Qi RG Needs Assessment 0901 en

NEEDSASSESSMENT
RESOURCE GUIDE
January 2009
Amended December 2010
ACKNOWLEDGEMENTS
TheNeedsAssessmentResourceGuideforFamilyHealthTeamsistheresultoftheeffortsofthe
QualityImprovementandInnovationPartnerships(QIIP)Evaluation,NeedsAssessmentand
PerformanceMeasuresWorkingGroup.TheworkofLynneLawrie,whocompiledtheresourceguide
onbehalfoftheworkinggroup,isgratefullyacknowledged.
Evaluation,NeedsAssessmentandPerformanceMeasuresWorkingGroupMembers
MikeGreenChair
LindaHilts
DavidWallik
StenArdal
BrianHutchison
ChristelWoodward
PaulaBrauer
SherryKennedy
BillCasey
BarbaraRoston
Foradditionalinformationaboutotherresourcescontact:
QualityImprovement&InnovationPartnership
10GeorgeStreet,Suite205
Hamilton,Ontario,Canada
L8P1C8
Phone: 9056670770
Fax:9056670771
info@qiip.ca
www.qiip.ca
Individualsmayreproducethesematerialsfortheiruseprovidedthatproperattributionisgivento
theappropriatesource.Therecommendedcitationforthisresourceguideis:QualityImprovement
andInnovationPartnership(January2009).NeedsAssessmentResourceGuideforFamilyHealth
Teams.www.qiip.ca
QIIPisfundedbytheOntarioMinistryofHealthandLongTermCare.Theopinionsexpressedinthis
publicationarethoseoftheauthorsanddonotreflecttheofficialviewsoftheOntarioMinistryof
HealthandLongTermCare.
TABLEOFCONTENTS
INTRODUCTION.................................................................................................................1
BACKGROUND...................................................................................................................1
HEALTHNEEDSASSESSMENT:ConceptsandDefinitions....................................................1
LevelsofNeedsAssessments.............................................................................................................1
DefinitionsofNeedsAssessment.......................................................................................................2
THECASEFORNEEDSASSESSMENTS..................................................................................3
GoodBusinessPractice......................................................................................................................3
PreparingfortheFuture.....................................................................................................................3
MaximizingtheNewDeliveryModelsforImprovedEfficiencyandPatientOutcomes....................4
THEPURPOSEOFANEEDSASSESSMENT...........................................................................4
TheNeedsAssessmentCheckList......................................................................................................4
UNDERSTANDINGHEALTHNEEDS....................................................................................6
EXAMININGHEALTHNEEDSBASEDONBURDENOFDISEASE.............................................7
UNDERSTANDINGDETERMINANTSOFHEALTH................................................................11
ENGAGINGTHETEAM......................................................................................................12
SWOT................................................................................................................................................12
AffinityExercises..............................................................................................................................13
CriteriaWeightingExercises.............................................................................................................13
ENGAGINGTHEPARTNERS...............................................................................................13
ENGAGINGTHEPATIENTS................................................................................................15
OTHERCONSIDERATIONS................................................................................................15
CONCLUDINGCOMMENTS...............................................................................................16
APPENDICES.....................................................................................................................17
AppendixAExamplesofFHTNeedsAssessmentApproaches......................................................18
AppendixBThePeopleandtheTimingofNeedsAssessmentswithinFHTs................................21
AppendixCGlossaryofTerms.......................................................................................................23
AppendixDNeedsImpactBasedModel.......................................................................................24
NeedsAssessmentResourceGuideforFamilyHealthTeams
January2009
INTRODUCTION
Thisresourceguideprovidesanoverviewofhealthneedsassessment,withafocusonneeds
assessmentapproachesandprocessesrelevanttotheFamilyHealthTeam(FHT)practicereality.Itis
meanttocomplementotherresourcesonneedsassessment.
TheresourceguideisaproductoftheQualityImprovementandInnovationPartnershipandits
WorkingGrouponEvaluation,MeasurementandNeedsAssessment.
BACKGROUND
TheQualityImprovementandInnovationPartnershiprecognizesthatFHTsacrossOntarioarein
highactivitymode,workingtorosterpatients,hirehealthprofessionalsfortheirteams,anddesign
programsthatwillhaveapositiveimpactontheirpracticeintermsofpatientoutcomesand
practiceefficiency.Informationonneedsisanimportantelementunderlyingtheaboveactivities.
Thetimeandresourcestoacquiretheinformationcanbeachallenge.
ManyFHTshaveundertakenprocessestoassisttheminestablishingsomeinitialpriorities.Some
groupsdidthisaspartofthestartupplanningandinitialdevelopmentphases.FHTshavesoughtto
identifyneedsaspartofpatientrosteringandthroughpatientsurveying,organizationalstrategic
planningsessions,andcommunityconsultations.AllthesetypesofeffortshaveassistedFHTsto
moveaheadwithplanningservicesandtargetingsomeinitialservicedeliverypriorities.
Thisresourceguideacknowledgesthepreviousneedsassessmentprocesses,andreflectssomeof
theapproachesandlessonslearnedfromthosewhohaveimplementedneedsassessmentactivities.
SomespecificinformationfromthreedifferentsitesisfoundinAppendixA.Thecontentsofthis
resourceguidewillsupportfutureneedsassessmentactivitiesofFHTs,andotherprimarycare
practicesthroughamenuofapproachestoneedsassessment,fromwhichtoselectbasedontheir
ownparticulargroup,communityandcapacity.
HEALTHNEEDSASSESSMENT:ConceptsandDefinitions
Anyhealthneedsassessmentmustestablishaprocesstoensuretheassessmentisconducted
withinavailabletimeandresources.1
LevelsofNeedsAssessments
Needsassessmentsarecommonlyusedatalllevelsofhealthcareand,mostoften,relatedtogoal
setting.
Attheinternationallevel,theWorldHealthOrganizationisthemostwellknowngrouptoundertake
thistypeofwork.InCanadatherehavebeenextensiveexercisesrelatedtounderstandingneeds
1
AssessingNeedsModule,HealthPlannersToolKit,HealthSystemIntelligenceProject,MinistryofHealthandLongTermCare,
GovernmentofOntario
January2009
anddeterminingnationalhealthstrategies.Ontariohasrecentlyundertakenconsultationstoset
healthgoalsfortheprovince
TheLocalHealthIntegrationNetworks(LHINs)arechargedwithlookingattheneedsoftheirarea,
andimplementinghealthsystemsthatrespondtothoseneeds.Thussignificantinformationaround
needsexistattheLHINlevel.AccessingLHINlevelreportsisarelativelyeasyexercisebyclickingon
totheMinistryofHealthandLongTermCareWebsite,determiningtheLHINtobesearched,and
movingintothatLHINswebsite.
