Reconsidering care at the “margins:”

1. Reconsidering care at the “margins:” Rural and remote services as the frontlines of health care reform in B.C. Dr. Neil Hanlon Geography Program Presentation to the BC Rural and Remote Health Research Network 18 November 2005

2. OUTLINE • Care at the “margins” • Case studies in northern B.C. • Regional & local responses to population aging • Emerging roles for the voluntary sector • Community-based health & social care networks • Discussion • Concluding remarks • Acknowledgements

3. Care at the margins • Major provincial health policy issues since mid 1990s • Funding Levels and Priorities • Regionalization • Wait Lists • Health Human Resources

4. “CORE CONCERNS” Metro/Urban Health Care Formal Autonomy / Independence Human Capital “MARGINAL ISSUES” Rural/Remote Social Care Informal Dependency / Support Social Capital Care at the margins

5. Case Studies • (1) Local and Regional Adaptations to Population Aging • (2) Emerging Roles and Challenges for the Voluntary Sector • (3) Mapping Community-Based Care Networks

6. Local and Regional Adaptations to Population Aging • Restructuring Welfare, Remaking Place: The Territoriality of Health Care Reform in ‘Remote’ British Columbia Communities (SSHRC Operating Grant #410-2003-0142) • Improve our understanding of change in the health sector through the interaction of provincial and regional directives and the more local exercises of planning, administration and service delivery • E.g., responding to population aging in northern BC

8. Population aging in northern BC Pop’n aged 65+ (2001) / Pop’n aged 65+ (1991)* “Red” = 1.40+ BC mean = 1.26 *Source: Adapted from BC Stats

9. Population aging in northern BC Source: Hanlon and Halseth, 2005

10. Central directives: continuing care reform / rationing • (1) Redefining levels of care • (2) Case management: assessment and entitlement • (3) Population benchmarks and spatial allocation

11. Central directives: continuing care reform / rationing Distribution of Continuing Care Capacity in Northern BC (Based on 2001 population and Provincial Benchmarks) Source: Hanlon and Halseth, 2005

12. Regional Responses: Network of Excellence in Rural and Remote Geriatric Services • Objectives: increase and improve geriatric services in northern BC • A collaborative approach • Frontline staff (e.g., nurses in LTC facilities) • Outreach educators • Visiting specialists • Planning staff / consultants • Regional administrators • A work in progress … Source: NHA, n.d.

13. Regional Responses: Network of Excellence in Rural and Remote Geriatric Services • Enabled by regionalization • Issues of critical mass • Rationalization • Coordination / integration • Fueled by social capital • Networks and partnerships • “Trust”

14. Emerging Roles and Challenges for the Voluntary Sector • Aging Across Canada: Comparing Service Rich and Service Poor Communities (PI: Dr Mark Rosenberg, Queen’s University) • Identifying how and why communities age differently and what it takes to create a healthy and service rich community • BC study site: • 21 key informant interviews with service providers (health care, housing, transportation, seniors’ centres, service organizations) • 10 formal sector • 5 in 2004 • 11 voluntary sector • 10 in 2004

15. Emerging Roles and Challenges for the Voluntary Sector • Themes emerging in first round of interviews (2002): • Issues around lack of coordination of activities and services • Under-recognition of role of voluntary sector services

16. Emerging Roles and Challenges for the Voluntary Sector • Themes emerging in second round of interviews (2004): • (1) role of voluntary sector services • (2) experience of institutional pressures on voluntary sector • (3) changes to voluntary organizations and service provision

17. Emerging Roles and Challenges for the Voluntary Sector • Role of voluntary sector • Complement or substitute? • Provision of instrumental and informational forms of support • Emerging advocacy roles

18. Emerging Roles and Challenges for the Voluntary Sector • Experience of institutional pressures • Voluntary sector absorbing offloaded responsibilities • E.g., help with IADLs • Volunteer strain • Funding squeeze • Changes in provincial funding • Greater emphasis on project-based funding

19. Earned by Organization Provincial Bingo Funds Direct Access Program

20. Emerging Roles and Challenges for the Voluntary Sector • Change in voluntary service provision • Cautious expansion of roles • Pressures to rationalize, consolidate locally • Identity fissures (organizational and individual)

21. Emerging Roles and Challenges for the Voluntary Sector • Identity fissures … • “If we lose gaming money, like Bingo money or anything, that’s big money for us. That keeps us going. That might be $40,000 a year. I would have to make up the deficit somehow.” • “I’m really afraid that I’m going to have to get into that proposal writing, funding fight thing. I don’t want to go there, but I think it might happen.”

