May ICE Team Meeting: Hamilton, ONT Project 1: Policy

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May ICE Team Meeting Hamilton, ONT Project 1
Policy Service Analysis

• Team Richards, Whitfield, Williams, Kelley
• Trainees Gillis
• Associate Summers

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Rationale

• a comprehensive historical review (1970 to
  present) of policies and key events impacting the
  design and delivery of P/EOL care
  programs/services in rural Canada
• systematically captures at national/provincial/loc
  al levels, the public policy/services that are
  within the domain of rural P/EOL care in the
  jurisdictions of PEI, Quebec, Ontario, Manitoba,
  Saskatchewan, Alberta
• provides the foundation for a range of research
  projects making up the ICE Program

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Methodological Approach

• modeled after Springate-Baginski and Soussans
  (2001) methodology for policy process analysis ?
• includes a documentary analysis which informs a
  policy/program trajectory, which is then
  confirmed and elaborated on via key-informant
  interviews in each provincial jurisdiction
• National overview captured via 3 key-informant
  interviews

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Summarized Policy Analysis Stages (adapted from
Springate-Baginski Soussan, 2001)

1. Define Key Policy Milestones
2. Explore Wider Policy Governance Context
3. Examine Key Policy Issues
4. Understand the Policy Development Process and its
   Outcomes
5. Analyze the Implementation Process
6. Consider the Future The Longer-term View

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Analytical Approach

• Modification of the traditional
  constant-comparison approach
• Three data types used
• documents for documentary review,
• policy/program time-line or trajectory produced
  from documentary review, and
• key-informant interview data (analysed using
  thematic analysis)
• Interview data, compiled as a set for each
  jurisdiction, provided a reinterpretation of the
  timeline and documentary review
• Data integrated via cross-referencing by theme

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The National Scene

• Thematic Results
• Current State of P/EOL Care in CND
• Characterized as underdeveloped fragmented
• Reasons for above
• Policy Issues Pallium project identified
• Role/Influence of Politicians
• Turning Points
• Unfinished Business
• Future Issues/Concerns ?

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6. Future Issues/Concernsor what we (ICE) may be
able to influence

• Meaning of rural specific to P/EOL services needs
  definition
• Partnerships needed between
• Different levels of govt (prov., fed., other)
• Govts and employors
• All service practitioners involved in order to
  achieve an integrated approach
• Change in care models, system organization care
  practices
• continuity across settings
• model requiring training across settings/systems
  and professions/services
• Recognition of a wide range of diseases (chronic
  and other)
• Enhanced local community development in order to
  best co-ordinate concerns and engage all parties
  involved (family caregivers, volunteers,
  churches, community resources, etc.)
• Recognize a population health approach in P/EOL
  (patient, family, community, geographies)
• Advocate for above funding via a national
  coalition

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Prince Edward IslandImportant turning points

• Hospice Palliative Care Association of Prince
  Edward Island (PEI)
• In response to grassroots pressure, the first
  palliative care program was created within the
  same year
• In conjunction with concerned citizens, pushed
  for further development of a distinct P/EOL care
  program
• Creation of the first 8 beds for palliative care
  on PEI at the Dr. Eric M. Found Health Center
• Continue to improve palliative care across PEI
  concerned citizens met with government officials
  to discuss government responsibilities concerning
  P/EOL care

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Prince Edward IslandImportant turning points

• Eleanor Davies President of Island Hospice
  Association
• Re-evaluated the state of P/EOL care and composed
  a proposition paper in 1995
• Puts forward recommendations and suggests an
  integrated palliative/hospice care service
• From her attempts to improve the existing
  programs, major progress was made within five
  years

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Prince Edward IslandImportant turning points

• PEI and Nova Scotia (NS) propose a Rural
  Palliative Home Care Model
• The trial program in West Prince county (PEI)
  became a model program for the rest of Canada
• After the success of this program, P/EOL care
  programs were created in every county of PEI

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Prince Edward IslandCurrent successes and
challenges

• Successes
• Approximately 1000 health care workers have been
  trained through the Support Worker Training
  Program at Holland College (mandatory for some)
• Challenges
• No Island-wide policy on P/EOL care
• Lost the Government Coordinator position

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QuébecImportant turning points

• The establishment of palliative care houses (PCH)
  in many regions across Québec
• Allowed P/EOL services to be taken out of
  institutions
• Allowed P/EOL services to be more accessible in
  rural and remote areas

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QuébecImportant turning points

• Foundation of the palliative care units at the
  Notre-Dame Hospital and Maison Michel-Sarrazin
• Notre-Dame Hospital acts as a resource for the
  Montréal region by providing training and
  internship opportunities for personnel working in
  P/EOL care
• The Maison Michel-Sarrazin fulfills the same
  functions for the Québec city region (only
  government-funded PCH)

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QuébecImportant turning points

• The desire of P/EOL care workers to see policy
  changes
• Creation of the Palliative Network by many P/EOL
  care centers to act as a resource for mutual
  assistance
• Pushed for change and the creation of policies by
  influencing the Minister of Health, the
  Honourable Pauline Marois

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QuébecCurrent successes and challenges

• Successes
• PCHs allow people in rural areas to remain at
  home while receiving P/EOL care
• Challenges
• Government funding to sustain PCHs

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OntarioPolitical Context

• government is largely hands-off, following lead
  of other provinces, committing funds only late
  into the process
• Managed competition introduced in 1996 has a
  somewhat negative affect on rural-based
  practitioners
• funding and policies for Health services in
  Ontario tend to be the same, whether it be
  Toronto or remote

