Clinical Services

It is essential that we make every effort  to work with the people we serve in a way that makes them feel respected and accepted. One of the best ways that clinicians can do this is to set aside time to hear the person’s story. This act alone can have profound healing benefits. The message to the client is loud and clear: I am not just some number. They are actually taking the time to hear what I have to say.

Of course, part of what a skilled clinician will do is to assemble important information for making referrals either to internal staff or external agencies. For example, is there a program, group or community initiative that a client might benefit from participating in?

Just by asking a few questions, you can quickly ascertain whether someone is socially isolated, which is important to know so that appropriate referrals can be made.

Feature: Intake and Navigation

Administered jointly by the Chigamik Community Health Centre and Midland Family Health Team, the North Simcoe Community Health Link is the first of its kind to use the Be Well survey as part of its intake and navigation process. The goal is to better understand who they serve: patients with complex needs who are contending with multiple chronic conditions and mental health issues, which are often compounded by poverty and social isolation. While these patients with the greatest health care needs make up just five percent of Ontario’s population, they use services that account for approximately two-thirds of the province’s health care spending.

By better understanding the issues they are facing, which extend beyond primary health care, the Health Link can tailor interventions to meet the needs of each patient.

The survey tool

The Be Well survey is a tool many AOHC members are using to measure and better understand the health and wellbeing of their clients. To ensure the results capture the complex interplay of factors that affect health and wellbeing, the Be Well survey is guided by the Canadian Index of Wellbeing (CIW) framework.

“The CIW is a way to understand what our community looks like from the lens of these particular individuals, so we’re digging into the Be Well survey,” says Chris Archer, Project Manager at the North Simcoe Community Health Link. “It is really important to everyone involved with this initiative that we not lose sight of the impact of the social determinants of health on our clients.”

Based on the preliminary findings obtained through the survey, it appears that North Simcoe Health Link clients are severely disadvantaged. Just consider,
  • 74% live in poverty while only 8.8% of Canadians live below the low income cut off rate.
  • 33% are food insecure. Many express concerns about not having access to fresh fruit and vegetables.
  • 20% report having no family support, while only 4% of Canadians have no family support.
  • North Simcoe Health Link clients are far more socially isolated than other Canadians when it comes to access to close friends having very few, if any, friends.


Understanding needs

Other than a few exceptions, intake begins with an in-depth interview with clients who are given a copy of the Be Well survey to complete and return during their second visit with the intake and navigation worker. Hard copies of the Be Well survey are then placed in client charts. According to Tracy Koval, Registered Nurse/Clinical System Navigator at the North Simcoe Health Link:

Already, there have been several instances where in reviewing the Be Well survey with some of my clients, we came across areas that helped me immediately ascertain some important next steps i.e. helping clients find affordable housing, arranging for rides to grocery stores, even finding clean mattresses.

“A lot of our work is the non-clinical piece,” says Koval, who worked with the Chigamik Community Health Centre before joining the North Simcoe Health Link. “Nursing is not just the clinical. It’s taking the whole person into account,” she says.

And the survey has encouraged a more holistic approach to clients with complex needs. Because right at intake, the barriers clients face such as poverty, transportation and lack of social support networks come to the forefront.

"Many clients do not feel connected to the community despite being here for a long time," says Koval. “And it's usually because they don’t have a social support network.”

In response, the local Health Link brought all their clients together for a Christmas meal. And that made a profound difference, says Koval. “They loved it. And they have requested that we do that again so they can come together. It’s fascinating because you have people who don’t have a large social network and then when you see them in a group, they discuss amazing things like their day to day life, their challenges. And they really felt connected. You could see it. You could see them making relationships.”

Understanding the impact loneliness and social isolation can have on the lives of these clients, the Health Link is looking to occasionally bring all the clients together so that they can enjoy meals together, and learn about navigating the system not just individually but as s group. Next steps include figuring out if there are programs that could connect clients with people but also provide education or support to them.

Taking action

This initiative provides new ways to address the social determinants of health in daily practice. It shows that taking a holistic approach at intake helps provide a more nuanced look not just of who they are serving, but what it is they are contending with — largely poverty. What’s more, these new insights can not only lead to more timely and appropriate referrals and interventions, but can help to improve health outcomes and reduce costs of care.