Setting the Stage. Planning Primary Health Care Services in French for Nova Scotia. Prepared by: Pyra Management Consulting Services Inc.

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1 Planning Primary Health Care Services in French for Nova Scotia Prepared by: Pyra Management Consulting Services Inc. March 2006

2 Acknowledgements is a joint initiative of Société santé en français and its 17 network members. This project was made possible with the financial assistance provided by Health Canada, the Primary Health Care Transition Fund. The opinions expressed in this publication do not necessarily reflect the views of Health Canada. The cooperation and assistance provided by members of the project steering committee, the Nova Scotia Department of Health, and the primary health care managers and coordinators from participating District Health Authorities of Nova Scotia is greatly appreciated. Prepared by Pyra Management Consulting Services Inc. Réseau Santé - Nouvelle-Écosse i

3 Executive Summary The key objective of the project was to support the activities of Réseau Santé Nouvelle-Écosse in its efforts to integrate the needs of the Acadian and francophone population into the decision-making processes at the provincial and district levels in primary health care service delivery. The project team conducted a review of the literature and a series of bilingual community focus groups to identify alternative approaches to improving access to primary health care, then consulted with decision makers to inform an analysis of the alternatives and finally developed the recommendations presented in this report regarding the most promising potential activities to improve primary health care for Nova Scotia s francophone and Acadian population. Improving How Stakeholders Work Together The Réseau Santé N.-É. represents the Acadian and francophone community of Nova Scotia in terms of their health needs, has experience in developing partnerships among all levels of government and in coordinating projects for the purposes of increasing access to French language health services. The following first recommendation is a critical step in enabling all of the following recommendations and ultimately impacting all of the subsequent implementation plans. Recommendation 1 The Department of Health and the Department of Health Promotion and Protection should establish an official partnership with the Acadian and francophone community by: officially recognizing Réseau Santé N.-É. as the voice for the Acadian and francophone community in the area of health; including Réseau Santé N.-É. as an integral part of the development of strategies to increase access to French language health services; Réseau Santé - Nouvelle-Écosse ii

4 supporting Réseau Santé N.-É. in continuously and aggressively seeking opportunities for conducting pilot projects to further explore alternative ways of improving access to health services; and providing Réseau Santé N.-É. with ongoing financial support for operational costs. Recommendation 2 The Department of Health and the Department of Health Promotion and Protection should create a collaborative forum through which decision makers at all levels of government, DHAs, the IWK, service providers, professional associations, training institutions and Réseau Santé N.-É. can regularly meet. This forum would serve to provide decision makers with the pertinent information, support, and resources to improve access to French language health services. The mandate of this forum should include: to coordinate with ongoing primary health care evaluation activities of the Department of Health and national organizations such as the Société Santé en français to ensure that best practices in evaluation are adopted; to establish and implement standards for French language health services and to oversee the evaluation of initiatives undertaken to improve access to French language primary health care; to establish and implement standards for French language signage in order to make a very visible commitment to recognizing the needs of the French speaking population and to raise awareness of the issue among service providers and decision makers; and to facilitate discussions between employers and health care service provider unions to develop mutually acceptable hiring practices, guidelines and strategies for promoting recruitment, retention and continuing education of more French speaking health professionals in the short, medium and longer terms. Réseau Santé - Nouvelle-Écosse iii

5 Addressing Human Resource Concerns Human Resources are an important part of providing health services in French. In partnership with Department of Health, Réseau Santé N.-É. has already developed an inventory and a directory of the current French-speaking primary health professionals. These tools must be maintained and regularly updated so that they remain useful to the community and as a planning tool for decision makers. In its role in developing the first directory, Réseau Santé N.-É. has gained experience and knowledge of both the need and the methods that would make the existing inventory and directory more comprehensive. Recommendation 3 Réseau Santé N.-É., in partnership with Department of Health, should continue to develop, maintain, and promote a comprehensive inventory and directory of Frenchspeaking health care service providers in Nova Scotia. In the ongoing maintenance and development of the inventory of French-speaking health care service providers, Réseau Santé N.-É. should explore how to best use the inventory to prioritize and address the health needs for the Acadian and francophone community. Human resource planning of French-speaking health professionals will become more important as provision of health services is increased and maintained for the Acadian and francophone community. The current inventory of French speaking primary health care professionals has already identified gaps among particular types of service providers. With ongoing work to maintain and further develop the inventory, this will become a tool for human resource planning. Recommendation 4 Réseau Santé N.-É., in partnership with the Department of Health, should conduct an indepth analysis of the information gathered through the development and maintenance of the inventory of French language health care service providers in Nova Scotia. This analysis should be used by decision makers at Department of Health, Department of Health Promotion and Protection, DHAs, IWK, service providers, training institutions including Réseau Santé - Nouvelle-Écosse iv