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OntarioKey Milestones

• Regional Health offices control their own
  palliative care policies (thus different across
  province). Reporting to province begins in
  2006.
• Cancer Care Ontario adds Palliative Care to its
  mandate in 2004
• Physicians to be paid for in-home palliative
  care services (goes provincial in 2007, 8 years
  after Toronto pilot)

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OntarioFactors Contributing to Overall Success

• Federal monies, polices and reports
• several non-government organizations in
  Ontario that do Palliative Care
• dedicated individuals across the province

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Alberta

• palliative care has sort of rolled out in
  Alberta as an urban to rural phenomenon- where
  the urban programs have developed and gotten
  themselves in a position to sort of- get the job
  done- and then the rural programs have largely
  sort of developed or been modeled after that
  (AB04, p.1)

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AlbertaPolitical Context

• History of strong individual initiative and
  leadership
• Decrease of Regional Health Authorities in 2003
• Implementation of Pallium Project in Alberta.

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AlbertaKey Policy Issues

• Lack of rural focus
• Lack of Home Care services
• service access
• specialized knowledge
• predictability and continuity
• Burdened acute care system
• small hospitals end up providing a lot of end of
  life care services because there is no
  hospice-level care in most rural communities
  (AB04, p.10)
• Only adequate long term care system.

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AlbertaFactors Contributing to Overall Success

• Available funds at pertinent times e.g. having
  the right people in the right places at the right
  time (AB02, p.11)
• Access to well-developed expertise and leadership
  by physicians and nurses
• Use of an integrated model of palliative care
• Some government commitment.

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AlbertaKey Milestones

• Commitment by government and the voluntary sector
  to advance palliative care policies and programs
• A history of success in palliative care (success
  begets success)
• Recent use of tele-health for consultation and
  care in rural areas
• Ability to provide palliative care services in a
  variety of environments.

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Saskatchewan

• There is still such a desire in rural areas to
  die close to home or in ones communitywe avail
  that for anybody who lives in an urban
  settingbut we are not that respectful of folks
  in rural areaswe ship them out and force them to
  leave their home community.
• That is not a good thing
• (S04, p.5)

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SaskatchewanPolitical Context

• Variations in funding for services people from
  reserves (Federal vs Provincial)
• Lack of flexibility in rural palliative care
  service delivery and related policies
• E.g. bed protection we are not willing to turn
  that one bed over to a palliative bed for a short
  period of time so that person who actually lives
  in that community could actually die there (S04,
  p.5)
• thats where the person wished to die but we
  wouldnt allow the person to die there because it
  was in another jurisdictionregional
  boundaries!(S04,p.10)

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SaskatchewanKey Policy Issues

• Lack of palliative care/end of life related
  awareness and education by
• Government
• Public
• Lack of palliative and end of life care expertise
  in rural communities
• Rural (is not) and needs to continually be
  addressed, to always ask
• how do rural people have access to that
  service? (S04, p.9)
• New models for rural palliative care and creation
  of new standards to determine needs of PC/E of L
  workers.

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SaskatchewanKey Milestones

• When province shifted to Health Regions
• The creation of the Guidelines for Development
  of Integrated Palliative Care Services in 1994

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SaskatchewanKey Obstacles to Policy Success

• Geographic distances and low density population
• Getting clinical resources (expertise) to rural
  areas
• Using a unique rural model
• you cant take the city and just plunk it into
  the rural (S04, p.4)
• Urban experts not viewing palliative care from a
  community developement view
• it was, we are the experts and we can tell you
  what to do to fix all this (S04, p.4)
• Silo-ing of health care professions yet
  palliative care requires a team approach

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SaskatchewanFactors Contributing to Overall
Success

• Palliative care education provided in rural and
  remote areas as a result of Pallium project
• That palliative and end of life care is an
  integrated model
• working together to assist the family and the
  client to get the services they need where they
  need it and where they wish to have it (S06,
  p.8)
• we are one of the truly integrated services in
  Canada (S06, p.1)
• 2004-Health Research Strategy-more focus on rural
  with attached resources to develop rural
  expertise
• Community Advisory Boards
• - sometimes if they are really squeaky, they
  can get things done that we didnt initially plan
  for(S04, p.9).
• The Rurban Initiative

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Manitoba

• palliative care here is uneventhere is
  still tremendous variation across the
  regionsthere is a lot of inconsistencyand we
  are behind other provinces (M05,p.3)

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Manitoba(very preliminary insights-in progress)

• Milestones/Turning Points
• Winnipeg-1974 the 1st hospital in Canada to
  create a palliative care program
• that has hada big impact. There are a lot of
  people who have died over the years in that
  palliative care unit. That has absolutely been
  positive (M05, p.4)
• 1974-Province wide home care prgm.
• providing care in rural communities as well as
  in the cities(S01, p.3)
• Palliative Drug Access Program (2002) allowed
  people to die at home-it offset costs incurred
  outside hospital e.g. drugs
• we really had in a sense a perverse incentive to
  hospitalize people because the drugs were covered
  in the hospital (M05, p.2)
• 2002-Provincial funding for Palliative Care
  Networks Palliative Care Crdn. in each health
  region its put palliative care on the map in
  the regionsits a good grassrootsfrontline
  force (M05, p.2)
• Key initiatives driven by individual leadership
• The impact of certain initiatives still unknown.

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to be continued

• Once all jurisdictions complete, will determine
  commonalities/variations and determine the assets
  and challenges in each
• Reports will be written and distributed to ICE
  members, as they correspond with field sites
  end of summer 07
• Dissemination includes conferences (CHPCA) and
  peer-reviewed papers