Linking Health Promotion Planning to Health Care Restructuring

June & July, 1996

Developed by:
The Centre for Health Promotion
University of Toronto

October, 1996

Introduction

The following abstracts briefly summarize the case studies that were presented at the District Health Council Information Sharing Forums held in June and July, 1996. The focus of these Forums was Linking Health Promotion Planning to Health Care Restructuring.

Some of the specific issues addressed in the case studies are:

• developing partnerships
• tools for conducting integrated planning
• developing an integrated health system.

Table of Contents

Integrating Health Promotion Into Hospital Restructuring Abstract of a Presentation by:Heather McCormack, Planner, Ottawa-Carleton District Health Council.. 4

Alignment Model: The Story of Change Abstract of a Presentation by:Lorraine Purdon, CoordinatorSouth East Toronto Organization 8

Health Service Integration: An Option for Health Promotion Abstract of a Presentation by:Jane Underwood, Director of Nursing Services Hamilton-Wentworth Regional Department of Public Health Services: 11

The Health Promotion Plan For York Region Abstract of a Presentation by: Jane Brown, Community Development CoordinatorYork Region District Health Council (13)

Metropolitan Toronto District Health Council Needs/Impact-Based Planning Method Abstract of a Presentation by: Natalia Klimko, Health Planner, Metropolitan Toronto District Health Council 16

Integrating Health Promotion Into Hospital Restructuring

Centre for Health Promotion, Information Sharing Forum

Abstract of a Presentation by:
Heather McCormack, Planner
Ottawa-Carleton District Health Council

Heather McCormack discussed the Ottawa-Carleton District Health Council's efforts to integrate health promotion into health care restructuring. Heather's presentation focused on two key DHC planning initiativesCthe District Health Promotion Plan (DHPP) and the Health Services Reconfiguration Project.

I. "Vision to Action: A Health Promotion Plan for Ottawa-Carleton"

Ms. McCormack began her presentation by briefly reviewing the Ottawa-Carleton DHPP, which was completed in July, 1995. Ms. McCormack described a number of important and innovative features of the plan, including approach/principles, key partnerships, the structure of the report, and recommendations. Outlined below are some highlights from the presentation:

The DHPP adopted an approach that:

• reflected the broad determinants of health perspective
• supported the reorientation of the health care system with new approaches and new ways of organizing
• stimulated action and promoted partnerships that go beyond traditional health service providers
• resulted in a Plan that is somewhere between a vision statement and a strategic plan, with clear recommendations for implementation.

In order to minimize duplication with other planning initiatives and enhance the quality of the Plan, the DHC developed a number of key partnerships. The DHC collaborated with the Regional Municipality of Ottawa-Carleton (RMOC) to use the outputs of their Community Vision exercise as inputs to the priority goals for the plan. Partnerships were also developed with the Ottawa-Carleton Health Department, Community Health Centres and the Community Resource Centres.

The DHC also built on a number of its own related planning initiatives. As part of planning for community health services, a community health profile and an inventory of community health services were completed and utilized for the DHPP.

The Health Goals were framed according to the five provincial health goals adopted by the Premier's Council on Health Strategy. An additional goal, on the coordination of health promotion activities, was added. For each of these broad goals, a corresponding vision statement, health goals and objectives were identified.

One of the goals and objectives for Ottawa-Carleton was to increase the allocation/reallocation of funding towards prevention and health promotion activities. Ultimately, the plan recommended "That the Health Services Reconfiguration Project identify funds to reallocate to health promotion that will double the present Ottawa-Carleton budget for prevention and health promotion."

II. Ottawa-Carleton DHC Health Services Reconfiguration Project

• The main focus of Ms. McCormack's presentation was the integration of health promotion into the DHC's Health Services Reconfiguration Project. Heather described the following aspects of the Project: system vision, core elements, individual program and service parameters, strategies for reducing the need for hospital care, and evaluation and implementation plans. Outlined below are some highlights from the presentation:

• The core elements of the strategy are promoting healthy lifestyle choices, preventing health problems, supporting the maintenance of good health, and early detection and prevention of problems.

• The individual program and service parameters include health promotion and disease prevention, support services, academic and research activities, acute care, chronic care, mental health services, and rehabilitation.