6 Université Sainte-Anne, and the Réseau Santé N.-É. to plan for recruitment, retention and continuing education initiatives such as linguistic training, as well as long term scholarship, incentive, and career developing educational opportunities for health care service providers. Improving Access to Information, Materials and Services During the consultation process, it was clear that community members, professionals and decision makers all view as a priority access to reliable and timely information, resource materials, and shared services. An effective means for sharing information, best practices and resources among District Health Authorities and provincial departments must be established. Recommendation 5 The Réseau Santé N.-É., in partnership with the Department of Health and Nova Scotia Health Promotion and Protection, should establish, maintain and promote a materials and services clearinghouse for French language health care resources, building upon the existing Health Promotion Clearinghouse. Réseau Santé N.-É. should also explore additional ways of encouraging national information exchange and for products and processes from other jurisdictions to be made available. Appropriate technology should be used to facilitate information sharing. Réseau Santé - Nouvelle-Écosse v

7 Table of Contents Acknowledgements... i Executive Summary... ii Introduction... 1 French Speaking People in Nova Scotia... 2 Chapter 1 Approach and Methodology... 3 Organization of the Project... 3 Project Phases... 4 Chapter 2 Situational Analysis... 6 Context... 6 Services Available in French... 6 Governmental Priorities in Primary Health Care... 6 French Language Primary Health Care Services Available in the Province... 9 Inventory of Existing Services... 9 The Health Status of the Acadian and Francophone Population in Nova Scotia Primary Health Care Needs of the Acadian/francophone Population Partnerships Chapter 3 Structure, Services and Strategic Initiatives Chapter 4 Recommendations and Implementation Plan Improving How Stakeholders Work Together Addressing Human Resource Concerns Improving Access to Information, Materials and Services Implementation Communications Plan and Dissemination Chapter 5 Conclusions Bibliography Appendices Appendix A: Implementation Plan Appendix B: Project Methodology Appendix C: District Health Authority Priorities Appendix D: Community Focus Groups Appendix E: Qualitative Cost Benefit Categories, Impacts and Weights Réseau Santé - Nouvelle-Écosse vi

8 Introduction The project was designed to support the activities of Réseau pour les services de santé en français Nouvelle-Écosse (Réseau Santé N.-É.) by contributing to its efforts to coordinate the development and enhancement of French-language primary health care services in Nova Scotia. 1-3 In 2000, a collaboration between the Fédération des communautés francophones et acadiennes (FCFA) and Health Canada resulted in the development of an Advisory Committee for Francophone Communities in a Minority Setting. 4 Their mandate was to document the level of access to primary health care services in French throughout Canada. 5, 6 In 2001, the Fédération acadienne de la Nouvelle-Écosse (FANE) was directed by provincial member organizations to assume a leadership role in the area of French services with an emphasis on health care. 7-9 Through consultations in Nova Scotia and a provincial forum in 2002, FANE demonstrated the need to raise awareness of French health care issues among the population, stakeholders, regional and provincial authorities. 10 After the 2002 FANE report, a national body, the Société Santé en français, was developed to provide financial and technical support for the formation of French-language health networks in all provinces and territories where French is a minority language. 11 In 2003, FANE established Réseau Santé N.-É. as a provincial organization to coordinate the development and enhancement of French-language primary health care services. 12 In 2004, Réseau Santé N.-É. developed and adopted a strategic plan and bylaws for the organization. A Board of Directors was established of 4 non-voting members and 13 voting members representing the major provincial health care sectors and youth, women and seniors. 13 Réseau Santé - Nouvelle-Écosse 1

9 French Speaking People in Nova Scotia In the 2001 Statistics Canada Census of the Population, 14 there were 897,565 people in Nova Scotia. There were 36,585 persons who reported speaking French: 34,025 reported French as their mother tongue, another 2,560 reported to be bilingual. In total this represented slightly more than four percent of the total population in the province. There are three regions of the province where francophones are concentrated. In the Yarmouth and Digby County region, served by the Southwest Nova District Health Authority (SWNDHA), there were 12,960 francophones. In Halifax County, served by the Capital District Health Authority (CDHA), there were 11,195 francophones; and in the Richmond and Inverness County region, served primarily by the Cape Breton District Health Authority (CBDHA), there were 6,005 francophones. According to data from Nova Scotia Community Counts, these three concentrated regions represented 82.4% of the francophone population in the province (28,225 of whom reported French as their mother tongue) Meanwhile other areas, such as in and around Bridgewater, served by South Shore Health, have experienced a 63% increase in the francophone population during the period between the 1996 and 2001 census. 19 Réseau Santé - Nouvelle-Écosse 2

