Fostering Quality & Accountabilities to Children & Families: The Case of the RICHER Initiative

Lorine Scott, NP(F) BC Children’s Hospital - RICHER Primary Care Lead Judith Lynam, RN, PhD, UBC Professor & RICHER Research Lead

R esponsive

I ntersectoral & Interdisciplinary

C hild & Community

H ealth

E ducation &

R esearch

RICHER is an innovative partnership

based community outreach PHC model

What is RICHER?

Research Colleagues: Dr. S. Wong, Dr. C. Loock, L. Scott, Dr. K. Khan, Funders CIHR, CNA and MSFHR & BCMSF Community Partners

NEVCO - NICCSS Ray Cam Child Health BC Vancouver Native Health ALIVE

UBC Academic Partners

School of Nursing Faculty of Medicine

Health Authorities

Provincial Health Services Authority BC Children’s, Sunny Hill & BC Women’s

Vancouver Coastal Health Authority (VCHA)

Why an Integrated RICHER Approach?

AIM

• to foster timely

access to healthcare

• across the spectrum

from primary care to

specialized services

• for children who have

disproportionately

high rates of

developmental

vulnerability &

disease burden

Marked Inequities in children’s health

• Complex health issues & developmental challenges

• Compounded by social conditions

Multiple barriers to health care access along the

continuum

• Prevention

• Primary care & specialized services

Limited access to primary health care

• Delays in diagnosis

• Delays in access to treatment & supports

• Lack of integration with specialized services

• Use of emergency services for non-emergent but significant health

issues

ALL are associated with poor health in childhood & over the life course

Hertzman & Kershaw, Human Early Learning Partnership, 201o, Provincial Mapping Report

Building a clinical team that is responsive to child health needs – PHC & Specialized services

Working in partnership to dismantle structural & social barriers to health services access –

• Building respect & trust.

Developing clinical relationships that extend and enrich families’ social relationships & foster child health & development.

• Intersectoral engagement

• Working ‘in place’

Strategies to Achieve Goals

Regular scheduled weekly primary health care clinics-

• Active regular participation with community agencies developing and/or delivering services for children – providing important health perspective

• Location of services : daycare, schools, community centers, non-profit family support agencies

Regular weekly integrated Pediatric Specialist/Subspecialist (SPOCK) consultation/intervention in place based venues

• Accept referrals from, & consult with, RICHER PHC & other community clinician

Weekly community table • Community identified issues affecting health &

development of the children in the community

• Provides for neighbourhood/community introductions & relationships

Weekly clinical rounds ‘BFF’ - Bright Family Futures

Group model for young families (15-25)

• RICHER in Operation

SPOCK

In our research programme, we have sought to understand:

• the influences on access to health services

•Appraisal of quality

• the characteristics of the RICHER approach associated with improved outcomes

RICHER Research

RICHER

Research Methods

• Participatory

• Asks questions identified as priorities by the community

• Conducts study in ways that are respectful of community

RICHER Results Phase I

• Outreach is enacted in Partnership. • Building relationships and conveying respect fosters access. • Partnerships enable families to ‘link in’ to traditional clinical

services, and enable clinicians to ‘link across’ to specialized services.

• Partnerships enable families to access services and resources to address social determinants of health.

• Community table creates mechanism for engagement and

accountability.

“This mother had to go to court to get her 3 children back. The parents and children in the neighbourhood filled the courtroom to show they were there to support this mother.

The judge closed the file and said the children should never have been taken in the first place.”

Relationships & Trust

• Building communities of support

• Challenging stereotypes of poverty & racialization

“This mother had to go to court to get her 3 children back. The parents and children in the neighbourhood filled the courtroom to show they were there to support this mother.

The judge closed the file and said the children should never have been taken in the first place.”

Relationships & Trust

• Building communities of support

• Challenging stereotypes of poverty & racialization

RICHER

Research Phase 2

Does RICHER foster access? What impact does RICHER have on patient outcomes?