• The basic principle of the reconfiguration project was to achieve improved efficiencies in the delivery of care. Resulting savings could then be used to meet community needs.
• The key methodology used was the clinical benchmark, whereby savings in bed days were projected on what utilization would be if Ottawa hospitals operated similar to the Ontario hospital at the 75th percentile in terms of lowest length of stay.
• The Project addressed primary, secondary and tertiary prevention strategies for preventing hospital use in non-hospital sectors, including public health units, primary care settings, and community services.
• Proposed strategies for reducing the demand on the hospital system were as follows:

1) Focus on healthy lifestyle choices:

• reinvesting to prevent substance abuse
• promoting health among children and youth
• community health promotion programs

2) Prevention of injuries and disease:

• low birth weight
• accidental falls in the elderly
• motor vehicle accidents in young adults

3) Supports for maintaining health:

• focusing on wellness in the elderly
• caregiver support
• supports for elderly in need
• keeping well with a chronic disability
• support for high risk parents

4) Early detection of health care problems/secondary prevention:

• breast cancer screening
• screening for high blood pressure
• community action for TB prevention

The impact of primary prevention strategies was expressed in terms of the attributable fraction (AF), or percent of cases which would be avoided if the risk factor in question were removed. The AF was calculated from the relative risk of the factor and the population prevalence of exposure to the factor. Estimates were obtained from the United States for diagnoses impacted by smoking, alcohol, and dietary factors.

The total impact of the recommended strategies was estimated to include the potential closure of 87 acute care beds and an additional $16.5 million in other savings through prevention of or delay in hospital utilization. The costs for implementation of the proposed strategy is approximately $7.7 million in annual operating dollars.

Ms. McCormack emphasized two important steps in linking health promotion to health care reformC"making the connection" and "doing the math." Health promotion planners must increase awareness and understanding of how health promotion initiatives can reduce the demand for health care services. Data must then be collected and analyzed in order to demonstrate the magnitude of this reduction.

Ms. McCormack also identified ways in which this "message" can be developed: by maintaining and strengthening key partnerships, identifying strategies, establishing targets and potential savings, prioritizing strategies, and consulting stakeholders and the public.

Potential Issues/Challenges to Linking Health Promotion with Health Care Restructuring

• Involving stakeholders
• Lack of clarity around government commitment to look at reinvestment strategies
• Need for government to develop integrated mechanisms for reviewing health system restructuring plans
• Developing clear strategies around health promotion and sponsors.

For more information, please contact Heather McCormack, Planner, Ottawa-Carleton District Health Council, 955 Green Valley Crescent, Suite 350, Ottawa, Ontario, K2C 3V4, ph: (613) 723-1440, fx: (613) 723-5162.

Alignment Model: The Story of Change

Centre for Health Promotion, Information Sharing Forum

Abstract of a Presentation by:
Lorraine Purdon, Coordinator
South East Toronto Organization

Lorraine Purdon discussed the South East Toronto Organization and its unique approach to integrated planning. Ms. Purdon's presentation focused on the following issues:

• SETO's mission, partners, and community
• The alignment model developed by SETO as a collaborative attempt to find alternatives to traditional approaches to planning and partnerships
• Two projects that SETO has successfully undertaken in the community (e.g., respiratory health, and the Quick Response Pilot Project for the homeless and marginally-housed)
• Five systemic "traditions" that challenge linking health promotion to health care restructuring.

Outlined below are excerpts from her presentation.

Alignment Model

The alignment model was developed by SETO in an effort to ensure the best way for large and small organizations to work together. Three basic principles describe how the model functions:

• The community, partner agencies and SETO are part of one system which works together in the best interests of everyone in the community.
• Effective change happens when the community is central to the model.
• Alignment occurs when the needs of the community and the skills of organizations are matched to work collectively to achieve a desired result in the community.

The alignment model is interactive and consists of two parts: opportunity alignment and operational alignment. Opportunity alignment is the art of aligning the community and partner agencies towards creative ways to enhance the health of southeast Toronto residents. It has three elements within it:

• 1) Strategic alignment develops clarity for the partners' long-range plans and how they complement each other.
• 2) Structural alignment provides opportunities to explore how organizational policies, procedures, and structure facilitate and empower the alignments and/or weaken them.
• 3) Cultural alignment provides an opportunity to explore the cultural likenesses and differences of the partner organizations and explore the degree of this diversity.

Each of these elements works together to create a system of planning that facilitates the coordination of local health and social services thus making them more accessible.

Operational alignment is the art of aligning the right mix of people, resources, and community members to complement agreed upon initiatives in the community. This part of the model has three alignment elements within it:

• 1) Planning ensures successful implementation and results.
• 2) Resources ensure the initiative has quality through the right mix of people, expertise and funds.
• 3) Evaluation ensures accountability and accurate documentation of results.

