Something more must be done to address the health challenges of Aboriginal seniors

Dr. Catherine Cook, councillor with the Health Council of Canada, is also a family physician, researcher, health care manager, and Métis. She currently has a joint role with the University of Manitoba and the Winnipeg Regional Health Authority. At the University of Manitoba, Dr. Cook is the Associate Dean for First Nations, Métis and Inuit Health in the Faculty of Medicine and is currently a leader of the newly established Section of First Nations, Métis and Inuit Health in the Department of Community Health Sciences, Faculty of Medicine. 

 First Nations, Inuit and Métis seniors are indeed Canada’s most vulnerable population. We know that they do not receive the same level of health care as non-Aboriginal seniors. Interviews with key stakeholders, literature searches and consultations across Canada, undertaken by the Health Council of Canada during the winter and spring of 2013, confirmed some glaring facts:

• Access to care is an issue. Most need to travel to urban areas for anything beyond the most basic care, with significant disruption to their lives.
• They often fall victim to the vagaries of government policies at the federal and provincial levels as to what costs are covered by whom and who is eligible for what services.
• There is little or no communication and coordination between services supported by governments, regional health authorities, and communities.
• Many Aboriginal seniors don’t have the same level of care in their communities as non-Aboriginal Canadians, so their health conditions can become more severe, increasing the amount of care they need. 

The situation is exacerbated by the impact of colonization, residential school experiences and by determinants of health such as poverty, poor housing, racism, language barriers, and cultural differences. Geographic isolation also comes into play: Aboriginal seniors are also more likely than younger generations to live in rural and remote communities where the majority of the population is Aboriginal, and where they can be connected to their culture. The result is that they have more complex health needs and are often living in regions where it is more challenging and expensive to provide care.

The Health Council report provides context on these challenges and why it is important to provide additional support and seamless care to First Nations, Inuit, and Metis seniors.  Without this, an already vulnerable population is at even greater risk. This issue that requires immediate attention by Canadians and governments alike.
However, there are some promising examples from across Canada where governments, health regions, and Aboriginal communities have formed partnerships to improve health care for Aboriginal seniors. I invite you visit www.healthcouncilcanada.ca/innovation to read about these practices. 

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Online education about elder care for community-based health care providers

Marney Vermette, Engagement Liaison, Saint Elizabeth First Nations, Inuit, and Métis Program

In my previous role as a nurse supervisor for a First Nations home and community care program, I saw that there were major challenges in finding affordable, accessible, and culturally appropriate health care provider training that meets the needs and realities of the First Nations people. Receiving an education within the community was not often an option for health care providers, and leaving the community for education and training had several negative impacts on the health care provider and the community—it affected the continuity of care for their clients, increased the burden on the family and community, and was a financial drain on already exhausted community budgets. These problems were especially common in remote communities.

It would take community home care staff several years to obtain their Personal Support Worker certificates. They would leave their families, communities, and positions for weeks at a time. If there were a crisis or a death in a community they would return home, losing out on training and delaying their education. In addition, many times nurses come to communities without a proper understanding of the importance of culture and protocol and of building relationships within the community.

Saint Elizabeth offers a First Nations Elder Care Course, one of several online professional development programs available at no cost to community-based health care providers across Canada. The course provides evidence-based, culturally sensitive education about First Nations history and culture, as well as clinical information on health topics related to elder care such as falls, medication, nutrition, depression, Alzheimer disease, elder abuse, and caring for yourself as a health care provider.

We were cautious not to develop a pan-Aboriginal approach. A key message spread throughout the course is the need to understand that every community is unique. Health care providers need to build relationships with the communities to learn more about community-specific cultural practices and protocols. They need to seek guidance from a community champion to learn about the culture, traditions, and practices within a community.

Our program uses a unique model involving First Nations health care providers, elders, and specialists in the development and review phases of our courses. Our goal was to ensure that we had comprehensive information to meet community needs and to develop relationships of mutual trust and respect.
The course was released in January 2013 and has received an enthusiastic response. Community representatives appreciate that the course provides their staff with understanding and knowledge to provide a safe environment along with respect and protocols in caring for the elders. The goal in many communities is to keep elders in their homes for as long as possible instead of moving them to long-term care facilities.

