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Fostering Quality & Accountabilities to Children & Families: The Case of the RICHER Initiative
Lorine Scott, NP(F) BC Children’s Hospital - RICHER Primary Care Lead Judith Lynam, RN, PhD, UBC Professor & RICHER Research Lead
R esponsive
I ntersectoral & Interdisciplinary
C hild & Community
H ealth
E ducation &
R esearch
RICHER is an innovative partnership
based community outreach PHC model
What is RICHER?
Research Colleagues: Dr. S. Wong, Dr. C. Loock, L. Scott, Dr. K. Khan, Funders CIHR, CNA and MSFHR & BCMSF Community Partners
NEVCO - NICCSS Ray Cam Child Health BC Vancouver Native Health ALIVE
UBC Academic Partners
School of Nursing Faculty of Medicine
Health Authorities
Provincial Health Services Authority BC Children’s, Sunny Hill & BC Women’s
Vancouver Coastal Health Authority (VCHA)
Why an Integrated RICHER Approach?
AIM
• to foster timely
access to healthcare
• across the spectrum
from primary care to
specialized services
• for children who have
disproportionately
high rates of
developmental
vulnerability &
disease burden
Marked Inequities in children’s health
• Complex health issues & developmental challenges
• Compounded by social conditions
Multiple barriers to health care access along the
continuum
• Prevention
• Primary care & specialized services
Limited access to primary health care
• Delays in diagnosis
• Delays in access to treatment & supports
• Lack of integration with specialized services
• Use of emergency services for non-emergent but significant health
issues
ALL are associated with poor health in childhood & over the life course
Hertzman & Kershaw, Human Early Learning Partnership, 201o, Provincial Mapping Report
Building a clinical team that is responsive to child health needs – PHC & Specialized services
Working in partnership to dismantle structural & social barriers to health services access –
• Building respect & trust.
Developing clinical relationships that extend and enrich families’ social relationships & foster child health & development.
• Intersectoral engagement
• Working ‘in place’
Strategies to Achieve Goals
Regular scheduled weekly primary health care clinics-
• Active regular participation with community agencies developing and/or delivering services for children – providing important health perspective
• Location of services : daycare, schools, community centers, non-profit family support agencies
Regular weekly integrated Pediatric Specialist/Subspecialist (SPOCK) consultation/intervention in place based venues
• Accept referrals from, & consult with, RICHER PHC & other community clinician
Weekly community table • Community identified issues affecting health &
development of the children in the community
• Provides for neighbourhood/community introductions & relationships
Weekly clinical rounds ‘BFF’ - Bright Family Futures
Group model for young families (15-25)
• RICHER in Operation
SPOCK
In our research programme, we have sought to understand:
• the influences on access to health services
•Appraisal of quality
• the characteristics of the RICHER approach associated with improved outcomes
RICHER Research
RICHER
Research Methods
• Participatory
• Asks questions identified as priorities by the community
• Conducts study in ways that are respectful of community
RICHER Results Phase I
• Outreach is enacted in Partnership. • Building relationships and conveying respect fosters access. • Partnerships enable families to ‘link in’ to traditional clinical
services, and enable clinicians to ‘link across’ to specialized services.
• Partnerships enable families to access services and resources to address social determinants of health.
• Community table creates mechanism for engagement and
accountability.
“This mother had to go to court to get her 3 children back. The parents and children in the neighbourhood filled the courtroom to show they were there to support this mother.
The judge closed the file and said the children should never have been taken in the first place.”
Relationships & Trust
• Building communities of support
• Challenging stereotypes of poverty & racialization
“This mother had to go to court to get her 3 children back. The parents and children in the neighbourhood filled the courtroom to show they were there to support this mother.
The judge closed the file and said the children should never have been taken in the first place.”
Relationships & Trust
• Building communities of support
• Challenging stereotypes of poverty & racialization
RICHER
Research Phase 2
Does RICHER foster access? What impact does RICHER have on patient outcomes?