10 Chapter 1 Approach and Methodology Late in 2004, the Réseau Santé N.-É. requested proposals for and awarded contracts for both and for a project to develop an Inventory of French Language Capacity Among Primary Health Care Providers (the Inventory project). These projects, working in collaboration, were to assess and improve primary health care services for the Francophone and Acadian populations of Nova Scotia. Pyra Management Consulting Services Inc. (PMCS) was awarded the contract. The Inventory project was delivered by the Health 20, 21 Care Human Resources Sector Council. Organization of the Project A Steering Committee for was formed including Réseau Santé N.-É Project Sponsor Paul d Entremont, the Department of Health s Coordinator of French Language Health Services (initially Micheline Daigle-LeBlanc and subsequently Nathalie Blanchet) and three members representing the District Health Authorities with the largest base of French language population in the province: Elaine Rankin from the Cape Breton District Health Authority (CBDHA), Susan Anderson from the Capital District Health Authority (CDHA) and Shirley Watson-Poole from the South West Nova District Health Authority (SWNDHA). The terms of reference of the Steering Committee were to oversee the projects, review their findings in light of ongoing primary health care renewal activities in the districts and provide advice and support to the Project Sponsor in the context of primary health care in the province of Nova Scotia. The project team was organized as shown in Figure 1. Project Sponsor Paul d Entremont Steering Committee Project Inventory Project Figure 1. and Inventory Project Organization Réseau Santé - Nouvelle-Écosse 3

11 Although much of the primary health care expertise in Nova Scotia is vested in the Englishspeaking community, the project team included a bilingual, bidirectional translator who was trained to act as the focus group facilitator for the project. In the development of this approach, the project team not only was able to gather input directly from the communities of interest, but has also helped build additional capacity in the province through exposure of such resource people to primary health care issues and context. Benefits have been realized by the translator s subsequent involvement in a national forum with the Project Sponsor, as well as the Annual General Meeting of the Réseau Santé N.-É. Project Phases The key objective of the project was to support the activities of Réseau Santé N.-É. by contributing to its efforts to integrate the needs of the Acadian and francophone population into the decision-making processes at the provincial and district levels in primary health care service delivery. To meet this objective, the project was organized into three phases, described below. The situational analysis phase was informed by the Inventory project s efforts to identify existing primary health care services available in French. During this phase, after conducting a literature review, the primary health care needs of the Acadian and francophone population were identified from the literature and through community consultations. A preliminary prioritization of needs was produced, as well as a project communications plan in collaboration with Réseau Santé N.-É. and the project Steering Committee. These activities informed the remaining phases of the project. The analysis of options phase established French language primary health care priorities to be implemented by validating the needs identified from the community consultations with primary health care service providers in each district. Workshops to present these findings were then held with the decision makers in each District Health Authority in order to solicit their ideas on identifying various models of French language primary health care services that could meet the Réseau Santé - Nouvelle-Écosse 4

12 needs of the community to be served. An analysis of the pros and cons of the models and a qualitative cost benefit analysis of the models best suited to the communities needs was then performed. The final phase of the project was to develop an implementation plan for short, medium and long term models to be implemented (including costs, timelines and responsibilities); to produce this report for presentation to principal stakeholders; and to participate in the project evaluation. Further details of the project methodology may be found in Appendix B. Réseau Santé - Nouvelle-Écosse 5

13 Chapter 2 Situational Analysis Context Services Available in French In the Province of Nova Scotia, government services are delivered in French by the Office of Acadian Affairs, a French language health services coordinator within the Department of Health, some services in other departments, and some designated bilingual positions within the Federal public service. There are 19 francophone schools in the province managed by the Conseil scolaire acadien provincial. In addition, there is one French university (Université Ste-Anne), in 18, 22 Nova Scotia. Very few health or community services are offered in French. The municipality of Clare is the only municipal jurisdiction in the province to guarantee service in French, although in the CBDHA, a francophone Wellness Coordinator has been recruited for a special initiative aimed at youth and seniors. 23 In October 2004, Bill No. 111, French-language Services Act (Loi sur les services en français) was passed by the Nova Scotia Government. 24 The purpose of this Act is to contribute to the preservation and growth of the Acadian and francophone community; and provide for the delivery of French-language services by designated departments, offices, agencies of Government, Crown corporations and public institutions to the Acadian and francophone community. Departmental regulations in support of this act are expected to be drafted by December Governmental Priorities in Primary Health Care The Province of Nova Scotia received funding through the Primary Health Care Transition Fund for primary health care renewal activities at the provincial system level as well as within individual District Health Authorities (DHAs). The DHAs are responsible for the management Réseau Santé - Nouvelle-Écosse 6

