Southwest Ontario Aboriginal Health Access Centre (SOAHAC) is using data to inform program development and improve care for their clients.
We spoke with Deanna Guernsey, Regional Director, London-Middlesex; and Catharine Campbell, Data Management Coordinator; to find out more.
Could you tell us about how you are collecting sociodemographic data? What data do you collect, and how do you collect it?
We’ve adopted the Toronto Central LHIN’s “We ask because we care” approach. We’ve included the eight standardized demographic questions in our intake process and have also added a few questions more specific to our population, such as whether the person had experience with residential schools, what languages they speak, and what communities they belong to.
We are also involved in some external initiatives – for example, we are working on the Our Health Counts initiative, a research project aimed at gathering population-based health information on First Nations adults and children living in urban settings. We’ve done this for the London area, although we are currently looking for funding to expand this to the rest of our population. This initiative used in-depth questionnaires and outreach to gather information about health and wellness in the community.
Can you give some examples of how this data has informed programming?
We use the Our Health Counts data to look at what people are self-identifying regarding their wellness to determine whether we need additional programs. Thanks to this data, we have a better understanding of health and wellness within the community, as well as the community’s experience with the health system and the barriers that our clients face. By applying this data, we can be proactive in addressing needs rather than reactive to situations in our community.
We know from our data that we have many clients with complex health needs. Our SAMI score is 1.54. This is a measure of morbidity and means that, on average, our clients have a 54% higher need for primary care services. Also, more than 60% of our clients from primary care have more than four comorbidities. We will be adding a new role – a registered nurse who will focus on clients with complex health needs and will help to address barriers these people may experience due to sociodemographic constraints. We feel that we could do more to link these clients to additional resources or supports to further stabilize them, such as providing assistance with adherence.
We recognized that there were significant gaps in supporting Indigenous clients to be able to die in their place of choice. Through the IDEAS (Improving & Driving Excellence Across Sectors) program, the LHIN and SOAHAC came together to provide resources and knowledge to create an Indigenous-led palliative care team. We wanted to improve culturally safe care plans. We went from zero home deaths (as the preferred place of death) to seven so far. The team is entirely mobile.
Another example is our midwifery program. We saw that people were leaving the community to travel to Brantford to work with Aboriginal midwives, and we have now started a midwifery program close to home.
The regional quality table at the South West LHIN is narrowing down to three of Health Quality Ontario’s quality standards to focus on. We plan to bring the Our Health Counts data to the table to help inform which practices we want to prioritize for adoption.
Did you encounter any challenges?
One challenge is how to get the sociodemographic information from their existing clients who did not go through our new intake process. We haven’t yet found the best way to go out and ask these questions again.We also still need to figure out the best way to keep the data current.
Do you have any advice for organizations starting to do similar work?
It would be helpful for any organization to have dedicated resources to deal with intake. If the person doing intake is a clinician, they will likely focus largely on clinical information, but if intake is led by someone whose focus is more general, they may be better able to keep it at a higher level. Organizations also need to be able to continually refine their intake process and train those involved – it’s a really important process.
Sometimes the questions we ask in the intake process are felt to be intrusive and must be dealt with carefully. If people decline to answer, we make sure they know this will not impact the care they get. They should also be able to update their answers at any time.
You may also be interested in:
Quorum’s Indicators & Change Ideas page for more information on QIP indicators and related change ideas.