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Caring for the community

Winnipeg's ACCESS centres provide health care and social services to people in need

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Winnipeg Health Region
Wave, Summer 2014

Amaninder Boparai was not sure what to do or where to go.

In 2011, the 28-year-old long-distance truck driver was diagnosed with Type 2 diabetes. By the end of 2013, his condition was starting to take a toll.

"I started getting numbness in my hands and in my right leg," Boparai explains. "The leg would go numb all day."

That's when his wife, Mandeep, insisted he seek help for his condition and visit ACCESS NorWest at 785 Keewatin Street.

There, Boparai was assessed by a clinic physician who determined that Boparai's blood sugar and cholesterol levels were the root of his health problems.

"(He) convinced me I needed to take my health seriously," says Boparai. "He told me I might have a stroke, and talked about other things that can happen."

In short order, Boparai was introduced to ACCESS NorWest's chronic disease team, a group of health-care providers who specialize in helping people better manage their conditions and includes chronic disease nurse Kelly Deveau, dietitian Lisa Zappitelli and shared-care counsellor Patricia Barter-Cook. They taught him how to monitor his blood-sugar levels daily, and educated him about diet and exercise, both of which help manage Type 2 diabetes. He also attended a series of diabetes education classes at NorWest. Today, he continues under the care of Dr. Naseer Warraich, visiting the clinic every few months to ensure his diabetes doesn't worsen.

As he went through the process, Boparai discovered he needed to break some bad habits. Changing his diet had the biggest effect on his condition. He credits ACCESS NorWest dietitian Lisa Zappitelli for helping him.

"I was eating road food, highway food. Burgers and fried foods, whatever was easiest to grab when I'd come in to a truck stop. And I was only eating one big meal a day," he says. "Lisa changed everything. I now eat regular meals all day, and I'm counting my carbs, looking at portion sizes and reading labels."

Inactivity was another bad habit he had to overcome. "I hated exercise," he says. "Now, I walk between 30 (and 90) minutes a day. I walk my daughter to the park. It took a while to work up to this, given the issue with my leg, but I'm feeling much better with all the activity."

Today, Boparai's blood sugar levels are great, and so are his cholesterol levels. As a result, Boparai is back driving for Bison Transport. "Bison has been tremendous. Knowing they're behind me means I can concentrate on my health," he says.

As Boparai's experience demonstrates, having access to health care can have a significant impact on one's quality of life. But it also illustrates something else: the important role ACCESS centres can play in making that care available.

Strategically located throughout the city, ACCESS centres were developed as an innovative way to house a wide range of health and social services under one roof.

The first of these centres - ACCESS River East - opened in 2004. Since then, the Winnipeg Health Region and Manitoba Family Services have worked together to open three more - Transcona, Downtown and NorWest. A fifth centre - ACCESS Winnipeg West - opened in May on the campus of the Grace Hospital. Additional centres are being planned for Fort Garry and St. Boniface.
    
The integration of health and social services delivery has two main advantages. First, it allows a person with complex health issues and a need for social services to get these programs in one location. Second, it allows health and social services staff to work together as a team to effectively and efficiently provide services to each patient/client.

Pat Younger is Senior Executive Director of Integrated Health and Social Services for Winnipeg West. She also heads up ACCESS Winnipeg West, which serves people living in St. James Assiniboia and Assiniboine South.

As she explains, ACCESS centres help fill a gap in the delivery of services. "They connect people to a variety of services, such as mental health, public health, home care, services to seniors, audiology and speech language pathology," says Younger. "People can also use services such as employment income assistance or child-specific programs."

Another patient's story demonstrates the benefits of the ACCESS approach. 

Janet Nolasco arrived here with her husband, Woodrick, and daugther, Leona Jayne, from the Philippines a few years ago. She went through a problem pregnancy before giving birth to a second daughter, Janica in 2012.

Since then, ACCESS NorWest has helped provide her with the primary care and social services she needs. For example, it was through ACCESS NorWest that Nolasco was able to see primary care nurse Melissa Forester. She ensured Nolasco's immunizations were up to date, and completed her required school immunization forms so she could attend a course for nursing assistants at Robertson College.

Nolasco also received visits from public health nurse Charan Kaler, who helped monitor the health of Nolasco and her newborn daughter Janica. Kaler also introduced Nolasco to other services offered through ACCESS NorWest, such as the Families First program.

Through home visits, the Family First worker provided Nolasco with health-related information on issues ranging from pregnancy to nutrition. 

"As new immigrants, Janet's family had to adapt to a new country, a new culture, a new neighbourhood, a new way of life along with welcoming a new baby," says Kaler.

Kaler also told Nolasco about Kristina McMillan and Ashley Smith, who work for Citizenship and Immigration Canada's Immigrant Settlement program. Immigrant settlement workers visit newcomer families and educate them about community resources, programs and services, primarily in the areas of education, skills, housing, employment supports, English classes and schools. Settlement workers also organize community events where newcomers and other community members can meet each other. This helps newcomers better understand Canadian culture.