Thetwotypesofneedsassessmentsmorefullyexaminedinthismoduleareorganizationaland
populationspecific.OrganizationssuchasFHTsmayconductneedsassessmentsfortheirgeographic
catchmentareaorforspecificpopulationssuchaschildren,seniors,personswithmentalhealth
issues,etc.
Asinglepieceofneedsassessmentworkmaybeworthwhileinthecontextofalarger
organizationalneedsassessmentorwhenaserviceisrelativelyprominentinanareaofparticular
need.Forexample,inadisadvantagedareawherementalhealthandaddictionservicesalready
makeupmuchofthetotalservicearray,aseparateanddistinctmentalhealth/addictionsneeds
assessmentmaybewarrantedinordertotailortheservicesmostappropriately.2
Individualclientlevelneedsassessmentsareconducteddailyinprovider/patientconsultations.
Needsassessmentatthislevelisbeyondthescopeofthecurrentguide.Differentneeds
assessmentsdoneindifferingcontextshighlighttheneedtodefinethescopeofneeds
assessment.
DefinitionsofNeedsAssessment
Itishelpfultoadaptaconsistentdefinitionofwhatisahealthneedsassessment.Thefollowing
definitionsspeaktocommonelementsofneedsassessments,namelygoingthroughadedicated
processtounderstandneedsofpeoplebeingservedandsettinginplaceactionstoaddressthose
needs.
Definition1
Healthneedsassessmentisasystematicmethodforreviewingthehealthissuesfacingapopulation,
leadingtoagreedprioritiesandresourceallocationthatwillimprovehealthandreduceinequities.3
Definition2
Acommunityhealthneedsassessmentisadynamicongoingprocessundertakentoidentifythe
strengthsandneedsofthecommunity,enablethecommunitywideestablishmentofprioritiesand
facilitatecollaborativeactionplanningdirectedatimprovingcommunityhealthstatusandqualityof
life.4
AssessingNeedsModule,HealthPlannersToolKit,HealthSystemIntelligenceProject,MinistryofHealthandLongTermCare,
GovernmentofOntario
NationalInstituteforClinicalEvidence,UK
4
ManitobaCommunityHealthNeedsAssessment
3
January2009
Definition3
Healthneedsassessmentisthesystematicapproachtoensuringthatthehealthserviceusesits
resourcestoimprovethehealthofthepopulationinthemostefficientway.5
Basedontheabove,adefinitionspecifictoprimarycaregroupsandFamilyHealthTeamsin
particular,maybeasfollows:NeedsassessmentsdonebyFamilyHealthTeamsareadeliberate
activityundertakentodescribetheneedsofcurrentandpotentialpatientswithinthepractice.
Onewouldthenfurtherstipulatethat:Theneedsassessmentinformationisusedtoidentify
opportunitiestoimprovethehealthofpatientsand/orcommunitybasedontheneedsthatare
judgedtobemosturgentandmostamenabletoprimarycare,teambasedintervention.
THECASEFORNEEDSASSESSMENTS
GoodBusinessPractice
Inanybusinessitisimportanttounderstandtheneedsofyourclients.Needsassessmentsare
routinelyconductedinmanysectorsincludinghealth,education,andcommunityservices.Needs
arealsoassessedwithintheprivatesector,butinthatcasetheyaremorecommonlyconsidered
marketresearcharoundconsumerwantsandpreferences.Thereisasignificantdifferencebetween
thepurposeoftheseactivitiesfortheprivateandpublicsector.Theprivatesectorisoftenengaged
inpromotingorcreatingdemandforparticularproducts,whereasinthepublicsector,providersof
servicesstruggletomeetgrowinganddiverseneeds,demandsandexpectations.
Needsassessmentsundertakenbyprovidersofhealthservicescanhelpthemidentifywhatisreal
needbasedonthedefinitionsorcriteria
Measurementsforspecificmorbidityinthe
thattheyselect.Underlyingneeds
populationmaybethebestapproachto
assessmentistheassumptionthatthereare
identifyingneedformedicalcare,sincethese
somespecificcommonneedsamonga
gaugedirectlythestateofillhealthforwhich
groupofpatientsthatcan,andshould,be
peopleseekhelpPrevalencedataisof
proactivelyaddressedbyprimarycare
greaterinteresttopeoplewhoaretryingto
practices.Thekeywordhereisproactive,as
predictdemandforservice.
theoppositeapproachtoneeds
assessmentsistosimplyreacttothe
Assessing Needs Module
patientsastheyflowintothepractice,
Health Planners Took Kit, MOHLTC
withoutexaminingthecommonalitiesof
needsandstrategiesavailabletoefficiently
andeffectivelyrespondtothoseneeds.
PreparingfortheFuture
Whileprimarycarepractitionerscommonlyuseclinicalguidelinesandtoolstoassesstheneedsof
patients,doingneedsassessmentsforentirepracticepopulations,orthecommunitythatfeedsthat
practicepopulation,isalargerandsomewhatdifferentprocess.Thepatientwhocomesthrough
thedoortodayandthepatientsdemandingthemostattentionthisweek,maynotnecessarily
representthelongterm,embeddedhealthneedsorhealthimprovementopportunities,withinthe
5
HealthNeedsAssessment:DevelopmentandImportanceofHealthNeedsAssessment,Wright,J.BMJ1998
January2009
practicecommunity.ForallFHTs,butespeciallythoseinareasundergoingchangessuchas
populationgrowth,growthinnumbersofimmigrants,increaseordecreaseofcommunityservice
capacityitisessentialtounderstandandplanforthepracticerosterprofileofthreetofiveyears
downtheroad.
