By Cecilia Nasmith
The Ontario Health Team Network-Northumberland is only 13 months old, but it is taking local care into new and exciting territory, the Northumberland Hills Hospital board heard at its February meeting.
Carol Beauchamp Rebound Child and Youth Services Executive Director) and Adrienne Bell-Smith (Northumberland Family Health Team Executive Director) - co-leads on the Outreach Committee – described an exciting Local Outreach Program initiative about to launch in Colborne. Chief of Northumberland Paramedics Susan Brown is the lead on the Community Paramedicine program gave details on that program since its July launch.
And NHH President and Chief Executive Officer Linda Davis gave some history behind the OHT-N.
“There's a very long history of health and social-service providers working together in Northumberland,” Davis began.
“When I arrived, I knew that was the case, and it was just a great environment to be part of.”
The process of channeling this collaboration into the OHT-N formally began with a March 2019 visit from Minister of Health Christine Elliot, who encouraged them to begin the process.
“We did not hire any consultant, we did the work ourselves and submitted a formal application in October 2019,” Davis said.
“In December 2019, we met again with Christine Elliot, announcing we were one of the first 24 to go forward as a designated Ontario Health Team.”
Then the pandemic hit, but the OHT-N carried on,.
“I have to remark on how the relationship of the members really helped support everyone during the pandemic with weekly calls, exchanging PPE, supporting each other, and we still have those calls now,” Davis said.
They are working on another provincial requirement just now, a Collaborative Decision Making Agreement. Meanwhile, the ministry has forwarded $375,000 for 2020 and approved $850,000 for the next fiscal year. NHH is the partner that serves as holder and disburser of the funds.
The governance structure is headed by a Governance Advisory Council, with representation of the boards of directors of each of the 11 partner agencies, under which is a Collaboration Council with a representative of each agency's leadership (executive directors, chief executive officers) and a Facilitators Council (with representative of the five major sectors of the OHT-N).
Under that is an array of working groups and project teams, such as the Local Outreach Program and Community Paramedicine - and one that had to be put on hold.
The Volunteer Peer Support program would have matched skilled or trained volunteers to support vulnerable people, with Community Care Northumberland acting as fund holder. As in-person training of volunteers became impossible when COVID-19 hit, it was postponed.
The Local Outreach Program aims to extend health and social services to rural and isolated communities through remote clinics.
“Our goal is to really reach patients in all our areas of Northumberland, regardless of their attachment to different services, whether they have a family doctor or are not attached at all,” Bell-Smith said.
“We really want to integrate and flow information between the outreach clinics and the patients' existing care providers. It's not in isolation from all other services the patient is receiving.”
And it all begins in late February or early March with the opening of the first outreach clinic in Colborne.
“And we also have our eyes on Roseneath as a potential second location,” Bell-Smith added.
They did extensive research to determine what services should be offered, including surveys of local residents. By a wide margin, the top two perceived needs were management of complex conditions and mental-health services, and they also plan to offer foot care, diabetes education, smoking cessation support, and seniors' assessment and wellness services.
The building on Victoria Street was provided by the Township of Cramahe. There will be a primary-care office, a counselling office and a third office, and a clinic co-ordinator is in place.
Beauchamp listed the partners in the initiative – Community Care Northumberland, the Community Health Centres of Northumberland, Northumberland County, Northumberland Hills Hospital, Northumberland Family Health Team, Lakeview Family Health Team, Trent Hills Family Health Team and Rebound Child and Youth Services.
“It's our intention to continue to get feedback from people accessing the clinic and do another survey in three or four months to further inform the services provided,” she said.
Brown said the Community Paramedicine currently has 15 trained community paramedics available 12 hours a day, seven days a week.
They have identified the people they want to focus on, like medically complex seniors, people of fragile health status, medically complex patient being discharged from the hospital (whom they serve in collaboration with the hospital), those with mental health and addiction issues, palliative care patients and rural residents requiring help but who have transportation challenges.
They are also proactive with the homeless, visiting Transition House and the local warming centres.
Services they provide upon referral from partner health-care agencies include home visits and assessments, work in mobile clinics (such as flu vaccines, diabetes checks and – in the future – COVID vaccinations), diagnostic and sampling services (including COVID tests) and remote patient monitoring.
“If we can provide the right care, I think that's going to reach the whole health-care continuum,” Brown said.
Since July, Brown said they have had 960 visits, participated in 138 primary-intake assessments, received 131 referrals from health-care partners, done remote monitoring for a caseload that varies from 32 to 50 patients, taken 144 blood samples, and performed more than 15,000 COVID tests.
Feedback they have received described people kept out of hospital and enjoying lower levels of anxiety and social isolation.
As for the Community Paramedicine workers, Brown said, “they are very, very excited.
“So may times on the 911 side, we are rushing in, getting people to the hospital. We feel this has given them the opportunity to slow down, see people, speak to them.”
