Results

54 records – page 1 of 3.

Health Canada consultation on proposed vaping products promotion regulations

https://policybase.cma.ca/en/permalink/policy14128

Date
2020-01-20
Topics
Health care and patient safety
Population health/ health equity/ public health
  1 document  
Policy Type
Response to consultation
Date
2020-01-20
Topics
Health care and patient safety
Population health/ health equity/ public health
Text
Since 1867, the Canadian Medical Association has been the national voice of Canada’s medical profession. We work with physicians, residents and medical students on issues that matter to the profession and the health of Canadians. We advocate for policy and programs that drive meaningful change for physicians and their patients The Canadian Medical Association (CMA) appreciates this opportunity to respond to the notice as published in the Canada Gazette, Part 1 for interested stakeholders to provide comments on Health Canada’s proposed Vaping Products Promotion Regulations “that would (1) prohibit the promotion of vaping products and vaping product-related brand elements by means of advertising that is done in a manner that can be seen or heard by young persons, including the display of vaping products at points of sale where they can be seen by young persons; and (2) require that all vaping advertising convey a health warning about the health hazards of vaping product use.” Canada’s physicians, who see the devastating effects of tobacco use every day in their practices, have been working for decades toward the goal of a smoke-free Canada. The CMA issued its first public warning concerning the hazards of tobacco in 1954 and has continued to advocate for the strongest possible measures to control its use. The CMA has always, and will continue to support, strong, comprehensive tobacco control legislation, enacted and enforced by all levels of government. This includes electronic cigarettes (e-cigarettes). Our approach to tobacco and vaping products is grounded in public health policy. We believe it is incumbent on governments in Canada to continue working on comprehensive, coordinated and effective tobacco control strategies, including vaping products, to achieve the goal of reducing smoking prevalence. Introduction It is imperative that the regulations concerning the promotion of vaping products be tightened sooner rather than later. While the CMA views Health Canada’s proposed regulations as a step in the right direction, they should only be considered as the start of extensive regulatory, policy and public health work required to effectively address the harms associated with vaping. Vaping is not without risks. Evidence continues to grow about the hazards associated with the use of e-cigarettes, especially for youth and young adults. The emergence of e-cigarette, or vaping, product use-associated lung injury (EVALI) in the United States and to a lesser extent in Canada, illustrates the danger these products can pose. The Centers for Disease Control and Prevention (CDC) reported that as of January 7, 2020 that there were 2,602 cases of hospitalized EVALI or deaths (57 so far) reported by all 50 states, the District of Columbia, and 2 U.S. territories (Puerto Rico, and the U.S. Virgin Islands). In an update published in the CDC’s Morbidity and Mortality Weekly Report, “younger age was significantly associated with acquiring THC-containing and nicotine-containing products through informal sources.” The report concludes with this warning: “Irrespective of the ongoing investigation, e-cigarette, or vaping, products should never be used by youths, young adults, or pregnant women.”3 In Canada, as of January 7, 2020, 15 cases of severe pulmonary illness associated with vaping have been reported to the Public Health Agency of Canada. A recent public opinion survey conducted by the Angus Reid Institute (ARI) indicates that Canadians are growing more concerned about the safety of vaping as more information on the potential harms becomes available. The survey found that the number of people saying that vaping does more harm than good rose from 35% in 2018 to 62% in 2019.5 Further, 17% of parents with children under 19 said their child either vaped or had tried it; 92% of those parents considered vaping harmful.5 Significant to this discussion is the fact that 90% of respondents support “banning advertisements of vaping products in areas frequented by young people. This includes areas such as bus shelters or parks, and digital spaces like social media.”5 As public unease continues to rise, the need for further tightening of regulations becomes vital. Unfortunately, the federal government is still behind the curve when it comes to the proliferation of vaping and the vaping industry. Health Canada will have to step up surveillance and enforcement if tightening of the regulations is to be effective. This brief will address the planned regulations as well as discuss important issues not covered such as nicotine levels and flavours. We have expressed concerns about these topics in previous consultations and will be reiterating them here. Promotion of Vaping Products The CMA appreciates Health Canada’s intent to tighten the regulations but this proposal is not sufficient, and we must reiterate our long-held position that the restrictions on the promotion of all vaping products and devices be the same as those for tobacco products. , The proposed regulations provides the vaping industry with too much latitude in their promotion activities to ensure youth are protected. As we noted in our response to Health Canada’s consultation on The Impact of Vaping Products Advertising on Youth and Nonusers of Tobacco Products, the advertisements that have been permitted to this point seem to have managed to find their way to youth, even if they are not directed at them, as has been asserted.7, We recommended vaping advertisements should not be permitted in any public places, broadcast media, and in publications of any type, with no exceptions. The CMA stands by that recommendation.7 The methods used by the vaping industry in the past succeeded in attracting more and more youth and young adults and it will no doubt continue efforts to find novel approaches for promoting their products, including the use of popular social media channels. , , , Indeed, “JUUL’s™ advertising imagery in its first 6 months on the market was patently youth oriented. For the next 2 ½ years it was more muted, but the company’s advertising was widely distributed on social media channels frequented by youth, was amplified by hashtag extensions, and catalyzed by compensated influencers and affiliates.”10 The vaping industry’s efforts to circumvent marketing restrictions in other jurisdictions are evident in view of some recent developments. A US study outlines an e-cigarette marketing technique that involves the promotion of scholarships for students. The study found 21 entities (manufacturers, e-cigarette review websites, distributors) offering 40 scholarships, ranging in value from $300 to $5000 (US).13 Most of the scholarships required “an essay submission, with most listing prompts related to e-cigarettes or eliciting information about the benefits of vaping.”13 The authors suggest “that prohibitions on e-cigarette scholarships to youth are also needed, as many of these scholarships require youth under the age of 18 years (for whom use of e-cigarettes are illegal) to write positive essays about vaping.”13 Health Warnings The CMA reiterates, yet again, its position that all health warnings for vaping products and devices should be similar to those presently required for tobacco packages in Canada.6, The need for such cautions is important in that we still do not understand fully the effects vaping can have on the human body. Harms More research is needed into the potential harms of using electronic cigarettes to understand the long-term effects users may face. , , The proposed health warnings are not strong enough in light of the research and knowledge that has emerged to date about the harms caused by e-cigarettes. For example, a recent US study highlighted the potential link between e-cigarette use and depression. It found “a significant cross-sectional association between e-cigarette use and depression, which highlights the need for prospective studies analyzing the longitudinal risk of depression with e-cigarette use.”18 As the authors note, “the potential mental health consequences may have regulatory implications for novel tobacco products.”18 Further, with respect to respiratory issues, a US study found that “use of e-cigarettes appears to be an independent risk factor for respiratory disease in addition to all combustible tobacco smoking.” The authors also don’t recommend the use of e-cigarettes as a smoking cessation tool because “for most smokers, using an e-cigarette is associated with lower odds of successfully quitting smoking.”19 Nicotine Levels Nicotine levels and flavours are not addressed in this consultation. However, the CMA considers these issues to be vital in the effort to protect youth and young adults from the harms associated with e-cigarettes and will therefore provide comment in effort to speed movement toward resolving these problems. The CMA remains very concerned about the rising levels of nicotine available through the vaping process. They supply “high levels of nicotine with few of the deterrents that are inherent in other tobacco products. Traditional e-cigarette products use solutions with free-base nicotine formulations in which stronger nicotine concentrations can cause aversive user experiences.” Hammond et al noted in their 2019 study that “JUUL® uses benzoic acid and nicotine salt technology to deliver higher concentrations of nicotine than conventional e-cigarettes; indeed, the nicotine concentration in the standard version of JUUL® is more than 50 mg/mL, compared with typical levels of 3-24 mg/mL for other e-cigarettes.”9 The salts and flavours available to be used with these devices reduce the harshness and bitterness of the taste of the e-liquids with some of the competition delivering even higher levels of nicotine. The CMA called on Health Canada to restrict the level of nicotine in vaping products to avoid youth (and adults) from developing a dependence.20 Health Canada set the maximum level at 66 mg/ml while a European Union (EU) directive of 2014 indicates the level should not exceed 20 mg/ml. , Nicotine, among other issues, “affects the developing brain by increasing the risk of addiction, mood disorders, lowered impulse control, and cognitive impairment. , Utilizing the EU level as an interim measure until more scientific research is available to determine an optimal level is acceptable. Flavours On December 5, 2019, the Government of Nova Scotia became the first province or territory to announce it would institute a ban on sale of flavoured e-cigarettes and juices, as of April 1, 2020. The CMA recommends that flavours banned to reduce the attractiveness of vaping to youth as much as possible; others share this sentiment.6,7, Flavours are strong factors in attracting youth, especially when coupled with assertions of lower harm. Their success in doing so is evidenced by the rise in the rates of vaping among youth.9, A recent US study found that “perceiving flavored e-cigarettes as easier to use than unflavored e-cigarettes may lead to e-cigarette use progression among youth never tobacco users. Determining the factors (including e-cigarette marketing and specific e-cigarette flavors) that lead to perceived ease of using flavored e-cigarettes would inform efforts to prevent and curb youth e-cigarette use.” The CMA recommends that flavours be banned to reduce the attractiveness of vaping to youth as much as possible. Recommendations 1. The CMA recommends that vaping advertisements should not be permitted in any public places, broadcast media, and in publications of any type, with no exceptions. 2. The CMA reiterates its position that all health warnings for vaping products and devices should be similar to those for tobacco packages. 3. The CMA believes that the European Union 2014 directive indicating the nicotine concentration not exceed 20 mg/ml should be adopted as an interim measure until more scientific research is available to determine an optimum level. 4. CMA recommends flavours be banned to reduce the attractiveness of vaping to youth as much as possible.

Documents

Less detail

The Lancet Countdown on Health and Climate Change - Policy brief for Canada, Dec 2020

https://policybase.cma.ca/en/permalink/policy14382

Date
2020-12-02
Topics
Population health/ health equity/ public health
  1 document  
Policy Type
Policy endorsement
Date
2020-12-02
Topics
Population health/ health equity/ public health
Text
The Lancet Countdown on Health and Climate Change Policy Brief for Canada DECEMBER 2020 Introduction Previously described as “the greatest threat to health of the 21st century”, climate change is compounding existing health disparities in Canada. Given this, addressing the current climate crisis offers what is perhaps our biggest opportunity to improve the health outcomes of Canadians. We see wildfires exacerbating respiratory illnesses and leading to community displacement in Western Canada; heat-related illness in urban areas; changes in the availability of traditional foods in the Arctic region; mental health stresses; extreme weather events such as floods and droughts; progression of infectious diseases such as Lyme disease and emergence1. Moreover, climate change drives inequities: older persons, those of low socioeconomic status, and racialized people living in Canada face a greater burden of the impacts of climate change on their health. In particular, climate change disproportionately impacts Indigenous peoples’ wellbeing. Colonialism has altered the ecological systems that support Indigenous peoples’ health, economies, cultural practices and self-determination. For First Nations, Métis and Inuit communities, the current climate crisis is understood and experienced as an intensification of the environmental changes imposed on Indigenous people by historic and ongoing colonial processes. Their remarkable and demonstrable resilience through these changes, however, reinforce the opportunity for learning and collaborating on solutions that draw on the ecological traditional knowledge, social and environmental adaptability of Indigenous peoples in Canada. This brief, written in collaboration with medical and public health experts, as well as Indigenous and allied scholars, outlines opportunities to address climate change. Based on data from the global Lancet Countdown report, it looks at the impacts of extreme heat and air pollution on the health of all people living in Canada. It also explores how, by applying a justice lens to all policies, Canada’s leaders can promote a healthy transition to a sustainable society in the dual crises era of climate change and COVID-19, including developing a more sustainable healthcare system and prioritizing health equity. This policy brief presents updated information and recommendations on two major clusters of indicators of climate-related health impacts in Canada: extreme heat and air pollution. It provides six evidence-based policy recommendations for a healthy response to climate change through enhancing resilience and adaptability. We offer recommendations that aim to reap co-benefits for physical, social, economic, and environmental well-being. Additionally, as economies are slowly recovering from the COVID-19 pandemic, this brief acknowledges the unique opportunity to shift toward a carbon-neutral society, and these policy recommendations enable progress towards this goal.* *Additional recommendations can be found in the 2017, 2018 and 2019 briefs. 2 1 Retrofit existing built infrastructure, improve current social and natural infrastructure, and better design novel urban and suburban communities to improve resilience to heat, especially for groups at risk. Turn down the heat Clean our air The way forward: healthy recovery Promote and be guided by the resilience of land-based Indigenous-led approaches that foster adaptation to rapid warming in Indigenous communities, particularly in the north. Recommendations Increase support for sustainable housing, including flexible strategies that financially and logistically support low emissions design and deployment of technologies for improved insulation and energy efficiency at the community and neighbourhood level. Prioritise funding for low emissions transport and affordable public and active transport initiatives, targeting communities who could benefit most from access to healthy transportation and identifying examples of successful community initiatives. Ensure a recovery from COVID-19 that is aligned with a just transition to a carbon-neutral society, considering health and equity impacts of all proposed policies to address the climate and COVID-19 dual crises, directly including and prioritizing the disproportionately affected, including Indigenous peoples, older persons, women, racialized people, and those with low income. Strengthen health system resilience in the face of climate change and other current and future health threats, prioritising decarbonisation, energy efficiency, and improved waste management and supply chains, aiming at a nation-wide “net-zero health service”. Turn down the heat Canada is warming at double the global average rate, and even more rapidly in northern regions.2 The number, intensity and duration of heatwaves are likely to increase, especially in southern Canada where most of the population lives. Extreme heat is associated with increases in all-cause mortality; risks of being hospitalized for cardiovascular and respiratory diseases;3 and congenital and birth complications.4,5 High temperatures also affect psychological and emotional health.6 During extremely hot periods, interpersonal and group violence tend to increase, especially in underprivileged neighbourhoods. Domestic violence rises, impacting the well-being of women.†,7 Additionally, extreme heat has been linked to insomnia;8 higher suicide rates;9 and an increase in mental health-related emergency department visits.10. Canada’s aging population‡ is at higher risk of suffering from extreme heat because of frequent social isolation, less access to energy-efficient and heat-resilient housing, decreased ability to regulate body temperature, and higher prevalence of pre-existing chronic conditions such as hypertension, diabetes and heart disease. Between 2014-2018, rapid warming in Canada led to a 58.4% increase in average annual heat-related mortality for the over 65 population, compared to the 2000-2004 baseline, exceeding the global average of 53.7%.13 A record high of over 2700 heat-related deaths in the over-65 population occurred across the country in 2018.13 In the summer of 2018, two heat waves affected Quebec, with 86 excess deaths resulting from the first of these two heatwaves alone.14 Heat exposure also affects outdoor workers, including those in the construction, service, manufacturing, and agriculture sectors. In Canada, the work hours lost due to exposure to extreme heat was 81% higher on average in 2015-2019 than in 1990-1994, with an average of 7.1 million extra work hours lost per year.§,13 In 2018, the monetised value of global heat-related mortality was equivalent to 0.7% of Canada’s gross national income, compared to 0.2% in 2000.13 These costs are comparable to the average income of 263, 400 Canadians, or roughly the population of Gatineau, Québec’s 4th biggest city, or Saskatoon, Saskatchewan’s biggest city. Physical, social and economic structures contribute to heat-related death in people at risk. Older persons, outdoor workers, and those living in low income neighbourhoods often have less access to green spaces, public transport and proper insulation, or are more likely to be socially isolated or to live on a low household income. For Indigenous peoples, rising temperatures further exacerbate disparities attributable to colonialism, such as food security, access to clean water, land use, ice safety and housing stability.15 Addressing these inequitable structures will support individuals’ and communities’ resilience and productivity and decrease preventable health consequences as temperatures rise. More sustainable infrastructure at community and household levels, such as trees and urban vegetation (including parks, on streets and ‘green walls’), water features, and cooler buildings (which are lighter in colour or better insulated to reduce heat absorption), can better equip Canada to prevent these health consequences.16 However, infrastructure changes to mitigate the above mentioned health impacts, if only focused on design of new structures, may not be sufficient and new buildings also can incur significant costs in resources and energy demands. Retrofit of existing buildings offers an additional significant opportunity to increase energy efficiency, reduce cooling costs, and mitigate health risks, and has been studied in other countries.17,18,19 Policy responses to extreme heat can be tailored to the most effective scales and be flexible to local realities, including scope for design of new structures, greening, and improving ventilation and insulation of existing ones. † Gender-based violence increases in times of acute disaster and crisis, including climate-related events such as flooding and wildfires, while at the same time, the services available to women, such as shelters and safehouses, decrease. ‡ According to Statistics Canada, the proportion of the population over 65 is 17.% and increasing to up to 30% in the next 50 years. § This data is calculated with the conservative assumption of work being undertaken in the shade. FIGURE 1: THE HEALTH IMPACTS OF HEAT3,5,6,7,10,11,12 Clean our air Air pollution has significant impacts on health, including exacerbating respiratory conditions like asthma and chronic obstructive pulmonary disease, and increasing risks of lung cancer, respiratory infections, stroke and heart disease. However, the burden of air pollution is not equally distributed across the population. Marginalized groups include children, older persons, people with pre-existing conditions, outdoor workers, racialized groups and low-income populations who are more likely to live in neighborhoods near busy roads or industrial sites.20,21 In 2018 in Canada, there were a total of 8400 premature deaths related to PM2.5 air pollution, of which 7200 were due to anthropogenic sources.13 Total PM2.5 air pollution related deaths were more than 4.5 times higher than the number of deaths from transport accidents, and almost double the number of deaths from all infectious diseases.22 While concerning, this number represents an opportunity to save over 8000 lives annually, and benefit the health of many others in Canada. Transitioning rapidly to renewable, low-emissions energy can help achieve this. The largest portion, over 30% of deaths from anthropogenic air pollution, occurred due to emissions from households (e.g. burning fuel for heating). 13,23 Notably, 17% of anthropogenic PM2.5 air pollution related deaths were attributable to land-based transport,13 which in 2018 also accounted for 25% of Canada’s greenhouse gas emissions (an increase of 53% since 1990).24 By reducing use of fossilfuel based transport and home energy systems, including adapting existing systems to incorporate energy-efficient technologies, it is possible to decrease air pollution and improve health. Total use of electricity for road transport increased 40% between 1990 and 2017.13 However, while Canada’s per capita use of electricity for road transport remains the highest use worldwide, it has increased only by 6.5% since 1990.13 Furthermore, electricity only accounts for 0.2% of road transport energy in Canada, whereas fossil fuels still account for over 95%.13 There remains large scope to increase uptake of sustainable transport and by doing so, save health and economic costs Active transportation has significant health co-benefits, including due to physical activity, improvements in air quality, and social connection. Studies have found reductions of approximately 20-30% in premature mortality rates in those who regularly cycle or exercise for transportation. 25 Both active travel and public transit are associated with increased physical activity and reduced rates of obesity compared to car use, and when supported by infrastructures that prioritise safety and access, can benefit the well-being of those with limited access to private vehicles.26 Transitioning to sustainable transport can avoid preventable transport-related emissions and deaths, and modelling has shown a cost-benefit ratio of more than 10 times in favour of integrating active travel for health and emissions benefits.27 FIGURE 2: MORTALITY DUE TO PM2.5 AIR POLLUTION IN CANADA13,22 The way forward: healthy recovery** The COVID-19 pandemic, subsequent crash in global energy prices, and overall global economic downturn have cast doubt on the world’s ability to prevent catastrophic and deadly effects of climate change. While rates of emissions stalled early in 2020 due to COVID-19 lockdowns, the total concentrations of major greenhouse gases have continued to rise. This is in stark contrast to the 7.6% annual decrease in GHG emissions necessary to limit global temperature increases to less than 1.5oC .28 An urgent transition to an environmentally sustainable, just and healthy society is an essential part of recovery that Canada and other countries must undergo. A just transition must include and prioritise groups most affected by the current crises, including low-income groups, migrant workers, older persons, and Indigenous peoples. Furthermore, the COVID-19 pandemic has put immense strain on Canada’s already overburdened healthcare system. Data from several sources indicates that Canada’s healthcare sector was already responsible for approximately 5%13,29,30 of annual greenhouse gas emissions prior to the pandemic. Per capita, Canada’s healthcare is consistently shown to have one of the largest carbon footprints in the world. In England, the National Health Service has pledged to deliver a net zero health service by 2040. Similarly, hospitals and health clinics in Canada could realise health and financial gains by committing to and implementing low-carbon, energy-efficient, reduced-waste health services. Canada’s political and economic choices as it emerges from this pandemic will determine whether it meets its commitment under the Paris Agreement to contribute to limiting global temperature rise well below 2oC. The country should lead by ambitiously updating its Nationally Determined Contribution (NDC) to the Paris Agreement††. Ultimately, governments and all sectors of society must make choices that put human, environmental and economic well-being at the centre of a sustainable recovery from COVID-19. These objectives are not only mutually reinforcing, but mutually dependent. Crucially, Canada must build resilience, equity and solidarity across groups, prioritising Indigenous peoples and other communities most at risk. Above all, through the pandemic, it is essential to prioritise a just recovery: an equity lens must be applied to all policies. Those most affected by climate change’s health impacts are those who currently lack power and representation in economic and social hierarchies. For Indigenous communities, addressing climate change is intimately tied to the renewal of traditional knowledge systems, reconciliation, and decolonizing approaches. All groups benefit when public and private sector leaders work with Indigenous people and other disproportionately impacted communities to ensure that historically underrepresented groups are meaningfully engaged in all policy development and recovery plans. Working together, the lessons learned in responding to COVID-19 and the increasing confidence in the power of collective action to care for one another can be integrated into a collective response to the climate emergency. This is an unprecedented opportunity to learn and act together. ** There is a lack of data specific to impacts on health equity and on disproportionately affected groups, including Indigenous peoples. Furthermore, conventional scientific data collection and reporting methods do not align with traditional ways of accumulating and sharing knowledge, thus it is difficult to use current indicators to capture the complex health impacts of climate change on Indigenous peoples. †† As of October 2020, according to Climate Action Tracker, Canada’s NDC is consistent with a global temperature rise above 2oC and near 3oC. This is not compatible with the 1.5oC of the Paris Agreement. Despite several promises to exceed the 2030 NDCs target (of 30% below 2005 emissions levels by 2030) and achieve net zero emissions by 2050, the federal government hasn’t adopted yet the policies required to respect these promises and has continued to financially support the oil and gas industries. Source: https://climateactiontracker.org/countries/canada/. 1. Howard, C et al. Lancet Countdown 2019 Policy brief for Canada. Lancet Countdown, Canadian Medical Association, and Canadian Public Health Association. November 2019. Available: https:// www.lancetcountdown.org/resources/ 2. Bush, E. and Lemmen, D.S., editors (2019) Canada’s Changing Climate Report, Government of Canada, Ottawa, ON. 444 p. 3. Lin S, Luo M, Walker RJ, Liu X, Hwang S-A, Chinery R. Extreme High Temperatures and Hospital Admissions for Respiratory and Cardiovascular Diseases. Epidemiology 2009; 20(5): 738-46. 4. Konkel L. Hot Days in Early Pregnancy: A Potential Risk Factor for Congenital Heart Defects. Environ Health Perspect 2017; 125(1): A25. 5. Chersich MF, Pham MD, Areal A, et al. Associations between high temperatures in pregnancy and risk of preterm birth, low birth weight, and stillbirths: systematic review and meta-analysis. BMJ 2020; 371: m3811. 6. Mon climat, ma santé. Online: Vagues de chaleur, Institut national de santé publique du Québec. http://www.monclimatmasante. qc.ca/vagues-de-chaleur.aspx 7. Burke M, Hsiang SM, Miguel E. Climate and conflict. Ann Rev Econom. 2015; 7:577-817 8. Obradovich N, et al. (2019). Nighttime temperature and human sleep loss in a changing climate. Science Adv. 2017. 9. Burke M, et al. Higher temperatures increase suicide rates in the United States and Mexico. Nature Climate Change. 2018;8:723- 729. 10. Wang X, et al. Acute impacts of extreme temperature exposure on emergency room admission related to mental and behavior disorders in Toronto, Canada. J Affect Disord. 2014;155:154-161 11. Xu Z, Crooks JL, Davies JM, Khan AF, Hu W, Tong S. The association between ambient temperature and childhood asthma: a systematic review. Int J Biometeorol 2018; 62(3): 471-81 12. de Lorenzo A, Liaño F. High temperatures and nephrology: The climate change problem. Nefrologia. 2017;37:492–500 13. Watts N, et al. The 2020 report of The Lancet Countdown on health and climate change: responding to converging crises. Lancet 2020; XXX: XXXX–XX 14. Institut national de santé publique du Québec. Surveillance des impacts des vagues de chaleur extrême sur la santé au Québec à l’été 2018. INSPQ. Available online: https://www.inspq.qc.ca/ bise/surveillance-des-impacts-des-vagues-de-chaleur-extremesur- la-sante-au-quebec-l-ete-2018 15. Ford, JD (2012) Indigenous Health and Climate Change, Am J Public Health, 2012 July; 102(7): 1260-1266. 16. C40. How to adapt your city to extreme heat. C40 Implementation Guides, August 2019. Available online: https:// www.c40knowledgehub.org/s/article/How-to-adapt-your-cityto- extreme-heat?language=en_US 17. Williams, K et al (2013) Retrofitting England’s suburbs to adapt to climate change, Building Research & Information, 41:5, 517-531. 18. Castleton H.F. et al (2010) Green roofs; building energy savings and the potential for retrofit, Energy and Buildings, 42:10, 1582- 1591. 19. Ren, Z et al (2011) Climate change adaptation pathways for Australian residential buildings, Building and Environment, 46:11, 2398-2412. 20. World Health Organization. Online: Ambient air pollution: health impacts. https://www.who.int/airpollution/ambient/healthimpacts/ en/ 21. Abelsohn, A and D.M. Stieb. 2011. Health effects of outdoor air pollution. Can Fam Physician 2011 Aug; 57(8): 881–887. 22. Statistics Canada. Table 13-10-0156-01 Deaths, by cause, Chapter XX: External causes of morbidity and mortality (V01 to Y89). 23. National Resources Canada. 2015 Survey of Household Energy Use (SHEU-2015) Data Tables. Available online: https://oee. nrcan.gc.ca/corporate/statistics/neud/dpa/menus/sheu/2015/ tables.cfm 24. Environment and Climate Change Canada (2020) National Inventory Report 1990-2018: Greenhouse Gas Sources and Sinks in Canada. 25. Giles-Corti et al (2010) The co-benefits for health of investing in active transport, N S W Public Health Bull, 21:5-6, 122-1277. 26. World Health Organization (2012) Health in the green economy : health co-benefits of climate change mitigation - transport sector, WHO, 144p., 27. Chapman et al (2018) A Cost Benefit Analysis of an Active Travel Intervention with Health and Carbon Emission Reduction Benefits, Int J Environ Res Public Health, 15(5): 962. 28. World Meteorological Organization (2020) Online: United in Science 2020: Greenhouse Gas Concentrations in the Atmosphere - Global Atmosphere Watch (GAW). Available: https://public.wmo.int/en/resources/united_in_science 29. Pichler P-P, Jaccard IS, Weisz U, Weisz H. International comparison of health care carbon footprints. Environmental Research Letters 2019; 14(6): 064004. 30. Eckelman MJ, Sherman JD, MacNeill AJ. Life cycle environmental emissions and health damages from the Canadian healthcare system: An economic-environmental-epidemiological analysis. PLoS Med 2018;15(7):e1002623. References Organisations and acknowledgements The concept of this brief was developed by the Lancet Countdown on Health and Climate Change. This brief was written by Dr. Claudel P-Desrosiers, MD; Dr. Finola Hackett, MD; Dr. Deborah McGregor, PhD; and Dr. Krista Banasiak, PhD. Guidance was provided by Dr. Céline Campagna, PhD, and Dr Robert Woollard, MD, CCFP, FCFP, LM. Review on behalf of the Canadian Medical Association was provided by Dr. Owen Adams, PhD, Dr. Jeff Blackmer, MD, MHSc, FRCPC, CCPE, and Ashley Chisholm, MSc. Contributions and review on behalf of the Lancet Countdown were provided by Jessica Beagley and Dr Marina Romanello, PhD. THE LANCET COUNTDOWN The Lancet Countdown: Tracking Progress on Health and Climate Change is an international, multi-disciplinary collaboration that exists to monitor the links between public health and climate change. It brings together 38 academic institutions and UN agencies from every continent, drawing on the expertise of climate scientists, engineers, economists, political scientists, public health professionals, and doctors. Each year, the Lancet Countdown publishes an annual assessment of the state of climate change and human health, seeking to provide decision-makers with access to high-quality evidence-based policy guidance. For the full 2020 assessment, visit www.lancet countdown. org/2020-report. n.

Documents

Less detail

National Standards for Long-Term Care: The art of the possible?

https://policybase.cma.ca/en/permalink/policy14383

Date
2020-12-08
Topics
Population health/ health equity/ public health
Health systems, system funding and performance
  1 document  
Policy Type
Policy endorsement
Date
2020-12-08
Topics
Population health/ health equity/ public health
Health systems, system funding and performance
Text
INTRODUCTION The COVID-19 pandemic has provided a tragic wake-up call to the shortcomings of Canada’s long-neglected long-term care (LTC) sector. The Canadian Institute for Health Information (CIHI) reported in late June that as of May 25, 2020, LTC residents accounted for 81% of COVID-19 deaths in Canada, more than double the average of 38% across 17 countries of the Organisation for Economic Co-operation and Development (OECD).1 Sadly, lockdown policies in LTC facilities meant that some family members were unable to be with their relatives as they passed away.2 COVID-19 has also taken a toll on health care workers. CIHI reported that as of July 23, health care workers accounted for almost one in five COVID-19 cases (19.4%), although a breakdown of the work location of these cases (e.g., LTC facilities and elsewhere) is not available.3 It should be stressed that the majority of LTC is provided outside LTC facilities in recipients’ homes, and this has received little attention since the pandemic began. According to the 2016 Census, there were 425,755 Canadians residing in nursing homes, residences for senior citizens and facilities that combined both.4 In comparison, according to the 2019 Canadian Community Health Survey, 1.8 million Canadians aged 12 years and older reported that they or someone in their household had received home care services in the previous 12 months and that nursing care was the most frequently reported service, by 870,000 Canadians. Moreover, an additional 733,500 Canadians reported that there had been a need for home care services for themselves or a household member in the previous 12 months that had not been filled.5 NATIONAL STANDARDS FOR LONG-TERM CARE: THE ART OF THE POSSIBLE? 2 THE FEDERAL GOVERNMENT CALL FOR NATIONAL LTC STANDARDS Reacting to the June CIHI report about the 81% of COVID-19 deaths in LTC facilities, Prime Minister Justin Trudeau made the following statement: “We will continue to work with the premiers on ensuring that our long-term care centres are properly supported, whether that’s by bringing in national standards, whether that’s by extra funding, whether that’s by looking at the Canada Health Act.”6 LTC standards were also highlighted in the Speech from the Throne (SFT) on Sept. 23, 2020. “The Government will also: n Work with the provinces and territories to set new, national standards for long-term care so that seniors get the best support possible; n And take additional action to help people stay in their homes longer.”7 Before a teleconference with the provincial and territorial (PT) premiers on Oct. 15, 2020, Trudeau indicated that he would push the premiers on “harmonized norms” or standardized rules for the level of care in LTC homes.8 In its Nov. 30 Economic Statement, the government announced up to $1 billion for a Safe Long-Term Care Fund to support the provinces and territories in infection prevention and control in LTC facilities and $9.8 million for related initiatives. The statement also repeats the commitment to work with the provinces and territories to set new national standards for LTC.9 THE PROVINCIAL-TERRITORIAL PREMIERS CALL FOR MORE FUNDING The premiers have not publicly collectively engaged with the prime minister’s call for national LTC standards and have focused on a demand for more funding with no strings attached. Quebec Premier François Legault was quoted in late May as saying, “We’re telling Mr. Trudeau if you really want to help us in long-term care facilities, please increase your transfers in health to all provinces. Then we’ll be able to hire, pay better and have more staff in our long-term care facilities.”10 In advance of the Sept. 23 SFT, the premiers upped the ante: in the past several years they had called for a 25% federal share of PT government health spending but they increased this to 35%, which would represent an increase in the Canada Health Transfer (CHT) of $28 billion annually to start.11 In their response to the SFT, the premiers demanded an “immediate and unconditional injection to the CHT to bring the federal share from 22% to 35%.”12 On Oct. 30, 2020, the premiers released a report from the Conference Board of Canada to buttress their demand that the federal government contribute a 35% share of PT government health spending. The report noted that between Jan. 1 and June 5, 2020, the PTs incurred nearly $11.5 billion in spending that was attributed directly to dealing with the COVID-19 pandemic. The report presented three scenarios that suggest that the additional health costs due to COVID-19 will range from $20.1 to $26.9 billion in 2020–21 and the total amount between 2020/21 and 2030/31 will range from $80 billion to $161 billion.13 In releasing the report the premiers called on the prime minister to confirm the date for a meeting to talk about the CHT.14 One example of these increased costs is the 2020 Ontario budget, which includes $15.2 billion in funding to support the health care system and the LTC sector.15 3 Suffice it to say that there is unlikely to be any concerted national action on LTC standards without a further infusion of federal funding, and it is unlikely that there will be an unconditional increase in the CHT on the basis of the evolving experience of targeted federal health funding over the past two decades. THE EVOLUTION OF TARGETED FUNDING The Canada Health Act explicitly addresses only insured hospital and medical–dental services, and although it is permissive about adding other services it continues to be interpreted as applying only to hospital and medical services. Moreover, the only criterion that has ever been enforced is the accessibility principle that bars private payment for insured services. It is noted, however, that when 50:50 cost sharing was replaced by Established Programs Financing (EPF) in 1977, an Extended Health Care Program was introduced. This was intended to cover nursing home intermediate care, adult residential care, converted mental hospitals, home care and ambulatory care. The initial payment under this program was set at $20 per capita in 1977–78, to be increased thereafter by the EPF escalator.16 This notional program allocation has been lost in the evolving fiscal machinations on transfers over the decades since EPF was implemented. Since that time the federal government has used its spending power to incentivize the provinces to experiment with and adopt new programs in exchange for reporting commitments, with mixed success. The 1995 federal budget announced the consolidation of health and social transfers into the Canada Health and Social Transfer (CHST) and the reduction in the cash transfer of $6 billion over two years beginning in 1996–97. This precipitated long wait times for care that continue to this day. The PT governments put great pressure on the federal government to restore transfers, which it began to do modestly in the 1999 budget. Significant targeted funding was introduced in the 2000 First Ministers’ Health Accord. The total increase of $21.2 billion in the CHST included an $800 million Primary Health Care Transition Fund, and $500 million each for health information technology and diagnostic and medical equipment. In exchange the PTs agreed to report to their citizens on jointly agreed-upon common indicators beginning in 2002.17 This approach was extended in the 2003 Accord on Health Care Renewal, at which time the PTs agreed to the establishment of the Health Council of Canada to monitor and report on the Accord commitments. The First Ministers’ 2004 10-Year Plan to Strengthen Health Care (the 2004 accord) took a more aggressive approach to targeted funding and accountability. The $41.3 billion deal included a $5.5 billion Wait Times Reduction Fund that called for the development of evidence-based benchmarks for medically acceptable wait times for five priority procedures by Dec. 31, 2005, and multi-year targets to achieve them by Dec. 31, 2007. 18 The 2004 accord also introduced “asymmetrical federalism” by which Quebec agreed to support the overall objectives and principles set out in the accord but would develop its own wait time reduction plan and other measures.19 The provinces and territories were successful in agreeing to common wait-time benchmarks for scheduled procedures in the priority areas, which were announced on Dec. 12, 2005.20 The next step was announced by the Harper government in the 2007 budget. The budget committed $612 million to a Patient Wait Times Guarantee Trust, funding that would be made available to those jurisdictions agreeing to implement a patient wait-time guarantee in at least one of the five priority areas. All jurisdictions signed on almost immediately.21 4 The most recent development in targeted funding was the series of bilateral agreements signed between the federal and PT governments in 2017–18 whereby they were to receive $11 billion over a 10-year period for home and community care and mental health and addictions. The foundation for the bilateral agreements is A Common Statement of Principles on Shared Priorities. The specific points for home and community care include: n spreading and scaling evidence-based models of home and community care; n enhancing access to palliative and end-of-life care; n increasing support for caregivers; and n enhancing home care infrastructure.22 In keeping with the principle of asymmetrical federalism, Quebec did not sign onto the statement of shared principles, but like the other jurisdictions it signed a funding agreement with its proposed actions set out in an annex. It also indicated that it would use comparable indicators to compare health and social services with other jurisdictions and would observe the Canadian Institute for Health Information’s (CIHI) work to develop them.23 CIHI has led the development of a set of 12 common indicators in the two areas. The six home care indicators are as follows: n hospital stay extended until home care services or supports ready; n caregiver distress; n new LTC residents who potentially could have been cared for at home; n wait times for home care services; n home care services helped the recipient stay at home; and n death at home / not in hospital. Results have been reported for the first three, and the plan is to report on the remaining three in 2021–22.24 To date there has been some success with targeted funding. For example, the funding for health information technology has greatly increased the uptake of electronic medical records and the Primary Health Care Transition Fund led to significant uptake of team-based models of care in Alberta, Ontario and Quebec. There has been mixed success with the Wait Times Reduction Fund — jurisdictions measure wait times in the priority areas but few have expanded beyond those and it would appear that the wait-time guarantees have not been sustained. Moreover, CIHI has reported that many jurisdictions have seen increases in wait times for joint replacement and cataract surgery since 2017.25 In general, the PT governments have resisted any sort of individual or collective accountability to the federal government for health transfers. 5 OPTIONS FOR TARGETED FUNDING LINKED TO LTC Since the prime minister’s initial comments, reports have addressed the LTC standards issue. A report by the Royal Society of Canada on LTC set out a series of principles, including this one: “the federal government must take a major role and develop a mechanism for supporting provincial and territorial governments to achieve high standards in LTC across Canada. This could be achieved through a similar framework to the Canada Health Act, where core standards are articulated. Provincial and territorial governments who meet those standards receive additional federal transfers.”26 Similarly, the CanAge advocacy organization has proposed national quality standards that would link federal funding to their implementation.27 Carolyn Tuohy has proposed a joint-decision model for LTC built on a social insurance approach with a joint federal, provincial and territorial governance mechanism modelled after the Canada Pension Plan and the Quebec Pension Plan.28 Another possibility would be for the federal government to use its spending power to adopt legislation that would establish criteria for federal funding for LTC. An example was the tabling of Bill C-213 in February 2020 by the New Democratic Party to establish a national pharmacare program. The bill includes four of the Canada Health Act principles — comprehensiveness, universality, portability and accessibility — but leaves the determination of the program details up to each jurisdiction.29 The bill was debated for the first time on Nov. 18.30 It would be useful to review international experience in the funding and regulation of LTC. Unlike Canada, Australia has divided jurisdiction between the commonwealth and state governments. Medical insurance and pharmacare are federal programs while hospitals fall mainly under the jurisdiction of the state governments. The federal Aged Care Act 1997 provides for funding and standards for aged care homes. There are eight national aged care quality standards: n consumer dignity and choice; n ongoing assessment and planning; n personal care and clinical care; n services and supports for daily living; n organisation’s service environment; n feedback and complaints; n human resources; and n organisational governance.31 Each aged care home is assessed against the quality standards and their performance is rated using four bars, which range from 1 (few requirements met) to 4 (all requirements met). Accreditation by the Aged Care Quality and Safety Commission is required to receive the Australian government subsidies. The government funds aged care service providers through subsidies and supplements, capital grants for residential aged care and program funding.32 Countries such as Germany, the Netherlands and Japan have social insurance schemes for LTC and one could look at their experience with regulation of quality and standards. 6 In terms of spending on LTC, according to the OECD, in 2017 Canada spent 1.3% of gross domestic product (GDP) on LTC. Although Canada is tied with France and Ireland for 10th place out of 36, Nordic countries such as Denmark (2.3%), Norway (2.6%) and Sweden (2.7%) spend double what Canada does.33 CONSIDERATIONS FOR NATIONAL STANDARDS FOR LTC Every Canadian province and territory except Nunavut has legislation in place for long-term residential care. The recent Royal Society study has a useful tabulation of the pertinent legislation.26 Accreditation Canada/Health Standards Organization has a standard for the accreditation of LTC services34 and also has standards for retirement homes and home care. LTC homes, retirement homes and home care programs can be accredited against these standards by Accreditation Canada’s Qmentum Accreditation Program.35 CIHI reports data on 14 indicators for more than 1,600 LTC facilities across Canada, and data collection and reporting have started for the common indicators agreed to in the 2017 bilateral accords as noted above. In 2013 the Canadian Home Care Association carried out an extensive national consultation process to develop six principles and descriptors for home care. These included: n patient- and family-centred care; n accessible care; n accountable care; n evidence-informed care; n integrated care; and n sustainable care.36 These principles then served as the foundation for a framework for the development of home care standards.37 This is an interesting approach that could have wider applicability on the LTC continuum. Since the start of the COVID-19 pandemic, several reports have put forward recommendations to address the LTC sector and many more will ensue from the commissions and inquiries yet to be struck. These include the following: n The Canadian Nurses Association has called for a federal commission of inquiry on aging and increased investments in community, home and residential care.38 n In May the Canadian Armed Forces released findings on the shocking conditions in LTC facilities in Ontario where they were called in to assist. n The Royal Society policy briefing sets out 16 guiding principles and nine recommended actions to address the workforce crisis in LTC facilities.26 n Ryerson University’s National Institute on Ageing has set out guiding principles and draft policies for families and general visitors to LTC facilities39 as well as other resources. 7 n The Canadian Foundation for Healthcare Improvement and the Canadian Patient Safety Institute have reported on a stakeholder consultation that identifies six areas of promising practices.40 n CanAge has put forward 135 recommendations as a road map to an age-inclusive Canada.27 n Ontario’s Long-Term Care COVID-19 Commission has put forward 11 recommendations that address the LTC workforce, linkages between LTC and hospitals and infection prevention and control.41 The commission’s recommendation of a minimum daily average of four hours of direct care per resident has been accepted by the government and is included in the 2020 Ontario budget (although not costed).15 It is clear that achieving any national standard with respect to the quality of life of residents of Canada’s LTC facilities is going to take more than agreeing on common indicators. There is also a need to build a functioning quality improvement process into care processes, for which there is currently little or no capacity. On Sept. 3, 2020, representatives from 10 national health organizations held a preliminary discussion on national standards for LTC. Several key points emerged from this discussion: n LTC must encompass the full continuum ranging from home care to long-term residential care to palliative care. n There is wide variability in medical staff engagement in LTC homes across Canada. n Standards must be based on resident outcomes and evidence-informed practices that provide safe and reliable care. n There is a need to recognize that there are multiple standards that exist at different levels and vary across Canada. Reflecting on the previous experience with targeted funding of the CHT, one could imagine a range of measurable commitments that could be built into a supplementary LTC transfer or a piece of legislation modelled on the Canada Health Act. This could include conditions such as: n a requirement for LTC services across the continuum to be accredited; n provision for a mechanism for a meaningful voice for residents and family members in LTC; n adoption of a risk-based policy for family/caregiver visits; n adoption of a health human resource competency framework(s) for LTC; n adoption of national recipient/resident quality-of-life and outcome indicators and public reporting; n adoption of targets to move to single-bedroom LTC facilities; 8 n adoption of employment standards that support high-quality care and the safety of both providers and receivers of care; n standards for nursing homes that ensure (a) training and resources for infectious disease control, including optimal use of personal protective equipment, and (b) protocols for expanding staff and restricting visitors during outbreaks; n mental health supports for staff providing LTC; and n a requirement that residents be immunized for influenza, pneumonia and shingles and that the immunization information be captured using a digitized record. CONCLUSION The COVID-19 pandemic has underscored the urgent need to address the capacity of the LTC sector and the quality of care it provides across the continuum of care. One indication of the challenge ahead is a 2017 report by the Conference Board of Canada that projected the need for an additional 199,000 LTC beds by 2035, almost double the existing stock of 255,000 beds, at an estimated cost of $64 billion to build and $7 billion per year to operate.42 Staffing these beds will be an even bigger challenge. RECOMMENDATION On the basis of the foregoing it is recommended that the upcoming discussions on the CHT between the prime minister and the PT premiers include a specific focus on the LTC sector with a view to including specific measurable commitments as a condition of increased federal transfers. Nov. 30, 2020 9 1 Canadian Institute for Health Information. Pandemic experience in the long-term care sector: How does Canada compare with other countries? Available: https://www.cihi.ca/sites/default/files/document/covid-19-rapidresponse- long-term-care-snapshot-en.pdf (accessed 2020 Nov 2). 2 Payne E. “It is inhumane”: daughter kept from dying mother’s bedside because of limits on long-term care visitors. Ottawa Citizen, 9 June 2020. Available: https://ottawacitizen.com/news/local-news/it-is-inhumanedaughter- kept-from-dying-mothers-bedside-because-of-limits-on-long-term-care-visitors (accessed 2020 Nov 2). 3 Canadian Institute for Health Information. COVID-19 cases and deaths among health care workers in Canada. Available: https://www.cihi.ca/en/covid-19-cases-and-deaths-among-health-care-workers-in-canada (accessed 2020 Nov 2). 4 Statistics Canada. 2016 Census of population. Statistics Canada catalogue no. 98-400-X2016019. 5 Statistics Canada. Canadian Community Health Survey (CCHS) – 2019. Annual component – Master file (rounded frequencies) Data dictionary (August 2020). Ottawa: Statistics Canada. 6 Tunney C. Provinces failed to support seniors, Trudeau says following release of troubling new pandemic study. Available: https://www.cbc.ca/news/politics/long-term-care-challenge-1.5626841 (accessed 2020 Sept 21). 7 Canada. Governor General. A stronger and more resilient Canada: Speech from the Throne to open the second session of the forty-third Parliament of Canada. https://www.canada.ca/en/privy-council/campaigns/speechthrone/ 2020/stronger-resilient-canada.html. Accessed 10/06/20. 8 Connolly A. Trudeau says he’ll push Premiers on “standardizing norms” in long-term care homes. Global News, 12 Oct 2020. Available: https://globalnews.ca/news/7394227/justin-trudeau-canada-care-home-nationalstandards/ (accessed 2020 Nov 2). 9 Department of Finance Canada. Supporting Canadians and fighting COVID-19. Fall economic statement 2020. https://www.budget.gc.ca/fes-eea/2020/report-rapport/FES-EEA-eng.pdf (accessed 30 Nov 2020). 10 Bryden J. Feds offer of help on sick leave, long-term care gets mixed reaction from provinces. Toronto Star, 28 May 2020. Available: https://www.thestar.com/news/canada/2020/05/28/feds-offer-of-help-on-sick-leave-longterm- care-gets-mixed-reaction-from-provinces.html (accessed 2020 Nov 2). 11 Canada’s Premiers. Canada’s Premiers outline priorities. 18 Sept 2020. Available: https://www.canadaspremiers.ca/wp-content/uploads/2020/09/Sept_18_COF_Communique_final.pdf (accessed 2020 Nov 2). 12 Council of the Federation. Canada’s Premiers reiterate priorities. 24 Sept 2020. Available: https://www.canadaspremiers.ca/wp-content/uploads/2020/09/Sept_24_COF_Communique_fnl.pdf (accessed 2020 7 Oct). 13 Conference Board of Canada. Health care cost drivers in Canada: pre- and post-COVID-19. Available: https://www.canadaspremiers.ca/wp-content/uploads/2020/10/CBOC_impact-paper_research-onhealthcare_ final.pdf (accessed 2020 Nov 2). 14 Canada’s Premiers. Premiers seek to confirm meeting with the Prime Minister on the CHT. 30 Oct 2020. Available: https://www.canadaspremiers.ca/wp-content/uploads/2020/10/CBOC_impact-paper_research-onhealthcare_ final.pdf (accessed 2020 Nov 2). 15 Phillips R. Ontario’s Action Plan: protect, support, recover. Available: https://budget.ontario.ca/2020/pdf/2020- ontario-budget-en.pdf (accessed 2020 Nov 8). 16 Parliamentary Task Force on Federal-Provincial Fiscal Arrangements. Fiscal federalism in Canada. Report of the Parliamentary Task Force on Federal-Provincial Fiscal Arrangements. Ottawa: Minister of Supply and Services Canada; 1981. 10 17 Canadian Intergovernmental Conference Secretariat. First Ministers’ meeting communique on health. 11 Sept 2000. Available: https://scics.ca/en/product-produit/news-release-first-ministers-meeting-communique-onhealth/ (accessed 2020 Sept 21). 18 Canadian Intergovernmental Conference Secretariat. A 10-year plan to strengthen health care. Available: https://scics.ca/wp-content/uploads/CMFiles/800042005_e1JXB-342011-6611.pdf (accessed 2020 Sept 21). 19 Canadian Intergovernmental Conference Secretariat. Asymetrical federalism that respects Quebec’s jurisdiction. Available: https://scics.ca/wp-content/uploads/CMFiles/800042012_e1JWF-342011-9468.pdf (accessed 5 Oct 2020). 20 Ontario Ministry of Health and Long-term Care. First ever common benchmarks will allow Canadians to measure progress in reducing wait times. 12 Dec 2005. 21 Department of Finance Canada. The budget plan 2007 Aspire to a stronger, safer, better Canada. Available: https://budget.gc.ca/2007/pdf/bp2007e.pdf (accessed 2020 Sept 21). 22 Government of Canada. A common statement of principles on shared health priorities. Available: https://www.canada.ca/content/dam/hc-sc/documents/corporate/transparency_229055456/healthagreements/ principles-shared-health-priorities.pdf (accessed 7 Oct 2020). 23 Government of Canada, Government of Quebec. Implementation agreement on the March 10, 2017, Asymmetrical agreement – home and community care and mental health and addictions services. Available: https://www.canada.ca/en/health-canada/corporate/transparency/health-agreements/shared-healthpriorities/ quebec.html (accessed 5 Oct 2020). 24 Canadian Institute for Health Information. Common challenges, shared priorities: measuring access to home and community care and to mental health and addictions services in Canada. Vol 2. Available: https://www.cihi.ca/sites/default/files/document/common-challenges-shared-priorities-vol-2-report-en.pdf (accessed 7 Oct 2020). 25 Canadian Institute for Health Information. Wait times for priority procedures in Canada. Available: https://www.cihi.ca/en/wait-times-for-priority-procedures-in-canada (accessed 7 Oct 2020). 26 Royal Society of Canada. Restoring trust: COVID-19 and the future of long-term care. 27 CanAge. Voices of Canada’s seniors: a roadmap to an age-inclusive Canada. Available: https://ddbfacb0-fa8a- 4eb5-8489-086cf8fcc173.filesusr.com/ugd/f614ae_b0035cb1e42645f287682b2f15a80678.pdf (accessed 3 Nov 2020). 28 Tuohy C. A new federal framework for long-term care in Canada. Available: https://policyoptions.irpp.org/magazines/august-2020/a-new-federal-framework-for-long-term-care-in-canada/ 29 House of Commons of Canada. Bill C-213 An act to enact the Canada Pharmacare Act. Available: https://parl.ca/Content/Bills/431/Private/C-213/C-213_1/C-213_1.PDF (accessed 2 Oct 2020). 30 Canada. House of Commons. House of Commons debates Volume 150 No. 031 Wednesday, November 18, 2020 https://www.ourcommons.ca/Content/House/432/Debates/031/HAN031-E.PDF. (accessed 30 Nov 2020). 31 Australian Government. Aged care quality standards. Available: https://www.myagedcare.gov.au/aged-carequality- standards#quality-standards 32 Australian Government, Department of Health. Funding for aged care service providers. Available: https://www.health.gov.au/health-topics/aged-care/providing-aged-care-services/funding-for-aged-careservice- providers#how-aged-care-funding-works (accessed 2020 Sept 21). 11 33 Organization for Economic Cooperation and Development. Health at a glance 2019. Chapter 11. Long-term care spending and unit costs. Available: https://www.oecd-ilibrary.org/docserver/4dd50c09- en.pdf?expires=1604337863&id=id&accname=guest&checksum=E3A45E877FBF72A54977B6B17209D82D (accessed 2 Oct 2020). 34 Accreditation Canada, Health Standards Organization. Available: https://store.accreditation.ca/products/longterm- care-services (accessed 2020 Sept 21). 35 Accreditation Canada. The Qmentum Accreditation Program. Available: https://accreditation.ca/accreditation/qmentum/ (accessed 20 Nov 2020). 36 Canadian Home Care Association. Harmonized principles for home care. https://cdnhomecare.ca/wpcontent/ uploads/2019/10/CHCA_Harmonized-Principles-2017-web.pdf. Accessed 09/21/20. 37 Canadian Home Care Association. A framework for national principle-based home care standards. https://cdnhomecare.ca/wp-content/uploads/2020/03/CHCA-Home-Care-Standards-Framework-final.pdf . Accessed 09/21/20. 38 Canadian Nurses Association. 2020 vision: improving long-term care for people in Canada. Available: https://www.cna-aiic.ca/-/media/cna/page-content/pdf-en/2020-vision_improving-long-term-care-for-peoplein- canada_e.pdf (accessed 3 Nov 2020). 39 National Institute on Ageing. Finding the right balance: an evidence-informed guidance document to support the re-opening of Canadian long-term carer homes to family caregivers and visitors during the COBID-19 pandemic. https://static1.squarespace.com/static/5c2fa7b03917eed9b5a436d8/t/5f0f2678f205304ab1e695be/159482841 0565/%27NIA+LTC+Visitor+Guidance+Document.pdf. Accessed 11/03/20. 40 Canadian Foundation for Healthcare Improvement, Canadian Patient Safety Institute. Reimagining care for older adults: next steps in COVID-19 response in long-term care and retirement homes. Available: https://www.cfhifcass. ca/docs/default-source/itr/tools-and-resources/reimagining-care-for-older-adults-covid-19-e.pdf (accessed 3 Nov 2020). 41 Ontario’s Long-Term Care COVID-19 Commission. First interim recommendations. Letter to Minister Fullerton. Available: http://www.ltccommission-commissionsld.ca/ir/pdf/20201023_First_Interim_Letter_English.pdf (accessed 3 Nov 2020). 42 Conference Board of Canada. Sizing up the challenge: meeting the demand for long-term care in Canada. Available: https://www.conferenceboard.ca/temp/27f4029e-9173-48c0-803cbe09691d6c22/ 9228_Meeting%20the%20Demand%20for%20Long-Term%20Care%20Beds_RPT.pdf (accessed 5 Oct 2020).

Documents

Less detail

Closing the Gaps: Advancing Emergency Preparedness, Response and Recovery for Older Adults