14 of service delivery and each of the nine DHAs has numerous and diverse activities underway consistent with the overall vision of primary health care in the province. Each of these elements is described further below. In addition, the Nova Scotia Department of Health issued the following position statement in November 2005: The Department of Health is committed to improving access and availability of French language health services through partnerships with District Health Authorities, the Izaak Walton Killam Health Science Centre and members/organizations in the Acadian and francophone community. The Department of Health has a full time Coordinator of French Language Health Services whose mandate includes: Consulting and collaborating with the District Health Authorities and other stakeholders to determine the present state of health services in French in the province; Participating in departmental, interdepartmental, and provincial planning to ensure delivery of French language health services is incorporated into the planning process; and Providing advice and feedback to the Department of Health and District Health Authorities on the implementation of new initiatives to enhance access and availability of services within the health system. 25 Primary Health Care Renewal in Nova Scotia The Report of the Nova Scotia Advisory Committee on Primary Health Care Renewal issued in May, 2003 by the Nova Scotia Department of Health articulates the vision of primary health care in Nova Scotia. The vision was developed by a multi-stakeholder advisory committee that included various health and community organizations as well as government. 26 It is important to note that the Nova Scotia vision defined Primary Health Care very broadly as health and well being at a community level. The current definition of Primary Health Care from the Nova Scotia website ( is: Réseau Santé - Nouvelle-Écosse 7

15 Primary health care is the first and continuing point of contact for Nova Scotians with the health care system. It focuses on promoting health, preventing illness, managing chronic diseases and treating people when they are sick. Primary health care also serves as a vehicle for ensuring continuity of care across the health care system. Provincial Priorities As part of the province s primary health care renewal strategy, 26 Nova Scotia has ongoing initiatives in the following areas: Service Delivery Capacity Building (the Building A Better Tomorrow Initiative); Diversity and Social Inclusion; Primary Health Care Information Management; and Health Literacy. These initiatives represent components of the overall vision of improving primary health care which will be evaluated by examining activities undertaken by specific programs and initiatives and which contribute to changes that occur in the primary health care system. Such changes directly and indirectly influence the ultimate outcomes of the primary health care system which include: Population-level health and wellness are improved. Health inequalities among Nova Scotians are reduced. Communities are health promoting environments. The primary health care system is accountable and sustainable. Addressing these outcomes is a long term activity, but in the short term, specific initiatives must be designed to meet the needs of the population and represent actions, policies, resources and strategies that are implemented to enact incremental changes to the primary health care system. District Health Authority Priorities As the decision making organizations that apply resources within the community and supported by Community Health Boards, each DHA has its own strategic plan, initiatives and programs Réseau Santé - Nouvelle-Écosse 8

16 within the broad spectrum of primary health care renewal. Some Districts have published their priorities and these are summarized in Appendix C. French Language Primary Health Care Services Available in the Province The Department of Health s Diversity and Social Inclusion initiative recently published A Cultural Competence Guide for Primary Health Care Professionals in Nova Scotia in which a brief profile of the Acadian and francophone population is included and which identifies the following issues faced by members of the community: Language barriers medical records, prescriptions and forms used within the health system are not bilingual; Geographical barriers sometimes hinder access to health services; There is a need for more bilingual primary health care professionals; Signage and posters promoting availability of services in French are lacking; and 18, 27 Written information in French should be provided in plain language. An interpretation service is available in the major hospitals in the region (within the CDHA) that provide tertiary care services for the Atlantic Provinces. The availability of the interpretation service is not widely known in the community and frequently informal supports through volunteers and family members are used. Anecdotally, it has been suggested that some primary health care service providers prefer not to engage interpreters suggesting that further investigation and possibly education among service providers may be required. Signage in health facilities, information available through the Department of Health and provision of services remain predominately if not exclusively available in English. Inventory of Existing Services During the course of the project, the Inventory project was undertaken as an important first step in ensuring that French speaking Nova Scotians are able to access health care 21, 28 in their preferred language. In February 2006, the Department of Health French Language Réseau Santé - Nouvelle-Écosse 9