22. Emerging Roles and Challenges for the Voluntary Sector • Identity fissures (cont.) • “We’re starting to compete within ourselves for … gaming funds, volunteers, space, city grants … . And this is going to get worse. As our needs increase, we’re going to start biting at each other.”

23. Emerging Roles and Challenges for the Voluntary Sector • Identity fissures (cont.) • “Last year, we only got [an amount less than one-quarter requested] from Direct Access because they said we didn’t qualify. We don’t have enough programs.”

24. Emerging Roles and Challenges for the Voluntary Sector • Summary of key findings: voluntary sector • Potential erosion of flexibility and personalization • Increasing pressures for consolidation • Emerging emphasis on competition, accountability and efficiency • Governance and accountability mismatch

25. Mapping Community-Based Networks of Care • Understanding Systems of Supports for Households Under Stress in Remote BC Communities • New Emerging Team for Health in Rural and Northern BC, CIHR Northern and Rural NET Competition (P.I.s: Dr Clyde Hertzman and Dr Aleck Ostry, UBC) • Where do individuals and families in remote communities turn for help if they experience a stressful event, such as job loss or a serious illness? What sorts of support networks are available for families with very young children, especially if these households are headed by a single parent? • Study sites: Fort St. John, Mackenzie, Terrace, Williams Lake • Methods (year one): key informant interviews (n=83) with service providers, site inventories, census data profiles

26. Mapping Community-Based Networks of Care • Organizations deeming themselves under-funded: • women’s resource centres • public health nursing • service providers for the disabled • mental health • addictions programs

27. Mapping Community-Based Networks of Care • Organizations deeming themselves adequately funded: • child development centres • community health programs • employment centres • aboriginal programs

28. Mapping Community-Based Networks of Care

29. Mapping Community-Based Networks of Care

30. Mapping Community-Based Networks of Care

31. Mapping Community-Based Networks of Care

32. Mapping Community-Based Networks of Care • Success in partnering • Complimentary models work best • General expressions of positive cohesion • Among formal sector providers (small town advantage) • Positive ‘bridging’ with voluntary groups enabled by funding adequacy • Diversity of experiences within and between sites • Next steps – experiences of service users

33. Discussion • Attention to “marginal issues” reveals much about the frontlines of health care reform • Grounded research • Unique research and training opportunities • “Leveraging” • Networking

34. Concluding Remarks • Care and care research: • Relationship building • Across sectors • Across disciplines • Across institutions • “Bridging” form of social capital • Resources for living / community capacity

35. Acknowledgements • SSHRC Standard Research Grant • Restructuring Welfare, Remaking Place: The Territoriality of Health Care Reform in ‘Remote’ British Columbia Communities • PI: N. Hanlon (UNBC) • CIHR Operating Grant No. YYI44646 • Aging Across Canada: Comparing Service Rich and Service Poor Communities • PI: M. Rosenberg (Queen’s) • CIHR NET Grant • Integrated Study of the Social Dimensions of Rural Health • PIs: A. Ostry (UBC) and C. Hertzman (UBC)

36. Acknowledgements • Anne Burrill • Rachael Clasby • Mollie Cudmore • Rebecca Goodenough • Greg Halseth • Regine Halseth • Martha MacLeod • Tom MacLeod • Carla Martin • Jessica McGregor • Aleck Ostry • Virginia Pow • Andrea Procyk • Mark Rosenberg • Pam Tobin