Concept of primary health care in canada chc dr shabon 2009

The CHC Model of Care

Prepared by the Education and
Development Team,

The Association of Ontario Health Centres

The information contained in this document is confidential and proprietary to the Association of Ontario
Health Centres (AOHC). Unauthorized distribution or use of this document or the information contained
herein is strictly prohibited.

1 21-Aug-12 Association of Ontario Health Centres

Table of Contents

A. Acknowledgments Pg. 4

B. Executive Summary Pg. 4

C. Introduction Pg. 5

D. Model of Care Fact Sheet – Definitions Pg. 7

E. Elaboration of the Model of Care Pg. 9
(MOC) Attributes includes:

A. Definition
B. Elaboration
C. Why this attribute is relevant to the Model of Care
D. Opportunities and Challenges to Addressing this
Attribute in your CHC
E. Summary
F. References

1. Comprehensive Pg. 9

2. Accessible Pg. 14

3. Client and Community Centred Pg. 20

4. Interprofessional Pg. 25

5. Integrated Pg. 29

6. Community-governed Pg. 34

7. Inclusive of the Social Determinants of Health Pg. 39

8. Grounded in a Community Development Approach Pg. 44

F. Glossary Pg. 49


A. Acknowledgments

The development of the training manual and toolkit on the Model of Care involved many
committed and passionate people whose support and contribution were vital to the production of
this document. These include the Community Health Centre (CHC) Charter Group: Lee McKenna,
Brenda McNeill, Cate Melito, Cary Milner, Hersh Sehdev, Wendy Talbot, and Adrianna Tetley,
and, the invaluable expertise from the AOHC’s Education and Development Team: Sophie Bart,
Keisa Campbell, Mary Chudley, Carolyn Poplak, Brian Sankarsingh, Roohullah Shabon, and
Sandra Wong. In addition, we would like to thank all AOHC staff for their support and the CHC
representatives who contributed their lived examples, experiences, opportunities and challenges
that helped bring these training tools to life.
Thank you.
Roohullah Shabon, Director of Education and Development
The Association of Ontario Health Centers
416-236-2539 ext. 231

B. Overview
The objective of this manual, and its accompanying toolkit, is to provide information and
resources on the CHC Model of Care for training purposes. The intended audience for the training
includes Community Health Centre staff, volunteers and Boards of Directors. This manual is an
elaboration on the eight attributes of the CHC Model of Care and provides appropriate references
and resources for a better understanding of this Model and how it is being implemented in CHCs.

The eight attributes of the CHC Model of Care include:

1. Comprehensive;
2. Accessible;
3. Client and community-centred;
4. Interprofessional;
5. Integrated;
6. Community-governed;
7. Inclusive of the social determinants of health;
8. Grounded in a community development approach

While the attributes are discussed and considered individually, they are also linked and fluid
elements that do not exist in isolation from one another. For a CHC to be comprehensive, for
example, it emphasizes the interprofessional team approach. For a Centre to be grounded in a
community development approach, it is also client and community centred, and so on.
Therefore, throughout this document, you will see overlapping themes and concepts. Defining
these eight attributes emphasizes the importance of each quality independently, while
highlighting their interconnectedness.

This document is a dynamic and living resource and we will continue to add to it. For comments
and suggestions please contact:
Roohullah Shabon, Director of Education and Development
The Association of Ontario Health Centres

416-236-2539 ext. 230
Roohullah@aohc.org


C. Introduction

Primary health care (PHC) as defined by the World Health Organization (WHO) is essential health
care made universally accessible to individuals and families in the community by means
acceptable to them, through their full participation and at a cost that the community and country
can afford. It forms an integral part both of the country's health system of which it is the nucleus
and of the overall social and economic development of the community1.

Primary care refers to the patient's first point of contact with a health-care provider and includes
but is not limited to: disease management and prevention, disease cure, rehabilitation, palliative
care and health promotion. The greatest difference between primary care and primary health
care is that primary health care is participatory in nature and involves the individual and their
community in their overall health care including prevention and management.

The Ottawa Charter for Health Promotion echoes the sentiments of the WHO. It states that the
role of the health sector must move increasingly in a health promotion direction, beyond its
responsibility for providing clinical and curative services. Health services need to embrace an
integrated mandate which is sensitive and respects cultural needs. This mandate should support
the needs of individuals and communities for a healthier life, and open channels between the
health sector and broader social, political, economic and physical environmental components.2

Canadians consistently describe Medicare as a defining feature of our identity. We are deeply
connected to the core values of Medicare and PHC, namely a just and equitable system of health
care equitably accessible to all Canadians. As individuals, we want to see Tommy Douglas’s
vision of Medicare renewed and revitalized not demolished (???). The First Stage of Medicare was
to remove the financial barriers between those who provide health-care services and those who
need them. The Second Stage, following the path of the First, was to amend our delivery system
to reduce costs and put an emphasis on preventative medicine.

The second stage of Medicare offers a vision for health that is embraced by CHCs: that as
Canadians we must care for one another, and break down the barriers that prevent many from
accessing care. With CHC Boards, management and staff on the same page about the CHC
Model of Care, we can better highlight to the greater community the story of who we are and
what we do, and further demonstrate how our Centres are champions of the Second Stage of
Medicare. We will continue to acknowledge and recognize that our CHC clients, the members of
our organizations who use our services, are at the heart of the work we do.

The CHC Model of Care captures consistent principles that underlie the work of Ontario CHCs. As
a sector, we acknowledge that the differences between CHCs reflect the great diversity of the
communities we serve. It is crucial that CHC Boards and staff share a common understanding of
the Model and apply its principles throughout our work. These principles help to define the CHC
role in what makes a stronger – and more caring – health-care system.

Based on the social determinants of health, the CHC sector provides accessible, community-
governed, interprofessional, primary health-care services, including health promotion, illness
prevention and treatment, chronic disease management, and individual and community capacity
building. Our ultimate goal is for all Ontarians facing barriers to health to have access to quality
primary health care within an integrated system of care.3

1
WHO (1978)
2
Ottawa Charter for Health Promotion (1986)
3
CHC Strategy Map and Balanced Scorecard (2006). Pg. 4

The programs and services we offer throughout the province demonstrate our commitment to
addressing Medicare’s core values. These include:

• All Canadians have timely access to health services on the basis of need, not
ability to pay, regardless of where they live or move in Canada;
• The health-care services available to Canadians are of high quality, effective,
patient-centred and safe; and
• Our health-care system is sustainable and affordable and will be here for Canadians and
their children in the future.4

The ultimate purpose of Medicare is to ensure Canadians:

• have access to a health-care provider 24 hours a day, 7 days a week;
• have timely access to diagnostic procedures and treatments;
• do not have to repeat their health histories or undergo the same tests for every
provider they see;
• have access to quality home and community care services;
• have access to the drugs they need without undue financial hardship;
• are able to access quality care no matter where they live; and
• see their health-care system as efficient, responsive and adapting to their
changing needs, and those of their families and communities now, and in the
future. 5

At the heart of our Model of Care are our clients – and the communities of which they are a part.
Because in CHCs Every One Matters. Every individual. Every community. Every staff person.

4
Health Canada Website - http://www.hc-sc.gc.ca/hcs-sss/delivery-prestation/fptcollab/2003accord/index-eng.php
5
Ibid

The CHC Model of Care Definitions6

CHCs offer a range of comprehensive primary health care and health promotion programs in
diverse communities across Ontario. Services within CHCs are structured and designed to
eliminate system-wide barriers to accessing health-care such as poverty, geographic isolation,
ethno- and cultural-centrism, racism, sexism, heterosexism, transphobia, language
discrimination, ageism, ableism and other harmful forms of social exclusion including issues such
as complex mental health that can lead to an increased burden or risk of ill health.