17 Services Coordinator transmitted an update on the status of the inventory project that included the following points: Initial Inventory survey response rates were low, but response rates may improve as reminders are sent out to primary health care workers through their respective professional associations. Some French speaking physicians, were not returning their surveys because they are a closed practice and are not accepting any new patients. Unfortunately, it is impossible to tell how many physicians are not returning surveys for similar reasons. Professional associations were instructed to send out the surveys to only those who worked in primary care, as per the scope of the inventory project. Therefore, if a nurse works in an acute care setting, then he/she would not receive the survey, regardless of the type of care they provide. The Health Care Human Resource Sector Council highly recommends that a follow up (Phase 2) Inventory be created of all those who work in health care, regardless of their setting. The Inventory project was limited to those professions recognized as providing primary health care by the Nova Scotia Department of Health. These eighteen primary health care occupations are: chiropractors, dental assistants, dental hygienists, dentists, dieticians and nutritionists, licensed practical nurses, occupational therapists, opticians, optometrists, pharmacists, physicians, physiotherapists, psychologists, recreational therapists, registered nurses, personal care workers/continuing care workers/home support workers, and nurse practitioners. The Health Care Human Resource Sector Council highly recommends that similar initiatives are undertaken in all areas of health care. Although great care was taken with the wording of survey questions, it is now clear that the language around French speaking must be addressed even more carefully in future Réseau Santé - Nouvelle-Écosse 10

18 initiatives. The Health Care Human Resource Sector Council recommends that further exploration be done to ascertain what kind of support could be given to health care workers to improve their capacity to provide services in French, and how that support may be provided. The final Inventory will be available online via the Department of Health website, beginning April 1, The Health Status of the Acadian and Francophone Population in Nova Scotia Although limited empirical evidence exists specific to the francophone and Acadian populations in Nova Scotia, according to the 2001 census, 14 Acadians account for more than 15% of the population in four of Nova Scotia s 18 counties. The 4% of the Nova Scotia population that are francophone or Acadian people are predominately located in the districts participating in the project, which include both urban and rural locations. As the province addresses general primary health care renewal objectives for the entire population, the general needs of all Nova Scotians are shared by the Acadian and francophone populations with the added concerns of access and availability of services and information in French, as has been outlined by the Diversity and Social Inclusion community consultation process. The literature identifies certain common concerns among minority language groups 30, 31 and specifically, in A Cultural Competence Guide for Health care Professionals in Nova Scotia the following common issues were identified as impacting access to primary health care for all of Nova Scotia s culturally diverse communities: 1. Discrimination: 20% of first generation Canadians who are visibly diverse report unfair treatment compared to 5% of first generation Canadians who are not visibly diverse. 2. There is a lack of race, ethnic, and language specific health data. 3. There is limited outreach to culturally diverse communities. Réseau Santé - Nouvelle-Écosse 11

19 4. There is a need for cultural health interpretation and bilingual services in primary health care settings. 5. There is a need for more representation of culturally diverse communities among primary health care professions. 6. There are too few health services provided in plain language. 7. Written health material is not always provided in plain language or different languages. 8. There is need for recognition and respect of the prominent role of spirituality in many culturally diverse populations. 9. There is a need for delivery of culturally competent primary health care. 18 Primary Health Care Needs of the Acadian/francophone Population The project held a series of nine community focus groups to identify what the Acadian and francophone communities believe are the primary health care issues of greatest concern. The stated purpose of the focus groups, explained to participants both in advance and at the beginning of the discussion was to: Identify the primary health care needs of the Acadian/francophone population; and to Identify models of service delivery that would address the needs of the population. Thematic analysis of transcripts of the focus groups identified those ideas that emerged repeatedly from multiple focus groups as well as interesting ideas that were raised strongly by at least one group, but not repeatedly among enough groups to constitute a theme. The themes that emerged from the discussion with community members about challenges facing the Acadian and francophone populations access to services were: Francophones who don t understand English; Service in French happens by chance; Lack of French language health resources; Lack of awareness about French speaking providers; and The need to build upon linguistic pride. In addition, a common theme among the focus groups that is not unique to the Acadian and francophone experience is the perception among community members that current health care service providers may be reluctant to change their approach to service delivery. This is an issue of change management that affects everyone involved in primary health care renewal. 32 Réseau Santé - Nouvelle-Écosse 12