https://policybase.cma.ca/en/permalink/policy14384

Date
2020-12-15
Topics
Population health/ health equity/ public health
Health systems, system funding and performance
  1 document  
Policy Type
Policy endorsement
Date
2020-12-15
Topics
Population health/ health equity/ public health
Health systems, system funding and performance
Text
Closing the Gaps: Advancing Emergency Preparedness, Response and Recovery for Older Adults 29 Evidence-Informed Expert Recommendations to Improve Emergency Preparedness, Response and Recovery for Older Adults Across Canada DECEMBER 2020 CLOSING THE GAPS: ADVANCING EMERGENCY PREPAREDNESS, RESPONSE AND RECOVERY FOR OLDER ADULTS iii Table of Contents Report Development Contributors ...............................................................................................1 Organizational Endorsements...................................................................................................... 4 Abbreviations .................................................................................................................................... 7 Executive Summary .........................................................................................................................8 Background and Context ...............................................................................................................15 Domain 1: Individuals and Unpaid Caregivers ......................................................................26 Domain 2: Community-Based Services and Programs ....................................................... 35 Domain 3: Health Care Professionals and Emergency Response Personnel ................ 41 Domain 4: Care Institutions and Organizations ...................................................................46 Domain 5: Legislation and Policy................................................................................................51 Domain 6: Research.......................................................................................................................58 Glossary.............................................................................................................................................62 References ........................................................................................................................................64 Appendices .......................................................................................................................................78 Appendix A: Index of Recommendations and Enabling Bodies ..................................................................... A1 Appendix B: Emergency Preparedness for Older Adults Summary of Relevant Legislation and Framework .......................................................................................................................................................................................B1 1 Report Development Contributors In January 2019, the Canadian Red Cross in partnership with the National Institute on Ageing reviewed the latest evidence and expert opinions to inform the development of recommendations for governments, organizations and individuals to improve emergency preparedness, response and recovery for older adults. Enlisted experts that contributed to the development of the report are listed below. Co-Chairs, Canadian Red Cross/ National Institute on Ageing Emergency Preparedness for Older Adults Project Samir K. Sinha, MD, DPhil, FRCPC, AGSF Co-Chair and Director of Health Policy Research, National Institute on Ageing Director of Geriatrics, Sinai Health and the University Health Network, Toronto, Ontario Assistant Professor, Department of Medicine, Johns Hopkins University School of Medicine Associate Professor, Departments of Medicine, Family and Community Medicine, and the Institute of Health Policy, Management and Evaluation, University of Toronto, Ontario Sarah Sargent, MA Vice President, Canadian Operations Programs Canadian Red Cross Ottawa, Ontario Expert Contributors: Christina Baert-Wilson Senior Director, Community Health Canadian Red Cross Dartmouth, Nova Scotia Jane Barratt, PhD Secretary General, International Federation on Ageing Toronto, Ontario Sarah Burke, MA Acting Director, Respect Education Canadian Red Cross Victoria, British Columbia Dan Carbin, MSc Principal, Santis Health Toronto, Ontario Nancy Cooper, MHSA Director of Quality & Performance Ontario Long-Term Care Association Toronto, Ontario Leslie Eckel Knowledge Exchange Associate InterRAI Canada, University of Waterloo Waterloo, Ontario Sharon Goodwin, BScN, NP, MN, PhD Senior Vice President of Home and Community Care Victorian Order of Nurses (VON) Ottawa, Ontario Tyler Hague, MPA Manager, Disaster Risk Reduction Canadian Red Cross London, Ontario Irene Hobuleic Senior Director, Practice Quality and Risk Victorian Order of Nurses (VON) Toronto, Ontario Jessica Hseih, MSW, RSW Research Coordinator National Initiative for Care of the Elderly (NICE) Toronto, Ontario Andrea Iaboni, MD, DPhil, FRCPC Assistant Professor, Department of Psychiatry, University of Toronto Medical Lead, Geriatric Psychiatry, Toronto Rehab, University Health Network Toronto, Ontario REPORT DEVELOPMENT CONTRIBUTORS CLOSING THE GAPS: ADVANCING EMERGENCY PREPAREDNESS, RESPONSE AND RECOVERY FOR OLDER ADULTS 2 Sophia Ikura, MPA Executive Director, Population Health Solutions Lab Sinai Health Toronto, Ontario Mackenzie Kiemele Coordinator Canadian Association of Retired Persons (CARP) Toronto, Ontario Michael Nicin, MA, MPP Executive Director National Institute on Ageing Toronto, Ontario Shawna Peddle, MSc Former Director, Disaster Risk Reduction Canadian Red Cross Guelph, Ontario Arianne Persaud Communications and Public Affairs Manager National Institute on Ageing Toronto, Ontario Veronica Said, MA Consultant, Santis Health Toronto, Ontario Jennifer Savoy, BA Manager, Emergency Management and Programs Branch Public Safety Canada Ottawa, Ontario Dallas Seitz, MD, PhD Associate Professor, Department of Psychiatry, Hotchkiss Brain Institute, and O'Brien Institute for Public Health Cumming School of Medicine, University of Calgary Calgary, Alberta Samina Talat, MHSc Associate Vice President, Health Innovations Canadian Red Cross Mississauga, Ontario Laura Tamblyn-Watts, LLB National Director of Law, Policy and Research Canadian Association of Retired Persons (CARP) Toronto, Ontario Sandy van Solm, PhD Manager, Emergency Management/CEMC Region of Waterloo Waterloo, Ontario Melinda Wells, MPA Director, Global Relations and Humanitarian Diplomacy International Operations Canadian Red Cross Ottawa, Ontario Ivy Wong, MPA Policy Director National Institute on Ageing Toronto, Ontario Caberry Yu, BHSc, MD(c) Junior Research Fellow National Institute on Ageing Toronto, Ontario Lina Zita, BHA Development and Marketing Coordinator Older Adults Centres’ Association of Ontario Caledon, Ontario 3 Project Staff Nicoda Foster, MPH, PhD(c) Project Manager CRC/NIA Emergency Preparedness for Older Adults Project Office of the Director of Geriatrics Sinai Health and the University Health Network Toronto, Ontario Laura Romero, BSc Research Assistant CRC/NIA Emergency Preparedness for Older Adults Project Office of the Director of Geriatrics Sinai Health and the University Health Network Toronto, Ontario Acknowledgments Shionne Hitchman, BScH Research Assistant ARC/AAN Emergency Preparedness for Older Adults Project Office of the Director of Geriatrics Sinai Health and the University Health Network Toronto, Ontario Elsa Nana Nzepa, BSc Program Assistant CRC/NIA Emergency Preparedness for Older Adults Project Office of the Director of Geriatrics Sinai Health and the University Health Network Toronto, Ontario The authors would like to thank Veronica Said, Dan Carbin, Peg Christensen, Daphne Horn, Chris Walsh and Allan McKee for their important contributions towards the development of this report. REPORT DEVELOPMENT CONTRIBUTORS CLOSING THE GAPS: ADVANCING EMERGENCY PREPAREDNESS, RESPONSE AND RECOVERY FOR OLDER ADULTS 4 International Federation on Ageing ecagp lacgp <:JIW,Ot,Ui.r.u.DfMYOf A(;A0£1,11£ ( 1tt,1,1oDlf_tlNI: GC RIAT RIC PSYCIII.O.TltY OEG(ROHlO~YCHlAl lttE CAOT · ACE canadlan Association of Occupational Therapists Association canadienne des ergotherapeutes $ CAEPIACMU
CASW ACTS Canadian Frailty Network Reseau canadien des soins aux personnes fragilisees C GN~ ~ anadian Geron)ol?gical .f"'1.: Nursing Association ASSOCIATION (£ MEDICALE l CANADIENNE CANADIAN MEDICAL ASSOCIATION CANADIAN NURSES ASSOCIATION ~- CanAge. Alzheimer Society CANADA
CanadianAssociation .., .,. for Long Term Care CANAOl,6,N H:D[RATION OF NIJRSES UNIO»S LA F"EOERATION (ANAOIENNE DES SYNDIC ATS D'INFIRMIEAES ET INFIRHIERS t Canadian Home Care Association canadienne de soins et services a domicile Canadian Network for the Health and Housing of People Experiencing Homelessness Organizational Endorsements The Canadian Red Cross in partnership with the National Institute on Ageing would like to thank the following organizations who have given their support and official endorsement of this work. 5 Canadian Physiotherapy Association ft NICE Association canadienne de physiotherapie National Initiative for the Care of the Elderly Initiative nationale pour le soin des personnes a.gees ' ( ' ,., Closing the Gap® HEALTHCARE - _.. ,._ CS TCM I Canadian Society for !IP L Long-Term Core Medicin1 National Pensioners f.ederat'on Nationale Federation ~ des Retra.ltes J.1Hnostmeae a SENIOR CARE ® HUllldll RKJhb do nol hc1ve d bf~I befoie d,He Health CARERS CANADA PROCHES AIDANTS au CANADA ORGANIZATIONAL ENDORSEMENTS CLOSING THE GAPS: ADVANCING EMERGENCY PREPAREDNESS, RESPONSE AND RECOVERY FOR OLDER ADULTS 6 Long Term & Continuing Care Association of Manitoba L’Association de soins continus et à long terme du Manitoba ALBERTA CONTTNUING CAREASSOC/ATTON
AdvantAge Ontario Advancing Senior Care OACAO The Voice of Older Adult Centres La voix des centres pour aines OCSA Ontario Community Support Association ¦ Provincial Geriatrics Leadership Office Region of Waterloo THE GERONTOLOGICAL NURSING ASSOCIATION ONTARIO ONTARIO LONG TERM CARE ASSOCIATION ~TDRDNm The New Brunswick Association of NURSING HOMES L'Association des FOYERS DE SOINS du Nouveau-Brunswick ~~E ONTARIO \ Bringing Health Care Home @ caAregiver ORGANIZATION OPS OUIUIIO PlfS OU, SJ PP 0 1 1 WOf)!PS A SSO CIJ 1 l II: HEALTH COMMONS SOLUTIONS LAB ~ 7 Abbreviations AAN......................................................................................................................................................American Academy of Nursing ADLs.................................................................................................................................................................Activities of Daily Living ADRD........................................................................................................................Alzheimer’s Disease and Related Dementias ARC ...........................................................................................................................................................................American Red Cross CARP...............................................................................................................................Canadian Association of Retired Persons CDC ............................................................................................................................Centers for Disease Control and Prevention CILs .....................................................................................................................................................Centers for Independent Living CRC ...........................................................................................................................................................................Canadian Red Cross ED .......................................................................................................................................................................Emergency Department EMS .........................................................................................................................................................Emergency Medical Services LTC .....................................................................................................................................................................................Long-Term Care PTSD ..................................................................................................................................................Post-Traumatic Stress Disorder PDA ................................................................................................................................................................Personal Digital Assistant PPE ......................................................................................................................................................Personal Protective Equipment SAC ...............................................................................................................................................................Scientific Advisory Council SDM ..............................................................................................................................................................Substitute Decision Maker SMART .....................................................................................................................................Simple Triage and Rapid Treatment SWiFT ...............................................................................................................................................Seniors Without Families Team US .....................................................................................................................................................................United States of America ABBREVIATIONS CLOSING THE GAPS: ADVANCING EMERGENCY PREPAREDNESS, RESPONSE AND RECOVERY FOR OLDER ADULTS 8 Executive Summary Older adults consistently experience the greatest proportion of casualties during and after emergencies in Canada, and internationally, when compared to younger age groups (Fernandez, Byard, Lin, Benson, & Barbera, 2002; Mokdad, et al., 2005). For instance, in 1998, ice storms resulted in widespread power outages across Quebec that saw 600,000 people, that included older adults, forced from their homes and a high mortality rate among older persons due to a lack of available heating equipment, less optimal housing conditions, and poor coordination between emergency, health and social services (Plouffe, Kang, & Kalache, 2008). Over a decade later in 2010, more than half of all deaths resulting from heat waves in Quebec were among persons aged 75 years or older (Bustinza, Lebel, Gosselin, Belanger, & Chebana, 2013). In the 2017 wildfires in British Columbia and floods in Quebec, older adults were impacted the hardest due to their greater levels of vulnerability, while poorly coordinated protocols left them more vulnerable due to delays in initiating evacuation procedures (Global News, 2017; Roslin, 2018). More recently, 97% of Canada’s first 10,000 COVID-19 deaths have occurred in older Canadians 60 years of age and older (Grant, 2020), with the greatest proportion of deaths occurring in long-term care and retirement homes (Canadian Institute for Health Information, 2020; Government of Canada, 2020). Several research studies have demonstrated that these poor outcomes are linked to physiological age-related changes, such as impairments to sensory, cognitive and mobility disabilities; access and functional needs; social isolation and lack of access to familial and other social supports; having limited financial resources; and insufficient policies and procedures (Al-Rousan, Rubenstein, & Wallace , 2014; Fernandez, Byard, Lin, Benson, & Barbera, 2002; Killian, Moon, McNeill, Garrison, & Moxley, 2017). Furthermore, interruption to the timely provision of routine medical care is recognized as a likely contributor to mortality and morbidity associated medical complications during emergencies, especially in the immediate months following major natural disasters. The high proportion of deaths that also seem to occur in older adult congregate living settings is further indicative of fundamental issues that will need to be addressed in these settings as well. There exists a diverse continuum of capacity for older adults, from reduced capacity due to physical and cognitive impairments, as noted above, to active, engaged members of their communities. Older adults themselves should be empowered to reach out and connect with their peers, particularly those who are more vulnerable, supporting each other in anticipating and preparing for emergencies. The critical role of older adults who act as the sole or primary caregivers of other older adults, whether they be partners, family members, or friends, must also be recognized and supported. There is a clear need to better support emergency preparedness for older Canadians living at home in the community or in congregate settings. In order to improve preparedness and response to 9 emergencies, Canada needs greater consideration and adoption of evidence-informed, uniform and collaborative emergency management interventions. These efforts will require improved resources and capacity to meet the emergency needs of all older adults, regardless of the variety of circumstances and settings in which they may be living. In 2018, to address these gaps in emergency and disaster preparedness and management, members of the American Red Cross Scientific Advisory Council (ARC SAC) and the American Academy of Nursing (AAN) Policy Expert Round Table on Emergency/Disaster Preparedness for Older Adults agreed to conduct a scientific review of the latest evidence, current available legislation, and policies, in order to develop a set of recommendations that were then further reviewed and strengthened by a broader panel of experts with specific expertise in the fields of social work, education, public health, research, health policy, emergency management, geriatrics, and nursing. Through a rigorous consensus decision-making process, a comprehensive final set of 25 evidenceinformed recommendations were ultimately developed and endorsed by this group. This report is an extension and continuation of that work with an expanded focus that includes epidemics and pandemics. The COVID-19 pandemic has had its greatest impact on older adults in Canada and globally. The challenges experienced by older Canadians has demonstrated the need for improvements in preparedness planning targeting one of the most vulnerable group in our society. This report highlights areas where there are opportunities to better support older Canadians and their caregivers and the system more broadly, to be prepared before and successfully recover after the emergency. To adapt the recommendations for the Canadian context, the Canadian Red Cross and the National Institute on Ageing agreed to collaborate on an identical consensus-based development process employed by the ARC and AAN. The Canadian process resulted in 29 evidence-informed expert recommendations. This paper presents those recommendations, and the rationale behind them, for improving emergency preparedness, response and recovery interventions for older adults across Canada. In order to achieve a collaborative approach to improving emergency management nation-wide, the recommendations are categorized across six relevant emergency management domains: 1. Individuals and unpaid caregivers; 2. Community-based services and programs; 3. Health care professionals and emergency response personnel; 4. Care institutions and organizations; 5. Legislation and policy; and 6. Research. The intention of these recommendations is to provide interventions that can bridge the existing gaps in emergency preparedness, response and recovery, and facilitate better outcomes for older adults across Canada. EXECUTIVE SUMMARY CLOSING THE GAPS: ADVANCING EMERGENCY PREPAREDNESS, RESPONSE AND RECOVERY FOR OLDER ADULTS 10 Summary of Recommendations 1. Individuals and Unpaid Caregivers Domain Recommendation 1.1: Older adults and their unpaid caregiver(s) should be provided with tailored, easy-to-access information and resources related to emergency preparedness and guidance on how to develop customized emergency plans that consider the functional and health needs of older adults and appropriate strategies to support infection/disease prevention. Volunteer representatives of older Canadians and their unpaid caregivers should be recruited and involved in developing and disseminating resources and training material, to ensure their voices and perspectives are reflected. Recommendation 1.2: Older adults who are reliant on mobility aids should remove or minimize barriers affecting their ability to evacuate, and should take steps to ensure their safety within their surroundings. Recommendation 1.3: If registries for people with functional and other needs, including persons with disabilities, have been established by local emergency response agencies, older adults and/or their unpaid caregiver(s) should register so they can be better assisted/supported during emergencies. Recommendation 1.4: Older adults who have a sensory impairment, such as a visual or hearing disability, should take additional precautions to prepare themselves for emergencies. Recommendation 1.5: Older adults who live with chronic health conditions should maintain a readily accessible list of their current medical conditions, treatments (medications, durable medical equipment, supplies and other health care needs), health care providers, and emergency contacts, including substitute decision makers (SDMs). Recommendation 1.6: Older adults who take medications should work with their Health Care professionals to ensure they have access to at least a 30-day supply of medications during an emergency. Recommendation 1.7: Older adults who are reliant on medical devices that require electricity, should ensure they have back-up power supplies in place, especially if required while sheltering-inplace.
Older adults and/or their unpaid caregivers should contact their electricity company in advance to discuss their needs and ensure options for alternative power sources are available, especially addressing the need for access to power to charge cell phones and other mobile devices.
Older adults and/or their unpaid caregivers should seek assistance with obtaining and maintaining an alternative power source at home, if required, such as when being required to move heavy equipment and fuel or in accessing these resources in rural locations, and operating equipment. Recommendation 1.8: Older adults should be encouraged to continually maintain an adequate local support network that can be called upon during impending disasters and unexpected emergencies, especially if they live alone or lack easy access to relatives. 11 EXECUTIVE SUMMARY Recommendation 1.9: Unpaid caregivers of persons with Alzheimer’s disease and/or other dementias should be supported to identify signs of distress, anxiety, or confusion, and use strategies to redirect attention, and help them stay calm during emergencies. In addition, unpaid caregivers should be prepared to prevent wandering, and have plans in place to locate their care recipients if they do wander or require medical intervention(s) during an emergency. 2. Community-Based Services and Programs Domain Recommendation 2.1: Access should be increased to tailored community-based programs that educate older adults and their unpaid caregivers about emergencies that could affect their region and how best to prepare for and respond to them. Volunteer representatives of older Canadians and their unpaid caregivers should be recruited and involved in training material development and implementation, to ensure their voices and perspectives are reflected.
Community-based programs and organizations should collaborate with regional public health authorities in developing and disseminating education resources on infection control, disease and injury prevention practices for older adults and their unpaid caregivers during emergencies. Recommendation 2.2: Programs that provide disaster relief and/or essential community services, such as Meals on Wheels, and daily living assistance for older people (financial, medical, personal care, food and transportation) should receive emergency preparedness training and education, as well as should develop and adhere to plans and protocols related to responding adequately to the needs of their clients during emergencies. Volunteer representatives of older Canadians and their unpaid caregivers should be recruited and involved in training material development and implementation, to ensure their voices and perspectives are reflected. Recommendation 2.3: Community-based programs that provide in-home health and personal care for older adults should integrate strategies that minimize unnecessary personal contact and leverage resources (e.g. personal protective equipment such as gowns, masks, gloves, hand sanitizer etc.) in their emergency preparedness plans and protocols. Recommendation 2.4: Local governments should leverage data sources that identify at-risk individuals to enable emergency responders to more easily prioritize their search and rescue efforts following an emergency. 3. Health Care Professionals and Emergency Response Personnel Domain Recommendation 3.1: Health care professionals and emergency response personnel should receive training on providing geriatric care relevant to their discipline and how best to assist older adults and their unpaid caregivers before, during and after emergencies. The additional education and training should also increase their awareness of best practices and precautions to minimize the risk of infectious disease transmission or spread while responding to emergencies. Volunteer representatives of older Canadians should be recruited and CLOSING THE GAPS: ADVANCING EMERGENCY PREPAREDNESS, RESPONSE AND RECOVERY FOR OLDER ADULTS 12 involved in training material development and implementation, to ensure their voices and perspectives are reflected. Recommendation 3.2: Health care professionals and emergency response personnel should strive to mitigate negative outcomes among older adults during and after emergencies by adopting effective strategies designed to protect the physical and mental health of older adults they may come in contact with. Strategies can include assessing the psychological well-being of older adults for signs of distress and providing appropriate treatments or referrals as needed. Recommendation 3.3: Health care professionals and emergency response personnel should receive cultural awareness training to provide appropriate care and support for older adults with different cultural and religious backgrounds before, during, and after an emergency. Providers should have options for providing support to older adults and their unpaid caregivers who face language or cultural barriers to accessing supports (e.g., translators, written materials in languages other than English or French, etc.). This is of particular importance for personnel that work with Indigenous populations, in diverse community-settings and during times of evacuation due to emergencies. 4. Care Institutions and Organizations Domain Recommendation 4.1: Care institutions and organizations should include emergency preparedness and response education in their routine training courses.
Multi-modality educational tools and practices should be used to better facilitate knowledge acquisition and behavioral change.
Volunteer representatives of older Canadians should be recruited and involved in developing and disseminating resources and training material, to ensure their voices and perspectives are reflected. Recommendation 4.2: Additional strategies to improve the collection and transfer of identifying information and medical histories should be adopted into current standardized patient handoff procedures to better facilitate effective tracking, relocation and care of patients during an emergency. Recommendation 4.3: Care institutions and other organizations should strive to develop comprehensive emergency plans that include effective response strategies for protecting older adults against infectious disease outbreaks and reflect evidence-based standards supported by organizations such as Infection Prevention and Control Canada (IPAC).
Care institutions should also regularly assess and address any barriers they identify that could affect the implementation of their emergency plans that build on their routine practices. 5. Legislation and Policy Domain Recommendation 5.1: A national advisory committee should be created to inform emergency preparedness, response and recovery program development and strategies for older Canadians. Individuals who are representative of older Canadians and their unpaid caregivers should be involved to ensure their voices and perspectives are reflected. 13 EXECUTIVE SUMMARY Recommendation 5.2: All provinces and territories should support the implementation of tax-free emergency preparedness purchasing periods during specific times of the year or prior to an impending emergency. Governments should also provide targeted funding to directly support/ subsidize the purchase of emergency preparedness kits for older Canadians. Items covered should include an agreed-upon list of emergency supplies (such as batteries, portable generators, rescue ladders, radios and ice packs), air conditioners, personal protective equipment (such as masks, gloves and hand sanitizer) and additional mobility aids (canes, walkers, etc.). Recommendation 5.3: All provinces and territories should support the creation of a national licensure process or program for nurses, physicians, allied health professionals and other emergency medical service personnel to allow them to provide voluntary emergency medical support across provincial/territorial boundaries during declared states of emergency. Recommendation 5.4: All provincial and territorial governments should support legislative requirements that mandate congregate living settings for older persons (e.g. nursing homes, assisted living facilities and retirement homes) to regularly update and report their emergency plans that outline actions and contingencies to take in case of emergencies. These plans should include:
Back-up generators in case of extended periods of power outages, and coordinated plans with relevant community agencies (e.g. municipal fire agencies) for efficient evacuations.
Direction on appropriate interventions (i.e. selfisolation, wearing face masks, physical distancing, etc.) to control and prevent outbreaks and spread of infectious diseases amongst the population in times of emergencies.
Clear thresholds for temperature regulation, specifically, maximum and minimum temperatures permissible based on occupational and environmental health standards, and the steps required to regulate temperatures and minimize fluctuations.
An outline of staffing levels that should be maintained during emergencies to minimize care and/or service interruptions. All provinces and territories should work towards standardizing requirements for emergency plans in congregate living settings in accordance with the priorities outlined in the 2019 Emergency Management Strategy for Canada and ensure that their emergency plans for congregate living settings are aligned with directives outlined in their provincial/territorial pandemic and emergency plans. Recommendation 5.5: All provinces and territories should adopt a standardized approach to promoting collaborations between local pharmaceutical prescribers and dispensers (i.e. community pharmacists), physicians and nurse practitioners, to ensure an adequate supply of prescription medications are dispensed to persons with chronic health conditions prior to and during an emergency. This approach should also outline the need for collaboration between pharmaceutical providers, hospitals and relief agencies to ensure an adequate supply of prescription medications are available at hospitals, relief and evacuation shelters.
All persons should be able to obtain at least a 30-day supply of emergency prescription medications prior to and during an emergency. CLOSING THE GAPS: ADVANCING EMERGENCY PREPAREDNESS, RESPONSE AND RECOVERY FOR OLDER ADULTS 14 6. Research Domain Recommendation 6.1: There is a need to prioritize the creation and funding of research efforts to better support the development of a common framework for measuring the quality and levels of emergency preparedness among care institutions, organizations, paid providers, community organizations, and other groups that work primarily with older adults and their unpaid caregivers during and after emergencies. Recommendation 6.2: There needs to be a more concerted effort in utilizing outcomes from existing evidence to support the planning, design, and refinement of more evidence-informed emergency preparedness interventions, policies, and regulations in support of older adults and unpaid caregivers, as well as organizations and paid care providers that will be responsible for meeting their needs during and after an emergency. Recommendation 6.3: A network of emergency preparedness researchers, older adults, unpaid caregivers, volunteers and providers needs to be created to encourage partnerships in the ongoing unpaid evaluation of emergency preparedness interventions targeting older adults. Network members should advocate for an increased focus on emergency preparedness research among the various societies or journals that they are members of. Recommendation 6.4: There is a need to focus on research about unpaid caregivers and emergency preparedness to better instruct unpaid caregivers on how to take care of their vulnerable family members and friends during an emergency. Recommendation 6.5: There is a need to focus on research about emergency preparedness and response in Canadian community and congregate living settings for older adults (e.g. nursing, retirement and group homes and assisted living facilities). Research should:
Determine the existing levels of preparedness across these environments as well as highlight the challenges they face in being prepared.
Characterize the impact of the emergency on the older adult population and emerging best practices on how to address it as soon as it emerges. 15 BACKGROUND AND CONTEXT The Current State of Emergency Outcomes for Older Adults in Canada Natural disasters and infectious disease pandemics are two of the most frequent emergencies that pose great risks to public health and safety because of their ability to disrupt the day-to-day functioning of a population. As a result, emergency preparedness and response efforts include both large and small scale strategies designed to minimize harm, particularly to vulnerable groups such as older adults, defined as those aged 65 and older. Over the last decade, several large scale emergencies have highlighted the particular vulnerabilities of older adults who were the most affected by them. For instance, in 1998, ice storms resulted in widespread power outages across Quebec that saw 600,000 people, that included older adults, forced from their homes and a high mortality rate among older persons due to a lack of available heating equipment, less optimal housing conditions, and poor coordination between emergency, health and social services (Plouffe, Kang, & Kalache, 2008; Steuter-Martin & Pindera, 2018). Over a decade later in 2010, more than half of all deaths resulting from heat waves in Quebec were among persons aged 75 years or older (Bustinza, Lebel, Gosselin, Belanger, & Chebana, 2013). In the 2017 wildfires in British Columbia and floods in Quebec, older adults were impacted the hardest due to their greater levels of vulnerability, while poorly coordinated protocols left them more vulnerable due to delays in initiating evacuation procedures (Global News, 2017; Roslin, 2018). More recently, 97% of Canada’s first 10,000 COVID-19 deaths have occurred in older Canadians 60 years of age and older (Grant, 2020), with the greatest proportion of deaths occurring in long-term care and retirement homes (Canadian Institute for Health Information, 2020; Government of Canada, 2020). Close to 1700 outbreaks have been reported in LTC and retirement homes, accounting for approximately 80% of all COVID-19 deaths in Canada (Canadian Institute for Health Information, 2020; NIA Long- Term Care COVID-19 Tracker Open Data Working Group, 2020). The impacts that emergencies such as natural disasters and infectious disease pandemics have on older adults rarely end once the emergency has ended. Interruptions to medical care, especially for those living with chronic conditions, can cause increased morbidity and mortality in the months during and following a large scale emergency. Despite the gaps in emergency preparedness and response efforts that have been highlighted over the past decade, older adults continue to experience a greater proportion of emergencyrelated mortality rates and emergency-related declines in health, while continuing to report lower rates of emergency preparedness (Al- Rousan, Rubenstein, & Wallace , 2014; Brunkard, Namulanda, & Ratard, 2008; Cherniack, Sandals, Brooks, & Mintzer, 2008; Gibson & Hayunga, 2006; Kosa, Cates, Karns, Godwin, & Coppings, 2012; Mokdad, et al., 2005; Marshall, Ryan, Robertson, Street, & Watson, 2009). As the baby boomers continue to age, it is expected that the population of older adults aged 65 years Background and Context CLOSING THE GAPS: ADVANCING EMERGENCY PREPAREDNESS, RESPONSE AND RECOVERY FOR OLDER ADULTS 16 and older in Canada will significant increase over the next few decades. By 2030, the proportion of the total Canadian population aged 65 and over will increase to upwards of 23.4%, from 17.2% of the overall population in 2018 (Statistics Canada, 2020). This proportion is projected to increase reaching upwards of 29.5% of the overall population by 2068 (Statistics Canada, 2020). This rapid growth in our population of older Canadians will increase the demand for emergency services to meet the emergency preparedness, response, and recovery needs of those individuals at greater risk for negative outcomes. The need for more age-friendly emergency response services is further supported by the expected increase in the frequency and severity of extreme weather events that can in turn lead to infectious disease outbreaks when they result in changes to human conditions or exacerbate existing health conditions (Field, Barros, Dokken, Mach, & Mastrandrea, 2014; Kouadio, Aljunid, Kamigaki, Hammah, & Oshitani, 2012). Further, in addition to post-disaster infectious disease outbreaks, the frequency and risk of epidemics and pandemics are always imminent given the population density in metropolitan cities and the openness of country borders that facilitate travel and migration. Consequently, ensuring the safety of older adults will require greater efforts in the overall area of emergency management for this growing population, and especially for those living in congregate settings. Studies have highlighted the socioeconomic factors that make older adults more vulnerable to experiencing adverse outcomes during and after emergencies, and the insufficiencies present among various levels of emergency management to respond to the vulnerabilities of this group (Aldrich & Benson, 2008; Banks, 2013; Bustinza, Lebel, Gosselin, Belanger, & Chebana, 2013; Tricco, Lillie, Soobiah, Perrier, & Straus, 2013). Particularly, older adults have been found to experience more adverse outcomes during an emergency compared to their younger counterparts due to their complex and individualized capabilities and challenges. As one gets older, age-related changes begin to take place, such as a natural gradual weakening of one’s immune system known as immunosenesence, and an increased chance of having a chronic health condition or multi-morbidity, living in social isolation, and experiencing declines in sensory, cognitive and physical functioning (Aldrich & Benson, 2008; Kosa, Cates, Karns, Godwin, & Coppings, 2012). While these changes are often sufficiently managed in an older adult’s day-today life, emergencies such as natural disasters and infectious disease pandemic can impose additional barriers to accessing resources and supports, and put older adults with complex needs at an increased risk of harm. Emergency management for older adults can be further weakened by health care providers’ low levels of emergency and geriatric specific education and training; limited provision of community-based emergency training programs for older adults and their unpaid caregivers; statutes and regulations that impose barriers to individual preparedness; and lack of a standardized approach to emergency 17 BACKGROUND AND CONTEXT preparedness nation-wide (Pesiridis, Galanis, Sourtzi, & Kalokairinou, 2014; Scott, Carson, & Greenwell, 2010; Wyte-Lake, Claver, Griffin, & Dobalian, 2014). However, there exists a diverse continuum of capacity amongst older adults, from reduced capacity due to physical and cognitive impairments, as noted above, to others who are active, engaged members of their communities. Older adults should be empowered to reach out and connect with their peers, particularly those who are more vulnerable, to support each other in anticipating and preparing for emergencies. The critical role of older adults who act as the sole or primary caregivers of other older adults, whether they be partners, family members, or friends, must also be recognized and supported. To address this gap in emergency preparedness members of the American Red Cross Scientific Advisory Council (ARC SAC) and the American Academy of Nursing (AAN) Policy Expert Round Table on Emergency Preparedness for Older Adults agreed to conduct a scientific review of the latest evidence, current available legislation, and policies, in order to develop a set of recommendations that were then further reviewed and strengthened by a broader panel of experts with specific expertise in the fields of social work, education, public health, research, health policy, emergency management, geriatrics, and nursing. Through a rigorous consensus decision-making process, a comprehensive final set of 25 evidenceinformed recommendations were ultimately developed and endorsed by this group. To bring this work into the Canadian context, members of the ARC Scientific Advisory Council from the Canadian Red Cross (CRC) and the National Institute on Ageing (NIA) reviewed the ARC/AAN’s findings, further reviewed additionally relevant Canadian literature, policy and legislative aspects, and hosted an Expert Policy Round Table on Emergency Preparedness for Older Canadians in May, 2019, in Toronto, ON. The Canadian Round Table brought together 18 experts from a variety of fields, including social work, education, research, health policy, emergency management, geriatrics, and nursing. The Policy Expert Round Table reviewed the ARC/ AAN’s original 25 recommendations, particularly the legislative recommendations, which had been updated for the Canadian context, and any additional evidence applicable to older Canadians. The majority of recommendations were generally applicable to Canada and were agreed to be appropriate and supported by the Round Table. The subsequent advent of the COVID-19 pandemic invited an even broader review of the literature to include a focus on infectious disease pandemics and opportunities to address gaps in preparedness. This report’s reference panel initially put forward 26 final recommendations that aimed to implement emergency preparedness-related changes among the following relevant emergency management domains: 1) individuals and unpaid caregivers; 2) community services and programs; 3) health care professionals and emergency response personnel; 4) care institutions and organizations; 5) legislation/policy; and 6) research. The CRC/NIA’s later decision to expand the report’s focus to also address preparedness for CLOSING THE GAPS: ADVANCING EMERGENCY PREPAREDNESS, RESPONSE AND RECOVERY FOR OLDER ADULTS 18 infectious disease pandemics ultimately resulted in a final total of 29 recommendations being presented in this document. Report Recommendations Development Approach Initial Scoping Review and Development of an Ecological Analytical Framework In the initiation of this project, the American Red Cross Scientific Advisory Council and the American Academy of Nursing Policy Expert Round Table on Emergency Preparedness for Older Adults began a scoping review of the agerelated factors that make older adults more vulnerable to adverse outcomes during and after an emergency, with the primary focus being on large scale natural disasters. For the purpose of the scoping review, a disaster was defined as a natural or man-made phenomenon that causes interruptions or loss of life. Disasters based on this definition included the following: floods, hurricanes, tornadoes, nuclear explosions, and complex disasters. Disasters arising from malicious biological and chemical agents, and terrorism were excluded. The impact of natural disasters is far reaching and can lead to other types of disasters that, though unintended, can be severe in nature and cause harm. Examples of such disasters include health care disasters that can be defined as a disaster that prevents access to health care in times of emergency (Swathi, Gonzalez, & Delgado, 2017). A health care disaster also happens when the destructive effects of natural disasters can overwhelm the ability of a given area or community to meet the demand for Health Care (Zibulewsky, 2001). It is important to note the clear causal link between natural disasters and health care disasters, as natural disasters can lead to a breakdown in the health system’s responsiveness to the need for health services following an emergency leaving affected communities without access to Health Care. The scope and focus of this search was primarily on natural disasters, which have produced some results that have overlapping content but this was not the primary focus. Older adults were found to be more vulnerable to adverse outcomes during and after emergencies due to seven factors: an increased prevalence of chronic health conditions, physical, cognitive and sensory disabilities, weak social networks, accessibility and equity issues, and limited financial resources. This literature review also identified older adults and unpaid caregivers, community services and programs, health care professionals and emergency response personnel, care institutions and organizations, policy/legislation, and research as the relevant domains that contribute to disaster/emergency management for older adults. Adequate emergency preparedness was found to depend on synergy between relevant emergency management domains in order to mitigate the factors creating increased vulnerability among older adults during emergencies. Surrounding five of the six emergency management domains, and the seven factors of vulnerability, is the domain of research. It can identify and help to fill the existing gaps in knowledge and behaviour. 19 BACKGROUND AND CONTEXT Bronfenbrenner’s Ecological Framework was adapted to illustrate the interacting relationship of the seven factors of vulnerability and the six emergency management domains identified (Figure 1). Systematic Review Process A subsequent systematic literature review was conducted with an expanded scope for the Canadian version that included a focus on preparedness for pandemics and spread of infectious diseases in addition to the original focus on preparedness for natural disasters. The objective of the systematic review was to examine existing gaps in emergency preparedness for pandemics among the six previously identified emergency management domains for older adults (see Figure 1) and to determine successful interventions. For the purposes of the expanded focus, a pandemic was defined as “an epidemic occurring worldwide, or over a very wide area crossing international boundaries and usually affecting a large number of people” (Kelly, 2011). Preparedness was defined as the capacity to respond to a public health threat that includes natural disasters and infectious disease outbreaks (Patel, et al., 2008). Research Older Adults and Caregivers Finances Care Institutions and Organizations (System Policies & Procedures) Health Care Professionals and Emergency Responders Community Services and Programs Research Policy/Legislation Figure 1. Adapted from: Bronfenbrenner, U (1977). Toward an experimental ecology of human development. American Psychologist, 32, 513- 531. ~ ~,, '). 4, :o.¾. ., ,, Research PsYcholOfJ/ca/ and Socia/ Factors 4,Jeasau ~ 'i \ ".--\ '\ \ 9 i /ft;> i if .I. CLOSING THE GAPS: ADVANCING EMERGENCY PREPAREDNESS, RESPONSE AND RECOVERY FOR OLDER ADULTS 20 The review was guided by the six research questions listed below (for a detailed summary of the search strategy, see Appendix A). 1. Individuals and Unpaid Caregivers Domain Question 1: What are the factors that make older adults more vulnerable to adverse outcomes during an emergency compared to younger adults? 1.1. Are there age and/or function-related factors that make older adults more vulnerable to adverse outcomes compared to younger adults? 1.2.
What is the incidence of psychological distress among older adults following an emergency (natural disaster or pandemic) compared to younger adults?
Is there a difference in the incidence of psychological distress among older adults across different socio-demographic factors (that is, education, income, race, geography, etc.) following an emergency (natural disaster or pandemic)?
Is there a difference in the incidence of psychological distress among older adults with dementia, dementia related disorders or other cognitive impairments? 1.3. Are there specific actions caregivers of older adults should pursue to minimize adverse outcomes of older adults they care for during or after an emergency (natural disaster or pandemic)? 2. Community-Based Services and Programs Domain Question 2: What are the strategies and resources that can be leveraged at the community and program levels to improve emergency (natural disasters or pandemic) preparedness for older adults? 2.1. Is there a need for more geriatric-focused supportive care strategies to better prepare older adults and/or family caregivers for emergencies? 2.2. Are conventional emergency preparedness resources effective at facilitating knowledge acquisition and behavioral change among older adults and/or family caregivers with low-literacy skills or among those who are not fluent in English or French? 2.3. What are the most effective formats that can be used to communicate guidance on preparedness, warning messages and messages on how to access recovery resources in times of pending emergency among older adults and/or family caregivers?
What types of community/not-for-profit led interventions can be implemented to facilitate positive recovery outcomes for older adults and/or family caregivers following an emergency (natural disaster or pandemic)? 3. Health Care Professionals and Emergency Response Personnel Domain Question 3: What are the strategies and resources that can be leveraged to improve emergency response among health care professionals and emergency response personnel during and after an emergency (natural disaster or pandemic)? 21 3.1. Is there a need for an increase in the use of geriatric-focused triage care strategies when assessing the needs of older adults before or during an emergency (natural disaster or pandemic)? 3.2. What are the age- and function-specific training methods that health care professionals and emergency response personnel should follow when caring for and assisting older adults with varying capabilities and limitations during an emergency (natural disaster or pandemic)?
What are the most effective methods to teach age- and function-specific education to facilitate knowledge acquisition and behavioral change? 3.3. What core competencies or skills do health care professionals and emergency response personnel need to facilitate the delivery of culturally appropriate and safe care during emergencies (natural disasters or pandemic) to older adults with different cultural and religious beliefs/preferences?
Are there specific accommodations needed for Indigenous older adults in the event of relocation following an emergency (natural disaster or pandemic)?
Are there differences in methods for providing support to Indigenous (on or offreserve) and other racialized older adults who live in Canada? 4. Care Institutions and Organizations Domain Question 4: What are the strategies and resources that can be leveraged at the organizational or institutional level to improve emergency (natural disaster or pandemic) preparedness and recovery efforts for older adults? 4.1 Is there a need for more geriatric-focused supportive care strategies or design elements to better prepare organizations or institutions (relief agencies and shelters) that may be required to provide care for older adults during or after an emergency (natural disaster or pandemic)? 5. LegislationPolicy Domain Question 5: Are there legislations or policies have been developed or adopted at the municipal, provincial or federal level to improve emergency (natural disaster or pandemic) preparedness and recovery efforts for older adults? 5.1. Is there evidence that shows the effectiveness/ positive impact of any particular piece of legislation or policy? 5.2. Is there any evidence to suggest any existing legislation or policy may contravene what existing evidence would support? 6. Research Domain Question 6: What research or evidence gaps have been noted in the literature that could better inform efforts to improve emergency preparedness and recovery efforts for older adults? BACKGROUND AND CONTEXT CLOSING THE GAPS: ADVANCING EMERGENCY PREPAREDNESS, RESPONSE AND RECOVERY FOR OLDER ADULTS 22 Search Strategy The search for academic literature was conducted in two phases. Phase one focused on natural disasters and was implemented between June 2017 and April 2019. Phase two focused on infectious disease pandemics and was implemented between March and May 2020. Searches for both phases were restricted to databases with literature relevant to the fields of medicine, public health, nursing, and health care, which included MEDLINE, HealthStar, UpToDate, Clinical Key, EBSCOhost, Cochrane, CINAHL, Scopus and Google Scholar. The reference lists of relevant articles were also manually searched. Phase one search was restricted to articles published in English between 2008 and 2019. Phase two had no date restrictions but limited articles to only those published in English. The search parameters were focused on identifying gaps that were not addressed by existing evidence based guidelines published by established agencies and public health authorities such as Public Health Agency of Canada (PHAC), Centers for Disease Control and Prevention (CDC), Public Health Ontario (PHO), etc. Study Selection The screening and shortlisting process was identical in both phases. The titles and abstracts of the populated articles were screened to identify peer-reviewed articles that were eligible for a full text review. Articles were selected based on the following inclusion criteria: titles and abstracts that contained the search terms or content relevant to emergency management outcomes for one of the six identified domains. Relevant populations of older adults included those that live in assisted living facilities, nursing homes, independently at home, and those that are homebound or homeless. There were no geographic restrictions for the study population. All articles that met the inclusion criteria were saved in the reference manager Mendeley for future review and referencing. Legislative and policy documents were retrieved using Google. A search to identify established best practice guidelines for infection control was also conducted using Google. The searches yielded a combined total of 4390 academic literature as well as 15 legislative/policy oriented documents and 19 guidelines. After screening and full-text review, 52 peer reviewed papers were selected for data extraction and inclusion in addition to the 15 legislative/policy documents and 19 guidelines. Review of the findings led to the generation of 29 evidence-informed recommendations. Media Scan and Content Analysis of Reports Given the focus of Domain 5 on policy/legislation, a media scan was conducted as a parallel process to identify news reports, discussion papers and policy/legislative documents from provincial to federal levels. A content analysis of predominantly media reports was conducted to identify disasters or emergencies in Canada that had not been captured by the academic literature between 2008 and 2018. News reports were reviewed for statistics that were reported on resulting causalities or number of people impacted. The scan was conducted with a special focus on rural and remote regions, and the First Nation, Inuit and Metis populations of Canada. Key themes were identified from the content analysis that were then integrated into the white paper. 23 Expert Interviews To gather information on the preparedness, response and recovery experience of Indigenous Older Adults in Canada, the Canadian Red Cross (CRC) undertook a series of interviews with provincial emergency response personnel in four provinces that highlighted key issues and good practices observed through the experience of collaborating with Indigenous communities on preparedness activities, as well as through CRC operational support in evacuation and recovery operations. The themes identified through these interviews informed the text that supports recommendation 3.3. Consensus Decision-Making Process In June 2018, the American Red Cross (ARC) Scientific Advisory Council (SAC) and the American Academy of Nursing (AAN) Policy Expert Round Table on Emergency/Disaster Preparedness for Older Adults hosted a Policy Expert Round Table on Emergency/Disaster Preparedness for Older Adults (Policy Expert Round Table) to evaluate the findings of our scientific review and the feasibility of the proposed recommendations. To facilitate an evaluation of the recommendations and potential remaining gaps in emergency preparedness, a consensus decision-making process was adapted for the Policy Expert Round Table because it is an effective method of facilitating a collective contribution to a solution or intervention by encouraging dialogue, with the aim of considering and addressing the opinions and concerns of each of the participating experts (Seeds for Change, 2010). Consensus decisionmaking is a problem-solving process that aims to develop solutions that are supported by all the contributors. This is in contrast to voting processes, which generate solutions that reflect and satisfy the opinions of the majority of the contributors, but not the entire group (Seeds for Change, 2010). Nineteen experts were invited to participate in the Policy Expert Round Table; however, only 15 participants were able to attend. The final group consisted of experts from a variety of backgrounds related to disaster preparedness for older adults, including social work, education, public health or public health research, health policy, emergency management, geriatrics, and nursing. To better facilitate engagement in the topic during group discussions, all the participants were emailed a copy of the summary of evidence tables from the American systematic literature review. This gave the participants an opportunity to become familiar with the findings that were used to formulate the initial recommendations and guide any external research of their own which could later be used in discussion and amendments to the recommendations. In August 2018, a draft of this US report was sent to all attendees of the Policy Expert Round Table, and additional experts and organizations who were not able to attend the Policy Expert Round Table. This gave all attendees another opportunity to provide final critiques of the recommendations, and all non-attendees an opportunity to contribute feedback to the recommendations. The combined contribution of the two rounds of review ultimately generated the 25 final recommendations presented in a white paper titled “Closing the Gap: Advancing Disaster Preparedness, Response and Recovery for Older Adults.” BACKGROUND AND CONTEXT CLOSING THE GAPS: ADVANCING EMERGENCY PREPAREDNESS, RESPONSE AND RECOVERY FOR OLDER ADULTS 24 In May 2019, the Canadian Red Cross and the National Institute on Ageing came together to host a similar Expert Policy Round Table using an identical process to adapt the initial recommendations to a Canadian context. The Round Table brought together 18 experts from a variety of fields, including social work, education, research, health policy, emergency management, geriatrics, and nursing. The Policy Expert Round Table used a consensus-based decision-making process to review and critique the existing scientific evidence that was retrieved during the scientific review, as well as the endorsed recommendations from the American Red Cross/ American Academy of Nursing Policy Expert Round Table on Emergency/Disaster Preparedness for Older Adults. Review of the recommendations by the panel led to the generation of 26 initial evidence-informed recommendations that aim to reduce the occurrence of adverse emergencyrelated outcomes for older adults by increasing emergency preparedness among individuals and unpaid caregivers, and leverage appropriate emergency-related resources and strategies among the remaining emergency management domains. To begin the decision-making process, the existing issues related to emergency preparedness, and the proposed recommendations for intervention, were introduced and explained to all the participants in one large group. This gave the participants an opportunity to briefly review the methodology, a summary of evidence tables and the recommendations for intervention. The recommendations were divided into six sections based on the emergency management domains that were determined to be responsible for adopting or enforcing a given recommendation. After reviewing the supporting documents, three rounds of breakout sessions divided the participants into smaller groups. Breakout session one was used to review the list of recommendations for individuals and unpaid caregivers, community services and programs, and health care professionals and emergency response personnel. Breakout session two was used to review the list of recommendations for care institutions and organizations, and legislation/policy. Breakout session three was used to review the list of recommendations for research. Participants were able to select which breakout session groups they wanted to be placed in by indicating their preferences during the week prior to the Policy Expert Round Table. Since there were 18 participants and six sets of recommendations, each panellist participated in one recommendation discussion per breakout session. In their discussion groups, each participant was asked to consider the following discussion questions when reviewing the recommendations:
What issues/topics related to this area are missing from the evidence available?
Are the current recommendations adequate to address the issues related to this area?
What further additions/edits do you suggest to the current recommendations and why? The goal of the research questions was to facilitate discussion regarding the feasibility of the recommendations and whether or not the proposed recommendations sufficiently addressed the current gaps in emergency preparedness, response and recovery for older adults. The time allocated to the breakout sessions was used to provide their comments and 25 critiques on the initial recommendations, make amendments to the initial recommendations, or propose additional recommendations that were not included in the initial draft, as well as to discuss and reach consensus on issues related to comprehension and syntax of each of the recommendations that were delegated to a specific group. A consensus was required before new recommendations were added to the list, or omissions or amendments were made to the initial recommendations. If participants reached a point of disagreement within their group, facilitators probed participants for additional comments, clarification, justification or new approaches to problem-solving in order to reach a consensus within the group. After the participants reviewed all the recommendations in their breakout groups, the Policy Expert Round Table concluded with a final face-to-face meeting with all 18 participants. This meeting gave each breakout group an opportunity to present the final copy of their proposed recommendations drafted from the outcomes of their discussions, and also provided the participants who were not present in the remaining two groups an opportunity to discuss the feasibility of these recommendations as well. Review of the recommendations by the panel led to the generation of the 26 evidenceinformed recommendations that aim to reduce the occurrence of adverse emergency related outcomes for older adults by increasing emergency preparedness among individuals and unpaid caregivers, and leverage appropriate emergencyrelated resources and strategies among the remaining emergency management domains. In May 2020, given the devastating impact that the COVID-19 pandemic was having on older adults, both the CRC and NIA agreed to expand this report’s focus to also include infectious disease epidemics. This led to a second phase systematic review being conducted to inform the updating of the existing recommendations and the creation of three additional ones. The report and its now 29 recommendations were circulated among the attendees of the Policy Expert Round Table, and additional experts and organizations who were not able to attend the Policy Expert Round Table in August 2019. This gave all attendees another opportunity to provide final critiques of the recommendations, and all non-attendees an opportunity to contribute feedback to the recommendations. The combined contribution of the rounds of review ultimately generated the 29 final evidence-informed expert recommendations presented in this white paper. BACKGROUND AND CONTEXT CLOSING THE GAPS: ADVANCING EMERGENCY PREPAREDNESS, RESPONSE AND RECOVERY FOR OLDER ADULTS 26 Domain 1: Individuals and Unpaid Caregivers Older adults, in particular those who are living with chronic health conditions, are low-income and/or have low literacy skills, tend to disproportionately experience adverse outcomes during emergencies. There is also an opportunity for less-vulnerable older adults to play an important role in reaching out and connecting with their peers (and their unpaid caregivers) in helping them anticipate and prepare for emergencies. Older adults can best ensure their needs and concerns are represented in the emergency management space, and should be encouraged to volunteer their time before, during and after emergencies. There is a clear opportunity to develop, implement and evaluate emergency preparedness and response activities at the individual level that can better improve knowledge and recovery outcomes for older adults and their unpaid caregiver(s). An investigation of the vulnerabilities of older adults during emergency was guided by Research Question 1: What are the factors that make older adults more vulnerable to adverse outcomes during an emergency compared to younger adults? (see Development Approach). The search strategies that were used yielded a combined total of 4,390 peer-reviewed journal articles, 13 of which were used along with five guidance documents for data extraction related to this specific question. The review of these 18 resources revealed that older adults who are reliant on medications, and life-sustaining or assistive devices to support their health and wellbeing, have an increased risk for experiencing an adverse outcome during an emergency. Older adults are also more susceptible to infectious diseases after diseases or as a result of a pandemic that may exacerbate their pre-existing health conditions. Consequently, in response to this gap, nine evidence-informed expert recommendations were developed with the aim of increasing the levels of emergency preparedness among older adults with health- and/or function-related declines, and their unpaid caregiver(s). Recommendation 1.1 Older adults and their unpaid caregiver(s) should be provided with tailored, easy-to-access information and resources related to emergency preparedness and guidance on how to develop customized emergency plans, that consider the functional and health needs of older adults and appropriate strategies to support infection/disease prevention. Volunteer representatives of older Canadians and their unpaid caregivers should be recruited and involved in training material development and implementation, to ensure their voices and perspectives are reflected. Recommendation 1.2 Older adults who are reliant on mobility aids should remove or minimize barriers affecting their ability to evacuate, and take steps to ensure their safety within their surroundings. Recommendation 1.3 If registries for people with functional and other needs, including persons with disabilities, have been established by local emergency response agencies, older adults and/or their unpaid caregiver(s) should register so they can be better assisted/supported during emergencies. 27 DOMAIN 1: INDIVIDUALS AND UNPAID CAREGIVERS Recommendation 1.4: Older adults who have a sensory impairment, such as a visual or hearing disability, should take additional precautions to prepare themselves for emergencies. Understanding the Unique Personal and Functional Needs of Older Adults During Emergencies An older adult’s access to the support services that they require to maintain their overall quality of life and independence, such as home care and community services, can be disrupted during emergencies, or while being evacuated or sheltering-in-place. These circumstances can be further challenged by a lack of age-friendly services, a lack of accommodations for older adults at shelters, and concerns around pet safety and evacuation. Indeed, households who own pets are less likely to evacuate than those without pets. This is likely because people are concerned that they will not be evacuated with their pets, which is often cited as one of the main contributors to why people do not evacuate during emergencies (Benson, 2017; Whitehead, et al., 2000). One of the many strategies that can be leveraged to improve emergency preparedness among older adults is to encourage self-preparedness through the provision of easy access to emergency preparedness educational materials and planning guides that are tailored to older adults. Many organizations currently provide access to online emergency preparedness resources, such as the Government of Canada’s Get Prepared Campaign and the Canadian Red Cross Be Ready Campaign, which provide resources specific to a variety of emergencies and links to additional community resources (Canadian Red Cross, 2019; Government of Canada, 2015). While many of these resources aim to encourage older adults to prepare for a variety of emergencies, they do not provide solutions to overcome the unique challenges that many older adults face when preparing for, responding to, and recovering from an emergency. To address this current gap in emergency preparedness resources for older adults, Recommendation 1.1 aims to encourage older adults and their unpaid caregivers to access preparedness information and resources tailored for older adults, and to be particularly mindful of their functional and health-related needs when developing an emergency plan. For those organizations developing and distributing these resources, involving older adults in preparation and delivery is critical to ensuring the needs, concerns, and perspectives of older Canadians are considered (Marshall, Ryan, Robertson, Street, & Watson, 2009; Al-Rousan, Rubenstein, & Wallace , 2014). Resources should also be tailored to meet the language needs of diverse communities to increase accessibility where needed among older adults from racialized communities. Emergencies such as pandemics affect the most vulnerable groups and particularly those who experience social adversities that are exacerbated by the intersection of factors such as age, race and income (Navaranjan, Rosella, Kwong, Campitelli, & Crowcroft, 2014; Tricco, Lillie, Soobiah, Perrier, & Straus, 2013; Blackmon, et al., 2017). By making emergency preparedness information more accessible and encouraging older adults from diverse groups and their unpaid caregivers to take the initiative in evaluating their needs and developing appropriate plans to accommodate their expected challenges, this can help older CLOSING THE GAPS: ADVANCING EMERGENCY PREPAREDNESS, RESPONSE AND RECOVERY FOR OLDER ADULTS 28 adults be more confident in their abilities to be self-reliant when responding to an emergency or provide the additional resources needed to help emergency response personnel better assist older adults with functional limitations. Older age is often associated with a decline in motor functioning which can put older adults at risk of harm if they are unable to access their daily assistive devices, such as walkers and wheelchairs, or their unpaid caregivers during an evacuation (Bhalla, Burgess, Frey, & Hardy, 2015). Health professionals such as occupational therapists can be a valuable resource in the preparation and development of an emergency plan that factors in the functional needs of older adults reliant on assistive devices. Occupational therapists can also identify and help address environmental barriers to accommodate the needs of older adults and people with disabilities in order to facilitate effective emergency preparedness (Jeong, Law, DeMatteo, Stratford, & Kim, 2016). For example, at evacuation shelters, people with disabilities require ramps wide enough to accommodate wheelchairs (American Occupation Therapy Association, 2006). In addition to functional needs, emergency plans should also reflect strategies to prevent health emergencies resulting from either a pandemic or infections following natural disasters such as floods (Kouadio, Aljunid, Kamigaki, Hammah, & Oshitani, 2012). Consequently, emergency preparedness resources for older adults should include strategies for the primary prevention of infectious disease transmission in the home (Centers for Disease Control and Prevention, 2020; Finkelstein, Prakash, Nigmatulina, McDevitt, & Larson, 2013). However, as outlined in Recommendation 1.2, by preparing to overcome barriers to preparedness, such as environmental barriers that prevent successfully and timely evacuation, older adults can independently ensure that they have developed a more effective emergency evacuation plan. Strategies to address environmental barriers include installing wheelchair ramps, evacuation chairs and/or arranging for home evacuation and transportation assistance from a family member, friend, or unpaid caregiver, (Government of Canada, 2018). Allied health professionals such as occupational therapists can help adapt living spaces in order to maximize independence, safety and security, and are therefore able to plan accordingly for safe and effective evacuations (Fagan & Sabata, 2011; Stark, Landsbaum, Palmer, Somerville, & Morris, 2009). The Potential Role of Registries for People with Functional and Other Needs, Including Persons with Disabilities Registries for people with functional and other needs, including persons with disabilities, who live in the community are resources and data sources that have been established in many municipalities to provide emergency response agencies with a reference of the functional needs of residents in a community to allow emergency responders to better serve them. While registries can act as a resource for quickly locating persons with functional or other needs, it is not being recommended as a primary source of assistance for older adults or emergency response agencies to prepare for and respond to emergencies. This is because governments and aid agencies cannot guarantee that their assistance will be provided due to the high demands for response assistance during emergencies, which limits the availability of these services. In addition, Round Table discussion of the limitations of registries identified 29 DOMAIN 1: INDIVIDUALS AND UNPAID CAREGIVERS that vulnerability can be event-specific, and these registries can quickly become outdated, and have proven to be sometimes ineffective at identifying individuals in their target audience because many persons avoid registering because they do not consider themselves to be vulnerable, or out of fear of the stigmas associated with being labeled as ‘vulnerable persons.’ There was also concern that registries often instill the incorrect assumption that persons who have registered will be provided with priority assistance during an emergency. In reality, severe emergencies such as natural disasters and pandemics can be so resource restricting and demanding that emergency services cannot be guaranteed regardless of the severity of an individual’s condition or needs. With these limitations in mind, the Round Table participants arrived at a consensus that older adults who live in municipalities that have established registries should consider registering for this service, however, establishment of these registries should not be a requirement, as stated in Recommendation 1.3. Instead, it is intended that Recommendation 1.1 through Recommendation 1.9 will facilitate sufficient self-preparedness at the individual level by providing the guidance needed to develop an emergency plan that is customized to meet the health and functional needs of an individual older adult. Supporting Older Adults with Sensory Impairments Vision or hearing impairments can make it challenging for older adults to safely respond during an emergency, such as when navigating their surroundings at night or in an unfamiliar environment, or being able to effectively recognize emergency warnings (Cloyd & Dyer, 2010). While many preparedness resources already recommend that persons with sensory impairments make changes to their environment or take extra precautions that will make it easier for them to protect themselves during an emergency, Recommendation 1.4 proposes additional considerations to better prepare older adults with sensory impairments to respond to emergencies. Older adults with hearing impairments may find it difficult to hear emergency updates, instructions or communicate in a noisy environment (Banks, 2013; Cloyd & Dyer, 2010). To better assist older adults with a hearing impairment to communicate with emergency personnel, strategies should be adopted to help notify assisting personnel of their hearing impairment as outlined in the Government of Canada’s Emergency Preparedness Guide for People with Disabilities/Special Needs (Government of Canada, 2018). Strategies include moving their lips without making a sound or pointing to their ear/hearing aid. An effective strategy for notifying others of their hearing impairment will help signal to assisting personnel that they should adjust their communication approach to better accommodate persons with a hearing impairment. Many emergency preparedness guides urge for the installation of alert devices and emergency plans that incorporate oral communication with support network members; however, these guides often neglect to provide recommendations specific to persons who are hearing impaired, and therefore may be unable to use traditional emergency devices (Government of Canada, 2018). To tailor emergency communication plans to better meet the capabilities of persons with CLOSING THE GAPS: ADVANCING EMERGENCY PREPAREDNESS, RESPONSE AND RECOVERY FOR OLDER ADULTS 30 hearing impairments, non-verbal communication devices, such as text messages and teletypewriters should be adopted for communication. Since these communication devices do not depend on verbal communication, they can allow persons with hearing impairments to quickly and effectively contact support network members to ask for assistance, provide updates on their status and location, and better mimic everyday communication devices used by persons who are hearing impaired. Additionally, emergency plans that encourage the installation of alert devices that use lights or vibrations in addition to sound, such as bed shaker alarm devices, may be more effective at alerting persons with hearing impairments of an emergency than conventional alert devices that solely produce loud sounds when activated. Plans should also include additional batteries to power devices in case of a long-term power outage. Persons who are visually impaired are likely to experience challenges in navigating their surroundings during an emergency, particularly in a poorly lit shelter or in unfamiliar places, which can cause them to respond more slowly to emergencies or have difficulty following guidance outlined in emergency protocols (Lamb & O'Brien, 2010). To increase preparedness and enable older adults and their unpaid caregivers to respond effectively to emergency directives assistive devices, such as mobility aids (canes, walkers), and strategies, such as, a buddy system or guide animals, should be incorporated into emergency plans. To plan for unexpected interruptions or evacuations, it is also recommended that older adults with visual impairments and/or their unpaid caregivers include alternative evacuation routes and transportation methods into their emergency plan. By tailoring their surroundings and their emergency plans to better meet their needs, older adults with sensory impairments can create a plan that will allow them to be prepared during an emergency. Recommendation 1.5: Older adults who live with chronic health conditions should maintain a readily accessible list of their current medical conditions, treatments (medications, durable medical equipment, supplies and other health care needs), health care providers, and emergency contacts, including substitute decision makers (SDMs). Recommendation 1.6 Older adults who take medications should work with their health care providers to ensure they have access to at least a 30-day supply of medications during an emergency. Recommendation 1.7 Older adults who are reliant on medical devices that require electricity, should ensure they have back-up power supplies in place, especially if required while sheltering-in-place.
Older adults and/or their unpaid caregivers should seek assistance with obtaining and maintaining an alternative power source at home, if required, such as when being required to move heavy equipment and fuel or in accessing these resources in rural locations, and operating equipment. 31 DOMAIN 1: INDIVIDUALS AND UNPAID CAREGIVERS Supporting Older Adults with Chronic Health Issues The resource-straining effects of severe emergencies continue to threaten access to resources needed to support the complex needs of older adults with chronic health conditions during an emergency. Emergencies such as natural disasters can detrimentally affect one’s health by not only disrupting health services but also by creating power outages that can interrupt medical interventions that depend on electricity, such as life-supporting devices or medications that must be refrigerated during storage. During the 1998 ice storm at least 600,000 people, including older adults in long-term care institutions, were forced from their homes into hotels or other shelter with emergency power backup (Steuter-Martin & Pindera, 2018). Lack of mobility, pre-existing medical conditions, lack of heating equipment, less optimal housing conditions, and poor coordination between emergency, health and social services contributed to the high mortality rate among older Quebec residents. Older adults were at increased risk because of increasing frailty combined with social isolation among individuals (van Solm A. , 2016). Barriers to accessing electricity and medications can be detrimental to the health of older adults due to the high prevalence of chronic health conditions, such as hypertension, high cholesterol, and diabetes within this subpopulation (National Council on Aging, 2018). Recommendation 1.5 aims to encourage the creation and/or incorporation of a resource for incorporating an individual’s medical history into their preparedness plan by encouraging older adults to prepare an outline of their medical condition(s), medical treatment(s) and their health care provider(s) and emergency contacts for their emergency kit. Having a summary of their medical history as a part of their emergency kit will help older adults minimize disruptions to their care during emergencies (Centers for Disease Control and Prevention, 2020; Kosatky, et al., 2009). In doing so, unpaid caregivers and health care providers who may be unfamiliar with their conditions will have the medical information necessary to effectively support their health needs, or continue their care in the case of a medical emergency or after relocation to a care facility or shelter. Improving Access to Necessary Medications During Emergencies Shortages of essential medications can often lead to an exacerbation of a pre-existing chronic medical condition. To prevent running out of medications and subsequent surges in medication refill requests during emergencies, as was experienced at the Staten Island University Hospital ED during Hurricane Sandy and at shelters during Hurricane Katrina, Recommendation 1.6 encourages older adults to work with their health care providers to obtain access to a supply of emergency medications for their emergency kit. It is essential that older adults explore their possible options for obtaining additional supplies of medications when preparing for emergencies (Ford, Trent, & Wickizer, 2016). Retrospective reviews of medical services provided during emergencies repeatedly cite surges in medication refill requests as a leading cause of medical services (Currier , King, Wofford , Daniel, & deShazo , 2006; Greenstein, Chacko, Ardolic, & Berwald, 2016; Jhung, et al., 2007; Kraushar & Rosenberg, 2015; Ochi, Hodgson, Landeg, Mayner, & Murray, CLOSING THE GAPS: ADVANCING EMERGENCY PREPAREDNESS, RESPONSE AND RECOVERY FOR OLDER ADULTS 32 2014). This high demand for prescription medications suggests that evacuees may benefit from reduced barriers to accessing medications during emergencies, increased education from health care professionals on the benefits of preparation through having enough medication during an emergency, or increased access to more information on how to access emergency medication supplies prior to an emergency. It is important that older adults are provided with the resources to adequately self-prepare to support their pharmaceutical needs during an emergency. Supporting Older Adults with Electronic Life-Supporting Devices To prevent interruptions to the supply of power to electronic life-supporting devices, as outlined in Recommendation 1.7, preliminary efforts should be made to contact the user’s electricity company to inquire about priority service restoration during emergencies to persons who have life-supporting devices at home, as well as alternative power sources that can be safely used at home. It should be noted that older adults may require assistance with obtaining and maintaining an alternative power source at home, such as when moving a generator and fuel, as well as accessing these resources in rural locations and operating them. During these instances, support network members may be a reliable source of assistance. By establishing plans to safely, effectively, and independently support the health of an older adult who is dependent on a life-supporting device during an emergency, scenarios that can lead to deteriorating health and hospitalizations can be prevented/avoided. Recommendation 1.8 Older adults should be encouraged to continually maintain an adequate local support network that can be called upon during impending disasters and unexpected emergencies, especially if they live alone or lack easy access to relatives. Developing and Maintaining a Personal Support Network Having a support network can greatly aid older adults by providing the emotional and material resources they need to reduce the stress of preparing for and surviving an emergency. Many older adults live without a spouse or a family member, and are more susceptible to social isolation and/or dependent on unpaid caregivers for assistance (Gibson & Hayunga, 2006). Dependence on the assistance of unpaid caregivers is so prevalent among older adults that 90 per cent of adults who are 65 years or older and living with a disability who report receiving assistance are supported by unpaid caregivers, (Gibson & Hayunga, 2006) while approximately 50 per cent of adults who are 85 years or older report living alone (Fernandez, Byard, Lin, Benson, & Barbera, 2002). An emergency can leave those that rely on daily assistance stranded and unable to care for themselves if rescuers and their unpaid caregiver(s) cannot reach them. To reduce the negative impacts of social isolation, Recommendation 1.8 advises all older adults to establish a support network they can depend on for assistance in preparing for and responding to all emergencies relevant to their region. Support networks act as protective factors against emergency events, especially among seniors. According to a study done in Quebec, a well-established social network benefits older 33 DOMAIN 1: INDIVIDUALS AND UNPAID CAREGIVERS adults’ overall health during extreme heat events (Laverdiere, et al., 2016). For older adults with chronic health conditions, each member of their support network should be able to provide basic support for their health, such as access to their medication list, and should have the knowledge needed to identify and operate all required medical equipment. It is intended that by being able to provide basic support, support network members will be able to work together with the person they are caring for to provide the assistance needed to prevent interruptions to their medical care and avoid hospitalizations. It is also important that their support network consist of at least two people who live in close proximity to them because this will enable members to provide assistance within minutes, which will prevent prolonged periods of being incapacitated or stranded. Recommendation 1.9 Unpaid caregivers of persons with Alzheimer’s disease and/or other dementias should be supported to identify signs of distress, anxiety, or confusion, and use strategies to redirect attention and help them stay calm during emergencies. In addition, unpaid caregivers should be prepared to prevent wandering and have plans in place to locate their care recipients if they do wander or require medical intervention(s) during an emergency. Supporting the Unique Needs of Older Adults Living with Dementia A decline in working memory and an impaired ability to filter out irrelevant information are two changes in cognitive function associated with Alzheimer’s disease and related dementias (ADRD). These changes can impede the more than 500,000 older Canadians living with Alzheimer’s disease and related dementias from identifying a disaster situation, following emergency preparedness recommendations, adapting to changes in their routine and environment, or following emergency warnings and instructions (Alzheimer Society of Canada, 2019; Alzheimer Society of Canada, 2018). In addition, new behavioural problems can arise, existing behaviours can become exacerbated, or function can deteriorate rapidly, if there are interruptions to the administration of dementia-related medications (Cloyd & Dyer, 2010). Re-establishing routines and valued occupations can also help disaster survivors cope with stress and anxiety (American Occupation Therapy Association, 2006). Dementia can also be compounded by the occurrence of delirium. Delirium is a state of confusion that comes on suddenly and is characterized by an inability to think clearly and pay attention, as well as an unawareness of one’s environment (American Delirium Society, 2015). The most common causes of delirium include infection, medications, electrolyte or blood sugar disturbances, hypoxemia, and low blood pressure (Cloyd & Dyer, 2010). Since individuals with more advanced dementias require daily assistance to help them perform their activities of daily living (ADLs) and protect them from dangers, it is necessary that their unpaid caregiver(s) be educated about the unique precautions that should be taken to reduce the occurrence of adverse behaviors and outcomes for the person they are caring for during an emergency. In particular, unpaid caregivers should receive education and support CLOSING THE GAPS: ADVANCING EMERGENCY PREPAREDNESS, RESPONSE AND RECOVERY FOR OLDER ADULTS 34 on addressing distress, anxiety, wandering, and confusion; approaches such as validation and gentle persuasion to address moments of agitation; how to communicate with and soothe older adults living with ADRD when they are in crisis; and methods of communication that aid in orientation and memory retention. Comfort Keepers of Canada is an organization that provides home care for older adults. Due to its vast experience with seniors suffering from dementia, Comfort Keepers of Canada suggests tips on how to prevent older adults with dementia from wandering which also include maintaining a calm and stress-free environment, especially during an emergency. With the help of health care professionals, caregivers can be better equipped to provide care during an emergency. For example, nurses, therapists and social workers can all provide interventions that take the form of education, training, and support for caregivers of persons with dementia. These interventions can include behaviour management strategies, communication skills, cognitive reframing, and mindfulness techniques that have been shown to greatly increase a caregiver’s ability to care for their loved ones (Etters, Goodall, & Harrison, 2008; Piersol, et al., 2017; Sorensen, Pinquart, Habil, & Duberstein, 2002). Further, emergencies such as infectious disease pandemics can present unique challenges for unpaid caregivers. It is important for unpaid caregivers of older adults with Alzheimer’s or advanced dementia to stay abreast of any relevant information regarding the pandemic and use strategies that can protect themselves and the older adult (Centers for Disease Control and Prevention, 2020). As an additional precaution, unpaid caregivers should register their care recipient for an emergency response service for persons with ADRD (Dyer, Regev, Burnett, Fest, & Cloyd, 2008), such as the Medic Alert Safely Home program, to provide emergency response assistance if their care recipient wanders away. 35 Community-based organizations and their staff are likely to be engaged in response and recovery efforts for older adults and their unpaid caregivers, depending on the level to which their services and programs support older adults and their unpaid caregivers. Therefore, a clear opportunity exists to develop, implement and evaluate preparedness and response activities for Community-Based Services and Programs that can better facilitate knowledge translation and exchange within the community and increase levels of preparedness, response and recovery efforts and outcomes among designated populations and those personnel that have the responsibility to support them. An investigation of existing community-based resources that can contribute to improving emergency preparedness, response and recovery outcomes for older adults was guided by Research Question 2: What are the strategies and resources that can be leveraged at the community and progam levels to improve emgergency (natural disaster or pandemic) preparedness for older adults? (see Development Approach). The search strategies that were used yielded a combined total of 4,390 peer-reviewed journal articles, five of which were used along with eight guidance documents for data extraction related to this specific question. The findings from these resources identified that there is a greater need for seniors-tailored community-integrated preparedness and response services to encourage and facilitate increased levels of preparedness and support recovery. Consequently, in response to this gap, four evidence-informed expert recommendations were developed with the aim of addressing identified opportunities noted for community-based services and programs to better support emergency preparedness and response. Recommendation 2.1 Access should be increased to tailored communitybased programs that educate older adults and their unpaid caregivers about emergencies that could affect their region and how best to prepare for and respond to them. Volunteer representatives of older Canadians should be recruited and involved in training material development and implementation, to ensure their voices and perspectives are reflected.
Community-based programs and organizations should collaborate with regional public health authorities in developing and disseminating education resources on infection control, disease and injury prevention practices for older adults and their caregivers during emergencies. Improving Community-Based Emergency Preparedness Educational Programs Many of the adverse outcomes that older adults face during and after an emergency can be avoided by simply being informed about the dangers associated with the emergency that could affect their region, the appropriate precautions they should take to keep themselves safe, and adopting behavioural changes that facilitate adequate self-preparedness. When interviewed about their self-perceived preparedness for emergencies, older adults have been found to report low levels of preparedness. In a study that investigated nation-wide preparedness of older adults, 23.6% of the 1,304 participants interviewed reported that they had an emergency evacuation plan, 24.8% did not have access to a car or other form of transportation in case of an emergency, and DOMAIN 2: COMMUNITY-BASED SERVICES AND PROGRAMS Domain 2: Community-Based Services and Programs CLOSING THE GAPS: ADVANCING EMERGENCY PREPAREDNESS, RESPONSE AND RECOVERY FOR OLDER ADULTS 36 only 4.9% reported that at least one of their health care providers had discussed what to do during an emergency with them (Al-Rousan, Rubenstein, & Wallace , 2014). Another study was conducted by Marshall, Ryan, Robertson, Street and Watson to measure community knowledge about and attitudes toward the threat of a pandemic influenza as well as community acceptability of strategies to reduce its effect (Marshall, Ryan, Robertson, Street, & Watson, 2009). Computer-aided telephone interviews were conducted with a cross-sectional sample of rural and metropolitan residents of South Australia among 1,975 households. Of those who responded, 50% indicated that they had never heard of a pandemic influenza or were unaware of its meaning. Only 10% were extremely concerned about the threat of a pandemic influenza (Marshall, Ryan, Robertson, Street, & Watson, 2009). Despite the widespread publicity regarding influenza and advocacy to build a base level of awareness and understanding among the population, it was found that the majority of adults in the community, particularly older adults, were unaware of the possibility of a pandemic influenza strain (Marshall, Ryan, Robertson, Street, & Watson, 2009). To increase the low levels of emergency preparedness found in the general public, community-based emergency preparedness training courses have been piloted and found to be effective tools for encouraging behavioral change. For example, in the United States, PrepWise is a disaster preparedness program designed to assist older adults in developing a tailored home-based disaster preparedness plan (Catizone, 2017). During the training sessions, the participants were guided through seven learning modules: (1) knowing types of emergencies and what to do, (2) vulnerability assessment (alerts/warnings, evacuations, transportation, communication, sheltering, personal care, and medical care and equipment), (3) developing a personal emergency support network (formal list of family/friends and local community members), (4) making an emergency plan, (5) keeping a supply of medications, (6) making an emergency supply kit, and (7) making home, school, work, and car travel safer (Ashida, Robinson, Gay, Slagel, & Ramirez, 2017). Upon follow up, it was reported that enrolment in the PrepWise program led to a greater understanding of disaster preparedness requirements, such as preparing an emergency kit and designating alternative shelters to be used in the event of an emergency (Ashida, Robinson, Gay, & Ramirez, 2016; Ashida, Robinson, Gay, Slagel, & Ramirez, 2017). The PrepWise program was also found to encourage participants to seek out additional emergency support network members to whom they could turn to for help, in addition to family members most participants had identified prior to being enrolled in PrepWise (Ashida, Robinson, Gay, Slagel, & Ramirez, 2017). Similar successes in using community-based emergency preparedness training sessions were also found with the Ready CDC disaster preparedness education program, which was designed to increase knowledge, influence attitudes and strengthen community resiliency. Ready CDC uses the following tactics: (1) gain attention, (2) present stimulus material, (3) provide learning guidance, (4) elicit performance and provide feedback, and (5) enhance retention and transfer to facilitate behavioural change (Thomas, et al., 2018). When levels of behavioural 37 change through the Trans-Theoretical Model (TTM) were evaluated within a sample of 212 CDC staff and public health employees who had completed the Ready CDC disaster preparedness education program, 44 per cent of enrollees progressed to at least one stage higher or remained at the “maintenance” stage for assembling an emergency kit, and 45 per cent of participants progressed to at least one stage higher or remained at the “maintenance” stage for developing a written emergency plan (Thomas, et al., 2018). In addition, during follow up, the 25 per cent, 27 per cent, and 43 per cent of participants in the “pre-contemplation”, “contemplation”, and “preparation” stages at baseline for assembling an emergency kit, respectively, were identified as having progressed to the “preparation” stage (Thomas, et al., 2018). These results suggest that community-based emergency preparedness sessions are effective methods for conveying emergency preparedness information to the public and facilitating behavioural change. Recommendation 2.1 outlines a strategy for the development of nation-wide community-based emergency preparedness education programs for older adults. The program’s content should include, but not be limited to, modules about the different types of natural and man-made disasters that affect a given region, the effects and associated dangers of these disasters, as well as guidance and participatory learning on how to perform a personal vulnerability assessment, how to make an emergency plan and kit, the importance of developing and maintaining a social support network, and strategies and resources to aid recovery. For those organizations developing and distributing these materials, involving older adults and local public health authorities in the preparation and delivery is critical to ensuring the needs, concerns, and perspectives of older Canadians are considered. Engaging with local public health authorities will provide another layer of expertise and infrastructure in the development and evaluation of health interventions to mitigate negative health outcomes. In Canada, the University of Manitoba, along with the Natural Resources Institute, arranged a workshop for practitioners in risk and hazard management titled Canadian Risks and Hazards in 2004. The organizers believed that a workshop titled around disaster management or emergency management would not attract the wide range of participants that they desired because those fields may be perceived to be too narrow in focus (Public Safety and Emergency Preparedness Canada, 2004). This issue emphasizes the lack of community knowledge on the connection between hazards, risks, disasters, and preparedness in Canada. Community-based emergency preparedness programs should aim to achieve accessibility for persons with lower literacy skills, non- English speakers and Indigenous seniors, and the incorporation of age-friendly considerations into its structure, such as appropriate visuals, and distribution of emergency kits that are easy to transport, if applicable. Community-based emergency preparedness training classes that have been adapted to address the unique needs of older adults should maximize the positive impact they have among older adults. Recommendation 2.2 Programs that provide disaster relief and/or essential community services, such as Meals on Wheels, and daily living assistance for older DOMAIN 2: COMMUNITY-BASED SERVICES AND PROGRAMS CLOSING THE GAPS: ADVANCING EMERGENCY PREPAREDNESS, RESPONSE AND RECOVERY FOR OLDER ADULTS 38 people (financial, medical, personal care, food and transportation) should receive emergency preparedness training and education as well as develop and adhere to plans and protocols related to responding adequately to the needs of their clients during emergencies. Volunteer representatives of older Canadians and their unpaid caregivers should be recruited and involved in training material development and implementation, to ensure their voices and perspectives are reflected. Better Leveraging Community Support Services to Aid in Emergency Response Efforts Community-accessible resources have been found to be associated with facilitating higher levels of preparedness among older adults. In a 2017 study that examined the socio-demographic factors that influence levels of emergency preparedness among persons 50 years and older, participants who discussed emergency plans with their physician were more likely to be prepared than older adults who did not (Killian, Moon, McNeill, Garrison, & Moxley, 2017). Similar to physician visits, community agencies and programs that have a significant proportion of older users could act as an accessible portal for encouraging older adults to access emergency preparedness and recovery aids and services. Recommendation 2.2 highlights need for community services and programs to receive emergency preparedness training and education to provide appropriate supports for older adults (Centers for Disease Control, 2020). An additional benefit to incorporating emergency preparedness and recovery efforts into the scope of services provided by community agencies and programs, as well as managers of housing for older adults, is the additional social support that these resources can provide. One Canadian study suggested that leveraging interRAI assessment databases to identify at-risk and vulnerable older adults who are more likely to experience negative outcomes as the result of an emergency could benefit them in all phases of emergency management. InterRAI is a collaborative network of researchers that develops tools with common metrics for clinicians to assess patients. InterRAI tools are now used across Canada and around the world in a variety of settings, including home and community care (van Solm, Hirdes, Eckel, Heckman, & Bigelow, 2017). Leveraging this data could support community service agencies to identify and prioritize older adults who are most at risk of negative outcomes after an emergency. Similarly, to facilitate a holistic recovery, community and local government services could provide further social support, in addition to tangible resources, particularly for older adults who have been identified as having limited or no social support. Recommendation 2.3 Community-based programs that provide in-home health and personal care for older adults should integrate strategies that minimize unnecessary personal contact and leverage resources (e.g. personal protective equipment such as gowns, masks, gloves, hand sanitizer, etc.) in their emergency preparedness plans and protocols. Enabling community-based programs to provide safe in-home supports for older adults during emergencies Many older adults, particularly those who reside at home, are the recipients of communitybased in-home services that are medical and/ 39 or supportive but non-medical in nature. Older adults with complex and often interrelated medical and social comorbidities often rely on these services in their day-to-day life. Emergencies as a result of a natural disaster or pandemic can lead to the disruptions in the delivery of in-home services for older adults as was seen during the COVID-19 global pandemic. The COVID-19 pandemic presented new challenges for care teams that provide in-home services for older adults as emergency protocols were needed to ensure minimal risk for the transfer and spread of the virus. Enabling community-based programs to provide safe in-home care during emergencies can minimize the risk of service interruptions and thereby any impact on older adults. Recommendation 2.3 notes the importance of community-based programs that provide in-home supports leveraging strategies that require minimal personal contact or the use of resources such as personal protective equipment in emergency preparedness. Emergencies such as pandemics and natural disasters both present new challenges with infection control where new pathogens continually emerge. In the event of a pandemic, hygiene and the use of personal protective equipment are seen as two important lines of defense (Bloomfield, Exner, Carlo, Nath, & Scott, 2012). For instance, during the COVID-19 pandemic several best practice guidelines in the use of personal protective equipment were developed and promoted by Infection Prevention and Control Canada (IPAC) (Infection Prevention and Control, 2020), Ontario Health (Ontario Health, 2020) and the World Health Organization (World Health Organization, 2020). Evidence showed that the virus was transmitted between people through droplets and close contact. Many of the recommendations outlined were updated to support health care and other organizations decision-making around the use of PPE and PPE conservation to minimize shortages. Where contact is required, best practice guidelines recommend the use of preventive measures such as maintaining physical distance and performing hand hygiene frequently with an alcohol based hand rub. The International Scientific Forum on Home Hygiene developed a risk-based approach to hygiene that breaks down the chain of infection transmission while addressing other risk factors. An individual’s hands and other environmental sites and surfaces are all a part of the chain of transmission that, if understood, can highlight areas where hygiene based interventions can be used to stop transmission (Bloomfield, Exner, Carlo, Nath, & Scott, 2012). Promoting proper hand hygiene (Ontario Agency for Health Protection and Promotion (Public Health Ontario), Provincial Infectious Diseases Advisory Committee, 2014) and proper environmental cleaning (Ontario Agency for Health Protection and Promotion (Public Health Ontario), Provincial Infectious Diseases Advisory Committee, 2018) inhome and community care settings can minimize the risk of infectious disease transmission. Other strategies that can be used by Home and Community Care providers include screening for both provides and clients in addition to wearing the necessary protective equipment while providing in home support. The Ontario Ministry of Health provided clear guidance on steps to take (Ontario Ministry of Health, 2020; Ontario Ministry of Health, 2020). Other strategies that emerged during the COVID-19 pandemic included an increased use DOMAIN 2: COMMUNITY-BASED SERVICES AND PROGRAMS CLOSING THE GAPS: ADVANCING EMERGENCY PREPAREDNESS, RESPONSE AND RECOVERY FOR OLDER ADULTS 40 of virtual care through telehealth, telemedicine and other virtual platforms. Virtual care programs were expanded during the COVID-19 pandemic to enable care providers in acute hospital care settings to provide new consults and follow-up appointments for their patients (Stamenova, et al., 2020). Acute care physical therapy, occupational therapy, and speech-language pathology telehealth strategies can add value by mitigating COVID-19- related harm and influencing recovery (Exum, et al.). Recommendation 2.4 Local governments should leverage data sources that identify at-risk individuals to enable emergency responders to more easily prioritize their search and rescue efforts following an emergency. Enabling the Development of Repositories of Data Sources to Support Local Government Emergency Response Efforts During the panel discussion, experts recognized that while many registries of people with functional needs, including persons with disabilities, exist for and are easily accessible to municipal authorities, they can be difficult for territorial and provincial authorities to access. To increase the efficiency and identification of at-risk persons by emergency response personnel, it is recommended that local governments create a repository of their data sources. The establishment of a repository of data sources will act as a singular, easy-to-access reference to facilitate a fast-integrated response from neighbouring provincial or federal emergency services. For example, it is intended that providing all national and local aid agencies with a repository of data sources, such as available registries, will help to facilitate the cooperation of different aid agencies to provide the workforce needed to assist with evacuations, distribute emergency supplies and provide medical care. 41 Response and recovery efforts for older adults can vary, depending on the level of training emergency health care professionals, emergency response personnel and other potential first responders receive. Health care professionals indeed play a critical role in emergency preparedness and response because they are often the first point of contact for health-related guidance and care. An investigation of the levels of emergency related competency for health care providers and emergency response personnel was guided by Research Question 3: What are the strategies and resources that can be leveraged to improve emergency response among health care professionals and emergency response personnel during and after an emergency (natural disaster or pandemic)? (see Development Approach). The search strategies that were used yielded a combined total of 4,390 peer-reviewed journal articles, 12 of which were used along with two guidance documents for data extraction related to this specific question. The review of these 14 resources revealed that some health care professionals feel insufficiently prepared to provide appropriate care for older adults during emergencies such as natural disasters. Further, more efforts can be made to increase awareness of precautions for infectious disease spread and control during emergencies. To address the gaps, three evidence-informed expert recommendations were developed with the aim of augmenting training for health care professionals and emergency response personnel to include additional culturally-aware considerations for assisting and caring for older patients and residents during and after an emergency. Recommendation 3.1 Health care professionals and emergency response personnel should receive training on providing geriatric care relevant to their discipline and how best to assist older adults and their unpaid caregivers before, during and after emergencies. The additional education and training should also increase their awareness of best practices and precautions to minimize the risk of infectious disease transmission or spread while responding to emergencies. Volunteer representatives of older Canadians should be recruited and involved in training material development and implementation, to ensure their voices and perspectives are reflected. Improving the Knowledge and Skills of Health Care Professionals in Geriatric and Emergency Health Care Principles Obtaining training in geriatric care is essential to ensuring that health care professionals are aware of the unique needs of older adults and how best to assist them, particularly during situations when they may be required to provide care during an emergency. In a report by Karen V. Lamb (2010), An Overview: Disaster Preparedness for Gerontological Nurses, the author identifies that cognitive impairment associated with dementias can be exacerbated during an emergency and produce feelings of confusion and delirium (Lamb & O'Brien, 2010). A Canadian study on nurses’ experiences with emergency management strongly recommends more extensive curricula in nurses’ training on how to provide better assistance during an emergency (Kulig, et al., 2017). It is recommended that health care providers and emergency response personnel be knowledgeable about how best to assist older adults in these situations. Using a multi-modal approach to DOMAIN 3: HEALTH CARE PROFESSIONALS AND EMERGENCY RESPONSE PERSONNEL Domain 3: Health Care Professionals and Emergency Response Personnel CLOSING THE GAPS: ADVANCING EMERGENCY PREPAREDNESS, RESPONSE AND RECOVERY FOR OLDER ADULTS 42 education can be effective in improving the knowledge, confidence and skills of health care professionals to respond to emergency situations (Pesiridis, Galanis, Sourtzi, & Kalokairinou, 2014; Roush & Tyson, 2012; Scott, Carson, & Greenwell, 2010). Lamb also emphasizes the need for nurses to be aware of the risks of providing care during a disaster (Lamb & O'Brien, 2010). Treatment can become a challenge because there is a possibility that medical records or resources, such as medications, oxygen, and dialysis, may not be available (Lamb & O'Brien, 2010). When combined with stress, limits to basic supplies, medications, and extreme changes in surroundings and temperature (Lamb & O'Brien, 2010), emergency situations can greatly exacerbate medical conditions and limit access to care interventions (Ardalan, et al., 2010). Considering that 80 per cent of older adults have at least one chronic health condition requiring medication and sometimes medical equipment, medical providers should be knowledgeable about alternative and effective methods for managing chronic conditions, and how to play an active role in emergency preparedness planning strategies at their local shelter or other temporary emergency care facilities (Bhalla, Burgess, Frey, & Hardy, 2015; Byrd, 2010). Therefore, emergency response personnel should be knowledgeable about conditions that are more likely to affect older adults, and how to effectively interact with or assist persons also living with dementia if they become agitated, confused, and anxious or wander away. Strengthening health care professionals’ and emergency response personnel’s knowledge of infection control practices can also support the provision of safe care to older adults in times of emergencies. The prolonged impact of natural disasters on a community can lead to the collapse of health facilities and health care systems, or disruptions in health programs (Kouadio, Aljunid, Kamigaki, Hammah, & Oshitani, 2012). Improved training for health care providers and emergency response personnel in infection control practices and increased awareness of best practices that can be used across all settings (Ontario Agency for Health Protection and Promotion, Provincial Infectious Diseases Advisory Committee, 2012; Ontario Agency for Health Protection and Promotion, Provincial Infectious Diseases Advisory Committee, 2012). Recommendation 3.2 Health care professionals and emergency response personnel should strive to mitigate negative outcomes among older adults during and after emergencies by adopting effective strategies designed to protect the physical and mental health of the older adults they may come in contact with. Strategies can include assessing the psychological well-being of older adults for signs of distress and providing appropriate treatments or referrals as needed. Better Addressing the Mental Health Needs of Older Adults During Emergencies While there is a preconceived notion that older adults are more emotionally fragile than younger adults, there are mixed reports about an existing difference in the incidence of psychological distress among older adults compared to younger adults following an emergency, which has indicated that older age may be a protective factor. When investigating potential differences between older adults and younger adults in the onset of psychological disorders following natural and 43 man-made disasters, anxiety and depressive symptoms have been found to not have a significant difference in incidence rates among older adults compared to younger adults (Parker, et al., 2016; Siskind, et al., 2016). However, differences were found in the incidence of posttraumatic stress disorder (PTSD). In a 2016 study conducted by Parker and colleagues, PTSD was found to have a significantly greater incidence among older adults compared to younger adults. Similar results were also found by Jia and colleagues (2010), who reported a greater prevalence of PTSD symptoms among a sample of survivors of the 2008 Sichuan earthquake (Jia, et al., 2010). Conversely, Siskind and colleagues (2016) found that older adults were 2.85 times less likely to experience PTSD symptoms compared to younger adults in a meta-analysis of the mental health outcomes of older adults following humaninduced disasters (Siskind, et al., 2016). However, differences in the onset of psychological distress among persons of different socio-demographic statuses have also been reported. Obtaining less than a high school education and/or a bachelor’s degree, being unemployed or becoming unemployed due to a disaster, living in social isolation, or witnessing three or more events associated with a disaster were associated with a greater likelihood of developing PTSD (Blackmon, et al., 2017; Ruskin, et al., 2018; Welch, et al., 2016). A study was conducted by Cheung, Chau and Yip (2008) to assess the impact of the 2003 SARS outbreak on suicide rates in Hong Kong. The study used suicide statistics for the period 1993-2004 and compared the profile of older adult suicide cases in the pre-SARS, peri-SARS and post-SARS periods. Results from the study showed an excess of older adults suicides in April 2003 as compared to the month of April of the other years. Results were consistent with a year over year comparison, as older adult’s suicide rates in 2003 and 2004 were significantly higher than that in 2002, suggesting that the suicide rate did not return to the level before the SARS epidemic (Cheung, Chau, & Yip, 2008). Cheung, Chau and Yip speculated that the spike in older adult suicide rates could be because of loneliness and disconnectedness among the older adults in the community. As such, maintaining and enhancing mental wellbeing of the public over the period of an epidemic is arguably just as important as curbing the spread of the disease (Cheung, Chau, & Yip, 2008). A historical gap in emergency management has been the prevention and/or treatment of psychological effects that survivors experienced during and after an emergency. During flooding in Quebec in 2017, one of the most widespread challenges among survivors was psychological distress, with 25% of individuals encountered by officials exhibiting symptoms (CBC News, 2017). Training of responders in psychological first aid could also assist in thoughtful and compassionate handling of older adults during response and into recovery (Ardalan, et al., 2010). Overall, while findings suggest that extensive additional resources do not need to be directed towards protecting the psychological well-being of older adults during emergencies, it is still recommended that health care professionals and emergency response personnel make greater efforts to assess the psychological well-being of older adults during and after an emergency and provide appropriate treatments in order to provide early interventions for the existing proportion of older adults that do develop a psychological disorder. Greater emphasis should also be given DOMAIN 3: HEALTH CARE PROFESSIONALS AND EMERGENCY RESPONSE PERSONNEL CLOSING THE GAPS: ADVANCING EMERGENCY PREPAREDNESS, RESPONSE AND RECOVERY FOR OLDER ADULTS 44 to assessing the psychological well-being of older adults who satisfy at least one of the many sociodemographic factors that have been linked to a greater likelihood of developing a psychological disorder during or after an emergency. An example of how to achieve this will be to increase older individuals’ access to services provided by counsellors, occupational therapy and social workers post-emergency, as they can play a role in addressing the resulting psychological distress by providing education and training in coping skills using a community-based rehabilitation approach (Jeong, Law, DeMatteo, Stratford, & Kim, 2016). Recommendation 3.3 Health care professionals and emergency response personnel should receive cultural awareness training to provide appropriate care and support for older adults with different cultural and religious backgrounds before, during, and after an emergency. Providers should have options for providing support to older adults and their unpaid caregivers who face language or cultural barriers to accessing supports (e.g., translators, written materials in languages other than English or French, etc.). This is of particular importance for personnel that work with Indigenous populations, in diverse community-settings and during times of evacuation due to emergencies. Cultural awareness and training for health care professionals and emergency response personnel is a key tenet to ensuring older adults with different cultural and religious backgrounds receive appropriate care and support before, during and after an emergency (James, Hawkins, & Rowel, 2007). The Aboriginal Nurses Association of Canada (2009), the Canadian Agency for Drugs and Technologies in Health (2018), the Canadian Association of Occupational Therapists (2011) and the College of Nurses of Ontario (2019) have developed cultural awareness and cultural safety guidance for health providers that could be considered in this regard. In 2012, Dr. Samir Sinha delivered a report to the Ontario Ministry of Health and Long-Term Care, Living Longer, Living Well, in which he identified that many health, social and community care providers were unaware of the cultural needs, health and social conditions and services that may or may not be available locally to support older Indigenous adults. In the province of Ontario, as the prevalence rates for having three or more chronic conditions are higher for the Indigenous population as compared to the non-Indigenous population, it is understandable why Indigenous people rely disproportionately on the need for emergency care, and are more likely to self-report having “poor” or “fair” health (Sinha, 2012). As a result, a key recommendation of the report was to promote the development of cultural competency training for all health, social and community services providers working with older Indigenous populations. Some professional associations have taken other approaches to increase the degree of cultural awareness in care settings by building capacity in communities experiencing vulnerabilities to participate in care delivery. For instance, the Canadian Association of Schools of Nursing (CASN), the Aboriginal Nurses Association of Canada (ANAC) and the Canadian Nurses Association (CNA), in collaboration with nursing schools across Canada, actively promoted the recruitment of First Nations, Inuit and Métis people into nursing programs and enabled them 45 to complete these programs by removing barriers, such as finances, and building structures of support (Hart-Wasekeesikaw, 2009). Increasing the number of First Nation, Inuit and Métis nurses facilitates improved access to culturally safe and appropriate care for Indigenous people. This collaboration with the CASN, ANAC and the CNA also aimed to integrate principles of cultural competence and cultural safety into curricula for all nursing students that instill an understanding of the historical and contemporary contexts of Indigenous communities (Hart-Wasekeesikaw, 2009). In 2018, the Canadian Association of Occupational Therapists released a position statement highlighting the role of occupational therapy in Indigenous health. Its purpose is “to enable occupational therapists to provide effective, respectful, culturally safe, and collaborative services with First Nation, Inuit, and Métis persons, families, communities, and nations”. A fundamental recommendation from this report is to develop partnerships and alliances in order to best provide space for Indigenous worldviews, knowledge and self-determination, in recognizing that moving forward is a shared responsibility (Canadian Association of Occupational Therapists, 2011). Within Indigenous communities, providers and personnel providing preparedness, response and recovery support need to consider and acknowledge the history as well as the knowledge, beliefs and perspectives about emergency preparedness held in Indigenous communities. Within the context of preparing for an emergency, recognizing the role of Indigenous older adults as community leaders and designing inclusive preparedness education activities that acknowledges and leverages their important role within community is important to successful emergency preparedness. In addition, developing preparedness materials that address additional traditional and ceremonial items that would be taken from the home in an evacuation, such as medicine pouches, eagle feathers, and sweet grass can also help to support Indigenous older adults to prepare for an emergency. When responding to an emergency, response personnel should develop an awareness that certain operational procedures have been observed to trigger trauma in some older Indigenous adults who survived the residential school system, the 60s Scoop and other traumatic episodes. Procedures that trigger these traumas should be replaced with culturally safe practices. In addition to how Indigenous communities are evacuated, it is equally important to recognize that many Indigenous older adults live with family members, and evacuating within the kin system is important. Separation from family and unpaid caregivers can be especially challenging. When recovering from an emergency, personnel should create space to acknowledge and grieve the cultural losses associated with evacuation, and provide activities that maintain a connection to home communities (e.g. sweat lodge, smudging ceremony, dancing/singing/sewing activities for children). DOMAIN 3: HEALTH CARE PROFESSIONALS AND EMERGENCY RESPONSE PERSONNEL CLOSING THE GAPS: ADVANCING EMERGENCY PREPAREDNESS, RESPONSE AND RECOVERY FOR OLDER ADULTS 46 Domain 4: Care Institutions and Organizations Care institutions and organizations that are responsible for the livelihood of their residents or patients during an emergency must make decisions that will support the health and well-being of their residents/patients. During emergencies such institutions and organizations should, for example, know when it is appropriate to evacuate or shelter-in-place and what to do in each case. An evaluation of the quality and levels of emergency preparedness within care institutions and organizations was guided by Research Question 4: What are the strategies and resources that can be leveraged at the organizational or institutional level to improve emergency (natural disaster or pandemic) preparedness and recovery efforts for older adults? (see Development Approach). The search strategies that were used yielded a combined total of 4,390 peer-reviewed journal articles, 17 of which were used along with nine guidance documents for data extraction related to this specific question. A review of these 26 resources revealed that greater action can be taken to prevent threats to an older patient’s/ resident’s health that can arise when severe emergencies disrupt the operations at care institutions and organizations, as well as patient handoff procedures. Consequently, in response to this gap, three evidence-informed expert recommendations were developed with the aims of increasing the levels of emergency preparedness knowledge among health care providers and care facility staff, as well as better facilitating effective patient hand-off during an emergency. Recommendation 4.1 Care institutions and organizations should include emergency preparedness and response education in their routine personnel training courses.