MaximizingtheNewDeliveryModelsforImprovedEfficiencyandPatient
Outcomes
WiththeadventofFamilyHealthTeams,wehavemovedtoformalizedgroupsofprimarycare
providers,whereinphysiciansdelivercareinconcertwithotherhealthprofessionalssuchasnurses,
nursepractitioners,dietitians,patienteducators,pharmacists,andsocialworkers.Thestrengthof
theFHTmodelwillberealizedthroughtheimplementationofevidencebased,proactive,
collaborativepatientcareprogramswithinthepractices.Theseprogramsshouldbedesignedafter
theFHTshavegonethroughaprioritysettingexercise,foundedonanunderstandingofthepractice
communityneedsandopportunitiesavailablefromtheteamofhealthprofessionalsavailableto
respondtothoseneeds.
THEPURPOSEOFANEEDSASSESSMENT
EveryFHTwillhavetodecideonthepurposeforundertakinganeedsassessmentactivity,andwill
needtoinvestresourcestoaddressthefindings.Thefirsttaskofneedsassessmentistodefinethe
questiontobeanswered.
Forexamplethequestioncouldbebroadas:
Whatarethecurrentandemergingprimarycareneedsofourcommunity?
Ordiseasespecific:
Whatarethethreemostimportantneedsofourpracticepopulationfromachronicdisease
perspective?
Orverytargeted:
Whattwonewinitiativeswillweundertakeinourpracticethisyear?
Thequestionisextremelyimportant,asitwilldefinethescopeoftheactivity,theinformationtobe
usedandthepartnerstobeengaged.
TheNeedsAssessmentCheckList
Havingdefinedthepurposeforundertakinganeedsassessment,therearethenaseriesofactivities
keytoanyneedsassessmentprocess.Withinthoseactivitiesorsteps,theamountoftimeand
resourcededicatedtoeachcanbedeterminedbyeachorganization.Thereisnomagicformulato
definewhatisenoughinformationorhowmuchconsultationisrequired.Todevelopaprocess
thatwillbeusefulforFHTplanning,theprocessshouldseektoprovideinsightsinthefourareas
notedbelow:
practiceassumptionsaroundpatientgroupneedsarevalidated,clarified,oramended(e.g.lackof
communitymentalhealthserviceoptions)
January2009
informationisobtainedthatwasnotpreviouslyknownoracceptedasfactbyallmembersofthe
practice(e.g.numberoffrailseniorswithinthepractice)
informationisobtainedthathasrelevancefordifferentmembers/professionswithinthepractice
(numbersofpatientswithriskfactorsfordiabetes,heartdisease,etc.)
informationbecomescompellinganddrivesconsensuswithinthepractice(e.g.needforcare
coordinationforpatientswithchronicillnesses)
Towarranttheinvestmentoftimeandresources,aneedsassessmentactivityhastobelinkedtoa
processforidentifyingprioritiesandfortakingaction.Thatinitselfimpliesthatresourcesneedtobe
balancedbetweenaprocesstounderstandneedswithactiontoaddressthoseneeds.
Asamplechecklistwhichincludespotentialleadsforeachactivity,andestimatedtimeframeis
attachedasAppendixB.
STEP1
Definetheplayers,
partnersand
informationsources
for
theexercise
STEP4
Identifyneeds
Identifyopportunities
toaddressneeds
STEP5
STEP3
Scopetheneeds
assessmentproject
(whatquestiontobe
answered)
STEP2
Table1NeedsAssessmentCheckList
Setpriorities
foraction
Definethepopulationtobestudied
Definethegoalsfortheneedsassessment(e.g.programdesign,
implementation,recruitment,retention,etc)
Definetheresourcesavailabletosupporttheneedsassessment
(e.g.datafrompublichealth,LocalHealthIntegrationNetworks,
hospitals,CCACs,etc)
Identifyprojectscope,potentialparticipants
Accessandreviewexistingreportsanddata(e.g.hospitalizations
forchronicillnesses,populationdemographics,riskfactors,
communityhealthstatusreports,etc.)
Gatherandsynthesizequalitativeinput(e.g.practitioner
perspectives,patientperspectives,communityagencypartner
perspectivesetc.)
Listneedsbasedoninformationfromstep2groupingwhere
possibleintobroadcategoriese.g.socialexperience(age,
ethnicity),disease,riskfactorsorothercategoriesdeterminedby
theFHT
Identifystrategies/evidencebasedinterventionstoaddress
needs
IdentifyFHTteamcompetencies,currentandanticipated
Identifypotentialprograms,interventions,approachesto
improveperformanceandhealthoutcomesinpriorityareas.
ApplycriteriaspecifictoFHTsuchasexistingexpertise,available
funding,andpartnershipswithotherproviders,abilitytoachieve
quickwins.
Confirmapproachwithkeystakeholders(e.g.focusgroupof
patientsandcommunitypartners)
STEP6
Implementandstudy
theimpact
January2009
UtilizeFHTrangeofhealthprofessionalstodesignprograms,
establishindicatorsforsuccess,andreporting
Implementnewapproaches
Followingaqualityimprovementtool,suchasthePlan,Do,
Study,Actapproach,establishtimetablesforreviewand
adjustmentifnecessaryofprograms,interventions,approaches
Useresultsforotherprogramplanning.
UNDERSTANDINGHEALTHNEEDS
FourdifferentconceptsofhealthneedsareillustratedinFigure1.
Figure1DefinitionsofHealthNeeds
Health Need as
Burden of Illness
(How sick or
incapacitated are we?)
Health Need as
Medical Necessity
(Expert authority
says it is a need)
PEOPLE
AND
POPULATIONS
Health Need as
Capacity to Benefit
(How much health and
wellbeing are we
capable of gaining?)
Health Need as
Comparative Health
Deficit
(Are we better or worse
than others?)
Source:TheHealthPlannersToolkit,MOHLTCHealthSystemIntelligenceProject2006
Allfouroftheseconceptsarerelevantforthoseplanningprimarycareservices.
Medicalnecessityiswellunderstoodandsanctionedthroughgovernmentmandatedpayments(e.g.
OHIPbillingcodes).
Giventhelackofanabsolutedefinition,healthneedexpressedascomparativehealthdeficit
providesawaytolookathealthneedsacrossdifferentpopulations,perhapsgeographicallydefined.
January2009
Anexampleofapplyingthisconceptistolookatsubpopulationssuchasaboriginalgroupswithin
largercommunities,comparinghealthstatusmeasurements.