The online training means that health care providers don’t have to leave their communities to develop the knowledge and skills they need to care for elders. Health care providers are sometimes intimidated by online training, but most of them know how to use Facebook and once they realize it’s just as easy, they are very enthusiastic.

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Community health aides help with nursing shortages and cultural safety

Tina Buckle, Community Health Nursing Coordinator, Nunatsiavut Department of Health and Social Development

In Nunatsiavut, we use Community Health Aides to support nursing staff in remote communities. We have a challenge recruiting and retaining nurses, and the aide position has allowed us to manage with fewer nurses. It’s a model that borrows from Labrador in the past and from Alaska in the present, where community health aides, local people from the community, help to deliver health care in remote communities.  In Nunatsiavut, the community health aide has a role in both public health and home and community care.

In the Home and Community Care program, the community health aides function as the nurses’ “right hands.” They manage the home support workers, go with the nurse to client visits as needed, order equipment and supplies, schedule appointments, sterilize equipment, complete month-end reports, and anything else that doesn’t require a nurse to do. The nurse is then able to concentrate on direct client care. The aides also do independent home visiting to support the programs, both when a nurse is in town and when the position is vacant.

Just as important, the aides are the cultural advisors to new nurses. They are so trusted in the community that any new nurse is immediately accepted if accompanied by the aide. From a senior care perspective, the aides have the ability to spend more time with seniors than the nurses do; also, they have personal connections and speak the language. We have also given the community health aides tours of the regional health and long-term care centres in Happy Valley-Goose Bay so that they can describe them to seniors and their families and help them become comfortable with the transition.

It’s hard to quantify or even to put into words the value of community health aides —essentially, we would not be able to deliver care without them and clients would not be as willing to receive care. It’s hard to understand why this model hasn’t spread to other parts of the country, particularly since it’s also well known in Alaska. I think there’s almost a strange fear that by allowing this kind of practice we’re encouraging people to be community health aides instead of going into the health professions, but that’s not what it’s about at all. There is an incredibly valuable role for these people at the community level that no one else can fill like they do.

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One home care program for everyone: Bella Coola, British Columbia

Glenda Phillips, Manager, Home & Community Support, Bella Coola General Hospital

In my community, Bella Coola, we have a fully integrated home and community care program situated in a new health centre on-reserve that is used by everyone in the community, whether they are First Nations or not. But it wasn’t always that way.

Bella Coola is a geographically remote community with limited resources. I was the federal health nurse there for years, until I went back to university. When I returned, I was hired by the province to set up home care in the region. I saw that people on-reserve weren’t getting services. There was no structured home and community care program, and no integrated service delivery model between the services offered on-reserve and those offered by the province. We had five long-term care beds in a small community hospital, and no assisted living. Complicating the situation were factors such as budget constraints, nursing shortages, and a lack of clarity around staff roles and responsibilities.  

We wanted to give people equal access to care and the option to remain at home as long as possible—not just in their community but in their own homes. We needed an integrated care program to support this and we wanted to build capacity for culturally sensitive care.  We started the planning by going to the Chief and Council of Nuxalk Nation and saying, “Why don’t we work together and set up a program for everyone?” Then we went out on the road talking to the community, conducting a community needs assessment, and meeting with the many different organizations and government representatives who needed to be consulted.

In the end, we made just one home care program where there had been two (the province’s program and the federal FNIHCC program). There is no new money; we pooled our funding streams to work around budget constraints. And by coming together, we expanded our capacity and flexibility. For instance, there is a four-hour cap on the number of hours of home support we can provide to a client in a day. But if a couple of more hours a day means that the client can stay in the community and in their home, then we provide more hours. It’s good quality care, and it’s cost effective for the system.

Other communities have asked us how they can do similar types of integrated programs. We tell them the standards of care are going to be the same—how you do your assessments, how you clean your tools, how you chart—but how you deliver the care might be a little different because of the culture in your community. You have to know the community. 