Volunteer representatives of older Canadians should be recruited and involved in developing and disseminating resources and training material, to ensure their voices and perspectives are reflected. A 2012 study by Roush and Tyson that assessed the knowledge of emergency preparedness among nurses enrolled in a community-accessible emergency preparedness workshop, many of whom were employed at a nursing home, found that the majority of participants had no formal emergency planning and response training and many reported low or no proficiency ratings in emergency preparedness knowledge (28%). After completion of the workshop, the proficiency ratings increased to 76% and the majority of participants reported that they planned on including portions of the content from the workshop into courses for students, colleagues and/or patients (Roush & Tyson, 2012). Findings from this and other studies suggest that some health care providers working within and outside of a geriatric health care setting would benefit from additional training in their knowledge of how to respond to emergencies and care for older adults during these times (Lamb & O'Brien, 2010). To address this gap in education and improve disaster management in hospitals, the New York City Department of Health and Mental Hygiene (NYC DOHMH) developed the Elderly Populations in Disasters: Hospital Guidelines 47 for Geriatric Preparedness toolkit (Ahronheim, Arquilla, & Gambale Greene, 2009). The toolkit outlines training in geriatric care for health care professionals that includes guidelines for managing geriatric patients, common age-related misdiagnoses, when to obtain a geriatric medicine consultation and appropriate dosages for common psychiatric medication for frail elderly, as well as the development of reference charts to help make appropriate medical assessments for older adults during emergencies (Ahronheim, Arquilla, & Gambale Greene, 2009). Given that this toolkit provides a focus on geriatric-specific care needs to hospitals aiming to address a variety of circumstances common among older adults during emergencies, it may be beneficial for all care institutions and organizations to develop similar emergency toolkits based on the services that their organization provides. Health care professionals can collaborate to create an interprofessional toolkit that integrates different care approaches for older adults informed by each discipline. For example, nurse professionals and therapists can apply the integrated theory of health behavior change to develop education curricula that foster knowledge and improve health outcomes among older adults (Ryan, 2009). Further, adult learning theories are at the core of the training received by physical and occupational therapists. They practice client-centeredness, which tailors responses to be primarily focused on their client needs’ (Papadimitriou & Carpenter, 2013). Building resources through interprofessional and collaborative approaches can enable more efficient care and response to the needs of older adults during emergencies. Advanced education and certification courses in emergency and disaster preparedness management in Canada are small; in 2004, there were fewer than 10 people who were both practitioners and academics in the field of emergency management (Public Safety and Emergency Preparedness Canada, 2004). The growth of emergency preparedness or management education was a gap identified by the Round Table attendees that was attributed, in part, to the absence of a lead entity that could advocate for the importance of this education across the country. Each province has adopted a different approach to education and credentialing around emergency preparedness/management, which has had an unfortunate effect of reducing cooperation and coordination. To solve this problem, Public Safety and Emergency Preparedness Canada initiated a federal/provincial/territorial working group to address the education requirements for Canadian emergency managers. Additionally, the United Nations Office for Disaster Risk Reduction has published the Global Assessment Report on Disaster Risk Reduction (DRR), which highlights the need for disaster risk reduction strategies to improve emergency and disaster preparedness, response and recovery efforts in the future, and outlines the required credentials and academic needs to foster future DRR professional expertise. Recommendation 4.1 addresses the need for institutions to include emergency preparedness and response training delivered through a multimodal platform. When teaching health care providers and hospitalbased staff about emergency preparedness, multi-modality teaching methods have been found to be an effective tool. A 2016 study by Collander and colleagues examined the efficiency of a multi-modality disaster preparedness training course for hospital-based health care providers, DOMAIN 4: CARE INSTITUTIONS AND ORGANIZATIONS CLOSING THE GAPS: ADVANCING EMERGENCY PREPAREDNESS, RESPONSE AND RECOVERY FOR OLDER ADULTS 48 called Hospital Disaster Life Support (HDLS) (Collander, et al., 2008). The program was taught using lectures, disaster exercises (pneumonia and bomb simulations), skills sessions and tabletop sessions. Upon assessment of the participants’ changes in knowledge acquisition and behaviours related to emergency preparedness, the results of a 1 to 5-point Likert scale, with 5 being the most favorable, showed that the mean response was 4.24. Comparisons of pre- and post-test scores revealed that all participants significantly improved their mean pre-test and post-test scores for emergency preparedness knowledge, the mean test score was 89.5% for the group. Recommendation 4.2 Additional strategies to improve the collection and transfer of identifying information and medical histories should be adopted into current standardized patient handoff procedures to better facilitate effective tracking, relocation and care of patients during an emergency. Improving Transitions of Care for Patients During Emergencies In the US, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) requires all facilities to have a standardized approach to patient hand-off procedures, which adequately supports communication between providers when patients are transported for diagnostic testing or procedures (Nursing, 2006). Similarly, in Canada, health care facilities typically have policies related to patient-hand off that enables communication between providers when patients are being transported. There are other patient transport policies that are specific to certain patient populations, such as Critical Care Services Ontario‘s Life or Limb Policy, developed through a collaboration among Critical Care Services Ontario, CritiCall Ontario, Local Health Integration Networks, Emergency Medical Services and several Hospital Administrators (Ministry of Health and Long-Term Care, 2013). The policy ensures that life or limb threatened patients, i.e. a patient at risk of losing their life or limb, receives care within a 4 hour window and clearly outlines the procedures that are to be followed when patients are being transported. Within the implementation guide are CritiCall Ontario’s five step switchboard processes that start when CritiCall Ontario calls hospital switchboards in order to process a referral for a life or limb case, and ends when hospitals implement their Critical Care Surge Capacity Management Plan to reserve a bed and allow for patient transfer. This streamlined process ensures quick communication between physicians and prompt patient transfer. Though these policies are not specifically geared towards natural disasters, it provides a framework that can be operationalized to minimize harm and errors should patients need to be transported urgently during critical periods. However, additional tracking strategies should be incorporated into traditional patient hand-off procedures to better facilitate patient/resident transfers during emergencies. To prevent interruptions to treatment after relocation, both electronic-based and non-electronicbased methods should be used to facilitate successful delivery of patient identification and their associated medical history to the receiving organization after relocation. Specifically, it is recommended that documents should include demographic characteristics, appearance specifications, and medical information. The inclusion of content specific to patient identification is intended to assist in 49 matching patients to their medical histories in the event that their medical files are misplaced or inaccessible due to disaster, or to assist in identifying patients, particularly those who are unable to successfully do so themselves. Electronic-based tracking methods identified through a systematic review of patient tracking methods used internationally included electronic triage tags such as smart tags and other sensors to determine triage level, radio-frequency identification tags, and personal digital assistants (PDAs) for triage in these situations (Smith & Macdonald, 2006). A similar approach should be adopted in Canada. A strong correlation was further noted between the impact of evacuations on increased hospitalization, mortality, stress and trauma, particularly among nursing home residents with cognitive impairment (Brown, et al., 2013). This reiterates the critical need for care institutions to have emergency management plans, as well as robust transition of care plans in place for when patients need to be evacuated. It also emphasizes the importance of reviewing and updating these plans on a regular basis (Blanchard & Dosa, 2009; Dosa, et al., 2010; Laditka, Laditka, Cornman, Davis, & Richter, 2009; Nomura, et al., 2013; Thomas, et al., 2012; Willoughby, et al., 2017). Improved transitions can be be further supported by enhancing the integration of hospitals into community emergency preparedness planning (Braun, et al., 2006). Supporting integrated planning between hospitals and community care settings can facilitate systems for patient tracking and communication during emergencies and ease transitions post emergencies. Recommendation 4.3 Care institutions and other organizations should strive to develop comprehensive emergency plans that include effective response strategies for protecting older adults against infectious disease outbreaks and reflect evidence-based standards supported by organizations such as Infection Prevention and Control Canada (IPAC).
Care institutions should also regularly assess and address any barriers they identify that could affect the implementation of their emergency plans that build on their routine practices Developing comprehensive organizationwide emergency preparedness strategies that include infectious disease prevention Care institutions such as hospitals and long-term care and nursing homes are prone to regular infectious disease outbreaks. Outbreaks can often be localized to a given unit or section of the facility and can be contained with early identification and intervention. These care settings become more vulnerable to large scale outbreaks during emergencies such as pandemics as infectious diseases spread rapidly among patients and residents. Recommendation 4.3 highlights the importance of care institutions and other organizations having emergency plans that include effective response strategies that address infectious disease spread and outbreaks. During the COVID-19 pandemic, Canada stood out amongst other industrialized countries in reporting the highest proportion of its deaths having occurred in long term-care and retirement homes (Canadian Institute for Health Information, 2020). The vulnerability of long-term care homes to respiratory disease outbreaks such as COVID-19, influenza and others is well recognized DOMAIN 4: CARE INSTITUTIONS AND ORGANIZATIONS CLOSING THE GAPS: ADVANCING EMERGENCY PREPAREDNESS, RESPONSE AND RECOVERY FOR OLDER ADULTS 50 (McMichael, et al., 2020). One study conducted in a skilled nursing facility in Kings County, Washington identified staff working in multiple facilities while ill and transfers of residents from one facility to another as potential challenges that introduced the virus into facilities, which was consistent with other studies (McMichael, et al., 2020; Lai, et al., 2020). Vaccination and timely introduction of antiviral treatments among workers in care institutions and other organizations is thought to be one of the most effective strategies to minimize the risk of infectious disease outbreaks (Cheng, Chen, Chou, Huang, & Huang, 2018; Rainwater- Lovett, Chun, & Lessler, 2014). Studies that assessed vaccination among care institution staff identified skepticism towards vaccination as a barrier to uptake (Huhtinen, Quinn, Hess, Najjar, & Gupta, 2019). Institutions that had on-site immunization programs for employees as well as policies that required immunization as a stipulation for employment showed high rates of vaccination among staff (Lai, et al., 2020). Nonpharmaceutical approaches can also be effective in preventing disease spread as indicated by the supported use of PPE as a preventative measure for spread (World Health Organization, 2020; Rainwater-Lovett, Chun, & Lessler, 2014). Closures of care institutions and facilities can also minimize the spread of infectious diseases among staff and residents alike. During the COVID-19 pandemic, many care institutions such as hospitals, long-term care homes closed their doors to non-essential visitors and restricted access to staff only. Early closures of these homes can be effective in containing disease outbreaks and shortening outbreak periods (Inns, et al., 2018). Other strategies include suspending new admissions, cohorting patients/residents by unit, active reinforcement of routine hygiene practices and use of disinfectant agents for regular cleaning of surfaces among others (Buffington, et al., 1993; Lee, Lee, Lee, & Park, 2020). Routine surveillance and regular reports are also recommended for early identification of infections (Ontario Agency for Health Protection and Promotion (Public Health Ontario), Provincial Infectious Diseases Advisory Committee, 2020). Bundled interventions have been demonstrated as the most effective approach to managing infection outbreaks in care facilities (Hayden, et al., 2015). Infection Prevention and Control Canada (IPAC) provides a repository of evidence-based guidelines with recommendations rooted in epidemiological studies that demonstrate the effectiveness of infection control interventions such as hand hygiene, routine cleaning practices, isolation among others across different health care settings (Ontario Agency for Health Protection and Promotion (Public Health Ontario), Provincial Infectious Diseases Advisory Committee, 2014; Ontario Agency for Health Protection and Promotion (Public Health Ontario), Provincial Infectious Diseases Advisory Committee, 2018; Ontario Agency for Health Protection and Promotion, Provincial Infectious Diseases Advisory Committee, 2012; Ontario Agency for Health Protection and Promotion, Provincial Infectious Diseases Advisory Committee, 2012; Siegel, Rhinehart, Jackson, & Chiarello, 2007; Canadian Committee on Antibiotic Resistance, 2007). Many of these guidelines are endorsed and published by agencies such as Public Health Ontario. Canadian care settings should leverage these guidelines and education resources to support the development of their emergency plans. 51 Federal, provincial and local governing bodies all play a regulatory role in emergency preparedness and response by outlining and enforcing how, and to what extent, relevant bodies and organizations should contribute to more effective emergency preparedness and response efforts through their policy and legislative powers. A review of existing gaps in emergency preparedness, response and recovery policies and legislation relevant to the outcomes of older adults was conducted. The investigation was guided by Research Question 5: Are there legislation or policies that have been developed or adopted at the local, provincial or federal levels to improve emergency (natural disaster or pandemic) preparedness and recovery efforts for older adults? (see Development Approach). The search strategies that were used yielded a combined total of 4,390 peer-reviewed journal articles, nine of which were used along with 15 legislative and policy-oriented documents that were used for data extraction related to this specific question. A review of the documents revealed that while some provinces and territories have developed and implemented new policies/ legislation in response to past experiences related to previous emergencies, there is still a gap in the application of these policies to address the needs of older adults and their unpaid caregivers. For the provinces that have not adopted legislation regarding emergency preparedness, available legislation as well as the current pandemic can serve as guides in making sure older adults are protected in times of emergencies. The gaps in legislation present a challenge in ensuring that sufficient supports are available to consistently address the needs of older adults during emergencies across Canada. Through the development of five policy/legislative evidenceinformed expert recommendations, an opportunity to implement legislation that can better improve emergency outcomes for older adults is proposed. Recommendation 5.1 A national advisory committee should be created to inform emergency preparedness, response and recovery program development and strategies for older Canadians. Individuals who are representative of older Canadians and their unpaid caregivers should be involved to ensure their voices and perspectives are reflected. Establishing a National Advisory Committee on Emergency Preparedness for Older Adults In 2017, the US Senate introduced Bill S. 1834 to amend title XXVIII of the Public Health Service Act to include the establishment of a National Advisory Committee on Seniors and Disasters (Protecting Seniors During Disasters Act, 2017). The Advisory Committee was intended to be established by the Secretary of the Senate, with the consultation of the Secretary of Homeland Security and the Secretary of Veterans Affairs. The duties tasked to the Advisory Committee included evaluating and providing input on activities related to the medical and public health needs of older adults during all-hazard emergencies, and providing advice and recommendations to the Secretary with respect to older adults, medical and public health grants and cooperative agreements related to preparedness and response activities authorized under the Secretary. To ensure that the committee has the expertise required to better serve its designated tasks, Bill S. 1834 outlines a list of appropriate representatives that the committee should comprise; representatives Domain 5: Legislation and Policy DOMAIN 5: LEGISLATION AND POLICY CLOSING THE GAPS: ADVANCING EMERGENCY PREPAREDNESS, RESPONSE AND RECOVERY FOR OLDER ADULTS 52 identified on the Bill include: the Director of the Centers for Disease Control and Prevention (CDC), the Administrator of the Center for Medicare & Medicaid Services (CMS), the Administrator of the Federal Emergency Management Agency (FEMA), at least two non-federal health care providers with expertise in medical disaster planning, preparedness, response or recovery and representatives from other relevant Federal agencies, such as the Department of Energy and the Department of Homeland Security (DHS). While the effectiveness of this committee has not yet been evaluated, the Canadian experts recognized the importance of the mandate of the committee established in the US and the potential impact it could have on emergency preparedness for older adults. To date, there has been no such committee established in Canada. Existing resources such as The Emergency Management Framework of Canada (see Summary of Relevant Frameworks and Legislations in Appendix B) could facilitate the creation of a national advisory committee that could inform decision-making and planning related to emergency preparedness and older adults. Federal groups such as Public Safety Canada may also have a role in the management and operation of this committee. Further, the engagement of older adults to participate as members of this committee would ensure that the perspectives of this population are appropriately integrated into any resulting outputs and products from the committee. Older adults have been found to play essential roles in policy development because they can provide insight on “salient barriers to active ageing and options for post-earthquake redevelopment that had not been previously considered” (Annear, Keeling, & Wilkinson, 2014). Other recommended members would include relevant private sector providers and geriatric care professionals (geriatricians, geriatric psychiatrists, gerontological nurses, social workers and pharmacists, physical and occupational therapists, and other geriatric care experts), and non-governmental organizations that work in preparedness, response and recovery for seniors, such as the Salvation Army and the Canadian Red Cross. Gerontologists can also provide insight and guidance on common geriatric syndromes, such as dementia, delirium, and psychosis, as well as common areas that older adults may require assistance with, such as taking medications, mobility, understanding emergency instructions and accessing social support, which are commonly managed by geriatric health care providers. Recommendation 5.2 All provinces and territories should support the implementation of tax-free emergency preparedness purchasing periods during specific times of the year or prior to an impending emergency. Governments should also provide targeted funding to directly support/subsidize the purchase of emergency preparedness kits for older Canadians. Items covered should include an agreed-upon list of emergency supplies (such as batteries, portable generators, rescue ladders, radios and ice packs), air conditioners, personal protective equipment (such as masks, gloves and hand sanitizer, etc.) and additional mobility aids (canes, walkers, etc.). Supporting Improved Self-Preparedness Activities When faced with the financial burdens associated with emergencies, older persons repeatedly experience less robust economic recovery than 53 younger age groups (Fernandez, Byard, Lin, Benson, & Barbera, 2002). Younger age groups tend to be less vulnerable to property damage due to a greater likelihood of having insurance, higher credit values, greater financial savings, and their reduced likelihood of living at or near the poverty line (Fernandez, Byard, Lin, Benson, & Barbera, 2002). The qualifications for receiving financial aid may also help explain why older adults may use them less than other age groups. This is often because older adults live on a fixed income or lack employment. Furthermore, in cases where aid is received, it is often difficult to obtain money to replace uncovered losses, making older adults more dependent on support from charities and their Social Security benefits (Fernandez, Byard, Lin, Benson, & Barbera, 2002). In Canada, Emergency Preparedness Week is a national awareness initiative that has taken place annually since 1996 during the month of May. It is a collaborative event undertaken by federal, provincial and territorial emergency management organizations that support emergency preparedness activities at the local level. Emergency preparedness week encourages Canadians to take three simple steps to become better prepared to face an emergency: 1) know the risks, 2) make a plan, and 3) get an emergency kit (Government of Canada, 2015). Tax-free emergency supplies can act as an incentive for older adults to purchase resources for their emergency kit or provide the price reductions needed to help older adults with limited resources access these essential supplies. Currently, 16 states in the United States have implemented tax-free weekends, however, only three have included ‘weather related’ preparedness or ‘severe weather’ preparedness supplies as part of the selected items that are eligible for a tax break or tax exemption. To provide all older adults with access to reduced costs for emergency supplies, it is recommended that all provinces and territories adopt tax-free emergency supplies and/or provide funding to support low-income seniors to purchase emergency kits. Supplies should include, but not be limited to, batteries, portable generators, mobility aids (canes and walkers), air conditioners, rescue ladders, radios, and ice packs. Furthermore, evidence shows that having a basic home kit comprised of non-pharmaceutical interventions such as hand hygiene and masks in addition to adequate ventilation, temperature control measures among other things greatly reduces the spread of illness and indirectly contributes to avoidable hospitalizations (Finkelstein, Prakash, Nigmatulina, McDevitt, & Larson, 2013). Thus, subsidizing these emergency essentials for older adults will improve emergency preparedness efforts. Recommendation 5.3 All provinces and territories should support the creation of a national licensure process or program for nurses, physicians, allied health professionals and other emergency medical service personnel to allow them to provide voluntary emergency medical support across provincial/territorial boundaries during declared states of emergency. Enhancing the Portability of Health Care Professional Expertise During Emergencies It is apparent that access to medical services must be provided as part of all emergency responses to support emergent medical needs. It is recommended that steps be taken to support the preliminary recruitment of health care providers DOMAIN 5: LEGISLATION AND POLICY CLOSING THE GAPS: ADVANCING EMERGENCY PREPAREDNESS, RESPONSE AND RECOVERY FOR OLDER ADULTS 54 to facilitate a faster and standardized assembly of emergent medical teams during emergencies. In the United States, the Medical Reserves Corps (MRC) acts as a database of medical and nonmedical volunteers who can provide medical support in their community during emergencies, and this has been demonstrated to be very effective. It is recommended that similar resources be created and made available in Canada. To increase the availability of medically trained volunteers during an emergency, actions should be taken to adopt inter-provincial licensing across all provinces and territories. All relevant health care providers should work with their respective professional provincial or territorial boards and legislators to pass the required legislation in their respective province or territory. In Canada, licensing is provincially regulated. During emergencies, provinces utilize their own resources first; however, in cases where there is a need for specialists, Canada has the mechanisms to call on extra resources. For instance, the Public Health Agency of Canada (PHAC) has the mechanisms to clear health care providers in a relatively short amount of time. Creating a national licensure program in Canada would facilitate shorter response timelines and ensure help is available when needed. For instance, the Atlantic Colleges of Physicians and Surgeons are working together to harmonize a number of processes and procedures as well as working on common Atlantic Colleges’ approaches to certain licences for physicians. The US has adopted a similar model whereby 31 states are licensure compact states for nursing (Nurse Licensure Compact, n.d.), 14 states and one territory are licensure compact states for emergency management services (EMS) personnel, (National Registry of Emergency Medical Technicians, n.d.), and 24 states are licensure compact states for physicians (Interstate Medical Licensure Compact, n.d.). A potential option for Canada is to allow health care providers to practice in different provinces or territories by pre-applying through PHAC for inter-provincial work during an emergency. Recommendation 5.4 All provincial and territorial governments should support legislative requirements that mandate congregate living settings for older persons (e.g. nursing homes, assisted living facilities and retirement homes) to regularly update and report their emergency plans that outline actions and contingencies to take in case of emergencies. These plans should include:
An outline of staffing levels that should be maintained during emergencies to minimize care and/or service interruptions. 55 All provinces and territories should work towards standardizing requirements for emergency plans in congregate living settings in accordance with the priorities outlined in the 2019 Emergency Management Strategy for Canada and ensure that their emergency plans for congregate living settings are aligned with directives outlined in their provincial/territorial pandemic and emergency plans. Improving Environmental Control Efforts in Nursing Homes and Assisted Living Facilities In Ontario, the Long-term Care Homes Act (2007) states that all nursing homes must have air conditioning and back-up generators to provide power for all support and life-supporting equipment in the case of an emergency. If central air conditioning is not available in the facility, there should be a designated cooling area for every 40 residents. However, this is not the case for all provinces and territories. For instance, in British Columbia, the legislation does not include requiring homes to have additional contingencies in their emergency plans to ensure that, in the event of a power outage, temperatures are kept at reasonable levels to avoid the exacerbation of existing health issues among nursing homes and assisted living plans in long-term care facilities. The panel recommends calling on all provinces and territories to standardize their requirements and ensure that the appropriate measures are in place to restore power within a reasonable timeframe, and mandate that facilities have additional contingencies to ensure that temperatures are maintained at appropriate levels. In addition to maintaining favorable in-house temperatures and ensuring constant power supply, emergency plans for congregate living settings should include contingencies to maintain appropriate staffing levels during emergencies. The COVID-19 pandemic highlighted significant challenges with maintaining appropriate staffing levels in settings such as group and retirement homes for older adults. Participation House, a group home in Markham, Ontario experienced high rates of staff resignations during the pandemic where staffing levels were described as “critical” (Rocca, 2020). The group home experienced a severe outbreak of the virus during the pandemic with 95% of its residents (40 of 42) and 38 of its staff members becoming infected (Riedner, 2020). Studies have shown that, among other things, staffing levels and patterns can have significant impact on outcomes in congregate living settings (Trivedi, et al., 2012; Li, Birkhead, Strogatz, & Coles, 1996; Lin, et al., 2011; Harrington, Zimmerman, Karon, Robinson, & Beutel, 2000; Horn, Buerhaus, Bergstrom, & Smout, 2005; Kim, Kovner, Harrington, Greene, & Mezey, 2009). Consequently, effective emergency planning will require actions to maintain appropriate staffing levels to minimize the risk of widespread and prolonged outbreaks in these settings. Ensuring that staff are adequately trained and prepared for an emergency will also improve outbreak efforts in nursing homes and assisted living facilities. In a study conducted by Bucy, Smith, Carder, Winfree and Thomas to determine how States required residential care and assisted living facilities to mitigate, prepare and respond to infections among their residents, found that 31 states had defined infection control policies some DOMAIN 5: LEGISLATION AND POLICY CLOSING THE GAPS: ADVANCING EMERGENCY PREPAREDNESS, RESPONSE AND RECOVERY FOR OLDER ADULTS 56 of which require staff to be trained in infection control) (Bucy, Smith, Carder, Winfree, & Thomas, 2020). Ten states include language surrounding epidemics, primarily regarding reportable disease and requirements for reporting to local Public Health departments, and two describe pandemic emergency preparedness. Only six States referenced resident isolation practices as an effective way to combat the spread of infections (Bucy, Smith, Carder, Winfree, & Thomas, 2020). Similarly, in Canada, the 2007 Emergency Management Act (Government of Canada, 2007) requires the federal Minister of Health to develop, test and maintain mandate-specific emergency plans for the federal Health Portfolio. Health emergency management in provinces and territories are governed by specific legislation specific to each jurisdiction that requires provincial and territorial governments to have comprehensive emergency plans. Each province and territory, in accordance with the legislation, has outlined emergency plans, some of which are specific to influenza and/or pandemics. Some provinces, such as Alberta, have stipulated actions for vulnerable groups (i.e. seniors) and health care workers and services in their Pandemic Influenza Plans (Alberta Government, 2014). The COVID-19 pandemic resulted in provincial governments issuing more specific guidance for community and health care settings to support evidence-informed decision making and actions in these settings. Lastly, legislation should take into account emergency plans for situations where a lack of infrastructure poses itself as an obstacle to physical distancing or self-isolation. Isolation is a recommended strategy to control disease outbreak in congregate living environments however many facilities have reported infrastructure challenges has a barrier to implementing isolation protocols among their residents (Huhtinen, Quinn, Hess, Najjar, & Gupta, 2019; McMichael, et al., 2020). Not being able to physically separate during an emergency can serve as a barrier to managing and controlling a disease outbreak. Recommendation 5.5 All provinces and territories should adopt a standardized approach to promoting collaborations between local pharmaceutical prescribers and dispensers (i.e. community pharmacists), physicians and nurse practitioners, to ensure an adequate supply of prescription medications are dispensed to persons with chronic health conditions prior to and during an emergency. This approach should also outline the need for collaboration between pharmaceutical providers, hospitals and relief agencies to ensure an adequate supply of prescription medications are available at hospitals, relief and evacuation shelters.
All persons should be able to obtain at least a 30-day supply of emergency prescription medications prior to and during an emergency. Ensuring Access to Medically Necessary Medications During Emergencies Older adults often live with multiple chronic health conditions that require ongoing management, which can include the help of prescription medicine. In Canada, prescription length policies are set largely by the regulatory bodies for physicians and pharmacists at the provincial level. Though there were no studies found related to access to medication during times of emergencies in Canada, there were many reports 57 that emerged from the US and other jurisdictions regarding the challenges that were experienced accessing prescription medications for people who were evacuated to shelters. For instance, in the aftermath of Hurricane Katrina, many older adults were relocated to public shelters miles away from their homes. Reflective discussions of the medical care provided in the Astrodome in Houston, TX, and the Mississippi Coliseum and the Mississippi Trade Mart in Jackson, MS, have exposed the impact that existing barriers to accessing at least a 30-day supply of emergency prescription medications can have on one’s health. In Jackson, MS, the Department of Medicine, in partnership with local medical facilities deployed a pop-up Katrina clinic in the Mississippi Coliseum and Mississippi Trade Mart shelters (Currier , King, Wofford , Daniel, & deShazo , 2006). Though many of the 2,394 evacuees left their homes with the conventionally recommended threeday supply of medications, most people required access to additional supplies of their medications to manage chronic health conditions (Aldrich & Benson, 2008; Currier , King, Wofford , Daniel, & deShazo , 2006). It was reported that the most common medical needs at the clinic were for prescription refills, particularly for cardiovascular, antihistamine/decongestant, psychotropic, analgesic and diabetic medications (Currier , King, Wofford , Daniel, & deShazo , 2006). A review of several pharmaceutical and drug prescribing policies in Canada has highlighted that emergency refill policies are not uniform across provinces and territories, and the issue was rarely addressed specifically. One province, British Columbia, allows physicians to provide prescriptions with renewals for up to a one-year period (two years for birth control). Additionally, pharmacists can independently renew most medications for a period of up to six months. During severe emergencies, where persons can be displaced for extended periods of time, ranging from a few days to a few months, it is critical that persons who are dependent on medications are able to evacuate their homes with a pharmaceutical supply that can support their health and well-being, particularly if they must evacuate to an isolated area or stay at a relief shelter where pharmaceutical supplies can be limited at warehouses and coordinating centres for emergency response (Currier , King, Wofford , Daniel, & deShazo , 2006). Consequently, it is recommended that all provinces and territories adopt a standardized approach to collaboration between local pharmaceutical prescribers and dispensers, specifically community pharmacists, physicians and nurse practitioners. To further facilitate access to prescription medications during emergencies, particularly in relief shelters, this approach should emphasize the need for inter-organizational collaboration between pharmaceutical providers and relief agencies to ensure that an adequate supply of prescription medications are available. DOMAIN 5: LEGISLATION AND POLICY CLOSING THE GAPS: ADVANCING EMERGENCY PREPAREDNESS, RESPONSE AND RECOVERY FOR OLDER ADULTS 58 Domain 6: Research A holistic review of the identified literature revealed that research in the field of emergency preparedness, response, and recovery for older adults is highly underdeveloped. The unpredictability of both the timing and types of emergencies make traditional research designs and methodologies difficult. Nevertheless, there is a clear opportunity to develop and evaluate preparedness initiatives and their potential impact during response and recovery efforts, as well as the outcomes for designated populations and those personnel and organizations with a responsibility for supporting them. Recommendation 6.1 There is a need to prioritize the creation and funding of research efforts to better support the development of a common framework for measuring the quality and levels of emergency preparedness among care institutions, organizations, paid providers, community organizations, and other groups that work primarily with older adults and their unpaid caregivers during and after emergencies. Recommendation 6.2 There needs to be a more concerted effort in utilizing outcomes from existing evidence to support the planning, design, and refinement of more evidence-informed emergency preparedness interventions, policies, and regulations in support of older adults and unpaid caregivers, as well as organizations and paid care providers that will be responsible for meeting their needs during and after an emergency. Prioritizing Emergency Preparedness and Response Research A review of the existing literature relevant to emergency preparedness, response, and recovery for older adults has highlighted a gap in this research field. Current research efforts have highlighted that older adults experience a disproportionately greater vulnerability to adverse outcomes during and after emergencies compared to younger adults; however, there is limited available research that evaluates interventions that can be implemented to induce more positive outcomes for older adults. Specifically, there are insufficient studies that evaluate best practices for assisting and caring for older adults with health and functional declines, and the most effective methods for delivering services and resources to them. Regarding system operations, there is research that documents the effects of surge capacity operations in the ED and patient tracking methods that are used internationally, but a lack of available research on the most effective policies and procedures to ensure a favorable outcome during surge capacity operations or patient hand-offs during emergencies. The development of a research agenda related to emergency preparedness, response and recovery for older adults is essential to facilitating greater experimental exploration of emergency-related interventions for older adults. Researchers should also develop a common framework for measuring the quality and levels of emergency preparedness among various institutions and organizations. A common evaluation framework can reduce the variability and biases that can be associated with comparing systems that have been evaluated using different frameworks, which can differ based on their chosen metrics and domains of measurement. 59 In a 2004 research report done by Public Safety and Emergency Preparedness Canada, participants acknowledged that there is little research related to emergency management in Canada. This highlights the need to encourage more graduate students to pursue research projects in emergency management. Furthermore, the outcomes of those projects needs to be translated to practitioners to bridge the gap between knowledge and practice (Public Safety and Emergency Preparedness Canada, 2004). There has been some work done to measure general preparedness among Canadians published in the 2014 report titled Emergency Preparedness in Canada. The report used data from the Survey of Emergency Preparedness and Resilience (SEPR), a cross sectional survey conducted by Statistics Canada for the first time in 2014, to investigate emergency preparedness activities and risk awareness among Canadians aged 15 and over from across the 10 provinces. Based on the survey, emergencies involving the outbreak of serious disease were named as a likely hazard by about half of those in each province, with the exception of Newfoundland and Labrador (37%), Prince Edward Island (40%) and New Brunswick (44%), where the proportion was about four in ten for each (Emergency Preparedness in Canada, 2014). Canadians believe a number of natural and human-induced disasters are events that their community is likely to face. Winter storms (86%) and extended power outages (76%), followed by outbreaks of serious or life-threatening disease (51%) and industrial or transportation accidents (50%) were the most frequently named events (Emergency Preparedness in Canada, 2014). Further, older adults aged 65 and older were highlighted as being less likely to have a large social network to turn to in an emergency (Emergency Preparedness in Canada, 2014). Though the SEPR provides a baseline to support understanding of preparedness across Canada, responses were collected from Canadians living in only the 10 provinces, excluding the territories. It also excluded Canadians living in institutions such as nursing and long-term care homes, which includes older adults who would be in greater need of support in emergency or disaster situations. Applying Relevant Research Findings to Real-Life Emergency Health Practices Recommendation 6.2 further supports the utilization of research in policy making by proposing that published studies related to emergency preparedness and recovery be made open access. Providing open access to emergency preparedness and recovery research can help facilitate greater experimental investigation in the field of emergency preparedness and response. Recommendation 6.3 A network of emergency preparedness researchers, older adults, unpaid caregivers, volunteers and providers needs to be created to encourage partnerships in the ongoing unpaid evaluation of emergency preparedness interventions targeting older adults. Network members should advocate for an increased focus on emergency preparedness research among the various societies or journals that they are members of. Establishing a Network of Emergency Health Researchers Unfortunately, emergency management research in Canada has not been identified as a priority. As a result, Recommendation 6.3 suggests creation of a national network for emergency DOMAIN 6: RESEARCH CLOSING THE GAPS: ADVANCING EMERGENCY PREPAREDNESS, RESPONSE AND RECOVERY FOR OLDER ADULTS 60 management and emergency preparedness comprised of providers, older adults and volunteers. The network could be leveraged for information sharing but would primarily advocate for an increased focus on emergency preparedness research. It was also suggested by Round Table participants that the network could be supported by an organization connected to all universities offering emergency management programs and conducting emergency management research, as well as by the federal and provincial authorities responsible for emergency management. The panel further recommends that this current network of emergency preparedness researchers be continued to support the progression of research efforts related to emergency preparedness for older adults. The tasks of the research group should include evaluating the efficiency of existing policies and procedures within care institutions/ organizations and government, identifying gaps in knowledge and knowledge delivery, and delegating priorities for research. It is intended that this group of researchers will fill the current gap in emergency preparedness, response and recovery research to support the development of evidencebased policies. Recommendation 6.4 There is a need to focus on research about unpaid caregivers and emergency preparedness to better instruct unpaid caregivers on how to take care of their vulnerable family members and friends during an emergency. Conducting Research on Emergency Preparedness Among Unpaid Caregivers Being an unpaid caregiver can at times be demanding. Dealing with an emergency, in addition to caregiving responsibilities, can quickly become overwhelming, with potentially devastating consequences. Consequently, it is essential for unpaid caregivers to be appropriately supported whereby they can identify potential challenges and take the steps necessary so that they and the older adult they are caring for can be prepared. The Round Table attendees recognized the vital role that unpaid caregivers play in emergency preparedness and reduction of casualties following a major event among older adults. The literature reviewed has highlighted the different levels of responsibilities and roles in reducing negative outcomes following an emergency. Research literature has consistently noted a need for evidence-informed strategies to address challenges to emergency preparedness, particularly among households with frail older adults and their unpaid caregivers (Levac, Toal- Sullivan, & O'Sullivan, 2012). Recommendation 6.4 notes the importance of conducting additional research with a particular focus on unpaid caregivers, which can further bridge this gap and provide an evidence base to develop strategies that can mitigate negative outcomes among older adults following an emergency. Recommendation 6.5 There is a need to focus on research about emergency preparedness and response in Canadian community and congregate living settings for older adults (e.g. nursing, retirement and group homes, and assisted living facilities). Research should:
Determine the existing levels of preparedness across these environments as well as highlight the challenges they face in being prepared. 61
Characterize the impact of the emergency on the older adult population and emerging best practices on how to address it as soon as it emerges. Preparing Congregate Living Settings for an Emergency Canada’s recent experience with the COVID-19 pandemic and the high number of deaths it has experienced to date in its long-term care homes (Canadian Institute for Health Information, 2020) has shown that there are gaps in the system which have rendered congregate living settings vulnerable in the midst of an emergency. Recommendations 6.5 highlights the need for more research to understand the existing levels of emergency preparedness in congregate living settings for older adults. Comprehensive emergency plans should reflect contingencies for a multitude of emergencies ranging in scale and nature, including pandemics. Emergency plans in congregate living settings for older adults should include clear protocols for pandemics. In a study conducted by Lum, Mody, Lona and Ginde (2014), a national survey to identify characteristics of residential care settings associated with having a pandemic plan in the US found that a majority of the residential care settings that lacked a pandemic influenza plan were smaller, for-profit, and non-chain-affiliated and also had lower staff vaccination rates (Lum, Mody, Levy, & Ginde, 2014). Understanding these characteristics may help target settings that need to develop plans to handle a pandemic, or other emergencies. Having a robust program of research on emergency preparedness in congregate living settings for older adults can facilitate the development of a body of evidence for best practices to address emergencies as soon as it emerges. Research should target all levels of emergency management including the resident/ patient, providers/staff, programs and institutions. Surveillance data, such as data from the COVID-19 pandemic, can provide the basis for new and ongoing studies. DOMAIN 6: RESEARCH CLOSING THE GAPS: ADVANCING EMERGENCY PREPAREDNESS, RESPONSE AND RECOVERY FOR OLDER ADULTS 62 Alzheimer’s Disease: a form of dementia that causes problems with memory, thinking, behavior and independent functioning; it is the most common cause of dementia (https://www.alz.org/alzheimers- dementia/whatis- alzheimers). Care Institution: an organization that provides health care and related services to the provision of inpatient and outpatient care, such as diagnostic or therapeutic services, laboratory services, medicinal drugs and other health services. Congregate Living Settings: refers to a range of congregate living environments (nursing and retirement homes, assisted living facilities, etc.) where older adults live or stay overnight and use shared spaces (https://www.publichealthontario.ca/en/diseasesand- conditions/infectious-diseases/respiratorydiseases/ novel-coronavirus/congregate-livingsettings- resources#:~:text=Congregate%20 living%20settings%20refer%20 to,Correctional%20facilities). Dementia: a general term used to categorize a group of diseases associated with progressive declines in cognitive abilities, including memory, communication, language, attention, reasoning, judgement and visual perception that negatively impact independent functioning (https://www.alz.org/alzheimers-dementia/whatis- dementia). Epidemic: the occurrence of disease cases in excess of normal expectancy (https://www.who.int/environmental_health_ emergencies/disease_outbreaks/en/). Emergency: a state whereby a territory is facing an event with public health consequences; here used to encompass a natural disaster or pandemic (https://www.who.int/emergencies/crises/en/). Emergency Response Personnel: personnel responsible for providing assistive services during an emergency, including firefighters, police, civil defense/emergency management officials, sheriffs, military and manufacturing and transportation personnel. Geriatric Care Professionals: practitioners that specialize in treating the physical, mental, emotional and/or social problems among older adults, including nurses, dentists, social workers, occupational and physical therapists, and pharmacists. Health Care Disaster: these happen when the destructive effects of a natural disaster can overwhelm the ability of a given area or community to meet the demand for healthcare (https://www.ncbi.nlm.nih.gov/pmc/articles/ PMC1291330/). Healthcare Professionals: an individual that has been certified and authorized to provide preventable, curable, rehabilitative, and promotional health services (http://www.who.int/hrh/statistics/Health_ workers_classification.pdf). Incident Command System: a standardized tool for enabling an effective command, control, and coordination of an emergency response, allowing agencies to work together to facilitate a consistent response (https://ops.fhwa.dot.gov/publications/ics_guide/ glossary.htm). Glossary 63 Natural disaster: an act of nature of such magnitude as to create a catastrophic situation in which the day-to-day patterns of life are suddenly disrupted and people are plunged into helplessness and suffering, and, as a result, need food, clothing, shelter, medical and nursing care and other necessities of life, and protection against unfavourable environmental factors and conditions (https://www.who.int/environmental_health_ emergencies/natural_events/en/) Pandemic: an epidemic occurring worldwide, or over a very wide area, crossing international boundaries and usually affecting a large number of people (https://www.who.int/bulletin/ volumes/89/7/11-088815/en/#:~:text=A%20 pandemic%20is%20defined%20as,are%20not%20 considered%20pandemics.) Personal Protective Equipment (PPE): items worn or used to provide barrier to help prevent potential exposure to an infectious disease. Shelter-in-place: a precaution taken when hazardous materials (chemical, biological or radiological) are released in the air. This requires seeking a small, interior room with no or minimal windows within the building one already occupies. State of Emergency: a circumstance declared by a government when a disaster has occurred and is severe or is imminent and expected to require state aid to supplement local resources to prevent or alleviate damage, loss and hardship within a region (http://ready.nj.gov/about-us/state-of-emergency. shtml). Unpaid Caregivers: individuals who provide help and care to members of their household and to people who reside in other households. GLOSSARY CLOSING THE GAPS: ADVANCING EMERGENCY PREPAREDNESS, RESPONSE AND RECOVERY FOR OLDER ADULTS 64 Ahronheim, J. C., Arquilla, B., & Gambale Greene, R. (2009). Elderly populations in disasters: Hospital guidelines for geriatric preparedness. New York: New York City Department of Health and Mental Hygiene. Retrieved from http://citeseerx.ist.psu.edu/viewdoc/ download?doi=10.1.1.468.704&rep=rep1&type=pdf Alberta Government. (2014, March). Alberta’s Pandemic Influenza Plan. Retrieved from Government of Alberta. Aldrich, N., & Benson, W. F. (2008, January). Disaster preparedness and the chronic disease needs of vulnerable older adults. Preventing Chronic Disease, 5(1), 1-7. Retrieved from http:// www.cdc.gov/ pcd//issues/2008/jan/07_0135.htm Al-Rousan, T. M., Rubenstein, L. M., & Wallace , R. B. (2014, March). Preparedness for natural disasters among older US adults: A nationwide survey. American Journal of Public Health, 104(3), 506-511. doi:10.2105/AJPH.2013.301559 Alzheimer Society of Canada. (2018, June 29). Latest information and statistics. Retrieved from Alzheimer Society of Canada: https://alzheimer.ca/en/Home/Get-involved/Advocacy/Latest-info-stats Alzheimer Society of Canada. (2019, May 12). Disaster preparation. Retrieved from Alzheimer Society of Canada: https://alzheimer.ca/en/Home/Living-with-dementia/Day-to-day-living/Safety/Disasterpreparation Alzheimer’s Association . (2018). Alzheimer’s & Dementia Facts and Figures . Retrieved July 4, 2018, from Alzheimer’s Association : https://www.alz.org/alzheimers-dementia/facts-figures American Delirium Society. (2015). What is delirium? Retrieved from American Delirium Society: https:// americandeliriumsociety.org/what-delirium American Occupational Therapy Association. (2006). The role of occupational therapy in disaster preparedness, response, and recovery. American Journal of Occupational Therapy, 60, 642-649. Retrieved from https://www.aota.org/About-Occupational-Therapy/Professionals/MH/Articles/ Disaster-Relief.aspx Annear, M., Keeling, S., & Wilkinson, T. (2014, March). Participatory and evidence-based recommendations for urban redevelopment following natural disasters: Older adults as policy advisers. Australasian Journal on Ageing, 33(1), 43-49. doi:10.1111/ajag.12053 Ardalan, A., Mazaheri, M., Naireni, K. H., Rezaie, M., Teimoori, F., & Pourmakek, F. (2010, January). Older people’s needs following major disasters: a qualitative study of Iranian elders’ experiences of the Bam earthquake. Ageing & Society, 30(1), 11-23. doi:10.1017/S0144686X09990122 References 65 Ashida, S., Robinson, E. L., Gay, J., & Ramirez, M. R. (2016, November). Motivating rural older residents to prepare for disasters: Moving beyond personal benefits. Aging & Society, 2117-2140. doi:10.1017/ S0144686X15000914 Ashida, S., Robinson, E. L., Gay, J., Slagel, L. E., & Ramirez, M. R. (2017, February). Personal disaster and emergency support networks of older adults in a rural community: Changes after participation in a preparedness program. Disaster Medicine and Public Health Preparedness, 11(1), 110-119. doi:10.1017/dmp.2016.197 Banks, L. (2013, January). Caring for elderly adults during disasters: Improving health outcomes and recovery. Southern Medical Journal, 106(1), 94-98. doi:10.1097/SMJ.0b013e31827c5157 Beatty, M. E., Phelps, S., Rohner , C., & Weisfuse, I. (2006). Blackout of 2003: Public Health Effects and Emergency Response. Public Health Rep, 36-44. Benson, W. F. (2017, June 27). CDC’s disaster planning goal: Protect vulnerable older adults. Retrieved from https://www.cdc.gov/aging/pdf/disaster_planning_goal.pdf Bhalla, M. C., Burgess, A., Frey, J., & Hardy, W. (2015, October). Geriatric disaster preparedness. Prehospital and Disaster Medicine, 30(5), 443-446. doi:10.1017/S1049023X15005075 Blackmon, B. J., Lee, J., Cochran, D. M., Kar, B., Rehner, T. A., & Baker, A. M. (2017, January). Adapting to life after Hurricane Katrina and the Deepwater Horizon oil spill: An examination of psychological resilience and depression on the Mississippi Gulf Coast. Social Work in Public Health, 32(1), 65-76. doi:10.1080/19371918.2016.1188746 Blanchard, G., & Dosa, D. (2009, November). A comparison of the nursing home evacuation experience between Hurricanes Katrina (2005) and Gustav (2008). Journal of the American Medical Directors Association, 10(9), 639-643. doi:10.1016/j.jamda.2009.06.010 Bloomfield, S. F., Exner, M., Carlo, S. C., Nath, K. J., & Scott, E. A. (2012). The chain of infection transmission in the home and everyday life settings, and the role of hygiene in reducing the risk of infection. Retrieved from http://www.ifh-homehygiene.org/IntegratedCRD. nsf/111e68ea0824afe1802575070003f039/9df1597d905889868025729700617093 ?OpenDocument Bohnert, N., Chagnon, J., & Dion, P. (2015, May 26). Population Projections for Canada (2013 to 2063), Provinces and Territories (2013 to 2038). Retrieved from Statistics Canada: https://www150.statcan. gc.ca/n1/en/pub/91-520-x/91-520-x2014001-eng.pdf?st=3J5XsLb_ Braun, B. I., Wineman, N. V., Finn, N. L., Barbera, J. A., Schmaltz, S. P., & Loeb, J. M. (2006, June 6). Integrating hospitals into community emergency preparedness planning. Annals of Internal Medicine, 144(11), 799-811. doi:10.7326/0003-4819-144-11-200606060-00006 REFERENCES CLOSING THE GAPS: ADVANCING EMERGENCY PREPAREDNESS, RESPONSE AND RECOVERY FOR OLDER ADULTS 66 Bronfenbrenner, U. (1977). Toward an experimental ecology of human development. American Psychologist(32), 513-531. Brown, L. M., Dosa, D. M., Thomas, K., Hyer, K., Feng, Z., & Mor, V. (2013, September). The effects of evacuation on nursing home residents with dementia. American Journal of Alzheimer’s Disease and other Dementias, 27(6), 406-412. doi:10.1177/1533317512454709 Brunkard, J., Namulanda, G., & Ratard, R. (2008, December). Hurricane Katrina deaths, Louisiana, 2005. Disaster Medicine and Public Health Preparedness, 2(4), 215-223. doi:10.1097/ DMP.0b013e31818aaf55 Bucy, T., Smith, L., Carder, P., Winfree, J., & Thomas, K. (2020, May). Variability in state regulations pertaining to infection control and pandemic resposnse in US assisted living communities. Journal of American Medical Director Association, 21(5), 701-702. doi:10.1016/j.jamda.2020.03.021 Buffington, J., Chapman, L. E., Stobierski, M. G., Hierholzer, J. C., Gary, H. E., Guskey, L. E., . . . Schonberger, L. B. (1993). Epidemic keratoconjunctivitis in a chronic care facility: Risk factors and measures for control. Journal of the American Geriatrics Society, 41, 1177-81. Bustinza, R., Lebel, G., Gosselin, P., Belanger, D., & Chebana, F. (2013). Health impacts of the July 2010 heat wave in Quebec, Canada. BMC Public Health, 1-7. Byrd, L. (2010). Crisis shelters for communities of elders (including nursing home residents). Gerontological Advanced Practice Nurses Association, 31(3), 230-232. doi:doi:10.1016/j.gerinurse.2010.04.007 Canadian Association of Occupational Therapists. (2011). CAOT policy statement: Occupation therapy and cultural safety. Retrieved from Advancing excellence in occupational therapy: https://www.caot.ca/ document/3702/O%20-%20OT%20and%20Cultural%20Safety.pdf Canadian Committee on Antibiotic Resistance. (2007). Infection Prevention and Control Best Practices for Long Term Care, Home and Community Care including Health Care Offices and Ambulatory Clinics. Toronto. Canadian Institute for Health Information. (2020). Pandemic Experience in the Long-Term Care Sector: How Does Canada Compare with Other Countries? Toronto: Canadian Institute for Health Information. Retrieved from https://static1.squarespace.com/static/5c2fa7b03917eed9b5a436d8/t/5 f071dda1fbff833fe105111/1594301915196/covid-19-rapid-response-long-term-care-snapshot-en.pdf Canadian Red Cross. (2019, August 15). Be ready: Emergency preparedness and recovery. Retrieved from Canadian Red Cross: https://www.redcross.ca/how-we-help/emergencies-and-disasters-in-canada/ be-ready-emergency-preparedness-and-recovery 67 Catizone, C. A. (2017). Model state pharmacy act and model rules of the national association of boards of pharmacy. Mount Prospect: National Association of Boards of Pharmacy. Retrieved from https:// nabp.pharmacy/publications-reports/resource-documents/model-pharmacy-act-rules/ CBC News. (2017, May 18). Flood victims suffering from psychological distress, Montreal officials say. Retrieved from CBC : https://www.cbc.ca/news/canada/montreal/flood-victims-suffering-frompsychological- distress-montreal-officials-say-1.4121037 Centers for Disease Control. (2020). CDC Interim Guidance for General Population Disaster Shelters During the COVID-19 Pandemic. Retrieved from https://www.cdc.gov/coronavirus/2019-ncov/downloads/ COVID19_Homeless-H.pdf Centers for Disease Control and Prevention. (2020, May 19). Additional COVID-19 Guidance for Caregivers of People Living with Dementia in Community Settings. Retrieved from Centers for Disease Control and Prevention: https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/caregiversdementia. html Centers for Disease Control and Prevention. (2020, June 25). COVID-19 Guidance for Older Adults. Retrieved from Centers for Disease Control and Prevention: https://www.cdc.gov/aging/covid19-guidance.html Cheng, H. Y., Chen, W. C., Chou, Y. J., Huang, A. S., & Huang, W. T. (2018). Containing influenza outbreaks with antirviral use in long-term care facilities in Taiwan, 2008-2014. Influenza and Other Respiratory Viruses, 12(2), 287-292. doi:10.1111/irv.12536 Cherniack, P. E., Sandals, L., Brooks, L., & Mintzer, M. J. (2008, May-June). Trial of a survey instrument to establish the hurricane preparedness of and medical impact on a vulnerable, older population. Prehospital and Disaster Medicine, 23(3), 242-9. doi:10.1017/S1049023X00064943 Cheung, Y. T., Chau, P. H., & Yip, P. S. (2008, May 23). A revisit on older adults suicides and Severe Acute Respiratory Syndrome (SARS) epidemic in Hong Kong. International Journal of Geriatrics Psychiatry, 23(12), 1231-1238. doi:10.1002/gps.2056 Cloyd, E., & Dyer, C. B. (2010, December). Catastrophic events and older adults. Critical Care Nursing Clinics of North America, 22(4), 501-513. doi:10.1016/j.ccell.2010.10.003 Collander, B., Green, B., Millo, Y., Shamloo, C., Donnellan, J., & DeAtley, C. (2008, January/February). Development of an “All-Hazards” hospital disaster preparedness training course utilizing multi-modality teaching. Prehospital and Disaster Medicine, 23(1), 63-67. doi:10.1017/ s1049023x00005598 Currier , M., King, D. S., Wofford , M. R., Daniel, B. J., & deShazo , R. (2006). A Katrina experience: Lessons learned. The American Journal of Medicine, 119(11), 986-992. doi:10.1016/j.amjmed.2006.08.021 REFERENCES CLOSING THE GAPS: ADVANCING EMERGENCY PREPAREDNESS, RESPONSE AND RECOVERY FOR OLDER ADULTS 68 Dosa, D., Feng, Z., Hyer, K., Brown, L. M., Thomas, K., & Mor, V. (2010). Effects of Hurricane Katrina on nursing facility resident mortality, hospitalization, and functional decline. Disaster Medicine and Public Health Preparedness, 4(Suppl 1), S28-S32. doi:10.1001/dmp.2010.11 Dyer, C. B., Regev, M., Burnett, J., Fest, N., & Cloyd, B. (2008). SWiFT: A rapid triage tool for vulnerable older adults in disaster situations. Disaster Medicine and Public Health Preparedness, 2(Suppl 1), S45-50. doi:10.1097/DMP.0b013e3181647b8 Emergency Preparedness in Canada. (2014). Retrieved from Statistics Canada: https://www150.statcan.gc.ca/ n1/pub/85-002-x/2015001/article/14234-eng.htm Etters, L., Goodall, D., & Harrison, B. E. (2008, August). Caregiver burden among dementia patient caregivers: A review of the literature. Journal of the American Academy of Nurse Practitioners, 20(8), 423-428. doi:10.1111/j.1745-7599.2008.00342.x Exum, E., Hull, B. L., Lee, A. W., Gumieny, A., Villareal, C., & Longnecker, D. (n.d.). Applying telehealth technologies and strategies to provide acute care consultation and treatment of patients with confirmed or possible COVID-19. Journal of Acute Care Physical Therapy, 11(3), 103-112. doi:10.1097/JAT.0000000000000143 Fagan, L. A., & Sabata, D. (2011). Home modifications and occupational therapy. Retrieved from American Occupational Therapy Association: https://www.aota.org/About-Occupational-Therapy/ Professionals/PA/Facts/Home-Modifications.aspx Fernandez, L. S., Byard, D., Lin, C.-C., Benson, S., & Barbera, J. A. (2002, April/June). Frail elderly as disaster victims: Emergency management strategies. Prehospital and Disaster Medicine, 17(2), 67-74. doi:10.1017/s1049023x00000200 Field, C. B., Barros, V. R., Dokken, D. J., Mach, K. J., & Mastrandrea, M. D. (2014). Summary for policymakers. Climate change 2014: Impacts, adaptation, and vulnerability - Part A: Global and sectoral aspects. Contribution of working group ii to the fifth assessment report of the Intergovernmental panel on climate change. Cambridge, United Kingdom and New York, USA: Cambridge University Press. Finkelstein, S., Prakash, S., Nigmatulina, K., McDevitt, J., & Larson, R. (2013, April 08). A home toolkit for primary prevention of Influenza by individuals and families. Disaster Medicine and Public Health Preparedness, 5(4), 266-271. doi:10.1001/dmp.2011.78 Ford, H., Trent, S., & Wickizer, S. (2016). An assessment of state board of pharmacy legal documents for public health emergency preparedness. American Journal of Pharmaceutical Education, 80(2), 20. doi:10.5688/ajpe80220 69 Gibson, M. J., & Hayunga, M. (2006). We Can Do Better. Retrieved May 25 , 2017, from American Association of Retired Persons: https://assets.aarp.org/rgcenter/il/better.pdf Global News. (2017, July 11). Seniors under pressure amid B.C. wildfires. Global News. Toronto, Ontario, Canada. Retrieved from https://globalnews.ca/news/3591341/seniors-under-pressure-amid-b-cwildfires/ Government of Canada. (2007). Emergency Management Act. Retrieved from Justice Laws: https://laws-lois. justice.gc.ca/eng/acts/e-4.56/ Government of Canada. (2015, January 15). About the Campaign. Retrieved from Get Prepared: https://www. getprepared.gc.ca/cnt/bt/index-en.aspx Government of Canada. (2018, February 27). Emergency preparedness guide for people with disabilities/ special needs. Retrieved from Get Prepared: https://www.getprepared.gc.ca/cnt/rsrcs/pblctns/ pplwthdsblts/index-en.aspx Government of Canada. (2020, July 16). Coronavirus disease 2019 (COVID-19): Epidemiology update. Retrieved from Government of Canada: https://health-infobase.canada.ca/covid-19/epidemiologicalsummary- covid-19-cases.html#a5 Grant, K. (2020, October 27). Grim milestone: Canada marks 10,000 COVID-19 deaths as country battles second wave. Retrieved from https://www.theglobeandmail.com/canada/article-canadaexceeds- 10000-covid-19-deaths/?utm_medium=Referrer:+Social+Network+/+Media&utm_ campaign=Shared+Web+Article+Links Greenstein, J., Chacko, J., Ardolic, B., & Berwald, N. (2016, June). Impact of Hurricane Sandy on the Staten Island university hospital emergency department. Prehospital and Disaster Medicine, 31(3), 335-339. doi:10.1017/S1049023X16000261 Harrington, C., Zimmerman, D., Karon, S. L., Robinson, J., & Beutel, P. (2000, September 1). Nursing home staffing and its relationship to deficiences. The Jounals of Gerontology: Series B, 55(5), S278-S287. doi:10.1093/geronb/55.5.S278 Hart-Wasekeesikaw, F. (2009). Cultural competence and cultural safety in nursing education; A framework for First Nations, Inuit and Métis nursing. Ottawa: Aboriginal Nurses Association of Canada. Retrieved from https://www.cna-aiic.ca/~/media/cna/page-content/pdf-en/first_nations_ framework_e.pdf Hayden, M. K., Lin, M. Y., Lolans, K., Weiner, S., Blom, D., Moore, N. M., . . . Weinstein, R. A. (2015). Prevention of colonization and infection by Klebsiella pneumoniae carbapenemase-producing enterobacteriaceae in long-term acute-care hospitals. Clinical Infectious Diseases, 60(8), 1153-63. doi:10.1093/cid/ciu1173 REFERENCES CLOSING THE GAPS: ADVANCING EMERGENCY PREPAREDNESS, RESPONSE AND RECOVERY FOR OLDER ADULTS 70 Horn, S. D., Buerhaus, P., Bergstrom, N., & Smout, R. J. (2005, November). RN staffing time and outcomes of long-stay nursing home residents: pressure ulcers and other adverse outcomes are less likely as RNs spend more time on direct patient care. American Journal of Nursing, 105(11), 58-70. doi:10.1097/00000446-200511000-00028 Huhtinen, E., Quinn, E., Hess, I., Najjar, Z., & Gupta, L. (2019). Understanding barriers to effective management of influenza outbreaks by residential aged care facilities. Australian Journal on Aging, 38(1), 60-63. doi:10.1111/ajag.12595 Infection Prevention and Control. (2020). IPAC Recommendations for Use of Personal Protective Equipment for Care of Individuals with Suspect of Confirmed COVID-19. Retrieved from https://www. publichealthontario.ca/-/media/documents/ncov/updated-ipac-measures-covid-19.pdf?la=en Inns, T., Keenan, A., Huyton, R., Harris, J., Iturriza-Gomara, M., O’Brien, S. J., & Vivancos, R. (2018). How timely closure can reduce outbreak duration: gastroenteritis in Care homes in North West England, 2012-2016. BMC Public Health, 12(1), 488. doi:10.1186/s12889-018-5413-x Interstate Medical Licensure Compact. (n.d.). Interstate Medical Licensure Compact. Retrieved from Interstate Medical Licensure Compact: https://imlcc.org/ James, X., Hawkins, A., & Rowel, R. (2007, September 25). An assessment of the cultural appropriateness of emergency preparedness communication for low income minorities. Journal of Homeland Security and Emergency Management, 4(3). doi:10.2202/1547-7355.1266 Jeong, Y., Law, M., DeMatteo, C., Stratford, P., & Kim, H. (2016). The role of occupational therapists in the contexts of a natural disaster: A scoping review. Disability and Rehabilitation, 38(16), 1620-1631. doi :10.3109/09638288.2015.110659 Jhung, M. A., Shehab, N., Rohr-Allegrini, C., Pollock, D. A., Sanchez, R., Guerra, F., & Jernigan, D. B. (2007, September). Chronic disease and disasters medication demands of Hurricane Katrina evacuees. American Journal of Preventive Medicine, 33(3), 207-210. doi:10.1016/j.amepre.2007.04.030 Jia, Z., Tian, W., Liu, W., Cao, Y., Yan, J., & Shun, Z. (2010, March 30). Are the elderly more vulnerable to psychological impact of natural disaster? A population-based survey of adult survivors of the 2008 Sichuan earthquake. BMC Public Health, 10(172). doi:10.1186/1471-2458-10-172 Kelly, H. (2011). The classical definition of a pandemic is not elusive. Bulletin of World Health Organization, 89, 540-541. doi:10.2471/BLT.11.088815 Killian, T. S., Moon, Z. K., McNeill, C., Garrison, B., & Moxley, S. (2017, February ). Emergency preparedness of persons over 50 years old: Further results from the health and retirement study. Disaster Medicine and Public Health Preparedness, 80-89. doi: 10.1017/dmp.2016.162 71 Kim, H., Kovner, C., Harrington, C., Greene, W., & Mezey, M. (2009, March). A panel data analysis of the relationships of nursing home staffing levels and standards to regulatory deficiences. Journal of Gerontology: Social Sciences, 64B(2), 269-278. doi:0.1093/geronb/gbn019 Kosa, K. M., Cates, S. C., Karns, S., Godwin, S. L., & Coppings, R. J. (2012, August 12). Are Older Adults Prepared to Ensure Food Safety During Extended Power Outages and Other Emergencies?: Findings from a National Survey. Educational Gerontology, 763-775. doi:10.1080/03601277.2011.645436 Kosatky, T., Dufresne, J., Richard, L., Renouf, A., Giannetti, N., Bourbeau, J., . . . Sauve, C. (2009, May). Heat awareness and response among Montreal residents with chronic cardiac and pulmonary disease. Canadian Journal of Public Health, 100(3), 237-240. doi:10.1007/BF03405548 Kouadio, I. K., Aljunid, S., Kamigaki, T., Hammah, K., & Oshitani, H. (2012). Infectious diseases following natural disasters: Prevention and control measures. Expert Review of Anti-infective Therapy, 10(1), 95-104. doi:10.1586/eri.11.155 Kraushar, M., & Rosenberg, E. R. (2015, August). A community-led medical response effort in the wake of Hurricane Sandy. Disaster Medicine and Public Health Preparedness, 9(4), 354-358. doi: 10.1017/ dmp.2015.60 Kulig, J. C., Penz, K., Karunanayake, C., MacLeod, M. L., Jahner, S., & Andrews, M. E. (2017, May). Experiences of rural and remote nurses assisting with disasters. Australasian Emergency Nursing Journal, 20(2), 98-106. doi:10.1016/j.aenj.2017.04.003 Laditka, S. B., Laditka, J. N., Cornman, C. B., Davis, C. B., & Richter, J. V. (2009, January/February). Resilience and challenges among staff of Gulf Coast nursing homes sheltering frail evacuees following Hurricane Katrina 2005: Implications for planning and training. Prehospital and Disaster Medicine, 24(1), 54-62. doi:10.1017/s1049023x00006543 Lai, E., Tan, H. Y., Kunasekaran, M., Chughtai, A. A., Trent, M., Poulos, C., & MacIntyre, C. R. (2020, February 18). Influenza vaccine coverage and predictors of vaccination among aged care workers in Sydney Australia. Vaccine, 38(8), 1968-1974. doi:10.1016/j.vaccine.2020.01.004 Lamb, K. V., & O’Brien, C. (2010). An overview: Disaster preparedness for gerontological nurses. Geriatric Nursing, 31(3), 228-230. Laverdiere, E., Payette, H., Gaudreau, P., Morais, J. A., Shatenstein, B., & Genereux, M. (2016, October 20). Risk and protective factors for heat-related events among older audlts of Southern Quebec (Canada): The NuAge study. Canadian Journal of Public Health, 107(3), e258-e265. doi:10.17269/ cjph.107.5599 REFERENCES CLOSING THE GAPS: ADVANCING EMERGENCY PREPAREDNESS, RESPONSE AND RECOVERY FOR OLDER ADULTS 72 Lee, M. H., Lee, G. A., Lee, S. H., & Park, Y. H. (2020). A systematic review on the causes on transmission and control measure of outbreaks in long-term care facilities: Back to basic infection control. PLoS One, 15(3), e0229911. doi:10.1371/journal.pone.0229911 Levac, J., Toal-Sullivan, D., & O’Sullivan, T. L. (2012, June). Household emergency preparedness: A literature review. Journal of Community Health, 37(3), 725-733. doi:10.1007/s10900-011-9488-x Li, J., Birkhead, G. S., Strogatz, D. S., & Coles, F. B. (1996, May 15). Impact of institution size, staffing patterns, and infection control practices on communicable disease outbreaks In New York State nursing homes. American Journal of Epidemiology, 143(10), 1042-1049. doi:10.1093/oxfordjournals. aje.a008668 Lin, H., Ng, S., Chan, S., Chan, W. M., Lee, K. C., Ho, S. C., & Linwei, T. (2011). Institutional risk factors for norovirus outbreaks in Hong Kong elderly homes: A retrospective cohort study. BMC Public Health, 11, 297. doi:10.1186/1471-2458-11-297 Lum, H. D., Mody, L., Levy, C. R., & Ginde, A. A. (2014). Pandemic influenza plans in residential care facilities. Journal of the American Geriatrics Society, 62(7), 1310-1316. doi:10.1111/jgs.12879 Marshall, H., Ryan, P., Robertson, D., Street, J., & Watson, M. (2009, October). Pandemic Influenza and community preparedness. American Journal of Public Health, 99(Suppl 2), S365-S371. doi:10.2105/ AJPH.2008.153056 McMichael, T. M., Currie, D. W., Clark, S., Pogosjans, S., Kay, M., Schwartz, N. G., . . . Duchin, J. S. (2020). Epidemiology of Covid-19 in a Long-Term Care Facility in King County, Washington. The New England Jounal of Medicine, 382(21), 2005-2011. doi:10.1056/NEJMoa2005412 Ministry of Health and Long-Term Care. (2013, December). Critical Care Strategy. Retrieved from health. gov.on.ca: http://www.health.gov.on.ca/en/pro/programs/criticalcare/life.aspx Mokdad, A. H., Mensah, G. A., Posner, S. F., Reed, E., Simoes, E. J., & Engelgau, M. M. (2005, November). When chronic conditions become acute: Prevention and control of chronic diseases and adverse health outcomes during natural disasters. Preventing Chronic Disease, 2 (Spec No), A04. National Council on Aging. (2018). Healthy aging facts. Retrieved June 15, 2018, from National Council on Aging (NCOA): https://www.ncoa.org/news/resources-for-reporters/get-the-facts/healthy-agingfacts/ National Registry of Emergency Medical Technicians. (n.d.). Recognition of EMS personnel licensure interstate compact. Retrieved from National Registry of Emergency Medical Technicians: https:// www.nremt.org/rwd/public/document/replica 73 Navaranjan, D., Rosella, L. C., Kwong, J. C., Campitelli, M., & Crowcroft, N. (2014, March 1). Ethnic disparities in acquiring 2009 pandemic H1N1 influenza: A case-control study. BMC Public Health, 14, 214. doi:10.1186/1471-2458-14-214 NIA Long-Term Care COVID-19 Tracker Open Data Working Group. (2020, August 4). NIA Long-Term Care COVID-19 Tracker. Toronto, Ontario, Canada. Nomura, S., Gilmour, S., Tsubokura, M., Yoneoka, D., Sugimoto, A., Oikawa, T., . . . Shibuya, K. (2013, March). Mortality risk amongst nursing home residents evacuated after the Fukushima nuclear accident: A retrospective cohort study. PLOS One, 8(3), e60192. doi:10.1371/journal.pone.0060192 Nurse Licensure Compact. (n.d.). Nurse Licensure Compact. Retrieved from Nurse Licensure Compact: https://www.nursecompact.com/privateFiles/Updated_1pager_NLCversion.pdf Nursing. (2006). JCAHO sets standards for patient handoffs. Nursing2006, 36(3), 35. Retrieved from https:// journals.lww.com/nursing/Fulltext/2006/03000/JCAHO_sets_standards_for_patient_handoffs.34. aspx Ochi, S., Hodgson, S., Landeg, O., Mayner, L., & Murray, V. (2014). Disaster-driven evacuation and medication loss: A systematic literature review. PLOS Current Disasters, 18. doi:10.1371/currents.dis. fa417630b566a0c7dfdbf945910edd96 Ontario Agency for Health Protection and Promotion (Public Health Ontario), Provincial Infectious Diseases Advisory Committee. (2014). Best Practices for Hand Hygiene in All Health Care Settings. 4th ed. Toronto: Queen’s Printer for Ontario. Ontario Agency for Health Protection and Promotion (Public Health Ontario), Provincial Infectious Diseases Advisory Committee. (2018). Best practices for environmental cleaning for prevention and control of infections in all health care settings. 3rd ed. Toronto: Queen’s Printer for Ontario. Ontario Agency for Health Protection and Promotion (Public Health Ontario), Provincial Infectious Diseases Advisory Committee. (2020). Best Practices for Prevention, Surveillance and Infection Control Management of Novel Respiratory Infections in all Health Care Settings. 1st Version. Toronto: Queen’s Printer for Ontario. Ontario Agency for Health Protection and Promotion, Provincial Infectious Diseases Advisory Committee. (2012). Best Practices for Infection Prevention and Control Programs in All Health Care Settings. 3rd ed. Toronto: Queen’s Printer for Ontario. Ontario Agency for Health Protection and Promotion, Provincial Infectious Diseases Advisory Committee. (2012). Routine Practices and Additional Precautions in all Health Care Settings. 3rd edition. Toronto: Queen’s Printer for Ontario. REFERENCES CLOSING THE GAPS: ADVANCING EMERGENCY PREPAREDNESS, RESPONSE AND RECOVERY FOR OLDER ADULTS 74 Ontario Health. (2020). Personal Protective Equipment (PPE) Use During the COVID-19 Pandemic. Retrieved from https://www.ontariohealth.ca/sites/ontariohealth/files/2020-05/Ontario%20 Health%20Personal%20Protective%20Equipment%20Use%20During%20the%20COVID-19%20 Pandemic_rev10May20%20PDF_v2.pdf Ontario Ministry of Health. (2020). COVID-19 Guidance: Home and Community Care Providers. Retrieved from http://www.health.gov.on.ca/en/pro/programs/publichealth/coronavirus/docs/2019_home_ community_care_guidance.pdf Ontario Ministry of Health. (2020). COVID-19 Guidance: Primary Care Providers in a Community Setting. Toronto. Retrieved from http://health.gov.on.ca/en/pro/programs/publichealth/coronavirus/ docs/2019_primary_care_guidance.pdf Papadimitriou, C., & Carpenter, C. (2013). Client-centered practice in spinal cord injury rehabilitation: A field guide. Chicago: National Institute on Disability and Rehabilitation Research. Retrieved from http://www.carf.org/ClientCenteredPracticeinSCIRehab/ Parker, G., Lie, D., Siskind, D. J., Martin-Khan, M., Raphael, B., Crompton, D., & Kisely, S. (2016, January). Mental health implications for older adults after natural disasters--a systematic review and metaanalysis-- Corrigendum. International Psychogeriatrics, 28(1), 21. doi:10.1017/S1041610215001465 Patel, M. S., Phillips, C. B., Pearce, C., Kljakovic, M., Dugdale, P., & Glasgow, N. (2008). General Practice and Pandemic Influenza: A Framework for Planning and Comparison of Plans in Five Countries. PLoS One, 3(5), e2269. doi:10.1371/journal.pone.0002269 Pesiridis, T., Galanis, P., Sourtzi, P., & Kalokairinou, A. (2014). Development, implementation and evaluation of a disaster training programme for nurses: A switching replications randomized controlled trial. Nurse Education in Practice, 63-67. doi:10.1016/j.nepr.2014.02.001 Piersol, C. V., Canton, K., Connor, S. E., Giller, I., Lipman, S., & Sager, S. (2017). Effectiveness of interventions for caregivers of people with alzheimer’s disease and related major neurocognitive disorders: a systematic review. American Journal of Occupational Therapy, 7105180020p1-7105180020p10. doi:10.5014/ajot.2017.027581 Plouffe, L., Kang, I., & Kalache, A. (2008). Older persons in emergencies: An active ageing perspective. Geneva: World Health Organization. Retrieved from https:// apps.who.int/iris/bitstream/handle/10665/43909/9789241563642_eng. pdf;jsessionid=AFE8166AA285B415FFF227043787123B?sequence=1 Protecting Seniors During Disasters Act. (2017, September 19). Retrieved 2018, from Library of Congress: https://www.congress.gov/115/bills/s1834/BILLS-115s1834is.pdf 75 Public Safety and Emergency Preparedness Canada. (2004). Emergency management education in Canada. Ottawa. Retrieved from https://bcaem.ca/wp-content/uploads/2019/05/PS4152005E.pdf Rainwater-Lovett, K., Chun, K., & Lessler, J. (2014). Influenza outbreak control practices and the effectiveness of interventions in long-term care facilities: a systematic review. Influenza and other respiratory viruses, 8(1), 74-82. doi:10.1111/irv.12203 Riedner, H. (2020, June 9). ‘Tears of joy’: COVID-19 outbreak at Markham’s Participation House officially over. Retrieved from York Region: https://www.yorkregion.com/news-story/10018164--tears-of-joycovid- 19-outbreak-at-markham-s-participation-house-officially-over/ Rocca, R. (2020, April 13). Coronavirus: ‘Critical’ staffing levels remain at Markham group home where most staff walked out. Retrieved from Global News: https://globalnews.ca/news/6812654/ coronavirus-participation-house-markham/ Roslin, A. (2018, November 19). Retrieved from Zoomer: https://www.everythingzoomer.com/ health/2018/11/19/seniors-natural-disaster-relief/ Roush, R. E., & Tyson, S. K. (2012, December). Geriatric emergency preparedness and response workshops: An evaluation of knowledge, attitudes, intentions, and self-efficacy of participants. Disaster Medicine and Public Health Preparedness, 6(4), 385-392. doi:10.1001/dmp.2012.63 Ruskin, J., Rasul, R., Schneider, S., Bevilacqua, K. G., Taioli, E., & Schwartz, R. M. (2018, April). Lack of access to medical care during Hurricane Sandy and mental health symptoms. Preventive Medicine Reports, 24(10), 363-369. doi:10.1016/j.pmedr.2018.04.014 Ryan, P. (2009, May/June). Integrated theory of health behavior change: Background and intervention development. Clinical Nurse Specialist, 23(3), 161-170. doi:10.1097/NUR.0b013e3181a42373 Scott, L. A., Carson, D. S., & Greenwell, B. (2010, August). Disaster 101: A novel approach to disaster medicine training for health professionals. The Journal of Emergency Medicine, 220-226. doi:10.1016/j. jemermed.2009.08.064 Seeds for Change. (2010). Consensus Decision Making. Retrieved July 18, 2018, from Seeds for Change: https://www.seedsforchange.org.uk/consensus Siegel, J. D., Rhinehart, E., Jackson, M., & Chiarello, L. (2007). Guideline for isolation precautions: Preventing transmission of infectious agents in healthcare settings. Retrieved from Centers for Disease Prevention and Control: https://www.cdc.gov/niosh/docket/archive/pdfs/NIOSH-219/0219- 010107-siegel.pdf REFERENCES CLOSING THE GAPS: ADVANCING EMERGENCY PREPAREDNESS, RESPONSE AND RECOVERY FOR OLDER ADULTS 76 Sinha, S. (2012). Living Longer, Living Well: Report submitted to the Minister of Health and Long-Term Care and the Minister responsible for Seniors on recommendations to Inform a Seniors Strategy for Ontario. Toronto: Queen’s Printer for Ontario. Retrieved from http://www.health.gov.on.ca/en/ common/ministry/publications/reports/seniors_strategy/docs/seniors_strategy_report.pdf Siskind, D. J., Sawyer, E., Lee, I., Lie, D. C., Martin-Khan, M., Farrington, J., . . . Kisely, S. (2016, May). The mental health of older persons after human-induced disasters; A systematic review and meta-analysis of epidemiological data. American Journal of Geriatric Psychiatry, 24(5), 379-388. doi:10.1016/j. jagp.2015.12.010 Smith, E., & Macdonald, R. (2006). Managing health information during disasters. Health Information Management Journal, 35(2), 8-13. doi:10.1177/183335830603500204 Sorensen, S., Pinquart, M., Habil, D., & Duberstein, P. (2002). How effective are interventions with caregivers? An updated meta-analysis. The Gerontologist, 42(3), 356-372. doi:10.1093/ geront/42.3.356 Stamenova, V., Agarwal, P., Kelley, L., Fujioka, J., Nguyen, M., Phung, M., . . . Bhattacharyya, O. (2020). Uptake and patient and provider communication modality preferences of virtual visits in primary care: a retrospective cohort study in Canada. BMJ Open, 10(7), e037064. doi:10.1136/ bmjopen-2020-037064 Stark, S., Landsbaum, A., Palmer, J., Somerville, E. K., & Morris, J. C. (2009, July). Client-centered home modifications improve daily activity performance of older adults. Canadian Journal of Occupational Therapy, 76(Spec No), 235-245. doi:10.1177/000841740907600s09 Statistics Canada. (2020). Population Projections for Canada (2018 to 2068), Provinces and Territories (2018 to 2043). Ottawa: Statistics Canada. Retrieved from https://www150.statcan.gc.ca/n1/en/ pub/91-520-x/91-520-x2019001-eng.pdf?st=WNdoAJ29 Steuter-Martin, M., & Pindera, L. (2018, January 4). Looking back on the 1998 ice storm 20 years later. CBC News. Otttawa, Ontario, Canada: CBC. Retrieved from https://www.cbc.ca/news/canada/montreal/ ice-storm-1998-1.4469977 Swathi, J. M., Gonzalez, P. A., & Delgado, R. C. (2017, Nov 30). Disaster management and primary health care: Implications for medical education. International Journal of Medical Education, 8, 414-415. doi:10.5116/ijme.5a07.1e1b Thomas, K. S., Dosa, D., Hyer, K., Brown, L. M., Swaminathan, S., Feng, Z., & Mor, V. (2012, October). The impact of forced transitions on the most functionally impaired nursing home residents. Journal of the American Geriatrics Society, 60(10), 1895-1900. doi:10.1111/j.1532-5415.2012.04146.x 77 Thomas, T. N., Sobelson, R. K., Wigington, C. J., Davis, A. L., Harp, V. H., Leander-Griffith, M., & Cioffi, J. P. (2018, January/February). Applying instructional design strategies and behavior theory to household disaster preparedness training. Journal of Public Health Management and Practice, 24(1), e16-e25. doi:10.1097/PHH.0000000000000511 Tricco, A. C., Lillie, E., Soobiah, C., Perrier, L., & Straus, S. E. (2013, September). Impact of H1N1 on socially disadvantaged populations: Summary of a systematic review. Influenza and other Respiratory Viruses, 7(Suppl 2), 54-58. doi:10.1111/irv.12082 Trivedi, T. K., DeSalvo, T., Lee, L., Palumbo, A., Moll, M., Curns, A., . . . Lopman, B. A. (2012, October 24). Hospitalizations and mortality associated with norovirus outbreaks in nursing homes, 2009-2010. JAMA, 308(16), 1668-1675. doi:10.1001/jama.2012.14023 van Solm, A. (2016). Application of interRAI assessments in disaster management: Identifying vulnerable persons in the community. Retrieved from UWSpace: https://uwspace.uwaterloo.ca/ handle/10012/10795 van Solm, A. I., Hirdes, J. P., Eckel, L. A., Heckman, G. A., & Bigelow, P. L. (2017, November/December). Using standard clinical assessments for home care to identify vulnerable populations before, during, and after disasters. Journal of Emergency Management, 15(6), 355-366. doi:10.5055/jem.2017.0344 Welch, A. E., Caramanica, K., Maslow, C. B., Brackbill, R. M., Stellman, S. D., & Farfel, M. R. (2016, April). Trajectories of PTSD among lower Manhattan residents and area workers following the 2001 World Trade Center disaster, 2003-2012. Journal of Traumatic Stress, 29(2), 158-166. doi:10.1002/ jts.22090 Whitehead, J. C., Edwards, B., Van Willigen, M., Maiolo, J. R., Wilson, K., & Smith, K. T. (2000, December). Heading for higher ground: Factors affecting real and hypothetical hurricane evacuation behavior. Environmental Hazards, Volume 2(4), 133-142. doi:10.1016/S1464-2867(01)00013-4 Willoughby, M., Kipsaina, C., Ferrah, N., Blau, S., Bugeja, L., Ranson, D., & Ibrahim, J. E. (2017, August 1). Mortality in nursing homes following emergency evacuation: A systematic review. Journal of the American Medical Directors Association, 18(8), 664-670. doi:10.1016/j.jamda.2017.02.005 World Health Organization. (2020). Rational use of personal protective equipment for coronavirus disease (COVID-19) and considerations during severe shortages. Retrieved from file:///C:/Users/mmedn7f/ Downloads/WHO-2019-nCov-IPC_PPE_use-2020.3-eng.pdf Wyte-Lake, T., Claver, M., Griffin, A., & Dobalian, A. (2014). The role of the home-based provider in disaster preparedness of a vulnerable population. Gerontology, 60(4), 336-345. doi:10.1159/000355660 Zibulewsky, J. (2001, April). Defining disaster: The emergency department perspective. Baylor University Medical Center Proceedings, 144-149. doi:10.1080/08998280.2001.11927751 REFERENCES CLOSING THE GAPS: ADVANCING EMERGENCY PREPAREDNESS, RESPONSE AND RECOVERY FOR OLDER ADULTS 78 Appendices Appendix A: Index of Recommendations and Enabling Bodies The index below provides an outline of the 29 recommendations presented in this whitepaper and an identification of the emergency management domains that have been determined to be responsible for adopting or enforcing a given recommendation. Recommendations Relevant Federal Agencies Provincial & Local Governments Care Institutions & Organizations Health Care Professionals & Emergency Response Personnel Community-Based Services & Programs Individuals & Unpaid Caregivers Domain 1: Individuals and Unpaid Caregivers Recommendation 1.1: Older adults and their unpaid caregiver(s) should be provided with tailored, easy-to-access information and resources related to emergency preparedness and guidance on how to develop customized emergency plans that consider the functional and health needs of older adults and appropriate strategies to support infection/disease prevention. Volunteer representatives of older Canadians and their unpaid caregivers should be recruited and involved in developing and disseminating resources and training material, to ensure their voices and perspectives are reflected. X X X X X X Recommendation 1.2: Older adults who are reliant on mobility aids should remove or minimize barriers affecting their ability to evacuate, and take steps to ensure their safety within their surroundings. X X Recommendation 1.3: If registries for people with functional and other needs, including persons with disabilities, have been established by local emergency response agencies, older adults and/or their unpaid caregiver(s) should register so they can be better assisted/supported during emergencies. X X X X Recommendation 1.4: Older adults who have a sensory impairment, such as a visual or hearing disability, should take additional precautions to prepare themselves for emergencies. X X X Recommendation 1.5: Older adults who live with chronic health conditions should maintain a readily accessible list of their current medical conditions, treatments (medications, durable medical equipment, supplies and other health care needs), health care providers, and emergency contacts, including substitute decision makers (SDMs). X X Recommendation 1.6: Older adults who take medications should work with their health care providers to ensure they have access to at least a 30-day supply of medications during an emergency. X X Recommendations Relevant Federal Agencies Provincial & Local Governments Care Institutions & Organizations Health Care Professionals & Emergency Response Personnel Community-Based Services & Programs Individuals & Unpaid Caregivers Recommendation 1.7: Older adults, and their unpaid caregivers, who are reliant on medical devices that require electricity, should ensure they have back-up power supplies in place, especially if required while sheltering-in-place.
Older adults and/or their unpaid caregivers should contact their electricity company in advance to discuss their needs and ensure options for alternative power sources are available, especially addressing the need for access to power to charge cell phones and other mobile devices.
Older adults and/or their unpaid caregivers should seek assistance with obtaining and maintaining an alternative power source at home, if required, such as when being required to move heavy equipment and fuel or in accessing these resources in rural locations, and operating equipment. X X X Recommendation 1.8: Older adults should be encouraged to continually maintain an adequate local support network that can be called upon during impending disasters and unexpected emergencies, especially if they live alone or lack easy access to relatives. X X X Recommendation 1.9: Unpaid caregivers of persons with Alzheimer’s disease and/or other dementias should to supported to identify signs of distress, anxiety, or confusion, and use strategies to redirect attention and help them stay calm during emergencies. In addition, unpaid caregivers should be prepared to prevent wandering, and have plans in place to locate their care recipients if they do wander or require medical intervention(s) during an emergency. X X X Domain 2: Community-Based Services and Program Recommendation 2.1: Access should be increased to tailored communitybased programs that educate older adults and their unpaid caregivers about emergencies that could affect their region and how best to prepare for and respond to them. Volunteer representatives of older Canadians and their unpaid caregivers should be recruited and involved in training material development and implementation, to ensure their voices and perspectives are reflected.
Community-based programs and organizations should collaborate with regional public health authorities in developing and disseminating education resources on infection control, disease and injury prevention practices for older adults and their unpaid caregivers during emergencies. X X X Recommendation 2.2: Programs that provide disaster relief and/or essential community services, such as Meals on Wheels, and daily living assistance for older people (financial, medical, personal care, food and transportation), should receive emergency preparedness training and education, as well as develop and adhere to plans and protocols related to responding adequately to the needs of their clients during emergencies. Volunteer representatives of older Canadians and their unpaid caregivers should be recruited and involved in training material development and implementation, to ensure their voices and perspectives are reflected. X APPENDIX A – A1 Recommendations Relevant Federal Agencies Provincial & Local Governments Care Institutions & Organizations Health Care Professionals & Emergency Response Personnel Community-Based Services & Programs Individuals & Unpaid Caregivers Recommendation 2.3: Community based programs that provide in-home health and personal care for older adults should integrate strategies that minimize unnecessary personal contact and leverage resources (e.g. personal protective equipment such as gowns, masks, gloves, hand sanitizer etc.) in their emergency preparedness plans and protocols. X Recommendation 2.4: Local governments should leverage data sources that identify at-risk individuals to enable emergency responders to more easily prioritize their search and rescue efforts following an emergency. X Domain 3: Health Care Professionals and Emergency Response Personnel Recommendation 3.1: Health care professionals and emergency response personnel should receive training on providing geriatric care relevant to their discipline and how best to assist older adults and their unpaid caregivers before, during and after emergencies. The additional education and training should also increase their awareness of best practices and precautions to minimize the risk of infectious disease transmission or spread while responding to emergencies. Volunteer representatives of older Canadians should be recruited and involved in training material development and implementation, to ensure their voices and perspectives are reflected. X X X Recommendation 3.2: Health care professionals and emergency response personnel should strive to mitigate psychological distress among older persons during and after emergency by making an effort to assess the psychological well-being of older adults and provide appropriate treatments as needed. X X Recommendation 3.3: Health care professionals and emergency response personnel should receive cultural awareness training to provide appropriate care and support for older adults with different cultural and religious backgrounds before, during, and after an emergency. Providers should have options for providing support to older adults and their unpaid caregivers who face language or cultural barriers to accessing supports (e.g., translators, written materials in languages other than English or French, etc.). This is of particular importance for personnel that work with Indigenous populations, in diverse community-settings, and during times of evacuation due to emergencies. X X Recommendations Relevant Federal Agencies Provincial & Local Governments Care Institutions & Organizations Health Care Professionals & Emergency Response Personnel Community-Based Services & Programs Individuals & Unpaid Caregivers Domain 4: Care Institutions and Organizations Recommendation 4.1: Care institutions and organizations should include emergency preparedness and response education in their routine personnel training courses.
Multi-modality educational tools and practices should be used to better facilitate knowledge acquisition and behavioral change.
Volunteer representatives of older Canadians should be recruited and involved in developing and disseminating resources and training material, to ensure their voices and perspectives are reflected X X X Recommendation 4.2: Additional strategies to improve the collection and transfer of identifying information and medical histories should be adopted into current standardized patient handoff procedures to better facilitate effective tracking, relocation and care of patients during an emergency. X Recommendation 4.3: Care institutions and other organizations should strive to develop comprehensive emergency plans that include effective response strategies for protecting older adults against infectious disease outbreaks and reflect evidence-based standards supported by organizations such as Infection Prevention and Control Canada.
Care institutions should also regularly assess and address any barriers they identify that could affect the implementation of their emergency plans that build on their routine practices. X Domain 5: Legislation and Policy Recommendation 5.1: A national advisory committee should be created to inform emergency preparedness, response and recovery program development and strategies for older Canadians. Individuals who are representative of older Canadians and their unpaid caregivers should be involved to ensure their voices and perspectives are reflected. X X X X X Recommendation 5.2: All provinces and territories should support the implementation of tax-free emergency preparedness purchasing periods during specific times of the year or prior to an impending emergency. Governments should also provide targeted funding to directly support/ subsidize the purchase of emergency preparedness kits for older Canadians. Items covered should include an agreed-upon list of emergency supplies (such as batteries, portable generators, rescue ladders, radios and ice packs), air conditioners, personal protective equipment (such as masks, gloves and hand sanitizer) and additional mobility aids (canes, walkers, etc.). X APPENDIX A – A2 Recommendations Relevant Federal Agencies Provincial & Local Governments Care Institutions & Organizations Health Care Professionals & Emergency Response Personnel Community-Based Services & Programs Individuals & Unpaid Caregivers Recommendation 5.3: All provinces and territories should support the creation of a national licensure process or program for nurses, physicians, allied health professionals and other emergency medical service personnel to allow them to provide voluntary emergency medical support across provincial/territorial boundaries during declared states of emergency. X Recommendation 5.4: All provincial and territorial governments should support legislative requirements that mandate congregate living settings for older persons (e.g. nursing homes, assisted living facilities and retirement homes) to regularly update and report their emergency plans that outline actions and contingencies to take in case of emergencies. These plans should include:
Back-up generators in case of extended periods of power outages, and coordinated plans with relevant community agencies (e.g. municipal fire agencies) for efficient evacuations.
Directions on appropriate interventions (i.e. self-isolation, wearing face masks, physical distancing, etc.) to control and prevent outbreaks and spread of infectious diseases amongst the population in times of emergencies.
Clear thresholds for temperature regulation, specifically, maximum and minimum temperatures permissible based on occupational and environment health standards, and the steps required to regulate temperatures and minimize fluctuations.
An outline of staffing levels that should be maintained during emergencies to minimize care and/or service interruptions. All provinces and territories should work towards standardizing requirements for emergency plans in congregate living settings in accordance with the priorities outlined in the 2019 Emergency Management Strategy for Canada and ensure that their emergency plans for congregate living settings are aligned with directives outlined in their provincial/territorial emergency plans. X X Recommendation 5.5: All provinces and territories should adopt a standardized approach to promoting collaborations between local pharmaceutical prescribers and dispensers (i.e. community pharmacists), physicians and nurse practitioners, to ensure an adequate supply of prescription medications are dispensed to persons with chronic health conditions prior to and during an emergency. This approach should also outline the need for collaboration between pharmaceutical providers, hospitals and relief agencies to ensure an adequate supply of prescription medications are available at hospitals, relief and evacuation shelters.
All persons should be able to obtain at least a 30-day supply of emergency prescription medications prior to and during an emergency. X X X X Recommendations Relevant Federal Agencies Provincial & Local Governments Care Institutions & Organizations Health Care Professionals & Emergency Response Personnel Community-Based Services & Programs Individuals & Unpaid Caregivers Domain 6: Research Recommendation 6.1: There is a need to prioritize the creation and funding of research efforts to better support the development of a common framework for measuring the quality and levels of emergency preparedness among care institutions, organizations, paid providers, community organizations, and other groups that work primarily with older adults and their unpaid caregivers during and after emergencies. X Recommendation 6.2: There needs to be a more concerted effort in utilizing outcomes from existing evidence to support the planning, design, and refinement of more evidence-informed emergency preparedness interventions, policies, and regulations in support of older adults and their unpaid caregivers, as well as organizations and paid care providers that will be responsible for meeting their needs during and after an emergency. X Recommendation 6.3: A network of emergency preparedness researchers, older adults, unpaid caregivers, volunteers and providers needs to be created to encourage partnerships in the ongoing unpaid evaluation of emergency preparedness interventions targeting older adults. Network members should advocate for an increased focus on emergency preparedness research among the various societies or journals that they are members of. X Recommendation 6.4: There is a need to focus on research about unpaid caregivers and emergency preparedness to better instruct unpaid caregivers on how to take care of their vulnerable family members and friends during an emergency. X X Recommendation 6.5: There is a need to focus on research about emergency preparedness and response in Canadian community and congregate living settings for older adults (e.g. nursing, retirement and group homes and assisted living facilities). Research should:
Determine the existing levels of preparedness across these environments as well as highlight the challenges they face in being prepared.
Characterize the impact of the emergency on the older adult population and identify best practices on how to address future emergencies. X X APPENDIX A – A3 Appendix B: Emergency Preparedness for Older Adults Summary of Relevant Legislation and Framework Policy/ Legislation Province/ National Link Alberta’s Pandemic Influenza Plan by the Government of Alberta Alberta https://open.alberta.ca/publications/alberta-s-pandemic-influenza-plan Community Care and Assisted Living Act British Columbia https://www.bclaws.ca/civix/document/id/complete/statreg/02075_01 Pharmacy Disaster Preparedness (2009) a professional practice policy statement British Columbia http://library.bcpharmacists.org/6_Resources/6-2_PPP/5003-PGP-PPP25.pdf Preparing for Pandemic Influenza in Manitoba (Public Health Emergency Preparedness and Response) Manitoba https://www.gov.mb.ca/health/publichealth/pandemic.html Long-Term Care Homes Act Ontario https://www.ontario.ca/laws/statute/07l08 Ontario Health Plan for an Influenza Pandemic (2013) Ontario http://www.health.gov.on.ca/en/pro/programs/emb/pan_flu/pan_flu_plan.aspx Quebec Pandemic Influenza Plan-Health Mission (2006) Quebec https://publications.msss.gouv.qc.ca/msss/en/document-001259/ An Emergency Management Framework for Canada (2017) by Public Safety Canada National https://www.publicsafety.gc.ca/cnt/rsrcs/pblctns/2017-mrgnc-mngmnt-frmwrk/index-en.aspx Canadian Pandemic Influenza Preparedness by Pan-Canadian public Health Network National https://www.canada.ca/en/public-health/services/flu-influenza/canadian-pandemic-influenza-preparedness-planning-guidancehealth- sector.html Department of Public Safety and Emergency Preparedness Act National https://laws.justice.gc.ca/eng/acts/P-31.55/ Emergency Management Act (S.C. 2007, c.15) National https://laws-lois.justice.gc.ca/eng/acts/E-4.56/ Emergency Preparedness in Canada (refer to the highlights on Page 3) National https://www.getprepared.gc.ca/cnt/rsrcs/pblctns/yprprdnssgd/index-en.aspx Federal/Provincial/Territorial Public Health Response Plan for Biological Events by Pan-Canadian Public Health Network (refer to Appendix L for the Response Plan) National https://www.canada.ca/en/public-health/services/emergency-preparedness/public-health-response-plan-biological-events.html North American Plan for Animal and Pandemic Influenza (by Public Safety Canada) National https://www.publicsafety.gc.ca/cnt/rsrcs/pblctns/nml-pndmc-nflnz/index-en.aspx Quarantine Act (2005) National https://laws-lois.justice.gc.ca/eng/acts/q-1.1/page-1.html APPENDIX B – B1 253901-05 1/20

