Founded 40 years ago in June 1979, the Hornby and Denman Community Health Care Society (HDCHS) has much to celebrate this week. A special exhibition, now in development, curated by Megan Davies of York University will showcase a model of rural health care support now recognized nationally as unique.
it’s not something to take for granted. Executive Director Lori Nawrot points out that HDCHS is one of the very few grassroots home support healthcare services to survive for so long. Perhaps the major reason is hardnosed economic efficiency. It was – and remains to this day – cheaper to provide healthcare support services on island rather than from across Baynes Sound. The travel was a big stumbling block. Grumble about BC Ferries as one might, they are also a sort of guarantor of independence.
Another reason for survival is the wellspring of community support to be found on both islands with traditions of volunteerism, community involvement, and sheer love of the place. You might think that is true for most rural islands, but Hornby and Denman were more resilient in that respect. In contrast, Lori points out, Quadra and Cortes have a tiny healthcare support service that is maintained by Island Health. Starting in the 70s and 80s, there used to be local community health care providers all over Vancouver Island, especially in Victoria, but almost all have disappeared, absorbed into the health care authorities. The fact that HDCHS was a fully functional service with a working structure and experienced staff gave them a head start that enabled them to resist that fate.
Beyond that is something that only a long record of successful service can generate: “Islanders,” Lori says, “have an expectation that the service is going to be there and have made plans around it.” No one is taking away something easily that is so tailored to the community and has worked for so long. “You talk with other islands and it’s never developed to the same level. As a result, the community expectation just isn’t there, so it’s easier for Island Health to change things.”
These are all solid fundamentals, but there is one other critical factor: the relationship with Island Health. HDCHS is only a very small part of a much larger picture. That picture is modelled on the delivery of health care to urban areas where there is not much understanding of the constraints of rural communities. For instance, Lori points out, home care on the islands does not always end with meals and meds. In many cases, their clients may not be able to get in the firewood they need for heat. A homecare worker is hardly going to leave someone to freeze, so they are going to get the fire started, but this isn’t the sort of thing normally anticipated in Island Health service requirements. HDCHS works constantly to get ISLAND HEALTH to understand these issues. Ironically, part of that is to encourage clients to tone down their pride in self-reliance and stop saying everything is fine when it’s not.
Part of the problem, Lori notes, is the perception that Denman and Hornby are relatively well-off communities with monied retirees, and that living is cheaper – a point that has been used to justify not meeting union wage scales. This just isn’t the case. HDCHS is aware of the high levels of poverty, especially amongst single parent families where it may approach 90%. Seniors who may have moved to the islands early in their lives have necessarily foregone economic opportunities that may leave them facing hardship. Meanwhile, escalation in property prices in the Comox Valley and the shortage of care spaces have now trapped people on island who may need more services or intensive care, putting pressure on HSCHS to provide more complex care for which the service was not originally intended.
These are the sort of points that are brought to Island Health’s attention. But with health care now 70% of the provincial budget, there are many layers of administration, so building a close working relationship with Island Health case managers, who determine the level and length of care, has always been crucial. While always hungry for demographic and economic data to make their case, there is no question that the continued success of the HDHCS is very much a matter of diplomacy.
Part of that is effective networking. HDCHS hosts regular monthly sessions where all the different health care providers, including doctors, public health nurses, paramedics as well as home care administrators, amongst others, share news and discuss issues.
Funding is a question of balancing the need to provide effective supervision with the focus on client service. The more money is paid for care providers, the less margin there is to pay for the program supervisors who are required under contract by Island Health. Its not straightforward – there are other factors at play such as contract expectations to deliver a certain amount of annual training, and increased insurance and auditing costs. Nonetheless, HDCHS is determined to make sure home care providers are paid at par with union rates. The scale for experienced staff is getting closer, and there are some wrinkles, but it is not fair to be paid less for the same (and in some ways, given the extra demands of rural service delivery) more demanding care. It is an important point for more than just economic reasons. Part of the reason HDCHS has survived and delivered is the value it places on itself. Pride may come before a fall, but it also comes before a raise.
The situation is complicated by the gradual professionalization of home health care and the development of ever more stringent standards. In the beginning, there were relatively informal agreements; their current contract is a document of 200 pages. HDCHS also provided their own training where home care providers must now be fully qualified through training provided by such institutions as North Island College, which can also be expensive. Likewise, program supervisors must now have advanced professional qualifications, and are stretched by a greater range of duties than might normally be expected. At all levels there is a great deal of sophisticated reporting to Island Health. Home care providers are expected to log their time for each scheduled task in increments as small as five minutes. Bean counter micromanagement may provide greater management insight and program accountability, but again, Lori feels this reflects a system designed for a bigger scale. It’s overkill for the Islands.
Seeing the results of the home support display project has been an opportunity for Lori to takes comfort from history, where the problem that seems such a big deal today has cycled through before and is nothing new. But with a steadily growing senior population and ever more oversight by governments desperate to head off a healthcare tsunami, there is no question that the future for HSCDS will be a mounting challenge. Fortunately, if there is one thing clearly understood on the islands, it is the value of independence.