Building a Stronger Foundation: A Framework for Planning and Evaluating Community-Based Services in Canada

10. Conclusion

Although policy makers have long acknowledged and advocated for a greater balance in emphasis between the institutional and community-based sectors of the health system, in reality, little evidence exists to support the contention that such a shift has actually occurred. In most provinces, community-based health services remain a fragmented series of marginalized services rather than offering a substantial, cohesive and complementary alternative to institutional care. Even in provinces which have attempted integrated and comprehensive models of community-based services delivery, the total health services dollars dedicated to these models remain only a small fraction of those extended to the institutional sector.

It is difficult to state at what point an existing service delivery model has truly embraced the concept and principles of a substantive community-based health services delivery system, as enunciated by the World Health Organization's definition of primary health care. This study did not set out to evaluate different community-based service delivery models (e.g., CHCs, CLSCs, HMOs) but to develop a framework whereby such evaluations may be conducted. Because previous studies have noted extreme variations within models, this study took the approach of identifying the relevant dimensions of models (i.e., modalities) which are considered to be the most appropriate for achieving desired outcomes. Thus, health human resources and organizational modalities such as provider roles, health workforce management, governance, service delivery approaches, and funding models were incorporated.

Having now identified the desirable characteristics of community-based service delivery models, however, it is possible to attempt comparisons across alternative models. For example, it is noted that some service delivery models encountered during the study closely approximate the concept of community-based health services, as defined and advocated in this framework (e.g., CLSCs). Other models demonstrate only a limited number of the desired characteristics (e.g., those involving defined catchment areas in which service delivery is dominated by single-discipline providers working under a capitation payment system). These latter models, while potentially forming a sub-set of a community-based health services delivery system, do not capture the comprehensiveness and cohesiveness of the substantive system advocated in this framework.

The framework identifies the following key directions for community-based health services in Canada:

1. Community-based health services delivery systems which are comprehensive, integrated and substantive.
   
   In order to accomplish the World Health Organization vision of community-based health services as a "central function and main focus" of the health system, it is necessary to acknowledge the very different but complementary objectives and approaches evident in institutional and community-based health services. The strengths of community-based services are its holistic and social oriented approaches to addressing individual and population health needs and its emphasis on working jointly with natural community partners in addressing the underlying determinants of health. In contrast, the strength of the institutional sector is in the development and application of specialized technological responses to specific health issues. In order for the health system to become more effective as a whole, it is suggested that these two sectors should be afforded equal and complementary status in addressing the multi-dimensional nature of health issues evident in today's society. For years, community-based health services in most Canadian jurisdictions have been offered to Canadians through a complex array of fragmented service delivery organizations and programs. These include public health agencies or departments, home care programs, primary medical care clinics, social services agencies, mental health departments, and the various forms of community health centres evident across the country. Coordination between service providers has often been lacking, leaving the consumer to fend for him or herself through numerous referral processes, service providers and locations. In addition, the availability of some community-based health services has been inconsistent across a province or territory. The concept advocated in this framework involves greater comprehensiveness and integration of community-based health services which are offered to consumers in readily accessible neighbourhood locations. As well, the system of CBHSs should encompass the entire province or territory.
2. Incorporation of organizational and human resources approaches which contribute to the desired outcomes of community-based health services.
   
   It is apparent, both through the literature reviews and the site visits undertaken as part of this study, that better ways of conceptualizing and delivering community-based health services exist than are currently practiced. Although no one Canadian model of community-based health services delivery is advocated for all jurisdictions, a desirable model should incorporate the following thirteen organizational and human resource management characteristics in order to achieve the outcomes desired of a comprehensive, integrated, and substantive community-based health service delivery model:
   • a clear definition of "community" based on geographical territory or common need;
   • a comprehensive range of coordinated health promotion, prevention, primary curative, rehabilitative and community support services which address the ongoing needs of the community under consideration, as well as the special needs of high-risk and vulnerable clients;
   • integrated, interdisciplinary, multi-service teams of providers with case coordination for each high need client or family;
   • client choice in the selection of provider and intervention strategies within reasonable parameters;
   • population-based funding of service jurisdictions, adjusted for health need;
   • non fee-for-service remuneration of service providers;
   • partnership between consumers and providers in the planning, delivery and evaluation of the health services delivery system (i.e., consumer involvement in decision-making occurs beyond a token level);
   • effective partnership with other community organizations in addressing the social and physical environmental determinants of health and to ensure health services are continuous with and complementary to other community services;
   • a human resources continuum which incorporates the appropriate use of and support for self-care, informal and formal service providers;
   • use of the most effective and economically efficient health service providers;
   • training/education of health services providers (self-care, informal and formal) consistent with the philosophy, objectives and approaches inherent in communitybased health services delivery (i.e., broad understanding of health and its determinants; interdisciplinary team approaches; and a focus on promotion/ prevention and early intervention);
   • legislative, organizational and professional policies which enable the use of cost-effective alternative service providers and which do not unnecessarily restrict competitive and creative professional practices; and
   • positive and flexible management practices.