Documents

Less detail

Pneumonia vaccination in at-risk groups: A Canadian perspective. Increasing relevance in a pandemic era

https://policybase.cma.ca/en/permalink/policy14385

Date
2020-12-15
Topics
Population health/ health equity/ public health
  1 document  
Policy Type
Policy endorsement
Date
2020-12-15
Topics
Population health/ health equity/ public health
Text
Pneumonia vaccination in at-risk groups: A Canadian perspective Increasing relevance in a pandemic era Consensus Statement From the Expert Meeting held 20 October 2020 Given the alarming frequency of infectious disease outbreaks and epidemics in recent history, the international community has repeatedly called for expanded and sustained investments in health promotion and preventive health strategies such as immunization.1,2 The current COVID-19 pandemic highlights critical gaps in immunization infrastructure, schedules and vaccination portals to those most at risk of serious and life threatening infectious diseases, namely older adults and those with underlying health conditions. Pneumonia is a common infectious disease which is significantly underestimated as a cause of mortality and long-term functional decline. Vaccine-preventable pneumonias include pneumococcus, pertussis, influenza and soon, COVID-19. Pneumonia ranks as the sixth leading cause of hospitalization and the eighth most common cause of death in Canada yet receives little attention compared with other respiratory infections.3 Pneumonia vaccination rates remain abysmally low even though immunization policies and practices are an integral part of an effective public health strategy. A recent study reported that just 58% of Canadians aged 65 years and older, and only 25% of adults aged 18 to 64 years with chronic conditions were vaccinated in 2019.4 Meanwhile the target vaccination coverage rate for children under the age of 2 years was set at 95%, with conservative estimates suggesting 80% of Canadian children have been vaccinated against pneumococcal disease.3 These disparities however will not change when pneumonia vaccines are neither uniformly recommended nor universally publicly funded in all Canadian provinces and territories for older people and at-risk populations.5 On 20th October 2020, the International Federation on Ageing (IFA) convened an expert meeting entitled “Pneumonia vaccination in at-risk groups: A Canadian Perspective – Increasing relevance in a pandemic era.” Experts in the field of infectious diseases, leaders in patient, ageing and at- risk population organizations, professional associations and health care providers deliberated on the factors contributing to the low rates of adult pneumonia vaccination and the significant social and economic consequences for a nation that is ageing and has a growing prevalence of noncommunicable diseases. This consensus statement outlines the issues and actions that delegates concurred must take place towards the common goal of improving the rates of adult pneumonia vaccination in Canada. Burden of Disease There is a significant underestimation of the burden of pneumonia in Canada due largely to insufficient data and inappropriate use of diagnostic tests. It is also likely that pneumonia may be recorded as secondary to another diagnosis, thus excluding those cases from the recorded pneumonia rates. An incomplete and inadequate evidence base is a considerable barrier in the development of effective pneumonia immunization policies. The rates of death and functional decline increase with population ageing and the increase in chronic underlying conditions. Adults aged 50-64 years accounted for 43% of pneumonia cases, compared with adults aged over 65 years who accounted for about 52% of cases in a recent study.6 Among the 50-64 years of age cohort, about 25% report a chronic medical condition such as asthma, diabetes, heart disease, and others, putting them at-risk for severe outcomes associated with pneumonia.7 Notwithstanding that these Canadians are at highest risk of pneumonia and its complications, there remain barriers to accessing potentially life-saving pneumonia vaccines due to variations in provincial and territorial adult vaccination schedules. Improving both the surveillance and reporting of pneumonia would help clarify when pneumonia is a primary or contributing cause of hospitalization and death. In spite of recent expansion in the use of diagnostic tools, barriers remain in effectively diagnosing pneumonia in older people and those with chronic conditions. This significantly affects data collection around incidence and long-term health outcomes. Currently, studies estimate about 12.5% of adult community acquired pneumonia hospitalizations are potentially vaccine-preventable.8 However, in addition to the significant cost of hospitalization of around $15,000CDN per patient, pneumonia significantly impacts the functional and cognitive abilities of older and at-risk Canadians in the long term. Studies have shown that upon hospitalization, pneumonia and influenza rank among the leading causes of “catastrophic disability,” defined as a loss of independence in at least 3 activities of daily living.9 Data on the subsequent cost for long- term care and repeat hospitalizations are not available. Consequently, the true social and economic burden on health, social and informal (family) care systems is substantially undervalued. The return on the investment into effective immunization programs is well-documented and offers considerable returns. There is a strong social and economic rationale for investing in improving adult immunization infrastructure. This includes research, surveillance, national immunization registry and measurable public health campaigns. National Immunization Information A barrier to increasing vaccination rates is the lack of adult vaccine registries across provinces and territories, and differences in the public health vaccination reporting requirements. Provincial and territorial Ministries of Health would benefit from comprehensive and accurate information on adult vaccinations to better understand in real time which adult has received what vaccinations, as well as when and where it was provided. All adult vaccines, whether provided in long term care facility, a pharmacy, or a clinic should be captured in a vaccine registry. This is made possible by utilizing already-exiting vaccine barcodes to track vaccinations and is critically important for the implementation of a safe and effective COVID-19 immunization strategy as well as other recommended adult vaccines.10 Public awareness of adult vaccines in Canada, particularly in comparison to childhood vaccines, remains inadequate. Further, the values and needs of those with underlying health conditions and older adults are insufficiently reflected in public health messages on immunization. The need for greater focus on adult pneumonia vaccination, and adult immunization more broadly is unprecedented. A public campaign on vaccination should emphasize that preventing illness and functional decline in older age is achievable and is a public health priority. Curating messaging that encourages positive behaviours which maintain health rather than incite fear is more likely to encourage adults to accept immunizations than negative messaging, and may help improve adult immunization rates for all Canadians. Harmonization of Good Practices Canada’s current immunization system is not equitable. Significant disparities across provinces and territories in adult immunization policies and practices are historical and ongoing. The COVID-19 pandemic presents an opportunity to reassess existing infrastructure. This must begin with robust provincial and territorial vaccine registries that in the future could together form a National Vaccine Registry, long a goal of public health. Children, youth, older people, those with chronic medical conditions and those with behavioral risk factors such as smoking and drinking or being homeless are all at potential risk for vaccine-preventable infections because of disharmony of schedules. The patchwork of vaccine schedules is confusing to patients and health care providers, and creates access inequities and added safety (reliability) issues in the system, particularly in the current COVID-19 pandemic. Provinces and territories should strive to learn from one another by sharing successful strategies proven to optimize adult vaccination rates. Expanding the role of pharmacists in Canada to provide immunizations as part of a greater immunization strategy across all provinces and territories is one means of increasing access to adult pneumonia vaccines for all Canadians. Streamlining immunization surveillance through a robust, all-inclusive, accessible immunization registry would enable Canadians to become more engaged in their immunizations and help to ensure timely vaccination. Building on the global momentum to improve adult vaccination as proposed by the World Health Organization Immunization Agenda 2030: A Global Strategy to Leave No One Behind and in the context of the Decade of Healthy Ageing, delegates call for a cross-sectoral approach to prioritize vaccination against respiratory disease to reduce functional decline, hospitalizations, morbidity, mortality and healthcare costs, especially in light of the COVID-19 pandemic. The “Pneumonia vaccination in at-risk groups: A Canadian perspective – Increasing relevance in a pandemic era” expert meeting represents the coming together of unlike groups to bridge professional boundaries with one voice to advocate for improved adult pneumonia immunization policies and practices across Canada, particularly for older Canadians and those with underlying health conditions. For queries relating to this document, please contact: astancu@ifa.ngo. Signatories Individual Signatories Ms. Betty Golightly, Go Travel Health Dr. Ronald Grossman, Trillium Health Partners References 1 Quinn, S. C., and Kumar, S. (2014). Health Inequalities and Infectious Disease Epidemics: A Challenge for Global Health Security. Biosecurity and Bioterrorism: Biodefense Strategy, Practice, and Science, 12, 5. Available from: https://bit.ly/3mqGrzx 2 Madhav, N., et al. (2017). Pandemics: Risks, Impacts, and Mitigation. In: Jamison, D. T., et al. Disease Control Pri- orities: Improving Health and Reducing Poverty. 3rd Edition. Washington (DC): The International Bank for Recon- struction and Development / The World Bank; 2017 Nov 27. Chapter 17. Available from: https://bit.ly/3mxdW3j 3 Canadian Institute for Health Information. (2020). Inpatient Hospitalization, Surgery and Newborn Statistics, 2018–2019. Available from: https://bit.ly/37IqqRv 4 Public Health Agency of Canada. (2019). Vaccine uptake in Canadian Adults 2019. Available from: https://bit. ly/2H5Fei2 5 Kaplan, A., et al. (2019). Vaccine strategies for prevention of community-acquired pneumonia in Canada; Who would benefit most from pneumococcal immunization? Canadian Family Physician, 65, 9, 625-633. Available from: https://bit.ly/34vYeiy 6 Shea, K. M., et al. (2014). Rates of Pneumococcal Disease in Adults With Chronic Medical Conditions. Open Fo- rum Infectious Diseases. Available from: https://bit.ly/37b5nVP 7 Pelton, S. I., et al. (2015). Rethinking Risk for Pneumococcal Disease in Adults: The Role of Risk Stacking. Open Forum Infectious Diseases. Available from: https://bit.ly/3q407vD 8 LeBlanc, J., et al. (2020). Age-stratified burden of pneumococcal community acquired pneumonia in hospitalised Canadian adults from 2010 to 2015. BMJ Open Respiratory Research, 7, e000550. Available from: https://bit. ly/2UzDHDW 9 McElhaney, J. E., et al. (2020). The immune response to influenza in older humans: beyond immune senescence. Immunity & Ageing, 17, 10. Available from: https://bit.ly/3pBTWPp 10 Gorfinkel, I. (2020). A national vaccine registry blueprint. Canadian Medical Association Journal. Available from: https://bit.ly/2IKSI3v Published December 2020 © Vaccines4Life

