Recommendations

National Forum on Closing the Care Gap Recommendations

On the Sunday afternoon of the Forum, invited stakeholders (see appendix) synthesized the information presented during the main part of the Forum and discussed six basic questions. The six questions were designed to elicit ideas on which steps should be taken next toward the goal of developing effective and appropriate health care policies and practices for Canadians. Dr. Pierre Soucie, who chaired the afternoon session, reiterated that the objectives of the Forum were to:

1. review the evidence for clinical efficacy and cost effectiveness of health care interventions, particularly among older persons;
2. examine differences in health care utilization patterns, treatment patterns, and outcomes both between men and women and between young and old persons;
3. explore the reasons for identified health care gaps between young and old and between men and women;
4. explore potential approaches to narrowing or removing identified gaps; and
5. explore the development of evidenced-based policies and practices that promote efficient, cost effective, and high quality health care for all Canadians.

Individuals representing the various stakeholder groups were divided into six groups, each of which were given a set of questions to work on for half an hour. At the end of this brainstorming session, one member from each group presented the ideas put forth by his or her group, and consensus was obtained as to what the next step to take should be. The questions discussed were:

1. How can we promote individual responsibility, at the community level, for engaging in healthy behaviours?
2. Is the population health model an appropriate one for guiding health policies and service delivery, or are there other models that we should consider?
3. How can we ensure that information is reaching seniors?
4. What can the public and private sectors do to promote the concept and practice of effective health care. What are the responsibilities of the various levels of government to provide health care services? What is the appropriate role of the private sector in Canada's health care system?
5. What are the major priorities that need to be developed in the areas of health promotion, disease prevention, health care policy, and education and health service delivery, in order to achieve the goal of equitable health care delivery? What are the major barriers, or challenges, to implementing these things?
6. Are these priorities and barriers similar across different sectors of the older Canadian population?

Recommendations and Future Directions

Promoting Individual Responsibility

Stakeholders believe that individual responsibility for engaging in healthy behaviours is an important key to the effective promotion of healthy, active living among Canadians. Moreover, the concept must be learned as early as possible in life, for it to be of benefit in later life. To promote self-responsibility for good health, stakeholders came up with the following suggestions:

1. Develop mechanisms that reinforce self-responsibility on a daily basis and in a natural manner. The reinforcement should take place where the person works, resides or plays. It should not be perceived as fulfilling a mandate enforced by some external agency or group. We should explore the use of socialization as a secondary reinforcer for promoting self-responsibility by all Canadians.
2. Explore the development of positive rewards to encourage individuals to invest in their own wellness, such as being able to accumulate health days which are days off awarded to those who using fewer sick days.
3. Develop peer-appropriate role models, people with whom the average older person can identify. One example is the survivors program of the Cancer Society in which individuals are connected to a network of cancer survivors who share their experiences.
4. Develop self-efficacy programs which use socialization as a secondary reinforcer.
5. Educate individuals through the media, and use the media more effectively. For example, initiate a senior's health channel or homecare channel which can provide concrete and helpful information on issues ranging from health promotion and disease prevention to management of care and pain.
6. Explore the use of high technology, such as the internet, to develop user-friendly health information networks designed with seniors' needs in mind. The information provided can be general as well as specific, such as a local outreach services directory.
7. Identify and study models of successful partnerships with private industry. Then, encourage appropriate members of the public sector to seek out these partnerships to design and provide educational programs on health and aging.
8. Integrate all levels of efforts to promote self-responsibility for health, be they local, regional, or national. As well, increase the integration of these activities across the different agencies within each level.
9. Involve older people, at the grass roots level, in identifying what is needed to promote self-responsibility for personal health. Too many outreach and educational programs are developed without the input of seniors themselves.

Population Health Model

The role of the population health model as a national strategy was discussed as well as its relevance to individual Canadians.

Stakeholders believe that it is appropriate for Health Canada to use the Population Health model as a framework upon which to build national health strategy, but they think the concept of health itself must be broadened. Participants stressed that the Population Health model must expand to include associated determinants of health, such as unemployment, level of education, type of housing, and degree of social involvement.

One major drawback of the Population Health model is that it does not address issues specific to sub-populations, such as particular cultural groups. The Population Health model is an evidence-driven approach which relies upon population data. However, national data is currently unavailable on health promotion behaviours of different cultural groups regarding diseases, care outcomes, and health care utilization. There is great concern that current and planned initiatives, designed using the Population Health approach, are not appropriate for those Canadians who are not part of the North American mainstream.

