinical Diagnostic & Therapeutic Services:– Laboratory, Pathology & Transfusion Medicine (in conjunction with PSBC and

the Provincial Lab Agency)– Diagnostic imaging– Pharmacy

A series of Tiers of Service Modules (for child health)

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Sample page– Surgery Example of one area of clinical responsibilities

68Refer to details in “Surgical Tiers “in brief”

and/or “in full””

• Clinical Services:– Emergency Department– Medicine– Medical Subspecialties– Surgery (Adult & Pediatric Surgical Specialists)– Intensive Care – Child Development & Rehabilitation– Home-based Services– Mental Health & Substance Use

• Clinical Diagnostic & Therapeutic Services:– Laboratory, Pathology & Transfusion Medicine (in conjunction with PSBC)– Diagnostic imaging– Pharmacy

Where are we at with the child health tiers?

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109/109 ED’s in BC completed self-assessment

Module developed, self-assessments completed

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To what tier are sites aligned?

18 © Child Health BC | January 19, 2016

Given their tier alignment, what are the strengths and

“opportunities”?

For each site, each HA, the province

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Hospitals providing ED care to children, with ED Tier designation

Example – HA map putting tier alignment in context of driving time

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Emergency TiersWhat action has happened since the self-assessment

• Close collaboration between CHBC and the MOH’s Committee (ESAC)

• Sites and regional action:– Received their reports– Site and regional “opportunities”

• Province wide action:– ESAC and CHBC have created provincial

working group– Agreed to a common work plan on

September 8, 2016 – heavily T1 and T2.– Links to academic health network and

mental health services– Links to national endeavours (e.g. TREKK) 75

Received agreement to proceed, in face of other priority areas

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Even now…

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What is the value in proceeding?Why is Tiers of Service work of assistance?

Clinical Services:• Planning and standardization of appropriate services: To reduce

risk/improve quality. To improve efficiency within and across sites. • Standardization of appropriate care: To set the stage for layering

on clinical standards which are appropriate to tier of service offered• Rural and Remote focus: Useful across province, especially in

rural and remote settings. • Capital planning: To focus capital projects to the service needs

appropriate to the community and volumes served – the Tiers necessary.

• Health human resource planning/Credentialing: To assist in predicting the nature of the services and subsequent HHR needs at a given Tier.

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What is the value in proceeding?Why is Tiers of Service work of assistance?

Quality Improvement/CQI: • Self-assessment identifies themes for QI and leads to QI action that

is appropriate by tier - enhances focus and efficiency of QI efforts with less duplication across sites and regions.

Health provide learning/KT• Educational competencies are identified for each Tier with then

suitable educational content and deliver methods (“Tiers of Learning”)

Formal Education and Research roles• Supports the academic mandate/health science network concept in

clear and appropriate ways.

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Tier by tier improvement opportunities

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Linked with Doctors of BC, MOH and “BC Guidelines”Mary Lou Matthews, Jennifer Scarr, Dr. C Yang (and advisory group)

Supporting Tiers 1 (Primary Care)Asthma Guideline and Tool Kit

Provincial childhood diabetes planning

Involves Provincial Advisory Committee and 4 working groups-multi-disciplinary including schools- all HA’s involved

– Care guidelines for BC (based on review of international standards)– Service plan for BC (aligned with Tiers of Service)– Education and resources – for parents and providers– Information and data– Research and Evaluation

Pediatric early warning system – PEWS – for inpatient care

– Large scale provincial implementation with research project and embedded QI– >30 hospitals in BC by end of 2016

Tier 4- leaders and impacted on both

Supporting Tiers 2 and 3

• Outreach

• Tele-health – Technology-enhanced accessTo care for children

– 19 community sites in BC are now “pediatric-enhanced”

Telehealth sites

– Surgical patient Journey– Pediatric medicine subspecialties

– Tele-PICU now live!– Tele-ED under very early development

Supporting Tiers 2 and 3

Cross-Tier Priorities Delivered at every tier – unique role/capacity of each tier must be considered

• Child and youth mental health

• Complex care – “frail children”

• Home care for children…

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Enablers of success so far - examples

• Legacy of Dr. Clyde Hertzman– Long standing awareness of child health and development issues – HELP

• Child Health BC table– Key players affecting policy, accountable for delivery, training and influence– Cohesive network with collaborative spirit– Expansion from focus on health services to cross continuum– Strong trusting relationships being built

• Focus on tiers has helped us– Generate improvement activities across tiers– Understand data – different meaning at different tiers– Have a common language– Understand the relationship between volume and quality

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Enablers of success

• BC Children’s Hospital Foundation and its donors

• Leveraging

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Much more to do

• Evaluate all initiatives– Process measures– Outcomes measures– Health status

• Learn from others

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Questions? Thoughts?

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oct 24 caphc plenary presentation - dr. maureen o'donnell

Healthcare