Documents

Less detail

Health Canada consultation on edible cannabis, extracts & topicals

https://policybase.cma.ca/en/permalink/policy14020

Date
2019-02-20
Topics
Pharmaceuticals/ prescribing/ cannabis/ marijuana/ drugs
Population health/ health equity/ public health
  1 document  
Policy Type
Response to consultation
Date
2019-02-20
Topics
Pharmaceuticals/ prescribing/ cannabis/ marijuana/ drugs
Population health/ health equity/ public health
Text
The Canadian Medical Association appreciates this opportunity to respond to Health Canada’s consultation on the proposed regulations for edible cannabis, cannabis extracts, and cannabis topicals. The CMA’s approach to cannabis is grounded in public health policy. It includes promotion of health and prevention of problematic use; access to assessment, counselling and treatment services; and a harm reduction perspective. The CMA endorsed the Lower-Risk Cannabis Use Guidelines and has expressed these views in our recommendations to the Task Force on Cannabis Legalization and Regulation, recommendations regarding Bill C-45. As well, we submitted comments to Health Canada with respect to the consultation on the proposed regulatory approach for the Cannabis Act, Bill C-45. Canada’s physicians have a longstanding concern about the health risks associated with consuming cannabis. , Consumers use these products for both recreational and medical purposes, compelling the need for accuracy in the labeling as well as quality control in the manufacturing process.10 Cannabis Edibles, Extracts and Topicals Cannabis will have a different effect on the user, depending on whether it is smoked or ingested, as in an edible. It has been found that “smoking marijuana results in clinical effects within 10 minutes, peak blood concentrations occur between 30 and 90 minutes, and clearance is complete within 4 hours of inhalation. Oral THC does not reach significant blood concentration until at least 30 minutes, with a peak at approximately 3 hours, and clearance approximately 12 hours after ingestion.” Because of the delay in absorption when ingested, people might consume more to feel the psychoactive effects faster. This might lead to the consumption of very high doses and result in toxic effects, such as anxiety, paranoia and in rare cases, a psychotic reaction with delusions, hallucinations, incoherent speech and agitation. Rates of use of edibles are not well known. A recent study in California high schools found that “polyuse via multiple administration methods was a predominant pattern of cannabis use and report the first evidence, to our knowledge, of triple product polyuse of combustible, edible, and vaporized cannabis among youths.” We are limiting our response to Health Canada’s consultation questions that pertain to the CMA’s position with respect to cannabis and relate to our expertise and knowledge base. Proposed THC limits for the new classes of cannabis products Standardization within all classes of cannabis products in a legal regime is essential. Tetrahydrocannabinol (THC) levels in black market products can vary widely so one can never be assured of the strength being purchased, creating the potential for significant harm. , Experience in jurisdictions where cannabis has been legalized has shown that restrictions on the potency of products (i.e., THC limits) are necessary, given the higher risks of harm associated with higher potencies.2 Prohibition of high potency products is important.3 THC limits should be based on the best available evidence of safety for consumers. The increased potency of cannabis over the years raises concerns about its use in edibles, extracts and topicals, offering a significant challenge with respect to regulating their use. This becomes particularly worrisome with respect to preadolescents and adolescents who should avoid using cannabis due to concerns with the impact on the developing brain.2 Use has been associated with a “significant increased risk of developing depression or suicidality in young adulthood.” More research is needed with respect to the effects of cannabis on all age groups, especially children, adolescents and seniors. Saunders et al describe the case of an elderly patient with a history of coronary artery disease suffering what appears to have been a myocardial infarction after ingesting most of a marijuana lollipop that contained 90 mg of THC. Such cases demonstrate how crucial it is to establish appropriate levels of THC. This is an especially important consideration because “consuming cannabis-infused edibles may inadvertently result in toxicity because absorption can take hours, compared with minutes when smoking. An individual who does not yet feel an effect may over-consume.” Small children and people with cognitive impairment will not be able to read labels, so preventive measures are very important, as with any pharmaceutical. Since legalizing cannabis, Colorado’s Rocky Mountain Poison & Drug Center has reported an increase in calls related to edible exposures. Children can accidentally eat products that contain cannabis, making them ill enough to seek medical assistance. The CMA maintains that the proposed draft regulations of 10 mg per discrete unit and package is too high and should be established at a maximum of 5 mg per dose, given the higher risks of overconsumption with edibles, the risks of accidents in children and the experience in other jurisdictions. Colorado’s limit was set at 10 mg per unit, and health authorities recognize that a lower limit would have been warranted to prevent more accidents. Other preventive measures, such as child proof packaging, are considered in other sections of this brief. The amount of THC must be displayed clearly and prominently on the package to help prevent accidental or overconsumption of the product. Rules addressing the types of ingredients and additives that could be used in edible cannabis, cannabis extracts, and cannabis topicals appropriately address public health and safety risks while enabling sufficient product diversity The CMA concurs with the proposed regulations. Experience in areas such as caffeinated, high-sugar alcoholic beverages provides ample evidence to proceed with restraint concerning the types of ingredients and additives that may be permitted in edible cannabis, cannabis extracts, and cannabis topicals. Proposed new rules for the packaging and labelling of the new classes of cannabis products The CMA reiterates its position with respect to the packaging and labelling of cannabis products as presented in its submission on the proposed approach to the regulation of cannabis.5 This includes:
a requirement for plain and standard packaging
prohibition of the use of appealing flavours and shapes,
a requirement for adequate content and potency labelling,
a requirement for comprehensive health warnings,
a requirement for childproof packaging, and
a requirement that the content in a package should not be sufficient to cause an overdose. Plain and standardized packaging is necessary with respect to edibles as their wider availability raises several public health issues, not the least of which is ingestion by young children. It is imperative that the packages and labels of edibles not resemble popular confectionaries, for example. As the Canadian Paediatric Society has noted, “the unintended consumption of edibles manufactured to look like sweets by younger children is particularly concerning.”15 Also, by “restricting the extent to which marijuana edibles can look and taste like familiar sweets, (it) could also keep the psychological barriers to marijuana initiation among children and adolescents from being lowered.” The CMA has adopted similar positions with respect to tobacco and vaping products. , , It is recognized that these regulations are targeted at products meant for the adult market, but the entry of these new classes also creates challenges beyond that audience. Teens are attracted to vaping cannabis rather than smoking it because “smoke is not combusted and also may allow for more covert use given the reduction in odor.” , As well, as “edibles have no odor, they are largely undetectable to parents.”23 The CMA views this as an opportunity to educate Canadians about the health, social and economic harms of cannabis especially in young people. Package inserts must outline and reinforce the health risks involved; they must also be designed by governments and health professionals, not cannabis producers or distributors. Inserts should include:5
information on securing the product in the home to prevent access by youth and children,
recommendations not to drive or to work with hazardous chemicals or operate equipment while using the contents of the package,
information on the health and social consequences (including legal penalties) of providing cannabis to those under a designated minimum age for purchasing, and
contact information for hotlines for poison control and for crisis support. Cannabis topicals, as outlined in the proposed regulations, would fall under the category of health products and be found in non-prescription drugs, natural health products, and cosmetics. The CMA believes that all health claims need to be substantiated with sufficient evidence that meets standards for efficacy, besides safety and quality, to protect Canadians from misleading claims.5 This is important because the level of proof required to obtain a Drug Identification Number (DIN) for prescription drugs is considerably higher than the level of proof required for a Natural Product Number (NPN); rigorous scientific evidence for effectiveness is needed for a DIN but not for an NPN. Consumers generally do not know about this distinction, believing that Health Canada has applied the same level of scrutiny to the health claims made for every product.5 Requirements for tamper-resistant and child-proof containers need to be in place to enhance consumer safety. More research is required to address the environmental concerns with extra packaging, which would result from single dose packaging. It is critical to put in place measures that make it difficult to ingest large doses of THC. Simply adding grooves to chocolate bars or baked goods, for example, separating different doses, is insufficient to prevent people, particularly children, from ingesting more than a dose (which in of itself is designed for an adult). As well, there is no guarantee that the THC is spread out uniformly throughout the product. More research is needed with respect to “determining risks and benefits through proper clinical trials;” that includes determining the safest level of THC for extracts and topicals to reassure consumers will not be harmed by these products.18 With regards to cannabidiol (CBD), it would seem that “published data from around the world has taught us that misleading labels as well as harmful contaminants are real and actual problems for CBD products.”18 Health claims need to be substantiated via a strong evidentiary process. There will be a need for careful monitoring of the health products released in the market and the health claims made.5 Experience has shown that regulations can and will be circumvented, and these activities will have to be addressed. Edible cannabis and the requirement for all products to be labelled with a cannabis-specific nutrition facts table Yes. The CMA supports the use of a cannabis-specific nutrition facts table (NFT) as described in the proposed regulations.1 These products should have the same standards and regulations applied to them as traditional food products do under the Food and Drugs Regulations. As such, a cannabis-specific nutrition facts table will help consumers differentiate them from standard food products. The proposal for the labelling of small containers and the option to display certain information on a peel-back or accordion panel The size of the container should not be an impediment to supplying consumers with the necessary information to make informed choices. Manufacturers should be required to use whatever method (peel-back or accordion panel) is most efficient and conveys all the necessary information. As the CMA noted in a recent brief with respect to tobacco labeling the “amount of space given to the warnings should be sufficient to convey the maximum amount of information while remaining clear, visible, and legible. The warnings should be in proportion to the packaging available, like that of a regular cigarette package.”20 Adding warnings on individual cigarettes, as we recommended, illustrates that it is feasible to apply important information to even the smallest surfaces.20 It is important to note that key information should be visible on the external part of the container, including the standardized cannabis symbol, ingredients and warnings. Proposal that the standardized cannabis symbol would be required on vaping devices, vaping cartridges, and wrappers Yes. As noted earlier, the CMA called for strict packaging requirements around both tobacco and vaping products.22 The requirement for the standardized cannabis symbol is an extension of that policy and to the labelling of cannabis products in general.5 Proposed new good production practices, such as the requirement to have a Preventive Control Plan, appropriately address the risks associated with the production of cannabis, including the risk of product contamination and cross-contamination Yes. The CMA concurs with this requirement. The requirement that the production of edible cannabis could not occur in a building where conventional food is produced Yes. The CMA concurs with this requirement. Separate facilities are necessary to prevent cross-contamination for the protection of consumer health and safety. Conclusion The CMA supports the federal government’s commitment to a three-year legislative review as it affords the opportunity to evaluate the regulations’ impact and adjust them as needed. It continues to be important to have good surveillance and monitoring systems, as well as to continue to learn from other jurisdictions where cannabis is legal for recreational purposes. Public education and awareness must accompany the introduction of new forms of cannabis, emphasizing the risks of accidental ingestion and overconsumption. It should also emphasize the need for safe storage of cannabis products, as well as personal possession limits. Much more research is needed into the impact of these new classes across all age groups, and into public health strategies that discourage use and increase harm reduction practices. It is fundamental that profit driven commercialization is rigorously controlled through taxation, regulation, monitoring and advertising controls, in a manner that is consistent with a public health approach. Government of Canada. Canada Gazette, Part I, Volume 152, Number 51: Regulations Amending the Cannabis Regulations (New Classes of Cannabis) Ottawa: Health Canada; 2018. Available: http://www.gazette.gc.ca/rp-pr/p1/2018/2018-12-22/html/reg4-eng.html (accessed 2018 Dec 22). Fischer B, Russell C, Sabioni P, et al. Lower-risk cannabis use guidelines: A comprehensive update of evidence and recommendations. AJPH. 2017 Aug;107(8):e1-e12. Available: https://ajph.aphapublications.org/doi/abs/10.2105/AJPH.2017.303818?url_ver=Z39.88-2003&rfr_id=ori%3Arid%3Acrossref.org&rfr_dat=cr_pub%3Dpubmed& (accessed 2019 Feb 01). Canadian Medical Association (CMA). Legalization, regulation and restriction of access to marijuana. CMA submission to the Government of Canada – Task Force on cannabis, legalization and regulation. Ottawa: CMA; 2016 Aug 29. Available: https://policybase.cma.ca/en/permalink/policy11954 (accessed 2019 Feb 01). Canadian Medical Association (CMA). Bill C-45: The Cannabis Act. Submission to the House of Commons Health Committee. Ottawa: CMA; 2017 Aug 18. Available: https://policybase.cma.ca/en/permalink/policy13723 (accessed 2019 Feb 01). Canadian Medical Association (CMA). Proposed Approach to the Regulation of Cannabis. Ottawa: CMA; 2018 Jan 19. Available: https://policybase.cma.ca/en/permalink/policy13838 (accessed 2019 Feb 04). Canadian Medical Association (CMA). Health risks and harms associated with the use of marijuana. CMA Submission to the House of Commons Standing Committee on Health. Ottawa: CMA; 2014. Available: https://policybase.cma.ca/en/permalink/policy11138 (accessed 2019 Feb 14). Canadian Medical Association (CMA). A public health perspective on cannabis and other illegal drugs. CMA Submission to the Special Senate Committee on Illegal Drugs. Ottawa: CMA; 2002. Available: https://policybase.cma.ca/en/permalink/policy1968 (accessed 2019 Feb 14). Monte A, Zane R, Heard K. The Implications of Marijuana Legalization in Colorado JAMA. 2015 January 20; 313(3): 241–242 Available: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4404298/ (accessed 2019 Feb 15). Peters E, Bae D, Barrington-Trimis J, et al. Prevalence and Sociodemographic Correlates of Adolescent Use and Polyuse of Combustible, Vaporized, and Edible Cannabis Products JAMA Network Open. 2018;1(5): e182765. Available: https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2703946 (accessed 2019 Feb 15). Wyonch R. Regulation of Edible and Concentrated Marijuana Products Intelligence Memos. Toronto: CD Howe Institute: 2018 Oct 2. Available: https://www.cdhowe.org/sites/default/files/blog_Rosalie_1002.pdf (accessed 2019 Feb 01). Vandrey R, Raber JC, Raber ME, et al. Cannabinoid Dose and Label Accuracy in Edible Medical Cannabis Products. Research Letter JAMA 2015 Jun 23-30;313(24):2491-3. Available: https://jamanetwork.com/journals/jama/fullarticle/2338239 (accessed 2019 Feb 06). Cascini F, Aiello C, Di Tanna G. Increasing Delta-9-Tetrahydrocannabinol ( -9-THC) Content in Herbal Cannabis Over Time: Systematic Review and Meta-Analysis. Curr Drug Abuse Rev. 2012 Mar;5(1):32-40. Available: https://www.datia.org/datia/resources/IncreasingDelta9.pdf (accessed 2019 Feb 14). Gobbi G, Atkin T, Zytynski T, et al. Association of Cannabis Use in Adolescence and Risk of Depression, Anxiety, and Suicidality in Young Adulthood. A Systematic Review and Meta-analysis JAMA Psychiatry. 2019 Feb 13. doi: 10.1001/jamapsychiatry.2018.4500. Available: https://jamanetwork.com/journals/jamapsychiatry/article-abstract/2723657 (accessed 2019 Feb 15). Saunders A, Stevenson RS. Marijuana Lollipop-Induced Myocardial Infarction. Can J Cardiol. 2019 Feb;35(2):229. Available: https://www.onlinecjc.ca/article/S0828-282X(18)31324-2/fulltext (accessed: 2019 Feb 11). Grant CN, Bélanger RE.Cannabis and Canada’s children and youth. Paediatr Child Health. 2017 May;22(2):98-102. Available: https://www.cps.ca/en/documents/position/cannabis-children-and-youth (accessed 2019 Feb 06). Denver Public Heath. Substance Use Exposure Dashboard. Denver: Denver Public Health; 2018. Available: http://www.denverpublichealth.org/community-health-promotion/substance-misuse/substance-use-exposure-dashboard (accessed 2019 Feb 06). Neuwirth, J. (Colorado Department of Public Health and Environment). Personal interview. (2019 Jan 30). Paradis C, April N, Cyr C, et al. The Canadian alcopop tragedy should trigger evidence-informed revisions of federal alcohol regulations. Drug Alcohol Rev. 2019 Feb 4. Available: https://onlinelibrary.wiley.com/doi/epdf/10.1111/dar.12896 (accessed 2019 Feb 14). MacCoun, RJ, Mello MM, Half-Baked — The Retail Promotion of Marijuana Edibles. N Engl J Med 2015; 372:989-991. Available: https://www.nejm.org/doi/full/10.1056/NEJMp1416014 (accessed 2019 Feb 5). Canadian Medical Association (CMA). Health Canada Consultation on Tobacco Products Regulations (Plain and Standardized Appearance). Ottawa: CMA; 2018. Available: https://policybase.cma.ca/en/permalink/policy13930 (accessed 2019 Feb 05). Canadian Medical Association (CMA). Health Canada’s Consultation on New Health-related Labelling for Tobacco Products Ottawa: CMA; 2018. Available: https://policybase.cma.ca/en/permalink/policy13939 (accessed 2019 Feb 05). Canadian Medical Association (CMA) CMA’s Recommendations for Bill S-5: An Act to amend the Tobacco Act and the Non-smokers’ Health Act and to make consequential amendments to other Acts Ottawa: CMA; 2017 Apr 7. Available: https://policybase.cma.ca/en/permalink/policy13641 (accessed 2019 Feb 05). Johnson RM, Brooks-Russell A, Ma M, et al. Usual Modes of Marijuana Consumption Among High School Students in Colorado. J Stud Alcohol Drugs. 2016;77(4):580-8. Available: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4987070/pdf/jsad.2016.77.580.pdf (accessed 2019 Feb 06). Friese B, Slater MD, Annechino R, et al. Teen Use of Marijuana Edibles: A Focus Group Study of an Emerging Issue. J Prim Prev. 2016 June 37(3):303–309. Available: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4864086/pdf/nihms-766186.pdf (accessed 2019 Feb 06).

Documents

Less detail

Health Canada consultation on the impact of vaping products advertising on youth and non-users of tobacco products

https://policybase.cma.ca/en/permalink/policy14022

Date
2019-03-22
Topics
Health care and patient safety
Population health/ health equity/ public health
  1 document  
Policy Type
Response to consultation
Date
2019-03-22
Topics
Health care and patient safety
Population health/ health equity/ public health
Text
The Canadian Medical Association (CMA) appreciates this opportunity to respond to Health Canada’s consultation on Potential Measures to Reduce the Impact of Vaping Products Advertising on Youth and Non-users of Tobacco Products under the authority of the Tobacco and Vaping Products Act (TVPA). Canada’s physicians, who see the devastating effects of tobacco use every day in their practices, have been working for decades toward the goal of a smoke-free Canada. The CMA issued its first public warning concerning the hazards of tobacco in 1954 and has continued to advocate for the strongest possible measures to control its use. The CMA has always supported strong, comprehensive tobacco control legislation, enacted and enforced by all levels of government, and we continue to do so. This includes electronic cigarettes. This brief will address the two main issues outlined in the Notice of Intent: the placement of advertising and health warnings. Placement of Advertising The CMA’s approach to tobacco and vaping products is grounded in public health policy. We believe it is incumbent on all levels of government in Canada to continue working on comprehensive, coordinated and effective tobacco control strategies, including vaping products, to achieve the goal of reducing smoking prevalence. In our April 2017 submission on Bill S-5 to the Senate Standing Committee on Social Affairs, Science and Technology we recommended that the restrictions on promotion of vaping products and devices should be the same as those for tobacco products. This would include the same approach to plain and standardized packaging regulations under consideration for tobacco products.2, The CMA is concerned that the proposed regulations leave too wide an opening for vaping manufacturers to promote their products, especially to youth. It is from a public health perspective that the CMA is calling for all vaping advertising to be strictly limited. The CMA supports the provisions proposed for point-of-sale information. The material offered will need to have the health warnings included in this Notice of Intent. However, the sections of the proposed regulations most problematic to the CMA are those encompassing public places, broadcast media, and the publications areas. Vaping advertisements should not be permitted at all in any of these spaces, with no exceptions.2 The advertisements permitted currently seem to have managed to find their way to youth, even if they are not directed at them, as claimed. A report published by the World Health Organization and the US National Cancer Institute indicated that websites dedicated to retailing e-cigarettes “contain themes that may appeal to young people, including images or claims of modernity, enhanced social status or social activity, romance, and the use of e-cigarettes by celebrities.” Social media provides an easy means of promoting vaping products and techniques, especially to youth.21 A US study found that the landscape is “being dominated by pro-vaping messages disseminated by the vaping industry and vaping proponents, whereas the uncertainty surrounding e-cigarette regulation expressed within the public health field appears not to be reflected in ongoing social media dialogues.” The authors recommended that “real-time monitoring and surveillance of how these devices are discussed, promoted, and used on social media is necessary in conjunction with evidence published in academic journals.”6 The need to address the issue of advertising around vaping is growing more urgent. Vaping is becoming more popular and more attractive to Canadian youth, especially with the arrival of more high-tech versions of electronic cigarettes such as the pod-based JUUL™. , A similar trend has been observed in the United States where a recent study indicated that “use by adolescents and young adults of newer types of e-cigarettes such as pod-based systems is increasing rapidly.” JUUL™ entered the US market in 2015 “with a novel chemistry (nicotine salts) enabling higher concentrations in a limited aerosol plume.” JUUL’s™ nicotine levels contained 5% nicotine salt solution consisting of 59 mg/mL in 0.7 mL pods. Some of JUUL’s™ competition have pods containing even higher levels (6% and 7%).10 The nicotine salts are “less harsh and less bitter, making e-liquids more palatable despite higher nicotine levels.”10 It has been noted by researchers that “among adolescents and young adults who use them, pod-based e-cigarettes are synonymous with the brand-name JUUL™ and use is termed “juuling,” whereas “vaping” has typically been used by youths to refer to using all other types of e-cigarettes.”9 The addition of a wide variety of flavours available in the pods makes them taste more palatable and less like smoking tobacco.10, The purpose in doing so is because “smoking is not a natural behavior, like eating or drinking, the manufacturers of these devices commonly add flavoring to the liquid from which the nicotine aerosol is generated, to make the initial exposures more pleasurable. The flavoring enhances the appeal to first-time users — especially teenagers.” The CMA and other expert groups would prefer to see flavours banned to reduce the attractiveness of vaping as much as possible.2, It is very important that the pod-based systems are cited specifically to ensure they are included under the new advertising regulations for all vaping products. Youth vaping has reached the point where the US Food and Drug Administration referred to it as an “epidemic,” calling it “one of the biggest public health challenges currently facing the FDA.” Durham Region Health Department, using data from the Ontario Student Drug Use and Health Survey conducted by CAMH and administered by the Institute for Social Research, York University, noted that 17% of high school students in that region had used an electronic cigarette in the past year (2016-17), numbers that are similar for the rest of Ontario. In the United States, a survey indicated that, among high school students, “current e-cigarette use increased from 1.5% (220,000 students) in 2011 to 20.8% (3.05 million students) in 2018;” between 2017 and 2018 alone it rose 78% (from 11.7% to 20.8%). Concern is growing across Canada among educators seeing a rise in the number of youths turning to vaping. , , The problem has reached the point where a school official resorted to removing the doors from the washrooms to “crack down” on vaping in the school. Youth themselves are aware of the increasing problem; many are turning to YouTube to learn “vape tricks” such as making smoke rings. Some refer to the practice of vaping as “the nic;” as a University of Ottawa student noted “They call it getting light-headed. Sometimes it's cool.” As the Canadian Paediatric Society noted in 2015, efforts to “denormalize tobacco smoking in society and historic reductions in tobacco consumption may be undermined by this new ‘gateway’ product to nicotine dependency.” , Decades of effort to reduce the incidence of smoking are in danger of being reversed. A growing body of evidence indicates that vaping can be considered the prime suspect. A Canadian study provides “strong evidence” that use of electronic cigarettes among youth is leading them to the consumption of combustible tobacco products. In a similar vein, a “large nationally representative study of US youths supports the view that e-cigarettes represent a catalyst for cigarette initiation among youths.” Granting vaping manufacturers scope to advertise will likely exacerbate this problem. Health Warnings The CMA reiterates its position that health warnings for vaping should be like those being considered for tobacco packages.2,3 We support the proposed warning labels being placed on all vaping products. The need for such warnings is important as there is still much that is not known about the effects vaping can have on the human body. Substances that have been identified in e-cigarette liquids and aerosols include “nicotine, solvent carriers (PG and glycerol), tobacco-specific nitrosamines (TSNAs), aldehydes, metals, volatile organic compounds (VOCs), phenolic compounds, polycyclic aromatic hydrocarbons (PAHs), flavorings, tobacco alkaloids, and drugs.” Researchers have noted that there is a “striking diversity of the flavorings in e-cigarette liquids, (and that) the effects on health of the aerosol constituents produced by these flavorings are unknown.” A US study found “evidence that using combusted tobacco cigarettes alone or in combination with e-cigarettes is associated with higher concentrations of potentially harmful tobacco constituents in comparison with using e-cigarettes alone.” Some researchers have found that there is “significant potential for serious lung toxicity from e-cig(arette) use.” , Another recent US study indicates that “adults who report puffing e-cigarettes, or vaping, are significantly more likely to have a heart attack, coronary artery disease and depression compared with those who don’t use them or any tobacco products.” Further, it was found that “compared with nonusers, e-cigarette users were 56 percent more likely to have a heart attack and 30 percent more likely to suffer a stroke.”32 The need for parents to be educated on the impact of vaping on children is also very important. A study examining how smoke-free and vape-free home and car policies vary for parents who are dual users of cigarettes and e-cigarettes, who only smoke cigarettes, or who only use e-cigarettes demonstrated that these parents may perceive e-cigarette aerosol as safe for children. It noted that “dual users were less likely than cigarette-only smokers to report various child-protective measures inside homes and cars.”33 Recommendations 1. The CMA calls for all vaping advertising to be strictly limited. The restrictions on the marketing and promotion of vaping products and devices should be the same as those for tobacco products. 2. The CMA recommends that vaping advertisements should not be permitted in any public places, broadcast media, and in publications of any type, with no exceptions. 3. The CMA supports the provisions proposed in this Notice of Intent for point-of-sale information. This should include health warnings. 4. The CMA reiterates its position that health warnings for vaping should be like those being considered for tobacco packages. We support the proposed warning labels being placed on all vaping products. 5. The CMA recommends more research into the health effects of vaping as well as on the components of the vaping liquids. Government of Canada. Notice to Interested Parties – Potential Measures to Reduce the Impact of Vaping Products Advertising on Youth and Non-users of Tobacco Products Ottawa: Health Canada; 2019 Available: https://www.canada.ca/en/health-canada/programs/consultation-measures-reduce-impact-vaping-products-advertising-youth-non-users-tobacco-products.html (accessed 2019 Feb 27) Canadian Medical Association (CMA) CMA’s Recommendations for Bill S-5: An Act to amend the Tobacco Act and the Non-smokers’ Health Act and to make consequential amendments to other Acts Ottawa: CMA; 2017 Apr 7. Available: http://policybase.cma.ca/dbtw-wpd/Briefpdf/BR2017-06.pdf (accessed 2019 Mar 1). Canadian Medical Association. Health Canada consultation on tobacco products regulations (plain and standardized appearance) Ottawa: CMA; 2018 Sep 6 Available: http://www.cma.corp/dbtw-wpd/Briefpdf/BR2019-01.pdf (accessed 2019 Mar 5) Gagnon E. IMPERIAL TOBACCO: Kids shouldn’t be vaping; our marketing is aimed at adults. Halifax Chronicle Herald March 5, 2019 Available: https://www.thechronicleherald.ca/opinion/imperial-tobacco-kids-shouldnt-be-vaping-our-marketing-is-aimed-at-adults-289673/ (accessed 2019 Mar 8) U.S. National Cancer Institute and World Health Organization. The Economics of Tobacco and Tobacco Control. National Cancer Institute Tobacco Control Monograph 21. NIH Publication No. 16-CA-8029A. Bethesda, MD: U.S. Department of Health and Human Services, National Institutes of Health, National Cancer Institute; and Geneva, CH: World Health Organization; 2016. Available https://cancercontrol.cancer.gov/brp/tcrb/monographs/21/docs/m21_complete.pdf (accessed 2019 Mar 8) McCausland K, Maycock B, Leaver T, Jancey J. The Messages Presented in Electronic Cigarette–Related Social Media Promotions and Discussion: Scoping Review J Med Internet Res 2019;21(2):e11953 Available: https://www.jmir.org/2019/2/e11953/ (accessed 2019 Mar 14) Glauser W. New vaping products with techy allure exploding in popularity among youth. CMAJ 2019 February 11;191:E172-3. doi: 10.1503/cmaj.109-5710 Available: http://www.cmaj.ca/content/191/6/E172 (accessed 2019 Mar 1) Crowe K. Canada's 'wicked' debate over vaping CBC News February 2, 2019 Available https://www.cbc.ca/news/health/vaping-juul-vype-health-canada-cigarette-smoking-nicotine-addiction-1.5003164 (accessed 2019 Mar 8) McKelvey K et al. Adolescents’ and Young Adults’ Use and Perceptions of Pod-Based Electronic Cigarettes. JAMA Network Open. 2018;1(6):e183535. doi:10.1001/jamanetworkopen.2018.3535 Available: https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2707425 (accessed 2019 Mar 1) Jackler RK, Ramamurthi D. Nicotine arms race: JUUL and the high-nicotine product market Tob Control 2019;0:1–6. doi:10.1136/tobaccocontrol-2018-054796 Available: https://www.ncbi.nlm.nih.gov/pubmed/30733312 (accessed 2019 Mar 12) Reichardt EM., Guichon J. Vaping is an urgent threat to public health The Conversation March 13, 2019 Available: https://theconversation.com/vaping-is-an-urgent-threat-to-public-health-112131 (accessed 2019 Mar 14) Drazen JM., Morrissey S., Campion, EW. The Dangerous Flavors of E-Cigarettes. N Engl J Med 2019; 380:679-680 Available: https://www.nejm.org/doi/full/10.1056/NEJMe1900484 (accessed 2019 Mar 13) Ireland N. Pediatricians call for ban on flavoured vaping products — but Health Canada isn't going there CBC News November 17, 2018 Available: https://www.cbc.ca/news/health/canadian-pediatricians-flavoured-vaping-second-opinion-1.4910030 (accessed 2019 Mar 13) Food and Drug Administration Statement. Statement from FDA Commissioner Scott Gottlieb, M.D., on new data demonstrating rising youth use of tobacco products and the agency’s ongoing actions to confront the epidemic of youth e-cigarette use Media Release February 11, 2019 Available: https://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm631112.htm (accessed 2019 Mar 11) Durham Region Health Department Students’ use of e-cigarettes in the past year, 2016-2017 Quick Facts December 2018 Available https://www.durham.ca/en/health-and-wellness/resources/Documents/HealthInformationServices/HealthStatisticsReports/E-cigaretteAlternativeSmokingDeviceStudents-QF.pdf (accessed 2019 Mar 11) Cullen KA et al. Notes from the Field: Use of Electronic Cigarettes and Any Tobacco Product Among Middle and High School Students — United States, 2011–2018 Morbidity and Mortality Weekly Report November 16, 2018 Vol. 67 No. 45 Available: https://www.cdc.gov/mmwr/volumes/67/wr/mm6745a5.htm (accessed 2019 Mar 13) Munro N. Vaping on the rise in Nova Scotia high schools Halifax Chronicle Herald March 5, 2019 Available: https://www.thechronicleherald.ca/news/local/vaping-on-the-rise-in-nova-scotia-high-schools-289761/ (accessed 2019 Mar 11) Soloducha A. Is your child vaping? Regina Catholic Schools educating parents as trend continues to rise CBC News March 1, 2019 Available https://www.cbc.ca/news/canada/saskatchewan/regins-catholic-schools-vaping-education-1.5039717 (accessed 2019 Mar 11) Emde W. Growth of vaping labelled ‘crisis’ in Vernon. Kelowna Daily Courier Available http://www.kelownadailycourier.ca/life/article_253d6404-4168-11e9-934f-7b6df68fb0fd.html (accessed 2019 Mar 11) Lathem C. Ottawa principal's solution to student vaping: Remove the washroom doors. CTV News January 9, 2019 Available https://www.ctvnews.ca/canada/ottawa-principal-s-solution-to-student-vaping-remove-the-washroom-doors-1.4246317 (accessed 2019 Mar 11)) Calioa D. Vaping an 'epidemic,' Ottawa high school student says CBC News November 27, 2018 Available https://www.cbc.ca/news/canada/ottawa/vaping-epidemic-ottawa-high-school-student-says-1.4918672 (accessed 2019 Mar 11) Schnurr J. New data is showing a worrisome trend about vaping and smoking among teens CTV News January 18, 2019 Available https://ottawa.ctvnews.ca/new-data-is-showing-a-worrisome-trend-about-vaping-and-smoking-among-teens-1.4260008 (accessed 2019 Mar 11) Stanwick R. E-cigarettes: Are we renormalizing public smoking? Reversing five decades of tobacco control and revitalizing nicotine dependency in children and youth in Canada Policy Statement Canadian Paediatric Society March 6, 2015 (Reaffirmed February 28, 2018) Available: https://www.cps.ca/en/documents/position/e-cigarettes (accessed 2019 Mar 12) Fairchild AL., Bayer R., Colgrove J. The renormalization of smoking? E-cigarettes and the tobacco “endgame.” N Engl J Med 370:4 January 23, 2014 Available: https://www.nejm.org/doi/pdf/10.1056/NEJMp1313940 (accessed 2019 Mar 12) Hammond d. et al. Electronic cigarette use and smoking initiation among youth: a longitudinal cohort study. CMAJ October 30, 2017 189 (43) E1328-E1336; Available: http://www.cmaj.ca/content/189/43/E1328 (accessed 2019 Mar 1) Berry KM et al. Association of Electronic Cigarette Use With Subsequent Initiation of Tobacco Cigarettes in US Youths JAMA Network Open. 2019;2(2):e187794. doi:10.1001/jamanetworkopen.2018.7794 Available: https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2723425?resultClick=3 (accessed 2019 Mar 12) National Academies of Sciences, Engineering, and Medicine. 2018. Public health consequences of e-cigarettes. Washington, DC: The National Academies Press. doi: https://doi.org/10.17226/24952. Available: https://www.nap.edu/catalog/24952/public-health-consequences-of-e-cigarettes (accessed 2019 Mar 13) Dinakar, C., O’Connor GT. The Health Effects of Electronic Cigarettes. N Engl J Med 2016;375:1372-81 Available: https://www.nejm.org/doi/full/10.1056/NEJMra1502466 (accessed 2019 Mar 13) Goniewicz ML. et al. Comparison of Nicotine and Toxicant Exposure in Users of Electronic Cigarettes and Combustible Cigarettes JAMA Network Open. 2018;1(8):e185937 Available: https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2718096 (accessed 2019 Mar 13) Chan LF. Et al. Pulmonary toxicity of e-cigarettes Am J Physiol Lung Cell Mol Physiol 313: L193–L206, 2017 Available: https://www.physiology.org/doi/full/10.1152/ajplung.00071.2017?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%3dpubmed (accessed 2019 Mar 13) Li D, Sundar IK, McIntosh S, et al. Association of smoking and electronic cigarette use with wheezing and related respiratory symptoms in adults: cross-sectional results from the Population Assessment of Tobacco and Health (PATH) study, wave 2. Tob Control. 0:1-8, 2019. American College of Cardiology. E-Cigarettes Linked to Heart Attacks, Coronary Artery Disease and Depression. Media Release March 7, 2019 Available: https://www.acc.org/about-acc/press-releases/2019/03/07/10/03/ecigarettes-linked-to-heart-attacks-coronary-artery-disease-and-depression (accessed 2019 Mar 13) Drehmer JE, Nabi-Burza E, Hipple Walters B, et al. Parental Smoking and E-cigarette Use in Homes and Cars. Pediatrics. 2019;143(4):e20183249 Available: https://pediatrics.aappublications.org/content/early/2019/03/07/peds.2018-3249 (accessed 2019 Mar 13)