The CHC Model of Care focuses on five service areas:

• Primary care
• Illness prevention
• Health promotion
• Community capacity building
• Service integration

The CHC Model of Care is:

Comprehensive:
CHCs provide comprehensive, coordinated, primary health care for their communities,
encompassing primary care, illness prevention, and health promotion, in one to one service,
personal development groups, and community level interventions.

Accessible:
CHCs are designed to improve access, participation, equity, inclusiveness and social justice by
eliminating systemic barriers to full participation. CHCs have expertise in ensuring access for
people who encounter a diverse range of social, cultural, economic, legal or geographic barriers
which contribute to the risk of developing health problems. This would include the provision of
culturally appropriate programs and services, programs for the non-insured, optimal location and
design of facilities, oppression-free environments and 24 hour on-call services.

Client and community centred:
CHCs are continuously adapting and refining their ability to reach and to serve their clients and
communities. CHCs plan based on population health needs and develop best practices for serving
those needs. CHCs strive to provide client-centred care.

Interprofessional:
CHCs build interprofessional teams working in collaborative practice. In these teams, salaried
professionals work together in a coordinated approach to address the health needs of their
clients. Depending on the actual programs and services offered, CHC interprofessional teams
may include physicians, nurses, nurse practitioners, dietitians, physiotherapists, occupational
therapists, social workers, Aboriginal traditional healers, chiropodists, counsellors, health
promoters, community development workers, and administrative staff.

Integrated:
CHCs develop strong connections with health system partners and community partners to ensure
the integration of CHC services with the delivery of other health and social services. Integration
improves client care through the provision of timely services, appropriate referrals, and the
delivery of seamless care. Integration also leads to system efficiencies.

Community-governed:
6
Revised June, 2008

CHCs are not-for-profit organizations, governed by community boards. Community governance
ensures that the health of a community is enhanced by providing leadership that is reflective of
its diverse communities. Community boards and committees provide a mechanism for centres to
be responsive to the needs of their respective communities, and for communities to develop a
sense of ownership over “their” centres.

Inclusive of the social determinants of health:
The health of individuals and populations are impacted by the social determinants of health
including shelter, education, food, income, a stable eco-system, sustainable resources, anti-
oppression, inclusion, social justice, equity and peace. CHCs strive for improvements in social
supports and conditions that affect the long term health of their clients and community, through
participation in multi-sector partnerships, and the development of healthy public policy, within a
population health framework.

Grounded in a community development approach:
CHC services and programs are responsive to local Community Initiatives and needs. The
community development approach builds on community leadership, knowledge and life
experiences of community members and partners to contribute to the health of their community.
CHCs increase the capacity of communities to improve community and individual health
outcomes.


D- Elaboration of Model of Care Attributes

1. Comprehensive
“Let's not forget that the ultimate goal of Medicare must be to keep people well rather
than just patching them up when they get sick”7

Thomas Clement “Tommy” Douglas, father of Medicare (1904 – 1986)

a. Definition

CHCs provide comprehensive, coordinated, primary health-care for their communities,
encompassing primary care, illness prevention, and health promotion in one-to-one service,
personal development groups, and community level interventions.

b. Elaboration

The needs of CHC clients extend beyond direct primary care services. CHCs use a variety of
strategies including health promotion and education because the health service needs of clients
do not occur in isolation from the broader determinants of health – including the socio-economic
environment of the community.

Anishnawbe Health’s Core Basket of CHCs work to improve the capacity of
Services: individuals, families and communities. Because
CHCs offer a core basket of services under one
• Traditional Healing roof – a one-stop shop, so to speak – clients can
• Primary Health Care access care and support in a variety of areas.
• Chiropractic medicine These include: primary care, language and
• Naturopathic medicine employment, settlement and shelter, the
• Fetal Alcohol Spectrum Disorder Services ecological environment, family and community
(FASD Services) relationships, nutrition, child development, legal
• Massage Therapy aid, community development and leadership,
• Traditional Counselling and the management of chronic disease.
• Enaadamged Kwe (Woman’s Helper)
Internal referrals (97,095 of which were made
• Babishkhan
across 37 CHCs in 2006/07)8 are part of our
• Psychiatric services
focus in providing comprehensive, barrier-free
• Chiropodist services
care. They can help address chronic diseases
• Oral health care and manage them accordingly. According to the
• Mental Health support Health Council of Canada, chronic diseases are
• Community Health Worker Training the most common cause of disability and
Program premature deaths in the country. The Council
• Nmakaandjiiwin (Finding My Way) has also noted that most primary health-care
organizations and individual providers are not organized in ways to maximize potential
improvements. This leaves far too many Canadians vulnerable to complications from chronic
conditions. 9 CHCs respond to this with the programs and services offered. For example, a client
enters a CHC with symptoms of diabetes. In one day, that same client receives primary health-
7
Tommy Douglas quoted in The Second Stage of Medicare (2007). Pg 1.
8
Every One Matters (2008). Pg 15
9
The Second Stage of Medicare (2007).Pg 17

care from a physician and is referred to a healthy cooking class for diabetes sufferers offered by
a dietician as well as a low impact exercise class provided by a volunteer at the Centre. This is an
example of comprehensive services offered by CHCs that support clients’ management of their
disease. For services that the CHC does not have at its disposal – under its own roof – it has the
information, resources and connections to ensure the client gets additional support though
external referrals.

To address chronic conditions and other health needs, CHCs offer more than just individual visits
for the client with their provider. CHCs also offer group and community supports, such as
Community Initiatives (CIs) which are organized to affect the health of the community10 as a
whole and personal development groups (PDGs) that focus on changing unhealthy attitudes or
behaviours in individuals.
c. Why this Attribute is Relevant to the CHC

To make comprehensive care a reality, CHC clients receive primary health-care from
interprofessional teams under the same roof. Case consultations between health-care teams
support the delivery of more efficient and effective health care. Improvements in primary
health-care are anchored in evidence-based decision making and responsiveness to health-care
needs. Through the collection of data used in conjunction with community engagement
initiatives, CHCs are able to provide relative and comprehensive services to our clients though
the programs and services we offer. The CHC sector uses best practices to guide the provision of
a range of prevention, early intervention and treatment programs and services.11

We know that positive health outcomes for clients occur when comprehensive partnerships
amongst primary health-care stakeholders are formed. 12 These stakeholders include patients and
families, health-care teams and community supporters. 13 The World Health Organization (WHO)
illustrates this by highlighting four essential elements for action that stakeholders should
consider. They include:

Somerset West’s Core Basket of
1. Support a paradigm shift towards Services:
integrated, preventative health care • Acupuncture services
• Immigration medical examinations
2. Promote financing systems and policies • Nutrition counselling that
support prevention in health-care • Mental health services
3. Equip patients with needed information, • Asthma care
motivation, and skills in prevention and • Foot care services self-
management • Breastfeeding information &
support
4. Make prevention an element of every • Obstetrical care & prenatal health-
care interaction 14 assessments
• Smoking Cessation
• Flu immunization clinics in the
These elements are being addressed by CHCs
community
across the province. Research tells us that
preventative health care can take huge • Health Education workshops in the burdens
off our health-care system. In addition, early detection procedures and techniques (paps,
mammograms, immunizations, smoking/alcohol cessation groups etc.) help deter many chronic
diseases that can affect not only the individual, but the family and collective health of the
community.