20 Potential solution strategies to improve Acadian and francophone access to primary healthcare that emerged as themes from the discussions were: Community pressure on government; Hiring policy changes or stipulations for bilingual positions; Financial support for French classes; Increase public awareness of francophone providers; Using media for prevention and recruiting; Using the Internet; Scholarships and other incentives for drawing providers; Put pressure on health authorities; Make a telephone health line available in both languages; Je parle français buttons / signs at workplace; Hire nurse practitioners; and Invest in resource materials. A detailed presentation of the challenges and potential solution strategies, including quotes from focus group participants may be found in Appendix D. Partnerships The delivery of the project in collaboration with the Inventory project has provided an introduction and opportunity for mutual understanding and relationship development among the Réseau Santé N.-É., private industry consultants that are heavily engaged in primary health care renewal activities throughout the province (PMCS), the Health Care Human Resources Sector Council, the Department of Health s French Language Health Services Coordinator and the various District Health Authority representatives. This work has not only strengthened the appreciation of Acadian and francophone issues among DHA decision makers but also has established a delivery capacity that previously did not exist for health service delivery planning within the context of French language primary health care in Nova Scotia. Further information about additional projects and key opportunities for partnership as well as existing partnerships that may be leveraged in the future may be obtained from the Réseau Santé N.-É. and include the following: Réseau Santé - Nouvelle-Écosse 13

21 Office of Acadian Affairs and other government agencies and departments; Cape Breton DHA Youth and Seniors Initiative; Capital, Annapolis Valley, Southwest Nova and South Shore DHAs Improving Access to Health Services and Information for the Francophone Population Initiative ; GASHA Youth Health and Service Centre; IWK Learning, Caring, Leadership; and Atlantic Metropolis Centre of Excellence for Research on Immigration, Integration and Cultural Diversity Réseau Santé - Nouvelle-Écosse 14

22 Chapter 3 Structure, Services and Strategic Initiatives The intended outcomes of the project were agreed at the national conference of the Societé Sante en français and its 17 Réseau Santé members to be to plan for ways to: Improve access to health care and services; and Improve the health status of francophone and Acadian communities. In order to achieve these outcomes, the national conference identified a number of strategies that may help. These include using a health promotion and prevention approach, creating new access points for care (such as integrated service networks or collaborative care models), developing and using technology (such as telehealth), ensuring that there are sufficient health care professionals offering services in French, building and maintaining consensus with authorities and partners, and strengthening the national network of the Réseau Santé. 33 The workshops held with each of the participating DHAs as part of Nova Scotia s Setting the Stage project were used to identify potential activities, and to establish priorities among those activities identified in terms of their impact, cost effectiveness and potential to tie into the existing primary health care renewal plans of each district. The workshops helped identify alternative models for service delivery and informed the analysis of the pros and cons of those alternatives in terms of their effectiveness, suitability, ease of implementation, and sustainability. The models that emerged as being of the greatest interest both in terms of the community needs and the decision makers considerations were then more rigorously analyzed using a qualitative cost benefit analysis 34 to inform the recommendations and implementation plan development. The strategies outlined above were not used to frame discussion in the workshops in order to avoid biasing participants, although during the workshops, findings of the literature from other jurisdictions as well as local experience and the ideas raised in the community focus groups were presented. The need to objectively compare alternatives for purposes of policy and programming decision making lends itself to economic analysis However the lack of data, particularly financial Réseau Santé - Nouvelle-Écosse 15

23 valuation data for costs and benefits associated with alternatives can be challenging. 54 Qualitative Cost Benefit Analysis is a simple technique to apply quantitative analytical approaches to qualitative data by consistently applying relative weight values to the impacts of the alternatives. 55 The weights, impacts and the factors that affect them such as time frame and significance in terms of impact in a primary health care setting were customized to reflect the needs of this particular analysis. The definition of cost and benefit categories and weights was informed by the literature as well as the Strategic Framework for the Evaluation of Primary Health Care in Nova Scotia 62, which was itself developed in accordance with Nova Scotia s Primary Health Care Vision 26, the draft Canadian Institutes for Health Information Primary Health Care Evaluation Framework, and the Canadian Council of Health Services Accreditation Quality Dimensions. 63 See Appendix E for the definition of cost and benefit categories and weights used. The specific potential activities identified by the participants in the district workshops were consolidated and reviewed in order to group similar ideas together and produce a synthesis of service delivery and improvement models proposed as approaches to address the needs that were identified by the community focus groups. Using the information gathered from all data sources, the qualitative cost benefit analysis then systematically assessed the potential benefits and costs of undertaking each potential activity in order to produce a comparative list of the relative cost benefits of each option. 53 Alternatives were also examined in terms of their relative overall benefit and their relative overall cost, so that the most cost beneficial, the most beneficial and the least costly alternatives could all be considered. The potential activities in decreasing relative order of cost benefit (from the most to the least amount of relative cost benefit) are: Department of Health Communication improving the flow of communication from the Department of Health regarding government priorities, expectations and available resources to assist in the delivery of French language services; Directory/Inventory of Service Providers developing and maintaining a comprehensive inventory and directory of healthcare service providers to help both the public and the Réseau Santé - Nouvelle-Écosse 16