Documents

Less detail

A new vision for Canada: family practice— the patient’s medical home 2019

https://policybase.cma.ca/en/permalink/policy14024

Date
2019-03-02
Topics
Physician practice/ compensation/ forms
Health systems, system funding and performance
  1 document  
Policy Type
Policy endorsement
Date
2019-03-02
Topics
Physician practice/ compensation/ forms
Health systems, system funding and performance
Text
The evolving needs of patients and their communities place ever-changing demands on the health care system to maintain and improve the quality of services provided. Changing population demographics, increasing complexity, and new technology make for a dynamic system. Family physicians are at the heart of the health care system, acting as the first point of contact and a reliable medical resource to the communities they serve, caring for patients and supporting them throughout all interactions with the health care system. The Patient’s Medical Home (PMH) is a vision that emphasizes the role of the family practice and family physicians in providing high-quality, compassionate, and timely care. The success of a PMH depends on collaboration and teamwork—from the patient’s participation in their care to interprofessional and intraprofessional care providers working together, to policy-makers who can offer infrastructure support and funding. PMH 2019 was created with invaluable feedback from a broad range of stakeholders reflective of such a joint approach. Its goal is to make the PMH a reality for patients and providers across Canada. In 2011 the College of Family Physicians of Canada (CFPC) released A Vision for Canada: Family Practice - The Patient’s Medical Home.1 It outlined a vision for the future of primary care by transforming the health care system to better meet the needs of everyone living in Canada. The vision outlined the 10 pillars that make up the PMH and provided detailed recommendations to assist family physicians and their teams, as well as policy-makers and health care system administrators, to implement this new model across the country. WHY A REVISED PMH? Since 2011 many principles of the PMH vision have been embraced in primary care reforms. New models have been introduced across Canada (see Progress on the PMH to Date). To better reflect current realties, meet the evolving needs of family physicians and their teams, and support continued implementation of the PMH, the CFPC has developed this revised edition of the vision. It reflects evolving realities of primary care in Canada, including the rapid adoption of electronic medical records (EMRs)2,3 and a shift toward interprofessional practice structures.2 While progress has been made, there is still work to be done to fully achieve the PMH vision. In 2016 almost 75 per cent of Canadians rated the quality of care received from their family physicians as good or excellent.4 In 2017 a CFPC survey found that 79 per cent of respondents rate the care they receive from their family doctor as excellent or good.5 However, at the same time 55 per cent of Canadians also believed that the overall health care system still required fundamental changes.4 In addition, Canada continues to perform below the international average on certain aspects of patient-centred care; for example, same- or next-day access to appointments. While most Canadians (84.7 per cent) have a regular doctor or place of care, they generally report longer wait times for medical care than adults in comparable countries.4 PMH 2019 addresses these concerns and proposes solutions that can help further improve the primary care system for all. Although the specific components of the revised PMH have been updated (see What is the Patient’s Medical Home?), the core principles remain the same. PMH 2019 focuses on providing high-quality, patient-centred, and comprehensive care to patients and their families during their lifetime. It embraces the critical role that family physicians and family practices play in the health care system, reflecting the fact that systems with strong primary health care deliver better health outcomes, enhance efficiency, and improve quality of care.6 PMH 2019 recognizes that a patient will not be able to see their personal family physician at every visit, but can rely on the PMH’s qualified team of health professionals to provide the most appropriate care responding to patient needs with continuous support and leadership from family physicians. PMH 2019 highlights the central importance of community adaptiveness and social accountability in primary care with a new pillar. The importance of being responsive to community needs through engagement, and ensuring the provision of equitable, culturally safe, antioppressive practise that seeks to assess and intervene into social determinants of health (SDoH), is now more clearly featured. 2 A NEW VISION FOR CANADA Family Practice— The Patient’s Medical Home 2019 PURPOSE OF THIS DOCUMENT PMH 2019 outlines 10 revised pillars that make up a PMH. Key attributes are defined and explained for each pillar. Supporting research is provided to demonstrate the evidence base for each attribute. This document is intended to support family physicians currently working in a PMH to better align their practice with the PMH pillars, or assist those practices looking to transition to a PMH. Furthermore, this document can guide governments, policy-makers, other health care professionals, and patients on how to structure a primary health care system that is best-suited to meet the needs of Canadians. Many resources for the PMH have been developed and will continue to be available. These include practical Best Advice guides on a range of topics and the self-assessment tool that can help quantify a practice’s progress toward PMH alignment. Moving forward, additional materials that address the new themes identified in PMH 2019 and the tools to support physicians in the transition to PMH structures—for example the PMH Implementation Kit— will be available at patientsmedicalhome.ca. What is a Patient’s Medical Home? The PMH is a family practice defined by its patients as the place they feel most comfortable presenting and discussing their personal and family health and medical concerns. The PMH can be broken down into three themes: Foundations, Functions, and Ongoing Development (see Table 1 and Figure 1). The three Foundation pillars are the supporting structures that facilitate the care provided by the PMH. All three aspects are required for the successful implementation and sustainability of a PMH. The Functions are areas central to the operation of a family practice and consist of the five core PMH pillars. These principles govern the type of care provided by the PMH practices to ensure it is effective and efficient for meeting the needs of the patients, families, and communities they serve. The pillars in this section reflect the Four Principles of Family Medicine,7 which underlines the important place they take in the overall PMH 2019. The pillars in Ongoing Development are essential to advancing the PMH vision. These areas make it possible for physicians to provide the best possible care for patients in various settings. Applying these pillars, the PMH will thrive through practising quality improvement (QI) principles to achieve the results necessary to meet the needs of their patients, their communities, and the broader health care community, now and in the future. The PMH is a vision to which every practice can aspire. Many practices across Canada have already begun transitioning to a PMH, thanks to the dedication and leadership of family physicians and their teams across Table 1. 10 Pillars of the revised PMH vision THEME PILLAR Foundations 1. Administration and Funding 2. Appropriate Infrastructure 3. Connected Care Functions 4. Accessible Care 5. Community Adaptiveness and Social Accountability 6. Comprehensive Team-Based Care with Family Physician Leadership 7. Continuity of Care 8. Patient- and Family-Partnered Care Ongoing Development 9. Measurement, Continuous Quality Improvement, and Research 10. Training, Education, and Continuing Professional Development A NEW VISION FOR CANADA Family Practice— The Patient’s Medical Home 2019 3 the country. This vision is a resource for these practices as they engage in ongoing practice assessment and QI initiatives. It can also assist other stakeholders, including government planners, policy-makers, and funders to better understand what defines an effective patientcentred family practice. By involving patients in all stages of the development, evaluation, and continuous quality improvement (CQI) activities of the practice, the PMH can contribute significantly to furthering the goals of transformation to a patient-centred health care system.8 What the Patient’s Medical Home is Not While it is important to understand what the PMH aspires to be, it is also important to highlight that it is not a one-size-fits-all solution. Solo practices in rural or remote settings or large group practices serving inner-city populations can align with PMH principles by incorporating strategies that match the realities of their unique settings. In fact, social accountability and community adaptiveness is an important new addition to the revised PMH vision to account for the need of every family practice to adapt and respond to the needs of their patients and communities. What works for one practice will not work for all. The PMH vision does not require that all practices be relocated or re-engineered, or that significant financial investments be made by physicians or other health care professionals. Instead, system level support and involvement is required to achieve the vision. The pillars and attributes listed in this document are signposts along the way to reform that aids practices on their journey. It is important to note that this vision is not intended to undermine or change any exciting initiatives involving family practice currently under way across Canada (several of which already embrace and incorporate the medical home concept; see Progress on the PMH to Date). Rather, it is meant to build on and strengthen these efforts. The more that health care initiatives meet PMH objectives, the more likely it is that the overall goals of creating a patient-centred health care system throughout Canada will be realized. Figure 1. The Patient’s Medical Home 4 A NEW VISION FOR CANADA Family Practice— The Patient’s Medical Home 2019 PROGRESS ON THE PMH TO DATE Since the release of the original PMH vision document, system-level change has occurred in almost all jurisdictions in Canada. More specifically, PMH-type practices are gaining traction in various provinces and currently exist in various stages of development. The CFPC took a snapshot of PMH uptake in all provinces in the PMH Provincial Report Card, published in early 2019.9 That report contains grades and descriptions for progress in each province up to late 2018, which acts as a useful gauge for where the vision stands at the time of publication of this new edition. Alberta In Alberta, primary care networks (PCNs)10 were established to link groups of family physicians and other health care professionals. Within PCNs clinicians work together to provide care specific to community and population health care needs. Currently, there are 42 PCNs operating in Alberta, comprised of more than 3,700 (or 80 per cent of) family physicians, and over 1,100 other health care practitioners. PCNs provide care to close to 3.6 million Albertans, 80 per cent of the population in Alberta. Primary care clinics are being asked to collect data for Third Next Available (TNA) appointments to improve access for Albertans.11 TNA measures the delay patients experience in accessing their providers for a scheduled appointment. TNA is considered a more accurate system measure of access than the “next available” appointment, since the next or second next available appointment may have become available due to a cancellation or other event that is not predictable or reliable. British Columbia The British Columbia government’s new primary care strategy focuses on expanding access to team-based care through PCNs.12 PCNs are in the initial stages of adoption and when fully rolled out will provide a systemlevel change—working to connect various providers to improve access to, and quality of, care. They will allow patients to access the full range of health care options, streamline referrals, and provide better support to family physicians, nurse practitioners, and other primary health care providers. The General Practice Services Committee13 (GPSC; a partnership of the provincial government and Doctors of BC) specifically references and builds on the PMH concept in their vision for the future of British Columbia’s health care system. Manitoba In Manitoba, PMHs are Home Clinics and PCNs are My Health Teams. My Health Teams bring together teams of health care providers (physicians, nurses, nurse practitioners, etc.) to collaborate in providing highquality care based on community and patient needs.14 As suggested by the name of the initiative itself, the goal is to improve health care by developing teams of health care professionals who will work together to address primary health care needs of Manitobans.15 The first two My Health Teams were established in 2014, and there are now 15 across the province.16 The Manitoba Centre for Health Policy did some work assessing the impact of My Health Teams. New Brunswick In 2017 the government announced the New Brunswick Family Plan, which placed a specific emphasis on access to team-based care. To achieve this goal, the provincial government and the New Brunswick Medical Society established a voluntary program called Family Medicine New Brunswick. In this team-based model, physicians have their own rosters of patients, but also provide a service to all patients of doctors on their team.17 It was announced in 2018 that 25 family physicians will be added to the provincial health care system to ensure more New Brunswick residents have access to a primary care physician and to help reduce wait times.18 Newfoundland and Labrador In 2015 the Newfoundland and Labrador government released Healthy People, Healthy Families, Healthy Communities: A primary health care framework for Newfoundland and Labrador. The strategy’s goals include ensuring “timely access to comprehensive, person-focused primary health care services and supports,” and “primary health care reform should work to establish teams of providers that facilitate access to a range of health and social services tailored to meet A NEW VISION FOR CANADA Family Practice— The Patient’s Medical Home 2019 5 the needs of the communities they serve.”19 Both goals align with the general PMH principles. Primary health care teams have been introduced in St. John’s and are planned for Corner Brook and Burin.20 Many initiatives under way as a part of this strategy are in the early stages of development. Continuing in the direction laid out will move Newfoundland and Labrador closer to integrating the PMH vision in their delivery of primary health care. Northwest Territories The recent creation of a single Territorial Health Authority has enabled work on primary care improvements across the Northwest Territories. In August 2018 the NWT Health and Social Services Leadership Council unanimously voted in favour of a resolution supporting redesigning the health care system toward a team- and relationshipbased approach, consistent with PMH values. In several regions, contracted physicians are already assigned to regularly visit remote communities and work closely with local staff to provide continuity of remote support between visits. Planning is under way for implementing PMH-based multidisciplinary care teams in several larger regional centres, with enhanced continuity and access to physician and nursing staff as well as co-located mental health support and other health care disciplines. This work is facilitated by a territory-wide EMR and increased use of telehealth and other modalities of virtual care. Nova Scotia The 2017 Strengthening the Primary Health Care System in Nova Scotia report recommended establishing “health homes,” consisting of interprofessional, collaborative family practice teams. The model is based on a population health approach that focuses on wellness and chronic disease management/prevention and incorporates comprehensive, team-based care. There are approximately 50 collaborative family practice21 teams and a number of primary care teams across Nova Scotia. Ontario The model most aligned with the PMH framework is the family health team (FHT).22 FHTs are comprised of family physicians, nurse practitioners, and other health care professionals, and provide community-centred primary care programs and services. The 184 FHTs collectively serve over three million enrolled Ontarians. Based on the results of a five-year evaluation undertaken by the Conference Board of Canada in 2014, FHTs have achieved improvements at the organizational and service-delivery levels.23 Much progress has also been made through patient enrolment models. Patient enrolment, or rostering, is a process in which patients are formally registered with a primary care provider or team. Patient enrolment facilitates accountability by defining the population for which the provider is responsible. Formal patient enrolment with a primary care physician lays the foundation for a proactive approach to chronic disease management and preventive care.24 Studies show that the models have achieved some degree of success in enhancing health system efficiency in Ontario through the reducing use of emergency departments for non-emergent care.25 Prince Edward Island In Prince Edward Island, primary care is provided through five PCNs.26 Each network consists of a team that includes family physicians, nurse practitioners, registered nurses, diabetes educators, licensed practical nurses, clerical staff, and in some cases dietitians and mental health workers. They offer a broad range of health services including diagnosis, treatment, education, disease prevention, and screening. Quebec The Groupes de médecine de famille27 (GMF) is the team-based care model in Quebec most closely aligned with the PMH. GMF ranking (obligations, financial, and professional supports) is based on weighted patient rostering. One GMF may serve from 6,000 to more than 30,000 patients. The resource allocation (financial and health care professionals) depends on the weighted patient target under which the GMF falls. In a GMF, each doctor takes care of their own registered patients, but all physicians in the GMF can access medical records of all patients. GMFs provide team-based care with physicians, nurses, social workers, and other health care professionals working collaboratively to provide appropriate health care based on community needs. Saskatchewan Saskatchewan has made investments in a Connected Care Strategy, which focuses on a team approach to care that includes the patient and family, and extends from the community to the hospital and back again. It is about connecting teams and providing seamless care for people who have multiple, ongoing health care needs, with a particular focus on care in the community.28 6 A NEW VISION FOR CANADA Family Practice— The Patient’s Medical Home 2019 FOUNDATIONS PMH foundations are the underlying, supporting structures that enable a practice to exist, and facilitate providing each PMH function. Without a strong foundation, the PMH cannot successfully provide high-quality, patient-centred care. The foundations are Administration and Funding (includes financial and governmental support and strong governance, leadership, and management), Appropriate Infrastructure (includes physical space, human resources, and electronic records and other digital supports), and Connected Care (practice integration with other care settings enabled by health IT). ADMINISTRATION & FUNDING PAGE 7 APPROPRIATE INFRASTRUCTURE PAGE 9 CONNECTED CARE PAGE 12 Patients as partners in health care Patient-centred or patient-partnered? Understanding and acknowledging patients as full partners in their own care is a small but powerful change in terminology. Considering and respecting patients as partners allows health care providers to better recognize and include the skills and experience each patient brings to the table. Patient perspectives and feedback can be more inclusively incorporated in the QI processes in place to improve care delivery. Understanding the nature of patient partnerships can help physicians better establish trusting relationships with those in their care.29 Pillar 1: Administration and Funding Practice governance and management Effective practice governance is essential to ensuring an integrated process of planning, coordinating, implementing, and evaluating.30 Every PMH should clearly define its governance and administrative structure and functions, and identify staff responsible for each function. While the complexity of these systems varies depending on the practice size, the number of members on the health care professional team, and the needs of the population being served, every PMH should have an organizational plan in place that helps guide the practice operations. From a governance perspective, policies and procedures should be developed and regularly reviewed and updated, especially in larger practices. These policies and procedures will offer guidance in areas such as organization of clinical services, appointment and booking systems, information management, facilities, equipment and supplies, human resources, defining PMH team members’ clinical and administrative/management roles and responsibilities, budget and finances, legal and liability issues, patient and provider safety, and CQI. In some cases, standardized defaults for these may be available based on the province of practice and existing structures supporting interprofessional teams. Structures and systems need to be in place that allow for compensated time for providers to undertake and actively participate in CQI activities. This needs to be scheduled and remunerated so that it is seen as being as important and critical as clinical time. To ensure that all PMH team members have the capacity to take on their required roles, leadership development programs should be offered. Enabling physicians to engage in this necessary professional development requires sufficient government funding to cover training A NEW VISION FOR CANADA Family Practice— The Patient’s Medical Home 2019 7 Practices need staff and financial support, advocacy, governance, leadership, and management in order to function as part of the community and deliver exceptional care. 1.1 Governance, administrative, and management roles and responsibilities are clearly defined and supported in each PMH. 1.2 Sufficient system funding is available to support PMHs, including the clinical, teaching, research, and administrative roles of all members of PMH teams. 1.3 Blended remuneration models that best support team-based, patient-partnered care in a PMH should be considered to incentivize the desired approach. 1.4 Future federal/provincial/territorial health care funding agreements provide appropriate funding mechanisms that support PMH priorities, including preventive care, population health, electronic records, community-based care, and access to medications, social services, and appropriate specialist and acute care. 8 A NEW VISION FOR CANADA Family Practice— The Patient’s Medical Home 2019 costs and financial support to ensure lost income is not a barrier (see Pillar 10: Training, Education, and Continuing Professional Development). External supports Every family practice in Canada can become a PMH and an optimal learning environment will only be achievable with the participation and support of all stakeholders throughout the health care system. This includes family physicians; other health professionals who will play critical roles on PMH teams; federal, provincial, and territorial governments; academic training programs; governing bodies for physicians and allied health care providers; and most importantly, the people of Canada themselves, individually and in their communities—the recipients of care provided by the PMH. To achieve their objectives, PMHs need the support of governments across Canada through the provision of adequate funding and other resources. Given that the structure, composition, and organization of each PMH will differ based on community and population needs, funding must be flexible. More specifically, PMH practices will differ in terms of the staff they require (clinical, administrative, etc.). Funding must be available to ensure that PMH practices can determine optimal staffing levels and needs, to best meet community needs. The health care system must also ensure that all health care professionals on the PMH team have appropriate liability protection, and that adequate resources are provided to ensure that each PMH practice can provide an optimal setting for teaching students and residents and for conducting practice-based research. These characteristics are also reflected in the Four Principles of Family Medicine, reinforcing the centrality of family medicine to the delivery of care. Experience through new models of family practice, such as patient enrolment models (PEMs) in Ontario, suggests that blended funding models are emerging as the preferred approach to paying family physicians.31–33 These models are best suited to incentivizing teambased, patient-partnered care. The current fee-forservice (FFS) model incentivizes a series of short consultations that might be insufficient to address all of the patient’s needs, while blended remuneration provides for groups of physicians to work together to provide comprehensive care through office hours and after-hours care for their rostered patients. Capitation allows for more in-depth consultations depending on population need, rather than a volume-based model. Research has also found that blended capitation models can lead to small improvements in processes of care (e.g., meeting preventive care quality targets)34 and can be especially useful for supporting patients in managing and preventing chronic diseases.35 The CFPC advocates for governments to implement blended payment mechanisms across the country to achieve better health outcomes (see the Best Advice guide: Physician Remuneration in a Patient’s Medical Home36 for more information). It is important to ensure that additional practice activities such as leadership development, QI, and teaching are supported through dedicated funding or protected time intended specifically for these activities and are not seen as financially disadvantageous. The sustainability of Canada’s health care system depends on a foundation of strong primary care and family practice.37 Indeed, “high-performing primary care is widely recognized as the foundation of an effective and efficient health care system.”38 Future funding for health care—in particular from the federal government through federal, provincial, and territorial agreements—must be sustained through appropriate and well-designed funding agreements that incentivize PMH visions of primary care; other medical home priorities including preventive care, population health, EMRs; communitybased care; along with access to medications, social services, and appropriate specialist and acute care. For the PMH vision to be successful and a part of the future of family practice care in Canada, we need the commitment and support of everyone in the Canadian health care system, including decision makers and patients. By working with all levels of government and with patients, we can improve the health care system so that everyone in Canada has access to patient-centred, comprehensive, team-based care. A NEW VISION FOR CANADA Family Practice— The Patient’s Medical Home 2019 9 Pillar 2: Appropriate Infrastructure The shift in Canada from paper-based patient records to EMRs is reaching saturation. As delivery of care evolves with greater integration of technology, potential applications to improve patient care expand.39 The proportion of family physicians using EMRs has grown from 16 per cent in 2004 to 85 per cent in 2017.40 As it becomes ubiquitous in health care delivery, information technology can be of great benefit in sharing information with patients, facilitating adherence to treatment plans and medication regimes, and using health information technology (HIT) in new and innovative methods of care. However, HIT also poses new risks and can create new barriers. Providers should be mindful of how the application about new technologies may hinder good quality patient care. When properly implemented, EMRs can help track data over time, identify patients who are due for preventive visits, better monitor patient baseline parameters (such as vaccinations and blood pressure readings), and improve overall quality of care in a practice.1 EMRs can enhance the capacity of every practice to store and recall medical information on each patient and on the practice population as a whole. They can facilitate sharing information needed for referrals and consultations. The information in an electronic record can be used for teaching, carrying out practice-based research, and evaluating the effectiveness of the practice change as part of a commitment to CQI.1 EMRs and HIT actively support other pillars in the PMH vision. In addition to storing and sharing information, the biggest benefit of this technology is the ability to collect data for practice performance and health outcomes of patients served by family practices.41 The data allow practices to measure progress through CQI goals. Larger-scale collection allows for the aggregation of anonymized data sets and measuring performance beyond the practice level.41 Strict privacy regulations ensure that patient data remain secure and confidential. Overall, QI and research benefit patients by guiding more appropriate and efficient care, which forms the basis of another key pillar of Physical space, staffing, electronic records and other digital supports, equipment, and virtual networks facilitate the delivery of timely, accessible, and comprehensive care. 2.1 All PMHs use EMRs in their practices and are able to access supports to maintain their EMR systems. 2.2 EMR products intended for use in PMHs are identified and approved by a centralized process that includes family physicians and other health care professionals. Practices are able to select an EMR product from a list of regionally approved vendors. 2.3 EMRs approved for PMHs will include appropriate standards for managing patient care in a primary care setting; e-prescribing capacity; clinical decision support programs; e-referral and consultation tools; e-scheduling tools that support advanced access; and systems that support data analytics, teaching, research, evaluation, and CQI. 2.4 Electronic records used in a PMH are interconnected, user-friendly, and interoperable. 2.5 Co-located PMH practices are in physical spaces that are accessible and set up to support collaboration and interaction between team members. 2.6 A PMH has the appropriate staff to provide timely access (e.g., having physician assistants and/or registered nurses to meet PMH goals). 2.7 A PMH has technology to enable alternative forms of care, such as virtual care/telecare. 2.8 Sufficient system funding and resources are provided to ensure that teaching faculty and facility requirements will be met by every PMH teaching site. the PMH vision— Pillar 9: Measurement, Continuous Quality Improvement, and Research. As EMR use becomes common, issues shift from rollout to optimization in the practice. Ideally, EMRs must be adequately supported financially and use a universal terminology to allow for standardized data management, and be interoperable with other electronic health records relevant to patient care.1 Training and ongoing technical support for effective use of technology must also be available. Digital information sources, especially in the sensitive areas of patient information and care planning, require a higher level of technical support to maintain faith in their use and application across stakeholder groups. A comprehensive, systematic analysis of peer-reviewed and grey literature found that cost sharing or financial sponsorship from governments is required to support the high cost of EMR adoption and maintenance. Governments in several European countries equip all primary care practices with interoperable, ambulatory care-focused electronic health records (EHRs) that allow information to flow across settings to enhance the continuity and coordination of care.1 Ensuring that government supports enable adoption, maintenance and effective use, coordination, and interoperability of electronic tools is crucial for meaningful use of this technology. A PMH will also use technology for alternative forms of care. Virtual care is clinical interactions that do not require patients and providers to be in the same room at the same time.42 Virtual visits will be financially compensated by provincial health plans. Consultations may be asynchronous, where patients answer structured clinical questions online and then receive care from a physician at a later time (e-visits), or synchronous, where patients interact with physicians in real time via telephone (teleconsultations), videoconference (virtual visits), or text.43 Virtual care increases accessibility for those living in rural and remote areas, but also in urban areas where some patients do not have a regular primary care physician or cannot access their physician for in-person appointments within a time frame that meets their current needs.43 Virtual care can also be an alternative solution for patients living in long-term care facilities and/or with mobility issues.43 Strong communication between team members allows PMH practices to function on a virtual basis when the health care professionals are not stationed in the same physical space. It is important to recognize when colocation is not feasible and maintain effective information flow in these situations, which may be especially relevant in rural and remote areas. Practices should ensure the electronic records they use are set up to support collaboration and interaction between all members of the team as much as possible, which includes all health care providers within the PMH as well as the patient’s circle of support. For example, ensuring that when patients see someone other than their most responsible provider is logged into the system and is easy to review to maintain the continuity of care. This becomes complex in situations where providers are not co-located, and further system level supports up to the level of more interoperable and universal electronic records is a prerequisite for full application of this principle. Appropriate infrastructure in a PMH is not just about technology—it includes efficient, effective, and ergonomically well-designed reception, administration, and clinical areas in the office. This is of significant benefit to staff and patients alike.44 Having a shared physical and/or virtual space where multiple team members can meet to build relationships and trust, and communicate with each other regarding patient care is essential to creating a collaborative practice. Team-based care thrives when care is intentional, when planned and regular patient care meetings are incorporated into usual PMH practice, and when these steps are included in remuneration. This collaboration ensures that patients are involved in all relevant Satisfaction with virtual visits A British Columbia study found that over 93 per cent of patients indicated that their virtual visit was of high quality, and 91 per cent reported that their virtual visit was very or somewhat helpful to resolve their health issue.43 10 A NEW VISION FOR CANADA Family Practice— The Patient’s Medical Home 2019 A NEW VISION FOR CANADA Family Practice— The Patient’s Medical Home 2019 11 discussions and are receiving the best care from professionals with a comprehensive set of skills. A family practice should be physically accessible to patients and their families. This includes ensuring all public areas, washrooms, and offices are wheelchair accessible.44 An examination room should comfortably accommodate the patient and whatever appropriate companion, or health care professionals, who may be in the room at the same time. Having multi-purpose rooms also reduces or eliminates the need to wait for an appropriate room to be available. To achieve their objectives, PMHs need the support of governments across Canada through the provision of adequate funding and other resources. Research demonstrates that in the case of EMRs, key barriers to adoption by family physicians include financial and time constraints, lack of knowledgeable support personnel, lack of interoperability with hospital and pharmacy systems,45 as well as provincial/territorial EHR systems. Therefore, government must assure funding to support the PMH team in their clinical, research, and administrative responsibilities. There must also be support for core practice components such as EMRs, patient-centred practice strategies such as group visits, and electronic communications between patients and health professionals (see Pillar 1: Administration and Funding). EMRs should help improve the delivery of care in community-based practices by enhancing productivity and processes. They are not intended to reduce time with patients, nor should they cause physician burnout or have a negative impact on physician wellness. While the structures supporting the PMH practices differs by province, it is important they cover a common set of principles enabling the base functionalities described in this document. The system must also ensure that all health professionals on the PMH team have appropriate liability protection and that adequate resources are provided so that each PMH practice can provide an optimal setting for teaching students and residents and for conducting practice-based research. Provider autonomy is critical to provider wellness: as physician leadership within the PMH is one of the key pillars, preservation of physician autonomy, while respecting the autonomy and ensuring the accountability of both patients and other health care professionals, must be addressed. Figure 2. The Patient’s Medical Neighbourhood Pillar 3: Connected Care Canada Health Infoway Established in 2001, Canada Health Infoway47 is an independent, not-for-profit organization funded by the federal government. It seeks to improve health care access, moving beyond traditional in-person care models to innovative strategies that accelerate the development, adoption, and effective use of digital health solutions across Canada. Key digital health priorities include electronic records, telehomecare, virtual visits, and patient portals. Connectivity and effective communication within and across settings of care is a crucial concept of a PMH. This ensures that the care patients receive is coordinated and continuous. To achieve this, each PMH should establish, maintain, and use defined links with secondary and tertiary care providers, including local hospitals; other specialists and medical care clinics; public health units; and laboratory, diagnostic imaging, physiotherapy, mental health and addiction, rehabilitation, and other health and social services. Connected care is a priority for many health care organizations in Canada. For example, the Canadian Foundation for Healthcare Improvement (CFHI) has established a unique program that looks at improving care connections between providers through improved use of technology.41 (See the Canadian Foundation for Healthcare Improvement textbox for more information). The Canadian Nurses Association (CNA), Canadian Medical Association (CMA), and HEAL recognize that giving Canadians the best health and health care requires creating a functionally integrated health system along the full continuum of care—a system based on interprofessional collaborative teams that ensure the right provider, at the right time, in the right place, for the right care.46 Similarly, Canada Health Infoway focuses on expanding digital health across the system to improve quality of and access to care. The PMH exists within the broader patient’s medical neighbourhood (see Figure 2), with links to all other providers in the community. It is important to maintain connections with colleagues in health care as well as social support organizations within the community, as described in Pillar 5: Community Adaptiveness and Social Accountability. Through links within the neighbourhood, PMH practices work with other providers to ensure timely access for referrals/consultations and define processes for information sharing. Establishing and maintaining these links requires open and frequent communication between all those involved in patient care. 12 A NEW VISION FOR CANADA Family Practice— The Patient’s Medical Home 2019 Practice integration with other care settings and services, a process enabled by integrating health information technology. 3.1 A PMH is connected with the health and social services available in the community for patient referrals. 3.2 Defined links are established between the PMH and other medical specialists, and medical care services in the local or nearest community to ensure timely referrals. 3.3 The PMH serves as a hub for collecting and sharing relevant patient information through information technology. It ensures the continuity of patient information received throughout the medical and social service settings. Ideally PMH practices act as the central hub for patient care by collecting and coordinating relevant patient information from external care providers and patients. This includes medical care and care accessed through other health and social services; for example, services received through home care programs. PMH practices should also be able to share relevant information with external providers where and when appropriate, while strictly adhering to relevant privacy regulations. This two-way flow of information ensures that all providers in the network of care have access to the most accurate and comprehensive information available, allowing them “… to spend less time looking for information and more time on what matters: treating the patient.” 49 Overall, connected care in the PMH and the health system is enabled through HIT systems. PMH practices continuously strive to work efficiently with other providers in the patient’s medical neighborhood by taking advantage of developing technologies that make links quicker to establish and easier to maintain. To use HIT systems for coordinated care, the following are required:51 Data standardization Interoperable EMR and other health information systems Real-time access to data and the ability to relay accurate information in a timely manner Reliable communication mechanisms between various health and social service providers and the PMH Privacy for patient information It is important to keep in mind that any patient information, generated during the provision of care, belongs to the patient, as outlined in the Personal Information Protection and Electronics Document Act (PIPEDA). The practice is responsible for secure and confidential storage and transfer of the information. Refer to the Data Stewardship module of the Best Advice guide: Advanced and Meaningful Use of EMRs50 for more information. Canadian Foundation for Healthcare Improvement The Canadian Foundation for Healthcare Improvement supports the RACE (Rapid Access to Consultative Expertise) and BASE eConsult services, which use telephone and web-based systems to connect patients with specialists.48 These programs have been successful and demonstrate that remote consultations can reduce wait times for accessing specialty care by enabling family physicians to more efficiently manage their patients in primary care settings. A NEW VISION FOR CANADA Family Practice— The Patient’s Medical Home 2019 13 14 A NEW VISION FOR CANADA Family Practice— The Patient’s Medical Home 2019 FUNCTIONS The functions describe the heart of the PMH and the care provided by PMH practices. These are the key elements that differentiate a PMH from other forms of primary care. A PMH offers: Accessible Care; Community Adaptiveness and Social Accountability; Comprehensive Team-Based Care with Family Physician Leadership; Continuity of Care; and Patient- and Family-Partnered Care. ACCESSIBLE CARE PAGE 15 COMMUNITY ADAPTIVENESS & SOCIAL ACCOUNTABILITY PAGE 17 COMPREHENSIVE TEAM-BASED CARE WITH FAMILY PHYSICIAN LEADERSHIP PAGE 20 CONTINUITY OF CARE PAGE 23 PATIENT & FAMILY PARTNERED CARE PAGE 25 Equitable and ethical practices The CMA has identified equitable access to care as a key priority for reform in the health care system.53 Similarly, accessibility is a key component of the primary health care approach, which is advocated for by the CNA.54 Through the CNA’s Social Justice Gauge, and with the further development of the social justice initiative, the CNA maintains its position as a strong advocate for social justice and a leader in equitable and ethical practices in health care and public health.55 Pillar 4: Accessible Care A NEW VISION FOR CANADA Family Practice— The Patient’s Medical Home 2019 15 Accessible primary care is fundamental to a highperforming health care system and is considered by patients52 and other health care organizations as one of the most important characteristics of primary health care. For care to be accessible, all patients should have access to a family physician who acts as their most responsible provider and is supported by a team of qualified health professionals. Patients must be able to access medical care and treatment when needed. While most Canadians currently have a regular family doctor,4 it is important that the goal be for everyone in Canada to have access to their own family physicians. Accessible care is about more than just quick access to appointments. It does include timely access principles, but also advanced access, virtual access, and teambased approaches to care that ensure patients can be seen by the most appropriate provider when they need to be seen. Because visits occur for different reasons it is not useful to define appropriate wait times for each type of visit unlike in other areas of health care, such as surgery. Therefore, the focus in family practice should be on enhancing access to ensure patients can access care when they feel it is necessary. This is not to say that family physicians in a PMH must be on call 24/7/365, but that methods for patients to access care through the design of practice operations and scheduling should be given more attention. On the other hand, as patients are offered more choice (e.g., by phone or e-communication), they should also expect practices to establish realistic parameters for what is reasonable. Practices should communicate clearly about what kind of provider availability and response time is reasonable to expect depending on access method and availability of resources. Obtaining this understanding from a practice’s patients and striving to meet these expectations is a By adopting advanced and timely access, virtual access, and team-based approaches, accessible care ensures that patients can be seen quickly. 4.1 A PMH ensures patients have access to medical advice, and information on available care options 24 hours a day, 7 days a week, 365 days a year. 4.2 Every patient is registered with a PMH. 4.3 PMH practices offer scheduling options that ensure timely access to appropriate care. 4.4 When the patient’s personal family physician is unavailable, appointments are made with another physician, nurse, or other qualified health professional member of the PMH team. 4.5 Patients are able to participate in planning and evaluation of their medical home’s appointment booking system. 4.6 Panel sizes for providers in a PMH should be appropriate to ensure timely access to appointments and safe, high-quality care. After-hours care A Waterloo, Ontario, study found that providing after-hours clinical services reduced wait times, with services from other health care providers seen as a key for improving patient access.59 Accessible care Accessible care reduces redundancy and duplication of services (e.g., when a patient takes a later appointment and also consults another provider in the interim), improves health outcomes, leads to better patient and provider satisfaction, and reduces emergency visits.56–58 16 A NEW VISION FOR CANADA Family Practice— The Patient’s Medical Home 2019 good way to maintain the patient-centred focus of the practice as described in Pillar 1: Administration and Funding. Significant shifts in providing alternative access must be supported by funding bodies. Same-day scheduling has been introduced in many PMH practices to better accommodate patient needs. Frequently referred to as doing “today’s work today,” advanced access offers the vast majority of patients the opportunity to book their appointments on the day they call regardless of the reason for the visit.60 Read more about same day scheduling in the Best Advice guide: Timely Access to Appointments in Family Practice.61 Whenever possible, patients should have clear reasons for the appointment at the time of booking. This ensures that adequate time is planned for each patient visit. If the need to address multiple problems arises, the problems can be triaged on the spot by one of the team and arrangements made to have these concerns dealt with in a timely manner either during the same visit or at another time. It is not always possible for patients to book appointments with their most responsible family physician. To ensure continuity, appointments can be made with other physicians or health care professionals in the team. The decision about who provides care in these cases is based on the patient’s needs, the availability of team members, and the scope of practice for each team member. In these cases, any relevant information from the appointment is communicated to the most responsible provider and taken into account in the long-term care of the patient. PMH practices can further meet patients’ needs through extended office hours, in which the responsibilities for coverage and care are shared by family physicians in one or more practices, as well as by increased involvement of other team members. PMH practices also provide their patients with email, after-hours telephone, and virtual services to guide them to the right place at the right time for the care they need. Appropriately directing patients to the next available appointment, or to a hospital or another emergency service, is critical to the effective management and sustainability of our health care system.62,63 A PMH can help ensure that patients are aware of where they can go to access care and health information 24 hours a day, 365 days a year by providing this information to patients in person or via other systems (website, voice mail messages, etc.). In alignment with Pillar 9: Measurement, Continuous Quality Improvement, and Research, PMH practices offer opportunities for patients to provide feedback on the accessibility of the practice. Specifically, patients should have the opportunity to evaluate and provide input for the appointment booking system. Mechanisms and supports need to be in place to ensure that practices and governing bodies can review and respond to feedback appropriately and communicate this back to patients. Determining the optimal panel size for each PMH practice is critical to ensuring accessible and safe, high-quality care.64 Establishing and incorporating recommendations from the PMH vision may enable practices to consider increasing their panel size. Actual panel size will vary depending on the number of physicians and other team members in the practice, the practice’s obligations and A NEW VISION FOR CANADA Family Practice— The Patient’s Medical Home 2019 17 Social accountability refers to the family physicians’ obligation to meet the needs of Canada’s communities.66 For health care to be socially accountable, it must be accessible by everyone and responsive to the needs of patients, communities, and the broader population.4 This obligation is embedded in the Family Medicine Professional Profile and the Four Principles of Family Medicine, highlighting that family physicians are community-adaptive, responding to the needs of their patients and communities. These principles of family medicine align well with the principles of social accountability. Family practice is relationship-based care that embraces all issues of need and endures over time and place of care. A generalist keeps the whole in mind while attending to the individual parts, the system in mind when fixing individual problems, and the end in mind when commencing the journey. Tools exist to help family physicians and other health care providers enhance their skills and training regarding social accountability and cultural safety through many professional organizations and cross-Canada resource hubs like the National Collaborating Centre of Determinants of Health67 and the National Collaborating Centre on Aboriginal Health,68 as examples. PMH practices are aware of how the SDoH influence the health of patients and communities. Family physicians are often the best-situated primary care professionals to act on Pillar 5: Community Adaptiveness and Social Accountability A PMH is accountable to its community, and meets their needs through interventions at the patient, practice, community, and policy level. 5.1 PMHs strive to assess and address the social determinants of health (e.g., income, education, housing, immigration status) as relevant for the individual, community, and policy levels. 5.2 Panel size will consider the community’s needs and patients’ safety. 5.3 PMHs use data about marginalized/at-risk populations to tailor their care, programming, and advocacy to meet unique community needs. 5.4 Family doctors in the PMH act as health advocates at the individual, community, and policy levels, using the CanMEDs–Family Medicine (CanMEDS-FM) Framework as a guide to advocacy and are supported in doing so. 5.5 Family doctors and team members within the PMH provide care that is anti-oppressive and culturally safe, seeking to mitigate the experiences of discrimination faced by many patients based on their age, gender, race, class, sexual orientation, gender identity, ability, etc. commitment to teaching and research, and the needs of the population being served (see Pillar 5: Community Adaptiveness and Social Accountability). When deciding panel size, each practice must determine how accepting more patients into the practice might impact the current population, the sustainability of the workload for physicians and other members of the PMH team, and the consequences of panel size on experience of care. Refer to the Best Advice guide: Panel Size for more information.65 issues that affect patients’ SDoH. Advocating for patients and the health care system overall is a natural part of a PMH structure. Advocacy can occur at three levels:69 Micro: In the immediate clinical environment, daily work with individual patients and predicated on the principles of caring and compassion Meso: In the local community, including the patient’s cultural community, the local community of medical providers, and the larger civic community, in which health professionals are citizens as well as practitioners Macro: In the humanitarian realm, where physicians are concerned with the welfare of their entire patient population and seek to improve human welfare through healthy public policy (such as reducing income inequality, supporting equitable and progressive taxation, and expanding the social safety net) The principles of advocacy in family practice are found in the CanMEDS–Family Medicine 201769 competency framework, under the Health Advocate role. The Best Advice guide: Social Determinants of Health70 describes how family physicians in the PMH can make advocacy a practical part of their practice. Poverty is a significant risk factor for chronic disease, mental illness, and other health conditions. Low income and other SDoH also present significant barriers to accessing care.71 To meet the needs of these patients, practices may need to extend hours, be more flexible and responsive, and spend additional time helping patients navigate and access necessary care. PMH practices consider other specific community needs when determining appropriate panel size. Demographics and health status of the patient population can influence the length and frequency of appointments needed, thereby impacting a physician’s caseload.65 For example, a PMH in a community with high rates of chronic conditions may need to reduce the panel size to provide timely and high-quality care, given that patients require more care time and resources. Similarly, a patient’s social situation may impact the time a family physician spends with them. Family physicians and team members may need to use a translator at clinical appointments, and may need to provide written resources in alternative languages, all factors affecting the time required to provide care. Enabling PMH practices to adjust panel size based on community needs requires governments to establish blended payment mechanisms. These remuneration systems ensure family physicians are adequately compensated, and are not financially disincentivized from spending the necessary time with patients (see Pillar 1: Administration and Funding, for more information). Social accountability and cultural competency Part of the response to being more socially accountable with care offered to the community resides within each and every health professional. While courses on cultural competency are now a standard part of medical education, physicians can take this learning further by seeking to reflect on, be aware of, and correct any unconscious biases that naturally forms and holds as a result of individual life experiences. Working to resolve implicit biases is a lifelong effort, but done diligently, can contribute to improving the quality of care provided,72 as well as the satisfaction of being an effective healer—of ourselves, our patients and our societies. Importance of social accountability Social accountability is a key value for health care organizations and professionals. For example, the Royal College of Physicians and Surgeons of Canada (Royal College), Resident Doctors of Canada, and the Association of Faculties of Medicine amongst others, have adopted policies that highlight the importance social accountability within their organizations and the work they do. 18 A NEW VISION FOR CANADA Family Practice— The Patient’s Medical Home 2019 Family physicians and their PMH teams are situated at the nexus of individual and population health, and can engage with their patients in addressing health promotion and disease prevention in creative ways. From accompanying individual patients through teachable moments (e.g., the smoker with pneumonia ready to quit) to influencing civic policy to address homelessness, the stories entrusted to family physicians in daily practice are powerful tools for healthy change. These teams are also key providers in many important public health areas, including illness and injury prevention; health promotion; screening and managing chronic diseases; immunizations; and health surveillance. PMH practices prioritize delivering evidence-based care for illness and injury prevention and health promotion, reinforcing them at each patient visit and other counselling opportunities. PMHs and local or regional public health units should cultivate and maintain strong links with one another. Health care professionals who are part of PMH teams may take on advisory, educational, supportive, or active roles in public health initiatives, in many different occupational, educational, or recreational settings throughout the community. An effective public health system should be inextricably linked to communitybased family physicians and PMHs, recognizing and supporting them as essential to the achievement of the broader population and public health goals. While PMHs focus primarily on the care of individuals and their families, it is important for team members to understand and address the health challenges facing their practice populations and the larger community. These broader challenges represent upstream factors (SDoH) that have greater impact on the health of patients than do the efforts of individual physicians. However, the relationships embedded in individual and collective practices can be central to engaging patients and citizens in building more just and healthier communities and societies. For example, with the help of HIT, details about the needs of populations can be more easily accessed through extraction from practice EMRs, or participation in programs such as the Canadian Primary Care Sentinel Surveillance Network (CPCSSN).73 The CPCSSN networks collect health information from EMRs of participating primary care providers, extract anonymous data, and share information on chronic conditions with governments, health care providers, and researchers to help inform meaningful systems and practice change. Programs like the CPCSSN allow practices to better understand the needs of their communities and implement specific health promotion and prevention programs that can contribute to the population’s overall well-being. Initiatives like this also ensure the avoidance of data duplication, and recognise that practices do not need (or have the resources) to collect data on their own. However, these data are just a part of caring—the heart of generalism is keeping the whole in mind while attending to its parts, whether it is at the level of the whole patient, the whole family, or the whole society. To meet the needs of their diverse panel of patients, family physicians and other team members in the PMH work to provide anti-oppressive and culturally-safe care, seeking to mitigate experiences of discrimination faced by many patients based on their SDoH. This requires understanding how historical and current injustices have impacted the well-being of certain populations, and working to ensure a safe and welcoming practice environment by focusing on the principles of caring and compassion. Sociodemographic data benefits The FHT at St Michael’s Hospital routinely collects sociodemographic data on all patients. Patients are surveyed about income, housing status, gender identity, and other key SDoH factors, and their responses are integrated into the secure EMR. This information is used to inform and direct individualized patient-centred care. The data will also be used for planning and evaluating the FHT’s programs.74 A NEW VISION FOR CANADA Family Practice— The Patient’s Medical Home 2019 19 Pillar 6: Comprehensive Team-Based Care with Family Physician Leadership Primary care practice teams Many allied health professional organizations have prioritized the importance of working together in a team to provide patients with the best possible care. The CFPC worked collaboratively with organizations—such as the CNA, the Canadian Association of Social Workers, the Canadian Psychological Association, and the Dieticians of Canada—to create the Best Advice guide: Team-Based Care in the Patient’s Medical Home.75 The guide includes implementation strategies for creating a primary practice team, and general descriptions of roles found in a collaborative team. 20 A NEW VISION FOR CANADA Family Practice— The Patient’s Medical Home 2019 A broad range of services is offered by an interprofessional team. The patient does not always see their family physician but interactions with all team members are communicated efficiently within a PMH. The team might not be co-located but the patient is always seen by a professional with relevant skills who can connect with a physician (ideally the patient’s own personal physician) as necessary. 6.1 A PMH includes one or more family physicians, who are the most responsible provider for their own panel of registered patients. 6.2 Family physicians with enhanced skills, along with other medical specialists, are part of a PMH team or network, collaborating with the patient’s personal family physician to provide timely access to a broad range of primary care and consulting services. 6.3 On-site, shared-care models to support timely medical consultations and continuity of care are encouraged and supported as part of each PMH. 6.4 The location and composition of a PMH’s team is flexible, based on community needs and realities; team members may be co-located or may function as part of virtual networks. 6.5 The personal family physician and nurse with relevant qualifications form the core of PMH teams, with the roles of others (including but not limited to physician assistants, pharmacists, psychologists, social workers, physiotherapists, occupational therapists, dietitians, and chiropractors) encouraged and supported as needed. 6.6 Physicians, nurses, and other members of the PMH team are encouraged and supported in developing ongoing relationships with patients. Each care provider is recognized as a member of the patient’s personal medical home team. 6.7 Nurses and other health professionals in a PMH team will provide services within their defined roles, professional scopes of practice, and personally acquired competencies. Their roles providing both episodic and ongoing care support and complement—but do not replace—those of the family physician. Team-based care is a core function of the PMH. Building a team with a diverse mix of professional backgrounds creates an opportunity to redefine what is considered optimal, based on the needs of the practice and the community it serves. A high-performing team is essential to delivering more comprehensive, coordinated, and effective care centred on the patient’s needs. While different circumstances call for aspects of patient care to be provided by different health professionals, it is important to ensure that family physician expertise is available to all team members through consultation. To practice effectively in an interprofessional health care team, there must be a clear understanding of each member’s unique contributions, including educational background, scopes of practice and knowledge, and areas of excellence and limitations.76 Practices that draw on the expertise of a variety of team members are more likely to provide patients with the care they need and respond to community needs.77 Relationships across all dynamics within a practice, whether between a patient and family physician or between a patient and other members of the team, should be encouraged and supported in the PMH. Establishing these relationships develops trust and confidence, and works toward the ultimate goal of achieving better health outcomes. While it should be left to each practice to determine who does what (within the boundaries of professional scopes of practice), the most responsible provider for the medical care for each patient in the practice should be the patient’s personal family physician. Family physicians with enhanced skills and family physicians with focused practices play an important role in collaborating with the patient’s personal family physician and team to provide timely access to a range of primary care and consulting services. They supplement their core skills and experience with additional expertise in a particular field, while remaining committed to their core generalist principles.78 These doctors can draw extensively on their generalist training and approach to disease management and patient-centred care, enabling them to work collaboratively at different levels of care, including with other specialists, to meet patient needs.79 These clinicians also serve as a resource for other physicians in their local health system by enhancing care delivery and learning and teaching opportunities. The Best Advice guide: Communities of Practice in the Patient’s Medical Home80 provides more information about intraprofessional collaboration between family physicians. Shared care strategies provide patients with timely access to consultations with other specialists or family physicians with enhanced skills at scheduled times in the family practice office setting. The consultant might assess several patients per visit, at which time a plan for ongoing care can be developed and agreed to by the family physician, consultant, other team members, and the patient. There is no one-size-fits-all model when determining what mix of health care professionals is right. Team composition depends on the professional competencies, skills, and experiences needed to address the health needs of the patient population.81 These needs vary, depending on the communities’ defining characteristics; Additional members of practice teams Not all health care professionals in a team need to be hired as a full-time team member. For example, a practice can hire a dietician for specific days to lead a diabetes education program and see scheduled patients. Practices can also host other health care professionals, such as those employed with a regional health authority, to provide care to patients on-site. However, funding bodies should recognize that family practice clinics hosting other health care professionals often carry the overhead costs associated with these practitioners working on site, and further supports should be made available to ensure that costs do not unduly fall on the physicians. Pillar 1: Administration and Funding and Pillar 2: Appropriate Infrastructure highlight that a PMH needs to be properly funded and have access to the right infrastructure (physical and governance) to support the initiatives described in this vision. A NEW VISION FOR CANADA Family Practice— The Patient’s Medical Home 2019 21 22 A NEW VISION FOR CANADA Family Practice— The Patient’s Medical Home 2019 for example, geography, culture, language, demographics, disease prevalence. Family physicians are encouraged to identify the gaps in health care provision in the local practice environment and work with other health care providers to meet those needs as much as possible. Data from EMRs—as well as input from patients, community members, and stakeholders—should inform team planning. Factors to consider include: Patient population Identified community health care needs Hours available for patient access Hours available for each physician to work Roles and number of non-physician providers Funds available81 Overlapping or variations of similar competencies can result in ambiguous expectations of what a defined role is within a practice. When teams are planned and developed, roles should be clearly outlined. This is best done at the local practice level relative to community needs and resources. This approach considers changes over the course of a health care professional’s career, including skills development, achievement of certifications, and professional interests.82 It is important to include time for team members to become comfortable in their role, at the outset of team-based care and with any changes to the team. It is also important to recognize that these arrangements are flexible and subject to change, provided the team engages in discussion and reaches consensus on needed adjustments. Team members might be in the same office or in the same building, but this is not necessary. For smaller and more remote practices, or larger urban centres where proximate physical space may be a barrier, some connections may be arranged with peers in other sites. Applying HIT judiciously allows for virtual referrals and consultations. Virtual links between PMH practices and other specialists, hospitals, diagnostic services, etc., can be enhanced with more formal agreements and commitments to provide timely access to care and services. By providing patients with a comprehensive array of services that best meet their needs, team-based care can lead to better access, higher patient and provider satisfaction, and greater resource efficiency.61,77,83 Although there are presently many systems in place that support the creation of health care teams, practices can also create a successful team on their own. To ensure team success, providers must have a clear understanding of the different role responsibilities and ensure that there are tools available to engage open dialogue and communication. Teams within the PMH are supported by a model that is flexible and adaptable to each situation. The skills that family physicians acquire during their training (as described in the CanMEDS-FM framework) make them well suited to provide leadership within interprofessional teams. As an important part of a PMH, teams are central to the concept of patient-centred care that is comprehensive, timely, and continuous. A NEW VISION FOR CANADA Family Practice— The Patient’s Medical Home 2019 23 Pillar 7: Continuity of Care Continuity of care is defined by consistency over time related to where, how, and by whom each person’s medical care needs are addressed throughout the course of their life.84 With strong links to comprehensive team-based care (see Pillar 6: Comprehensive Team-Based Care with Family Physician Leadership), continuity of care is essential to any practice trying to deliver care truly centred on the needs of the patient. Continuity of care is rooted in a long-term patient-physician partnership in which the physician knows the patient’s history from experience and can integrate new information and decisions from a whole-person perspective efficiently without extensive investigation or record review.84 From the patient’s perspective, this includes understanding each person’s life journey and the context this brings to current health status, and the trust they have in their provider that is built over time. Past studies show that when the same physician attends to a person over time, for both minor and more serious health problems, the patient-physician relationship is strengthened and understanding grows—an essential element of effective primary health care.85 The personal physician offers their medical knowledge and expertise for a more complete understanding of the patient as a person, including the patient’s medical history and their broader social context, such as personal, family, social, and work histories (see Pillar 5: Community Adaptiveness and Social Accountability). In this model, patients, their families and/or personal caregivers, and all health care providers in the PMH team are partners in care, working together to achieve the patient’s goals and engaging in shared decision making. Understanding the patient’s needs, hopes, and fears, and their patterns of response to illness, medications, and other treatments, deepens the physician’s ability to respond to larger trends, not just the medical issue presented at any given appointment. Continuity of care can ideally support the health and well-being of patients actively and in their daily lives without focusing only on care when they are ill. The strong physician-patient relationship developed over time allows them to maintain good health and prevent illness and injury, as the physician uses their deep knowledge of their patient to work with teams of qualified health professionals to best support the patient’s well-being. Family physicians in the PMH, acting as the most responsible provider, can provide continuous care over the patient’s lifespan and develop strong relationships with patients. Research demonstrates that one of the most significant contributors to better population health is continuity of care.86,87 It found that those who see the same primary care physician continuously over time have better health outcomes, reduced emergency department use, and reductions in hospitalizations versus those who receive care from many different physicians. A Canadian study found that after controlling for demographics and health status, continuity of care was a predictor of decreased hospitalization for ambulatory caresensitive conditions (such as such as COPD, asthma, diabetes, and heart failure) and decreased emergency department visits for a wide range of family practicesensitive conditions.85 Overall “the more physicians patients see, the greater the likelihood of adverse effects; seeking care from multiple physicians in Patients live healthier, fuller lives when they receive care from a responsible provider who journeys with them and knows how their health changes over time. 7.1 The PMH enables and fosters long-term relationships between patients and the care team, thereby ensuring continuous care across the patient’s lifespan. 7.2 PMH teams ensure continuity of care is provided for their patients in different settings, including the family practice office, hospitals, long-term care and other community-based institutions, and the patient’s residence. 7.3 A PMH serves as the hub that ensures coordination and continuity of care related to all the medical services their patients receive throughout the medical community. the presence of high burdens of morbidity will be associated with a greater likelihood of adverse side effects.”86 It has been reported that a regular and consistent source of care is associated with better access to preventive care services, regardless of the patient’s financial status. Continuity of care also requires continuity in medical settings, information, and relationships. Having most medical services provided or coordinated in the same place by one’s personal family physician and team has been shown to result in better health outcomes.88 As described in Pillar 3: Connected Care, when care must be provided in different settings or by different health professionals (i.e., the medical neighbourhood), continuity can still be preserved if the PMH plays a coordination role and communicates effectively with other providers. The PMH liaises with external care providers to coordinate all aspects of care provided to patients based on their needs. This includes but is not limited to submitting and following up on referrals to specialized services, coordinating home care, and working with patients before and after discharge from hospitals or other critical care centres. In addition to this coordination role, the PMH acts as a hub by sharing, collecting, storing, and acting as a steward for all relevant patient information. This ensures that the family physician, as the most responsible provider, has a complete overview of the patient’s history. A record of care provided for each patient should be available in each medical record (preferably through an EMR) and available to all appropriate care providers (see Pillar 2: Appropriate Infrastructure for more information about EMRs). Knowing that medical information from all sources (i.e., providers inside and outside the PMH) is consolidated in one location (physical or virtual) increases the comfort and trust of patients regarding their care. Continuity for patient health Research demonstrates that continuity of care is a key contributor to overall population health. Patients with a regular family physician experience better health outcomes and fewer hospitalizations as compared to those without.69 24 A NEW VISION FOR CANADA Family Practice— The Patient’s Medical Home 2019 Pillar 8: Patient- and Family-Partnered Care External factors for patient health care Patient- and family-partnered care is considered a key value to stakeholders across the health care system. In 2011, the CMA and the CNA released a set of principles to guide the transformation of Canada’s health care system.91 Patient-centred care is listed as the first principle, and as a key component of improving the overall health care experience.91 Similarly, in 2016 Patients Canada called on all levels of government to ensure that patients are at the centre of any new health accords and future health care reform.92 * Family caregivers include relatives, partners, friends, neighbours, and other community members. Patient-centred care is at the core of the PMH. Dr. Ian McWhinney—often considered the “father of family medicine”—describes patient-centred care as the provider “enter[ing] the patient’s world, to see the illness through the patient’s eyes … [It] is closely congruent with and responsive to patients’ wants, needs and preferences.”89 In this model, patients, their families and/ or personal caregivers, and all health care providers in the PMH team are partners in care, working together to achieve the patient’s goals and engaging in shareddecision making. Care should always reflect the patient’s feelings and expectations and meet their individual needs. Refer to the Best Advice guide: Patient-Centred Care in a Patient’s Medical Home90 for more information. Family caregivers* play an important role in the PMH. They help patients manage and cope with illness and can assist physicians by acting as a reliable source of health information and collaborating to develop and enact treatment plans.93 The level and type of engagement from family caregivers should always be determined by the patient. Physicians “should routinely assess the patient’s wishes regarding the nature and degree of caregiver participation in the clinical encounter and strive to provide the patient’s desired level of privacy.”94 They should revisit this conversation regularly and make changes based on patient desires. PMH practices focus on providing patient-centred care and ensuring that family caregivers are included. A NEW VISION FOR CANADA Family Practice— The Patient’s Medical Home 2019 25 Family practices respond to the unique needs of patients and their families within the context of their environment. 8.1 Care and care providers in a PMH are patient-focused and provide services that respond to patients’ feelings, preferences, and expectations. 8.2 Patients, their families, and their personal caregivers are active participants in the shared-decision making process. 8.3 A PMH facilitates patients’ access to their medical information through electronic medical records as agreed upon with their care team. 8.4 Self-managed care is encouraged and supported as part of the care plans for each patient. 8.5 Strategies that encourage access to a range of care options beyond the traditional office visits (e.g., telehealth, virtual care, mobile health units, e-consult, etc.) are incorporated into the PMH. 8.6 Patient participation and formalized feedback mechanisms (e.g., patient advisory councils, patient surveys) are part of ongoing planning and evaluation. As part of their commitment to patient-centred care, PMH practices facilitate and support patient self-management. Self-management interventions such as support for decision making, self-monitoring, and psychological and social support, have been demonstrated to improve health outcomes.95 PMH team members should always consider recommendations for care from the patient’s perspective. They should work collaboratively with patients and their caregivers to develop realistic action plans and teach problem-solving and coping. This is particularly important for those with chronic conditions, who must work in partnership with their physician and health care team to manage their condition over time. (Refer to the Best Advice guide: Chronic Care Management in a Patient’s Medical Home96 for more information). The goal of self-managed care should be to build the patient’s and caregiver’s confidence in their ability to deal effectively with illnesses, improve health outcomes, and foster overall well-being. To facilitate patient- and family-partnered care, a range of user-friendly options for accessing information and care beyond the traditional office visit should be available to patients when appropriate. These include email, telehealth, virtual care, mobile health units, e-consults, home visits, same-day scheduling, group visits, self-care strategies, patient education, and treatment sessions offered in community settings. Providing a range of options allows patients to access the type of care they prefer based on individual needs. Patients also need to be informed about how they can access information and resources available to them; for example, resources such as Prevention in Hand (PiH).97 Allowing patients to access to their medical records can improve patient-provider communication and increase patient satisfaction.98,99 The specific information accessible to patients should be discussed and agreed upon by the patient and their care team. Patient education about accessing and interpreting the available information is necessary. Facilitating this type of access requires each PMH to have an EMR system that allows external users to access information securely (see Pillar 2: Appropriate Infrastructure). Patient surveys and opportunities for patients to participate in planning and evaluating the effectiveness of the practice’s services should be encouraged; practices must be willing respond and adapt to patient feedback. To strengthen a patient-centred approach, practices may consider developing patients’ advisory councils or other formalized feedback mechanisms (e.g., using patient surveys) as part of their CQI processes (see Pillar 9: Measurement, Continuous Quality Improvement, and Research). Patient self-management The Ajax Harwood Clinic (AHC) is a good example of how a practice that enables patient self-management can improve long-term health outcomes, especially for patients with chronic conditions.94 The AHC has created an environment of learning and seeks to encourage health literacy among its patients through its various programs. The clinic is focused on patient education and empowerment, and all programs at the clinic are free of charge to patients to remove financial barriers to access. 26 A NEW VISION FOR CANADA Family Practice— The Patient’s Medical Home 2019 A NEW VISION FOR CANADA Family Practice— The Patient’s Medical Home 2019 27 ONGOING DEVELOPMENT Each PMH strives for ongoing development to better achieve the core functions. The PMH and its staff are committed to Measurement, Continuous Quality Improvement, and Research; and Training, Education, and Continuing Professional Development. MEASUREMENT, CONTINUOUS QUALITY IMPROVEMENT, AND RESEARCH PAGE 28 TRAINING, EDUCATION, AND CONTINUING PROFESSIONAL DEVELOPMENT PAGE 30 28 A NEW VISION FOR CANADA Family Practice— The Patient’s Medical Home 2019 Continuous quality improvement CQI is an important value among health organizations such as the CFHI.100 Pillar 9: Measurement, Continuous Quality Improvement, and Research CQI is an essential characteristic of the PMH vision. It encourages health care teams to make practical improvements to their practice, while monitoring the effectiveness of their services, the health outcomes and safety of their patients, and the satisfaction of both patients and the health professionals on the team. Every PMH is committed to establishing a CQI program that will improve patient safety, and enhance efficiency and quality of the services provided to patients. As part of CQI activities, a structured approach is used to evaluate current practice processes and improve systems and to achieve desired outcomes. To engage in CQI, the PMH team must identify the desired outcomes and determine appropriate evaluation strategies. Once the process and the desired outcome are defined with patients, the CQI activity will track performance through data collection and comparison with the baseline. Performance measures can be captured through structured observation, patient and staff surveys (see Pillar 8: Patient- and Family- Partnered Care), the PMH self-assessment tool, and the practice’s EMR (see Pillar 1: Administration and Funding and Pillar 3: Connected Care). The indicators selected should be appropriate to each practice and community setting, be meaningful to the patients and community, and the CQI process could be introduced as a practice’s self-monitoring improvement program or as an assessment carried out by an external group. In some jurisdictions, funding is tied to achieving performance targets, including those that provide evidence for the delivery of more cost-effective care and better health outcomes.101 Some provinces in Canada have begun to link financial incentives to clinical outcomes and targets that have been achieved (“pay for performance” models).102 Although there may be some benefits derived by this approach, there can also be risks if funding incentives and resource supports become overly focused on patients with certain medical problems or on those who have greater potential to reach prescribed targets, while at the same time care is being delayed or denied for others.101,103 Future development A NEW VISION FOR CANADA Family Practice— The Patient’s Medical Home 2019 28 Family practices strive for progress through performance measurement and CQI. Patient safety is always a focus, and new ideas are brought to the fore through patient engagement in QI and research activities. 9.1 PMHs establish and support CQI programs that evaluate the quality and cost effectiveness of teams and the services they provide for patient and provider satisfaction. 9.2 Results from CQI are applied and used to enhance operations, services, and programs provided by the PMH. 9.3 All members of the health professional team (both clinical and support teams), as well as trainees and patients, will participate in the CQI activity carried out in each PMH. 9.4 PMHs support their physicians, other health professionals, students, and residents to initiate and participate in research carried out in their practice settings. 9.5 PMHs function as ideal sites for community-based research focused on patient health outcomes and the effectiveness of care and services. A NEW VISION FOR CANADA Family Practice— The Patient’s Medical Home 2019 29 of financial incentive models should consider these unintended consequences that might impair the ability of practices to provide good quality patient care to their full population. The objectives that define a PMH could be used to develop the indicators for CQI initiatives in family practices across Canada. These criteria could be augmented by indicators recommended by organizations such as Accreditation Canada, Health Quality Ontario, Health Standards Organization, and the Patient-Centered Medical Home model in the United States. The CFPC is committed to collaborating with these groups to further develop the CQI process for PMHs and family practices. Consult the CFPC’s Practice Improvement Initiative (Pii)104 for a list of available resources. CQI is a team activity and should involve all members of the PMH team as well as patients and trainees. This will ensure buy-in from the team, allow for patient engagement and participation, and provide trainees with valuable learning opportunities.105 PMHs are committed to using the results of CQI initiatives to make tangible changes in their practice to improve operations, services, and programs. Time and effort invested into participation in CQI activities should be recognized as valuable and not be disincentivized through existing remuneration models. Dedicated time and capacity to perform these activities should be built into the practice operational principles. On a larger scale, PMHs function as ideal sites for community-based research focused on patient health outcomes and the effectiveness of care and services. The PMH team should be encouraged and supported to participate in research activities. They should also advocate for medical students, residents, and trainees to take part in these projects. In Canada, the Canadian Primary Healthcare Research Network (CPHRN) and the commitment of the Canadian Institutes for Health Research’s (CIHR’s) Strategy for Patient-Oriented Research (SPOR) are vitally important.106 The focus on supporting patient-oriented research carried out in community primary care settings is consistent with the priorities of the PMH. Competitions for research grants such as those announced by SPOR should be strongly encouraged and supported. PMHs are ideal laboratories for studies that embrace the principles of comparative effectiveness research (CER) and the priorities defined by the CPHRN and CIHR’s SPOR project. They provide excellent settings for multi-site research initiatives, including projects like those currently undertaken by the CPCSSN—a nationwide network of family physicians conducting surveillance of various chronic diseases. 30 A NEW VISION FOR CANADA Family Practice— The Patient’s Medical Home 2019 Pillar 10: Training, Education, and Continuing Professional Development PMH practices serve as training sites for medical students, family medicine residents, and those training to become nurses and other health care professionals.107 They create space for modelling and teaching practices focused on the essential roles of family physicians and interprofessional teams as part of the continuum of a health care system. One of the goals of family medicine residency training is for residents to learn to function as a member of an interdisciplinary team, caring for patients in a variety of settings including family practice offices, hospitals, long-term care and other communitybased institutions, and patients’ residences.70,108 A PMH also models making research and QI initiatives a standard feature of a family practice. Professional development and opportunities to participate in these activities should be available and supported within PMH practices through resources, guidance, and specifically dedicated time. Family medicine training is increasingly focused on achieving and maintaining competencies defined by the CFPC’s Triple C Family Medicine Curriculum.109 Triple C includes five domains of care: care of patients across the life cycle; care across clinical settings (urban and rural); a defined spectrum of clinical responsibilities; care of marginalized/disadvantaged patients and populations; and a defined list of core procedures. Triple C also incorporates the Four Principles of Family Medicine and the CanMEDS-FM Roles. PMHs allow family medicine students and residents to achieve the competencies of the Triple C curriculum and to learn how to incorporate the Four Principles of Family Medicine, the Family Medicine Professional Profile, and the CanMEDS-FM roles into their professional lives. Learners gain experience with patient-partnered care, teams/networks, EMRs, timely access to appointments, comprehensive continuing care, management of undifferentiated and complex problems, coordination of care, practice-based research, and CQI—essential elements of family practice in Canada. Furthermore, PMH practices serve as optimal sites for trainees in other medical specialties and health professions to gain valuable experience working in interprofessional teams and providing high quality, patient-centred care. Medical schools and residency programs should encourage learners to conduct some of their training within PMH practices. Emphasis on training and education ensures that the knowledge and expertise of family physicians can be shared with the broader health care community, and also over time by creating learning organizations where both students and fully practising family physicians can stay at the forefront of best practice. 10.1 PMHs are identified and supported by medical and other health professional schools as optimal locations for the experiential training of their students and residents. 10.2 PMHs teach and model their core defining elements including patient-partnered care, teams/networks, EMRs, timely access to appointments, comprehensive continuing care, management of undifferentiated and complex problems, coordination of care, practice-based research, and CQI. 10.3 PMHs provide a training environment for family medicine residents that models, and enables residents to achieve, the competencies as defined by the Triple C Competency-based Family Medicine Curriculum, the Four Principles of Family Medicine, and the CanMEDS-FM Roles. 10.4 PMHs will enable physicians and other health professionals to engage in continuing professional development (CPD) to meet the needs of their patients and their communities both individually and as a team. 10.5 PMHs enable family physicians to share their knowledge and expertise with the broader health care community. Practising family physicians must engage in CPD to keep current on medical and health care developments and to ensure their expertise reflects the changing needs of their patients, communities, and learners. Mainpro+® (Maintenance of Proficiency) is the CFPC’s program designed to support and promote family physicians’ CPD across all CanMEDS-FM Roles and competencies. CPD refers to physicians’ professional obligation to engage in learning activities that address their own identified needs and the needs of their patients; enhance knowledge, skills, and competencies across all dimensions of professional practice; and continuously improve their performance and health care outcomes within their scope of practice.110 Three foundational principles for CPD in Canada have been recently described: Socially responsive to the needs of patients and communities Informed by scientific evidence and practicebased data Designed to achieve improvement in physician practice and patient outcomes CPD is inclusive of learning across all CanMEDS-FM Roles and competencies, including clinical expertise, teaching and education, research and scholarship, and in practice-based QI. PMH practices support their physicians, and all other staff members, to engage in CPD activities throughout their careers by creating a learning culture in the organization. This includes providing protected time for learning and team-based learning, and access to practice data both to discern patient/community need and practice gaps to inform CPD choices and to evaluate the impact of learning on patient care. This learning culture and the will to be constantly improving quality and access to care is essential to ensuring that the PMH continues to support high performing care teams. To ensure that all PMH team members have the capacity to take on their required roles, leadership development programs should be offered. Enabling physicians to engage in this necessary professional development requires sufficient funding by governments to cover costs of training and financial support to ensure lost income and practice capacity do not prevent this. Physicians in the PMH share their knowledge with colleagues in the broader health care community and with other health care professionals in the team by participating in education, training, and QI activities in collaboration with the pentagram partners.† This is particularly relevant for family physicians who are focused on a particular area of practice (possibly holding a Certificate of Added Competence) and are able to share their extended expertise with others. This can happen either informally or through more official channels. For example, physicians may participate in activities organized by the CFPC or provincial Chapters (e.g., Family Medicine Forum, provincial family medicine annual scientific assemblies), or lend their expertise to interprofessional working groups addressing specific topics in health care. Family physicians should be encouraged to engage in these types of events to share their knowledge and skills for the betterment of the overall health system. Continuing professional development CPD is an integral value across the entire health care system. Organizations such as the Royal College, CMA, and CNA emphasize the value and importance of continuing education for health care professionals to improve patient care. † Pentagram partners: policy-makers—federal, provincial, territorial, and regional health authorities; health and education administrators; university; community; health professionals—physicians and teams A NEW VISION FOR CANADA Family Practice— The Patient’s Medical Home 2019 31 32 A NEW VISION FOR CANADA Family Practice— The Patient’s Medical Home 2019 CONCLUSION The revised PMH vision of a high-functioning primary care system responds to the rapidly evolving health system and the changing needs of Canadians. The pillars and attributes described in this document can guide practices at various stages in the transition to a PMH, and many characteristics are found in other foundational documents of family medicine such as the Family Medicine Professional Profile111 and the Four Principles of Family Medicine. Supporting resources, such as the PMH Implementation Kit, are available to help those new to the transition overcome barriers to change. Although the core components of the PMH remain the same for all practices, each practice will implement the recommendations according to their unique needs. The PMH is focused on enhancing patient-centredness in the health care system through collaboration, access, continuity, and social accountability. It is intended to build on the long-standing historical contribution of family physicians and primary care to the health and wellbeing of Canadians, as well as on the emerging models of family practice and primary care that have been introduced across the country. Importantly, this vision provides goals and recommendations that can serve as indicators. It enables patients, family physicians, other care health professionals, researchers, health planners, and policy-makers evaluate the effectiveness of any and all models of family practice throughout Canada. Those family practices that meet the goals and recommendations described in this vision will have become PMHs, but the concept is ever evolving. As family physicians commit to making change in their practices, the CFPC commits to supporting developments in the PMH by creating and promoting new resources, which will be available through the PMH website. The CFPC will also play an important advocacy role to ensure that the necessary supports are in place to reach the goals of a PMH. Every family practice across Canada should be supported and encouraged by the public, governments, and other health care stakeholders (the pentagram partners) to achieve this objective. Doing so will ensure that every person in Canada is able to access the best possible primary care for themselves and their loved ones. A NEW VISION FOR CANADA Family Practice— The Patient’s Medical Home 2019 33 REFERENCES 1. College of Family Physicians of Canada. A Vision for Canada: Family Practice - The Patient’s Medical Home. Mississauga, ON: College of Family Physicians of Canada; 2011. Available from: www.cfpc.ca/uploadedFiles/Resources/ Resource_Items/PMH_A_Vision_for_Canada.pdf. Accessed 2019 Jan 21. 2. National Physician Survey. 2014 National Physician Survey website. http:// nationalphysiciansurvey.ca/surveys/2014-survey/. Accessed 2019 Jan 22. 3. Canadian Medical Association. CMA Workforce Survey 2017 website. http:// cma.andornot.com/en/surveydata/default.aspx. Accessed 2019 Jan 22. 4. Canadian Institute for Health Information. How Canada Compares: Results from the Commonwealth Fund’s 2016 International Health Policy Survey of Adults in 11 Countries. Ottawa, ON: Canadian Institute for Health Information; 2017. Available from: www.cihi.ca/sites/default/files/document/text-alternativeversion- 2016-cmwf-en-web.pdf. Accessed 2019 Jan 22. 5. Ipsos Public Affairs. The College of Family Physicians of Canada: Family Medicine in Canada Report. Toronto, ON: Ipsos; 2017. 6. World Health Organization. Primary Health Care website. www.who.int/ primary-health/en/. Accessed 2019 Jan 22. 7. College of Family Physicians of Canada. Four Principles of Family Medicine website. www.cfpc.ca/Principles/. Accessed 2019 January. 8. Canadian Medical Association. Health Care Transformation in Canada: Change that works. Care that lasts. Ottawa, ON: Canadian Medical Association; 2018. Available from: http://policybase.cma.ca/dbtw-wpd/ PolicyPDF/PD10-05.PDF. Accessed 2019 Jan 22. 9. College of Family Physicians of Canada. The Patient’s Medical Home Provincial Report Card—February 2019. Mississauga, ON: College of Family Physicians of Canada; 2019. Available from: https://patientsmedicalhome.ca/ files/uploads/PMH_ReportCard_2018.pdf. Accessed 2019 February. 10. Alberta Health. Primary Care Networks website. www.health.alberta.ca/ services/primary-care-networks.html. Accessed 2018 August 16. 11. Access Improvement Measures (AIM) Alberta. Third Next Available Appointments website. https://aimalberta.ca/index.php/2016/07/19/the-world-of-third-nextavailable- appointments-2/. Accessed 2019 Jan 22. 12. Office of the Premier, Ministry of Health. B.C. government’s primary healthcare strategy focuses on faster, team-based care [news release]. Victoria, BC: Government of British Columbia; 2018. 13. General Practice Services Committee. What We Do: Patient Medical Homes website. www.gpscbc.ca/what-we-do/patient-medical-homes-and-primary-carenetworks. Accessed 2018 Aug 22. 14. Government of Manitoba. Frequently Asked Questions about My Health Teams website. www.gov.mb.ca/health/primarycare/myhts/faq.html#manitoba. Accessed 2018 Aug 15. 15. Chateau D, Katz A, Metge C, Taylor C, McDougall C, McCulloch S. Describing Patient Populations for the My Health Team Initiative. Winnipeg, MB: Manitoba Centre for Health Policy; 2017. Available from: http://mchp-appserv.cpe. umanitoba.ca/reference//hiusers_Report_web.pdf. Accessed 2019 Jan 22. 16. Government of Manitoba. Budget Paper F: Reducing Poverty and Promoting Community Involvement. Winnipeg, MB: Government of Manitoba; 2018. Available from: www.gov.mb.ca/finance/budget18/papers/F_Reducing_ Proverty_r.pdf. Accessed 2019 Jan 22. 17. Government of New Brunswick. New model for family medicine aims to improve physician access [news release]. Fredericton, NB: Government of New Brunswick; 2017. Available from: www2.gnb.ca/content/gnb/en/news/ news_release.2017.06.0849.html. Accessed 2019 Jan 22. 18. Health, Office of the Premier. Twenty-five new doctors to be added to New Brunswick’s health-care system to reduce wait times [news release]. Fredericton, NB: Government of New Brunswick; 2018. Available from: www2.gnb.ca/ content/gnb/en/news/news_release.2018.02.0140.html. Accessed 2019 Jan 22. 19. Government of Newfoundland and Labrador. Healthy People, Healthy Families, Healthy Communities: A Primary Health Care Framework for Newfoundland and Labrador 2015-2025. St. John’s, NL: Government of Newfoundland and Labrador; 2015. Available from: www.health.gov.nl.ca/health/ publications/PHC_Framework_update_Nov26.pdf. Accessed 2018 November. 20. Health and Community Services. Supporting Health Communities: Primary Health Care Team has Success at the Gathering Place [news release]. St. John’s, NL: Government of Newfoundland and Labrador; 2016. Available from: www. releases.gov.nl.ca/releases/2016/health/1124n01.aspx. Accessed 2018 Nov. 21. Nova Scotia Health Authority. Collaborative Family Practice Teams website. www. nshealth.ca/collaborative-family-practice-teams. Accessed 2019 January. 22. Government of Ontario. Family Health Teams website. www.health.gov.on.ca/ en/pro/programs/fht/. Accessed 2018 August 16. 23. Conference Board of Canada. Final Report: An External Evaluation of the Family Health Team (FHT) Initiative. Ottawa, ON: The Conference Board of Canada; 2014. Available from: www.conferenceboard.ca/e-library/abstract.aspx?did=6711. Accessed 2019 Jan 22. 24. Kralj B, Kantarevic J, OMA Economics Department. Primary care model enrolment and hospital length of stay in Ontario: patient rostering associated with reduced length of stay, significant health system savings. Ontario Medical Review. Sept 2012, 16-19. Available from: www.oma.org/wp-content/ uploads/sept2012_primary_care_model.pdf. Accessed 2019 Jan 22. 25. Tiagi R, Chechulin Y. The Effect of Rostering with a Patient Enrolment Model on Emergency Department Utilization. Healthcare Policy. 2014;9(4):105-121. Available from: www.longwoods.com/content/23809//the-effect-of-rosteringwith- a-patient-enrolment-model-on-emergency-department-utilization. Accessed 2019 Jan 22. 26. Health PEI. Health Centres Offer Primary Care [news release]. Charlottetown, PE: Government of Prince Edward Island; 2015. Available from: www. princeedwardisland.ca/en/information/health-pei/health-centres-offerprimary- care. Accessed 2019 Jan 22. 27. Gouvernement du Québec. Groupe de médecine de famille (GMF), groupe de médecine de famille universitaire (GMF-U) et super-clinique website. www. quebec.ca/sante/systeme-et-services-de-sante/organisation-des-services/gmfgmf- u-et-super-clinique/. Accessed 2019 January. 28. Government of Saskatchewan. Fact Sheet: Connected Care [news release]. Regina, SK: Government of Saskatchewan; 2018. 29. Pomey MP, Ghadiri DP, Karazivan P, Fernandez N, Clavel N. Patients as partners: a qualitative study of patients’ engagement in their health care. PLoS One. 2015;10(4):e0122499. 30. Pointer DD, Orlikoff JE. Board Work: Governing Health Care Organizations. 1st ed. San Francisco, CA: Jossey-Bass; 1999. 31. Canadian Foundation for Healthcare Improvement. Mythbusters: Most Physicians Prefer Fee-for-Services Payments. Ottawa, ON: Canadian Foundation for Healthcare Improvement; 2010. Available from: www.cfhi-fcass. ca/sf-docs/default-source/mythbusters/Myth-Fee-for-Service-E.pdf?sfvrsn=0. Accessed 2019 Jan 22. 32. Blomqvist A, Busby C. How to Pay Family Doctors: Why “Pay per Patient” is Better than Fee for Service. Toronto, ON: C.D Howe Institute; 2012. Available from: www.cdhowe.org/sites/default/files/attachments/research_papers/ mixed/Commentary_365.pdf. Accessed 2019 Jan 22. 33. Holden M, Madore O. Remuneration of Primary Care Physicians (PRB 01-35E). Ottawa, ON: Library of Parliament, Parliamentary Research Branch; 2002. Available from: http://publications.gc.ca/collections/Collection-R/LoPBdP/ PRB-e/PRB0135-e.pdf. Accessed 2019 Jan 22. 34. Carter R, Riverin B, Levesque JF, Gariepy G, Quesnel-Vallee A. The impact of primary care reform on health system performance in Canada: a systematic review. BMC Health Serv Res. 2016;16:324. 35. Kiran T, Kopp A, Moineddin R, Glazier RH. Longitudinal evaluation of physician payment reform and team-based care for chronic disease management and prevention. CMAJ. 2015;187(17):E494-502. 36. College of Family Physicians of Canada. Best Advice guide: Physician Remuneration in a Patient’s Medical Home. Mississauga, ON: 34 A NEW VISION FOR CANADA Family Practice— The Patient’s Medical Home 2019 College of Family Physicians of Canada; 2016. Available from: https:// patientsmedicalhome.ca/resources/best-advice-guides/best-advice-guidephysician- remuneration-patients-medical-home/. Accessed 2019 Jan 22. 37. Hutchison B, Levesque JF, Strumpf E, Coyle N. Primary health care in Canada: systems in motion. Milbank Q. 2011;89(2): 256-288. 38. Aggarwal M, Hutchison B. Toward a Primary Care Strategy for Canada. Ottawa, ON: Canadian Foundation for Healthcare Improvement; 2012. Available from: www.cfhi-fcass.ca/Libraries/Reports/Primary-Care-Strategy- EN.sflb.ashx. Accessed 2019 Jan 22. 39. PricewaterhouseCoopers. Canada Health Infoway: The emerging benefits of electronic medical record use in community-based care. Toronto, ON: PricewaterhouseCoopers; 2013. Available from: www.pwc.com/ca/en/healthcare/ publications/pwc-electronic-medical-record-use-community-based-care-report- 2013-06-en.pdf. Accessed 2018 Jul 3. 40. Canada Health Infoway. Use of Electronic Medical Records among Canadian Physicians, 2017 Update. Toronto, ON: Canada Health Infoway; 2017. 41. College of Family Physicians of Canada. Supporting access to data in electronic medical records for quality improvement and research [position statement]. Mississauga, ON: College of Family Physicians of Canada; 2017. Available from: www.cfpc.ca/uploadedFiles/Health_Policy/CFPC_Policy_ Papers_and_Endorsements/CFPC_Policy_Papers/CFPC-Position-Statement- Supporting-access-data-electronic-medical-records-EN.pdf. Accessed 2019 Jan 22. 42. Jamieson T, Wallace R, Armstrong K, Agarwal P, Griffin B, Wong I, et al. Virtual Care: A Framework for a Patient-Centric System. Toronto, ON: Women’s College Hospital Institute for Health Systems Solutions and Virtual Care; 2015. Available from: www.womenscollegehospital.ca/assets/pdf/wihv/WIHV_ VirtualHealthSymposium.pdf. Accessed 2019 Jan 22. 43. McGrail KM, Ahuja MA, Leaver CA. Virtual Visits and Patient-Centered Care: Results of a Patient Survey and Observational Study. J Med Internet Res. 2017;19(5):e177. 44. Canadian Medical Association. Managing your Practice website. www.cma.ca/ managing-your-practice. Accessed 2019 Jan 22. 45. Chang F, Gupta N. Progress in electronic medical record adoption in Canada. Can Fam Physician. 2015;61(12):1076-1084. 46. Canadian Nurses Association, Canadian Medical Association, Health Action Lobby. Integration: A New Direction for Canadian Health Care—A Report on the Health Provider Summit Process. Ottawa, ON: Canadian Nurses Association; 2013. Available from: www.cna-aiic.ca/~/media/cna/files/en/cna_ cma_heal_provider_summit_transformation_to_integrated_care_e.pdf. Accessed 2019 Jan 22. 47. Canada Health Infoway website. www.infoway-inforoute.ca/en/. Accessed 2019 Jan 22. 48. Canadian Foundation for Healthcare Improvement. Connected Medicine website. www.cfhi-fcass.ca/WhatWeDo/connected-medicine. Accessed 2018 Aug 15. 49. Rajakulendra N, Macintosh E, Salah H. Transforming Health: Toward decentralized and connected care. Toronto, ON: MaRS Discovery District; 2014. Available from: www.marsdd.com/wp-content/uploads/2014/09/Sep15- MaRS-Whitepapers-SmartHealth.pdf. Accessed 2019 Jan 22. 50. College of Family Physicians of Canada. Best Advice guide: Advanced and Meaningful Use of EMRs. Mississauga, ON: College of Family Physicians of Canada; 2018. Available from: https://patientsmedicalhome.ca/resources/ best-advice-guides/best-advice-guide-advanced-and-meaningful-use-ofemrs/. Accessed 2019 Jan 22. 51. Ontario Primary Care Council. Position Statement: Care Co-ordination in Primary Care. Toronto, ON: Ontario Primary Care Council; 2015. Available from: www.afhto.ca/wp-content/uploads/OPCC_Care-Coordination-Position. pdf. Accessed 2019 Jan 22. 52. Wong ST, Watson DE, Young E, Regan S. What do people think is important about primary healthcare? Healthcare Policy. 2008; 3(3):89-104. 53. Canadian Medical Association. CMA Position Statement: Ensuring Equitable Access to Care: Strategies for Government, Health System Planners and the Medical Profession. Ottawa, ON: Canadian Medical Association; 2014. Available from: www.cma.ca/sites/default/files/2018-11/PD14-04-e.pdf. Accessed 2019 Jan 22. 54. Canadian Nurses Association. Position Statement: Primary Health Care. Ottawa, ON: Canadian Nurses Association; 2015. Available from: www.cna-aiic. ca/-/media/cna/page-content/pdf-en/primary-health-care-position-statement. pdf. Accessed 2019 Jan 22. 55. Canadian Nurses Association. Social Justice … a means to an end, an end in itself; 2nd edition. Ottawa, ON: Canadian Nurses Association; 2010. Available from: www.cna-aiic.ca/~/media/cna/page-content/pdf-en/social_justice_2010_e. pdf. Accessed 2019 Jan 22. 56. Barry DW, Melhado TV, Chacko KM, Lee RS, Steiner J, Kutner JS. Patient and physician perceptions of timely access to care. J Gen Intern Med. 2006;21(2):130-133. 57. Glass DP, Kanter M, Jacobsen SJ, Minardi PM. The impact of improving access to primary care. J Eval Clin Pract. 2017;23(6):1451-1458. 58. Hudec JC, MacDougall S, Rankin E. Advanced access appointments: effects on family physician satisfaction, physicians’ office income, and emergency department use. Can Fam Phys. 2010;56(10):e361-e367. 59. Stalker CA. How have physicians and patients at New Vision Family Health Team experienced the shift to a family health team model? Final Report. Unpublished; 2010. 60. Murray M, Tantau C. Same-day appointments: exploding the access paradigm. Fam Pract Manag. 2000;7(8):45-50. 61. College of Family Physicians of Canada. Best Advice guide: Timely Access to Appointments in Family Practice. Mississauga, ON: College of Family Physicians of Canada; 2012. Available from: https://patientsmedicalhome.ca/ resources/best-advice-guides/best-advice-guide-timely-access/. Accessed 2019 Jan 22. 62. Lemire F. First contact: what does it mean for family practice in 2017? Can Fam Phys. 2017;63(3):256. 63. Williams DL. Balancing rationalities: gatekeeping in health care. J Med Ethics. 2001;27(1):25-29. 64. Murray M, Davies M, Boushon B. Panel size: How many patients can one doctor manage? Fam Pract Manag. 2007;14(4):44-51. 65. College of Family Physicians of Canada. Best Advice guide: Panel Size. Mississauga, ON: College of Family Physicians of Canada; 2012. Available from: https://patientsmedicalhome.ca/resources/best-advice-guides/bestadvice- guide-panel-size/. Accessed 2019 Jan 22. 66. Buchman S, Woollard R, Meili R, Goel R. Practising social accountability. Can Fam Phys. 2016; 62(1):15-18. 67. National Collaborating Centre of Determinants of Health website. www.nccdh. ca/. Accessed 2019 Jan 22. 68. National Collaborating Centre on Aboriginal Health website. www.nccahccnsa. ca/en/. Accessed 2019 Jan 22. 69. College of Family Physicians of Canada. CanMEDS–Family Medicine 2017: A competency framework for family physicians across the continuum. Mississauga, ON: College of Family Physicians of Canada; 2017. Available from: www.cfpc.ca/uploadedFiles/Resources/Resource_Items/Health_ Professionals/CanMEDS-Family-Medicine-2017-ENG.pdf. Accessed 2019 Jan 22. 70. College of Family Physicians of Canada. Best Advice guide: Social Determinants of Health. Mississauga, ON: College of Family Physicians of Canada; 2017. Available from: https://patientsmedicalhome.ca/resources/bestadvice- guides/best-advice-guide-social-determinants-health/. Accessed 2019 Jan 22. 71. Lightman E, Mitchell A, Wilson B. Poverty is making us sick: A comprehensive survey of income and health in Canada. Toronto, ON: The Wellesley Institute; 2008. Available from: www.wellesleyinstitute.com/wp-content/uploads/2011/11/ povertyismakingussick.pdf. Accessed 2019 Jan 18. 72. White AA 3rd, Logghe HJ, Goodenough DA, Barnes LL, Hallward A, Allen IM, et al. Self-Awareness and Cultural Identity as an Effort to Reduce Bias in Medicine. J Racial Ethn Health Disparities. 2018;5(1):34-49. 73. Canadian Primary Care Sentinel Surveillance Network website. http://cpcssn. ca/. Accessed 2019 Jan 22. 74. Pinto AD, Bloch G. Framework for building primary care capacity to address the social determinants of health. Can Fam Phys. 2017;63(11):e476-482. A NEW VISION FOR CANADA Family Practice— The Patient’s Medical Home 2019 35 75. College of Family Physicians of Canada. Best Advice guide: Team-Based Care in the Patient’s Medical Home. Mississauga, ON: College of Family Physicians of Canada; 2017. Available from: https://patientsmedicalhome.ca/resources/ best-advice-guides/best-advice-guide-team-based-care-patients-medical-home/. Accessed 2019 Jan 22. 76. Grant R, Finocchio L, Pew Health Professions Commission, California Primary Care Consortium. Interdisciplinary collaborative teams in primary care: a model curriculum and resource guide. San Francisco, CA: Pew Health Professions Commission; 1995. 77. Schottenfeld L, Petersen D, Peikes D, Ricciardi R, Burak H, McNellis R, et al. Creating Patient-Centered Team-Based Primary Care. AHRQ Pub. No. 16- 0002-EF. Rockville, MD: Agency for Healthcare Research and Quality; 2016. 78. Department of Health. Part 3: The accreditation of GPs and Pharmacists with Special Interests, In: Implementing care closer to home: Convenient quality care for patients. London, UK: Department of Health; 2007. Available from: www.pcc-cic.org.uk/sites/default/files/articles/attachments/improved_quality_ of_care_p3_accreditation.pdf. Accessed 2019 Jan 22. 79. Department of Health. Part 1: Introduction and overview, In: Implementing care closer to home: Convenient quality care for patients. London, UK: Department of Health; 2007. Available from: www.pcc-cic.org.uk/sites/default/ files/articles/attachments/improved_quality_of_care_p1_introduction.pdf. Accessed 2019 Jan 22. 80. College of Family Physicians of Canada. Best Advice guide: Communities of Practice in the Patient’s Medical Home. Mississauga, ON: College of Family Physicians of Canada; 2016. Available from: https://patientsmedicalhome. ca/resources/best-advice-guides/communities-practice-patients-medicalhome/. Accessed 2019 Jan 22. 81. Dinh T. Improving Primary Health Care Through Collaboration: Briefing 2— Barriers to Successful Interprofessional Teams. Ottawa, ON: The Conference Board of Canada; 2012. Available from: www.conferenceboard.ca/e-library/ abstract.aspx?did=5181&AspxAutoDetectCookieSupport=1. Accessed 2019 Jan 22. 82. Nelson S, Turnbull J, Bainbridge L, Caulfield T, Hudon G, Kendel D, et al. Optimizing Scopes of Practice: New Models for a New Health Care System. Ottawa, ON: Canadian Academy of Health Sciences; 2014. 83. Mautner DB, Pang H, Brenner JC, Shea JA, Gross KS, Frasso R, et al. Generating hypotheses about care needs of high utilizers: lessons from patient interviews. Popul Health Manag. 2013;16(Suppl1):S26-33. 84. American Academy of Family Physicians. Definition of Continuity of Care website. www.aafp.org/about/policies/all/definition-care.html. Accessed 2018 July 25. 85. Canadian Institute for Health Information. Continuity of Care With Family Medicine Physicians: Why It Matters. Ottawa, ON: Canadian Institute for Health Information; 2015. Available from: https://secure.cihi.ca/free_products/UPC_ ReportFINAL_EN.pdf. Accessed 2019 Jan 22. 86. Starfield B, Chang HY, Lemke KW, Weiner JP. Ambulatory specialist use by nonhospitalized patients in us health plans: correlates and consequences. J Ambul Care Manage. 2009;32(3):216-25. 87. Pereira Gray DJ, Sidaway-Lee K, White E, Thorne A, Evans PH. Continuity of care with doctors-a matter of life and death? A systematic review of continuity of care and mortality. BMJ Open. 2018;8(6):e021161. 88. Starfield B, Shi L. The medical home, access to care, and insurance: a review of evidence. Pediatrics. 2004;113(Supplement 4):1495. 89. McWhinney I. The Need for a Transformed Clinical Method. In: Communicating with Medical Patients. London, UK: Sage; 1989:25. 90. College of Family Physicians of Canada. Best Advice guide: Patient-Centred Care in a Patient’s Medical Home. Mississauga, ON: College of Family Physicians of Canada; 2014. Available from: https://patientsmedicalhome. ca/resources/best-advice-guides/best-advice-guide-patient-centredness/. Accessed 2019 Jan 22. 91. Canadian Medical Association, Canadian Nurses Association. Principles to Guide Health Care Transformation in Canada. Ottawa, ON: Canadian Medical Association; 2011. 92. Patients Canada. Why we need a Health Accord with Patients at the Centre [news release]. Toronto, ON: Patients Canada; 2016. Available from: https:// patientscanada.ca/2016/01/18/why-we-need-a-health-accord-with-patients-atthe- centre/. Accessed 2019 Jan 22. 93. Omole FS, Sow CM, Fresh E, Babalola D, Strothers H. Interacting with patients’ family members during the office visit. Am Fam Physician. 2011; 84(7): 780-784. 94. Mitnick S, Leffler C, Hood VL; American College of Physicians Ethics, Professionalism and Human Rights Committee. Family caregivers, patients and physicians: ethical guidance to optimize relationships. J Gen Intern Med. 2010;25(3):255-60. 95. Panagioti M, Richardson G, Small N, Murray E, Rogers A, Kennedy A, et al. Self-management support interventions to reduce health care utilisation without compromising outcomes: a systematic review and meta-analysis. BMC Health Serv Res. 2014;14:356. 96. College of Family Physicians of Canada. Best Advice guide: Chronic Care Management in a Patient’s Medical Home. Mississauga, ON: College of Family Physicians of Canada; 2016. Available from: https://patientsmedicalhome.ca/ resources/best-advice-guides/best-advice-guide-chronic-care-managementpatients- medical-home/. Accessed 2019 Jan 22. 97. Prevention in Hand website. www.preventioninhand.com. Accessed 2019 Jan 22. 98. Kruse CS, Argueta DA, Lopez L, Nair A. Patient and provider attitudes toward the use of patient portals for the management of chronic disease: a systematic review. J Med Internet Res. 2015;17(2):e40. 99. Kruse CS, Bolton K, Freriks G. The effect of patient portals on quality outcomes and its implications to meaningful use: a systematic review. J Med Internet Res. 2015;17(2):e44. 100. Health Council of Canada. Which way to quality? Key perspectives on quality improvement in Canadian health care systems. Toronto, ON: Health Council of Canada; 2013. Available from: https://healthcouncilcanada.ca/files/ QIReport_ENG_FA.pdf. Accessed 2019 Jan 22. 101. Mattison CA, Wilson MC. Rapid Synthesis: Examining the Effects of Valuebased Physician Payment Models. Hamilton, ON: McMaster Health Forum; 2017. Available from: www.mcmasterforum.org/docs/default-source/productdocuments/ rapid-responses/examining-the-effects-of-value-based-physicianpayment- models.pdf?sfvrsn=2. Accessed 2019 Jan 22. \ 102. Kaczorowski J, Hearps SJ, Lohfeld L, Goeree R, Donald F, Burgess K, et al. Effect of provider and patient reminders, deployment of nurse practitioners, and financial incentives on cervical and breast cancer screening rates. Can Fam Phys. 2013; 59(6): e282-9. 103. Hutchison B. Pay for performance in primary care: proceed with caution, pitfalls ahead. Healthc Policy. 2008; 4(1): 10-15. 104. College of Family Physicians of Canada. The Practice Improvement Initiative (Pii) website. www.cfpc.ca/pii/. Accessed 2019 Jan 22. 105. Ontario College of Family Physicians. Advancing Practice Improvement in Primary Care – Final Report. Toronto, ON: Ontario College of Family Physicians; 2015. Available from: https://ocfp.on.ca/docs/default-source/ default-document-library/hqo_final_report_advancing_practice_improvement_in_ primary_care.pdf?sfvrsn=d793f489_4. Accessed 2019 Jan 22. 106. Canadian Institutes of Health Research. Strategy for Patient-Oriented Research website. www.cihr-irsc.gc.ca/e/41204.html. Accessed 2019 Jan 22. 107. Hasley PB, Simak D, Cohen E, Buranosky R. Training residents to work in a patient-centered medical home: What are the outcomes? J Grad Med Educ. 2016; 8(2): 226-231. 108. College of Family Physicians of Canada. Specific Standards for Family Medicine Residency Programs – The Red Book. Mississauga, ON: College of Family Physicians of Canada; 2016. 109. College of Family Physicians of Canada. Triple C Competency Based Curriculum website. www.cfpc.ca/Triple_C/. Accessed 2019 Jan 22. 110. Filipe HP, Silva ED, Stulting AA, Golnik KC. Continuing professional development: Best practices. Middle East Afr J Ophthalmol. 2014; 21(2): 134-141. 111. College of Family Physicians of Canada. Family Medicine Professional Profile website. www.cfpc.ca/fmprofile/. Accessed 2019 Jan 22.