10
For more information on Community Initiatives, please view Module 8.
11
CHC Strategy Map and Balanced Scorecard (2006). Pg. 5
12
WHO (2002)
13
Ibid
14


d. Opportunities & Challenges to Addressing this Attribute in your CHC

Sometimes the contribution of individuals and organizations is not always deemed of equal
‘value’ and this can lead to conflict and dissatisfaction. In addition, people come to the table with
different skills, experiences, motivations, and prejudices. Furthermore, a collaborative effort
involving individuals from different walks of life can often magnify personal conflicts and
differences. There are often different power dynamics at play between clients, families and
service providers which can affect true collaboration amongst these stakeholders. This can have
a further impact on the health outcome of our clients and we need to bring them back to the
centre of our focus and decision making.

Four Villages’ Core Basket of Services: An additional challenge to addressing
comprehensive care in CHCs is to find and
• Treatment of acute illnesses &chronic balance the resources needed to really
conditions support the provision of a comprehensive
• Mental health counselling basket of services. Also, health promotion
and illness prevention sit on the sidelines of
• Physiotherapy & Occupational therapy
our health-care system and are not
• Care & support for healthy children & adults integrated or embedded as a primary focus.
• Diabetes management and support There is still a focus on the hierarchy of care.
• Nutrition counselling and education Many strategies to address burdens on our
• Arthritis self-management health-care system are clinically focused and
• Social connection do not take into account the broader
• Active living and healthy eating determinants of health
• Foot care / Shoe clinic
• New mothers and families with children Mary Berglund’s Core Basket of Services:
• Pregnancy care and education
• Healthy child development • Food Bank
• Support and education for parents • Physiotherapy
• OHIP applications/document assistance • Chiropodist services
• Community kitchens
• Dietician ser vices
• Orthopedics
Division between clinical and health promotion • Mobile Eye-Care Unit (Partner)
teams arises from different payment structures • Mobile Breast Screening Unit (Partner)
(funding and salaries) and different prestige in • Diabetic Education
the health-care discourse between clinical and • Chronic Disease Follow-up Program
social service/health promotion services • Lab Specimen Collection
furthering the hierarchy of care. • Immunization Program
• Health Promotion Services
The challenges to comprehensive care can • Focus/Core Program (Lead Agency)
particularly resonate with rural communities. • Men’s & Women’s Wellness Clinic’s
Public health has limited presence/activity in rural • Blood Sugar Screening Programs
townships and this leads rural residents traveling • Blood Pressure Screening Programs
to the city for both their comprehensive health care as well as employment in the health-care
field. Also, both rural and urban physicians have too many patients to engage in preventive work
and due to work overload have very limited involvement with other providers.

Another challenge presents itself when health-care teams need to refer a client to an external
provider. If a client needs to attend cooking classes for diabetes at another institution because
the CHC is not offering that service, in what way can we ensure it is accessible for the client.


CHCs might also want expand services to address additional health needs, but have limited
physical space. This hinders CHCs’ abilities to expand services, to enhance existing services and
meet the demands and rising needs of the community.

e. Summary

CHCs are addressing these challenges, not only one-by-one through innovative programs and
services designed to support the needs of particular communities, but as a unified sector. CHCs
are providing comprehensive services that are effectively addressing the key attributes of
primary health care such as accessibility, coordination, continuity of services, and accountability.
In short, we are providing interprofessional care, flexible service approaches, programs that
build community capacity to address the social determinants of health, accountability to our
communities through community-governed Boards of Directors, partnerships with other
community stakeholders, and infrastructure that supports the integration of primary care with
the delivery of other health and social services.15

15
Strategic Review of the CHC Program (2001). Pg. v.

f. References

Association of Ontario Health Centres. (July 2006) CHC Sector Strategy Map Project: Strategy
Map and Balanced Scorecard.

Association of Ontario Health Centres. (March 2008). Everyone Matters: Who We are and What
We Do.

Association of Ontario Health Centres. (March 2007). Second Stage of Medicare: Conference
Report.

Shah P. Chandrakant & Moloughney W. Brent. A Strategic Review of the CHC Program. (May
2001). Community and Health Promotion Branch Ontario Ministry of Health and Long-Term Care.

The Ottawa Charter for Health Promotion: An International Conference on Health Promotion.
(November 1986).
[Online] Available: http://www.who.int/hpr/NPH/docs/ottawa_charter_hp.pdf [1986, November
17-21] Page 4

World Health Organization: Integrating Prevention into Health-care. (October 2002). [Online]
Available: http://www.who.int/mediacentre/factsheets/fs172/en/[2008, April 14].


2. Accessible

“Access is the ability or right to approach, enter, exit, communicate with, or make use of health
services.”16

a. Definition

CHCs are designed to improve access, participation, equity, inclusiveness and social justice by
eliminating systemic barriers to full participation. CHCs have expertise in ensuring access for
people who encounter a diverse range of social, cultural, economic, legal or geographic barriers
which contribute to the risk of developing health problems. This would include the provision of
culturally appropriate programs and services, programs for the non-insured, optimal location and
design of facilities, oppression-free environments and 24-hour on-call services.

b. Elaboration

In CHCs, access is about eliminating barriers and providing equitable17 health care to our clients
and our communities. While this may seem obvious, we must remember that clients often have
needs that are not adequately provided for by the existing health and social service system.
Hamilton Urban Core Oral
There are generally two aspects to access18. Firstly, client
Health Program
access is the extent to which our clients are able to attain
needed services. For example, if a parent The goal of the Oral Health Program needs to
bring her children in for immunizations but is to increase levels of good oral she works
from 8:00am-6:00pm then accessing health (Oral Health enhancement) services that
are only available from 9am-5pm will be and prevent and reduce oral health very difficult.
Also, if a client cannot speak the language problems (health promotion and of her
provider and has serious symptoms that she risk reduction). The Oral Health needs to
express to her providers, having someone Program aims to promote oral that can
health among individuals and
translate and interpret will be very useful to her.
groups that are underserved and
lack access to adequate oral health
The second aspect to access is care. In addition to services
organizational. Organizational access is the provided to individuals such as extent to
which our clients are represented and cleaning, fluoridation, pits and involved in
the design, development, implementation, fissure sealants, check-ups and so delivery and
administration of CHC services. As on, the Oral Heath Coordinator discussed in
the third Module, the integrity of the care provides oral health education that CHCs
provide is based on client and community sessions to schools, ESL programs, needs.
and a variety of community
Clients identify their health-care needs, and CHCs support
agencies and community groups.
the delivery of care to address these needs.

Below is a Chart of both Client and
Organizational Barriers:

16
A Cultural Competence Guide for Primary Health-care Professionals in Nova Scotia (2005). Pg 4.
17
For more discussion on ‘equity’, please view Module 3
18
Equal Access Pilot Project.

