Mar 1, 2019
By Andrew Longhurst and Marcy Cohen
Community Health Centres (CHCs) have been an effective but under-valued model for delivering primary health care1 for decades in Canada and the US. One of the unique features of the model is its strong focus on the social determinants of health and preventing acute illness among groups who are more likely to experience poor health and suffer from chronic conditions, including low-income people, ethno-cultural communities, Indigenous peoples, and frail seniors.
So what are community health centres? CHCs are non-profit primary care organizations that provide integrated health care and social services, with a focus on addressing the social determinants of health.
- CHCs provide team-based inter-professional primary care that includes a range of health care and social service providers, including social workers, family physicians, nurse practitioners, nurses, dieticians, occupational therapists, clinical pharmacists, physiotherapists, respiratory therapists, cross-cultural health brokers, First Nations elders, mental health counsellors, and outreach workers, among others.
- CHCs integrate medical care, mental health and substance use services, health promotion and chronic disease management programs. Many CHCs also provide vision and dental care.
- CHCs are community-governed and responsive to the patients/members they serve. This means that they are legally established as non-profit societies or co-operatives and provide open membership to their patients (who are members of the organization). It also means that patient-members can participate on the board of directors and in other parts of the governance of the organization.
- CHCs actively address the social determinants of health such as poverty, access to housing, education, language barriers and other factors that have a direct impact on health. CHCs take an upstream approach intended to prevent illness and promote wellness.
- CHCs demonstrate commitment to health equity and social justice, and recognize that disparities in health status among the population are socially, economically, and institutionally structured—and that these disparities are avoidable and unfair. CHCs work to eliminate these health inequities through a community development approach and advocating for public policies that address the upstream determinants of health, including fair taxation, living wages, decent working conditions, safe and affordable housing and quality public services.
On February 1, 2019, the BC Health Coalition, Canadian Centre for Policy Alternatives, and Health Sciences Association of BC convened an invitational roundtable followed by a public talk in response to growing interest in the CHC model from communities across the province. That interest has also been taken up by government; in 2017, the NDP made an election campaign commitment to support the development of new (and existing) CHCs—a commitment that was re-affirmed in the new government’s May 2018 primary care directions.
Over 70 people from a broad range of community non-profit and health sector organizations participated in the roundtable including health professionals, immigrant and newcomer-serving organizations, the Ministry of Health, Divisions of Family Practice and Health Authority representatives, the First Nations Health Authority, seniors’ organizations, the BC Rural Health Network, and leaders from the CHC sector in BC. Participants heard how CHCs in Ontario, Saskatchewan, and Oregon provide responsive, team-based primary care that is community-led and that has proven very effective in addressing the unmet needs of vulnerable populations as well as the broader neighbourhoods and communities where they are situated (audio available below).
As BC moves to support a role for CHCs within a larger agenda for reforming primary care, what can we learn from other jurisdictions where CHCs are integrated into the broader primary care system? How can we support CHCs in BC to be leaders in improving the quality of care for the entire health system?
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Videos:
Panel 1: Learning from other jurisdictions
In the first panel discussion, Simone Thibault (Executive Director, Centretown CHC in Ottawa), Lisa Clatney (Executive Director, Saskatoon Community Clinic), and Gil Muñoz (Chief Executive Officer, Virginia Garcia Memorial Health Center, Hillsboro, Oregon) reflected on the important role CHCs have played in their respective jurisdictions. The panel was moderated by Marcy Cohen (Canadian Centre for Policy Alternatives – BC Office).
Panel 2: The situation in BC
In the second panel discussion, leaders and practitioners from BC’s CHCs discussed the benefits of the services they provide—and why a bigger role for CHCs in BC holds great potential for patients, providers, diverse communities and for the overall health system:
- Moderator: Zarghoona Wakil, MOSAIC/Umbrella Multicultural Health Co-op
- Esther Hsieh, Executive Director at Umbrella Multicultural Health Co-op, New Westminster
- Edward Staples, Chair of the BC Rural Health Network
- Grey Showler, President of the BC Association of Community Health Centres and Director of Health and Support Services at Victoria Cool Aid Society
Notes
1. ‘Primary health care’ refers to a system-wide approach to designing health services based on primary care as the first point of contact in a system with a focus on addressing the social determinants of health and reducing avoidable disparities in health outcomes between different groups in society. A large body of evidence demonstrates that primary care is the foundation of an effective, efficient and high-performing health care system.
‘Primary care’ refers to the clinical level of primary health care, which should serve as the first point of contact with the health care system and where the majority of health problems are identified, treated and where other health and social care services can be mobilized and coordinated to prevent illness and support wellness.
2. Office of the Auditor General of Ontario (2017), Community Health Centres (3.03), p.189. All other primary care models are funded directly by the Ontario Ministry of Health/Ontario Health Insurance Plan. It is also worth noting that each CHC has an accountability agreement with their LHIN. Other primary care models do not have accountability agreements because non-CHC physicians are remunerated by the Ontario Ministry of Health/Ontario Health Insurance Plan (OHIP).
3. The only budget line that the clinic cannot change is the number of practitioners (i.e. physicians and/or physicians and nurse practitioners). But in most CHCs, these practitioners represented a minority of their total budget allocation.
4. See also: Daniel Muzyka (2012), The Inconvenient Truth about Canadian Health Care, Conference Board of Canada; Marcy Cohen (2014), How Can We Create a Cost-Effective System of Primary and Community Care Built Around Interdisciplinary Teams? Submission to the Select Standing Committee on Health, Vancouver: Canadian Centre for Policy Alternatives—BC Office; and Andrew Longhurst (2018, Jan. 15), How (and how much) doctors are paid in BC: why it matters, Policy Note, Canadian Centre for Policy Alternatives—BC Office.
5. The 2012 study concluded that “CHCs stood out in their care of disadvantaged and sicker populations and had substantially lower ED visit rates than expected” (p. iv).
6. Slides prepared by Adrianna Tetley (Executive Director, Alliance for Healthier Communities) show that the portion of CHC patients with a serious mental illness is more than twice that of other primary care models in Ontario.
7. The 2017 Ontario Auditor General’s report references articles from 2015 suggesting that CHCs had higher rates of hospital readmissions and emergency visits, but unlike the Glazier et al. 2012 study, the Conference Board research does take into account patient complexity (see Office of the Auditor General of Ontario, 2017, p. 194).
8. A large of body evidence shows that people with lower incomes have worse health outcomes, higher rates of chronic conditions and lower life expectancies. Chronic conditions account for nearly 67 per cent of health care costs in Canada (Provincial Health Services Authority (2011), Towards Reducing Health Inequities: A Health System Approach to Chronic Disease Prevention. A Discussion Paper.
9. In other primary care models, often referred to as patient enrolment models (i.e. capitation) physicians are paid for the number of patients enrolled with their practices and for a predetermined basket of services. In the Ontario patient enrolment model there is no adjustment for the differences in the complexity of health needs among different patient populations, and as a consequence, there is nothing to guard against practices favouring a patient population with lower complexity.
10. Ontario’s ‘family health teams’ (one of the province’s primary care models) is the only other model that is required to develop and submit quality improvement plans to Health Quality Ontario (the provincial agency that supports health care quality improvement).
11. This work was coordinated through the Alliance for Healthier Communities (previously the Ontario Association of Community Health Centres).
12. See, for example, the BC Medical Association’s (now called Doctors of BC) opposition to alternatives to fee-for-service compensation including the population-based capitation model: BC Medical Association (1995), Capitation: A Wolf in Sheep’s Clothing? Vancouver: BCMA.