The model attempts to build on the capacities within Southeast Toronto to strengthen the community and individuals by closing the gap between policy makers and those affected by the policies. Integrated planning takes place over an extended period of time. Building consensus, clarifying perspectives, language, approaches and shifting resources are all important steps in the process of aligning the Partners with each other and the community.

Five Systemic "Traditions" That Challenge Linking Health Promotion to Health Care Restructuring

• tendency to organize resources around the reduction of negative traits
• holding health promotion programs accountable in terms of what they provide rather than in terms of what is achieved
• separating planning authority of health and social services
• separating planning authority from resource allocation
• healthy promotion as a program vs. a philosophy.

Conclusion

The alignment model is a collaborative attempt to find alternatives to traditional planning and partnership approaches. The key to SETO's success is project-based planning, and the absence of unnecessary structure or governance. SETO has developed a model that does not threaten the partners' autonomy and can work in the midst of enormous changes.

For more information, please contact Lorraine Purdon, SETO, 277 Victoria Street, 5th Floor, Toronto, ON, M5B 1W1, ph: (416) 392-7415, fx: (416) 392-0712.

Health Service Integration: An Option for Health Promotion

Centre for Health Promotion, Information Sharing Forum

Abstract of a Presentation by:
Jane Underwood, Director of Nursing Services
Hamilton-Wentworth Regional Department of Public Health Services

The Hamilton-Wentworth Regional Department of Public Health Services has developed funded secondment arrangements with community agencies and institutions to encourage systemized collaboration and build a structural foundation for health promotion within the health system. Ms. Underwood reviewed the project's goals and objectives, conditions of agreement, and several examples of successful collaborations. Outlined below are some highlights from her presentation.

Goals and Objectives

The goal of the project is to partner with agencies in order to provide them with access to both health promotion expertise and a health promotion philosophy. On a system level, such a program supports a "critical mass" of health promotion knowledge and experience within a community through the Public Health Department (PHD). It also provides a mechanism for enhancing collaboration between the primary care and population health promotion sectors.

Specific objectives of the project include:

• providing health promotion expertise for selected customers
• blurring boundaries (e.g., community and institutional sectors)
• minimizing costs (e.g., to the system, to PHDs, and to agencies (training, maintaining and expertise)) customer satisfaction.

Conditions of Agreement

• 1) Program goals must be congruent with goals of both partners.
• 2) All costs must be covered, including salary, benefits, travel, continuing education allowance, supplies (if necessary) and an overhead allocation.
• 3) Staff maintains active involvement in Health Department Team.

Examples

To date, the Public Health Department has conducted seven funded secondments with a variety of agencies including a detention centre for young offenders, a geriatric outreach program, a hospital outpatient-parent child program, community health centres, a hospital sponsored AIDS clinic, and a psychiatric hospital.

For more information, please contact Jane Underwood, Director of Nursing Services, Hamilton-Wentworth Regional Department of Public Health Services, 25 Main Street West, 4th Floor, P.O. Box 897, Hamilton, ON, ph: (905) 546-3516, fx: (905) 546-4075.

The Health Promotion Plan For York Region

Centre for Health Promotion, Information Sharing Forum

Abstract of a Presentation by:
Jane Brown, Community Development Coordinator
York Region District Health Council

Jane Brown presented an overview of The Health Promotion Plan For York Region, which was developed in February, 1996. The presentation identified a number of innovative aspects and components of the District Health Promotion Plan (DHPP) including:

The purpose of the planCit is not a disease prevention plan. Rather, it is a story and a guide to the different ways health promotion is done in York Region and the resources which exist to support it.

An extensive community outreach strategy that included "community conversations." The strategy targeted people with few social supports, low incomes, and low education and employment status.

Asset-based planningCthe DHPP is designed to release the power of community capacity.

Four strategies to increase effectiveness of health promotionCcommunity education, community mapping, community mobilization, and integration.

PATHCa planning tool that provides a way for diverse people, who share a common situation, to align their purposes, their understanding of a situation, and the possibilities of change.

Implementation plan.

Outlined below are some excerpts from the presentation.

Community Conversations

The York Region District Health Council hosted eight "Community Conversations." The locations included a community hall, two public libraries, agricultural fairgrounds, a mall, a recreation centre, a family resource centre in a subsidized housing complex, and a private not-for-profit housing complex.

The sessions were advertised in all print media, the Picture of Health newsletter and on cable television. The DHC used the following educational tools:

• displays featuring the Committee's definition of health and health promotion
• the Premier's Council video, Nurturing Health
• the Committee's Picture of Health Newsletter
• Health Promotion in the News, a collection of newspaper articles
• notices of the DHC's proposal call for the 1995-96 Healthy Community Grants Program
• video tape of the cable television show
• an idea box that asked people about their health promotion priorities, and how they wanted to turn these priorities into action.