Questions to consider in identifying barriers to
Barriers
accessing care at a CHC

- Is the facility designed in a way that creates or reduces
physical barriers for clients?
- Does the facility meet the physical needs of clients who have
Physical mobility restrictions, are deaf or hard-of-hearing or are blind
or have vision problems?
- Are CHC programs and services available outside of regular
business hours?
Geographic
- Is the CHC accessible by car or public transit?
- If the CHC has a large geographic catchment area, how does
it enable clients to access services?
- Do appropriate outreach programs exist to support the
care of those who are immobile or cannot reach services by
transportation?
Communications
- Are services and resources available in the language needed?
- Are interpreters available, when needed and of the gender
preferred by clients?
- Are clients informed of changes or plans to their programs
and services?
- Are signs written in plain language?
Cultural
- Do CHC staff understand the implications of how a client’s
culture impacts their health and access to care?
- Are CHC programs respectful of clients’ cultural needs?
Economic
- Are CHC programs responsive to the needs of clients who
cannot afford health-related costs (e.g. medications, healthy
foods, oral care, cost to get to the CHC, time off work or
childcare needed when accessing care, etc.)?
- Do CHCs programs and services provide support for clients
living in abject poverty?
- Do CHCs programs and services take into account the class
realities experienced by clients?
- Does the CHC provide care for non-insured clients (e.g.
recent immigrants, people without health cards, people who
do not want to enrol)?
Social
- Are CHC programs designed to respond to the realities of
different social situations (e.g. being addicted to drugs, living
on the street, choosing to stay with an abusive spouse, etc.)?
- Are CHC programs designed to support the needs of the
LGBTTQQ community?

C. Why this Attribute is Relevant to the CHC

When CHCs strive to provide accessible care, their work is informed by an anti-oppression
commitment. The Board of Directors of the Association of Ontario Health Centres (AOHC) is
committed to embedding anti-oppression in all aspects of its governance policies, processes and
practices. The Board seeks to:

 increase access, participation, equity,
Centre de santé communautaire inclusiveness and social justice by eliminating
de Sudbury program for Franco- systemic barriers to full participation;
Ontarian youth  Promote positive relations and attitudinal change
by creating a climate where discriminatory or
Fifty young Francophones participate oppressive behaviours are not tolerated;
in the program, which connects
 Foster an AOHC Board that is reflective of its
students in high school and post-
membership and inclusive of racialized and
secondary institutions to their rich
minoritized groups
French heritage. More than 8,000
students have joined in the St. Jean
Some CHCs are at the forefront of anti-oppression
Baptiste musical shows as organizers,
work. As explained in the anti-oppression statement
performers or enthusiastic audience
of Access Alliance Multicultural Health and Community
members. The young people also
Services:
organize a homeless supper and, on
Ste. Catherine’s Day, conduct a mass
“ Racism, xenophobia, classism, sexism,
collection of personal-care products
homophobia and heterosexism, ableism, and
for people living on the street.
ageism cause pain and humiliation and have far-
The youth programming reminds
reaching consequences. Each one in its own way,
young Franco-Ontarians that their
prevents equality in opportunity, access to asylum,
roots run deep and that they are part
immigration opportunities, education, jobs,
of a vital and connected community.
housing, health-care and social services, and limits
And it also familiarizes young
participation in decision-making bodies.19
Francophones with other local
Francophone agencies and services.”
CHCs prioritize offering services to those clients who
face challenges in finding appropriate care within the
mainstream health-care system. For
example, in the 2006 / 07 fiscal year: Regent Park CHC
Responding to religious and spiritual diversity
 In just 37 CHCs across the province,
18,466 non-insured and 8,253 Regent Park Community Health Centre has adapted its
homeless clients were served services to respond better to diabetic Muslim clients
when they are fasting during the holy month of
 49.5% of CHC clients across the Ramadan. Potential health complications include
province had annual family incomes altered nutritional levels, prescription medication issues
of less than $20,000 per year and mental and emotional health issues stemming
from the intensity of the month’s devotions.
 9,454 CHC clients received service in
15 languages other than English or Physicians, nurses and other providers have worked
French.20 with community and religious leaders to develop
guidelines for better care and treatment. They also
actively encourage clients to “have the conversation
When working to provide accessible care about fasting” with their health-care providers. This is
to our clients, CHCs recognize that our supported through educational materials endorsed by
clients face numerous and diverse religious leaders and distributed at the local mosque.
barriers that affect if and how they

19
Access Alliance, Anti-Oppression Policy & Practice
20
Everyone Matters (2008)

access care. CHCs strive to reduce these barriers. Furthermore, when we view accessibility
under the lens of the social determinants of health, we are better able to provide relevant
services and improve overall health outcomes.

d. Opportunities & Challenges to Addressing this Attribute in your CHC

A key challenge to providing an accessible The NorWest CHCs:
environment is to acknowledge that some Reaching out to isolated
populations and communities face communities barriers.

The Ontario Healthy Communities Of all Ontario’s Community Health
Coalition states: Centres, the NorWest Community
Health Centres has the largest
“People do not necessarily choose to catchment area: 24,567 hectares,
deliberately discriminate against those approximately the size of the entire
who are different from themselves. Many province of New Brunswick.
of the barriers to participation within Its newest CHC satellite is an
community organizations exist because of innovative mobile unit that travels
a lack of awareness of differing wants or around the vast catchment area with
needs… There is no simple formula for a nurse practitioner, an RN foot-care
alleviating all barriers, as each person’s nurse and a community health
needs are unique.” 21 worker. Clients receive primary
health-care like Pap smears,
The [AOHC] Board understands that there physicals and the identification and When
are similarities, intersections and
monitoring of chronic illnesses. The
differences between forms of oppression
unit is also a platform for health-
and the ways in which they manifest
themselves. There is also recognition of promotion programs on healthy
the issues of power and privilege and how eating, effective parenting and
they inform organizational dynamics. The alcohol and substance- abuse
[AOHC] Board acknowledges the particular prevention.
pervasiveness and impact of racism in
society at large even after decades of considering how to make an environment more
legislation and initiatives. accessible to an individual or a group of individuals,
it is important to hear from the person or people
Board Governance and Anti-Oppression involved as to what the real barriers are. However,
Framework, the AOHC. it is not always simple for individuals to identify their
needs or fully grasp the systemic barriers that are
hindering their access to care.

Another challenge for CHCs can be balancing the implementation of a particular solution with the
impact the change can have on the organization itself. Sometimes answers to problems cannot
be immediately implemented. For example, if a CHC needs to apply physical changes to its
infrastructure, this is a long process that can often require resources (financial or otherwise) that
the organization does not have at its disposal.

e. Summary
Anne Johnston Health
In summary, to demonstrate respect for lived experiences Station
and to ensure that solutions make sense to clients we need to Women/Youth with
engage “people who experience barriers to access in Disabilities Programs
discussions on how to remove those barriers”22. This kind of
dialogue can also help CHCs find solutions that work for both Anne Johnston is a unique
the organization and the person/people experiencing the CHC at it provides services
to clients who experience
21
Ontario Healthy Communities Coalition (2004) various forms of disabilities.
16 21-Aug-12 Association of Ontario Health Centres This CHC also offers specific
programs and services for
women and youth with
disabilities.

barrier. While CHCs work to address barriers to health care, we can still be limited by the greater
barriers and prejudices that exist in our social system. Nevertheless, CHCs are acknowledging
these barriers and working towards providing equitable health care to all Ontarians. This is
evident from the relevant programs and services offered throughout our organizations.

Anishnawbe Health Toronto
Providing culturally competent care

Anishnawbe Health Toronto is an Aboriginal-focused CHC. Its mission is to “improve the health
and well being of Aboriginal People in spirit, mind, emotion and body by providing Traditional
Healing within an interprofessional health-care model.” The mission is put into practice through
programs and services based on Aboriginal Traditional Healing. As well, in this environment,
physicians and nurses work together with traditional healers, elders, medicine people and
traditional counselors to meet the health-care needs of their clients.

22
Building Inclusive Communities Tips Tool (2003)

f. References

A Cultural Competence Guide for Primary Health-care Professionals in Nova Scotia.
(2005). [Online]. Available:
http://www.gov.ns.ca/psc/pdf/Diversity/toolkit/Cultural%20Competence%20Guidelines.pdf
[2005] Page 4.