Documents

Less detail

Health Canada consultation on reducing youth access and appeal of vaping products

https://policybase.cma.ca/en/permalink/policy14078

Date
2019-05-24
Topics
Pharmaceuticals/ prescribing/ cannabis/ marijuana/ drugs
Population health/ health equity/ public health
  1 document  
Policy Type
Response to consultation
Date
2019-05-24
Topics
Pharmaceuticals/ prescribing/ cannabis/ marijuana/ drugs
Population health/ health equity/ public health
Text
The Canadian Medical Association (CMA) appreciates this opportunity to respond to Health Canada’s consultation on Reducing Youth Access and Appeal of Vaping Products - Consultation on Potential Regulatory Measures.1 Canada’s physicians, who see the devastating effects of tobacco use every day in their practices, have been working for decades toward the goal of a smoke-free Canada. The CMA issued its first public warning concerning the hazards of tobacco in 1954 and has continued to advocate for the strongest possible measures to control its use. The CMA has always supported strong, comprehensive tobacco control legislation, enacted and enforced by all levels of government, and we continue to do so. This includes electronic cigarettes (e-cigarettes). Our approach to tobacco and vaping products is grounded in public health policy. We believe it is incumbent on all levels of government in Canada to continue working on comprehensive, coordinated and effective tobacco control strategies, including vaping products, to achieve the goal of reducing smoking prevalence. The CMA has stated its position to the federal government on electronic cigarettes and vaping clearly in recent years.2,3 In our April 2017 submission on Bill S-5 to the Senate Standing Committee on Social Affairs, Science and Technology we recommended that the restrictions on promotion of vaping products and devices should be the same as those for tobacco products.2 We also argued that the government should take the same approach to plain and standardized packaging regulations for e-cigarettes as has now been implemented for tobacco products.2 In our most recent brief we addressed the two main issues outlined in the government’s Notice of Intent with respect to the advertising of vaping products: the placement of that advertising and the use of health warnings.3,4 We expressed concerns that the proposed regulations leave too wide an opening for vaping manufacturers to promote their products, especially to youth. Further, we reiterated our position that health warnings for vaping should be like those being considered for tobacco packages. This brief will address the issues of greatest concern to the CMA with respect to vaping and youth. This includes marketing, flavours, nicotine levels, and reducing vaping and e-cigarette use among youths. Introduction The Council of Chief Medical Officers of Health have expressed alarm at the rising number of Canadian youths who are vaping, finding this trend “very troubling.”5 The Canadian Medical Association concurs with this assessment and appeals to the federal government to move urgently on this important public health issue. As our knowledge about the risks of using e-cigarettes increases, there is an even greater imperative to dissuade youth from taking up the habit. This is important because those youth “who believe that e-cigarettes are not harmful or are less harmful than cigarettes are more likely to use e-cigarettes than youth with more negative views of e-cigarettes.”6 Marketing The e-cigarette marketplace is evolving quickly as new products emerge. The industry has made clever use of social media channels to promote their wares by taking advantage of the belief that they are a safer alternative to cigarettes.7 They have also promoted “innovative flavoring and highlighted the public performance of vaping.”7 It is no surprise that the United States Food and Drug Administration (FDA) has referred to youth vaping as an “epidemic,” calling it “one of the biggest public health challenges currently facing the FDA.”8 As the US National Academies of Sciences, Engineering, and Medicine has noted “young people who begin with e-cigarettes are more likely to transition to combustible cigarette use and become smokers who are at risk to suffer the known health burdens of combustible tobacco cigarettes.”9 However, some of the efforts employed to convince youth to take up vaping are especially troublesome. As the 4 US Centers for Disease Control and Prevention (CDC) reported, “one in 5 (US) high school students and 1 in 20 middle school students reported using e-cigarettes in the past 30 days in 2018,” a significant rise in the number of high school students between 2011 and 2018.10 The use of social media campaigns employing “influencers” to capture more of the youth and young adult market or influence their choices shows the need to be especially vigilant.11 In an attempt to counter this influence, a group of over 100 public health and anti-tobacco organizations from 48 countries “are calling on Facebook, Instagram, Twitter and Snap to take “swift action” to curb advertising of tobacco products on their platforms.”12 As much as the industry is making major efforts to attract or sway customers through advertising, youth themselves may hold the key to countering that pressure. A recent US study found that “adolescents generally had somewhat negative opinions of other adolescents who use e-cigarettes. Building on adolescents’ negativity toward adolescent e-cigarette users may be a productive direction for prevention efforts, and clinicians can play an important role by keeping apprised of the products their adolescent patients are using and providing information on health effects to support negative opinions or dissuade formation of more positive ones.”13 Health Canada can play a major role in encouraging and facilitating peer-to-peer discussions on the risks associated with vaping and help to offset the social media influencers.14 We reiterate the concerns we expressed in our recent brief on the potential measures to reduce advertising of vaping products and to help diminish their appeal to youth. The CMA noted that the sections most problematic to the Association were those encompassing public places, broadcast media, and the publications areas.3 Vaping advertisements should not be permitted at all in any of these spaces, with no exceptions.3 These areas need to be addressed on an urgent basis. Flavours As of 2013, over 7,000 flavours had been marketed in the US.15 The data indicated that “about 85% of youth who used e-cigarettes in the past 30 days adopted non-tobacco flavors such as fruit, candy, and dessert.”15 Flavours are helpful in attracting youth, especially when coupled with assertions of lower harm.13 And they have been successful in doing so, as evidenced by the rise in the rates of vaping among youth.8, 16 The addition of a wide variety of flavours available in the pods makes them taste more palatable and less like smoking tobacco.16,17,18 The concern is that e-cigarettes “may further entice youth to experiment with e-cigarettes and boost e-cigarettes’ influence on increased cigarette smoking susceptibility among youth.”15 More worrisome, flavoured e-cigarettes “are recruiting females and those with low smoking-risk profile to experiment with conventional cigarettes.”19 Limiting the availability of “child-friendly flavors” should be considered to reduce the attraction of vaping to youth.19 In a recent announcement, the US FDA has proposed to tighten e-cigarette sales and “remove from the market many of the fruity flavors …blamed on fueling “epidemic” levels of teen use.”20 As we have noted in previous submissions, the CMA would prefer to see flavours banned to reduce the attractiveness of vaping to youth as much as possible, a sentiment shared by other expert groups. 2,3,21 Nicotine Levels One of the most popular devices to vape with is JUUL™, entering the US market in 2015.22 JUUL’s™ nicotine pods contain 5% nicotine salt solution consisting of 59 mg/mL in 0.7 mL pods.17 Some of JUUL’s™ competition have pods containing even higher levels (6% and 7%).17 The CMA is very concerned about the rising levels of nicotine available through the vaping process, especially by the newer delivery systems. They supply “high levels of nicotine with few of the deterrents that are inherent in other tobacco products. Traditional e-cigarette products use solutions with free-base nicotine formulations in which stronger nicotine concentrations can cause aversive user experiences.”23 Nicotine, among other issues, “affects the developing brain by increasing the risk of addiction, mood disorders, lowered impulse control, and cognitive impairment.15,24 In addition to flavours, and to ease delivery and to make the taste more pleasant, nicotine salts are added to make the e-liquid “less harsh and less bitter” and “more 5 palatable despite higher nicotine levels.”17 Addressing the Rise in Youth Vaping There are many factors that lead youth to experiment with vaping and e-cigarettes. For some it is simple curiosity, for others it is the availability of different flavours while still others perceive vaping as “cool,” especially when they can use the vapour to perform “smoke tricks.”25 The pod devices themselves (e.g., JUUL™) help enhance the allure because of the “unique aesthetic appeal of pod devices, ability to deliver nicotine at high concentrations and the convenience of using them quickly and discreetly.”26 As vaping continues to grow in popularity, it will not be easy to curb youths’ enthusiasm for it. However, it is too important of a public health issue to not intervene More research is needed into how youth perceive vaping and e-cigarettes as they do not hold a universally positive view of the habit.7,13 As well, there is evidence to suggest that many are coming to see vaping as being “uncool” and that there are potential health consequences to continued use.25 In view of the still-evolving evidence of the safety of vaping and e-cigarettes, “strategic and effective health communication campaigns that demystify the product and counteract misconceptions regarding e-cigarette use are needed.”25 Further, “to reduce youth appeal, regulation efforts can include restricting the availability of e-cigarette flavors as well as visible vapors.”25 Another approach to consider is the state of Colorado’s recent creation of “a health advisory recommending that health care providers screen all youth specifically for vaping, in addition to tobacco use, because young people may not necessarily associate tobacco with vaping.”27 Recommendations 1. The CMA calls for all vaping advertising to be strictly limited. The restrictions on the marketing and promotion of vaping products and devices should be the same as those for tobacco products. 2. The CMA recommends the limitation of number of flavours available to reduce the attractiveness of vaping to youth. 3. Health Canada should work to restrict the level of nicotine available for vaping products to avoid youth becoming addicted. 4. Health Canada must play a major role in encouraging and facilitating peer-to-peer discussions on the risks associated with vaping and help to offset the social media influencers. 5. Health Canada must develop communication campaigns directed at youth, parents and health care providers to demystify vaping and e-cigarettes and that create a link between tobacco and vaping. 1 Government of Canada. Reducing Youth Access and Appeal of Vaping Products - Consultation on Potential Regulatory Measures. Ottawa: Health Canada; 2019. Available: https://www.canada.ca/en/health-canada/programs/consultation-reducing-youth-access-appeal-vaping-products-potential-regulatory-measures.html (accessed 2019 Apr 11). 2 Canadian Medical Association (CMA). CMA’s Recommendations for Bill S-5: An Act to amend the Tobacco Act and the Nonsmokers’ Health Act and to make consequential amendments to other Acts. Ottawa: CMA; 2017 Apr 7. Available: https://policybase.cma.ca/en/permalink/policy13641 (accessed 2019 May 13). 3 Canadian Medical Association (CMA). Health Canada consultation on the impact of vaping products advertising on youth and non-users of tobacco products. Ottawa: CMA; 2019 Mar 22. Available: https://policybase.cma.ca/en/permalink/policy14022 (accessed 2019 May 13). 4 Government of Canada. Notice to Interested Parties – Potential Measures to Reduce the Impact of Vaping Products Advertising on Youth and Non-users of Tobacco Products. Ottawa: Health Canada; 2019. Available: https://www.canada.ca/en/health-canada/programs/consultation-measures-reduce-impact-vaping-products-advertising-youthnon-users-tobacco-products.html (accessed 2019 Feb 27). 5 Public Health Agency of Canada. Statement from the Council of Chief Medical Officers of Health on the increasing rates of youth vaping in Canada. Health Canada; 2019. Available: https://www.newswire.ca/news-releases/statement-from-the-council-of-chief-medical-officers-of-health-on-the-increasing-rates-of-youth-vaping-in-canada-812817220.html (accessed 2019 May 14). 6 6 Glantz SA. The Evidence of Electronic Cigarette Risks Is Catching Up with Public Perception. JAMA Network Open 2019;2(3):e191032. doi:10.1001/jamanetworkopen.2019.1032. Available: https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2729460 (accessed 2019 May 14). 7 McCausland K., et al. The Messages Presented in Electronic Cigarette–Related Social Media Promotions and Discussion: Scoping Review. J Med Internet Res 2019;21(2):e11953). Available: https://www.jmir.org/2019/2/e11953/ (accessed 2019 May 14). 8 Food and Drug Administration (FDA). Statement from FDA Commissioner Scott Gottlieb, M.D., on new data demonstrating rising youth use of tobacco products and the agency’s ongoing actions to confront the epidemic of youth e-cigarette use. Silver Spring, MD: FDA; February 11, 2019. Available: https://www.fda.gov/news-events/press-announcements/statement-fda-commissioner-scott-gottlieb-md-new-data-demonstrating-rising-youth-use-tobacco (accessed 2019 May 17). 9 National Academies of Sciences, Engineering, and Medicine. Public health consequences of e-cigarettes. Washington, DC: The National Academies Press; 2018. Available: https://www.nap.edu/catalog/24952/public-health-consequences-of-e-cigarettes (accessed 2019 May 17). 10 Kuehn B. Youth e-Cigarette Use. JAMA. 2019;321(2):138. Available: https://jamanetwork.com/journals/jama/fullarticle/2720740 (accessed 2019 May 14). 11 Kirkum C. Philip Morris suspends social media campaign after Reuters exposes young 'influencers'. New York: Reuters; May 10, 2019. Available: https://www.reuters.com/article/us-philipmorris-ecigs-instagram-exclusiv/exclusive-philip-morris-suspends-social-media-campaign-after-reuters-exposes-young-influencers-idUSKCN1SH02K (accessed 2019 May 13). 12 Kirkham C. Citing Reuters report, health groups push tech firms to police tobacco marketing. New York: Reuters; May 22, 2109. Available: https://www.reuters.com/article/us-philipmorris-ecigs-socialmedia/citing-reuters-report-health-groups-push-tech-firms-to-police-tobacco-marketing-idUSKCN1SS1FX (accessed 2019 May 22). 13 McKelvey K, Popova L, Pepper JK, Brewer NT, Halpern-Felsher. Adolescents have unfavorable opinions of adolescents who use e-cigarettes. PLoS ONE 2018;13(11): e0206352. Available: https://doi.org/10.1371/journal.pone.0206352 (accessed 2019 May 14). 14 Calioa D. Vaping an 'epidemic,' Ottawa high school student says. Ottawa: CBC News; November 27, 2018. Available: https://www.cbc.ca/news/canada/ottawa/vaping-epidemic-ottawa-high-school-student-says-1.4918672 (accessed 2019 May 14). 15 Chen-Sankey JC, Kong G, Choi K. Perceived ease of flavored e-cigarette use and ecigarette use progression among youth never tobacco users. PLoS ONE 2019;14(2): e0212353. Available: https://doi.org/10.1371/journal.pone.0212353 (accessed 2019 May 17). 16 Drazen JM, Morrissey S, Campion EW. The Dangerous Flavors of E-Cigarettes. N Engl J Med 2019; 380:679-680. Available: https://www.nejm.org/doi/pdf/10.1056/NEJMe1900484?articleTools=true (accessed 2019 May 17). 17 Jackler RK, Ramamurthi D. Nicotine arms race: JUUL and the high-nicotine product market Tob Control 2019;0:1–6. Available: https://www.ncbi.nlm.nih.gov/pubmed/30733312 (accessed 2019 May 20). 18 Reichardt EM., Guichon J. Vaping is an urgent threat to public health. Toronto: The Conversation; March 13, 2019. Available: https://theconversation.com/vaping-is-an-urgent-threat-to-public-health-112131 (accessed 2019 May 20). 19 Chen JC. et al. Flavored E-cigarette Use and Cigarette Smoking Susceptibility among Youth. Tob Regul Sci. 2017 January ; 3(1): 68–80. Available: https://www.ncbi.nlm.nih.gov/pubmed/30713989 (accessed 2019 May 20). 20 LaVito A. FDA outlines e-cigarette rules, tightens restrictions on fruity flavors to try to curb teen vaping. New Jersey: CNBC; March 13, 2019 Available: https://www.cnbc.com/2019/03/13/fda-tightens-restrictions-on-flavored-e-cigarettes-to-curb-teen-vaping.html (accessed 2019 Mar 20). 21 Ireland N. Pediatricians call for ban on flavoured vaping products — but Health Canada isn't going there. Toronto: CBC News; November 17, 2018 Available: https://www.cbc.ca/news/health/canadian-pediatricians-flavoured-vaping-second-opinion-1.4910030 (accessed 2019 May 20). 22 Huang J, Duan Z, Kwok J, et al. Vaping versus JUULing: how the extraordinary growth and marketing of JUUL transformed the US retail e-cigarette market. Tobacco Control 2019;28:146-151. Available: https://tobaccocontrol.bmj.com/content/tobaccocontrol/28/2/146.full.pdf (accessed 2019 May 21). 23 Barrington-Trimis JL, Leventhal AM. Adolescents’ Use of “Pod Mod” E-Cigarettes — Urgent Concerns. N Engl J Med 2018; 379:1099-1102. Available: https://www.nejm.org/doi/pdf/10.1056/NEJMp1805758?articleTools=true (accessed 2019 May 20). 24 U.S. Department of Health and Human Services. E-Cigarette Use Among Youth and Young Adults. A Report of the Surgeon General. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health; 2016. Available: https://e-cigarettes.surgeongeneral.gov/documents/2016_sgr_full_report_non-508.pdf (accessed 2019 May 20). 25 Kong G. et al. Reasons for Electronic Cigarette Experimentation and Discontinuation Among Adolescents and Young Adults. Nicotine & Tobacco Research, 2015 Jul;17(7):847-54. Available: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4674436/pdf/ntu257.pdf (accessed 2019 May 21). 26 Keamy-Minor E, McQuoid J, Ling PM. Young adult perceptions of JUUL and other pod electronic cigarette devices in California: a qualitative study. BMJ Open. 2019;9:e026306. Available: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6500190/pdf/bmjopen-2018-026306.pdf (accessed 2019 May 21). 27 Ghosh TS, Et al. Youth Vaping and Associated Risk Behaviors — A Snapshot of Colorado. N Engl J Med 2019; 380:689-690.Available: https://www.nejm.org/doi/full/10.1056/NEJMc1900830 (accessed 2019 May 21).

Documents

Less detail

Health Canada consultation on vaping products labelling and packaging regulations

https://policybase.cma.ca/en/permalink/policy14124

Date
2019-09-05
Topics
Health care and patient safety
Population health/ health equity/ public health
  1 document  
Policy Type
Response to consultation
Date
2019-09-05
Topics
Health care and patient safety
Population health/ health equity/ public health
Text
The Canadian Medical Association (CMA) appreciates this opportunity to respond to the notice as published in the Canada Gazette, Part 1 for interested stakeholders to provide comments on Health Canada’s intent to establish a single set of regulations under the authorities of the Tobacco and Vaping Products Act (TVPA) and the Canada Consumer Product Safety Act (CCPSA) with respect to the labelling and packaging of vaping products.1 Canada’s physicians, who see the devastating effects of tobacco use every day in their practices, have been working for decades toward the goal of a smoke-free Canada. The CMA issued its first public warning concerning the hazards of tobacco in 1954 and has continued to advocate for the strongest possible measures to control its use. The CMA has always supported strong, comprehensive tobacco control legislation, enacted and enforced by all levels of government, and we continue to do so. This includes electronic cigarettes (e-cigarettes). Our approach to tobacco and vaping products is grounded in public health policy. We believe it is incumbent on all levels of government in Canada to continue working on comprehensive, coordinated and effective tobacco control strategies, including vaping products, to achieve the goal of reducing smoking prevalence. Introduction In our most recent brief, the CMA expressed its concerns regarding vaping and youth. This included marketing, flavours, nicotine levels, and reducing vaping and e-cigarette use among youths.2 In April 2019, the Council of Chief Medical Officers of Health expressed alarm at the rising number of Canadian youths who are vaping, having found this trend “very troubling.”3 The CMA concurred with this assessment and supports Health Canada’s intention to further tighten the regulations.2 Identifying Vaping Substances The findings of a recent Canadian study indicate an increase in vaping among adolescents in Canada and the United States.4 The growing acceptance of this practice is of concern to the CMA because of the rapidly emerging popularity of vaping products such as JUUL® and similar devices.4 It will be very important to identify clearly on the packaging all the vaping substances contained therein, along with a list of ingredients, as not enough is known about the long-term effects users may face.5,6 Users need to know what they are consuming so they can make informed choices about the contents. Studies have found substances in e-cigarette liquids and aerosols such as “nicotine, solvent carriers (PG and glycerol), tobacco-specific nitrosamines (TSNAs), aldehydes, metals, volatile organic compounds (VOCs), phenolic compounds, polycyclic aromatic hydrocarbons (PAHs), flavorings, tobacco alkaloids, and drugs.”7 Nicotine Content As Hammond et al noted in their recent study, “JUUL® uses benzoic acid and nicotine salt technology to deliver higher concentrations of nicotine than conventional e-cigarettes; indeed, the nicotine concentration in the standard version of JUUL® is more than 50 mg/mL, compared with typical levels of 3-24 mg/mL for other e-cigarettes.”4 The salts and flavours available to be used with these devices reduce the harshness and bitterness of the taste of the e-liquids. Some of its competition deliver even higher levels of nicotine.8 The CMA has expressed its concerns about the rising levels of nicotine available through the vaping process.2 They supply “high levels of nicotine with few of the deterrents that are inherent in other tobacco products. Traditional e-cigarette products use solutions with free-base nicotine formulations in which stronger nicotine concentrations can cause aversive user experiences.”9 The higher levels of nicotine in vaping devices is also of concern because it “affects the developing brain by increasing the risk of addiction, mood disorders, lowered impulse control, and cognitive impairment.”10,11 The CMA has called on Health Canada to restrict the level of nicotine in vaping products to avoid youth (and adults) from developing a dependence.2 4 Health Warnings The CMA reiterates, again, its position that health warnings for vaping should be similar to those for tobacco packages.12,13 We support placing warning labels on all vaping products, regardless of the size of the package. The “space given to the warnings should be sufficient to convey the maximum amount of information while remaining clear, visible, and legible. The warnings should be in proportion to the packaging available.”13 The need for such cautions is important as there is still much that is not known about the effects vaping can have on the human body. A US study found “evidence that using combusted tobacco cigarettes alone or in combination with e-cigarettes is associated with higher concentrations of potentially harmful tobacco constituents in comparison with using e-cigarettes alone.”14 Some researchers have found that there is “significant potential for serious lung toxicity from e-cig(arette) use.”15,16 Another recent US study indicates that “adults who report puffing e-cigarettes, or vaping, are significantly more likely to have a heart attack, coronary artery disease and depression compared with those who don’t use them or any tobacco products.”17 Further, it was found that “compared with nonusers, e-cigarette users were 56 percent more likely to have a heart attack and 30 percent more likely to suffer a stroke.17 A worrisome development has emerged in the United States. The Centers for Disease Control and Prevention is working in consultation with the states of Wisconsin, Illinois, California, Indiana, and Minnesota regarding a “cluster of pulmonary illnesses linked to e-cigarette product use, or “vaping,” primarily among adolescents and young adults.”18 Additional possible cases have been identified in other states and are being investigated. Child-Resistant Containers The CMA supports the need for child-resistant containers in order to enhance consumer safety; we have adopted a similar position with respect to cannabis in all forms.19,20 The need to include warning labels should reinforce the need for packaging these vaping products such that they will be inaccessible to small children. Recommendations 1. The CMA recommends more research into the health effects of vaping as well as on the components of the vaping liquids. 2. Health Canada should work to restrict the level of nicotine available for vaping products to avoid youth and adults from developing a dependence. 3. The CMA reiterates its position that health warnings for vaping should be like those being considered for tobacco packages. We support the proposed warning labels being placed on all vaping products. 4. The CMA recommends that all the vaping substances be identified clearly on the packaging, along with a list of ingredients. 5. The CMA supports the need for child-resistant containers. 5 1 Government of Canada. Canada Gazette, Part I, Volume 153, Number 25: Vaping Products Labelling and Packaging Regulations. Ottawa: Government of Canada; 2019. Available: http://gazette.gc.ca/rp-pr/p1/2019/2019-06-22/html/reg4-eng.html (accessed 2019 Jul 10). 2 Canadian Medical Association (CMA). Health Canada Consultation on Reducing Youth Access and Appeal of Vaping Products. Ottawa: CMA; 2019 May 24. Available: https://policybase.cma.ca/en/permalink/policy14078 (accessed 2019 Jul 10). 3 Public Health Agency of Canada. Statement from the Council of Chief Medical Officers of Health on the increasing rates of youth vaping in Canada. Ottawa: Health Canada; 2019. Available: https://www.newswire.ca/news-releases/statement-from-the-council-of-chief-medical-officers-of-health-on-the-increasing-rates-of-youth-vaping-in-canada-812817220.html (accessed 2019 Jul 24). 4 Hammond David, Reid Jessica L, Rynard Vicki L, et al. Prevalence of vaping and smoking among adolescents in Canada, England, and the United States: repeat national cross sectional surveys BMJ. 2019; 365:2219. Available: https://www.bmj.com/content/bmj/365/bmj.l2219.full.pdf (accessed 2019 Jul 24). 5 WHO Report on the Global Tobacco Epidemic, 2019. Geneva: World Health Organization; 2019. Available: https://apps.who.int/iris/bitstream/handle/10665/326043/9789241516204-eng.pdf?ua=1 (accessed 2019 Jul 30). 6 Dinakar, C., O’Connor GT. The Health Effects of Electronic Cigarettes. N Engl J Med. 2016;375:1372-81. Available: https://www.nejm.org/doi/full/10.1056/NEJMra1502466 (accessed 2019 Jul 30). 7 National Academies of Sciences, Engineering, and Medicine. Public health consequences of e-cigarettes. Washington, DC: The National Academies Press; 2018. Available: https://www.nap.edu/catalog/24952/public-health-consequences-of-e-cigarettes (accessed 2019 Jul 29). 8 Jackler RK, Ramamurthi D. Nicotine arms race: JUUL and the high-nicotine product market Tob Control 2019;0:1–6. 9 Barrington-Trimis JL, Leventhal AM. Adolescents’ Use of “Pod Mod” E-Cigarettes —Urgent Concerns. N Engl J Med 2018; 379:1099-1102. Available: https://www.nejm.org/doi/pdf/10.1056/NEJMp1805758?articleTools=true (accessed 2019 Jul 30). 10 Chen-Sankey JC, Kong G, Choi K. Perceived ease of flavored e-cigarette use and ecigarette use progression among youth never tobacco users. PLoS ONE 2019;14(2): e0212353. Available: https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0212353 (accessed 2019 Jul 30). 11 U.S. Department of Health and Human Services. E-Cigarette Use Among Youth and Young Adults. A Report of the Surgeon General. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health; 2016. Available: https://e-cigarettes.surgeongeneral.gov/documents/2016_sgr_full_report_non-508.pdf (accessed 2019 Jul 30). 12 Canadian Medical Association (CMA) CMA’s Recommendations for Bill S-5: An Act to amend the Tobacco Act and the Non-smokers’ Health Act and to make consequential amendments to other Acts. Ottawa: CMA; 2017 Apr 7. Available: https://policybase.cma.ca/en/permalink/policy13641 (accessed 2019 Jul 30). 13 Canadian Medical Association. Health Canada consultation on tobacco products regulations (plain and standardized appearance) Ottawa: CMA; 2018 Sep 6. Available: https://policybase.cma.ca/en/permalink/policy13930 (accessed 2019 Jul 30). 14 Goniewicz ML. et al. Comparison of Nicotine and Toxicant Exposure in Users of Electronic Cigarettes and Combustible Cigarettes JAMA Network Open. 2018;1(8):e185937. Available: https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2718096 (accessed 2019 Jul 30). 15 Chan LF. Et al. Pulmonary toxicity of e-cigarettes Am J Physiol Lung Cell Mol Physiol. 313: L193–L206, 2017 Available: https://www.physiology.org/doi/pdf/10.1152/ajplung.00071.2017 (accessed 2019 Jul 30). 16 Li D, Sundar IK, McIntosh S, et al. Association of smoking and electronic cigarette use with wheezing and related respiratory symptoms in adults: cross-sectional results from the Population Assessment of Tobacco and Health (PATH) study, wave 2. Tob Control. 0:1-8, 2019. 17 American College of Cardiology. E-Cigarettes Linked to Heart Attacks, Coronary Artery Disease and Depression. Media Release March 7, 2019 Available: https://www.acc.org/about-acc/press-releases/2019/03/07/10/03/ecigarettes-linked-to-heart-attacks-coronary-artery-disease-and-depression (accessed 2019 Jul 30). 18 Centers for Disease Control and Prevention. CDC, states investigating severe pulmonary disease among people who use e-cigarettes. Media Statement 2019 Aug 17. Available: https://www.cdc.gov/media/releases/2019/s0817-pulmonary-disease-ecigarettes.html (accessed 2019 Aug 20). 19 Canadian Medical Association (CMA). Health Canada Consultation on Edible Cannabis, Extracts & Topicals Ottawa: CMA; 2019 Feb 20. Available: https://policybase.cma.ca/en/permalink/policy14020 (accessed 2019 Aug 6). 20 Canadian Medical Association (CMA). Proposed Approach to the Regulation of Cannabis Submission to Health Canada. 2018 Jan 19 Available: https://policybase.cma.ca/en/permalink/policy13838. (accessed 2019 Aug 6).

Documents

Less detail

Health Canada consultation on potential market for cannabis health products that would not require practitioner oversight

https://policybase.cma.ca/en/permalink/policy14125

Date
2019-09-03
Topics
Health care and patient safety
Population health/ health equity/ public health
  1 document  
Policy Type
Response to consultation
Date
2019-09-03
Topics
Health care and patient safety
Population health/ health equity/ public health
Text
The Canadian Medical Association (CMA) appreciates this opportunity to respond to Health Canada’s consultation on potential markets for cannabis health products that would not require practitioner oversight.1 The CMA’s approach to cannabis is grounded in public health policy. It includes promotion of health and prevention of problematic use; access to assessment, counseling and treatment services; and a harm reduction perspective. The CMA endorsed the Lower-Risk Cannabis Use Guidelines2 and has expressed these views in our recommendations to the Task Force on Cannabis Legalization and Regulation,3 and recommendations regarding Bill C-45.4 As well, we submitted comments to Health Canada with respect to the consultation on the proposed regulatory approach for the Cannabis Act, Bill C-45.5 We also responded to Health Canada’s recent Consultation on Edible Cannabis, Extracts & Topicals.6 Overview The CMA first expressed its concerns about the sale of natural health products containing cannabis in our response to the proposed regulatory approach to the Cannabis Act, Bill C-45.5 We recognize that, in general, health products include prescription health products, non-prescription drugs, natural health products, cosmetics and medical devices. Although all these products are regulated by Health Canada, they are subject to different levels of scrutiny for safety, efficacy and quality, and in some cases, industry does not need to provide scientific evidence to support the claims made on the label. Health Claims As with all health products, the CMA supports an approach in which higher risk products, that is, those for which health claims are made, must be subject to a more meticulous standard of review. Rigorous scientific evidence is needed to support claims of health benefits and to identify potential risks and adverse reactions. We support Health Canada’s proposal that authorized health claims for cannabis health products (CHP) would be permitted for treatment of minor ailments, on the strict condition they are substantiated via a strong evidentiary process. It is the view of the CMA that all such products making a health claim must be reviewed thoroughly for efficacy, as well as safety and quality, for the protection of Canadians.5 Recent experience in the United States supports this approach. A warning letter was sent to Curaleaf Inc. of Wakefield, Massachusetts, by the US Food and Drug Administration (FDA) “for illegally selling unapproved products containing cannabidiol (CBD) online with unsubstantiated claims that the products treat cancer, Alzheimer’s disease, opioid withdrawal, pain and pet anxiety, among other conditions or diseases.”7 This is not the first time it was necessary for the FDA to take such action. The agency had sent letters on previous occasions to other businesses over claims “to prevent, diagnose, treat, or cure serious diseases, such as cancer. Some of these products were in further violation of the Federal Food, Drug and Cosmetic Act because they were marketed as dietary supplements or because they involved the addition of CBD to food.”7 The CMA shares the FDA’s concerns that such claims “can put patients and consumers at risk by leading them to put off important medical care.”7 A study conducted by Dalhousie University found that only 35.8% of respondents were familiar with the biochemical properties of CBD when asked what cannabinoid they thought was potentially a pain killer.8 Systematic reviews and guidelines have highlighted the state of the science and the limited indications for which there is evidence.9,10,11 Both cannabis and CBD specifically have been approved for use in a few conditions, but more research is needed in this rapidly growing field. For example, medical cannabinoids have been approved in several jurisdictions for the treatment of multiple sclerosis but the evidence of how well it works is limited. As the Canadian authors note, “carefully conducted, high-quality studies with thought given to the biologic activity of different cannabis components are still required to inform on the benefits of cannabinoids for patients with MS.”12 Consumers need to be reassured that health claims are being assessed thoroughly so they can make informed decisions.13 4 Packaging and Labelling Requirements The CMA has laid out its position with respect to packaging and labelling with respect to cannabis products.5,6 Strict packaging requirements are necessary as their wider availability raises several public health issues, not the least of which is ingestion by young children. Requirements for tamper-resistant and child-proof containers need to be in place to enhance consumer safety. To reiterate:
a requirement for plain and standard packaging
prohibition of the use of appealing flavours and shapes,
a requirement for adequate content and potency labelling,
a requirement for comprehensive health warnings,
a requirement for childproof packaging, and
a requirement that the content in a package should not be sufficient to cause a poisoning Prescription Drugs Containing Cannabis The CMA addressed prescription drugs containing cannabis in a previous brief.5 The level of proof required to obtain a Drug Identification Number (DIN) for prescription drugs is considerably higher than the level of proof required for a Natural Product Number (NPN); rigorous scientific evidence to support claims of efficacy is needed for a DIN but not for an NPN. Consumers generally do not know about this distinction, believing that Health Canada has applied the same level of scrutiny to the health claims made for every product. As a result, consumers presently do not have enough information to choose appropriate products. Prescription drugs are subject to Health Canada’s pharmaceutical regulatory approval process, based on each drug’s specific indication, dose, route of administration and target population. Health claims need to be substantiated via a strong evidentiary process. All potential prescription medications containing cannabis must meet a high standard of review for safety, efficacy and quality, equivalent to that of the approval of prescription drugs (e.g., Marinol® and Sativex®), to protect Canadians from further misleading claims. The CMA urges caution especially around exemptions for paediatric formulations that would allow for traits that would “appeal to youth.” The CMA understands that these products, used under strict health professional supervision, should be child friendly, for example, regarding palatability, but we do not support marketing strategies that would suggest their use is recreational (e.g., producing them in candy or animal formats). Recommendations 1. The CMA recommends that all cannabis health products, including those with CBD, making a health claim must be reviewed thoroughly for efficacy, as well as safety and quality, for the protection of Canadians. 2. The CMA recommends that strict packaging requirements be put in place with respect cannabis health products as their wider availability raises several public health issues, not the least of which is ingestion by young children. 3. The CMA recommends tamper-resistant and child-proof containers need to be in place to enhance consumer safety. 4. The CMA recommends that all potential prescription medications containing cannabis must meet a high standard of review for safety, efficacy and quality, equivalent to that of the approval of prescription drugs to protect Canadians from further misleading claims. 5 1Health Canada. Document: Consultation on Potential Market for Cannabis Health Products that would not Require Practitioner Oversight. Ottawa: Health Canada; 2019. Available: https://www.canada.ca/en/health-canada/programs/consultation-potential-market-cannabis/document.html (accessed 2019 Aug 8). 2 Fischer B, Russell C, Sabioni P, et al. Lower-risk cannabis use guidelines: A comprehensive update of evidence and recommendations. AJPH. 2017 Aug;107(8):e1-e12. Available: https://ajph.aphapublications.org/doi/abs/10.2105/AJPH.2017.303818?url_ver=Z39.88-2003&rfr_id=ori%3Arid%3Acrossref.org&rfr_dat=cr_pub%3Dpubmed&. (accessed 2019 Aug 8). 3 Canadian Medical Association (CMA). Legalization, regulation and restriction of access to marijuana. CMA submission to the Government of Canada – Task Force on cannabis, legalization and regulation. Ottawa: CMA; 2016 Aug 29. Available: https://policybase.cma.ca/en/permalink/policy11954 (accessed 2019 Aug 8). 4 Canadian Medical Association (CMA). Bill C-45: The Cannabis Act. Submission to the House of Commons Health Committee. Ottawa: CMA; 2017 Aug 18. Available: https://policybase.cma.ca/en/permalink/policy13723 (accessed 2019 Aug 8). 5 Canadian Medical Association (CMA). Proposed Approach to the Regulation of Cannabis. Ottawa: CMA; 2018 Jan 19. Available: https://policybase.cma.ca/en/permalink/policy13838 (accessed 2019 Aug 8). 6 Canadian Medical Association (CMA). Health Canada Consultation on Edible Cannabis, Extracts & Topicals Ottawa: CMA; Available: https://policybase.cma.ca/en/permalink/policy14020 (accessed 2019 Aug 8). 7 Food and Drug Administration (FDA). FDA warns company marketing unapproved cannabidiol products with unsubstantiated claims to treat cancer, Alzheimer’s disease, opioid withdrawal, pain and pet anxiety. Media Release. Silver Spring, MD: FDA; 2019 Jul 23. Available: https://www.fda.gov/news-events/press-announcements/fda-warns-company-marketing-unapproved-cannabidiol-products-unsubstantiated-claims-treat-cancer (accessed 2019 Aug 15). 8 Charlebois S., Music J., Sterling B. Somogyi S. Edibles and Canadian consumers’ willingness to consider recreational cannabis in food or beverage products: A second assessment. Faculty of Management: Dalhousie University; May, 2019 Available: https://cdn.dal.ca/content/dam/dalhousie/pdf/management/News/News%20%26%20Events/Edibles%20and%20Canadian%20Consumers%20English_.pdf (accessed 2019 Aug 20). 9 Allan GM. Et al. Simplified guideline for prescribing medical cannabinoids in primary care. Canadian Family Physician. Feb 2018;64(2):111. Available: https://www.cfp.ca/content/cfp/64/2/111.full.pdf (accessed 2019 Aug 29). 10 Health Canada. Information for Health Care Professionals. Cannabis (marihuana, marijuana) and the cannabinoids) Dried or fresh plant and oil administration by ingestion or other means Psychoactive agent. Ottawa: Health Canada; October 2018. Available: https://www.canada.ca/content/dam/hc-sc/documents/services/drugs-medication/cannabis/information-medical-practitioners/information-health-care-professionals-cannabis-cannabinoids-eng.pdf (accessed 2019 Aug 29). 11 National Academies of Sciences, Engineering, and Medicine. The health effects of cannabis and cannabinoids: Current state of evidence and recommendations for research. Washington, DC: The National Academies Press; 2017. Available: http://www.nationalacademies.org/hmd/reports/2017/health-effects-of-cannabis-and-cannabinoids.aspx (accessed 2019 Aug 29). 12 Slaven M., Levine O. Cannabinoids for Symptoms of Multiple Sclerosis JAMA Network Open. 2018;1(6):e183484. Available: https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2706491 (accessed 2019 Aug 26). 13 Food and Drug Administration (FDA). What You Need to Know (And What We’re Working to Find Out) About Products Containing Cannabis or Cannabis-derived Compounds, Including CBD Consumer Updates. Silver Spring, MD: FDA; 2019 July 17. Available: https://www.fda.gov/consumers/consumer-updates/what-you-need-know-and-what-were-working-find-out-about-products-containing-cannabis-or-cannabis (accessed 2019 Aug 29).

Documents

Less detail

Clinical guideline for homeless and vulnerably housed people, and people with lived homelessness experience

