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Research Transfer > Message from Gina Browne, Founder and Director of the SLRU
   

When the System-Linked Research Unit on Health and Social Service Utilization was created in 1991, we had two complementary goals.

We wanted to measure the effects on health and well-being and the costs of proactive, coordinated and comprehensive health and social services for vulnerable populations. We also wanted to conduct research that was relevant and useful for people involved in health and social services at the community level - so that evidence would drive positive change.

Interview with Dr. Gina Browne

In this interview Dr. Browne shares her experiences of measuring outcomes in economic terms. Dr. Browne’s research not only demonstrates the cost effectiveness of a number of interventions but suggests that we can capture a return on our investment - in the case of recreation and child care for single moms - in a single year... Learn More »


Strategic Alliances
/Integrated Networks

Strategic alliances are key to an innovative linked approach to service delivery that coordinates services previously administered in a piecemeal fashion. Strategic alliances are also an essential part of our Unit's modus operandi.

Just as our delivery systems in health and social services are generally fragmented, the cultures of research and practice have traditionally been estranged. Because of mutual misunderstanding and miscommunication, a great amount of research data has been irrelevant, inaccessible or incomprehensible to planners, policy-makers and practitioners.

For that reason, the SLRU brings investigators together with a number of community health and social service providers, planners, and policy-makers to help guide our research agenda.

Strategic alliances with community organizations are built into the research projects. In other words, not only have our community partners been research advisors, they have been research participants. As a consequence, they "own" the results, as opposed to receiving them. Back to Top

They have led the way in implementation of findings, have actively supported policy changes, and have assisted with dissemination.

However, research information is but one input to the decision-making process. Results must resonate in the context of current challenges, values, institutional realities and political agendas.

We have all learned just how much time, effort, expertise and expense is involved in communicating findings and implications to a broader audience, and translating new knowledge into practice.

The partnerships that have been fostered within the SLRU have been an invaluable aid in the necessary process of networking and alliance-building at the local, provincial and national levels.

We currently have both a theoretical framework to measure the components of Integration (Browne G., Kingston D., Grdisa V., Markle-Reid M. Conceptualization and Measurement of Integrated Human Service Networks for Evaluation. Journal of Integrated Care, In Press, 2007-2008) and a measure of the extent, depth, scope, reciprocity and congruence of intersectoral network integration (Browne G, Roberts J, Gafni A, Byrne C, Kertyzia J, Loney P. Conceptualizing and validating a measure of human integration. International Journal of Integrated Care, May 2004; 4:1-9).

For more information on our experiences, see: "Browne G. Happenings: Evidence that informs practice and policy: The role of strategic alliances at the municipal, provincial, and federal levels. Canadian Journal of Nursing Research, 1999; 31(1):79-94.

What we have learned from our alliance

In the area of community health information, there is an important distinction between the policy/planning environment and the research environment. In the former, the community requires access to information so that it can assess the need for and impact of health programs, but it often lacks the methodological and analytical skills necessary for valid interpretation of health data. In the research environment, on the other hand, those involved in activities around collecting and analyzing community health data are often ill-informed about the informational needs of policy-makers and planners. As a result, a vast amount of the health data they produce is irrelevant, inaccessible, or incomprehensible to planners and policy-makers. Synthesis and dissemination strategies are required to link policy/planning decisions with research evidence. The existence of these two organizational cultures, each with its own value system and each lacking knowledge of the other, prevents:

Appropriate diffusion of community health information,
Development of health policy and planning based on knowledge (evidence information) from the target community and other jurisdictions, and
Effective information transfer between policy/planning and research.

It was reasoned that a research unit as a strategic alliance of investigators and a number of community health and social service providers, planners, and policy-makers would not only foster the production of relevant information, but also facilitate its dissemination and use in decision-making.

The effectiveness and efficiency of proactive joint service ventures were tested among people in co-existing chronic circumstances such as chronic illness, poor adjustment, functional disability, school problems, poverty, joblessness, psychiatric disturbance, poor problem-solving ability, and charged with the care of cognitively impaired relatives. Some of these have been aimed at improving the coping ability of the chronically ill, the functional capacity of elderly people being seen by family physicians, the school adjustment of children, the functional outcomes of disabled and chronically ill people receiving community rehabilitation services, health and recreational services for mothers and children on welfare, immigrant women and their families, children in need of protection, children with disabilities, adult mental health and home care. Back to Top

The innovative linked approach to service delivery co-ordinates services previously administered in a piecemeal way: those that had been delivered autonomously are now often co-ordinated with another service and delivery as part of a joint venture.

Through the strategic alliance, investigators and partners have learned that there can be more amid less; balance without compromised quality; simultaneous delivery without homogenization. Rigour can co-exist with relevance; impartiality can co-exist with advocacy. Agencies can participate in joint ventures without one threatening to take over the other. Research funding from third-party government and private sources can only enhance the enterprise and increase the number of services available to the public.

“It can be otherwise



Key Findings

Vulnerability in an individual implies "inequality" in the person's biological characteristics (age, gender, genetic endowment), personal resources (cognitive, emotional, intellectual), and/or environmental supports (social, material, cultural). All three are determinants of health.