Access Alliance: Anti-Oppression Principles & Practice. [Online]. Available:
http://www.accessalliance.ca/index.php?option=com_content&task=view&id=35&Itemid=12

Association of Ontario Health Centres. (May 2006). Anti-Racism and
Anti-Discrimination Working Group Report: Advice and recommendations to the
Board for policy changes and/or development to reflect AOHC’s commitment to the
principles of anti-racism and anti-discrimination

Association of Ontario Health Centres. (February 2007). Board Governance Anti
Oppression Framework.

Association of Ontario Health Centres. (March 2008). Everyone Matters: Who We are and What
We Do.

Building Inclusive Communities Tips Tool. (2003). [Online]
Available: http://whiwh.com/BIC_tips.pdf [2003]

Ontario Healthy Communities Coalition: Inclusive Community Organizations: A Tool Kit. (2004).
[Online]. Available http://www.healthycommunities.on.ca/publications/ICO/ICO_1.pdf [2004
October]


3. Client & Community Centered
“Nothing about me without me”23

a. Definition

CHCs are continuously adapting and refining their ability to reach and to serve their clients and
communities. CHCs plan based on population health needs and develop best practices for
serving those needs. CHCs strive to provide client-centered care.

b. Elaboration

The CHC sector develops individual and community capacity through the lens of the social
determinants of health. This perspective allows for the identification of root causes of health
issues, and for a strategic response to community needs. We will continue to be community led,
provide community infrastructure, and assist communities to develop their own unique
solutions.24
Examples and Experiences from
CHCs
Client and community-centered care includes Woolwich essential
elements25. These are:
Mennonite children leave school
1. Superb access to care earlier than most other students (age
2. Respect for patients’ values, preferences, 14) and are engaged in farming/shop and
expressed needs activities while at home on the farm.
Local teachers and WCHC recognized
3. Clinical management systems that support the need for specialized instruction in
high-
quality care, practice-based learning, and the area of safety and injury quality
improvement prevention. The Rural Community
4. Emotional support to relieve fear and Health Worker provides this anxiety
5. Involvement of family and friends education with volunteer support to
6. Integration of health care and health-care many public, catholic and parochial settings
7. Physical comfort schools on a rotating basis. The
education covers topics such as:
8. Ongoing routine patient feedback to a practice
chemicals, tractors, chainsaws, silo
9. Publicly available information on practices gases, shop safety, animals,
10. Increased patient education lawnmowers, as well as buggy road
safety, first aid, food safety and
In CHCs, we often use the term ‘client’ rather babysitting. than
‘patient’. ‘Patient’ implies that the provider is the all-knowing expert and the patient is the
passive receiver of care26. In CHCs, ‘clients’ are active contributors to the care we receive. Also,
a CHC ‘client’ uses many other services that are not focused on primary health care. For
example, a client that participates in a personal development group that focuses on
breastfeeding, nutrition, literacy, environmental health, or employment skills.

23
Health-care in a land called People Power: nothing about me without me (2001)
24
CHC Strategy Map and Balanced Scorecard (2006) Pg 5.
25
Adapted from Audet et al (2006)
26
Neuberger, Julia (1999).

The use of the terms ‘equity’ and
Examples and Experiences from CHCs
Women’s Health in Women’s Hands ‘equality’ also need to be clarified
when talking about client and
Many WHIWH clients come from all over the globe. community-centred care.
“They’ve often lived through the unthinkable,” says According to Competence
Eunadie Johnson, former Executive Director. “They Consultants & Associates27,
may have survived the trauma of genital ‘equality’ is defined as treating
mutilation, the horror of war or the oppression of a people the same based on the
police state. In their quest for immigrant status assumption that everyone is the
they’re at the mercy of their sponsors – often the
same and has the same needs.
very men who are abusing them. HIV/AIDS may be
a pervasive foe for themselves and their loved ‘Equity’, on the other hand, refers
ones”. to treating people differently based
on our different needs in order to
“We give health and social service professionals ensure we can access the same
information that comes directly from the women services as others who are not
themselves,” says Johnson. “It helps them challenged with the same needs.
understand that women have special needs; they When it comes to client and
can’t use the regular medical model to assess community-centered care, we
them.” Indeed, with all its advocacy initiatives,
WHIWH is guided by the conviction that every
Examples and Experiences from CHCs
woman has an inherent ability to advocate on her
LAMP
own behalf and that she is ultimately the best judge
of her own needs. All of the centre’s advocacy
Historically a highly industrialized
neighbourhood, LAMP’s (Lakeshore Area
Multi-Service Project) catchment area had a
large population of workers seeking help
with occupational health and safety
concerns. LAMPS community is less
geographical and more occupational. The
work has taken them into every
environment, from soft rock mines to day
care centers. The centre only serves
workplaces with less than 200 employees.
Special projects take staff out into the
Greater Toronto Area investigating
workplace issues brought to their attention
by employees, their unions and companies
themselves.
The centre’s research on occupational
illnesses appears in professional journals
and sparks worldwide demand for speakers
from among its staff.
emphasize that not everyone requires the same kind of care, in the same manner, at
the same time. For a service and/or organization to be truly community and client-
centered, it must have an equitable foundation.


According to a 2004 paper published by the Health Network28, almost 80% of
Canadians believe that it is important for individuals to be involved in major decisions
about our health-care system. Responding to population health needs is essential
when providing client and community-centered care. Often when focusing on a

27
Competence Consultants & Associates (2005).
28
Abelson, Julia and Francois-Pierre Gauvin (2004)


priority population, the expertise developed is sought after by other academic and
health-care institutions around the world.

To adequately respond to the local population health needs, CHCs conduct community
health needs assessments, which involve reviewing both quantitative and qualitative
information from the local community. Quantitative data include statistics, current
health and social research, socio-demographic and -economic data and health status
reports. Qualitative data can be gathered by engaging with community members to
hear directly from them as to what the local health priorities are. This information is
used to help define a Centre’s priority populations, what

programs and services should be offered, what staff are needed and what community
partnerships should be developed.

d. Opportunities & Challenges to Addressing this Attribute in
your CHC

Examples and Experiences from CHCs One of the challenges in
Centre Francophone de Toronto addressing community-centred
care at a CHC is servicing all
Francophone individuals or families who have those in the community who
immigrated to Toronto or who are newcomers to experience barriers to
Toronto can receive services that will facilitate their accessing care. Due to limited
entry into Canadian society and help them get adjusted financial and human resources,
in their daily lives. The Centre francophone offers a
sometimes it is not always
considerable number of services to newcomers,
including:
feasible for a CHC to satisfy the
• Social services (emergency housing, financial needs of every priority
assistance)
population in the community.
• Immigration services Furthermore, some CHCs have
a wide variance in the
• Government services
demographics of their clients.
• Community services
Some CHCs serve mixed
The counselors may also offer assistance with filling in
forms managing budgets. In one-on-one meetings,
income populations and it is a
they can determine each person’s specific needs and challenge to ensure each
guide the client to those programs at the Centre that populations gets the
best meet his or her needs. There is also an outreach appropriate service at the
service to support the Francophone community. appropriate time.

An additional challenge in addressing client-centred care is that there can be a real
diversity of needs among individual clients and meeting everyone’s unique needs can
be challenging.