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Supporting Métis seniors and families

Wenda Watteyne, Director of Healing and Wellness, and Dr. Storm J. Russell, Senior Policy and Research Analyst, Métis Nation of Ontario

Few Canadians realize that one third of all Aboriginal people in Canada are Métis, and that the Métis population is older compared to other Aboriginal groups. From our research, we know that many of our seniors are experiencing significantly higher rates of chronic disease and other complex conditions compared to non-Métis Ontarians. Métis people also fall under a different legislative and regulatory structure than do other Aboriginal groups, and do not have access to programming supports such as the Non-Insured Health Benefits program that is available to many Aboriginal peoples. Many also live in remote and rural areas, where access to services and supports can be limited. For Métis seniors living on limited incomes, things like transportation to see doctors and specialists, as well as having the means to fill expensive prescriptions, can also serve as barriers to care.  Finally, access to culturally safe care can be a challenge for older Métis citizens.

It is for all these reasons and more that the Métis Nation of Ontario (MNO) provides programs and services at the community level. Situated in 18 Métis communities distributed across the province, MNO community centres serve as important cultural and service hubs that link our Métis citizens to each other, as well as to health services and supports in their local areas. The MNO community centres are especially important in providing our Métis seniors with the kinds of culturally grounded services and supports they need, along with help in accessing medical services. Some of our MNO centres also offer specialist services such as foot care clinics for seniors and other Métis people suffering from diabetes. MNO community centre workers also much in the way of outreach to Métis seniors in need of assistance, visiting their homes to help with things like meal preparation, house maintenance, and other tasks of daily living, while at the same time providing that important cultural connection and support. Through the MNO Community Support Services program we are also able to provide transportation services to help Métis seniors travel to and from their medical appointments.

For the many Métis seniors and other community members who are suffering from significantly higher rates of chronic diseases and conditions, MNO community centres provide a place where they meet with other Métis community members and receive much-needed support and care, and get help in linking to essential services and programs in the broader community. The centres also provide a haven for culturally safe community care. 

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Minding the Gaps in Quality Improvement in Canada

John G. Abbott

John G. Abbott is the CEO of the Health Council of Canada

What can Canada gain by upping its investment to advance the health quality improvement agenda? And, in what areas should it invest?

A lot, in my opinion; and the focus needs to be on increasing the capability and capacity of our system and its leaders to deliver transformative change. 

This week, the Health Council of Canada held a national symposium on quality improvement under the theme: Towards a High-Performing Health Care System: The Role of Canada’s Quality Councils. 

Dr. Ross Baker

Over 200 senior leaders from across the country converged to talk about health system performance measurement and reporting, and building system capacity for quality improvement.  It was clear that there is no ‘one size fits all' when it comes to performance measurement or reporting and each jurisdiction with a quality and/or patient safety organization (there are seven in total) have adopted approaches that are working for them. So what are the gaps in Canada’s current quality improvement approach that need to be closed?

The first gap is the absence of a burning platform for transformative change so that quality improvement is embedded in everything we do in health care. Are health leaders and Canadians themselves convinced that we need to improve the quality of the care being delivered in each hospital, clinic and doctor’s office in this country? The evidence says we need to, but is that enough to make the case?

Panel on Building System Capacity for Quality Improvement

The second gap or challenge is treating QI as an add-on. Shouldn’t our health system encourage all its leaders to begin their day with the question: what have we got to do today to ensure all our activities deliver safe and appropriate care for our patients; and end their day by asking:  how do we know that we achieved this objective? If QI is its own silo, we are not going to achieve transformative change in any setting.

The third gap relates to resources. We need to increase the level of investment in resources to successfully design and manage a QI agenda. We need to train people at the front lines and in the back rooms to think as one, using a common language around performance improvement.  We need to continually support the work of quality councils in this country who in turn are aligning their activities in support of the health systems that they both monitor and engage on quality improvement initiatives.

A fourth gap is not appreciating the magnitude of managing complex system change.

A fifth gap lies in the area of technology and information sharing. We need to leverage the use of today’s technology to collect data and share information about system performance and patient outcomes in a consistent and timely way that can be used by all parts of the system to improve the quality of care.

No one organization or system has all the answers to addressing these gaps. All in all, we need to collaborate within and across organizations and jurisdictions to build capacity and capability in all these areas.  The Health Council’s report on the proceedings of its event will cover these points in greater detail and will be released on December 16, 2013 at www.healthcouncilcanada.ca.

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