E5-a - Improving Community Prosperity by Addressing Social Determinants of Health

5. Community and social accountability

  • Date: Friday, September 20, 2019
  • Concurrent Session E
  • Time: 11:00am–11:45am

  • Room: TBA
  • Style: Presentation (information provided to audience, with opportunity for audience to ask question)
  • Focus: Balance between both (e.g. Presentation of a best-practice guideline that combines research evidence, policy issues and practical steps for implementation)
  • Target Audience: Leadership (ED, clinical lead, board chair, board member, etc.), Clinical providers, Administrative staff, Representatives of stakeholder/partner organizations

Learning Objectives

  • System navigation for social needs and social assistance  
  • Development of community partnerships and creating community neighbourhoods  
  • Integrated system communication through co-ordinated care plans  
  • Development of programs through patient population and service mapping  
  • Expansion of team based care outside of the healthcare system 

Summary/Abstract

The Community Health Prosperity Program (CHP) through the Niagara Medical Group Family Health Team was developed in partnership with Niagara Region Public Health.  The mission of the CHP Program is to “improve the quality of care provided to marginzalized patients within the Niagara Region.” Standardized tools were developed to assess social and legal needs and social determinants of health for patients that identified that they had difficulty making ends meet.  As the program evolved we have collaborated with many community projects including HealthLinks which has allowed for coordination of care through integrated systems of communication with other health care resources. This includes the uploading of coordinated care plans to Health Partners Gateway.    IPC funding for this program has allowed for partnerships with physician groups, shelters, emergency medical services, home and community care in the region, legal aid, etc.  As a result the program has expanded through all 12 municipalities of Niagara, servicing rostered and non-rostered patients alike.  With accessibility to a multitude of marginizalied populations we have seen the creation of community neighbourhoods of services based on population needs.      The CHP Program has identified an improvement to access for transportation, medical compliance and financial literacy, and an increased guaranteed income for patients.  Through validated tools, the team has identified an improvement in quality of health care and life for these patients throughout the region despite their diversity of needs and required services.
 

Presenter

  • Katie MacNeill, Health Promoter/Intake Worker, Niagara Medical Group FHT
  • Colin Fenwick, Health Promoter/Intake Worker, Niagara Medical Group FHT
  • Brian Turner, Financial Advisor , Niagara Medical Group FHT
  • Frank Ruberto, Executive Director, Niagara Medical Group FHT

Authors/Contributors

  • Dr. Roxan Guise, Board President, Niagara Medical Group Family Health Team
  • Dr. Erik Zufelt, Medical Lead, Niagara Medical Group Family Health Team