While biological characteristics cannot be modified, personal resources and environmental supports can. Variation in an individual's personal resources or environmental supports can greatly alter the degree of their vulnerability or resilience (Rogers, 1997), which in turn influences their use of health care services.

The work of the System-Linked Research Unit over the past years documents the reasons why some people with a particular disease or condition are healthier and less costly to the health care system than others.

We make the case that, in a system of national health insurance such as we have in Canada, measures to reduce inequalities will pay for themselves within a year, and health care costs can be reduced by simply helping people to get the services they require. The most expensive services we now provide are those that are not tailored to people's needs (vulnerabilities).

In making this case, we first had to develop an economic evaluation tool that included not only the cost of the specific program provided to the vulnerable group, but other costs in the health care system and other publicly-funded services. The unit developed an inventory to track direct and indirect costs, including frequency of visits to the doctor or hospital, medications used, and whether the person was receiving social assistance.

This broader aspect of cost-effectiveness is often overlooked in other evaluations of different approaches. When two programs are compared, the economic analysis tends not to go beyond the costs of the programs themselves.

Over the past decade, the Unit's investigators have conducted studies on a variety of samples, settings, sectors and services. What we have found is both simple and profound: helping people to find the means to feel better and function more effectively costs no more, in a system of national health insurance, than doing nothing.

Why? Because people who are hurting will usually try to find a remedy, yet the services they use are not necessarily the ones that will solve their problem. A piecemeal approach to helping them can be expensive and still fail to identify the cause of the problem. Even a trained professional will have difficulty sorting out the differences among the person's condition (e.g. severe diabetes), circumstances (recent job loss), challenges (depression), and context (a child in trouble with the law).

Savings can be achieved not because an effective service is cheap, but because making people healthier and better able to cope with their life circumstances results in savings elsewhere. The greatest cost savings tend to accrue among those people who are high users of the health care system. Back to Top

The research has taught us a great deal about the kinds of services that produced improved health at the same or lower cost. Our current health care system is geared to offering services one provider at a time, one problem at a time, and on demand. The System-Linked Research Unit has found the most successful strategies to be those that are:

cooperative and cross-sector, linking physical health care to social services, mental health services, and other services;
comprehensive and holistic (rather than disease-by-disease), treating the whole person or the whole family in context;
proactive, reaching out to those who are unlikely to find the help they need on their own.

The most serious barrier to the delivery of these services is the separate funding of the various sectors. Savings created by an innovative program funded in one sector may be realized in another sector. Ways must be found to overcome financial disincentives and reward alliances among the health, social, education, recreation and corrections sectors.

For a more detailed summary of our findings, see "Translating Research. The Costs and Effects of Addressing the Needs of Vulnerable Populations: Results of 10 Years of Research" in the Canadian Journal of Nursing Research, 2001.

Some learnings from our findings

We have learned that the majority of people with chronic illnesses lead full and independent lives; only a small proportion are poorly adjusted or become dependent on formal services. Similarly, the majority of people with chronic illness adjust without a change in their emotional status or their social role. A small proportion of people with chronic poor health or in chronically poor social circumstances consume a large proportion of the formal services offered.

Studies completed by the Unit have resulted in a number of important observations:

Emotional and social function as well as attitudinal factors such as individual’s interpretation of being ill, combined with social-support factors such as family function, explain 34% to 57% of the variance in poor adjustment of the chronically ill to their situation.
Poor adjustment to chronic illness is, in turn, a leading individual characteristic related to the high use of all types of services.
When left untreated, poor adjustment is related to persistently high use of services.
People who are high users of primary and secondary care services are high users of other services, and vice versa.
Proactive (health promotion) and treatment interventions in community-based health and social service agencies can improve or maintain the independence of the chronically ill in spite of disadvantages such as poverty or synergistic risks such as depression, while reducing expenditures on health and social services.

Despite the diversity of information produced, the qualities of effective and efficient services are evident. Services are more effective and less expensive when their direction is proactive, when their scope is pervasive, when their timing is preventative and predictable, when they are respectful and responsive to changing circumstances, and when they strengthen the factors that determine health.Back to Top

Through the strategic alliance at a regional level, Unit information is produced and interpreted by the relevant stakeholders, who digest, mould, and apply the findings to their current regional circumstances. This process of dissemination, uptake, and digestion occurs at regional workshops involving the relevant stakeholders in the regional agencies.

Research information is but one scientific input to the decision-making process. Results must be relevant to current questions, translated, interpreted, and synthesized with assessments of values/ideologies and institutional realities/logistics. The use of research information in policy-making is in part determined by how that information does or does not resonate with individual and groups values, and the use of frameworks that do or do not facilitate that process of resonance.

Considerable time, effort, networking skills, and an inclusive method of working - as well as scholarly publication - are required in carrying out these interpretation, dissemination and utilization functions. Additional strategic alliances with professional associations and government offices are being used for the purpose of dissemination, with inclusion and ownership of findings offered in exchange. Dissemination strategies that foster utilization require strategic alliances and networking among organizations at the municipal, provincial and national levels.


