Enhancing Support for Ontario Individuals with Chronic Health Conditions and Disabilities.

Introduction

Health is a fundamental aspect of human life, and many countries’ governments aim to provide their citizens with access to quality healthcare. In Canada, the Canada Health Act (CHA) is the principal legislation governing the country's healthcare system. The CHA aims to ensure all Canadians have adequate access to healthcare services, regardless of their ability to pay for those services ​(Government of Canada, 2023)​. In recent years, there have been calls for the modernization of the CHA to address emerging health issues, including COVID-19, chronic disease prevention and management, and accessibility for persons with disabilities. As a registered nurse in the Ontario healthcare system, I have seen firsthand the challenges patients and healthcare providers face in accessing and delivering care. This blog post summarizes and synthesizes the key health system issues affecting Ontarians and Canada at large, focusing on similarities between residents living in congregate settings such as long-term care and Ontarians living with chronic disease. In addition, the impact of social determinants of health will be considered. One way to tie these concepts together is to focus on the overall quality of care and support for these individuals. There are several similarities between individuals living with chronic disease and those living with disabilities; impact on daily living, need for accommodation, stigma, and discrimination as well as the need for community support. In the following sections, I will explore individual concepts related to the elements described by reviewing the Canada Health Act, summarizing a Levels of Influence framework application to long-term care residents, and analyzing social determinants of health and the impact on those living with chronic diseases and disabilities in Canada.

Modernizing the Canada Health Act

The Canada Health Act (CHA) was introduced in 1984 to ensure all Canadian residents have reasonable access to healthcare without financial or other barriers​ (Flood & Thomas, Modernizing the Canada Health Act, 2016)​. However, there are challenges in determining which aspects of healthcare are essential for physical and mental well-being and how to make them universally accessible. This has led to a passive tendency to focus on restoring rather than protecting and promoting well-being, as evidenced by the introduction of user fees and premiums in select provinces. To strengthen the CHA, there needs to be enhanced relationships between federal and provincial governments and increased government accountability. A potential solution is the creation of a new cost-sharing statute between the levels of government, with the federal government transferring funds to the provincial government if they demonstrate compliance with a defined set of standards​ (Flood & Choudhry, Strengthening the Foundations: Modernizing the Canada Health Act, 2002)​. This would increase accountability and ensure adherence to the essence of the original act. By strengthening relationships between the levels of government and increasing coverage of essential services such as prescription medications, the regulatory bodies could also drive down costs. The key principles of the act - Universality, Portability, Public Administration, Accessibility, and Comprehensiveness - could be reframed to reflect better governance and accountability to maintain the spirit of Tommy Douglas' original Medicare introduced in 1962.

Social-Ecological Framework applied to COVID-19 in Long-Term Care

The recent COVID-19 pandemic has exposed the extent of previously underappreciated health disparities in Ontario’s Long-Term Care (LTC) Sector. Have these cracks in the foundation of a system designed to protect and care for seniors requiring complex care been fractured beyond repair?

The social-ecological framework developed by Brofenbrenner in 1979​ (Social Ecological Model, 2023)​ has been described as a 5-stage model for which healthy public policy and interventions can be designed, implemented, monitored, and evaluated. The model considers the individual, their affiliation with people and groups, and their communities ​(White, 2015)​.

My blog post updated on March 7, 2023, discusses the impact of COVID-19 on the long-term care (LTC) sector in Ontario, Canada, at various levels of the framework. Provincial and regional structures were responsible for developing operational oversight, but limited resources prevented effective coordination and response. Public policy is crucial for controlling the spread of infectious diseases. At the community level, local public health agencies were unable to support LTC residents in any meaningful way other than vaccinations. LTC homes struggled at the organizational level due to the lack of personal protective equipment and staffing challenges. The residents were most impacted at the interpersonal level, with visitation restrictions and limited staff interactions leading to social isolation. At the individual level, LTC residents had complex physical and psychosocial needs and struggled to understand the severity of the situation. However, stakeholders worked together to address the challenges, including setting up virtual visiting options, partnering with acute care hospitals, and deploying mobile response teams. Figure 1 demonstrates the application of this model to the events which unfolded in LTC during the COVID-19 pandemic. These interventions have strengthened the healthcare system in Ontario by increasing understanding, transparency, and knowledge among different sectors.

Figure 1 - Social-Ecological Model applied to COVID-19 in LTC in Ontario

Social Determinants of Health

The Government of Canada defines the social determinants of health as a “broad range of personal, social, economic, and environmental factors which determine individual and population health” ​(Social determinants of health and health inequalities., 2022)​. It is important to recognize additional contributors to social determinants of health such as racism, discrimination, and historical trauma affecting certain populations.

Churchill et al. (2021), describe how Canada allocates a great deal of money and resources to healthcare compared to other well-established countries but not an equal measure of time or energy into health policy to address or minimize the inequities associated with the social determinants of health. There have been examples of sustained positive change across the country aimed at reducing the impact of specific inequities. Many Canadians continue to tie personal behaviour and decision-making as the highest-ranking contributor to overall individual health. There is a lack of understanding from the general population of the extent to which social determinants of health impact the overall health and well-being of a community. Lobbyists for public policy change continue to advocate for a shift in thinking and the adoption of a framework recognizing the role of “social and structural factors in determining health” ​(Churchill, et al., 2021)​. They further analyze how the content and type of messaging delivered can impact the level of empathy experienced in a community. This empathy may then elicit a stronger drive and force to analyze and ensure appropriate policy change is made to adequately address social determinants of health and thus resulting in a potential decrease in healthcare inequities.