Also, social needs are experienced as greater than medical needs. However, dollars
are primarily available for clinical services. The challenge is for funders to understand
the broader picture of health, as Examples and Experiences from CHCs
well as comprehend the available West Elgin Community Health Centre
capacities and resources that
extend beyond medical services
Farmers and rural farm families are one of West Elgin
that could be made available to
Community Health Centre’s priority populations. In the
the community. summer of 2005 over 400 farmers from Western Elgin
County participated in a “Farm Family Survey” that looked
In addition, providing ongoing at Occupational Illness and the Health and Safety of the
needs assessments of individual farming community. As a result of this, CPR classes were
client services and community conducted for farm families in the community and a
subsequent Asthma Program was developed. An
21 21-Aug-12 Association of Ontario Health Illness screening questionnaire was developed
Occupational Centres
and continues to be used by West Elgin Physicians and
Nurse Practitioners to identify and help manage individuals
who have work related illnesses.

needs assessments to ensure that programs and services continue to meet changing
needs requires certain resources and capacity. The CHC workload can often be more
than employees can handle and community health worker and health promoter
positions are often under funded. This can lead to CHC team members

being asked to do jobs that are not part of their job description. This can lead to
employee dissatisfaction.

e. Summary

Ontario CHCs ensure our clients are engaged meaningfully in decisions about our
health and health care in our communities. Case studies and research reviews
suggest that meaningful community engagement, with community members actually
involved in decision making, improves health and health care. 29 In the CHC sector, we
are taking the opportunities to engage our clients and communities in the development
of programs and services to foster and encourage better health outcomes.

29
Everyone Matters (2008). Pg. 34.

f. References
Abelson, Julia and Francois-Pierre Gauvin. (2004 April). Engaging Individuals: One
Route to Health Care Accountability. Health-care Accountability Papers – No/2. Health
Network.

Adapted from World Health Organization (1985) as cited in J. Abelson and B.
Hutchison. (1994) Primary health-care delivery models: a review of the international
literature. McMaster University Centre for Health Economics and Policy Analysis.
Paper. 94-15.

Association of Ontario Health Centres. (March 2008). Everyone Matters: Who We are
and What We Do.

Association of Ontario Health Centres. (July 2006). CHC Sector Strategy Map Project:
Strategy Map and Balanced Scorecard.

Audet, A. et al. Adoption of Patient Centered Care Practices by Physicians. (2006).
[Online].
Available: http://www.commonwealthfund.org/publications/publications_show.htm?
doc_id=365654
(2006, April 10)

Competence Consultants & Associates. (2005). Tool Kit: Tool #1: What we mean by
some words.

Community Organizational Health Inc. (2008). [Online]. Available: http://www.cohi-
soci.ca/index.php?page=e1403

Delbanco, Tom. MD et al. (2001, September). From Health-care in a land called
People Power: nothing about me without me. Health Expectations. Blackwell Science
Ltd. Volume 4, 144-150.

Neuberger, Julia. (1999) Do we need a new word for patients? BMJ. Volume 318:
1756-8


4. Interprofessional

“The right care, by the right provider, at the right time”30

a. Definition

CHCs build interprofessional teams working in collaborative practice. In these teams,
salaried professionals work together in a coordinated approach to address the health
needs of their clients. Depending on the actual programs and services offered, CHC
interprofessional teams may include physicians, nurses, nurse practitioners, dietitians,
physiotherapists, occupational therapists, social workers, Aboriginal traditional healers,
chiropodists, counsellors, health promoters, community development workers, and
administrative staff.

b. Elaboration

Many CHC clients have complex health conditions and need to see multiple providers.
In 2006/07, 37 CHCs made over 200,000 referrals either internally to other health-
care providers on the team or to external health-care providers.31
Clients were internally referred to child-care workers, chiropodists, counsellors,
cultural interpreters, oral health-care workers, dietitians, physical therapists,
surgeons, and traditional healers.
Also in 2006/07, over 8,000 CHC
An interprofessional process for communication
and decision making that enables the separate clients saw more than four health-
and shared knowledge and skills of care providers care providers during a single visit;
to synergistically influence the client care almost 20,000 clients saw more than
provided. A foundational component of three health-care providers; and
collaborative practice is ‘equality’ within the team almost 35,000 saw more than two. 32
framework and not hierarchy. This improves the effectiveness of
case consultation which has a
Building Better Teams pg.27
positive impact on the delivery of
care. Furthermore, coordination and
continuity of care improve when clients’ needs are met through provider collaboration
and teamwork. Teamwork improves access to primary health-care especially in under-
serviced areas of the province, which ultimately results in more cost-effective care.

The effective use of all health-care professionals will enable them to maximize their
skills and work to the full extent of their qualifications, training, and scope of practice.
Evidence demonstrates that a substantial proportion of the current activities of family
physicians could be done equitably well by nurse practitioners, for example. In
Ontario, the top five physician billing codes that accounted for approximately 69% of
the total amount billed by primary care physicians in 1996/97 ($1.2 billion) included
intermediate assessments/well-baby care, general assessments, minor assessments,
individual psychotherapy and counselling. There is a great deal of evidence from other
jurisdictions that demonstrate that these services can be done by other qualified
practitioners at a much lower cost to the system.
30
AOHC Fact Sheet CHCs and the “Three Rs”
31
Everyone Matters (2008).
32
Ibid.

The benefits to the client in engaging in a collaborative practice model include:
seamless access to a wide variety of health-care services; options when one’s primary
provider is absent; and more choice of appropriate providers to meet one’s needs.


Interprofessional teams mirror (on
the provider side) the complexity Experiences and Examples from CHCs
of the health issues experienced by Teen Health CHC Eating Disorders Program
the client. The inter-disciplinary
Serving 12-to-24-year-old Windsor and Essex County
team approach acknowledges that
youth for the past 15 years, the centre takes teamwork
the health of an individual is to heart. Once every other week, the centre’s eating
intricate and multi-dimensional. disorders team meets to review every file in its
When community health workers caseload. Working in conjunction with the Bulimia and
and health promoters are part of Anorexia Nervosa Association (of Essex County), the
the team, preventative health gathering draws together everyone from every
issues as well as mental and discipline within the centre who is, or has, worked on
psycho-social issues are active files. Social workers, nutritionists, physicians –
addressed.33 three people from the agency and four from outside –
touch base on "everything everyone is doing with each
client," says primary care services manager Tom
Ontario’s Community Health Groulx. "The clients get ‘unidirectional’ help," says
Centres acknowledge the Groulx. That is, "we don’t have several different people
importance of collaboration not giving clients contradictory and therefore confusing
only in healing but also in advice. If we decide on a course of action in a unified
preventative care and overall front, it makes more sense for everyone."
health promotion. As communities
and as a sector, we are working towards building an understanding of health as more
than simply patching up the ill, but keeping people well. This work entails the
commitment of more than one person, and more than one profession. It takes the
passion and time of a wide range of health service providers.

In Ontario, most private physicians are paid on a fee for service model. Ontario CHC
physicians are paid a salary as are other providers. CHC physicians are therefore able
to see clients with complex care needs because they can address more than one issue
in a single service event and provide more time to their clients. More time with clients
allows for more counselling and preventative care by primary care providers which
leads to better health outcomes.

your CHC

Despite the tremendous benefits of collaborative practice models, there are still
significant barriers to surmount.

“…we’re still educating health professionals in silos…formal education of
health-care professionals around collaborative patient-centred practice
as well as informal education to help team members understand the
scope of practice of their colleagues is essential”34.

33
AOHC Fact Sheet. What does it mean to work in Collaborative Practice?
34
AOHC Fact Sheet. What does it mean to work in Collaborative Practice?

