Through the Systems Navigation Access and Partnership (SNAP) Project, Community Health Centre (CHC) grantees are working to advance systems navigation efforts to improve access and health across Canada. This blog explores the work of Ottawa based CHC, CentretownCHC and the impact the funding has had in their community.

Centretown CHC is a nonprofit, multi-service Community Health Centre that is playing an active role in the community since 1969. They offer a full range of community services delivered by a diverse team of professionals. Their team includes doctors, nurses, social workers, counsellors, dietitians, community developers, health promoters, and outreach workers. Care is delivered in more ways than one: one-on-one services, personal-development groups, and community level involvement. While most services are offered in both English and French, cultural interpretation is available and some groups are offered in other languages. Through active community engagement, Centretown CHC strives to respond to local needs and deliver tailored services. They contribute to the collective effort of improving individual and community health by addressing underlying conditions.

Centretown CHC created a Well-Baby Clinic (WBC) during the pandemic, as the local public health unit fully pivoted towards its COVID response. There was a sudden and evident need to ensure that unattached babies (those without a primary care provider) did not fall through the cracks for their routine immunizations and developmental assessments.

The clinic provides temporary wraparound support for babies from 2 – 18 months of age, and relies on a multi-disciplinary team of a nurse, nurse practitioner and physician. The clinic continues to focus on supporting the most vulnerable families facing numerous barriers in navigating health and social service systems, with the majority of clients being refugee claimants and those living in shelter. Post-pandemic, the clinic continues to fill a resource void for these priority populations, and operates at/near capacity at all times. In addition to providing clinical care, the nurse also provides all of the health teaching and discharge planning for families in the program.

There is an ongoing primary care crisis with a shortage of primary care providers. This means that most families discharged from the WBC will not be rostered with a provider yet, and will have to navigate through walk-in and urgent care clinics. They will also continue to face barriers in finding and accessing community resources. As such, there is a clear need to better support families as they transition from the well-supported WBC model into the complex and ever-changing City of Ottawa network of resources. Teaching and supporting system navigation skills, and being provided with an initial resource from the WBC will better set these families up for ongoing success.

The goal of the SNAP Project is to help CHCs adopt, adapt, scale up, and improve systems navigation efforts to improve client outcomes and grow the CHC knowledge and practice base across Canada and  help improve overall healthcare access for equity-deserving populations in Canada and overcome barriers to accessing services and continuity of care.

The SNAP Project grant allowed for dedicated time to update the program to better meet the needs of the clients and ensure best use of knowledge and skills of the team members, provide administrative support, as well as piloting the addition of a Community Health Worker (CHW) role into the team for support specifically with the family navigation component.

Centretown CHC Temp OB and Temp Well Baby clinics support the most vulnerable including those who are asylum seekers (and therefore may not speak English or French) and those who are precariously housed. These contributes to further complexities and vulnerabilities in navigating complex health and social systems at a time when there can already be considerable strain. Without adequate support and services to babies and families in this period, families and babies can experience significant harm, developmental and health risks and other challenges that can have a life-long impact. Offering fundamental health care services through well baby checks and teaching/support to families and navigation to ongoing supports and services offers the best chances of success and healthy lives. This can also prevent additional and ongoing costs to the health and social systems that are under great strain.

The reorganization of the program and addition of the CHW in the well baby clinic has provided advantages to clients and providers. Work has been redistributed to the correct role which has allowed more time to support clients and improved access. Clients feel better supported in a holistic way and better connected to their community. Navigation takes longer when there are fewer resources to navigate people to. By starting earlier and having the CHW to support the work and clients with navigating the system, we have been able to empower clients with a better understanding of what is available and how to access it.

The timing ended up being even better than we had hoped to create this project. We were able to navigate some staffing challenges and used this as a moment to examine who should be doing what and look at other expertise within the Centre to help. Centretown CHC were able to loop in earlier the Early Years team and Urban Outreach/Newcomer to Canada Community Support Workers who were a tremendous support and create better working relationships between the complimentary program teams.

By providing clients with a good start and by teaching them how to navigate, what is available and how to access it, clients will be better able to interact with the system for efficiently and effectively as well as advocate for themselves and their needs.

The changes to the program processes and flow, and the preparing of a program manual and resources as well as the relationship building have been established and maintaining and enhancing them into the future will be much easier and less resource intensive. We will be able to focus on continuous improvement. We are currently looking for funding to maintain the CHW role as the preparation and groundwork have been completed and we have been able to assess what is required for the role to be successful for the team and clients