Overall, this emphasizes the importance of understanding the impact of social determinants of health and collecting and analyzing granular data specific to the populations within our communities to address healthcare inequities attributed to social determinants of health. This is particularly important for individuals living with chronic disease and disability who may already face significant challenges related to their health status and may be disproportionately affected by social determinants of health.

Chronic Disease Prevention / Management and Ontarians Living with Disabilities

As a leader in Quality and Patient Safety for a large acute care health service system and an Emergency Department nurse, I examined various chronic diseases that are relevant to my practice in my blog post titled “Chronic Disease Prevention and Management in Ontario's Acute Care Sector.” These diseases often lead to recurrent presentations and required hospital admissions, resulting in a strain on acute care resources.

Chronic diseases like Chronic Obstructive Pulmonary Disease (COPD), Congestive Heart Failure, Stroke, Diabetes, Depression, Anxiety, and various forms of cancer are some of the most common and complex presentations in acute care hospitals, resulting in longer hospital stays and creating the greatest strain on acute care resources​ (Economic Burden of Illness in Canada, 2018)​. Like individuals living with chronic diseases, those living with disabilities face significant challenges.

There has been growing recognition in the past few years regarding the significance of addressing the needs of marginalized communities in our society. These groups have faced social exclusion in the past, leading to considerable challenges in accessing critical resources and services. Among these groups, people with disabilities have been especially neglected.

People with disabilities make up approximately 16% of the world's population, and yet they continue to face significant challenges in accessing basic services and resources​ (Disability Fact Sheet, 2023)​. These challenges include physical and social barriers, as well as discrimination and stigmatization ​(Disability Fact Sheet, 2023)​. My blog post from March 16, 2023, provides details on targeted strategies to create a more inclusive society that values and respects the needs and rights of all individuals.

Conclusion

In conclusion, this blog post has explored key health issues affecting Ontarians and Canadians at large. The Canada Health Act was introduced to ensure all Canadian residents have reasonable access to healthcare without financial or other barriers, but there are challenges in determining which aspects of healthcare are essential for physical and mental well-being and how to make them universally accessible. Strengthening the CHA through enhanced relationships between federal and provincial governments and increased accountability is necessary. The impact of COVID-19 on the long-term care sector in Ontario has exposed health disparities and highlighted the importance of the social-ecological framework to address health disparities at various levels. The social determinants of health play a significant role in individual and population health, and more efforts are needed to address the underlying factors contributing to health inequities for Ontarians living with disability and chronic disease. Overall, this blog post, supported by my learnings throughout this course, highlights the need for ongoing efforts to modernize and enhance the healthcare system to address emerging health issues and ensure access to quality healthcare for all Canadians.

References

​​Churchill, E., Shankardass, K., Perrella, A., Lofters, A., Quinonez, C., Brooks, L., . . . Kirst, M. (2021). Effectiveness of Narrative Messaging Styles about the Social Determinants of Health and Health Inequities in Ontario, Canada. International Journal of Environmental Research and Public Health, 18(20), 10881. Retrieved from https://doi.org/10.3390/ijerph182010881

​Disability Fact Sheet. (2023, March 7). Retrieved from World Health Organization: https://www.who.int/news-room/fact-sheets/detail/disability-and-health

​Economic Burden of Illness in Canada. (2018, 07 07). Retrieved from Government of Canada: https://www.canada.ca/en/public-health/services/chronic-diseases/chronic-disease-knowledge-development-exchange/economic-burden-illness-canada.html

​Flood, C. M., & Choudhry, S. (2002). Strengthening the Foundations: Modernizing the Canada Health Act. Toronto: Commission on the Future of Healthcare in Canada. Retrieved from https://publications.gc.ca/collections/Collection/CP32-79-13-2002E.pdf

​Flood, C. M., & Thomas, B. (2016). Modernizing the Canada Health Act. Dalhousie Law Journal, 39(2), 397-411. Retrieve from https://digitalcommons.schulichlaw.dal.ca/cgi/viewcontent.cgi?article=2075&context=dlj

​Government of Canada. (2023, January 29). Government of Canada. Retrieved from Canada Health Act: https://www.canada.ca/en/health-canada/services/health-care-system/canada-health-care-system-medicare/canada-health-act.html

​Social determinants of health and health inequalities. (2022, 06 14). Retrieved from Government of Canada: https://www.canada.ca/en/public-health/services/health-promotion/population-health/what-determines-health.html

​Social Ecological Model. (2023). Retrieved from Encyclopedia of Public Health Theories: https://bu.digication.com/GH720_PublicHealthTheories/Socio-Ecological_Model

​White, F. (2015). Primary Health Care and Public Health: Foundations of Universal Health Systems. Medical Principles and Practice: international journal of the Kuwait University, Health Science Centre, 24(2), 103-116. Retrieved from https://doi.org/10.1159/000370197