Models of multidisciplinary working: international review

Appendix 3: Canada Documents for Case Study

1.The Rural Road Map for Action: directions

Introduction

• The College of Family Physicians of Canada (CFPC) and the Society of Rural Physicians of Canada (SRPC) came together in 2014 to create a task force to deal with the challenges facing the rural community.
• Statistically, although rural Canadian make up 18% of the population, they only have access to 8% of the doctors/health care professionals there.^[3]
• The task force developed 4 directions to create a framework.

Direction 1:

Reinforce the social accountability mandate of medical schools and residency programs to address health care needs of rural and Indigenous communities.

• Like Australia, there is a need for cultural safety education for the indigenous population as there is a fear over going to hospital.
• There is also a need to identify specific competencies relating to rural medicine, and to provide support for said competencies through training.

Direction 2:

Implement policy interventions that align

medical education with workforce planning.

• If training positions do not take into account anticipated rural community needs, then they will not be able to provide appropriate medical care.
• The report recommends that general physicians (GPs) develop broad skill sets and acquire additional skills in order to address rural community needs.
• There should also be increased mobility of services – the report says that "it is easier to do relief work overseas than to respond to emergency needs within our own country".^[4]

Direction 3:

Establish practice models that provide rural and Indigenous communities with timely access to quality health care that is responsive to their needs.

• One of the challenges facing rural practitioners (and in retaining them) is being able to access high-quality healthcare outside the community.
• This direction aims to develop the right care and to address concerns from rural GPs.

Direction 4:

Institute a national rural research agenda to support rural workforce planning aimed at improving access to patient-centred and quality-focused care in rural Canada.

• This direction deals with the accuracy of information gathering in the rural community.
• Initiatives should provide support for rural communities and increase means for ongoing research.

Conclusion

• Current gaps should be addressed in order to fulfil the task force's vision of a well skilled and broad ranged generalist serving each rural community of Canada.

2.TV Ontario [TVO] – Practicing Medicine in Northern Ontario – 5 Feb 2018

• This was a panel discussion chaired by Steve Paikin with responses from Chuck Schmitt, Recruitment Coordinator for the Dryden Regional Health Centre, Sarah Newbery, Rural Physician in Marathon and Catherine Cervin, Vice Dean of Academic for the Northern Ontario School of Medicine, or NOSM as it is more commonly known. NOSM was set up in Thunder Bay and Sudbury in order to address Northern Ontario's chronic need for doctors.
• According to the mayor of White River, Angelo Bazzoni, although there is funding for a clinic there, residents are "penalised for being in the north" because the local taxpayers pay some of the operating costs of the clinic.
• Although 90% of Northern graduates are practising in Northern Ontario, there is still some work to do in terms of joining up rural care and also ensuring spousal employment in the area (spouse who is not a doctor).