"Janet also began participating in the Immigrant Women of Inkster group, where she developed friendships with other newcomer mothers, participated in fun activities and learned about life in Canada," says McMillan.

With support from the multidisciplinary team at NorWest, Nolasco was able to overcome her health challenges and take advantage of various supports for new Canadians. "She was great to work with - educated, driven and competent. I know she will excel in whatever she chooses to do," says McMillan.

Nolasco, meanwhile, is grateful for all the help and support she has received. "I can't thank the ladies at NorWest enough," says Nolasco, who has since gone back to school to train to become a nursing assistant. "They've connected me to so many people, and I've made friends."

As Nolasco's comments suggest, ACCESS centres do more than provide health and social services. They also play an important role in helping to build community.

"This goes to the very heart of the idea of community-based care," says Nancy Heinrichs, Executive Director of NorWest Co-op Community Health and Winnipeg Health Region Team Manager.

To that end, ACCESS centres are equipped with kitchens that can be used to teach classes on cooking and nutrition. They also have community rooms that can be used for a variety of activities, including classes in parenting, exercise and other health-related subjects.

In addition, staff members spend a great deal of time learning about the community they serve. This allows each centre to develop outreach programs for the surrounding community touching on a variety of areas, including diabetes support, nutrition counselling, parent and child support groups, supported living services, employment and income assistance, and family violence counselling.

ACCESS NorWest is a case in point. In addition to providing primary health care and social services, the centre also holds cooking classes several times a month. Users of the community room include the Hans Kai group, which encourages self-tracking of the participants' health, exercise and nutrition.

In addition, the centre has a daycare with space for 12 children ages three months to two years, as well as a parental support group.

"We have the Bright Start group, which supports parents from birth through to five years, to help them with the struggle of raising a baby through to toddlerhood," says Heinrichs. "The group comes to NorWest, and learns about everything from nutrition to getting primary care, counselling and family services. We know people in our community have complex needs, and that it takes a team approach to help them succeed."

ACCESS NorWest has also developed a number of outreach programs, tailored to the needs of the community.

"We've opened resource centres in the neighbourhoods to help people with public health, mental health, physical activity, seniors, youth and parenting," says Heinrichs. "For example, we have NorWest Co-op at Bluebird, which is a satellite location at 100-97 Keewatin Avenue. Its health-care and social services staff are working with the large population of seniors in that area. It also has family medical care, counselling, prenatal care and more."

NorWest Co-op Community Health also plans to open a community food centre at the site of its old location on Tyndall Avenue. The food centre will have a lunch program, community kitchens and gardens, along with a low-cost market and cooking classes. It will serve several free lunches a week, operate a greenhouse and community gardens, and feature culturally appropriate cooking classes.

"Cooking healthy on a budget is a challenge - especially for low-income groups or people who are new to Canada," says Heinrichs. "Learning how to grow and cook healthy food, how to stretch your grocery budget and having a place to share a good meal increases health and social connection in the community."

The community-based care model is also evident across the city, where ACCESS River East and ACCESS Transcona have partnered with Home Care and Primary Care programs to establish a health-care team to support clients with complex health and social needs.

The Hospital Home Team program consists of an intensive case co-ordinator and an administrative assistant who work closely with ACCESS centre physicians, nurses, nurse practitioners and other staff. The team provides care to approximately 50 clients at any given time, says Debra Vanance, Community Area Director in charge of ACCESS River East and ACCESS Transcona.

The program has been so successful that the teams in River East/Transcona and St. James/Assiniboine South are being expanded to include a broader range of health-care professionals to support more clients. In addition, a third team is being established in the River Heights/Fort Garry community area.

"The goal of the Hospital Home Team is to provide a different level of support to individuals so they can remain in their homes and have less need to be seen in the Emergency Department or admitted to hospital or a personal care home," says Vanance.  

Arle Jones, an intensive case co-ordinator, offers an example of how one couple has been helped by the team. The clients have multiple medical challenges, including diabetes and mental health issues. In addition, one of the clients also has arthritis and an injured knee, while the other has heart trouble.

Prior to being added to the team's care list, one of the clients was making weekly Emergency visits, either for heart trouble or a mental health problem, says Jones.

But that changed once the couple were placed on the team's care list. Now, the couple make regular visits to ACCESS River East, where they meet with their care team, including a doctor, a mental health worker, a primary care nurse and their case coordinator.

The couple were also referred to the Emergency Paramedic in the Community (EPIC) program. A pilot project of the Region and the Winnipeg Fire Paramedic Service, EPIC provides an alternative to the traditional ambulance response where appropriate. An EPIC paramedic assesses the patient's needs and connects them with the right resources, often avoiding the need for an Emergency Department visit.

"We've really improved their continuity of care, by having the professionals on their team talking to each other so there are no gaps or duplications," says Jones. "Now they're very well linked in."

