Integrated primary care improves access to healthcare for newly arrived refugees in Canada.

In this study we quantify the impact of a partnership between a dedicated health clinic for government assisted refugees (GARs), a local reception centre and community providers, on wait times and referrals. This study used a before and after, repeated survey study design to analyze archived administrative data. Using various statistical techniques, outcomes for refugees arriving 18 months prior to the introduction of the clinic were compared with those of refugees arriving in the 18 months after the clinic was established. Our investigation revealed wait times to see a health care provider decreased by 30 % with the introduction of a dedicated refugee health clinic. The likelihood of GARs being referred to physician specialists decreased by 45 %, but those referred were more likely to require multiple referrals due to increasingly complex medical needs. Referrals to non-physician specialist health care providers nearly doubled following the availability of the clinic. The time-limited, but intense health needs of GARs, require an integrated community-based primary healthcare intervention that includes dedicated health system navigators to support timely, more culturally appropriate care and successful integration.

Evaluation of a changed model of care delivery in a Canadian province using outcome mapping.

BACKGROUND: Collaboration between the Nova Scotia Department of Health and Wellness, the province's District Health Authorities (DHAs) and the Izaak Walton Killam (IWK) Health Center led to the development and implementation of a new collaborative model of patient-centered care delivery in the province. OBJECTIVE: The objective was to determine the effectiveness of the initiative in arriving at the envisioned care model by investigating its impacts (if any) on patient, system, and providers outcomes. METHODS: A repeated surveys study design with mixed methods in an outcome mapping framework was used to measure process and outcome indicators for patients and families, providers, and the system. RESULTS: Almost all outcomes at the patient and family, provider, and system level improved following the implementation of the model, and these effects were stronger on units where the model was more fully implemented. CONCLUSIONS: The efforts of the province, DHAs and IWK to improve patient care through the new care model have been successful. This evaluation is unique in the broad range of indicators it incorporates. Comprehensive monitoring and evaluation of health system changes is critical to system effectiveness.

Pilot-testing an applied competency-based approach to health human resources planning.

A competency-based approach to health human resources (HHR) planning is one that explicitly considers the spectrum of knowledge, skills and judgement (competencies) required for the health workforce based on the health needs of the relevant population in some specific circumstances. Such an approach is of particular benefit to planners challenged to make optimal use of limited HHR as it allows them to move beyond simply estimating numbers of certain professionals required and plan instead according to the unique mix of competencies available from the existing health workforce. This kind of flexibility is particularly valuable in contexts where healthcare providers are in short supply generally (e.g. in many developing countries) or temporarily due to a surge in need (e.g. a pandemic or other disease outbreak). A pilot application of this approach using the context of an influenza pandemic in one health district of Nova Scotia, Canada, is described, and key competency gaps identified. The approach is also being applied using other conditions in other Canadian jurisdictions and in Zambia.

Research to Action: an evaluation.