Thedefinitionofneedwidelyfavouredbyhealtheconomistsistheabilityofpeopletobenefitfrom
healthcareprovision.Inotherwordsneedonlyexistsifthereissomecapacitytobenefitfroma
particularhealthcareintervention.Underthisapproach,interventionswouldbesupportedwhen
thereisgoodevidencethattheyproducebenefitssuchashealthenhancement,diseaseprevention
orthepostponementofdeath.Inaprimarycarecontext,thisapproachpromotesdiscussions
aroundchoices.Forexamplepatientswhoareseniorswithinagivenpracticemaybenefitboth
sociallyandmedicallyfromastronglypromotedfallspreventionprogram.Timespentsettingupthis
programwithotherteammembersand/orothercommunitypartnersmaybemoreusefulthan
additionalonetoonephysician/patientofficeappointments.Whileattractive,thereisoftenless
informationoncapacitytobenefit,comparedtotheotherthreedefinitionsofhealthneed.
LastlytheburdenofdiseasemaybetheareawithmostpotentialforFHTsdoingneedsassessments.
Itspeakstowhypeoplemayseekprimarycare,andhowoften.Italsoalignswellwiththe
governmentsinitiativesonChronicDiseasePreventionandManagement,andrecognizesthat
proactiveinterventionsattheprimarycarelevelmaysignificantlyimprovepatienthealthoutcomes
overtheshortandlongterm.
EXAMININGHEALTHNEEDSBASEDONBURDENOFDISEASE
AccordingtotheMOHLTCNeedsAssessmentModule,conventionalhealthneedsassessment
definesneedaccordingtothegeneralburdenofdiseaseinthepopulation.
Prevalenceandincidence(seeAppendixC
Eveninconventionalneedsassessments,
GlossaryofTerms)ofdiseasearemeasuresof
however,choicesmustbemadeamong
diseasefrequentlyusedinneedsassessmentas
indicatorschoiceswhichhaveimplications
indicatorsofdiseaseburden.Prevalence
forhowhealthneedisidentifiedand
measuresareimportantforplanningcurative
described.
andrehabilitativeservices,whileincidence
AssessingNeedsModule
basedmeasuresaremoreusefulforplanning
HealthPlannersTookKit,MOHLTC
preventiveprogramming.
Burdenofdiseasereferstomeasuresthatincludebothquantitativeandqualitativeinformation.
Theconceptincorporatesbothpersonalhealthexperienceanddiseasefrequency.
Thereareatleastnineindicatorsthatcanbeappliedtounderstandthehealthneedsfromaburden
ofdiseaseperspective.TheyareillustratedinFigure2.
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Figure2NineCategoriesofIndicators
Eachofthesetypesofindicatorsareexaminedverybrieflywithaviewtowheretheinformation
maybefoundandhowtheinformationmayhelpwithneedsassessmentattheprimarycarelevel.
Informationisprimarilycollectedandmadeavailableatthefederal,provincialandLocalHealth
IntegrationNetworklevelsofgeography.LHINsusedatasuppliedbytheMinistryofHealthandLong
TermCareandothersourcestodevelopprofilesoftheirareaoverall,aswellassomesubareas
withintheLIHNboundaries.LHINswillbeausefulsourcetoFHTsforplanning.TheMinistrysHealth
SystemIntelligenceProjectcreatedanumberofexcellentresourcesandisausefulstartingpointfor
anygroupinitiatinganeedsassessmentprocess.ReportsareavailablethroughtheHealthAnalytics
Branchattheministry,withmostaccessibleonlineat:
http://www.health.gov.on.ca/transformation/providers/information/im_resources.html.
PublicHealthunitsarealsoakeysourceforinformation.Notonlydotheyhaveinformationrelated
tothehealthstatusofthecommunity,theyoftenhaveadditionalreportsspecifictotheircatchment
area.Forexample,TorontoPublicHealthhasdoneconsiderableworkontuberculosis;some
northernunitshavedoneconsiderableworkonaboriginalhealth.
January2009
Table2IndicatorSourceInformationandApplication
Indicator
Relevance
(forprimarycareplanning)
Source(s)
HealthServicesUtilization
Hospitaladmissions
Avoidablehospitalizations
ERusage
ACSC(AmbulatoryCare
SensitiveConditions)
HospitalLengthofStay
Waitlists
MortalityMeasures,e.g.
deathsrelatedtospecific
causessuchasbreast
cancer,CHF,asthma,heart
disease,etc.
HealthMeasures
Morbidity
Disability
Selfassessedhealth
RiskFactors
Healthbehaviourssuchas
smoking,heavydrinking,
dietandphysicalactivity
CIHI
MOHLTC
LHINs
CCACs
Providers(e.g.
hospitals)
StatisticsCanada
MOHLTC
LHINs
MOHLTC
LHINs
CIHI
StatisticsCanada
(HealthSurveys
CCHS)
StatisticsCanada
(CCHS)
LHINs
Obesity,smoking
alcohol,Physical
activity
HealthCanada
EconomicBurden
Deprivation
Lowincome/poverty
Foodinsecurity
Demographics
Populationgrowth
Populationstructure
Populationdistribution
(i.e.,
rural/urban/suburban)
StakeholderPerceptions
PublicHealth
StatisticsCanada
(Census,CCHS)
StatisticsCanada
PublicHealth,
LHINs,
MunicipalReports
LHINs
Hospital/ERusage
speakstoprimary
care/afterhoursneed
Mayindicateaccessissues
forhealthservicesbyarea
Indicateoverallhealthof
apopulation
Medium
to
High
Indicatereasonswhy
personsseekprimary
care/orbehospitalized
High
Indirecthealthpredictor
HightoMedium
morbidity,etc
(unlessavailableby
patient)
Influenceongovtpolicy,
employeeassistance
programs
Predictorofhealthstatus
Indicatesinfluencessuch
asgeography,age,
regionsgrowth
Factorslikelytodrive
usageofprimarycare
services
Ranking
(forprimarycare
planning)
High
Low
High
High
Medium
(unlessavailableby
rosterpopulation)
Indicator
CommunityIndicators
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Relevance
(forprimarycareplanning)
Source(s)
PublicHealth,
StatisticsCanada
CIHI
Includesnotionofsocial
capitalanditsimpacton
health
Ranking
(forprimarycare
planning)
Low
(difficultto
measureand
accessbyFHTarea)
AcronymGlossary
ACSCAmbulatoryCareSensitiveConditions
CIHICanadianInstituteforHealthInformation
MOHLTCMinistryofHealthandLongTermCare
LHINsLocalHealthIntegrationNetworks
CCACsCommunityCareAccessCentres
StatisticsCanada(CCHS)2002CanadianCommunityHealthSurvey
FHTFamilyHealthTeam
10
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UNDERSTANDINGDETERMINANTSOFHEALTH
AsFHTsundertaketheirneedsassessmentexercises,questionswillariseaboutthescopeofneeds,
mostespeciallythevalueofunderstandingneedsbeyondthemedical.Thesocial,political,
geographicandeconomicdeterminantsofhealthhavesignificantimpactonthehealthofpatients,
ontheirabilitytobenefitfromtreatmentandlifestyleadvice,andonthealternativesandextended
supportsthatcaninfluencepatientshealth.