While all ACCESS centres are rooted in the same philosophical approach to community-based care and offer many of the same types of services and programs, each centre also has its own particular character, history and mandate.

Take ACCESS Winnipeg West, for example. Because it is located on the Grace Hospital campus, it expects to receive a large number of visits from patients who already use the hospital next door. "Within Winnipeg West, we work in an integrated model of health and social services within the ACCESS centre, and the Grace Hospital," says Kellie O'Rourke, Chief Operating Officer of Winnipeg West Integrated Health and Social Services. "The ACCESS centre provides a wide range of services, creating a one-stop source of information to residents of St. James Assiniboia and Assiniboine South. We're expecting to see patients from the hospital, which will make their care seamless as they move over to our centre and use our services."

Like other centres, ACCESS Winnipeg West will have a child-care centre with infant and preschool spaces, a community meeting space and a kitchen.

"On the main floor, it will house a primary care clinic and will offer a range of services," says Krista Williams, Executive Director and Chief Nursing Officer for Winnipeg West Integrated Health and Social Services. The list includes physicians, mental health workers, nurse practitioners, a psychologist, a physiotherapist, an occupational therapist, a psychiatrist, a dietitian and a pharmacist.

The second floor houses Child and Family Services and Home Care Nursing, as well as the Program for Assertive Community Treatment (PACT), which has been created to enhance the delivery of mental health services. Looking ahead, Younger says ACCESS Winnipeg West may also add a home care nursing clinic, and may offer expanded clinic hours.

While all ACCESS centres specialize in complex patients with multiple health and social service needs, the ACCESS Downtown primary care clinic's patients' complexity is exacerbated by factors such as poverty, unemployment, gangs, violence, addictions, mental health and homelessness.

"We're serving some of the most marginalized populations in Winnipeg, including the homeless, refugees and immigrants from around the world, First Nations and the working poor," says Jade Nayler, Team Manager, Primary Care Services, noting that the clientele includes residents of the Salvation Army hostel, the Bell Hotel, Main Street Project, and downtown hotels such as the Woodbine, McLaren and Red Road Lodge.

Various agencies communicate with ACCESS Downtown's nurse practitioners frequently for clients requiring health care, says Nayler. The nurse practitioners make a priority list of referrals from those agencies, and have customized their approach to providing primary care to clients who are not used to keeping appointments.

"This may mean site visits, squeezing them in when they are present at the front desk, as well as being strong advocates for their needs," she says. "We have to be flexible."

ACCESS Downtown opened in early 2010, when it moved from its long-time location on Elgin Avenue to the corner of Main Street and Logan Avenue. The main floor of the centre has a primary care clinic, which includes nurses, nurse practitioners and doctors, along with a shared counsellor, social worker, lab technician, speech language pathologist and a dietitian, supported by primary care assistants.

"Many of our patients need help navigating health services and social services, which requires a team approach with our social worker and community health worker playing vital roles," she says.

The primary care clinic works with other Winnipeg Health Region programs and Family Services on the second floor of the building at 640 Main Street. This includes Community Mental Health, Employment and Income Assistance, Public Health, the Healthy Aging Resource Team, Health Outreach and Community Supports, Vocational Rehabilitation, Supported Living and Winnipeg Child and Family Services. ACCESS Downtown also has a dental clinic, run by the University of Manitoba, which treats toddlers to seniors.

Staff members at the centre are attuned to helping clients who may face many challenges. "We run on the philosophy of advanced access," says Nayler. "When our patients call for an appointment, we try to get them in within three days. That's health care when they need it."

The team holds daily huddles to review the day's appointments. Reminder calls made by the primary care assistants and community health worker help to get the patients to their appointments. "Some patients don't have phones. If they miss appointments, outreach workers will help track them down," she says. 

To illustrate the important role ACCESS Downtown plays in the lives of its clients and patients, Nayler shares a story about a 40-year-old woman with an organic brain dysfunction and a long history of substance abuse and homelessness.

When provided with an apartment, the woman couldn't cope when her friends arrived and began to party. Not only that, but her walker and food prepared by Home Care would go missing.

"Advocacy by the clinic team finally resulted in her moving to housing where she's safe and happy," says Nayler.

Another story involves a worker at a nearby hotel who called the clinic out of concern about a sick tenant who was refusing to go to hospital. A nurse practitioner from ACCESS Downtown visited the patient several times, taking along equipment for blood work. The lab tests indicated a problem, so the nurse practitioner advised that the Winnipeg Fire Paramedic Service be called, and the patient was transported to hospital and admitted to intensive care in critical condition. Fortunately, the patient recovered and is back home. 

"This isn't the sort of thing you can do in your usual 15-minute appointment," says Nayler. "We have to be more hands-on, take longer and earn the patient's trust. We are very connected to the community, and can plug people into appropriate programs at the same time as we're taking care of their primary care needs."

Susie Strachan is a communications advisor with the Winnipeg Health Region.

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