24 policy makers become aware of the French language service providers in their area, and to help in the identification of needs and the development of additional resources; Service and Material Clearinghouse creating a clearinghouse of materials (such as translated healthcare information or new material developed in French) and services (such as translation or the vetting of translations) that could be consistently made available to individual districts and healthcare service provider organizations throughout the province; Hiring Practices making French language skills a mandatory or desirable qualification sought among candidates for selected primary health care positions; DHA Sharing creating a vehicle for sharing experience, best practices and perhaps ultimately resources for the delivery of French language health care services among districts and organizations across the province; Patient Navigator(s) establishing roles and staffing requirements for bilingual and culturally competent patient navigators for the francophone community; Scholarships, Incentives and Career Promotion over the long term, aiming to increase the number of healthcare service providers with French language skills through scholarships, incentives and career promotion, including potential return to service commitments as part of such programs; French Schools making use of French schools as natural community gathering sites for information dissemination as well as potential sites for increased delivery of public health services; Signage implementing appropriate signage for way finding and temporary signage to indicate the availability of French speaking healthcare providers; Pilot Telecare piloting provision of access to selfcare/telecare services in French that is already provided in other provinces or jurisdictions; Community Communications helping develop community communication strategies and vehicles for reaching minorities within communities; Linguistic Training providing support to health care services providers for both conversational as well as technical French language training; Encourage French at facilities supporting French speaking for practice as well as increasing the comfort and acceptance of the language at primary care facilities; Réseau Santé - Nouvelle-Écosse 17

25 Diversity Video developing a short diversity oriented video that could help introduce new staff and health care service providers to the cultural diversity within the community; Communication Tools examining tools that help improve communications in medical setting such as software, phrasebooks, and visual communication system; Census developing a better understanding of the nature of the francophone population in each area including transient and immigrant populations, trends and locations of need; and CHB Representation requiring stronger representation of the francophone community on Community Health Boards. Of these alternative potential activities, the seven with the highest cost benefit had notably greater relative cost benefit than the others. Those alternatives are: Department of Health Communication, Directory/Inventory of Service Providers, Service and Material Clearinghouse, Hiring Practices, DHA Sharing, Patient Navigator(s), and Scholarships, Incentives and Career Promotion. Some locations also enjoy the presence of federal government or Canadian Forces facilities that provide additional resources that could potentially increase the availability of French language primary health care services available. Exploring ways to access and make the best use of such resources is therefore another potential service delivery model, however since not all sites have a military base or similar facility available to them it is more of a potential local solution strategy rather than a province-wide approach. Of the potential solution strategy models described above, those with notably greater relative benefit without considering the costs involved are: Directory/Inventory of Service Providers; Service and Material Clearinghouse; Pilot Telecare; and Patient Navigator(s). The alternatives with notably lesser costs regardless of the benefits are: Réseau Santé - Nouvelle-Écosse 18

26 Encourage French at facilities; DHA Sharing; Diversity Video; Community Communications; and Department of Health Communication. Considering the national strategies outlined at the beginning of this chapter, the matrix presented in tabular form on the next page demonstrates how each potential activity (in order of decreasing relative cost benefit) supports the national strategies that can ultimately lead to the desired outcomes of improving access to primary healthcare for French speaking people in Nova Scotia. Réseau Santé - Nouvelle-Écosse 19

27 Potential Activities in Terms of the National Strategies Health Promotion and Prevention Increase Access Points Technology Sufficient Professionals Partnerships Support Network Potential Activities in Order of Decreasing Relative Cost Benefit Department of Health Communication * $ Directory/Inventory of Service Providers * + Service and Material Clearinghouse * + Hiring Practices * DHA Sharing * $ Patient Navigator(s) * + Scholarships, Incentives and Career Promotion * French Schools Signage Pilot Telecare + Community Communications $ Linguistic Training Encourage French at facilities $ Diversity Video $ Communication Tools Census CHB Representation * = Notably greater relative cost benefit + = Notably greater relative benefit $ = Notably lesser relative cost Réseau Santé - Nouvelle-Écosse 20