Example:Healthyeatingforpatientswithdiabetesandtheirfamiliesismoredifficultforthoseliving
inlowincomesituations.Inthoseinstancesaccesstohealthyfoodmaybecompromisedbythe
costoffreshfoodorbydifficultyaccessingsupermarkets.Recognitionofthesefactorsmayleadto
differingtypesofinterventions.
Example:Personswhoareemployedmayormaynothaveaccesstodrugandotherhealthbenefits
throughemployersubsidizedextendedhealthbenefitplans.Suchplansmayincludeaccessto
EmployeeAssistanceProgramsthatprovidesmentalhealthorgriefcounseling,whichthenneednot
beofferedbytheFHT.Conversely,iftheFHTprovidesservicestoalargecontingentofunemployed
persons,suchservicesmaybeappropriatelyofferedbytheFHT.
Example:Seniorswithpoorsocialsupportsmayhavedifficultygettingtoappointments,gettingout
toshop,andwillbemorelikelytobelonelyanddepressed.
Astheaboveexamplesindicate,primarycarepractitionerswilloftenbeconfrontedwithpatients
whosehealthissuesstronglylinktosocial,economicand/orenvironmentalconditions.Thusitis
importanttounderstandtheinterplayofthesefactorsandtoaddressthemasmuchaspossiblein
interactionswithpatientsandtheirfamilies.Atthesametime,thesolutionsorrelieftothetypesof
issuesnotedaboveareusuallyfoundoutsidetheFHToffice.Socialworkerswithinthepracticesare
usefulresourcesforconnectingpatientsto
outsidesupports.
Thehealthfieldcanbebrokenupintofour
Informationaboutthedeterminantsofhealthin
broadelements:humanbiology,environment,
areasinOntarioisavailablefromsourcessuchas
lifestyleandhealthcareorganizations.These
LHINsandPublicHealthandprovidesimportant
fourelementswereidentifiedthroughan
contextfortheFHTneedsassessmentand
examinationofthecausesandunderlying
planningactivities.Howevertheywouldnotbe
factorsofsicknessanddeathinCanada,and
theprimaryfocusfortheFHTneedsassessment
fromanassessmentofthepartstheelements
exercise.Agoodwaytolookattheinteractions
playinaffectingthelevelofhealthinCanada.
betweenthevarioustypesandlevelofplanning
population,healthsystem,servicescanbe
ANewPerspectiveontheHealthofCanadians(1974)Lalonde.
foundinFigure3.
11
January2009
Figure3ConnectionsamongTypesofPlanning
POPULATION HEALTH PLANNING
Identifyingdesirablehealth
outcomesforthehealth
systemandothersystems
Planningforasystem
ofhealthservices
HEALTH SYSTEM
PLANNING
HEALTH GOALS
PLANNING
Planningfortheengagement
ofallsystemstopromote
health
HEALTH SERVICES
PLANNING
Planning for a particular

healthservice
ENGAGINGTHETEAM
WorkingthroughaneedsassessmentprocesswithinFHTswillinvolveallmembersofthepractice,
atleasttosomeextent.Theabilityoftheteamtodialogueandshareinformationingeneralwill
affecttheneedsassessmentexercise,aswellasbeenhancedbyit.
Forexample,ateamworkingthroughadiscussiononthedeterminantsofhealthfortheir
population,inconjunctionwiththereviewofhealthstatusinformation,willprovideusefulcontext
fortheFHTmovingforward.Throughthisdiscussion,twoimportanteventswilloccur,namelythe
membersoftheFHTteamwillhaveanimprovedawarenessoftheirindividualphilosophiesof
healthcare,andsecondlytheFHTteamwillbegintomakesomedecisionsaboutthewaysthe
practicewilladdressthehealthneedsoftheirpracticeunderthenewFHTmodel.
Sometoolshelpfultoteamsgoingthroughneedsassessmentprocessesandtherelatedpriority
settingarenotedbelow.
SWOTexercise
Affinityexercises
Criteriaweightingexercises
SWOT
SWOTisatoolcommonlyappliedinstrategicplanningexercisesandstandsforStrengths,
Weaknesses,OpportunitiesandThreats.LookingattheFHTinthiswaycanbedoneinarelatively
shortperiodoftimeandwillbeusefultohelptheteamestablishcriteriafortheirneedsassessment.
Forexample,ifamajorthreatfortheFHTisthelackoflocalspecializedgeriatriccare,thentheFHT
maydecidetoputhighpriorityoninformationandcriteriarelatedtofrailseniors.
12
January2009
AffinityExercises
Affinityexercisesareexcellentwaystoidentifyissues,orprioritizeamongthem.Initssimplest
form,eachparticipanthasanopportunitytorespondtoaquestionandpostuptheiransweror
answers.Thenextstepisforoneperson,oftenanexternalfacilitator,toleadthegroupthrougha
processofputtinglikeideastogether(establishingaffinity),afterwhichtherearegroupsofideas
thatrepresentmorevotesorideasthanothers.Theseareusuallydeemedtobethefirstlayerfor
furtherdiscussionaboutmovingforward.
CriteriaWeightingExercises
Eachteamwillhavetodeterminewhatweighttoassigninexaminingevidencearoundneeds,and
possiblyaroundwaystoaddresstheneeds.Oneplacetostartcouldbetorankthenineindicators
undertheburdenofdiseaseumbrella,givinghigherweighttoinformationunderindicatorsthatare
deemedmorerelevantforprimarycareprovision.Forexample,apracticemaydeterminethat
informationaboutmortality,morbidity,selfreportedhealthandriskfactorsismostimportant.FHTs
inlargeurbanareasmaywanttoputemphasisaswellondemographics,especiallypopulation
growth.
