1. Addressing the Rural HHR Challenge: A Decade of Canadian Experimentation Joshua Tepper MD, CFPC, MPH, MBA

2. Declaration of Competing Interests Representing only myself No COI

3. About Canada

5. Canadian Health Care National Health System since 1964 reaffirmed in Canada Health Act 1984 Provincial/Territorial administration Approx. 30% of costs paid by individual Slow privatization (Diagnostics and Surgery) 1.1M employed in health care Approx. 149,000 Nurses, 75,000+ MD A system in crisis (HHR, Cost/Value, Access)

6. Distance to Specialist Care 0.52 - 14.99 15.00 - 24.99 25.00 - 49.99 50.00 - 99.99 100.00 - 2005.72 Sparsely Populated Area (KM)

7. Home to 22-30% of Canadians (50%+ of Aboriginal) More likely to be obese, smoke, drink alcohol to excessive levels, be less physically active; have a disability; die from cancer, heart disease, suicide, homicide, have traumatic injury & death More likely to have a lower level of income, education and employment Health status and access to health services both decline with increasing remoteness. Chronic Maldistribution of health workforce Rural and Remote Canada

8. Home to 1/3 of Australians More likely to be obese, smoke, drink alcohol to excessive levels, be less physically active; have a disability; die from cancer, heart disease, suicide More likely to have a lower level of income, education and employment Health status and access to health services both decline with increasing remoteness. Maldistribution of health workforce Remoteness Areas in Australia Source: ABS (2008) Australian Social Trends. Rural and Remote Australia Thanks to Tanya Lehman

9. “The success of our health care system as a whole will be judged not by the quality or services available in the best urban facilities, but by the quality of service Canada can provide to its remote and Northern communities” - Jose Amaujaq Kusugak

10. “Canada may, in fact, have a very good health care system with health outcomes that are generally among the best in the world. But there are growing signs that this is not the reality for Canadians living in smaller or more isolated communities across the country.” - Roy Romanow, 2002

11. Examples of Rural HHR Initiatives

12. Caveats Snapshots not a comprehensive review Many areas have similar initiatives Does not speak to impact Ontario Focus Medicine focus Impact needs to be studied If you have seen one rural town…If you have been to one Canadian Province/Territory….

13. New Educational Models Ontario

15. Comprehensive Approaches British Columbia: Rural Retention Program Rural Continuing Medical Education Fund Recruitment Incentive Funding Recruitment Contingency Fund Isolation Allowance Fund Rural Emergency Enhancement Fund Rural Education Action Plan Northern and Isolation Travel Assistance Program Rural Locum Program (GP/GP-Anaethesia/Specialist) http://www.health.gov.bc.ca/library/publications/year/2013/rural-guide-mar2013.pdf

16. Rural Education Action Plan Undergraduate Rural Participation Program Undergraduate Teacher’s Stipend CME Advanced Skills and Training Program First Year in Practice Enhancement Program Rural Locum Service Upgrade Program Urban Skills Enhancement Program Rural GP Locum CME Program (ACLS) Specialty Training Bursary Program (FM PGY3) Comprehensive Approaches British Columbia:

18. Regionalization & Service Closures: Pan-Canadian Saskatchewan closed 52 of 112 hospitals; 1993-1994 Ontario major restructuring Urban and Rural hospitals 225-150; 1996-2000 Surgery, Maternity, Labs, Mental Health and Emergency Departments

19. Primary health care Specialized Models and Programs: Ontario Ontario Rural Northern Physician Group Agreement (RNPGA) Groups of physicians committed to providing core primary health care services in certain rural communities The RNPGA provides a global payment to a group of physicians and ensures patients will receive a wide range of comprehensive primary care services in 38 northern communities. The RNPGA provides physician access to all people in the defined geographic area including residents in Long Term Care Homes, patients in hospital and emergency department coverage for communities with hospitals. 19

21. More than Doctors: Newfoundland

23. Aboriginal Health Human Resources Initiative

24. Increase capacity and number of education and training programs provided by Aboriginal institutions Improving the contribution of mainstream education and training programs to the development of Aboriginal human resources Improve Aboriginal students’ ability to pursue education and training through financial and other supports Improving the cultural appropriateness and effectiveness of education and training programs to meet the needs of Aboriginal students and communities Aboriginal Health Human Resources Initiative

26. The Role of Technology Nunavut: 1/5 of Canada’s land mass; 27,000 people, 25 communities (148 to 7,000); only sea and air access Ikajuruti Inungnik Ungasiktumi (IIU) Telehealth Network - ‘a tool to help people from far away’; More than medical services: social services, educational, public health, administration Live and ‘store and bring forward’ Four languages, Inuktituk, Innuinaqtun, French and English

28. Reflections on Rural HHR

33. JAMA 2012

35. Final Thoughts High degree of variation – Pros and Cons No ‘silver bullet’ Urban context has high degree of impact on rural HHR Definition of rural is problematic but important Major focus of initiatives is on medicine, some in nursing and not enough elsewhere Addressing HHR Challenge in rural areas is a chronic challenge