In addition, the elements that help and encourage team work and collaboration
(regular meetings, activities, and communiqués among staff) require time, energy,
commitment, and financial resources. When providers and front-line staff are stressed
and overworked, they often cannot attend regular meetings and participate in staff
activities.
York Community Service Legal Clinic Furthermore, issues of liability
are frequently raised
The clinic launched in 1978, just five years after the
centre opened. "This kind of interprofessional structure concerning the roles of
helps us help people with complex, multiple problems providers and their legal
because of the wide system of support available," says responsibilities and
Francie Kendal, director, communications and accountabilities. According to a
development. For instance, a client may come in for joint document released by the
primary health-care treatment. The health-care Canadian Medical Protective
professional may then find out the client is about to be Association and the Canadian
evicted — and the distress may be a factor in his or her Nurses Protective Society35,
ill health. So they may refer the client to the legal
there are steps that
team, or even the eviction prevention program, and
other support programs the centre offers. collaborative teams can take
“Having professionals from other disciplines on-site (including purchasing liability
enhances the quality of care that staff can offer by way insurance) that will protect
of their quick access to others. For instance, a providers should an issue arise.
counselor who needs to find some legal information While these issues are
need not go outside the centre – the expert is just infrequent, it does concern
down the hall”. physicians as to how much of
their work can be shared with
nurse practitioners, nurses and
other CHC staff. Through education, open discussion and knowledge sharing, this
concern will be diminished.

The current Ontario Medical Association’s incentives that have been rolled out to CHCs
in an attempt to increase compensation to physicians require CHC clients to be
enrolled to an ‘assigned physician’. Clients are enrolled to physicians and not the CHC,
which does not take into account that other providers (nurse practitioners, nurses etc.)
often provide primary care to clients. Also, clients go to their CHCs for programs and
services that do not require a physician and so enrolment figures do not adequately
present the work that all health-care providers are doing at their CHC.

The design and infrastructure of CHCs also provides challenges to interprofessional
work. Specifically when clinical teams and health promotion teams are separated. This
decreases the potential for case conferencing and discussion as well as developing
social relationships with colleagues.

Also, funders have very different pay scales for different types of work. Members of
the clinical team are better supported by funding than members of the social team.
Furthermore, different providers offering the same services get paid differently. Nurse
practitioners, for example, performing pap smears are paid differently to a physician
performing the same task.

e. Summary

Strong teams ensure there is a shared philosophy and vision and involve participatory
leadership where every member on the team has a formal/informal leadership role.
35
CMPA/CNPS Joint Statement (2005)

We know that collaborative and interprofessional team work can develop trusting and
respectful working environments which serve the client better as health outcomes are
improved. When we adopt an integrated teamwork approach that values different
professional approaches and perspectives that create well-defined roles and role
expectations and develop leadership as a core competency then the environment for
both staff and clients improves. Working towards integrating clinical teams with the
non-clinical teams develops an environment of continuous learning and improvement
which further serves to benefit our clients.36

f. References

A. Mitchell et al. (1993). Utilization of Nurse Practitioners in Ontario. A Discussion
Paper Requested by the Ontario Ministry of Health. Nursing Effectiveness, Utilization
and Outcomes Research Unit. Paper 93-4.

36
Building Better Teams (2007)

Association of Ontario Health Centres (2007). Building Better Teams: A Toolkit for
Strengthening Teamwork in Community Health Centres. Resources, Tips, and
Activities you can Use to Enhance Collaboration.

Association of Ontario Health Centres (June, 2007). Building Better Teams: Learning
from Ontario’s Community Health Centres. A Report of Research Findings.

Association of Ontario Health Centres Fact Sheet. CHCs and the Three Rs: The right
care, by the right provider, at the right time.

Association of Ontario Health Centres (March 2008). Everyone Matters: Who We are
and What We Do.

Association of Ontario Health Centres Fact Sheet. What does it mean to work in
Collaborative Practice?

CMPA/CNPS. (2005). Joint Statement on Liability Protection for Nurse Practitioners
and Physicians in Collaborative Practice. [Online]. Available:
http://www.cnps.ca/joint_statement/English_CMPA_CNPS_joint_stmt.pdf (2005
March).

Community Organizational Health Inc. (2008). [Online]. Available: http://www.cohi-
soci.ca/index.php?page=e1403


5. Integrated

“Every door leads to service.”37

a. Definition

CHCs develop strong connections with health system partners and community partners
to ensure the integration of CHC services with the delivery of other health and social
services. Integration improves client care through the provision of timely services,
appropriate referrals, and the delivery of seamless care. Integration also leads to
system efficiencies.

b. Elaboration

Integration involves cross-sectoral partnerships with organizations and institutions that
provide both direct client care (such as community organizations) and indirect client
care (such as universities and municipal and/or provincial governments). When we
work in partnership with others to solve problems by using common resources, we are
more likely to support clients and provide accessible and comprehensive care.
Integrated care is not about passing the
Linkages across sectors and between responsibility of care to someone else,
providers support clients to successfully but rather its about unifying goals and
transition, with due respect for the barriers resources across organizations to
that they may face and the complexity of improve the overall quality of care.
their care issues.
CHCs integrate with partners in a
http://www.aohc.org/app/wa/doc?docId=168
number of different ways, from physical
integration, such as co-locating in the
same building, to functional integration, such as sharing resources, to program
integration. In 2006-07 alone, 54 CHCs were part of 1,275 partnerships, an average
of 24 partnerships per CHC.38

Within the CHC accreditation process, Building Healthy Experiences and Examples from CHCs
Organizations39, working with partners (defined as GayZoneGaie
“organizations that CHCs work closely with to jointly
operate programs and services or work on joint A partnership of organizations in Ottawa
planning or advocacy initiatives to benefit their have come together using existing
resources to provide a service that includes
communities”) is an essential criterion for
HIV and STD testing as well as offering a
accreditation. variety of wellness programming for gay
men and ‘guys into guys’.
As outlined in the 2006 CHC Strategy Map, CHCs are Partners include: Sommerset West
an entry point to the health-care system for people Community Health Centre, Centretown
facing barriers to health. Benefits to integration affect Community Health Centre, Ottawa Public
our clients in profound and meaningful ways. If certain Health, the Youth Services Bureau of
services and sectors are not connected, people Ottawa; the AIDS Committee of Ottawa,
accessing health-care services can fall through the Pink Triangle Services, and Ottawa Gay
Men’s Wellness Initiative.
cracks. CHCs have established the expertise in
developing partnerships enabling us to provide
integrated primary health care both within the sector
37
Every Door Leads to Service (2006)
38
Everyone Matters (2008)
39
Building Healthy Organizations (2008)

and beyond. CHCs continue to develop partnerships and to enhance cross-sectoral
service coordination that complements the programs and services of other service
providers, leads to appropriate use of resources, and increases the sustainability of the
health-care system.40
C. Why this Attribute is Relevant to the CHC

Working in an integrated way with community members and service providers is a
natural and fundamental component of the CHC Model. Integrated work helps prevent
clients from falling through the cracks and is effective in reducing costs to the entire
health-care system.

