Toronto, ON February 12, 2015

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1 Toronto, ON February 12,

2 Associate Professor Family and Community Medicine, University of Toronto Ada Slaight and Slaight Family Director of Maternity Care, Department of Family Medicine, Mt Sinai Hospital 2

3 3 Creating a system of primary care Promises for patients: - Timely access - Seamless links Family physicians need: - Timely access to diagnostics, consultants - Home care for patients

4 First contact care Provided by Family Physicians, Midwives, Obstetricians and Pediatricians Childbirth is the most common reason for hospitalization (CIHI) Access is issue Timeliness is critical 4

5 Proposed: - better coordinated and integrated care in the community closer to home Reality: - Centralization drives birth farther from home - Smaller birth units closing - Hospitals determining obstetric volumes by budgetary demands, not population planning 5

6 6 Critical for all aspects of primary care - Even more for maternity care Some linkages have been made - However, still huge gaps Primary care provider is the hub for each patient - Give patient chart and copies of all investigations? Determining standards, monitoring outcomes, engaging primary care providers and CPD tailored to their needs/ their population

7 Patient s medical home - real or virtual Family Health Teams - Embed midwives, lactation consultants (in addition to existing health care providers) - Clear, accessible referral lines to dedicated consultants including genetic testing - Direct coordination with Public Health Healthy Babies, Healthy Children Aim: Seamless transitions between home and hospital and home again 7

8 Means being patient-centred Means giving patients choice - Of care provider - Of birth place Means a robust system of primary care which meets the needs of women, children and their care providers. Let s build these patient medical homes! 8

9 9 Registered midwife at North York General Hospital s Mother-Baby unit. Committee member of the Midwifery Advisory Committee for Born Ontario Committee member for the OMama project advisory committee. Committee member of the PCMCH Maternal-Newborn Advisory Committee (M-NAC) Member of the PCMCH expert panel for the Low Risk Birth QBP, and for the Low Risk Maternal Newborn group.

10 10

11 there is no organization accountable for planning primary care or specialist care services Patients First Discussion Paper, p. 12 Ontario: left maternity care out of primary care strategy Accountability: Who is responsible for maternity care programming? - Providers? MOHLTC? PCMCH? Women and families? MOHLTC support for primary care maternity services comes up against dominant specialist maternity care model of care - Professional silos persists 11

12 12 Ontario s maternity care program is poorly defined - Self-referral specialist care? - Boutique primary maternity care? How should we frame primary care maternity reform? - Restricting specialist care? - Promoting community based care?

13 13 Scaling up: - Addresses institutional and logistical barriers - Pays attention to access and uptake - Focuses on consensus building among patient and provider communities - Creates a coalition of willing participants among governments, health authorities, providers and patients.

14 14 Can a primary maternity care strategy mean better more effective health integration and more cost reduction? The scaling up lens: - Partnerships - Infrastructure - Financial frameworks - Governance systems - Behavioural change

15 15 Public Health Specialist since 2004 (Stratford, Toronto, Peterborough) Practiced Family Medicine in Hamilton and Toronto, Low Risk Obstetrics Coordinator, St. Joseph`s Health Care Centre, Toronto OMCEP member, Retired MNAC member

16 16 1. Health service delivery better reflects population needs 2. Public health and health service delivery better integrated to address the health needs of populations and individuals 3. Stronger linkages between disease prevention, health promotion and care. 4. Social determinants of health and health equity incorporated into health care planning

17 17 Healthy People First (TPH) Upper tier: Working with LHINs: Using social demographics, risk factor data, health outcomes and utilization to identify priority populations/geographic areas ON the ground: Working with providers: EMR data can be aggregated and mined, with GIS to provide organized primary care organizations with feedback and useful planning information

18 Preconception Health? Tobacco? Alcohol? HBHC good example of integration with early prenatal referral and follow-up up to 6 years Immunization is a shared responsibility: preconception, infancy and early years, school-based, adult 18

19 19 Primary prevention versus 2 nd and 3 rd ROI is compelling Standardizing, through provincial resource centres, the messaging and resource materials Central support required for development and roll-out (PH and PC can adapt) DANGER!!!