Asset-Based Planning

Asset-based community development starts with what is present in the community, the capacitates of people, community groups and institutions, rather than what is missing (Kretzmann and McKnight, 1993) . The process is internally controlledCthat means it depends on the community's capacity for self-determination and self-management. The process is also relationship-drivenCthat means it is always building and rebuilding relationships between residents, community groups and local institutions.

The keys to community development and effective health promotion are:

• finding all of the available local assets
• connecting them with one another in ways that multiply their effectiveness
• harnessing local institutions for community development purposes.

Four Strategies

The DHPP recommended four strategies that reflect the concepts of asset-based community development. The strategies utilize existing community resources and assets to deal with the threats to and weaknesses of health promotion in York Region. They rely on the community's capacity to define their own health issues and to act on the solutions they propose. The strategies are:

• 1) Community education to explain the broader determinants of health, health promotion theory and practice, and asset-based community development.
• 2) Locate all the community resources and assets available for health promotion in York Region.
• 3) Look for ways that the community can organize around a community-determined purpose using a collaborative process.
• 4) Work toward making service providers and government institutions a supportive part of a community-determined vision and plan on the determinants of health.

Conclusion

Ms. Brown emphasized that one of most important roles of the York Region DHC throughout the entire planning process was to ensure communication with all stakeholders and participants, and to encourage and support key community leaders. Moreover, she viewed her role as moving beyond traditional planning to include acting as a catalyst/animator for community action.

The completion of the DHPP for York Region does not mark the end of the DHC's role in health promotion. The York Region DHC Health Promotion Coordinating Group will continue to work with local health promotion initiatives at the community level, and to identify and mobilize resources to support community-based efforts. Local "storytelling" and "capacity brainstorming" sessions are scheduled to begin in mid-November, 1996. The Health Promotion Planning Group is committed to working at the community level, and sharing the Health Promotion Plan as a valuable tool for capacity building. The group is also committed to working with the York Region DHC as it moves towards the development of an Integrated Health Care System which includes health promotion as a key component.

For more information, contact Jane Brown, Community Development Coordinator, York Region District Health Council, 1091 Gorham Street, Suite 300, Newmarket, ON, L3Y 7V1, ph: (905) 830-9899, fx: (905) 830-9903.

Metropolitan Toronto District Health Council
Needs/Impact-Based Planning Method

Centre for Health Promotion, Information Sharing Forum

Abstract of a Presentation by:
Natalia Klimko, Health Planner
Metropolitan Toronto District Health Council

Under the leadership of the Metropolitan Toronto District Health Council, the Needs/Impact-Based Planning Committee was commissioned by the Community Health Division of the Ministry of Health to develop a planning approach that could be used by DHCs, Public Health Units, and local community service level organizations and agencies interested in needs/impact-based planning. The Committee developed an outcome-based planning approach designed to reorient the planning and funding of the health system. The method is evidence- and population-based.

Natalia Klimko provided an overview of the following aspects of the methodology: information sources for assessing need and impact, potential community indicators, key ethical issues, relative involvement of stakeholders in each of the seven stages of the process, key strengths, levels of application (e.g., province, region/district, local community, research), and lessons learned. Two examplesClong term care and community violenceCwere used to illustrate how the planning method works.

Outlined below are some highlights from the presentation.

Seven Stages of the Needs/Impact-Based Planning Method

• 1) assessing need
• 2) assessing impact of strategies
• 3) prioritizing issues
• 4) analyzing service gaps
• 5) allocating resources
• 6) taking action
• 7) monitoring measures of need and evaluating impact of chosen strategies.

Strengths of Planning Method

• evidence-based approach to planning
• oriented to empirical literature
• flexible and systematic approach to planning
• planning based on indicators and data sources relevant to the planning jurisdiction
• gives explicit consideration to the value and varying perceptions among decision makers and stakeholders
• goes beyond traditional compartmentalized approaches to health planning by encouraging a team-based approach.

Lessons Learned

• 1) The health issue(s) should be clearly articulated from a population health perspective.
• 2) The scope of the exercise must be comprehensive.
• 3) Data must be available at the appropriate level of aggregation.

For more information, please contact Natalia Klimko, Health Planner, Metropolitan Toronto District Health Council, 4141 Yonge Street, Suite 200, Willowdale, Ontario M2P 2A8, ph: (416) 222-6522, fx: (416) 222-5587.