Parents’ ratings of RICHER: Access Continuity Responsiveness Relationship
Empowerment, which is associated with: Satisfaction Compliance Optimal utilization Positive orientation Patient activation
Characteristics of parent
respondents
(n=86)
(If not from Canada) Number of years living in Canada,M(SD) 11.0 (7.6)
English spoken at home Cantonese/Mandarin spoken at home Other language spoken at home
58.1% 32.6% 9.3%
1-2 person household 3 person household 4 person household ≥ 5 person household
22.1% 19.8% 25.6% 32.6%
No children under 18 in household 1 child under 18 in household 2 children under 18 in household 3 children under 18 in household ≥ 4 children under 18 in household
4.7% 39.5% 29.1% 14.0% 12.8%
Less than $10,000 household income $10,000 - $30,000 household income $30,000 - $50,000 household income $50,000 - $80,000 household income More than $80,000 household income Missing
25.6% 40.7% 11.6% 5.8% 3.5%
12.8%
Apartment House Other (e.g. room, basement suite)
50.0% 44.2% 5.8%
Length of time in home, M (SD) 3.8 (3.3)
Rent home Own home Other Missing
81.4% 14.0% 2.3% 2.3%
Receive financial support for housing 43.0%
•2) What characteristics of the RICHER approach are correlated with (indicators of) positive outcomes?
Social • Characteristics of the providers’
interpersonal style are strongly associated with positive outcomes
Structural • Features of the clinics-
schedules, venues etc.
64%
24%
12%
Strength of Affiliation
Strong affiliation
Weak/Less strong
No/Weakest
Experiences of Primary Care
Number of times used clinic in past 12 months:
Mean 7.2 SD 10.5
88%
11% 1%
How important is it to you to have an NP that treats you as an equal?
VeryimportantSomewhatimportantMissing
PHC Quality Dimensions Processes of Care
Likert Scale 1-5
78%
16%
5% 2%
How important is it for you to have an NP include you in decision-making of
treatment plans?
Veryimportant
Somewhatimportant
Not important
Missing
General clarity of communication scale, M (SD)
4.6 (0.6)
Explained results scale 4.3 (0.9)
Decision making scale 3.7 (1.3)
Compassionate, Respectful scale 4.7 (0.5)
Empowerment scale 4.2 (0.9)
The PHC experience of clinician’s interpersonal style is positively associated with patient empowerment (p<0.01).
Demographics & Experience (r2= 0.47) Demographics & Experience Reduced
Set (r2= 0.36)
Variable N % Odds ratio Overall p value/CI Odds ratio Overall p value/CI
Education NS
Did not complete high school or secondary school 22 30.6 0.27 (0.04, 2.00)
Completed high school or secondary school 18 25 0.87 (0.07, 11.39)
At least some college, university or post-secondary 32 44.4 (ref)
Self-reported Ethnicity NS
White/Caucasian/European 15 20.8 (ref)
Chinese 24 33.3 1.06 (0.06, 18.70)
Aboriginal (First Nations/Metis) 21 29.2 5.55 (0.19, 161.60)
Other 12 16.7 0.92 (0.04, 19.45)
Strength of Affiliation NS
Scale range 0 to 4, treated as continuous 0.52 (0.13, 2.11)
IPC Communication: Clarity of Communication NS
Scale range 3 to 5, treated as continuous 1.59 (0.43, 5.95)
IPC Style: compassionate, respectful <0.005 <0.0001
Scale range 2.67 to 5, treated as continuous 15.43 (2.58, 92.23) 34.52 (7.54, 157.93)
NP Knowledge of child NS
Scale range 1.67 to 5, treated as continuous 2.59 (0.83, 8.09)
What characteristics of providers’ approaches to service delivery are associated with patient empowerment? (n=76)
Purposeful integration of activities within ‘place’ fosters cohesion, connection and relationship.
Systems can be ‘re-formed’ to be responsive !
Fostering cohesion Creating infrastructure Fostering linkages Capacity building
Publications Lynam, M. J., Loock, C., Scott, L. & Khan, K.B. (2008) Culture, health and inequalities: new
paradigms, new practice imperatives. Journal of Research in Nursing , 13(2): 138-148.
Lynam, M.J., Loock, C., Scott, L., Wong, S., Munroe, V. & Palmer, B.(2010) Social Pediatrics: Creating organizational processes and practices to foster health care access for children ‘at risk’. Journal of Research in
Nursing. OnlineFirst February 15: doi:10,1177/17449871093605/ pp: 1-17.
Lynam, M.J., Scott, L., Loock, C.L., Wong, S. (2011). The RICHER Social Pediatrics Model: Fostering Access and Reducing Inequities in Children’s Health, Healthcare Quarterly. 14 Special Issue, (3): 41-
56. http://www.longwoods.com/content/22576
Lynam, M.J., Grant, E. & Staden, K. (2012) Engaging With Communities to Foster Health: The Experience of Inner-City Children and Families With Learning Circles. Canadian Journal of Nursing Research, 44(2): June.
Wong, S.T., Lynam, M.J., Khan, K., Scott, L. & Loock, C. The social paediatrics initiative: a RICHER model of
primary health care for at risk children and their families BMC Pediatrics, 12:158 (04 Oct 2012)
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