Patient Navigation Certificate - Lesson 2: Canadian Health Care System

Please watch the following recorded lecture and respond to the discussion question below.

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Reflecting on your setting, what gaps in care do you identify?

Instructions: You must post your responses in the comments section below before the next live lesson starting at 10 AM ET on Day 2. The instructor will review your comments and have a debrief discussion at the start of the next live session. The comments section will not be moderated otherwise.

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10 comments on “Patient Navigation Certificate - Lesson 2: Canadian Health Care System

  1. I have noticed that gaps frequently occur when patients are transitioning either from community to acute care or vice versa. It can be challenging to access information from other agencies that have been delivering services to patients when admitted to an acute care environment. \Eligibility requirements (as mentioned yesterday during discussion) also can be barriers or gaps for patients in accessing care, for example access to transportation to and from the hospital.

    I know from working as an agency nurse that many times patients who are discharged from hospital who previous to admission were receiving home care nursing services may then be switched to a different agency depending on the length of hospital admission. This creates many challenges as these patients then have to be re-admitted to the nursing agency and are required to go through all of the lengthy admission steps. At any point in this transition miscommunication can occur.

    Just a brief comment about the paramedic community program. From what I have witnessed it seems to be a fantastic way to promote connectivity between community and acute care environments. The paramedics that I have worked have been very helpful in providing valuable collateral information about patients who are admitted to hospital which allows the nursing staff to better serve their patients.

  2. Where I see the gaps in the healthcare system is in long-term care and seniors trying to survive in their homes. Seniors often need several hours per day to get showered, make food, help with basic day to day needs and ensuring they take their medication. Unfortunately, they may only receive 2 hours two or three times a week. I know that when I was assisting elderly clients with doctors appointments, banking and grocery shopping, they would often purchase more than they needed, just to end up throwing away a lot of food that had gone bad. They would bring a list of ailments to their physicians because they had missed the last appointment because they could not get there. If the goal is to keep our seniors at home as long as possible, then the health care system needs to review current policy and ensure that this population is safe and comfortable. On both the federal and provincial levels, we need to invest more money and time to provide basis rights to our again population.

  3. In the hospital setting, there are many gaps that I can identify in the delivery of healthcare. I will use the following example wearing my patient flow hat to explain. If you require a hip replacement, the government places caps on the number of hip surgeries that each hospital can perform each year. This is tied to funding of course and larger hospitals receive more money as it is assumed that they can perform more surgeries. If you don't have a primary care practitioner, the referral process will be muddy for you as most specialists in Ontario require a referral from primary care. If you have money and are willing to pay out of pocket, you may be able to get better hardware in your hip. Some insurance companies will pay for better for hardware than others as well. This creates a tiered system which mimics private the healthcare model that you would see in the states.
    Now let's say you need home care upon discharge. Home care sets limits on the amount of care that they can provide. If you live in a home with dogs, no running water, you smoke and happen to be a hoarder, they likely won't come in because they will deem your living situation to be unsafe. If you have money to pay for private duty care in your home, this is a possibility however it will be difficult to navigate on your own because of the push to utilize the home care provided by the LHIN.
    Now let's say you have to visit the emergency department because of a post-op complication. Hopefully, you don't have a previous mental health diagnosis as often times, you won't be taken seriously as having post-op pain but rather deemed to be seeking drugs and this will change the trajectory of your visit significantly. Follow up care, both from the initial surgery and the emerg visit will require a primary care practitioner as well.
    I should have prefaced that not every situation in Ontario looks this grim but I believe that this illustrates some of the gaps in our fractured system.

  4. Within the paramedic realm we see many gaps in the healthcare delivery system. Not only are we dealing with individuals from different socioeconomic classes but also those from different ethnicities. We see many patients as "frequent flyers" who overuse the 911 system. For these people they often have anxiety in managing their conditions ( COPD, diabetes etc), frequent falls because of mobility challenges, drug use, mental health issues etc. We also see a lot of patients simply because they do not have access to a family practitioner or can't afford a cab to a more suitable location like a clinic. ( the government covers the cost of an ambulance for those on ODSP or OW and all but $40 for those not) In most instances this is much cheaper than a cab ride.
    It is so wonderful to see paramedics being included as an integral step in bridging the gap. Most of the early community paramedicine research is showing that we can provide unique information and identification of individuals who have fallen through the cracks for a multitude of reasons. We truly can provide a bridge between primary and emergency care.

  5. I think the initial gap is the lack of primary care. I can't speak for the rest of the provinces, but in Nova Scotia, you are considered lucky if you have a family doctor. And if you are one of the lucky ones, you have a considerable wait most of the time to get an appointment. Another of these gaps that I have witnessed first hand, over and over again in my years of working in health care, are that these primary care physicians are so overworked that when they do send referrals in to specialists, there are often mistakes, errors, and limited information resulting in referrals having to be sent back causing longer waits for the patients to be seen, which could directly impact the diagnosis.