Anotherplacetostarttoestablishcriteriawouldbetorankaccordingtothevaluesofthe
organization.Forexample,ifaccessandequityarekeyvaluesofaFHT,theninformationcollected
underdeprivationandstakeholderperceptionswouldberankedhigh.
Athirdoptionwouldbetoidentifytypesofinformationrelatedtoneedsandthenundertake
surveysforrankingpurposesofstaff,patientsandcommunitypartners.Inthecaseofasurveyto
rankneeds,itwillbeimportanttoremindrespondentstorankwithaviewtotheabilityofthe
primarycareproviderstoaddresstheneed.Apotentialdualbenefittothistypeofsurveyistouse
thesurveytohighlighttherangeofprovidersandserviceswithintheFHT,asbackground
informationtothequestions.
Whateverprocessisundertakentodevelopcriteriabasedoninformationcollectedonneeds,it
shouldbespecifictotheFHTcommunity,reflectiveoftheFHTcultureandvalues,andalignedwith
theabilityoftheFHTtousetheinformationmovingforward.
ENGAGINGTHEPARTNERS
Asuccessfactorinanyprogramplanningactivityistheabilitytoengagekeystakeholdersearlyand
oftenintheprocessofplanning,aswellasimplementationandevaluation.Whilesomeprogram
goalsmaybeabletobeachievedentirelywithintheFHTenvironment(suchasnumbersofpersons
screenedforaparticularhealthissue),programsaimedatspecificpopulations(seniors,children,
personswithmentalhealthproblems,etc.)willbemoresuccessfulwhenlinkedtotheactivitiesof
othercommunityprovidersforthesesamepopulations.
Primarycareisoftenreferredtoasthegatewaytothebroaderhealthsystem.Impliedinthisisa
coordinationrolethatisoftenbeyondthecapacityofindividualpractitionersorevengroupsof
practitioners.Howevertheprimarycarelevelisthestartingpointfordiagnosisandongoingregular
healthcareandhealthadviceformostpeople.Somefamilypractitionersviewtheirrolewith
13
January2009
patientswithinalifecyclecontext,astheyoftenseepatientsthroughmanystagesoftheirlivesand
manytypesofhealthcareneeds.Throughthesestagestheymayneedothersupportsandservices.
Somekeypartnersarenotedbelow,alongwiththeirareasofparticularexpertiseandpotential
partnerroleswithFHTs.
Table3KeyPriorities,ExpertiseandPartnerRoles
Organization
CommunityCareAccess
Centre(CCAC)
CommunitySupport
Services(Seniors)
Hospitals
PublicHealth
CommunityMental
HealthandAddictions
Services
Associations
E.g.AlzheimerSociety,
CanadianDiabetes
Association,Canadian
CancerSociety,etc.
MandatedServices
PotentialPartnerRoles
Seniors
Childrenwithspecialneeds
Posthospitalpatientsrequiring
homecare
Supportservicestoseniors,
includingbutnotlimitedto,
transportation,dayprograms,
mealsonwheels,friendly
visiting
Acutecareservices
Emergencyservices
Assistwitharrangingservicesfor
frail,isolatedseniors
Assistwithactivationand/or
increasingsocializationoffrailor
isolatedseniors
Providingridestoappointments
Providingnutritiousmeals
Communicationregarding
dischargedordeceasedpatients
Specialtyconsults
Programs,e.g.fallsprevention
Collaborationaroundwellbaby
Populationhealth
followup
Targetedpriorityprograms,e.g.
healthybabies,healthychildren Collaborationondisease
preventionstrategiesand
programs,e.g.tuberculosis,
SARS,HIV/AIDs
Crisisintervention(insome
areas)rementalhealth
Collaborationaroundpatients
Supportservicesformental
withongoingmentalhealthor
healthandaddictions,e.g.
addictionsissues
counseling,supportivehousing,
LinkswithACTteamsthrough
Employmentprograms,peer
hospitalsandcommunitybased
supportnetworks
agencies
Crisissupports
Advocacy,research,education Sourceofinformationand
andsupportprograms
referralforpatientsandtheir
families
14
Organization
MandatedServices
Other
Specifictogroupor
organization
Relativetolocal
circumstances,e.g.groups Generallyformedfor
informationandcounseling
supportingnew
purposesandtofacilitate
immigrantsandrefugees,
accesstoservices
aboriginalcounsellors,
churchgroups
January2009
PotentialPartnerRoles
Sourceofinformationand
referralforpatientsandtheir
families
ENGAGINGTHEPATIENTS
Needsassessmentprocessesseemattheircoretobehighlytechnicalactivities,usinghealthdata
andrelyingheavilyoninformationabouthealthcareutilizationandillness.Withthatinmindthere
isacasetobemadeforengagingsomeofthepracticepopulationintheneedsassessmentprocess.
Patientinputcanbeparticularlyusefulforvalidationpurposesoncetheinitialreviewandrankingof
informationaroundneedshasbeendone.Patientperceptionswillalsobeusefulindetermining
howthatinformationistranslatedintoactionorprograms.
Forexample,patientfocusgroupscouldbeusedtodeterminereceptivitytogroup(versus1:1)
educationsessions,careprovisionbynonphysicianteammembers,methodsforinformation
translation,etc.
SomeexamplesofhowFHTshaveengagedpatientswithintheirneedsassessmentprocessescanbe
foundinthedescriptionsinAppendixA.
OTHERCONSIDERATIONS
Inanyneedsassessmentprocessitisimportanttoacceptthefactthatnotallofthepotentially
relevantinformationwillbeavailableandanswerstoallofthequestionsemergingfromaneeds
assessmentmaynotexist.Itisequallyimportantnottobestalledwhenthishappens.In1995when
theMinistryofHealthendorsedTheGuidetoNeedsImpactPlanning,createdbyacollaborationof
MinistryandDistrictHealthCouncilparticipants,theyacknowledgedthatneedsassessmentsmust
sometimesproceedwiththeinformationonhand,andwithassumptionsratherthanevidence.As
thediagraminAppendixDillustrates,inthesecases,oneestablishesaseparateprocesstolookinto
theresearchintheareainquestion,butwherepossible,continuestoworkwiththefacts,
observationsandexpertiseonhandintheprocess.