At the individual level, it is unclear what meaning, if any, the Population Health model has. Stakeholders believe that the term is not understood by the average Canadian, that it is, rather, a concept discussed only by academics and government representatives. As the model will have such far-reaching consequences in how we understand health and in how we plan for health care services, it is urgent that it be explained to Canadians.

Stakeholders expressed concern that Population Health is a federal model only. The provinces and territories have not adopted it for themselves. For Population Health to be viable and truly define health care and health promotion in Canada, it must be adopted and implemented at all levels, from the individual, to the municipal, to the provincial and territorial, to the federal government.

Participants made the following suggestions to promote the Population Health model:

1. Develop educational strategies to inform average Canadians of what the Population Health model is and how it affects them.
2. Develop processes to encourage seniors' involvement in identifying and prioritizing mechanisms to promote the Population Health model.
3. Develop mechanisms to integrate and co-ordinate Population Health activities at all levels of government.
4. Develop mechanisms to include seniors and the public and private sectors in Population Health initiatives.
5. Explore private and public sector partnerships for funding Population Health activities.

Information Dissemination

Central to any attempt to address gaps in health care services to Canada's seniors is the sharing of information. Traditionally, information has only been shared either within a narrow organizational sector or among academic disciplines. It is imperative that information move beyond such restricted domains to include all involved parties. Research findings and government statements and policies must be translated into language that is meaningful to average Canadians. Stakeholders believe that concepts are of no use if they are either misunderstood or perceived as being irrelevant.

Participants made the following suggestions to improve the dissemination of information to seniors:

1. Use seniors' organizations to reach other seniors, e.g., to make public service announcements on the radio and television.
2. Employ a multimedia approach, that is, use print, radio and television to convey important information.
3. Develop video or audiotapes to be loaned through outlets such as libraries.
4. Develop private sector partnerships to promote "health literacy" initiatives, aimed at seniors, on a variety of health issues.
5. Utilize seniors' grassroots organizations to deliver health information to socially isolated older adults.
6. Provide the information in formats that are useful to seniors with physical disabilities, e.g., written in Braille or recorded on audiotapes.
7. Develop senior-oriented websites where the information can be found. This particular initiative must include the provision of both computer access and internet-access training for interested seniors. Perhaps pursue private sector donations of computers to seniors' groups.

The Role of the Public and Private Sectors

Stakeholders strongly believe that, to address gaps in seniors' health care, the most effective approaches involve close partnerships and collaborations between the public and private sectors. They also view each sector as having a specific role which should not be confused or abrogated.

Participants suggested the following strategies to improve the effectiveness of public sector efforts:

1. Improve communication between Governmental departments and agencies to ensure that only consistent messages and statements are made to the public.
2. Co-ordinate lobbying efforts for issues commonly shared by seniors groups, non-profit groups, and departments of any of the three levels of government, municipal, provincial/territorial, and federal.
3. Work to protect against any reduced attention by the government to those health issues and diseases most prevalent among people who lack a powerful voice.
4. Work toward governmental protection of both health rights and equitable health care access for disadvantaged groups.
5. The participants believe that, while the government should have jurisdiction over health care planning, it should not have complete control over the provision of care.
6. Work toward having the federal government fulfill a proactive role in encouraging provincial/territorial governments to fund initiatives such as "Health of First Nation Seniors."
7. Ensure, at the governmental level, that funded projects are appropriately evaluated and project results disseminated.
8. Establish appropriate standards of care for private and public health services. These standards should be developed with the assistance of professional regulatory bodies.

Participants suggested that members of the private sector are also members of the community and, as such, should take on the following roles:

1. Supporting projects such as CAG's Forum on Closing the Care Gap and senior centres as good community members.
2. Assisting in the exploration of determinants of health through projects such as ICONS.
3. Assisting in the development of effective educational packages and programs.
4. Utilizing their expertise, where applicable, to examine health problems. For example, the problem of polypharmacy could be studied by community-based pharmacists.

Barriers and Priorities

The barriers to providing equitable and effective care to Canada's seniors range from ageism to the realities of living in a sparsely populated and geographically large country. Participants expressed a concern regarding the definition of equitable and effective care. Since, at present, it is unclear how people define the two concepts, there is no common ground from which a consensus can be built.