20 20 Integrate performance management so that all sectors of the health care system are setting and working towards joint targets: ZERO cases congenital rubella ZERO neonatal Pertussis 100% 2 month olds fully immunized on time Reduce rate of FASD

21 21 Disaggregate health outcome or risk factor data by neighbourhood income quintiles and set shared targets to narrow the gap: Smoking rates for women of reproductive age Adolescent pregnancy rates Immunization coverage for infants Breastfeeding rates

22 22

23 23 Human Rights and Democratic Reform Sanitation and Access to Clean Drinking Water Reducing GHG Emissions Food Security Income Equality Housing Parenting and Early Childhood Development Universality Access to education Vaccination Healthy Urban Design

24 2 Cindy-Lee Dennis, PhD Professor, University of Toronto Faculties of Nursing and Medicine, Department of Psychiatry Canada Research Chair in Perinatal Community Health Shirley Brown Chair in Women s Mental Health, Women s College Research Institute Co-chair, the Healthy Human Development Table for Public Health Ontario and the Public Health Early Years group

25 2 Initial Reaction to Patients First Paper Visually targeted older adults and those with chronic disabilities pictures reflected the text 4 objectives related to Access, Connect, Inform and Protect would be applicable and highly relevant to maternal-newborn care in general

26 2 Perinatal Mental Health Perinatal mental health is a major public health issue Approximately 13% of women will experience depression during their pregnancy and first year postpartum Socially disadvantaged women rates are significantly higher Most frequent form of maternal morbidity following childbirth 10% fathers also experience depression in the first year postpartum Children are at significant risk for poor cognitive, behavioural and emotional development continues into adolescence Perinatal mental health is a family affair

27 2 Perinatal Mental Health Care in Ontario The recent CAMH report Pathways to Promoting Mental Health (a 2015 survey of Ontario public health units) found: 1. All public health units (PHUs) engaged in mental health promotion activities 2. The staff were most often public health nurses 3. Target populations were: New parents/postnatal mothers (37%) Parents of children and youth (36%) Pregnant women (35%) Healthy Human Development Table supported by Public Health Ontario surveyed all PHUs regarding perinatal mental health services 1. Currently in Ontario there is NO systematic approach to the management of perinatal depression 2. Differences in identification/screening and treatment approaches 3. Very little related to prevention

28 Excellent Opportunities Exist Triple Aim Framework and Patients First Report 1. Population Health Approach Identification Treatment PCMCH recently updated the antenatal record US Preventive Services Task Force now recommends screening PHUs across Ontario are engaging in screening/identification activities Effective treatment is available based on mild to severe symptomatology PHUs across Ontario are engaging in treatment activities and referrals Treatment trial - telephone-based IPT by trained nurses rural and remote Prevention and Health Promotion 2 Prevention trial telephone-based peer support - published BMJ Improve Access providing faster access to the right care

29 Patients First - Access, Connect, Inform Collaborative care is an approach to treatment that is highly effective for the management of general depression In a collaborative care model, case identification occurs at the primary care level A depression care manager (often a nurse) directs individuals to appropriate treatment and monitors progress all in collaboration with a mental health specialist based on patient s treatment preferences and perceived barriers Follow-up to remission Ongoing randomized controlled trial

30 Costs of Perinatal Mental Health Problems 2014 Report released by London School of Economics and Centre for Mental Health, UK Taken together, perinatal depression, anxiety and psychosis carry a total long-term cost to society of about 8.1 billion for each one-year cohort of births in the UK This is equivalent to a cost of just under 10,000 for every single birth in the UK Nearly three-quarters (72%) of this cost relates to adverse impacts on the child rather than the mother About half of all cases of perinatal depression go undetected and many of those which are detected fail to receive evidence-based forms of treatment The estimated cost of extra provision to achieve detection and treatment is about 400 per average birth

31 Summary Perinatal mental health is a major condition that significantly impacts society Over $6 million CIHR funding invested into research in Ontario PHUs already engaged in perinatal mental health activities but there are no standards or systematic approach need to engage primary care Healthy Human Development Table (with PHO) working towards achieving a systematic approach We could be trailblazers in Ontario what we do here could scaled-up be applied across Canada

32 32

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