  6. Working in the social service system, I notice a few gaps that relate to the healthcare system but then I can connect other system gaps that have an impact of the original healthcare gap. For example, as a caseworker for income assistance often I need to help clients access service. Most times I may be the first person that they are opening up to about their health concerns. I’ll use a mental health concern as an example. They may be describing symptoms and feelings of depression. Having a social work background I am at an advantage to be able to spend some time gathering more information in an attempt to provide a relevant referral or recommendation. Many times these individuals do not have family physicians and they are also relying on our provincial health coverage (OHIP and Ontario drug benefit). Usually a referral from within the healthcare field is needed or through a social worker. Since my current role is not a social worker I am not able to provide that direct referral. I usually encourage them to connect with a clinic to start the process of having a home base for their healthcare needs. From there they would be able to build a file and history in hopes to get the appropriate referral they need. In the interim, I refer to a walk-in counselling service which has now transitioned to phone base (due to covid-19).

    I suppose the gaps I have identified in care are in the referral process and service access (limited access and availability when private insurance or additional funds are not an option, long wait times). I work with a population of youth (aged 16-29) who are homeless or under housed. They can be transient, moving around a lot, changing phone numbers often as they may be using different service providers. This type of lifestyle can create gaps in service access, as contacting these patients would be difficult and these client’s may have moved around several times and away from their clinic making it harder to access service. Gaps in service within the social service system are connected with transportation and phone access. There is medical transportation funds available. Eligibility for this requires a client to have travel costs of at least $15 and a doctors note indicating frequency of medical appointments. One appointment to and from a clinic would be rated at the public transit rate of $3.25 one way, making it a $6.50 trip and not meeting that $15 minimum. Mind you there is discretion on the worker’s part to support client’s and issue monies as appropriate when needed ie. issuing one month of transportation pending documentation of ongoing appointments as an example. Additionally, there are no funds issued to clients for phone bills. It can be difficult for me to reach client’s and can only imagine how they miss communication from healthcare professionals and fall through the gaps.

  7. Within my community health work environment, I believe a gap exists in the referral/service delivery process. Referrals are received for several program areas at the same time, i.e., early intervention programs and Speech-Language Pathology (SLP). For example, a client may be referred to these services to address social communication deficits. Both service areas can address part of the concerns; however, the most appropriate service, in this instance, Speech-Language Pathology, are known to have high wait times, and therefore other services such as early interventionists generally provide programming to the clients first. The client starts to receive a service that will address some of the concerns, but they do not necessarily get the right service they require from the beginning. The SLP will become involved later and then there may be two services being provided for the same concern. There is now duplication in service.
    I believe one way to resolve this is to create one centralized intake for children and youth within health care to best optimize the right service, at the right place, at the right time. This would better address the needs of the client and caregivers which would involve the support of a patient navigator who can assist the families and clients as required.

  8. In my current setting the majority of gaps is lack of access to a primary care physician. We are seeing patients who have issues with breast health and are seeking care via the emergency departments. Immediate testing from the ER is triggered but if an issue or follow up within a year or 6 months is required these patients are not being notified of the follow up appointments required these patients can "fall through the cracks". The other piece to that is if a patient has a positive work-up for Ca they have no family physician to trigger referrals to many of the Allied Health Services other than with the Oncology department which is much later in their treatment journey. These same patients require yearly mammogram studies and once they have been discharged from Oncology again start the process over again with needing a referral from a physician for annual screening leading to referral again from ER physician with no continuity of care.

  9. When I think about the population I am interested in working with, it is individuals who are underserved in the community who would be guests at a drop-in shared kitchen/dining area for individuals who experience food insecurity, unemployment, housing insecurity, mental health issues/mental illness, substance use issues, to name a few. I am proposing a mixed methods study where we will have 2 focus groups and some individual interviews to talk about the needs individuals with diabetes identify and involve them as "patient" partners in the planning of the second phase of the study. The second phase would then be an RCT where one group received patient navigation (based on identified needs) and the other does not and compare outcomes like self-efficacy, glycosylated hemoglobin, foot care health, accessing necessary services, QOL, etc.

    Right now the diabetes clinic provides access to a diabetes educator and nutritionist but the wait is long and it is generally a one-time visit and often focused on Type 1 diabetes and insulin pumps. I see the patient navigation role as someone who can arrange foot care, blood work testing, counselling, health teaching, etc at this drop-in center mentioned above and address the needs of this group of patients.

    This is totally separate but I also think there is a significant gap in care available for transgender and non-binary individuals.

    1. I feel there is a lot of education and change needed throughout our systems in Canada to address the gaps in service/care for transgender and non-binary individuals - healthcare, social service, legal. It wasn't until recently that our system was changed to ask for and populate a preferred gender and name on an application for financial assistance - before it always had to be the legal information. Even the word preferred can create a barrier since for the individual it is not their 'preferred' anything, it's who they are.

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