Participants identified the following major barriers to defining equitable and effective health care in Canada:

1. There is a wide disparity of access to care and health promotion programs across different geographical regions in Canada. In general, access is more sparse in rural and northern Canada than it is in urban centres.
2. Morale among both formal and informal health care providers is low.
3. Ageism is very much alive and well. We need to put our energies into dispelling the myths of aging and attack this problem from a number of fronts.
4. There is poor sharing and communication of information.
5. There is poor communication among all levels of the health care system.
6. Similar and related initiatives made at the national, provincial and local levels are not coordinated with one another. There is also a conflict between discussing health promotion on the one hand while the other hand is dismantling the health care system.
7. Increased specialization is contributing to the lack of health service co-ordination and poor communication across health professionals.
8. A lack of co-ordination exists among organizations advocating for seniors.
9. Discussions of and planning sessions for health care for the elderly too often exclude the very people they are intended to help — seniors.

Participants identified four areas of priority for future actions:

I. Health promotion and disease prevention:

1. There is a great need for the collection, analysis and dissemination of health promotion and disease prevention data at all levels, including the government and seniors' organizations.
2. There is a need for specific programs, especially in the area of surveillance of health problems, e.g., to educate people about the risk factors for adverse events.
3. Funding is needed for public education and health promotion initiatives.
4. Health promotion is needed, as well, long before people become seniors.
5. Programs should be taking advantage of the social capital that seniors themselves bring to addressing health promotion and disease prevention.
6. Initiatives are needed to explore the role of families and communities in promoting positive, healthy aging.

II. Health care education and research:

1. We need to expand how we view health beyond a purely clinical model to emphasize the relationship between health and determinants of health, such as income and housing.
2. We need to adopt a holistic approach to the promotion of health and well-being.
3. Appropriate government funding is needed to support educational training for nurses, researchers, etc.
4. Through the sharing of information, we need to explore ways to better integrate the need for specialized professional services with the supply of these services.
5. We need to reinforce the ethic of basing health care practice on evidence of efficacy.
6. We need to improve the quality of education of health professionals and informal caregivers. Curriculum at Canada's educational centres must include content which is both important and specific to the elderly.

III. Health policy development:

1. We need to develop a surveillance mechanism for collecting, analyzing and disseminating information on the health status and health behaviours of Canada's senior population. The level of analyses should provide regional as well as national information.
2. We need to develop mechanisms to facilitate partnerships among seniors, advocacy groups, researchers, care planners, and policy decision makers.
3. We need to obtain consensus and clarification of the priorities of our health policy. We also need to re-examine the Lalonde paper with the aim of incorporating his stated goals in a living document capable of bringing equitable health care to all of Canada.
4. We must involve seniors directly in policy planning.
5. The development of policies must be done using an evidence-based process at its core.
6. We need clarification and consensus of the roles and responsibilities of the private and public sectors in the development of integrated and co-ordinated health care policies across Canada.
7. We need to develop mechanisms by which policies are "owned" by all and not seen as sterile documents dictated by some governmental or academic body.
8. The experience and concerns of informal caregivers must be recognized so that we can support them as well as capitalize on their efforts. They are, after all, the ones who are caring for the bulk of Canada's seniors. Initiative should explore issues such as time off for care giving as well as direct financial assistance.
9. We need to develop standardized report cards for rating policies regarding seniors at all levels of government concerning health care services, access, health promotion, disease prevention, etc.

IV. Health services planning:

1. We need to explore models of providing health services to informal caregivers, who typically deny their needs when caring for others.
2. Uniformity of caregiver services is needed in each of the provinces.
3. We need to develop an integrated, shared, and person-oriented health record system which is accessible to health care providers. Access should also be available to clients themselves.
4. Inclusion of seniors in health service planning at all levels of government is needed.
5. We need to openly discuss both what is equitable health care, and what should be funded by the public purse.
6. We need to develop single points of access for health information and health care services.
7. We need to examine the basic premises of Canada's health care and ensure that they are reflected the health care planning process itself, rather than focusing only on financial issues.
8. We need to explore the development of multidisciplinary outreach services to under serviced regions so that, for example, some regions won't find themselves with, perhaps, geriatric assessment but without physiotherapy services.