Needsassessmentsareabalanceofscienceandart,inthattheycombinethelearningfromdata
withtheobservationsandcreativityofthepeopledrivingtheprocess.
15
January2009
CONCLUDINGCOMMENTS
NeedsassessmentsareimportanttoolstoassistFHTstounderstandthepopulationtheyserveor
mightserveinthefuture.Aneedsassessmentprocessshouldbeaccompaniedbyaprocessto
prioritizeamongtheneedsandamongtheopportunitiestoaddressthoseneeds.Infactthe
opportunityforaFHTtoaddressaneedmaybethefirstcriterionappliedinaprioritizationexercise.
IfanissueislargelybeyondthescopeorcurrentcapacityoftheFHT(forexample,specialized
geriatricassessments)thenitshouldnotbeapriorityactionitem.Inshort,aneedmayexistandbe
legitimizedthroughaneedsassessmentprocessdrivenbyaFHT,butdefiningactionsfromthe
needsshouldbedrivenbytheFHTmandateandresources.Throughneedsassessmentprocesses,
FHTscanidentifycareand/orknowledgegapissues,andlooktopartnershipdevelopmentasa
possiblesolution.
Organizationsinitiatingneedsassessmentprocessesshouldbeclearastothepurposeandscopeof
theexercise,andtheresourcesandtimecommitmentstobeallottedtotheprocess.Manytools
existandthereisawealthofdataavailableattheregionaland,inmostcases,subregionallevel.
Overtime,aselectronichealthrecordsareinplaceforallpatients,FHTswillbebetterableto
analyzetheirdataandworkwithprofilesoftheiractualpatients.Inthemeantimeneeds
assessmentsbuiltfromacombinationofinformationaboutthelocalcommunityandthequalitative
informationprovidedbyFHTteammembers,patientsandotherpartnerswillbemostuseful.
16
January2009
APPENDICES
AppendixAExamplesofFHTNeedsAssessmentApproaches
AppendixBThePeopleandtheTimingofNeedsAssessmentswithinFHTs
AppendixCGlossaryofTerms
AppendixDNeedsImpactBasedModel
17
January2009
AppendixAExamplesofFHTNeedsAssessmentApproaches
ThreeFHTs,demonstratingneedsassessmentactivitiesfromrural,urbanandnorthern
communities,areincluded.
Example1:NorthYorkFHT(Toronto)
Contact
Dr.DavidKaplandavid@davidkaplanmd.com4164943003
ContextForNeedsAssessment Needsassessmentdoneaspartofbusinessplandevelopment
andFHTstrategicplanning
PopulationToBeServed
Catchmentareaalignedwithhospitalcatchment
Enableddatasharingandjointplanning
PlanningPartners
Hospital(primarypartner)
CCAC
PublicHealth
Healthandsocialserviceproviders
OtherStakeholders/Programs BetterBeginningsNow
Organizationsservingnewimmigrants
DataSources
Hospital(NorthYorkGeneralHospital)
LocalHealthIntegrationNetwork(Central)
CommunityCareAccessCentre(NorthYorkCCACformerly)
Information/Data
Populationhealthdata
Hospitalplanning/utilizationdata
Physicianpracticeprofiles
Surveyandfocusgroupinformation
Activities
Datareviewandanalysis
Providerforums
Keyinformantsurveys
Strategicplanningsessions
Results
ClinicalprioritiesandcrosscuttingFHTstrategiesidentified
throughthisprocess.
Fiveclinicalprioritiesareidentified:
1. Palliativecare
2. Mentalhealth
3. Chronicdiseasemanagementandhealthpromotion
4. Maternal/child
5. Seniors/geriatrics.
CrosscuttingstrategiesalignedwithMOHLTCsystemgoalsand
includedenhancingaccesstoprimarycareforpersonslivingin
thearea(rosteringorphanpatients,afterhourscare
expansion),andenhancinglinkages,partnerships,coordination
andoverallsystemnavigation(workinginmoreintegratedways
withhospital,CCAC,publichealth,communitymentalhealth
providers).
18
January2009
Example2:STARFHT(Tavistock,Stratford)
Contact
Mr.BlainMcCutchen(BusinessManager)5193012161
ContextForNeedsAssessment Needsassessmentdoneaspartofbusinessplandevelopment
andinitialFHTstartup/programdevelopment
Stratford,Tavistockandsurroundinggeographiccommunities
DeterminedbyFHTphysicianspracticepopulations,plus
potentialrosterpatients
PlanningPartners
PerthDistrictHealthUnit
CCACStratford
HuronPerthDiabetesProgram
HuronPerthHealthcareAllianceStratfordGeneralHospital
UofTDeptofFamilyandCommunityMedicineResearch
Program
OtherStakeholders/Programs
DataSources
PublicHealthreports
FormerDistrictHealthCouncilreports
LocalHealthIntegrationNetwork(SouthWest)
CommunityCareAccessCentre
Information/Data
Populationhealthdata
Physicianpracticeprofiles
Summaryfromteamstrategicplanningsession
Keyinformantinterviews(physicianandofficestaff)
Activities
Datareviewandanalysis
Communitypartnersinput
Consumerinput
Results
Fivekeyprogramareasareidentified:
1. Mentalhealthcare
2. Chronicdiseasemanagementandprevention/promotion
3. Childandmaternalhealthcare
4. Servicesforseniors
5. Palliativecare
Alsoincludedresearch
19
January2009
Example3:BlueSkyFHT(NorthBay)
Contact
Dr.WendyGrahamper
Jessica.belecque@blueskyfht.on.ca7054767747
ContextForNeedsAssessment Needsassessmentsdonebasedongoalsaroundserving
community,andspecificgoalsforchronicdiseaseprogramming
(andrelatedhiring)andendoflifecare.
Focusbothonpracticerosterandcommunityasawhole,as
wellastargetedpopulations,e.g.potentialnumberofpersons
seekingendoflifesupportoutsideofhospital,pain
management(pressureonER);potentialpersonswithCOPD,
diabetes
PlanningPartners
Hospital,longtermcareproviders,CCAC,EndofLifeNetwork,
Rotary,ArthritisSociety,etc.