3.Building a Flourishing Physician Workforce – Summit North 2018

• This paper documents both the inputs to, and outcomes of, Summit North 2018, a day designed to bring together groups and organizations that need to work together to ensure that rural and remote communities in Northern Ontario will have a sustainable supply of well-trained physicians to meet their health care needs.
• Accountability > who is accountable when a decision is not equitable • Need a Northern lens • Need to travel Start the conversation • Value stream mapping • Care givers group • Gather information Rural and remote health accountability commissioner (like auditor general) Build relationships and trust • Bring physicians under the same contract as AHPs Staff the OMA and the politics
• Accurate and up-to-date image of community needs • Stats based (scorecard of demographics) • Community needs base > driven by local people Set standards of expectations and benchmark for care providers • Same level for all Engage all involved parties on needs, standards, benchmark • Policy, practitioners, communities, etc.
• Ensure access to community based enhanced skills development based on community need • Leverage Local Education Groups (LEGs) funding (where possible) to hire someone to do needs assessment for each community • Develop education plan based on N.A. including CME, online and face to face education, faculty development, and formal advanced skills training • Ensure adequate infrastructure and funding • Ensure data for program planning and indicators for monitoring • Formalize partnerships between NOSM, LHINs, communities and physicians • Identify community priorities and gaps from ground up and work through partnership locally • Establish (delegate) high-level representation from organizations to work together • Develop shared decentralized approach to engagement and understanding of community needs to build vision/ action/ advocacy from their input • Integrate allied health, interprofessional learners (nursing, PA, OT/PT) to train at the same time
• Increase elective opportunities for rural and remote communities - Curriculum development to meet needs Review the curriculum.
• There may be a need to concentrate or consolidate special services and recognize and incorporate extended roles of generalist providers (e.g. Family Practice Anaesthesia, Care of the Elderly) Build new models of care e.g.- Primary Health Care Key responsibility for MOHLTC, Indigenous peoples and professional associations: Ensure model is population based for equity and sustainability Be clear re: scope of model Identify core teams Clarify models of leadership governance Consider infrastructure including support for learners Adapt payment and funding to support goal including teaching Building technologies Build networks of caregivers within clusters Building a Flourishing Physician Workforce — Summit North 2018 23 Work with the willing Join up other systems – Emergency Health Services (EHS) Educational supply Building strategies by discipline and professionals based on forecasts Recognize limitations of data but also strengths Remember lead times ( it takes 10 years to train a surgeon, 6 – 7 to train a Family Physician) Recognize mobility of residency
• Commit to a positive and constructive solution-oriented attitude towards recruitment Be nice to each other Be open to hearing bold ideas Remember the client, both learners and the patients who we are here to serve Engage broadly and early and frequently with the actual communities for who you are making plans Steering Committee, please consider/remember - Summarized Remember to ensure that each community is treated uniquely Continue to ensure active community participation with all other partnership pentagram members to develop a successful model in Northern Ontario for Northern Ontario Include Public Health in all aspects of these initiative Keep open to inter-jurisdictional collaboration and learning much to be gained from rural collaboration Remember the importance of support for the rural physician • Educational, social, collegial, financial, personal growth & resources Building a Flourishing Physician Workforce — Summit North 2018 45 Please don't forget to make provision of rural obstetrical area a priority Remember the FN communities.
• Funded • Funding to support locums should not disadvantage full time local physicians New grads commit to locum pool; • Rotate through communities Each community upon locum arrival; engagement session Create network with residents and mentors • Co-deployment Create regional networks (with LHINs) Pool of locums of physicians near end of career or beginning QI Coordinator compiles feedback from each community and locum participants Using this feedback, we can see where we are lacking with cultural sensitivity Create governance structure for ownership and accountability Champions to advocate, "buy-in" Begin engagement sessions with leaders Create an advisory committee Clarify expectations > accountability Create pool of locums Stakeholders to establish consensus of priority Create common orientation packages 40 Building a Flourishing Physician Workforce — Summit North 2018 Stop community competition Funding options Policies, administration formation Continue communicating engagement Provincial workforce planning Broader consideration than physicians Transition plan for decentralization mentorship program Career development/ advice mentorship Equity: All decisions made, and all resources assigned by Equity.
• Introduce NAN Oshki Education Program to mental health social service students Build relationships between primary care providers and referral centre specialists: formal regional network E-referral systems, central intake and waitlist management Expand visiting specialist programs Enhance regional programs and consider regional lead for Cancer care Stroke Virtual critical care Psychiatry Obstetrics Peds ENT Renal Environmental scan, population health Administered jointly with NOSM, LHIN Building a Flourishing Physician Workforce — Summit North 2018 33 technology: Create system-wide, coordinated distance technology in Northern Ontario to support local family physicians and health care teams in their clinical and academic work.
• needs • Social • Mental • Physical • Emotional • Spiritual Access to databases Development of common EMR database accessible by all health care providers provincially – continuous quality improvement initiatives Cultural sensitivity training Understand local demographics and cultures Identify community stakeholders and engage Develop purpose statement and clear direction EMR: determine feasibility of an all-encompassing system Analyse effectiveness and include in HHR planning Funding of framework and accountabilities Develop provincial integration plan: funding, stakeholders, timelines, targets Continue to work collaboratively with all stakeholders to ensure outcomes are achieved.
• Ensuring healthy and resilient physicians and teams Development of a regional locum pool for Northwest and Northeast LHINS • Create an advisory committee to oversee locum pool and community collaboration • Identify coordinator role and metrics for success and evaluation of locums in pool (metrics to include cultural sensitivity) • Address funding and return of service (ROS) options for locum pool • Funding model should encourage locums, but not discourage full time commitment to a community (should be some incentive to come out of locum pool at some point).