28 Based on the evaluation of the alternatives, the potential activities that should be the priorities for improving access to French language primary health care in Nova Scotia are: Department of Health Communication improving the flow of communication from the Department of Health regarding government priorities, expectations and available resources to assist in the delivery of French language services; Directory/Inventory of Service Providers developing and maintaining a comprehensive inventory and directory of healthcare service providers to help both the public and the policy makers become aware of the French language service providers in their area, and to help in the identification of needs and the development of additional resources; Service and Material Clearinghouse creating a clearinghouse of materials (such as translated healthcare information) and services (such as translation or the vetting of translations) that could be consistently made available to individual districts and healthcare service provider organizations throughout the province; Hiring Practices making French language skills a mandatory or desirable qualification sought among candidates for selected primary health care positions; District Health Authority Sharing creating a vehicle for sharing experience, best practices and perhaps ultimately resources for the delivery of French language health care services among districts and organizations across the province; Patient Navigator(s) pilot the establishing of roles and staffing requirements for bilingual and culturally competent patient navigators for the francophone community; and Scholarships, Incentives and Career Promotion over the long term, aiming to increase the number of healthcare service providers with French language skills through scholarships, incentives and career promotion, including potential return to service commitments as part of such programs. Additionally, since the literature suggests that selfcare/telecare can be extremely effective and New Brunswick already offers such a bilingual service, consideration should be given to exploring the piloting of accessing such a service for French speaking people in Nova Scotia. However, pilot programs like this or for other initiatives like the implementation of patient navigator roles 67 first require an investment in the capability to conduct such pilots effectively. Réseau Santé - Nouvelle-Écosse 21

29 Finally, although the benefits in terms of improving primary health care are not necessarily as high as other activities, the use of simple signage to designate French speaking health care service providers and/or areas where French is spoken in primary health care service settings should be considered. Decision makers from every district recognized the relatively small cost for the potential positive response from the community such signs could bring. The need for such a reassurance mechanism was a common theme emerging from the communities and just by implementing such a measure the issue of French language health care gains significant profile and visibility and demonstrates commitment to improvement. Réseau Santé - Nouvelle-Écosse 22

30 Chapter 4 Recommendations and Implementation Plan The consultative process used to develop recommendations started with community focus groups, worked collaboratively with the Inventory and other ongoing initiatives, worked with decision makers across the province to identify potential solution strategies and then performed a qualitative cost benefit analysis on the results to identify the most promising potential activities that should be undertaken to improve access to primary health care services for Nova Scotia s francophone and Acadian populations. In considering those potential activities and how progress can be made most effectively toward their implementation, it is apparent that there are overarching needs that should be addressed first, to establish the pre-requisites for the success of subsequent implementation. The activities to be implemented may be grouped into categories of action that help to clarify some of these overarching needs and how they may be addressed while advancing toward implementation. This chapter presents recommendations grouped into categories of action that should be pursued by stakeholders and decision makers to improve access to French language health care in Nova Scotia. The categories are: improving how stakeholders work together; addressing human resource concerns; and improving access to information, materials and services; Addressing the recommendations in each of these areas will enable stakeholders to successfully implement change. Following the recommendations, an implementation plan is presented to help frame the specific actions, timelines, responsibilities, potential costs and other issues that should be considered in addressing the recommendations in terms of real activities. It should be noted that although this document is explicitly concerned with primary health care, other health care needs of the Acadian and francophone populations of Nova Scotia would also benefit from the recommended actions described here. Therefore the more general term health care services has been used in the recommendations. Réseau Santé - Nouvelle-Écosse 23

31 Improving How Stakeholders Work Together As we aim to improve access to health care services for the Acadian and francophone community, it is crucial that the community has a strong voice in health care decision making. The Réseau Santé N.-É. represents the Acadian and francophone community of Nova Scotia in terms of their health needs, has experience in developing partnerships among all levels of government and in coordinating projects for the purposes of increasing access to French language health services. The following first recommendation is a critical step in enabling all of the following recommendations and ultimately impacting all of the subsequent implementation plans. Recommendation 1 The Department of Health and the Department of Health Promotion and Protection should establish an official partnership with the Acadian and francophone community by: officially recognizing Réseau Santé - N.-É. as the voice for the Acadian and francophone community in the area of health; including Réseau Santé - N.-É. as an integral part of the development of strategies to increase access to French language health services; supporting Réseau Santé - N.-É. in continuously and aggressively seeking opportunities for conducting pilot projects to further explore alternative ways of improving access to health services; and providing Réseau Santé N.-É. with ongoing financial support for operational costs. Although partnerships exist among government, DHAs, service providers, professional associations, and communities; by strengthening such partnerships the further development and sustainability of French language health services in the province can be assured. Recommendation 2 The Department of Health and the Department of Health Promotion and Protection should create a collaborative forum through which decision makers at all levels of government, Réseau Santé - Nouvelle-Écosse 24