OtherStakeholders/Programs FEDNOR(applicationforfundingtosupportcommunityneeds
assessmentprocessforendoflifecareandsupport)
CARP
DataSources
Hospital,PublicHealth,practicerosteranalysis,LHIN,LTC
facilities
Information/Data
Burdenofillnessdata,hospitaladmissionandERdata,FHT
practicebillingsanalyzedforspecifictargetareas
Activities
Designatedcommitteestructuresetuptoleadneeds
assessmentwork.
Linksestablishedwithpartnerorganizationsattheplanningand
deliverylevel.
Systemoverwhelmedsoengagementverytargetedtospecific
goalsandoutcomes,e.g.creationoflocalhospiceprogramsand
services
WorkingwithhospitaltowardAPPforphysiciansdoingendof
lifecare
Results
Afterhoursclinicsestablished
Coverageoflocalnursinghomesestablished
1stcallcoverageforFHTpatientsinhospital
Designated1stchoiceprojectforRotary(hospiceprograms)
ImplementingCDPMprogramswithinFHT.
20
January2009
AppendixBThePeopleandtheTimingofNeedsAssessmentswithinFHTs
Sequence
Step1
Activity
Scopepurposeand
contextforneeds
assessment
Identifykeyplayersand
partners
Step2
Step3
IdentifyNeeds
Gatherandreview
information
Identifyopportunitiesto
addressneeds
Step4
Step5
Step6
Setpriorities
Setcriteriaandrank
amongopportunitiesto
addressneeds
Implementprograms,
protocols
Studyimpact
Lead
Timeframe
PotentialLeads
FHTBoard
FHTLeadPhysicians
FHTmanagementgroup
Consultantworkingwith
anyofabove
AsaboveORneeds
assessmentworkinggroup
.5Day
(maybelessanddoneas
partofregularboardor
teammeeting)
Needsassessmentleads
(orworkinggroup)
And/or
AllFHTmembers
And/or
Consultant
Asabove
12Days
12Days
Ongoing
.5Day
(ifdoneatboardmeeting,
shouldbevalidatedby
samplingofFHTteam
members)
Needsassessmentworking 35Days
group
Consultant
Theparticipantsandtimeframesaboveareestimatesonly.TheapproachwillvarybyFHT,andbe
basedlargelyonavailableresources(abilitytocommitdollarsandtimeofteammembers).
UseofOutsideConsultant
FHTsmaydecidetoretaintheassistanceofanexternalconsultantandtodefineamaximum
numberofdaysinwhichtoaccomplishthetask.Thetwomainreasonsforusinganoutside
resourcewouldbeefficientprocessfacilitationandreductionofFHTstafftimeinmanagementof
theactivities.Inthiscase,theconsultanttoberetainedshouldhaveaccesstokeystakeholders,
insideandoutsidetheFHT,withwhichtovalidateconclusionspriortobringingthemforwardtothe
largerdecisionmakinggroup.
FHTNeedsAssessmentLeadsorWorkingGroup
Whatevertheapproach,theprocessrequiresongoingownershipbydesignatedpersonsfromwithin
theFHT.Thiscouldrangefromaphysicianandnursepartnershipasleads,toaworkinggroup
21
January2009
comprisedofonememberofeachprofessionwithintheFHT.Externalpartnersareessentialfor
Step3,andshouldbeconsideredasparticipantsandcontributorstoSteps4,5and6.
TheEssentialPlayers
Thedecisiontoundertakeaneedsassessmentprocess,andtherelatedprioritysettingandaction,
willusuallybemadebytheleadershipoftheFHT.Theideas,though,mayarisefromanymemberof
theFHTorotherstakeholders.Thefocusingoftheneedsassessmentwillideallybetheresultofa
seriesofconversationsamonginterestedandinformedteammembers,boardmembers,patient
advocatesorcommunitypartners.
Aneedsassessmentprocesswillusuallybeundertakentoguideplanningandprioritysettingfor
overallFHTservices.Thatbeingsaid,individualpractitionerswithinFHTs,forexamplethesocial
workersordietitians,mayrecommendandleadneedsassessmentactivitiesspecifictoparticular
servicesorpopulationissues.
22
January2009
AppendixCGlossaryofTerms
QuantitativeandQualitativeInformation
Quantitativeinformationcomesfromnumbersandisconsideredharddata.Forexamplethe
numbersofdeathsinpersons50andoverduetosmokinginaparticularareaisquantitative
information.
Qualitativeinformationisinformationthatisderivedfromobservations,interviewsandstories.For
example,areportbasedonkeyinformantinterviewsaskingpeopletheirperspectivesonanew
interventionwouldbeadocumentderivedfromaqualitativeprocess.Whilequalitativeinformation
issometimesconsideredsoftdata,ithassignificantvalueforunderstandingtheperceptionsand
receptivityofapopulation,keyfactorsindesigninghealthcareprograms.
Forexample,theCanadianCommunityHealthSurvey,whichproducesinformationonselfperceived
health,isamajorsourceforhealthplanningandprioritysettingactivitiesbygovernments,health
plannersandproviders.
Prevalence
Theprevalenceofadiseaseistheproportionofapopulationthathasadiseaseorillnessata
specificpointintime.Prevalenceisparticularlyimportantwhenthedurationoftheillnessislong,
forexample,asthmaordiabetes,implyingongoingneedforservices.
Incidence
Theincidenceofadiseaseistherateatwhichnewcasesoccurinapopulationduringaspecified
period;themortalityrateistheincidenceofdeath,mortalityfromspecificconditionsbeingthe
incidenceofdeathfromthoseconditions
Morbidity
Stateofbeingillordiseased.Morbidityistheoccurrenceofadiseaseorconditionthataltershealth
orwellbeing.
23
January2009
AppendixDNeedsImpactBasedModel
Research
DETERMINETHENEEDS
Identifyissueswithgreatestimpact
onhealthusingdefinedHealth
Statusscores
POTENTIAL&
EVALUATEIMPACT
CURRENTSTRATEGIES
Evaluateimpactofthechosen
Identifypotentiallyfeasible
strategies
interventions
Estimateimpactontheidentified
issues
Research
EVALUATESTRATEGIES
ACTION&ADVOCACY
Determineefficacy,effectiveness,
Implement
efficiency,availabilityand
Advocateforimplementation
appropriatenessofthestrategies
whereappropriate
Research
DETERMINEPRIORITIES
Ranktheidentifiedhealthissuesonthe
basisoftheevaluation
Settargetsforimplementation
Identifybarrierstoimplementation
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