4. Physician Resources Action Plan for Northern Ontario

• This Physician Resources Action Plan is based on the many ideas generated at Summit North – a conference of key stakeholders representing Northern Ontario, held January 2018 in Thunder Bay, whose primary focus was developing short- and long-term solutions to help build a flourishing physician workforce, primarily family physicians in rural and remote communities.
• Recruitment Create education for communities regarding health human resources Engagement and orientation session for each new locum arriving in a community Create ways for communities to collaborate rather than compete, (e.g. "join up" recruiters and opportunities for physicians to find "good fit" with communities) Ensure continuing development including coaching and mentoring for recruitment Leverage the experience of students and residents in communities.
• Communities in Northern Ontario become more engaged and active in recruiting, retaining and strengthening the integration of physicians and their families into their communities Retention Development of a regional locum pool for North East and North West LHINs Intentional approach to physician wellness Create system-wide, coordinated distance technology in Northern Ontario to support local family physicians and health care teams in their clinical and academic work.
• Compensation Supporting contracts for physicians and their teams Ensure funding models support post-residency work in groups for new grads Models of Care Integrate allied health, inter-professional learners (including Nursing, Physician Assistants, Therapists) to train at the same time Establish Networks across practices Consider specialist lead for networks of care Establish Networks for referral and patient transfer Single electronic medical record (EMR) for the entire region to hold all hospital and other health care data (one patient, one record, one EMR). Ensure that technology supports and enhances care but is not central to care Develop leadership capacity and create accountability tools Policies that require timely acceptance of transfers and appropriate consultations from rural communities to secondary and tertiary care across Northern Ontario could better support family physicians to access the care their patients need.
• Expand the role and number of Physician Assistants in Northern Ontario through targeted training in rural primary care (new or evolution of existing) PA program built along NOSM MD model) and sustainable funding model Education & Training Ensure process to review admission criteria that supports rural/remote students and provides opportunities for rural/remote community exposure in undergraduate years Ensure that all postgrad family medicine residents have rural rotations with adequate infrastructure support Increase elective opportunities, and remove barriers to electives for all learners Ensure access to community-based enhanced skills development based on community need Strengthen & formalize partnerships in Northern Ontario between communities, LHINs, universities and physicians to support delivery of medical education in rural communities.
• Stream high school students interested in northern, rural and remote community health care careers and refine admission criteria that supports their admission to medical school
• NOSM to meet with students in the remote/Francophone and First Nations stream and the rural stream to better understand why they selected their learning stream and what the School can do to attract more students to these streams; and follow-up with graduates to better understand their community selection process in terms of preferred practice locations
• Consult the students that dropped out and address the reasons why
• NOSM to build strategic support for all learners (UG and PG) in rural and remote/Francophone and First Nations streams to ensure cohesion, support and continuity of path from high school to practice destination
• NOSM to re-create and provide tangible support for RMIG (Rural Medicine Interest Group) Review of successful initiatives in other jurisdictions to build the 'rural generalist path' o Set specific targets for intake.
• Create ways for communities to collaborate rather than compete, (e.g. "join up" recruiters) and ensure continuing professional development for recruiters o Support recruitment that begins with making rural communities visible and attractive to medical students and residents as well as licensed physicians, and welcoming and supporting medical students and residents when they arrive in a community o Increase access to free marketing supports (i.e. increase social media presence, e-blasts to locum lists) Explore the feasibility of Recruiters Association for North East Ontario o Explore with NAN, WAHA, Meno Ya Win, NOMA, NOFOM, RMEFNO the feasibility of shared recruitment initiatives Align sub-region HHR planning with collaborative local recruitment initiatives Develop branding for specific regions/the North that focuses on regional recruitment and promoting rural generalism
• Integrate regional approach into the locum registry to reduce competition for locums.
• Following Lennox's successful 3-year Rural Generalist program in Australia, define and explore options for creating Rural Generalist education and training within the current 2-year Family Medicine program and Post-Grad programs such as: (i) seeking out medical students in first year who want to be rural generalists and facilitating their career path with tailored learning experiences and possibly extra scholarships; (ii) welcoming any graduate who wants to do rural practice into the rural residency stream; (iii) reviewing and where appropriate revising the 2-year Family Medicine curriculum so that graduates are better prepared for comprehensive rural medical practice; (iv) tailored rural CME options for those who commit to rural practice (e.g. 12 months of skills-based CME over a 5-year period that is planned by the physician and based on what the community needs and what their own interests are and includes locum support) o Partnering with other postgrad FM departments that have rural streams or have residents interested in rural/northern practice to provide opportunities for residents to learn in Northern communities
• Evaluate current rural and remote placements for students and residents to assess and improve effectiveness.

5. Interprofessional Rural Program of British Columbia IRPbc

The Interprofessional Rural Program of British Columbia IRPbc was established in 2003 as an important first step for the Province of British Columbia, Canada, in creating a collaborative interprofessional education initiative that engages numerous communities, health authorities and post-secondary institutions in working toward a common goal. Designed to foster interprofessional education and promote rural recruitment of health professionals, the program places teams of students from a number of health professional programs into rural and remote British Columbia communities. In addition to meeting their discipline specific learning objectives, the student teams are provided with the opportunity to experience the challenges of rural life and practice and advance their interprofessional competence. To date, 62 students have participated in the program from nursing, social work, medicine, physical therapy, occupational therapy, pharmaceutical sciences, speech language pathology, audiology, laboratory technology, and counselling psychology. While not without numerous struggles and challenges, IRPbc has been successful in meeting the program mandate. It has also had a number of positive outcomes not anticipated at the time the program was established.