Parents’ ratings of RICHER: Access Continuity Responsiveness Relationship

Empowerment, which is associated with: Satisfaction Compliance Optimal utilization Positive orientation Patient activation

Characteristics of parent

respondents

(n=86)

(If not from Canada) Number of years living in Canada,M(SD) 11.0 (7.6)

English spoken at home Cantonese/Mandarin spoken at home Other language spoken at home

58.1% 32.6% 9.3%

1-2 person household 3 person household 4 person household ≥ 5 person household

22.1% 19.8% 25.6% 32.6%

No children under 18 in household 1 child under 18 in household 2 children under 18 in household 3 children under 18 in household ≥ 4 children under 18 in household

4.7% 39.5% 29.1% 14.0% 12.8%

Less than $10,000 household income $10,000 - $30,000 household income $30,000 - $50,000 household income $50,000 - $80,000 household income More than $80,000 household income Missing

25.6% 40.7% 11.6% 5.8% 3.5%

12.8%

Apartment House Other (e.g. room, basement suite)

50.0% 44.2% 5.8%

Length of time in home, M (SD) 3.8 (3.3)

Rent home Own home Other Missing

81.4% 14.0% 2.3% 2.3%

Receive financial support for housing 43.0%

•2) What characteristics of the RICHER approach are correlated with (indicators of) positive outcomes?

Social • Characteristics of the providers’

interpersonal style are strongly associated with positive outcomes

Structural • Features of the clinics-

schedules, venues etc.

64%

24%

12%

Strength of Affiliation

Strong affiliation

Weak/Less strong

No/Weakest

Experiences of Primary Care

Number of times used clinic in past 12 months:

Mean 7.2 SD 10.5

88%

11% 1%

How important is it to you to have an NP that treats you as an equal?

VeryimportantSomewhatimportantMissing

PHC Quality Dimensions Processes of Care

Likert Scale 1-5

78%

16%

5% 2%

How important is it for you to have an NP include you in decision-making of

treatment plans?

Veryimportant

Somewhatimportant

Not important

Missing

General clarity of communication scale, M (SD)

4.6 (0.6)

Explained results scale 4.3 (0.9)

Decision making scale 3.7 (1.3)

Compassionate, Respectful scale 4.7 (0.5)

Empowerment scale 4.2 (0.9)

The PHC experience of clinician’s interpersonal style is positively associated with patient empowerment (p<0.01).

Demographics & Experience (r2= 0.47) Demographics & Experience Reduced

Set (r2= 0.36)

Variable N % Odds ratio Overall p value/CI Odds ratio Overall p value/CI

Education NS

Did not complete high school or secondary school 22 30.6 0.27 (0.04, 2.00)

Completed high school or secondary school 18 25 0.87 (0.07, 11.39)

At least some college, university or post-secondary 32 44.4 (ref)

Self-reported Ethnicity NS

White/Caucasian/European 15 20.8 (ref)

Chinese 24 33.3 1.06 (0.06, 18.70)

Aboriginal (First Nations/Metis) 21 29.2 5.55 (0.19, 161.60)

Other 12 16.7 0.92 (0.04, 19.45)

Strength of Affiliation NS

Scale range 0 to 4, treated as continuous 0.52 (0.13, 2.11)

IPC Communication: Clarity of Communication NS

Scale range 3 to 5, treated as continuous 1.59 (0.43, 5.95)

IPC Style: compassionate, respectful <0.005 <0.0001

Scale range 2.67 to 5, treated as continuous 15.43 (2.58, 92.23) 34.52 (7.54, 157.93)

NP Knowledge of child NS

Scale range 1.67 to 5, treated as continuous 2.59 (0.83, 8.09)

What characteristics of providers’ approaches to service delivery are associated with patient empowerment? (n=76)

Purposeful integration of activities within ‘place’ fosters cohesion, connection and relationship.

Systems can be ‘re-formed’ to be responsive !

Fostering cohesion Creating infrastructure Fostering linkages Capacity building

Publications Lynam, M. J., Loock, C., Scott, L. & Khan, K.B. (2008) Culture, health and inequalities: new

paradigms, new practice imperatives. Journal of Research in Nursing , 13(2): 138-148.

Lynam, M.J., Loock, C., Scott, L., Wong, S., Munroe, V. & Palmer, B.(2010) Social Pediatrics: Creating organizational processes and practices to foster health care access for children ‘at risk’. Journal of Research in

Nursing. OnlineFirst February 15: doi:10,1177/17449871093605/ pp: 1-17.

Lynam, M.J., Scott, L., Loock, C.L., Wong, S. (2011). The RICHER Social Pediatrics Model: Fostering Access and Reducing Inequities in Children’s Health, Healthcare Quarterly. 14 Special Issue, (3): 41-

56. http://www.longwoods.com/content/22576

Lynam, M.J., Grant, E. & Staden, K. (2012) Engaging With Communities to Foster Health: The Experience of Inner-City Children and Families With Learning Circles. Canadian Journal of Nursing Research, 44(2): June.

Wong, S.T., Lynam, M.J., Khan, K., Scott, L. & Loock, C. The social paediatrics initiative: a RICHER model of

primary health care for at risk children and their families BMC Pediatrics, 12:158 (04 Oct 2012)