With the establishment of the Local Health Integration Networks (LHINs), CHCs are
expected to continue and increase integration with other providers in the community
for the purpose of “maintaining and sustaining a world-class health-care system that
will help keep people healthy, deliver good care when they are sick and will be there
for their children and grandchildren”.41

your CHC

Integration and working in partnerships makes it possible to leverage resources and
often produces cost effective approaches to the provision of services and programs,
but working with partners is challenging in the best of times and requires resources.
This is often an overlooked or neglected
aspect of integration and partnership Service Integration is most usefully defined
work. It is challenging to balance program as an on-going process whereby local
needs with the need to focus on policy agencies engage in progressively greater
change and community capacity building. degrees of joint service activities along an
In addition, many programs need a lot of integration continuum.
administrative support and it sometimes is
a challenge to identify on whose shoulders Ryans & Robinson 2005
this responsibility should fall.

Also, some organizations serve particular priority populations and are isolated from
integration because other institutions and agencies within the same geographic
community serve different clients and address different health-care issues.

Integration requires perseverance and commitment to address issues when they arise.
Respect and acknowledgement of the contribution of all parties are essential.

In summary, successfully partnering can present some
Woolwich CHC Hospice Programs
challenges for the various partners involved. They are:
Woolwich and Wellesley Hospice
 Differences in funding and accountability to programs have an advisory
government committee made up of WCHC staff,
 Organizational and professional cultures that may clergy, hospice volunteers, and
work against integrated models Community Care Access Centres
 Differing ‘frameworks for practice’ (CCAC) The advisory committee and
staff implement hospice programs
 Inequitable power amongst potential partners and services collaborating with CCAC,
KW Alzheimers Society and other
hospices in South West Ontario.
40
These include the Association for
CHC Strategy Map and Balanced Scorecard (2006). Pg 5 Community Living, Community Care
41
Ontario Local Health Integration Networks (2006) Concepts, Canadian Cancer Society
30 21-Aug-12 Association of Ontario Health Centres and Long Term Care facilities to meet
the hospice and long-term care needs
of the community.

 Histories of unsuccessful partnerships42

Successful integration requires that the autonomy of each organization remains intact.
Organizations develop common goals related to the integration, and identify the
strategies and inputs each organization will implement individually and collaboratively.
This ensures that organizations remain autonomous and partner rather than merge
completely.

At the 2007 AOHC conference43, Guelph CHC put on a workshop entitled Partnership
Supporting Healthy Childhood Development. They also identified ways that agencies
should work together across sectors. These include:

1. Find a legitimating agent to call the community of service providers together.
2. Define the range of services to be included at the table.
3. Insist that those attending the committee meetings will be executive directors or
very senior management staff who have an appropriate degree of decision making
power.
4. The initial meetings of the inter-agency Experiences and Examples from CHCs
Centretown CHC
committee should be spent coming to an
agreement on the concepts and language of
Since 1998, a community-based program for type
service integration. 2 diabetes education has operated in Ottawa out
5. Set realistic goals and meet as often as the work of Centretown Community Health Centre. The
requires. Diabetes Network serves all of the community
6. Provide a modest amount of funding to support health and resource Centres across the city, co-
administrative expenses associated with inter- ordinating services among community members,
agency activity. hospital-based programs, public health, CCAC,
the Canadian Diabetes Association and, more
7. Devise and pursue a rigorous progress evaluation recently, local family health teams. From April 1,
and continuous quality improvement strategy. 2007, to June 30, 2007, the program served 592
new clients in groups and individually, in addition
e. Summary to offering almost 800 follow-up visits. Services
are available in 11 different languages.
CHCs have integrated in a meaningful way with other In addition, a dietician designed an award-
winning diabetes food guide that is now available
organizations as well as other CHCs to ensure our
across Canada in many languages.”
clients get the most appropriate service by the
organization/staff with the best expertise to provide this service. Our Centres have
partnered with the Centre for Addiction and Mental Health, Community Care Access
Centres, the Canadian Diabetes Association, various hospitals, numerous universities,
Legal Aid Ontario, family service organizations, and many more. We have a proven
willingness and commitment to address challenges; an evolutionary approach to
change; an ability to respect the views and opinions of others; and accountable
governance structures 44 to ensure our clients remain at the heart of what we do.

42
Integrated Primary Health-care. (2007)
43
www.aohc.org
44

Integrated Primary Health-care. May 23, 2007

f. References

AOHC, OCSA and OFCMHAP. Every Door Leads to Service: Enhancing Access
And Building a Culture of Service Integration for a Made in Ontario Health System.
(2006). [Online]
Available: http://www.aohc.org/app/wa/doc?docId=168 [2006, July]

Association of Ontario Health Centres. (March 2008). Everyone Matters: Who We are
and What We Do.

Association of Ontario Health Centres. (July 2006). CHC Sector Strategy Map Project:
Strategy Map and Balanced Scorecard.

Community Organizational Health Inc. (March 2008). Building Healthier Organizations.
www.cohi-soci.ca

Edwards, Karen. Integrated Primary Health-care. (2007). NSW Health. [Online].
Available: http://www.achse.org.au/nsw/seminars/23may07_edwards.ppt (2007, May
23).

Local Health System Integration Act. (2006). Ministry of Health and Long-Term Care.
[Online].
Available: http://www.e-
laws.gov.on.ca/html/statutes/english/elaws_statutes_06l04_e.htm (2006).

Local Health Integration Network / Health Service Provider Governance Resource and
Toolkit for Voluntary Integration Initiatives. (2008). [Online].
Available: http://www.centrallhin.on.ca/page.aspx?id=3860 (2008, Sept 8).

Ontario’s Local Health Integration Networks (2006). [Online]. Available:
www.lhins.on.ca/legislation.aspx

Ryan B., Robinson R. Service Integration in Ontario: Critical Insights from the Service
Community. (2005). [Online] Available: http://www. tns-global.com

.


6. Community-governed
“The CHC Board’s role is not just to reflect the community but to reflect the
community that it serves!”45

a. Definition

CHCs are not-for-profit organizations, governed by community boards. Community
boards and committees provide a mechanism for Centres to be responsible to the
needs of their respective communities, and for communities to develop a sense of
ownership over “their” Centres.

b. Elaboration

CHCs participate in democratic governance of health-care delivery
[The Board shall consist
through locally-elected community-based boards to ensure health
of] active members who
care remains responsive and customized to the priority needs of our collectively demonstrate
clients46. Therefore, our Boards remain accountable to CHC clients by a broad range of
ensuring relevant programs and services. relevant skills and
experience and reflect
CHC Boards are composed of the community, by the community and the community being
or the community, and have governance guidelines. Examples of served.
guidelines include:
MOHLTC (2001)
 Improving upon the quality and relevance of services provided.
 Ensuring transparency and accountability of the services provided and the intended
populations.
 Empowering the communities by reinforcing authentic participation.
 Understanding community governance as a determinant of health.
 Encouraging sustainability through community ownership and community
participation.
 Improving individual and community health outcomes as the representatives elicit
local knowledge and expertise.
 Being more cost effective as genuine community ties are built and more
appropriate services are delivered to the right people at the right time. 47

As Karen Patzer outlines in her research project Review of the When governance Boards
shift from representing
Trends and Benefits of Community Engagement and Local
their silos, to representing
Community Governance in Health Care, the best interests of the
“The most significant value added of community governance in ‘owners’, the system will
health appears to be related to its ability to achieve better health begin to truly transform.
outcomes for both individuals and communities by increasing
empowerment and social capital. A research review undertaken by Adamson et al (2007)
Health Canada (2003) indicated that “research associating social
capital with health shows that the higher the level of social capital
in a community, the better the health status and that strengthening the social capital
of communities would consequently constitute a promising means of reducing

45
AOHC Fact Sheet. Community Governance as a Determinant of Health.
46
AOHC conference report (2007). Pg 4
47
Adamson et al (2007)

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