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Overcoming barriers to access, one community support at a time

A PHN and a community health broker team up to improve cancer screening rates in a low-income neighbourhood and find ways to provide practical help to its residents

Apr 07, 2016, By: Diane Peart, RN, BScN , Denise Crabb

Navigating the health-care system is a complex process, requiring skills and knowledge that many people with low incomes do not have. As a result, they may not pursue or receive the health care they need.

Four public health units in southern Ontario came up with an idea to improve cancer screening rates in low income/hard-to-reach populations. With two-year funding provided by the Public Health Agency of Canada, the units developed the Creating Access to Screening and Training in the Living Environment (CASTLE) project and launched it in 2012. Each health unit’s public health nurses health promoters would be paired with community health brokers (CHBs) hired for the project. These outreach workers, who themselves lived in low-income neighbourhoods, understood and often had lived experience of the challenges of low incomes.

In Brantford, served by the Brant County Health Unit, the PHN had positive working relationships with community partners. She trained and mentored the CHB, using her critical thinking skills and knowledge of the public health context. The CHB’s strength was in knowing how to interact with, educate and encourage people in her community.

The practical help provided to Bill and Sally,* his partner, demonstrates the innovative approach this team used. Bill and Sally were living on a meagre cheque from the Workplace Safety and Insurance Board and often went to community dinners at a local church. The CHB began attending the dinners twice a week to develop positive relationships with the residents, with the goal of helping improve their health and wellness. After three months, she made a short presentation on screening for breast, cervical and colorectal cancer during one of the meals, then answered questions and gave out door prizes.

Sally reached out to the CHB to discuss her fears about screening and eventually decided she wanted to have a mammogram. Sally does not have a telephone and had no money to use a pay phone to make an appointment at the Ontario Breast Screening Program. Without the CHB making the appointment for her, Sally probably would not have followed through. Because the first available appointment was seven weeks away, the team met with Sally regularly to ensure she remained interested in being screened.

Sally would be walking to her appointment. Inclement weather might have prevented her from making the trip, so the team put a backup plan in place. The CHB accompanied an anxious Sally to her appointment and offered to fill out the required paperwork when she realized that Sally might not be able to read.

Sally asked the CHB to help Bill replace his Ontario Health Insurance (OHIP) card. All of his identification had been stolen. Bill was unable to get a new card because he had no birth certificate, and the cost to replace it was $35. When he became very ill and required an emergency department visit, no specialist was willing to see him without a health card. He was sent home with a prescription he could not afford to fill. The CHB was able to find a church group willing to pay for his medication.

The CHB called an OHIP representative to inquire about the card. This person quite rudely suggested that Bill should have replaced the card right away and that the CHB “cared too much” to be doing this job. The PHN helped the CHB reflect on this frustrating interaction and pointed out how well she was handling challenging situations.

Where would the $35 come from? The team thought about Bill’s strengths. Bill collects beer bottles to earn money to take Sally out for an occasional meal. With help from friends in the community, enough bottles were collected to cover the cost. Bill had no credit card, so the CHB purchased a prepaid card with the money and helped him apply online on a computer at the library.

The local hospital was able to contact the CHB for assistance in finding Bill. They had a physician who would provide services for him. The CHB delivered this news to Bill and Sally at a church breakfast. He requested that the CHB accompany him so she could hear all of the information and help him understand it.

Bill started to experience additional health problems that landed him back in the emergency department. He was unable to void and required an indwelling catheter. Because he still did not have a health card, neither the urologist nor home care services would see him. Bill looked after his own catheter care at home for a significant length of time.

Eventually, a specialist was found who was willing to see Bill, and arranging transportation to the site became the next challenge. The Canadian Cancer Society (CCS) required three days’ notice for such requests. The PHN and CHB were determined to get Bill to this appointment, which was two days away.The CHB approached a local organization and received a $150 donation to cover the taxi ride there and back.

As it turned out, Bill had a large cancerous mass in his chest and would need many treatments. The CCS was willing to provide free rides to future appointments but needed a phone number to organize this for him. The CHB became the contact person, and she would then get in touch with Bill.

Two months later, the birth certificate had still not arrived. The PHN and the CHB contacted the local MPP’s office for assistance in ending the long wait. His office called Service Ontario and was informed that a guarantor’s letter was required. The CHB found a guarantor through a church she knew Bill had attended, prepared the form and faxed it.

Finally, Bill received his birth certificate, and he and the CHB waited in line at the local Service Ontario Centre to get his health card. They were told he would have to go to a full service centre, located several miles away. Bill was now quite ill and had neither the money nor the physical strength for this trip. The PHN met with the manager to discuss Bill’s situation, and she made the necessary arrangements. After having overcome many barriers, Bill had an OHIP card.

Now he could be seen by the urologist for followup care. As well, the PHN called the home care services manager, and catheter care, pain management and social work support were arranged.

Without the team’s assistance, Bill would not have been able to get his health card. Without this, he would not have received the health care he needed and deserved. One can postulate that Bill most likely would have died. Bill and Sally were highly appreciative of the help they received from the team. Bill is now able to navigate the system on his own, and Sally is grateful that she was given “another birthday with Bill.”

Although funding for the CASTLE project ended in 2014, the Brant County Health Unit created a permanent position for the CHB. She continues to work closely with a PHN on improving health and wellness in Brantford. The CHB learned the importance of looking at all aspects of a person’s life — the individual’s strengths, the circle of friends, the places frequented — to locate needed supports.

*Names have been changed

Diane Peart, RN, BScN, was a public health nurse at the Brant County Health Unit in Brantford, Ont., until retiring earlier this year.
Denise Crabb is a community health broker at the Brant County Health Unit.