The evaluation of the Research to Action project was conducted using an Outcome Mapping (OM) methodology (Earl et al. 2001) with a mixed-methods, repeat survey (before/after) study design. This design uses concurrent measurement of process and outcome indicators at baseline and follow-up. The RTA project proved effective at improving work environments and thereby promoting the retention and recruitment of nurses. Nurses involved in the RTA initiatives had a higher perception of leadership and support in their units, improved job satisfaction, increased empowerment and occupational commitment, and a greater intention to stay on the job.The pilot projects were most successful when there were clearly stated objectives, buy-in from nurses, support from the steering committee and management, and adequate communication among stakeholders. Committed coordination and leadership, both locally and nationally, were central to success.Considerable evidence has documented the challenges facing Canada's nursing human resources and their workplaces, such as high levels of turnover, excessive use of overtime and persistent shortages. There is a growing imperative to translate this research into action, and much of the available evidence presents viable policy alternatives for consideration. For example, a recent national synthesis report (Maddalena and Crupi 2008) recommended that, in consultation with stakeholders, processes should be put in place to share knowledge and best practices in nursing management, practice, staffing models and innovations in workplace health and well-being.Nurses across the country report a desire to be more involved in decisions affecting them and their patients (Wortsman and Janowitz 2006). A recent study on the shortage of registered nurses in Canada (Tomblin Murphy et al. 2009) highlighted the need for collaboration among governments, employers, unions and other stakeholders to improve working conditions for nurses. Another report notes the potential benefits of reduced turnover among nurses, the cost of which has been identified as a major burden on the Canadian healthcare system (O'Brien-Pallas et al. 2010). One of the goals of the pan-Canadian framework for health human resources (HHR) planning adopted by the Federal/Provincial/Territorial Advisory Committee on Health Delivery and Human Resources is to enhance all jurisdictions' capacity to build and maintain a sustainable workforce in healthy, safe work environments (ACHDHR 2005).Within this context, Health Canada's Office of Nursing Policy provided funding to the Canadian Federation of Nurses Unions (CFNU) and partner agencies in October 2008 to develop pilot projects across the country aimed at improving nurse retention and recruitment through various workplace improvement schemes. Each of the provincial partners contributed funds, in-kind support or both to the projects. The initiative was entitled Research to Action: Applied Workplace Solutions for Nurses (RTA). A national steering committee including representation from unions, governments and employers, each pilot project, CFNU and its national partners ­ the Canadian Nurses Association, the Canadian Healthcare Association and the Dietitians of Canada ­ was formed to oversee the development of 10 pilot projects. There was one project in each of Newfoundland and Labrador, Nova Scotia, New Brunswick, Prince Edward Island, Ontario, Manitoba, Saskatchewan, Alberta, British Columbia and Nunavut. The pilot projects, led by their own steering committees, focused on various aspects of nursing practice identified as particularly relevant to each jurisdiction, with a specific emphasis on improving the work life of nurses and transforming research knowledge into practice. The goals of the RTA initiative were to promote high-quality workplace environments, improve the retention and recruitment of nurses (RNs and LPNs), enhance the quality of patient care and engage stakeholders in collaborative partnerships. The first project began in May 2009 and the last project was completed in March 2011.

Eliminating the shortage of registered nurses in Canada: an exercise in applied needs-based planning.

OBJECTIVE: To demonstrate the application of a needs-based framework for health human resources (HHR) planning to illustrate the potential effects of policies on the shortage of Registered Nurses (RNs) in Canada. METHODS: A simulation model was developed to simultaneously estimate the supply of and requirements for RNs based on data on the health needs of Canadians with current service delivery patterns and levels of productivity as a baseline scenario. The potential individual and cumulative effects of various policy scenarios on the 'gap' between these were simulated. RESULTS: A baseline scenario estimated a shortage of about 11,000 RN FTEs in 2007 for Canada, increasing to over 60,000 by 2022. However, multifaceted approaches have the potential to eliminate the estimated shortage. CONCLUSIONS: Estimating the requirements for health human resources must explicitly consider population health needs, levels of service delivery and HHR productivity while changing supply to meet requirements involves consideration of a broad range of comprehensive interventions. Investments in improved data collection and planning tools are needed to support more effective HHR planning. The estimated Canadian shortage of RNs based on current circumstances can be resolved in the short to medium tern through modest improvements in RN retention, activity and productivity.

Health human resources planning and the production of health: development of an extended analytical framework for needs-based health human resources planning.

Health human resources planning is generally based on estimating the effects of demographic change on the supply of and requirements for healthcare services. In this article, we develop and apply an extended analytical framework that incorporates explicitly population health needs, levels of service to respond to health needs, and provider productivity as additional variables in determining the future requirements for the levels and mix of healthcare providers. Because the model derives requirements for providers directly from the requirements for services, it can be applied to a wide range of different provider types and practice structures including the public health workforce. By identifying the separate determinants of provider requirements, the analytical framework avoids the "illusions of necessity" that have generated continuous increases in provider requirements. Moreover, the framework enables policy makers to evaluate the basis of, and justification for, increases in the numbers of provider and increases in education and training programs as a method of increasing supply. A broad range of policy instruments is identified for responding to gaps between estimated future requirements for care and the estimated future capacity of the healthcare workforce.