Impact: Policy and Practice Decisions Made


Distant measures of impact can be seen as far as Newcastle, England and the University of Northumbria in Newcastle where a unit similar to our own was created and affectionately known as “McMaster Upon-the-Tyne”. This international collaboration continues. An AIDS/HIV community linked services evaluation unit, modeled after our own was created in Ontario in partnership with AIDS Service Organizations (1999-2007). The UOIT in Durham created a research office moulded after the SLRU.

We have files of acknowledging testimonials from clients served in our projects and still a greater number of requests for reprints, working papers and particularly our approach to measuring expenditures for the use of health services. We thank this attentive following. Most importantly however, a number of service and policy decisions have been made over the eight years.

Decisions

The Halton VON Day Program for cognitively impaired was doubled in size based on the finding that “the day program was equally effective but less expensive than alternative home care services.”
The Halton Community Rehabilitation Programmes funding was reinstituted ($500,000/year) based on the finding that the program was equally effective but less expensive than alternative community approaches to persons with disability.
Targeting seniors over 75 years of age, who lived alone in a Halton HSO was made practice policy based on the finding that screening, casefinding and treatment of 25 treatable health conditions resulted in better social function, and less expense for this subgroup of elderly.
Home based traction for children with Legg Perthes and Congenital Hip Problems became a practice within Chedoke-McMaster Hospitals in collaboration with Home Care based on the finding that this approach was acceptable, safe and less expensive.Back to Top
The Halton Co-operative Mental Health Program was discontinued based on the finding that this approach was no more effective in the long run and very expensive given the few adolescents reached.
Findings that public health nurse visits are more effective, no more expensive to the health system and result in double the exits from social assistance reaffirms Ontario’s investment in the Healthy Babies Initiative and the practice of in-home visits by PHN’s.
Findings that age appropriate recreation quality child care for children/youth pays for itself within one year resulted in many regions of Ontario investing in programming for children and parents on social assistance. The services of youth serving agencies are part of this initiative. These same findings have informed the investment strategies of the Peel Region entitled "Families First Peel" and in Edmonton "Families First Edmonton.
Targeting seniors over 75 years who lived alone in a Halton HSO was made practice policy based on the finding that screening, casefinding and treatment of 25 treatable health conditions resulted in better social function, and less expense for this subgroup of elderly.
Cultural sensitivity training for providers of in-home services has become more common based on the finding “sensitive providers are more effective and no more expensive.”
Two Southern Ontario Hospitals have invested with a community care access center in a quick response programme because it is more effective for elderly in the emergency to return home quickly and no more expensive to the system as a whole. The hospital costs were shifted to the community.
The Town of Flamborough Council is designing new services based on a needs assessment performed by the unit.
Combination counselling and pharmacotherapy for dythymia in primary care has increasingly become a standard of practice based on the one-year findings of “combination treatment is more effective and less expensive.” Children's behavior improves when the parents with dysthmia respond to treatment.
Providing “special steps” by occupational therapists to relatives with dementia receiving services from St. Elizabeth’s Visiting Nurses reduces caregiver burden and pays for itself by the reduced use of other services.
Augmenting specialists services to those chronically ill who are poorly adjusted, live alone and have lower ability to problem solve is more effective and less expensive to society as a whole than specialist care alone. Hospitals have to be compensated for this expenditure that saves the whole system money. Back to Top
The Regional Palliative Care team knows that the patient travelling record in palliative care reduces uncertainty for people under 65 years but makes people > 65 years more uncertain.
The regional department of public health now knows that structured education provided by public health nurses to people with chronic schizophrenia living in lodging homes is most effective for people who rate their life low in quality at the outset. This intervention is cost effective in that more effect is achieved for more expenditure for community services to this group of poorly served clientele.
The Hamilton-Wentworth mental health team (St. Joseph’s) knows that its service results in reduced expenditure for people’s use of crises services.
Augmenting usual homemaker services with an RN is more effective for both the patient and caregiver and pays for itself by their reduced use of other services.
Hamilton and Halton provide and evaluate “Youth Net Services” to reach hard to serve youth based on information about the prevalance, correlates and costs of adolescent mood disorder in primary care.
The results of the effects and expense of health promotion efforts with immigrant women were used to inform public health and English as a second language services and other initiatives funded by the Hamilton Community Foundation.
Our Randomized Trial of Differential Response for children in need of protection await results.
Our Randomized Trial of more and less integration of services for children with disabilities and their families await results.
Our measure of integrated human services is gaining in popularity with Ontario's Local Integration Health Network.
 

These are just some of the decisions made about provision of services based on unit findings. The atmosphere of collaboration between agencies has increased markedly during the past eight years.

We now have an enlarged view of intersectoral services based on their financing and foci.

We have learned there is more than “impact”. There is a “splash” a “ripple” and continuing “waves”. Investments in intersectoral, comprehensive, proactive services pays for itself by the reduced use of other publically funded services. Social entrepreneurship creates social capital! Philanthropy has a major impact.

"Pooled resources makes everyone richer,
pooled information makes everyone wiser,
nothing is lost in the dispersal
"
( Ferguson, 1980, p.332)

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Gina Browne

 
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