https://policybase.cma.ca/en/permalink/policy14165

Date
2019-10-17
Topics
Health care and patient safety
Population health/ health equity/ public health
  1 document  
Policy Type
Policy endorsement
Date
2019-10-17
Topics
Health care and patient safety
Population health/ health equity/ public health
Text
Homeless and vulnerably housed populations are heterogeneous and continue to grow in numbers in urban and rural settings as forces of urbanization collide with gentrification and austerity policies.2 Collectively, they face dangerous living conditions and marginalization within health care systems.3 However, providers can improve the health of people who are homeless or vulnerably housed, most powerfully by following evidence-based initial steps, and working with communities and adopting anti-oppressive practices.1,4,5 Broadly speaking, “homelessness” encompasses all individuals without stable, permanent and acceptable housing, or lacking the immediate prospect, means and ability of acquiring it.6 Under such conditions, individuals and families face intersecting social, mental and physical health risks that significantly increase morbidity and mortality.7,8 For example, people who are homeless and vulnerably housed experience a significantly higher prevalence of trauma, mental health conditions and substance use disorders than the general population.7,9 Canadian research reports that people who experience homelessness face life expectancies as low as 42 years for men and 52 years for women.7 A generation ago, homeless Canadians were largely middleaged, single men in large urban settings.10 Today, the epidemiology has shifted to include higher proportions of women, youth, Indigenous people (Box 1), immigrants, older adults and people from rural communities.13,14 For example, family homelessness (and therefore homelessness among dependent children and youth) is a substantial, yet hidden, part of the crisis.15 In 2014, of the estimated 235 000 homeless people in Canada, 27.3% were women, 18.7% were youth, 6% were recent immigrants or migrants, and a growing number were veterans and seniors.10 Practice navigators, peer-support workers and primary care providers are well placed to identify social causes of poor health and provide orientation to patient medical homes.16,17 A patient’s medical home is “a family practice defined by its patients as the place they feel most comfortable presenting and discussing their personal and family health and medical concerns.”18 Medical care is “readily accessible, centred on the patients’ needs, provided throughout every stage of life, and seamlessly integrated with other services in the health care system and the community” (https://patientsmedicalhome.ca). Primary care providers are also well positioned to mobilize health promotion, disease prevention, diagnosis and treatment, and rehabilitation services.19 GUIDELINE VULNERABLE POPULATIONS CPD Clinical guideline for homeless and vulnerably housed people, and people with lived homelessness experience Kevin Pottie MD MClSc, Claire E. Kendall MD PhD, Tim Aubry PhD, Olivia Magwood MPH, Anne Andermann MD DPhil, Ginetta Salvalaggio MD MSc, David Ponka MDCM MSc, Gary Bloch MD, Vanessa Brcic MD, Eric Agbata MPH MSc, Kednapa Thavorn PhD, Terry Hannigan, Andrew Bond MD, Susan Crouse MD, Ritika Goel MD, Esther Shoemaker PhD, Jean Zhuo Jing Wang BHSc, Sebastian Mott MSW, Harneel Kaur BHSc, Christine Mathew MSc, Syeda Shanza Hashmi BA, Ammar Saad, Thomas Piggott MD, Neil Arya MD, Nicole Kozloff MD, Michaela Beder MD, Dale Guenter MD MPH, Wendy Muckle BScN MHA, Stephen Hwang MD, Vicky Stergiopoulos MD, Peter Tugwell MD n Cite as: CMAJ 2020 March 9;192:E240-54. doi: 10.1503/cmaj.190777 CMAJ Podcasts: author interview at https://soundcloud.com/cmajpodcasts/190777-guide See related article at www.cmaj.ca/lookup/doi/10.1503/cmaj.200199 KEY POINTS
Clinical assessment and care of homeless and vulnerably housed populations should include tailoring approaches to a person’s gender, age, Indigenous heritage, ethnicity and history of trauma; and advocacy for comprehensive primary health care.
As initial steps in the care of homeless and vulnerably housed populations, permanent supportive housing is strongly recommended, and income assistance is also recommended.
Case-management interventions, with access to psychiatric support, are recommended as an initial step to support primary care and to address existing mental health, substance use and other morbidities.
Harm-reduction interventions, such as supervised consumption facilities, and access to pharmacologic agents for opioid use disorder, such as opioid agonist treatment, are recommended for people who use substances. GUIDELINE CMAJ
MARCH 9, 2020
VOLUME 192
ISSUE 10 E241 However, the social and health resources available to homeless and vulnerably housed people may vary based on geographic setting, municipal resources, housing coordination, and patients’ mental health and substance use–related care needs. In addition, many physical and mental health disorders remain undiagnosed or inconsistently treated because of missed opportunities for care, patient mistrust of the health care system or limited access to health services.3 Homeless and vulnerably housed people can benefit from timely and effective health, addiction and social interventions. Our guideline provides initial steps for practice, policy and future research, and is intended to build collaboration among clinicians, public health providers and allied health providers. Values such as trauma-informed and patient-centred care, and dignity are needed to foster trust and develop sustainable therapeutic relationships with homeless and vulnerably housed people.20,21 Scope The purpose of this clinical practice guideline is to inform providers and community organizations of the initial priority steps and effective interventions for homeless and vulnerably housed people. The guideline addresses upstream social and health needs (i.e., housing), as well as downstream health-related consequences of inadequate housing. The target audiences are health providers, policymakers, public health practitioners and researchers. Our guideline does not aim to address all conditions associated with homelessness, nor does it aim to discuss in depth the many etiologies of homelessness, such as childhood trauma, the housing market, or the root causes of low social assistance rates and economic inequality. Rather, this guideline aims to reframe providers’ approach toward upstream interventions that can prevent, treat and work toward ending the morbidity and mortality associated with homelessness. A parallel set of Indigenous-specific clinical guidelines is currently being developed by an independent, Indigenous-led team.22 This process recognizes the distinct rights of Indigenous Peoples, including the right to develop and strengthen their own economies, social and political institutions; the direct links between historic and ongoing colonial policies and Indigenous homelessness; and the need for Indigenous leadership and participation in research that is about Indigenous Peoples. Recommendations The steering committee and guideline panel members developed and approved recommendations to improve social and health outcomes for homeless and vulnerably housed people. The order of these recommendations highlights priority steps for homeless health care. We list a summary of the recommendations in Table 1 and we present our list of good practice statements in Table 2. These good practice statements are based on indirect evidence and support the delivery of the recommendations. The methods used to develop the recommendations are described later in this document. A summary of how to use this guideline is available in Box 2. Permanent supportive housing
Identify homelessness or housing vulnerability and willingness to consider housing interventions.
Ensure access of homeless or vulnerably housed individuals to local housing coordinator or case manager (i.e., call 211 or via a social worker) for immediate link to permanent supportive housing and/or coordinated access system (moderate certainty, strong recommendation). Evidence summary Our systematic review (Tim Aubry, University of Ottawa, Ottawa, Ont.: unpublished data, 2020) identified 14 trials on permanent supportive housing (PSH).30–43 Several trials across Canada and the United States showed that PSH initiatives house participants more rapidly compared with usual services (73 v. 220 d; adjusted absolute difference 146.4, 95% confidence interval [CI] 118.0 to 174.9);30 increase the number of people who maintain stable housing at 2 years (pooled odds ratio [OR] 3.58, 95% CI 2.36 to 5.43);30,40 and significantly increase the percentage of days spent stably housed.41 No trials showed a significant improvement in mental health symptoms compared with standard care.30,31,33,34,41,42 Two studies found that the mental health of PSH participants did not improve as much as that of usual care participants (e.g., mean difference –0.49, 95% CI –0.85 to –0.12).30,31 The At Home/Chez Soi trial showed small improvements in quality of life for high-needs (adjusted standardized mean difference 0.15, 95% CI 0.04 to 0.24)30 and moderate-needs (mean difference 4.37, 95% CI 1.60 to 7.14) homeless participants in patients receiving PSH.41 Youth receiving PSH saw larger improvements in their quality of life during the first 6 months (mean difference 9.30, 95% CI 1.35 to 17.24), which diminished over time (mean difference 7.29, 95% CI –1.61 to 16.18).44 No trials showed a significant improvement in substance use compared with standard care.30,33,41–43 Most trials reported no effect of PSH on acute care outcomes (e.g., number of emergency department visits and percentage of participants admitted to hospital).30,41 However, 2 trials suggest that PSH participants had lower rates of hospital admission (rate reductions of 29%, 95% CI 10 to 44) and time in hospital (e.g., mean difference –31, 95% CI –48 to –14).34,38,45 One trial found no effect of PSH on job tenure, hours of work per week or hourly wage compared with standard care.46 Participants receiving PSH may have increased odds of employment, but this depends on the severity of participant needs.46 One trial found no effect on income outcomes.46 Box 1: Indigenous homelessness Indigenous homelessness is a term used to describe First Nations, Métis and Inuit individuals, families or communities who lack stable, permanent and appropriate housing, or the immediate prospects, means or ability to acquire such housing. However, this term must be interpreted through an Indigenous lens to understand the factors contributing to this condition. These factors include individuals, families and communities isolated from their relationships to land, water, place, family, kin, each other, animals, cultures, languages and identities as well as the legacy of colonialism and genocide.11 It is estimated that urban Indigenous people are 8 times more likely to experience homelessness than the general population.11,12 GUIDELINE E242 CMAJ
ISSUE 10 The certainty of the evidence was rated moderate, because blinding of participants and personnel was not feasible in any of the trials we examined as a result of the nature of the intervention. Furthermore, several trials did not employ allocation concealment or blinding of outcome-assessment procedures, which could introduce high risks of detection and performance biases. Income assistance
Identify income insecurity.
Assist individuals with income insecurity to identify incomesupport resources and access income (low certainty, conditional recommendation). Evidence summary We identified 10 trials on income-assistance interventions, including rental assistance,47–56 financial empowerment,47 social enterprise interventions,48 individual placement and support,48,54 and compensated work therapy.52 Our systematic review showed the benefit that income-assistance interventions have on housing stability (Gary Bloch, University of Toronto, Toronto, Ont., and Vanessa Brcic, University of British Columbia, Vancouver, BC: unpublished data, 2020). Rental assistance increased the likelihood of being stably housed (OR 4.60, 95% CI 3.10 to 6.83).56 Rental assistance combined with case management increased the number of days in stable housing per 90-day period compared with case management alone (mean Table 1: Summary of evidence-based recommendations Recommendations and clinical considerations Grade rating* Recommendation 1: A homeless or vulnerably housed person Moderate certainty
Ensure access for homeless or vulnerably housed individuals to local housing coordinator or case manager (i.e., call 211 or via a social worker) for immediate link to permanent supportive housing and coordinated access system. Clinical considerations: Many jurisdictions will provide alternative housing services for specific marginalized populations, for example, Indigenous people, women and families, youth, those who identify as LGBTQ2+, those with disabilities, refugees and migrants. Strong recommendation Recommendation 2: A homeless or vulnerably housed person with experience of poverty, income instability or living in a low-income household Low certainty
Assist individuals with income insecurity to identify income-support resources and access income. Clinical considerations: Consult poverty screening tools when needed (e.g., https://cep.health/clinical-products /poverty-a-clinical-tool-for-primary-care-providers). Conditional recommendation Recommendation 3: A homeless or vulnerably housed person with multiple comorbid or complex health needs (including mental illness and/or substance use) Low certainty
Identify history of severe mental illness, such as psychotic or mood and anxiety disorders, associated with substantial disability, substance use, or multiple/complex health needs.
Ensure access to local community mental health programs, psychiatric services for assessment, and linkage to intensive case management, assertive community treatment or critical time intervention where available. Clinical considerations: Call 211 or consult primary care providers, social workers or case managers familiar with local access points and less intensive community mental health programs. Conditional recommendation Recommendation 4: A homeless or vulnerably housed person currently using opioids Very low certainty
Identify opioid use disorder.
Ensure access within primary care or via an addiction specialist to opioid agonist therapy (OAT), potentially in collaboration with a public health or community health centre for linkage to pharmacologic interventions. Clinical considerations: Encourage all patients taking opioid medication to have a naloxone kit. Though barriers to prescribing methadone and buprenorphine remain, be aware of new regulations that aim to facilitate OAT access and options in your jurisdiction, in particular for buprenorphine. Conditional recommendation Recommendation 5: A homeless or vulnerably housed person with substance use disorder Very low certainty
Identify, during history or physical examination, problematic substance use, including alcohol or other drugs.
Identify the most appropriate approach, or refer to local addiction and harm-reduction/prevention services (e.g., supervised consumption facilities, managed alcohol programs) via appropriate local resources such as public health or community health centre or local community services centre. Clinical considerations: In case of active opioid use disorder, facilitate patient access to OAT. Patients should be made aware of supervised consumption facility locations (Appendix 1, available at www.cmaj.ca/lookup/suppl/ doi:10.1503/cmaj.190777/-/DC1). Conditional recommendation Note: LGBTQ2+ = lesbian, gay, bisexual, transgender, questioning and two-spirited. *See Box 2 for definitions. †211 is a special abbreviated telephone number reserved in Canada and the United States as an easy-to-remember 3-digit telephone number meant to provide information and referrals to health, human and social service organizations. GUIDELINE CMAJ
ISSUE 10 E243 difference 8.58, p < 0.004).55 Compensated work therapy was found to reduce the odds of homelessness (OR 0.1, 95% CI 0.1 to 0.3).52 No income interventions showed an effect on mental health outcomes.47,52,55,56 The impact of these interventions on substance use outcomes were mixed. Provision of housing vouchers did not affect substance use over 3 years;55 however, compensated work therapy showed immediate reductions in drug (reduction: –44.7%, standard error [SE] 12.8%; p = 0.001) and alcohol use problems (–45.4%, SE 9.4%; p = 0.001), as well as the number of substance use–related physical symptoms (–64.4%, SE 8.0%; p = 0.001).52 These differences, however, tended to decline with time. No significant effects were found on overall quality-of-life, finances, health and social relations scores. Provision of housing vouchers resulted in higher family-relations score and satisfaction, and quality of housing compared with standard care.55 One trial reported that rental assistance was associated with reduced emergency department visits and time spent in hospital, but this reduction was not significantly different than in the comparator group.56 Individual placement and support was found to improve employment rates only when there was high fidelity to the model (OR 2.42, 95% CI 1.13 to 5.16).54 Financial-empowerment education and provision of housing vouchers had no effect on employment outcomes.47,55 Financial-empowerment education and individual placement and support had no effect on hourly wages.47,54 Provision of housing vouchers had no effect on monthly income.55 The certainty of the evidence was rated low because several trials introduced high risk of detection and performance bias. Furthermore, 1 trial reported low consent rates of 47% and a 1:4 sampling ratio that further limited statistical power.52 As well, participants in the control group wanting to enter income-assistance programs after completing the study had incentives to underreport symptoms, which introduced high risk for measurement bias. Case management
Identify history of severe mental illness, such as psychotic or mood and anxiety disorders, associated with substantial disability, substance use disorders, or multiple or complex health needs.
Ensure access to local community mental health programs, psychiatric services for assessment and linkage to intensive case management, assertive community treatment or critical time intervention where available (low certainty, conditional recommendation). Evidence summary Our systematic review examined the effectiveness of standard case management, as well as specific intensive casemanagement interventions, such as assertive community treatment, intensive case management and critical time intervention among homeless and vulnerably housed populations and corresponding level of need (David Ponka, University of Ottawa, Ottawa, Ont.: unpublished data, 2020). We included a total of 56 citations, of which 10 trials reported on standard case management,51,57–65 8 trials on assertive community treatment,66–73 16 trials on intensive case management74–89 and 5 trials on critical time intervention.90–94 Box 2: How to use and understand this GRADE guideline (www.gradeworkinggroup.org) This guideline supplies providers with evidence for decisions concerning interventions to improve health and social outcomes for people who are homeless or vulnerably housed. This guideline is not meant to replace clinical judgment. Statements about clinical considerations, values and preferences are integral parts of the recommendations meant to facilitate interpretation and implementation of the guideline. Recommendations in this guideline are categorized according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system as strong or conditional recommendations. Strong recommendations indicate that all or almost all fully informed patients would choose the recommended course of action, and indicate to clinicians that the recommendation is appropriate for all or almost all individuals. Strong recommendations represent candidates for quality-of-care criteria or performance indicators. Conditional recommendations indicate that most informed patients would choose the suggested course of action, but an appreciable minority would not. With conditional recommendations, clinicians should recognize that different choices will be appropriate for individual patients, and they should help patients arrive at a decision consistent with their values and preferences. Conditional recommendations should not be used as a basis for standards of practice (other than to mandate shared decision-making). Good practice statements represent common-sense practice, are supported by indirect evidence and are associated with assumed large net benefit. Clinical considerations provide practical suggestions to support implementation of the GRADE recommendation. GRADE certainty ratings High: further research is very unlikely to change our confidence in the estimate of effect. Moderate: further research is likely to have an important impact on the confidence in the estimate of effect and may change the estimate. Low: further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate. Very low: any estimate of the effect is very uncertain. Table 2: Good practice statements to support delivery of care Good practice statement Indirect evidence (reference) 1. Homeless and vulnerably housed populations should receive trauma-informed and personcentred care. 23–26 2. Homeless and vulnerably housed populations should be linked to comprehensive primary care to facilitate the management of multiple health and social needs. 27 3. Providers should collaborate with public health and community organizations to ensure programs are accessible and resources appropriate to meet local patient needs. 28,29 GUIDELINE E244 CMAJ
ISSUE 10 Of 10 trials on standard case management, 10 evaluated housing stability. Only 3 reported significant decreases in homelessness,57,62,63 an effect that diminished over time in 1 trial of a time-limited residential case management in which participants in all groups accessed substantial levels of services.57 A program tailored to women reduced the odds of depression at 3 months (OR 0.38, 95% CI 0.14 to 0.99), but did not show improvements in the women’s overall mental health status (mean difference 4.50, 95% CI –0.98 to 9.98).64 One trial reported higher levels of hostility (p < 0.001) and depression symptoms (p < 0.05) among female participants receiving nurse-led standard case management compared with those receiving standard care.60 Few studies reported on substance use, quality of life, employment or income outcomes. Findings of assertive community treatment on housingstability, quality-of-life and hospital-admission outcomes are mixed. Two trials found that participants receiving the treatment reported fewer days homeless (p < 0.01)71 and more days in community housing (p = 0.006),70 whereas 2 trials reported no effect on episodes of homelessness or number of days homeless.66,73 Further, these interventions showed an added benefit in reducing the number of participants admitted to hospital (mean difference –8.6, p < 0.05) and with visits to the emergency department (mean difference –1.2, p = 0.009).67 Most trials of assertive community treatment reported no significant differences in mental health outcomes, including psychiatric symptoms, substance use, or income-related outcomes between the treatment and control groups. Intensive case management reduced the number of days homeless (pooled standardized mean difference –0.22, 95% CI –0.40 to –0.03), but not the number of days spent in stable housing.78,80,89 In most studies, there was no major improvement in psychological symptoms between the treatment and control groups. However, 1 trial reported significantly greater reductions in anxiety, depression and thought disturbances after 24 months (mean difference change from baseline –0.32, p = 0.007), as well as improved life satisfaction (mean difference 1.23, p = 0.001) using intensive case management.86 One trial reported no significant difference in quality of life.83 Findings on substance use were mixed. Six of the 10 trials reported that intensive case management was associated with improvements in substance use behaviours.74,78,82,84,87,88 Participants receiving intensive case management reported fewer visits to the emergency department (mean difference 19%, p < 0.05) but did not have shorter hospital stays compared with control groups.85 Intensive case management had no effect on the number of days of employment, or on income received from employment; however, income received by participants through public assistance increased (e.g., mean difference 89, 95% CI 8 to 170).78,85 Critical time intervention was beneficial in reducing the number of homeless nights (mean difference –591, p < 0.001) and the odds of homelessness (OR 0.23, 95% CI 0.06 to 0.90) during the final 18 weeks of follow-up.91 Participants receiving the treatment were rehoused sooner than those receiving standard care,95 but did not spend more days rehoused.90 Adults receiving critical time intervention showed significant improvements in psychological symptoms (mean difference –0.14, 95% CI –0.29 to 0.01).90 However, findings for children’s mental health were mixed: children aged 1.5–5 years showed improvements in internalizing (ß coefficient –3.65, 95% CI –5.61 to –1.68) and externalizing behaviours (ß coefficient –3.12, 95% CI –5.37 to –0.86), whereas changes for children aged 6–10 years and 11–16 years were not significant.93 There were no significant effects of critical time intervention on substance-use,90 quality-of-life90,92 or income-related outcomes.96 Two trials reported mixed findings on hospital admission outcomes; in 1 study, allocation to critical time intervention was associated with reduced odds of hospital admission (OR 0.11, 95% CI 0.01 to 0.96) and total number of nights in hospital (p < 0.05) in the final 18 weeks of the trial.97 However, another study reported a greater total number of nights in hospital for the treatment group compared with usual care (1171 v. 912).98 The certainty of the evidence was rated low because several trials introduced high risk of detection and performance bias. Opioid agonist therapy
Ensure access to opioid agonist therapy in primary care or by referral to an addiction specialist, potentially in collaboration with public health or community health centre for linkage to pharmacologic interventions (low certainty, conditional recommendation). Evidence summary We conducted a review of systematic reviews on pharmalogic interventions for opioid use disorder.99 Twenty-four reviews, which included 352 unique primary studies, reported on pharmacologic interventions for opioid use disorder among general populations.100–123 We expanded our inclusion criteria to general populations, aware that most studies among “general populations” had a large representation of homeless populations in their samples. We did not identify any substantial reason to believe that the mechanisms of action of our interventions of interest would differ between homeless populations who use substances and the general population of people who use substances. Reviews on pharmacologic interventions reported on the use of methadone, buprenorphine, diacetylmorphine (heroin), levo-a-acetylmethadol, slow-release oral morphine and hydromorphone for treatment of opioid use disorder. We found pooled all-cause mortality rates of 36.1 and 11.3 per 1000 person years for participants out of and in methadone maintenance therapy, respectively (rate ratio 3.20, 95% CI 2.65 to 3.86), and mortality rates of 9.5 per 1000 person years for those not receiving buprenorphine maintenance therapy compared with 4.3 per 1000 person years among those receiving the therapy (rate ratio 2.20, 95% CI 1.34 to 3.61).116 Overdose-specific mortality rates were similarly affected, with pooled overdose mortality rates of 12.7 and 2.6 per 1000 person years for participants out of and in methadone maintenance therapy, and rates of 4.6 and 1.4 per 1000 person years out of and in buprenorphine maintenance therapy.116 Compared with nonpharmacologic approaches, methadone maintenance therapy had no significant GUIDELINE CMAJ
ISSUE 10 E245 effect on mortality (relative risk 0.48, 95% CI 0.10 to 2.39).110 With respect to morbidity, pharmacologic interventions for opioid use disorder reduced the risk of hepatitis C virus (HCV) acquisition (risk ratio 0.50, 95% CI 0.40 to 0.63)112 and HIV infection.103 Adverse events were reported for all agents.100,109,119,122 Treatment with methadone and buprenorphine was associated with reduced illicit opioid use (standardized mean difference –1.17, 95% CI –1.85 to –0.49).109 Availability of buprenorphine treatment expanded access to treatment for patients unlikely to enrol in methadone clinics and facilitated earlier access for recent initiates to opioid use.117 The relative superiority of one pharmacologic agent over another on retention outcomes remains unclear; however, use of methadone was found to show better benefits than nonpharmacologic interventions for retention (risk ratio 4.44, 95% CI 3.26 to 6.04).110 The certainty of evidence ranged from very low to moderate, primarily because of inconsistency, high risk of bias and evidence from nonrandomized studies. Harm-reduction interventions
Identify problematic substance use, including alcohol or other drugs.
Identify the most appropriate approach or refer to local addiction and harm reduction/prevention services (e.g., supervised consumption facilities, managed alcohol programs) via appropriate local resources, such as public health or community health centre or les centres locaux de services communautaires (low certainty, conditional recommendation). Evidence summary We conducted a review of systematic reviews on supervised consumption facilities and managed alcohol programs.99 Two systematic reviews, which included 90 unique observational studies and 1 qualitative meta-synthesis reported on supervised consumption facilities.124–126 For managed alcohol programs, 1 Cochrane review had no included studies,127 and 2 greyliterature reviews reported on 51 studies.128,129 Establishment of supervised consumption facilities was associated with a 35% decrease in the number of fatal opioid overdoses within 500 m of the facility (from 253.8 to 165.1 deaths per 100 000 person years, p = 0.048), compared with 9% in the rest of the city (Vancouver).124 There were 336 reported opioid overdose reversals in 90 different individuals within the Vancouver facility over a 4-year period (2004–2008).125 Similar protective effects were reported in Australia and Germany. Observational studies conducted in Vancouver and Sydney showed that regular use of supervised consumption facilities was associated with decreased syringe sharing (adjusted OR 0.30, 95% CI 0.11 to 0.82), syringe reuse (adjusted OR 2.04, 95% CI 1.38 to 3.01) and public-space injection (adjusted OR 2.79, 95% CI 1.93 to 3.87).125 These facilities mediated access to ancillary services (e.g., food and shelter) and fostered access to broader health support.125,126 Attendance at supervised consumption facilities was associated with an increase in referrals to an addiction treatment centre and initiation of methadone maintenance therapy (adjusted hazard ratio 1.57, 95% CI 1.02 to 2.40).125 Evidence on supervised consumption facilities was rated very low to low, as all available evidence originated from nonrandomized studies. There was a lack of high-quality evidence for managed alcohol programs. Few studies reported on deaths among clients of these programs.128 The effects of managed alcohol programs on hepatic function are mixed, with some studies reporting improvement in hepatic laboratory markers over time, and others showing increases in alcohol-related hepatic damage;129 however, this may have occurred regardless of entry into such a program. This evidence suggested that managed alcohol programs result in stabilized alcohol consumption and can facilitate engagement with medical and social services.128 Clients experienced significantly fewer social, health, safety and legal harms related to alcohol consumption.129 Individuals participating in these programs had fewer hospital admissions and a 93% reduction in emergency service contacts.128 The programs also promoted improved or stabilized mental health128 and medication adherence.129 Cost effectiveness and resource implications Permanent supportive housing We found 19 studies assessing the cost and net cost of housing interventions.30,41,45,130–145 In some studies, permanent supportive housing interventions were associated with increased cost to the payers, and the costs of the interventions were only partially offset by savings in medical and social services as a result of the intervention.30,41,131–134,142 Six studies showed that these interventions saved payers money.135,137,139,141,144,145 Four of these studies, however, employed a pre–post design.135,139,141,145 Moreover, 1 cost-utility analysis of PSH suggested that the provision of housing services was associated with increased costs and increased quality-adjusted life years, with an incremental cost-effectiveness ratio of US$62 493 per quality-adjusted life year.136 Compared with usual care, PSH was found to be more costly to society (net cost Can$7868, 95% CI $4409 to $11 405).138 Income assistance Two studies55,146 focused on the cost effectiveness of incomeassistance interventions. Rental assistance with clients receiving case-management intervention had greater annual costs compared with usual care or groups receiving only case management.55 For each additional day housed, clients who received income assistance incurred additional costs of US$58 (95% CI $4 to $111) from the perspective of the payer, US$50 (95% CI –$17 to $117) from the perspective of the health care system and US$45 (95% CI –$19 to $108) from the societal perspective. The benefit gained from temporary financial assistance was found to outweigh its costs with a net savings of US$20 548.146 Case management Twelve publications provided evidence on cost and costeffectiveness of case-management interventions.44,55,67,69,73,75,88,96,147–150 Findings of these studies were mixed; the total cost incurred by clients of standard case management was higher than that of clients receiving usual or standard care61,88 and assertive GUIDELINE E246 CMAJ
ISSUE 10 community treatment,67,147 but lower compared with a US clinical case-management program that included housing vouchers and intensive case management.55 Cost-effectiveness studies using a societal perspective showed that standard case management was not cost effective compared with assertive community treatment for people with serious mental disorders or those with a concurrent substance-use disorder, as it was more expensive.67 For intensive case management, the cost of supporting housing with this program could be partially offset by reductions in the use of emergency shelters and temporary residences.41 Intensive case management is more likely to be cost effective when all costs and benefits to society are considered.41 A pre–post study showed that providing this program to high-need users of emergency departments resulted in a net hospital cost savings of US$132 726.150 Assertive community treatment interventions were associated with lower costs compared with usual care.66,67,73,148,149 We identified only 1 study on the cost effectiveness of critical time intervention that reported comparable costs (US$52 574 v. US$51 749) of the treatment compared with the usual services provided to men with severe mental illness.96 Interventions for substance use We identified 2 systematic reviews that reported findings from 6 studies in Vancouver on the cost effectiveness of supervised consumption facilities;124,125 5 of these 6 studies found the facilities to be cost effective. After consideration of facility operating costs, supervised consumption facilities saved up to Can$6 million from averted overdose deaths and incident HIV cases. Similarly, Can$1.8 million was saved annually from the prevention of incident HCV infection. Clinical considerations Providers can, in partnership with directly affected communities, employ a range of navigation and advocacy tools to address the root causes of homelessness, which include poverty caused by inadequate access to social assistance, precarious work, insufficient access to quality child care, social norms that allow the propagation of violence in homes and communities, inadequate supports for patients and families living with disabilities or going through life transitions, and insufficient and poor-quality housing stock.151 In addition, providers should tailor their approach to the patient’s needs and demographics, taking into account access to services, personal preferences and other illnesses.152 Providers should also recognize the social and human value of accepting homeless and vulnerably housed people into their clinical practices. The following sections provide additional evidence for underserved and marginalized populations. Women A scoping review of the literature on interventions for homeless women (Christine Mathew, Bruyère Research Institute, Ottawa, Ont.: unpublished data, 2020) yielded 4 systematic reviews153–156 and 9 randomized controlled trials (RCTs)36,60,92,95,157–161 that focused specifically on homeless and vulnerably housed women. Findings showed that PSH was effective in reducing the risk of intimate partner violence and improving psychological symptoms.158 For women with children experiencing homelessness, priority access to permanent housing subsidies can reduce child separations and foster care placements, allowing women to maintain the integrity of their family unit.158 As well, Housing First programs for families, critical time interventions during times of crisis, and therapeutic communities are associated with lower levels of psychological distress, increased self-esteem and improved quality of life for women and their families.92,155 A gender-based analysis highlighted the importance of safety, service accessibility and empowerment among homeless women. We suggest that providers focus on patient safety, empowerment among women who have faced genderbased violence, and improve access to resources, including income, child care and other social support services. Youth A systematic review on youth-specific interventions reported findings from 4 systematic reviews and 18 RCTs.162 Permanent supportive housing improved housing stability. As well, individual cognitive behavioural therapy has been shown to result in significant improvements in depression scores, and family-based therapies are also promising, resulting in reductions in youth substance use through restoring the family dynamic. Findings on motivational interviewing, skill building and case-management interventions were inconsistent, with some trials showing a positive impact and others not identifying significant benefits. Refugee and migrant populations A qualitative systematic review on homeless migrants (Harneel Kaur, University of Ottawa, Ottawa, Ont.: unpublished data, 2020) identified 17 qualitative articles that focused on the experiences of homeless migrants.163–179 Findings indicated that discrimination, limited language proficiency and severed social networks negatively affected homeless migrants’ sense of belonging and access to social services, such as housing. However, employment opportunities provided a sense of independence and improved social integration. Methods Composition of participating groups In preparation for the guideline, we formed the Homeless Health Research Network (https://methods.cochrane.org/equity/ projects/homeless-health-guidelines), composed of clinicians, academics, and governmental and nongovernmental stakeholders. The Homeless Health Guideline Steering Committee (K.P. [chair], C.K., T.A., A.A., G.S., G.B., D.P., E.A., V.B., V.S. and P.T.) was assembled to coordinate guideline development. Expert representation was sought from eastern and western Canada, Ontario, Quebec and the Prairie provinces for membership on the steering committee. In addition, 5 people with lived experience of homelessness (herein referred to as “community scholars”180) were recruited to participate in the guideline-development activities. A management committee (K.P., C.K. and P.T.) oversaw the participating groups and monitored competing interests. The steering committee decided to develop a single guideline publication informed by a series of 8 systematic reviews. The GUIDELINE CMAJ
ISSUE 10 E247 steering committee assembled expert working groups to operationalize each review. Each working group consisted of clinical topic experts and community scholars who were responsible for providing contextual expertise. The steering committee also assembled a technical team, which provided technical expertise in the conduct and presentation of systematic reviews and meta-analyses. Finally, the steering committee assembled the guideline panel, which had the responsibility to provide external review of the evidence and drafted recommendations. The panel was composed of 17 individuals, including physicians, primary care providers, internists, psychiatrists, public health professionals, people with lived experience of homelessness, medical students and medical residents. Panel members had no financial or intellectual conflicts of interest. A full membership list of the individual teams’ composition is available in Appendix 2, available at www.cmaj.ca/lookup/ suppl/doi:10.1503/cmaj.190777/-/DC1. Selection of priority topics We used a 3-step modified Delphi consensus method (Esther Shoemaker, Bruyère Research Institute, Ottawa, Ont.: unpublished data, 2020) to select priority health conditions for marginalized populations experiencing homelessness or vulnerable housing. Briefly, between May and June 2017, we developed and conducted a survey (in French and English), in which we asked 84 expert providers and 76 people with lived homelessness experience to rank and prioritize an initial list of needs and populations. We specifically asked participants, while answering the Delphi survey, to keep in mind 3 priority-setting criteria when considering the unique challenges of implementing health care for homeless or vulnerably housed people: value added (i.e., the opportunity for a unique and relevant contribution), reduction of unfair and preventable health inequities, and decrease in burden of illness (i.e., the number of people who may have a disease or condition).181 The initial top 4 priority needs identified were as follows: facilitating access to housing, providing mental health and addiction care, delivering care coordination and case management, and facilitating access to adequate income. The priority marginalized populations identified included Indigenous people; women and families; youth; people with acquired brain injury, or intellectual or physical disabilities; and refugees and other migrants (Esther Shoemaker, Bruyère Research Institute, Ottawa, Ont.: unpublished data, 2020). Each working group then scoped the literature using Google Scholar and PubMed to determine a list of interventions and terms relating to each of the priority-need categories. Each working group came to consensus on the final list of interventions to be included (Table 3). Guideline development We followed the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach for the development of this clinical guideline, including the identification of clinical questions, systematic reviews of the best available evidence, Table 3: Descriptions of priority-need interventions Intervention Description Permanent supportive housing
Long-term housing in the community with no set preconditions for access. Housing may be paired with the provision of individualized supportive services that are tailored to participants’ needs and choices, including assertive community treatment and intensive case management.
This guideline groups the Housing First model (a homeless assistance approach that prioritizes providing housing) with permanent supportive housing. Income assistance
Benefits and programs that improve socioeconomic status. This may include assistance that directly increases income and programs that help with cost reduction of basic living necessities.
This guideline also groups employment programs (e.g., individual placement and support, and compensated work therapy) in this category. Case management
Standard case management allows for the provision of an array of social, health care and other services with the goal of helping the client maintain good health and social relationships.
Intensive case management offers the support of a case manager who brokers access to an array of services. Case-management support can be available for up to 12 hours per day, 7 days a week, and each case manager often has a caseload of 15–20 service users.
Assertive community treatment offers team-based care to individuals with severe and persistent mental illness by a multidisciplinary group of health care workers in the community. This team should be available 24 hours per day, 7 days per week.
Critical time intervention supports continuity of care for service users during times of transition. Case management is administered by a critical time intervention worker and is a time-limited service, usually lasting 6–9 months. Pharmacologic interventions for substance use disorder
Pharmacologic interventions for opioid use disorder, including methadone, buprenorphine, diacetylmorphine, levo-a-acetylmethadol and naltrexone.
Pharmacologic agents for reversal of opioid overdose: opioid antagonist administered intravenously or intranasally (e.g., naloxone). Harm reduction for substance use disorders
Supervised consumption facilities: facilities (stand-alone, co-located or pop-up) where people who use substances can consume preobtained substances under supervision.
Managed alcohol programs: shelter, medical assistance, social services and the provision of regulated alcohol to support residents with severe alcohol use disorder. GUIDELINE E248 CMAJ
ISSUE 10 assessment of the certainty of the evidence and development of recommendations.182 We conducted a series of systematic reviews to answer the following clinical question: Should PSH, income assistance, case management, pharmacologic agents for opioid use, and/or harm-reduction interventions be considered for people with lived experience of homelessness? Systematic reviews for each intervention were driven by a logic model. A detailed description of the methods used to compile evidence summaries for each recommendation, including search terms, can be found in Appendix 3, available at www.cmaj.ca/ lookup/suppl/doi:10.1503/cmaj.190777/-/DC1. We sought evidence on questions considering population, interventions and comparisons according to published a priori protocols.183–186 We used relevant terms and structured search strategies in 9 bibliographic databases for RCTs and quasi-experimental studies. The technical team reviewed titles, abstracts and full texts of identified citations, selected evidence for inclusion and compiled evidence reviews, including cost-effectiveness and resource-use data, for consideration by the guideline panel. The technical team collected and synthesized data on the following a priori outcomes: housing stability, mental health, quality of life, substance use, hospital admission, employment and income. Where possible, we conducted meta-analyses with random effects and assessed certainty of evidence using the GRADE approach. Where pooling of results was not appropriate, we synthesized results narratively. In addition to the intervention and cost-effectiveness reviews, the technical team conducted 3 systematic reviews to collect contextual and population-specific evidence for the populations prioritized through our Delphi process (women, youth, refugees and migrants) (Christine Mathew, Bruyère Research Institute, Ottawa, Ont.: unpublished data, 2020; Harneel Kaur, University of Ottawa, Ottawa, Ont.: unpublished data, 2020).162 Additionally, we conducted 1 qualitative literature review to capture patient values and preferences, focused on the experiences of people who are homeless in engaging with our selected interventions.20 Drafting of recommendations The steering committee hosted a 2-day knowledge-sharing event, termed the “Homeless Health Summit,” on Nov. 25–26, 2018. Attendees included expert working group members, community scholars, technical team members, and other governmental and nongovernmental stakeholders. Findings from all intervention reviews were presented and discussed according to the GRADE Evidence to Decision framework.187 After the meeting, the steering committee drafted GRADE recommendations (Box 2) through an iterative consensus process. All steering-committee members participated in multiple rounds of review and revision of the drafted clinical recommendations. Guideline panel review We used the GRADE Evidence to Decision framework to facilitate the development of recommendations187–189 (Appendix 4, available at www.cmaj.ca/lookup/suppl/doi:10.1503/cmaj.190777/-/DC1). We used GRADEpro and the Panel Voice software to obtain input from the guideline panel.190 Panellists provided input on the wording and strength of the draft recommendations. They also provided considerations for clinical implementation. We required endorsement of recommendations by 60% of panel members for acceptance of a recommendation. After review by the guideline panel, the steering committee reviewed the final recommendations before sign-off. Good practice statements We developed a limited number of good practice statements to support the delivery of the initial evidence-based recommendations. A good practice statement characteristically represents situations in which a large and compelling body of indirect evidence strongly supports the net benefit of the recommended action, which is necessary for health care practice.191–193 Guideline-development groups consider making good practice statements when they have high confidence that indirect evidence supports net benefit, there is a clear and explicit rationale connecting the indirect evidence, and it would be an onerous and unproductive exercise and thus a poor use of the group’s limited resources to collect this evidence. The steering committee came to a consensus on 3 good practice statements based on indirect evidence. Identification of implementation considerations We completed a mixed-methods study to identify determinants of implementation across Canada for the guideline (Olivia Magwood, Bruyère Research Institute, Ottawa, Ont.: unpublished data, 2020). Briefly, the study included a survey of 88 stakeholders and semistructured interviews with people with lived experience of homelessness. The GRADE Feasibility, Acceptability, Cost (affordability) and Equity (FACE) survey collected data on guideline priority, feasibility, acceptability, cost, equity and intent to implement. We used a framework analysis and a series of meetings (Ottawa, Ont., Jan. 13, 2020; Hamilton, Ont., Aug. 16, 2019; Gatineau, Que., July 18, 2019) with relevant stakeholders in the field of homeless health to analyze our implementation data. Management of competing interests Competing interests were assessed using a detailed form adapted from the International Committee of Medical Journal Editors Uniform Disclosure Form for Potential Conflicts of Interest194 and the Elsevier sample coauthor agreement form for a scientific project, contingencies and communication.195 These forms were collected at the start of the guideline activities for the steering committee, guideline panel and community scholars. All authors submitted an updated form in June 2019 and before publication. The management committee iteratively reviewed these statements and interviewed participants for any clarifications and concerns. A priori, the management committee had agreed that major competing interests would lead to dismissal. There were no competing interests declared. Implementation Our mixed-methods study (Olivia Magwood, Bruyère Research Institute, Ottawa, Ont.: unpublished data, 2020) looking at guideline priority, feasibility, acceptability, cost, equity and intent to implement, identified the following concerns regarding implementation of this guideline. GUIDELINE CMAJ
ISSUE 10 E249 Stakeholders highlighted the importance of increasing primary care providers’ knowledge of the process of applying to PSH programs and informing their patients about the resources available in the community. The major concerns regarding feasibility arose around the limited availability of existing services, such as housing, as well as administrative and human resources concerns. For example, not all primary care providers work in a team-based comprehensive care model and have access to a social worker or care coordinator who can help link the patient to existing services. Furthermore, wait lists for PSH are frequently long. Despite this, all stakeholders agreed that access to PSH was a priority and is a feasible recommendation. Allied health practitioners and physicians do not always agree with their new role in this area. Some feedback suggested pushback from family physicians who have limited time with patients and less experience exploring social determinants of health, such as housing or income. The initial steps outlined in this guideline would come at an opportunity cost for them. Stigma attached to the condition of homelessness was recognized as an important barrier to care for homeless populations. Many stakeholders recognized that successful implementation of these recommendations may require moderate costs to increase the housing supply, income supports and human resources. However, supervised consumption facilities, with their range of benefits, were perceived as cost-saving. Many interventions have the potential to increase health equity, if available and accessible in a local context. Many stakeholders highlighted opportunities to increase knowledge of the initial steps and advocate on a systematic level to increase availability of services. Suggested performance measures We developed a set of performance measures to accompany this guidleline for consideration by providers and policy-makers:
The proportion of adults who are assessed for homelessness or vulnerable housing over 1 year.
The proportion of eligible adults who are considered for income assistance over 1 year.
The proportion of eligible adults using opioids who are offered opioid agonist therapy over 1 year. Updates The Homeless Health Research Network will be responsible for updating this guideline every 5 years. Other guidelines This guideline complements other published guidelines. This current guideline aims to support the upcoming Indigenousspecific guidelines that recognize the importance of Indigenous leadership and methodology that will recognize distinct underlying causes of Indigenous homelessness (Jesse Thistle, York University, Toronto, Ont.: personal communication, 2020). The World Health Organization has developed guidelines to promote healthy housing standards to save lives, prevent disease and increase quality of life.196 Other guidelines specific to opioid use disorder exist,197,198 including 1 for “treatment-refractory” patients.199 In the United Kingdom, the National Institute for Health Care and Excellence has published guidelines for outpatient treatment of schizophrenia and has published multimorbidity guidelines (www.nice.org.uk/guidance). The National Health Care for the Homeless Council in the US has adapted best practices to support front-line workers caring for homeless populations.200 How is this guideline different? This guideline distills initial steps and evidence-based approaches, to both homeless and vulnerably housed people, with the assistance of patients and other stakeholders. It also introduces a new clinical lens with upstream interventions that provide a social and health foundation for community integration. Its initial steps support the vision of the Centre for Homelessness Impact in the UK, which envisions a society where the experience of homelessness, in instances where it cannot be prevented, is only ever rare, brief and nonrecurrent.201 Finally, we hope that our stakeholder engagement inspires and equips future students, health providers and the public health community to implement the initial step recommendations. Gaps in knowledge Evidence-based policy initiatives will need to address the accelerating health and economic disparities between homeless and general housed populations. As primary care expands its medical home models,27 there will be a research opportunity for more traumainformed care202 to support the evidence-based interventions in this guideline. Indeed, clinical research can refine how providers use the initial steps protocol: housing, income, case management and addiction. With improved living conditions, care coordination and continuity of care, research and practice can shift to treatable conditions, such as HIV and HCV infection, substance use disorder, mental illness and tuberculosis.203 Medical educators will also need to develop new training tools to support the delivery of interventions. Curricula and training that support the delivery of interventions, such as traumainformed and patient-centred care, will also be needed.12 Many of the recommended interventions in this guideline rely on collaboration of community providers, housing coordinators and case management. Interdisciplinary primary care research and maintenance of linkages to primary care will benefit from new homeless health clinic networks. Monitoring transitions in care and housing availability will be an important research goal for Canada’s National Housing Strategy and the associated Reaching Home program. Conclusion Homelessness has become a health emergency. Initial steps in addressing this crisis proposed in this guideline include strongly recommending PSH as an urgent intervention. The guideline also recognizes the trauma, disability, mental illness and stigma GUIDELINE E250 CMAJ
ISSUE 10 facing people with lived homelessness experience and thus recommends initial steps of income assistance, intensive case management for mental illness, and harm-reduction and addictiontreatment interventions, including access to opioid agonist therapy and supervised consumption facilities. The successful implementation of this guideline will depend on a focus on the initial recommendations, trust, patient safety and an ongoing collaboration between primary health care, mental health providers, public health, people with lived experience and broader community organizations, including those beyond the health care field. References 1. Frankish CJ, Hwang SW, Quantz D. Homelessness and health in Canada: research lessons and priorities. Can J Public Health 2005;96(Suppl 2):S23-9. 2. 31 days of promoting a better urban future: Report 2018. Nairobi (Kenya): UN Habitat, United Nations Human Settlement Programme; 2018. Available: https://oldweb.unhabitat.org/wp-content/uploads/2019/01/Final-short-version -UN-Habitat-Urban-October-Report.pdf (accessed 2019 Apr. 1). 3. Wen CK, Hudak PL, Hwang SW. Homeless people’s perceptions of welcomeness and unwelcomeness in healthcare encounters. J Gen Intern Med 2007;22:1011-7. 4. Coltman L, Gapka S, Harriott D, et al. Understanding community integration in a housing-first approach: Toronto At Home/Chez Soi community-based research. Intersectionalities 2015;4:39-50. 5. Hwang SW, Burns T. Health interventions for people who are homeless. Lancet 2014;384:1541-7. 6. Canadian definition of homelessness. Toronto: Canadian Observatory on Homelessness; 2012. Available: www.homelesshub.ca/sites/default/files/ attachments/Definition of Homelessness.pdf (accessed 2019 Apr. 1). 7. Hwang SW, Wilkins R, Tjepkema M, et al. Mortality among residents of shelters, rooming houses, and hotels in Canada: 11 year follow-up study. BMJ 2009;339: b4036. 8. Nordentoft M, Wandall-Holm N. 10 year follow up study of mortality among users of hostels for homeless people in Copenhagen. BMJ 2003;327:81. 9. Fazel S, Geddes JR, Kushel M. The health of homeless people in high-income countries: descriptive epidemiology, health consequences, and clinical and policy recommendations. Lancet 2014;384:1529-40. 10. Gaetz S, Dej E, Richter T, et al. The state of homelessness in Canada 2016. Toronto: Canadian Observatory on Homelessness Press; 2016. 11. Thistle J. Indigenous definition of homelessness in Canada. Toronto: Canadian Observatory on Homelessness Press; 2017. 12. Belanger YD, Awosoga O, Head GW. Homelessness, urban Aboriginal people, and the need for a national enumeration. Aboriginal Policy Studies 2013;2: 4-33. 13. Taylor M. How is rural homelessness different from urban homelessness? Toronto: The Canadian Observatory on Homelessness/Homeless Hub; 2018. Available: www.homelesshub.ca/blog/how-rural-homelessness-different -urban-homelessness (accessed 2019 Feb. 6). 14. Rodrigue S. Hidden homelessness in Canada. Cat no 75-006-X. Ottawa: Statistics Canada; 2016. 15. Gulliver-Garcia T. Putting an end to child & family homelessness in Canada. Toronto: Raising the Roof; 2016. 16. Andermann A.; CLEAR Collaboration. Taking action on the social determinants of health in clinical practice: a framework for health professionals. CMAJ 2016; 188:E474-83. 17. Jackson GL, Powers BJ, Chatterjee R, et al. The patient-centered medical home: a systematic review. Ann Intern Med 2013;158:169-78. 18. A new vision for Canada: family practice — the patient’s medical home 2019. Mississauga (ON): The College of Family Physicians of Canada; 2019. 19. Declaration of Alma-Ata. Proceedings of the International Conference on Primary Health Care, Alma-Ata; 1978 Sept. 6–12. Geneva: World Health Organization. 20. Magwood O, Leki VY, Kpade V, et al. Common trust and personal safety issues: A systematic review on the acceptability of health and social interventions for persons with lived experience of homelessness. PLoS One 2019;14:e0226306. 21. Luchenski S, Maguire N, Aldridge RW, et al. What works in inclusion health: overview of effective interventions for marginalised and excluded populations. Lancet 2018;391:266-80. 22. Thistle JA, Laliberte N. Pekiwewin (Coming Home): Clinical practice guidelines for health and social service providers working with Indigenous people experiencing homelessness. Verbal concurrent session presented at the Canadian Alliance to End Homelessness Conference, 2019 Nov. 4; Edmonton. 23. Stewart MA. Effective physician-patient communication and health outcomes: a review. CMAJ 1995;152:1423-33. 24. Racine N, Killam T, Madigan S. Trauma-informed care as a universal precaution: beyond the adverse childhood experiences questionnaire. JAMA Pediatr 2019 Nov. 4 [Epub ahead of print]. doi: 10.1001/jamapediatrics.2019.3866. 25. Reeves E. A synthesis of the literature on trauma-informed care. Issues Ment Health Nurs 2015;36:698-709. 26. Hopper E, Bassuk E, Olivet J. Shelter from the storm: trauma-informed care in homelessness services settings. Open Health Serv Policy J 2009;2:131-51. 27. A new vision for Canada: family practice — The patient’s medical home. Mississauga (ON): College of Family Physicians of Canada; 2019. Available: www. cfpc.ca/A_Vision_for_Canada (accessed 2019 Dec. 2). 28. Valaitis RK, O’Mara L, Wong ST, et al. Strengthening primary health care through primary care and public health collaboration: the influence of intrapersonal and interpersonal factors. Prim Health Care Res Dev 2018;19:378-91. 29. Akhtar-DaneshN, Valaitis R, O’Mara L, et al. Viewpoints about collaboration between primary care and public health in Canada.BMC Health Serv Res 2013;13:311. 30. Aubry T, Goering P, Veldhuizen S, et al. A multiple-city RCT of housing first with assertive community treatment for homeless Canadians with serious mental illness. Psychiatr Serv 2016;67:275-81. 31. Cherner RA, Aubry T, Sylvestre J, et al. Housing first for adults with problematic substance use. J Dual Diagn 2017;13:219-29. 32. Goldfinger SM, Schutt RK, Tolomiczenko GS, et al. Housing placement and subsequent days homeless among formerly homeless adults with mental illness. Psychiatr Serv 1999;50:674-9. 33. Hwang SW, Gogosis E, Chambers C, et al. Health status, quality of life, residential stability, substance use, and health care utilization among adults applying to a supportive housing program. J Urban Health 2011;88:1076-90. 34. Lipton FR, Nutt S, Sabatini A. Housing the homeless mentally ill: a longitudinal study of a treatment approach. Hosp Community Psychiatry 1988;39:40-5. 35. Martinez TE, Burt MR. Impact of permanent supportive housing on the use of acute care health services by homeless adults. Psychiatr Serv 2006;57:992-9. 36. McHugo GJ, Bebout RR, Harris M, et al. A randomized controlled trial of integrated versus parallel housing services for homeless adults with severe mental illness. Schizophr Bull 2004;30:969-82. 37. Rich AR, Clark C. Gender differences in response to homelessness services. Eval Program Plann 2005;28:69-81. doi: 10.1016/j.evalprogplan.2004.05.003. 38. Sadowski LS, Kee RA, VanderWeele TJ, et al. Effect of a housing and case management program on emergency department visits and hospitalizations among chronically ill homeless adults: a randomized trial. JAMA 2009;301:1771-8. 39. Siegel CE, Samuels J, Tang D-I, et al. Tenant outcomes in supported housing and community residences in New York City. Psychiatr Serv 2006;57:982-91. 40. Stefancic A, Tsemberis S. Housing First for long-term shelter dwellers with psychiatric disabilities in a suburban county: a four-year study of housing access and retention. J Prim Prev 2007;28:265-79. 41. Stergiopoulos V, Hwang SW, Gozdzik A, et al.; At Home/Chez Soi Investigators. Effect of scattered-site housing using rent supplements and intensive case management on housing stability among homeless adults with mental illness: a randomized trial. JAMA 2015;313:905-15. 42. Tsemberis S, Gulcur L, Nakae M. Housing First, consumer choice, and harm reduction for homeless individuals with a dual diagnosis. Am J Public Health 2004;94:651-6. 43. Young MS, Clark C, Moore K, et al. Comparing two service delivery models for homeless individuals with complex behavioral health needs: preliminary data from two SAMHSA treatment for homeless studies. J Dual Diagn 2009;5: 287-304. 44. Kozloff N, Adair CE, Palma Lazgare LI, et al. “Housing First” for homeless youth with mental illness. Pediatrics 2016;138:e20161514. 45. Gulcur L, Stefancic A, Shinn M, et al. Housing, hospitalization, and cost outcomes for homeless individuals with psychiatric disabilities participating in continuum of care and housing first programmes. J Community Appl Soc Psychol 2003;13:171-86. doi: 10.1002/casp.723. 46. Poremski D, Stergiopoulos V, Braithwaite E, et al. Effects of Housing First on employment and income of homeless individuals: results of a randomized trial. Psychiatr Serv 2016;67:603-9. 47. Booshehri LG, Dugan J, Patel F, et al. Trauma-informed Temporary Assistance for Needy Families (TANF): a randomized controlled trial with a twogeneration impact. J Child Fam Stud 2018;27:1594-604. GUIDELINE CMAJ
ISSUE 10 E251 48. Ferguson KM. Employment outcomes from a randomized controlled trial of two employment interventions with homeless youth. J Soc Social Work Res 2018;9:1-21. 49. Forchuk C, MacClure SK, Van Beers M, et al. Developing and testing an intervention to prevent homelessness among individuals discharged from psychiatric wards to shelters and “No Fixed Address”. J Psychiatr Ment Health Nurs 2008;15:569-75. 50. Gubits D, Shinn M, Wood M, et al. What interventions work best for families who experience homelessness? Impact estimates from the family options study. J Policy Anal Manage 2018;37:735-66. 51. Hurlburt MS, Hough RL, Wood PA. Effects of substance abuse on housing stability of homeless mentally Ill persons in supported housing. Psychiatr Serv 1996;47:731-6. 52. Kashner TM, Rosenheck R, Campinell AB, et al. Impact of work therapy on health status among homeless, substance-dependent veterans: a randomized controlled trial. Arch Gen Psychiatry 2002;59:938-44. 53. Pankratz C, Nelson G, Morrison M. A quasi-experimental evaluation of rent assistance for individuals experiencing chronic homelessness. J Community Psychol 2017;45:1065-79. doi: 10.1002/jcop.21911. 54. Poremski D, Distasio J, Hwang SW, et al. Employment and income of people who experience mental illness and homelessness in a large Canadian sample. Can J Psychiatry 2015;60:379-85. 55. Rosenheck R, Kasprow W, Frisman L, et al. Cost-effectiveness of supported housing for homeless persons with mental illness. Arch Gen Psychiatry 2003; 60:940-51. 56. Wolitski RJ, Kidder DP, Pals SL, et al.; Housing and Health Study Team. Randomized trial of the effects of housing assistance on the health and risk behaviors of homeless and unstably housed people living with HIV. AIDS Behav 2010;14:493-503. 57. Conrad KJ, Hultman CI, Pope AR, et al. Case managed residential care for homeless addicted veterans. Results of a true experiment. Med Care 1998; 36:40-53. 58. Graham-Jones S, Reilly S, Gaulton E. Tackling the needs of the homeless: a controlled trial of health advocacy. Health Soc Care Community 2004;12:221-32. 59. Lapham SC, Hall M, Skipper BJ. Homelessness and substance use among alcohol abusers following participation in project H&ART. J Addict Dis 1995;14:41-55. 60. Nyamathi A, Flaskerud JH, Leake B, et al. Evaluating the impact of peer, nurse case-managed, and standard HIV risk-reduction programs on psychosocial and health-promoting behavioral outcomes among homeless women. Res Nurs Health 2001;24:410-22. 61. Nyamathi AM, Zhang S, Salem BE, et al. A randomized clinical trial of tailored interventions for health promotion and recidivism reduction among homeless parolees: outcomes and cost analysis. J Exp Criminol 2016;12:49-74. 62. Sosin MR, Bruni M, Reidy M. Paths and impacts in the progressive independence model: a homelessness and substance abuse intervention in Chicago. J Addict Dis 1995;14:1-20. 63. Towe VL, Wiewel EW, Zhong Y, et al. A randomized controlled trial of a rapid rehousing intervention for homeless persons living with HIV/AIDS: impact on housing and HIV medical outcomes. AIDS Behav 2019;23:2315-25. 64. Upshur C, Weinreb L, Bharel M, et al. A randomized control trial of a chronic care intervention for homeless women with alcohol use problems. J Subst Abuse Treat 2015;51:19-29. 65. Weinreb L, Upshur CC, Fletcher-Blake D, et al. Managing depression among homeless mothers: pilot testing an adapted collaborative care intervention. Prim Care Companion CNS Disord 2016;18. 66. Clarke GN, Herinckx HA, Kinney RF, et al. Psychiatric hospitalizations, arrests, emergency room visits, and homelessness of clients with serious and persistent mental illness: findings from a randomized trial of two ACT programs vs. usual care. Ment Health Serv Res 2000;2:155-64. 67. Essock SM, Frisman LK, Kontos NJ. Cost-effectiveness of assertive community treatment teams. Am J Orthopsychiatry 1998;68:179-90. 68. Essock SM, Mueser KT, Drake RE, et al. Comparison of ACT and standard case management for delivering integrated treatment for co-occurring disorders. Psychiatr Serv 2006;57:185-96. 69. Fletcher TD, Cunningham JL, Calsyn RJ, et al. Evaluation of treatment programs for dual disorder individuals: modeling longitudinal and mediation effects. Adm Policy Ment Health 2008;35:319-36. 70. Lehman AF, Dixon LB, Kernan E, et al. A randomized trial of assertive community treatment for homeless persons with severe mental illness. Arch Gen Psychiatry 1997;54:1038-43. 71. Morse GA, Calsyn RJ, Allen G, et al. Experimental comparison of the effects of three treatment programs for homeless mentally ill people. Hosp Community Psychiatry 1992;43:1005-10. 72. Morse GA, Calsyn RJ, Klinkenberg WD, et al. An experimental comparison of three types of case management for homeless mentally ill persons. Psychiatr Serv 1997;48:497-503. 73. Morse GA, Calsyn RJ, Klinkenberg WD, et al. Treating homeless clients with severe mental illness and substance use disorders: costs and outcomes. Community Ment Health J 2006;42:377-404. 74. Braucht GN, Reichardt CS, Geissler LJ, et al. Effective services for homeless substance abusers. J Addict Dis 1995;14:87-109. 75. Burnam MA, Morton SC, McGlynn EA, et al. An experimental evaluation of residential and nonresidential treatment for dually diagnosed homeless adults. J Addict Dis 1995;14:111-34. 76. Cauce AM, Morgan CJ, Wagner V, et al. Effectiveness of intensive case management for homeless adolescents: rof a 3-month follow-up. J Emot Behav Disord 1994;2:219-27. 77. Clark C, Rich AR. Outcomes of homeless adults with mental illness in a housing program and in case management only. Psychiatr Serv 2003;54:78-83. 78. Cox GB, Walker RD, Freng SA, et al. Outcome of a controlled trial of the effectiveness of intensive case management for chronic public inebriates. J Stud Alcohol 1998;59:523-32. 79. Felton CJ, Stastny P, Shern DL, et al. Consumers as peer specialists on intensive case management teams: impact on client outcomes. Psychiatr Serv 1995; 46:1037-44. 80. Grace M, Gill PR. Improving outcomes for unemployed and homeless young people: findings of the YP4 clinical controlled trial of joined up case management. Aust Soc Work 2014;67:419-37. 81. Korr WS, Joseph A. Housing the homeless mentally ill: Findings from Chicago. J Soc Serv Res 1996;21:53-68. 82. Malte CA, Cox K, Saxon AJ. Providing intensive addiction/housing case management to homeless veterans enrolled in addictions treatment: a randomized controlled trial. Psychol Addict Behav 2017;31:231-41. 83. Marshall M, Lockwood A, Gath D. Social services case-management for longterm mental disorders: a randomised controlled trial. Lancet 1995;345:409-12. 84. Orwin RG, Sonnefeld LJ, Garrison-Mogren R, et al. Pitfalls in evaluating the effectiveness of case management programs for homeless persons: lessons from the NIAAA Community Demonstration Program. Eval Rev 1994;18: 153-207. 85. Rosenblum A, Nuttbrock L, McQuistion H, et al. Medical outreach to homeless substance users in New York City: preliminary results. Subst Use Misuse 2002; 37:1269-73. 86. Shern DL, Tsemberis S, Anthony W, et al. Serving street-dwelling individuals with psychiatric disabilities: outcomes of a psychiatric rehabilitation clinical trial. Am J Public Health 2000;90:1873-8. 87. Stahler GJ, Shipley TF Jr, Bartelt D, et al. Evaluating alternative treatments for homeless substance-abusing men: outcomes and predictors of success. J Addict Dis 1996;14:151-67. 88. Shumway M, Boccellari A, O’Brien K, et al. Cost-effectiveness of clinical case management for ED frequent users: results of a randomized trial. Am J Emerg Med 2008;26:155-64. 89. Toro PA, Passero Rabideau JM, Bellavia CW, et al. Evaluating an intervention for homeless persons: results of a field experiment. J Consult Clin Psychol 1997;65:476-84. 90. de Vet R, Beijersbergen MD, Jonker IE, et al. Critical time intervention for homeless people making the transition to community living: a randomized controlled trial. Am J Community Psychol 2017;60:175-86. 91. Herman DB, Conover S, Gorroochurn P, et al. Randomized trial of critical time intervention to prevent homelessness after hospital discharge. Psychiatr Serv 2011;62:713-9. 92. Lako DAM, Beijersbergen MD, Jonker IE, et al. The effectiveness of critical time intervention for abused women leaving women’s shelters: a randomized controlled trial. Int J Public Health 2018;63:513-23. 93. Shinn M, Samuels J, Fischer SN, et al. Longitudinal impact of a family critical time intervention on children in high-risk families experiencing homelessness: a randomized trial. Am J Community Psychol 2015;56:205-16. 94. Susser E, Valencia E, Conover S, et al. Preventing recurrent homelessness among mentally ill men: a“ critical time” intervention after discharge from a shelter. Am J Public Health 1997;87:256-62. 95. Samuels J, Fowler PJ, Ault-Brutus A, et al. Time-limited case management for homeless mothers with mental health problems: effects on maternal mental health. J Soc Social Work Res 2015;6:515-39. 96. Jones K, Colson PW, Holter MC, et al. Cost-effectiveness of critical time intervention to reduce homelessness among persons with mental illness. Psychiatr Serv 2003;54:884-90. GUIDELINE E252 CMAJ
ISSUE 10 97. Tomita A, Herman DB. The impact of critical time intervention in reducing psychiatric rehospitalization after hospital discharge. Psychiatr Serv 2012;63: 935-7. 98. Jones K, Colson P, Valencia E, et al. A preliminary cost effectiveness analysis of an intervention to reduce homelessness among the mentally ill. Psychiatr Q 1994;65:243-56. 99. Magwood O, Salvalaggio G, Beder M, et al. The effectiveness of substance use interventions for homeless and vulnerably housed persons: a systematic review of systematic reviews on supervised consumption facilities, managed alcohol programs, and pharmacological agents for opioid use disorder. PLoS ONE 15(1):e0227298. https://doi.org/10.1371/journal.pone.0227298. 100. Bahji A, Bajaj N. Opioids on trial: a systematic review of interventions for the treatment and prevention of opioid overdose. Can J Addict 2018;9:26-33. 101. Clark N, Lintzeris N, Gijsbers A, et al. LAAM maintenance vs methadone maintenance for heroin dependence. Cochrane Database Syst Rev 2002;(2):CD002210. 102. Ferri M, Davoli M, Perucci CA. Heroin maintenance treatment for chronic heroin-dependent individuals: a Cochrane systematic review of effectiveness. J Subst Abuse Treat 2006;30:63-72. 103. Gowing L, Farrell MF, Bornemann R, et al. Oral substitution treatment of injecting opioid users for prevention of HIV infection. Cochrane Database Syst Rev 2011;(8):CD004145. 104. Jones HE, Heil SH, Baewert A, et al. Buprenorphine treatment of opioiddependent pregnant women: a comprehensive review. Addiction 2012; 107(Suppl 1):5-27. 105. Karki P, Shrestha R, Huedo-Medina TB, et al. The impact of methadone maintenance treatment on HIV risk behaviors among high-risk injection drug users: a systematic review. Evid Based Med Public Health 2016;2:pii: e1229. 106. Kirchmayer U, Davoli M, Verster AD, et al. A systematic review on the efficacy of naltrexone maintenance treatment in opioid dependence. Addiction 2002;97: 1241-9. 107. Larney S, Gowing L, Mattick RP, et al. A systematic review and meta-analysis of naltrexone implants for the treatment of opioid dependence. Drug Alcohol Rev 2014;33:115-28. 108. Lobmaier P, Kornør H, Kunøe N, et al. Sustained-release naltrexone for opioid dependence. Cochrane Database Syst Rev 2008;(2):CD006140. 109. Mattick RP, Breen C, Kimber J, et al. Buprenorphine maintenance versus placebo or methadone maintenance for opioid dependence. Cochrane Database Syst Rev 2014;(2):CD002207. 110. Mattick RP, Breen C, Kimber J, et al. Methadone maintenance therapy versus no opioid replacement therapy for opioid dependence. Cochrane Database Syst Rev 2009;(3):CD002209. 111. Minozzi S, Amato L, Vecchi S, et al. Oral naltrexone maintenance treatment for opioid dependence. Cochrane Database Syst Rev 2011;(4):CD001333. 112. Platt L, Minozzi S, Reed J, et al. Needle syringe programmes and opioid substitution therapy for preventing hepatitis C transmission in people who inject drugs. Cochrane Database Syst Rev 2017;9:CD012021. 113. Roozen HG, de Waart R, van der Windt DAWM, et al. A systematic review of the effectiveness of naltrexone in the maintenance treatment of opioid and alcohol dependence. Eur Neuropsychopharmacol 2006;16:311-23. 114. Saulle R, Vecchi S, Gowing L. Supervised dosing with a long-acting opioid medication in the management of opioid dependence. Cochrane Database Syst Rev 2017;4:CD011983. 115. Simoens S, Matheson C, Bond C, et al. The effectiveness of community maintenance with methadone or buprenorphine for treating opiate dependence. Br J Gen Pract 2005;55:139-46. 116. Sordo L, Barrio G, Bravo MJ, et al. Mortality risk during and after opioid substitution treatment: systematic review and meta-analysis of cohort studies. BMJ 2017;357:j1550. 117. Helm S, Trescot AM, Colson J, et al. Opioid antagonists, partial agonists, and agonists/antagonists: the role of office-based detoxification. Pain Physician 2008;11:225-35. 118. Strang J, Groshkova T, Uchtenhagen A, et al. Heroin on trial: systematic review and meta-analysis of randomised trials of diamorphine-prescribing as treatment for refractory heroin addiction. Br J Psychiatry 2015;207:5-14. 119. Thomas CP, Fullerton CA, Kim M, et al. Medication-assisted treatment with buprenorphine: assessing the evidence. Psychiatr Serv 2014;65:158-70. 120. Weinmann S, Kunstmann W, Rheinberger P. Methadone substitution — a scientific review in the context of out-patient therapy in Germany [article in German]. Z Arztl Fortbild Qualitatssich 2004;98:673-82. 121. Wilder C, Lewis D, Winhusen T. Medication assisted treatment discontinuation in pregnant and postpartum women with opioid use disorder. Drug Alcohol Depend 2015;149:225-31. 122. Klimas J, Gorfinkel L, Giacomuzzi SM, et al. Slow release oral morphine versus methadone for the treatment of opioid use disorder. BMJ Open 2019;9: e025799. 123. Maglione MA, Raaen L, Chen C, et al. Effects of medication assisted treatment (MAT) for opioid use disorder on functional outcomes: a systematic review. J Subst Abuse Treat 2018;89:28-51. 124. Kennedy MC, Karamouzian M, Kerr T. Public health and public order outcomes associated with supervised drug consumption facilities: a systematic review. Curr HIV/AIDS Rep 2017;14:161-83. 125. Potier C, Laprévote V, Dubois-Arber F, et al. Supervised injection services: what has been demonstrated? A systematic literature review. Drug Alcohol Depend 2014;145:48-68. 126. McNeil R, Small W. ‘Safer environment interventions’: a qualitative synthesis of the experiences and perceptions of people who inject drugs. Soc Sci Med 2014;106:151-8. 127. Muckle W, Muckle J, Welch V, et al. Managed alcohol as a harm reduction intervention for alcohol addiction in populations at high risk for substance abuse. Cochrane Database Syst Rev 2012;12:CD006747. 128. Ezard N, Dolan K, Baldry E, et al. Feasibility of a Managed Alcohol Program (MAP) for Sydney’s homeless. Canberra (AU): Foundation for Alcohol Research and Education; 2015. 129. Nielsen E, Novotna G, Berenyi R, et al. Harm reduction interventions for chronic and severe alcohol use among populations experiencing homelessness: a literature review. Regina: University of Regina, Carmichael Outreach Inc.; 2018. 130. Basu A, Kee R, Buchanan D, et al. Comparative cost analysis of housing and case management program for chronically ill homeless adults compared to usual care. Health Serv Res 2012;47:523-43. 131. Culhane DP, Metraux S, Hadley T. Public service reductions associated with placement of homeless persons with severe mental illness in supportive housing. Hous Policy Debate 2002;13:107-63. 132. Dickey B, Latimer E, Powers K, et al. Housing costs for adults who are mentally ill and formerly homeless. J Ment Health Adm 1997;24:291-305. 133. Gilmer TP, Manning WG, Ettner SL. A cost analysis of San Diego County’s REACH program for homeless persons. Psychiatr Serv 2009;60:445-50. 134. Gilmer TP, Stefancic A, Ettner SL, et al. Effect of full-service partnerships on homelessness, use and costs of mental health services, and quality of life among adults with serious mental illness. Arch Gen Psychiatry 2010;67:645-52. 135. Hunter S, Harvey M, Briscombe B, et al. Evaluation of housing for health permanent supportive housing program. Santa Monica (CA): RAND Corporation; 2017. 136. Holtgrave DR, Wolitski RJ, Pals SL, et al. Cost-utility analysis of the housing and health intervention for homeless and unstably housed persons living with HIV. AIDS Behav 2013;17:1626-31. 137. Larimer ME, Malone DK, Garner MD, et al. Health care and public service use and costs before and after provision of housing for chronically homeless persons with severe alcohol problems. JAMA 2009;301:1349-57. 138. Latimer EA, Rabouin D, Cao Z, et al.; At Home/Chez Soi Investigators. Costeffectiveness of Housing First intervention with intensive case management compared with treatment as usual for homeless adults with mental illness: secondary analysis of a randomized clinical trial. JAMA Netw Open 2019; 2:e199782. 139. Lenz-Rashid S. Supportive housing program for homeless families: Foster care outcomes and best practices. Child Youth Serv Rev 2017;79:558-63. 140. Lim S, Gao Q, Stazesky E, et al. Impact of a New York City supportive housing program on Medicaid expenditure patterns among people with serious mental illness and chronic homelessness. BMC Health Serv Res 2018;18:15. 141. McLaughlin TC. Using common themes: cost-effectiveness of permanent supported housing for people with mental illness. Res Soc Work Pract 2010;21: 404-11. 142. Mares AS, Rosenheck RA. A comparison of treatment outcomes among chronically homelessness adults receiving comprehensive housing and health care services versus usual local care. Adm Policy Ment Health 2011;38:459-75. 143. Pauley T, Gargaro J, Falode A, et al. Evaluation of an integrated cluster care and supportive housing model for unstably housed persons using the shelter system. Prof Case Manag 2016;21:34-42. 144. Schinka JA, Francis E, Hughes P, et al. Comparative outcomes and costs of inpatient care and supportive housing for substance-dependent veterans. Psychiatr Serv 1998;49:946-50. 145. Srebnik D, Connor T, Sylla L. A pilot study of the impact of housing firstsupported housing for intensive users of medical hospitalization and sobering services. Am J Public Health 2013;103:316-21. 146. Evans WN, Sullivan JX, Wallskog M. The impact of homelessness prevention programs on homelessness. Science 2016;353:694-9. GUIDELINE CMAJ
ISSUE 10 E253 147. Clark RE, Teague GB, Ricketts SK, et al. Cost-effectiveness of assertive community treatment versus standard case management for persons with cooccurring severe mental illness and substance use disorders. Health Serv Res 1998;33:1285-308. 148. Lehman AF, Dixon L, Hoch JS, et al. Cost-effectiveness of assertive community treatment for homeless persons with severe mental illness. Br J Psychiatry 1999;174:346-52. 149. Wolff N, Helminiak TW, Morse GA, et al. Cost-effectiveness evaluation of three approaches to case management for homeless mentally ill clients. Am J Psychiatry 1997;154:341-8. 150. Okin RL, Boccellari A, Azocar F, et al. The effects of clinical case management on hospital service use among ED frequent users. Am J Emerg Med 2000;18:603-8. 151. Hwang SW. Homelessness in health. CMAJ 2001;164:229-33. 152. National Clinical Guideline Centre (UK). Patient experience in adult NHS services: improving the experience of care for people using adult NHS services — patient experience in generic terms. NICE Clinical Guidelines No 138. London (UK): Royal College of Physicians; 2012. Available: www.ncbi.nlm.nih.gov/ books/NBK115230 (accessed 2019 Dec. 12). 153. Jonker IE, Sijbrandij M, Van Luijtelaar MJA, et al. The effectiveness of interventions during and after residence in women’s shelters: a meta-analysis. Eur J Public Health 2015;25:15-9. 154. Rivas C, Ramsay J, Sadowski L, et al. Advocacy interventions to reduce or eliminate violence and promote the physical and psychosocial well-being of women who experience intimate partner abuse. Cochrane Database Syst Rev 2015;(12):CD005043. 155. Speirs V, Johnson M, Jirojwong S. A systematic review of interventions for homeless women. J Clin Nurs 2013;22:1080-93. 156. Wathen CN, MacMillan HL. Interventions for violence against women: scientific review. JAMA 2003;289:589-600. 157. Constantino R, Kim Y, Crane PA. Effects of a social support intervention on health outcomes in residents of a domestic violence shelter: a pilot study. Issues Ment Health Nurs 2005;26:575-90. 158. Gubits D, Shinn M, Wood M, et al. Family options study: 3-year impacts of housing and services interventions for homeless families. 2016. doi: 10.2139/ ssrn.3055295. 159. Milby JB, Schumacher JE, Wallace D, et al. To house or not to house: the effects of providing housing to homeless substance abusers in treatment. Am J Public Health 2005;95:1259-65. 160. Nyamathi AM, Leake B, Flaskerud J, et al. Outcomes of specialized and traditional AIDS counseling programs for impoverished women of color. Res Nurs Health 1993;16:11-21. 161. Nyamathi A, Flaskerud J, Keenan C, et al. Effectiveness of a specialized vs. traditional AIDS education program attended by homeless and drug-addicted women alone or with supportive persons. AIDS Educ Prev 1998;10:433-46. 162. Wang JZ, Mott S, Magwood O, et al. The impact of interventions for youth experiencing homelessness on housing, mental health, substance use, and family cohesion: a systematic review. BMC Public Health 2019;19:1528. 163. Couch J. ‘My life just went zig zag’: refugee young people and homelessness. Youth Stud Aust 2011;30:22-32. 164. Couch J. ‘Neither here nor there’: refugee young people and homelessness in Australia. Child Youth Serv Rev 2017;74:1-7. 165. Couch J. On their own: perceptions of services by homeless young refugees. Dev Pract 2012;(31):19-28. 166. D’Addario S, Hiebert D, Sherrell K. Restricted access: The role of social capital in mitigating absolute homelessness among immigrants and refugees in the GVRD. Refuge 2007;24:107-15. 167. Dwyer P, Brown D. Accommodating “others”?: housing dispersed, forced migrants in the UK. J Soc Welf Fam Law 2008;30:203-18. 168. Flatau P, Smith J, Carson G, et al. The housing and homelessness journeys of refugees in Australia. AHURI Final Rep No 256. Melbourne (AU): Australian Housing and Urban Research Institute Limited; 2015. 169. Hulín M, Hulínová VA, Martinkovic M, et al. Housing among persons of international protection in the Slovak Republic. Rajagiri J Soc Dev 2013;5. 170. Idemudia ES, Williams JK, Wyatt GE. Migration challenges among Zimbabwean refugees before, during and post arrival in South Africa. J Inj Violence Res 2013;5:17-27. 171. Im H. A social ecology of stress and coping among homeless refugee families. Vol. 73, Dissertation Abstracts International Section A: Humanities and Social Sciences. University of Minnesota Digital Conservancy; 2012:355. Available: http://ovidsp.ovid.com/ovidweb.cgi?T=JS&PAGE=reference&D=psyc9&NEWS= N&AN=2012-99130-061 (accessed 2019 Sept. 1). Login required to access content. 172. Kissoon P. From persecution to destitution: a snapshot of asylum seekers’ housing and settlement experiences in Canada and the United Kingdom. J Immigr Refug Stud 2010;8:4-31. 173. Kissoon P. An uncertain home: refugee protection, illegal immigration status, and their effects on migrants’ housing stability in Vancouver and Toronto. Can Issues 2010;64-7. 174. Mostowska M. Migration and homelessness: the social networks of homeless Poles in Oslo. J Ethn Migr Stud 2013;39:1125-40. 175. Mostowska M. Homelessness abroad: “place utility” in the narratives of the Polish homeless in Brussels. Int Migr 2014;52:118-29. 176. Paradis E, Novac S, Sarty M, et al. Homelessness and housing among status immigrant, non-status migrant, and Canadian-born Families in Toronto. Can Issues 2010. 177. Sherrell K, D’Addario S, Hiebert D. On the outside looking in: the precarious housing situations of successful refugee claimants in the GVRD. Refuge 2007;24:64-75. 178. Sjollema SD, Hordyk S, Walsh CA, et al. Found poetry: finding home — a qualitative study of homeless immigrant women. J Poetry Ther 2012;25:205-17. 179. Walsh CA, Hanley J, Ives N, et al. Exploring the experiences of newcomer women with insecure housing in Montréal Canada. J Int Migr Integr 2016;17: 887-904. 180. Kendall CE, Shoemaker ES, Crowe L, et al. Engagement of people with lived experience in primary care research: living with HIV Innovation Team Community Scholar Program. Can Fam Physician 2017;63:730-1. 181. Swinkels H, Pottie K, Tugwell P, et al.; Canadian Collaboration for Immigrant and Refugee Health (CCIRH). Development of guidelines for recently arrived immigrants and refugees to Canada: Delphi consensus on selecting preventable and treatable conditions. CMAJ 2011;183:E928-32. 182. Guyatt G, Oxman AD, Akl EA, et al. GRADE guidelines: 1. Introduction — GRADE evidence profiles and summary of findings tables. J Clin Epidemiol 2011;64: 383-94. 183. Pottie K, Mathew CM, Mendonca O, et al. PROTOCOL: A comprehensive review of prioritized interventions to improve the health and wellbeing of persons with lived experience of homelessness. Campbell Syst Rev 2019;15:e1048. 184. Magwood O, Gebremeskel A, Ymele Leki V, et al. Protocol 1: The experiences of homeless and vulnerably housed persons around health and social services. A protocol for a systematic review of qualitative studies. Cochrane Methods Equity; 2018. Available: https://methods.cochrane.org/equity/sites/methods.cochrane. org.equity/files/public/uploads/protocol-_the_experiences_of_homeless_and_ vulnerably_housed_persons_around_health_and_social_services.pdf (accessed 2019 Dec. 12). 185. Kpade V, Magwood O, Salvalaggio G, et al. Protocol 3: Harm reduction and pharmacotherapeutic interventions for persons with substance use disorders: a protocol for a systematic review of reviews. Cochrane Methods Equity; 2018. 186. Wang J, Mott S, Mathew C, et al. Protocol: Impact of interventions for homeless youth: a narrative review using health, social, Gender, and equity outcomes. Cochrane Methods Equity; 2018. Available: https://methods.cochrane.org/ equity/sites/methods.cochrane.org.equity/files/public/uploads/youth_narrative _review_protocol.pdf (accessed 2019 Dec. 12). 187. Alonso-Coello P, Oxman AD, Moberg J, et al.; GRADE Working Group. GRADE Evidence to Decision (EtD) frameworks: a systematic and transparent approach to making well informed healthcare choices. 2: Clinical practice guidelines. BMJ 2016;353:i2089. 188. Alonso-Coello P, Schünemann HJ, Moberg J, et al.; GRADE Working Group. GRADE Evidence to Decision (EtD) frameworks: a systematic and transparent approach to making well informed healthcare choices. 1: Introduction. BMJ 2016;353:i2016. 189. Schünemann HJ, Mustafa R, Brozek J, et al.; GRADE Working Group. GRADE Guidelines: 16. GRADE evidence to decision frameworks for tests in clinical practice and public health. J Clin Epidemiol 2016;76:89-98. 190. GRADEpro GDT: GRADEpro Guideline Development Tool [software]. Hamilton (ON): McMaster University; 2015 (developed by Evidence Prime, Inc.). Available: https://gradepro.org (accessed 2019 Feb. 1). 191. Tugwell P, Knottnerus JA. When does a good practice statement not justify an evidence based guideline? J Clin Epidemiol 2015;68:477-9. 192. Guyatt GH, Alonso-Coello P, Schünemann HJ, et al. Guideline panels should seldom make good practice statements: guidance from the GRADE Working Group. J Clin Epidemiol 2016;80:3-7. 193. Guyatt GH, Schünemann HJ, Djulbegovic B, et al. Guideline panels should not GRADE good practice statements. J Clin Epidemiol 2015;68:597-600. 194. Drazen JM, de Leeuw PW, Laine C, et al. Toward more uniform conflict disclosures: the updated ICMJE conflict of interest reporting form. JAMA 2010;304:212-3. GUIDELINE E254 CMAJ
ISSUE 10 195. Primack RB, Cigliano JA, Parsons ECM, et al. Coauthors gone bad; how to avoid publishing conflict and a proposed agreement for co-author teams [editorial]. Biol Conserv 2014;176:277-80. 196. WHO housing and health guidelines. Geneva: World Health Organization; 2018. 197. Korownyk C, Perry D, Ton J, et al. Managing opioid use disorder in primary care: PEER simplified guideline. Can Fam Physician 2019;65:321-30. 198. Bruneau J, Ahamad K, Goyer M-È, et al.; CIHR Canadian Research Initiative in Substance Misuse. Management of opioid use disorders: a national clinical practice guideline. CMAJ 2018;190:E247-57. 199. Fairbairn N, Ross J, Trew M, et al. Injectable opioid agonist treatment for opioid use disorder: a national clinical guideline. CMAJ 2019;191:E1049-56. 200. Montauk SL. The homeless in America: adapting your practice. Am Fam Physician 2006;74:1132-8. 201. Teixeira L, Russell D, Hobbs T. The SHARE framework: a smarter way to end homelessness. London (UK): Centre for Homelessness Impact; 2018; Available: www. homelesshub.ca/resource/share-framework-smarter-way-end-homelessness (accessed 2019 Dec. 12). 202. Purkey E, Patel R, Phillips SP. Trauma-informed care: better care for everyone. Can Fam Physician 2018;64:170-2. 203. Homelessness & health: What’s the connection [fact sheet]. Nashville (TN): National Health Care for the Homeless Council; 2011. Available: https://nhchc.org/wp-content /uploads/2019/08/Hln_health_factsheet_Jan10-1.pdf (accessed 2019 June 1). Competing interests: Gary Bloch is a founding member, former board member and currently a clinician with Inner City Health Associates (ICHA), a group of physicians working with individuals experiencing homelessness in Toronto, which provided funding for the development of this guideline. He did not receive payment for work on the guideline and did not participate in any ICHA board decision-making relevant to this project. Ritika Goel, Michaela Beder and Stephen Hwang also receive payment for clinical services from ICHA, and did not receive payment for any aspect of the submitted work. No other competing interests were declared. This article has been peer reviewed. Affiliations: C.T. Lamont Primary Health Care Research Centre (Pottie, d Wendy Muckle led the Homeless Health Summit. Esther Shoemaker led the Delphi consensus. Olivia Magwood led the reviews on lived experiences and substance use, Tim Aubry led the review on housing, Gary Bloch and Vanessa Brcic led the review on income, David Ponka and Eric Agbata led the review on case management, Jean Zhuo Jing Wang and Sebastian Mott led the homeless youth review, Harneel Kaur led the homeless migrant review, Christine Mathew and Anne Andermann led the homeless women review, Syeda Shanza Hashmi and Ammar Saad led medical student engagement and competency review, Thomas Piggott co-led the GRADE Assessment with Olivia Magwood and Kevin Pottie, Michaela Beder and Nicole Kozloff contributed substantially to the substance use review, and Neil Arya and Stephen Hwang provided critical policy information. All of the named authors engaged in the writing and review, gave final approval of the version of the guideline to be published, and agreed to be accountable for all aspects of the work. Funding: This guideline was supported by a peer-reviewed grant from the Inner City Health Associates, and supplemental project grants from the Public Health Agency of Canada, Employment Social Development Canada, Canadian Medical Association and Champlain Local Integrated Health Network. Personnel from collaborating agencies provided nonbinding feedback during the preparation of systematic reviews and the guideline. The funders had no role in the design or conduct of the study; collection, analysis and interpretation of the data; or preparation, review or final approval of the guideline. Final decisions regarding the protocol and issues that arose during the guideline-development process were solely the responsibility of the guideline steering committee. Acknowledgements: The authors thank everyone who participated in the development of this guideline, including community scholars, technical team leads, guideline panel members and working group members. Endorsements: Canadian Medical Association, Canadian Public Health Association, Canadian Federation of Medical Students, The College of Family Physicians of Canada, Public Health Physicians of Canada, Canadian Association of Emergency Physicians, The Canadian Alliance to End Homelessness, Canadian Nurses Association Disclaimer: The views expressed herein do not necessarily represent the views of the funding agencies. Correspondence to: Kevin Pottie, kpottie@uottawa.ca

Documents

Less detail

The Lancet Countdown on Health and Climate Change - Policy brief for Canada

https://policybase.cma.ca/en/permalink/policy14257

Date
2019-11-01
Topics
Population health/ health equity/ public health
  1 document  
Policy Type
Policy endorsement
Date
2019-11-01
Topics
Population health/ health equity/ public health
Text
The Lancet Countdown on Health and Climate Change Policy brief for Canada 1 Finding: Exposure to wildfires is increasing in Canada, with more than half of the 448,444 Canadians evacuated due to wildfires between 1980 and 2017 displaced in the last decade. Recommendation: Incorporate lessons learned from recent severe wildfire seasons into a strengthened pan-Canadian emergency response approach that anticipates increasing impacts as the climate continues to change. Finding: The percentage of fossil fuels powering transport in Canada remains high, though electricity and biofuels are gaining ground. Fine particulate air pollution generated by transportation killed 1063 Canadians in 2015, resulting in a loss of economic welfare for Canadians valued at approximately $8 billion dollars. Recommendation: Develop provincial and territorial legislation requiring automakers to gradually increase the annual percentage of new light-duty vehicles sold that are zero emissions, working toward a target of 100% by 2040. Finding: Canada has the third-highest per capita greenhouse gas emissions from healthcare in the world, with healthcare accounting for approximately 4% of the country’s total emissions. Recommendation: Establish a sustainable healthcare initiative that assembles experts from research, education, clinical practice, and policy to support Canada’s healthcare sector in reducing greenhouse gas emissions and preventing pollution-related deaths, consistent with healthcare’s mandate to ‘do no harm’ and the timelines and goals of the Paris Agreement, charting a course for zero-emissions healthcare by 2050. Finding: The health of Canadians is at risk due to multiple and varied risks of climate change, including those described in this policy brief (see Figure 1). An ongoing, coordinated, consistent and pan-Canadian effort to track, report, and create healthy change is required. Recommendation: Integrate health considerations into climate-related policymaking across sectors, including in Canada’s updated 2020 Nationally Determined Contribution Commitments under the United Nations Framework Convention on Climate Change (UNFCCC) process, and increase ambition to ensure Canada commits to doing its fair share in achieving the goals of the Paris Agreement. Introduction Climate change is the biggest global health threat of the 21st century,1 and tackling it could be our greatest health opportunity.2 “The health of a child born today will be impacted by climate change at every stage in their life. Without significant intervention, this new era will come to define the health of an entire generation.”3 However, another path is possible: a world that meets the ambition of the Paris Agreement and proactively adapts to protect health from the climate impacts we cannot now avoid. This year’s briefing presents key findings and recommendations toward this path. Key messages and recommendations Health and climate change in Canada Imagine an infant born today in Canada. This child enters a country warming at double the global rate, with the average temperature in Canada having increased 1.7oC between 1948-2016.4 The North is warming even faster: areas in the Northwest Territories’ Mackenzie Delta are now 3oC warmer than in 1948.5 Climate-related impacts on health and health systems are already being felt,6 with examples outlined in Figure 1. By the time the child is in their twenties, in all feasible emissions scenarios, Canada will have warmed by at least 1.5oC as compared to a 1986-2005 reference period.4 Two scenarios are possible for the remainder of the child’s life. If GHG emissions continue to rise at the current rate (a situation referred to by the Intergovernmental Panel on Climate Change (IPCC) as the “high emissions scenario,” or ‘RCP8.5’) temperature increases in Canada will continue after 2050, reaching 6oC relative to 1986-2005 by the time the child is in their child’s sixties.4 Globally, this degree of warming places populations at a greater risk of wildfires, extreme heat, poor air quality, and weather-related disasters. It will also lead to changes in vector-borne disease, as well as undernutrition, conflict, and migration. These impacts and others negatively impact mental health,3 including via ecological anxiety and grief.8 Climate change will not impact everyone equally, and can widen existing disparities in health outcomes between and within populations, with Indigenous populations, people in low-resource settings,28 and future generations29 disproportionately affected.30 This degree of warming has the potential to disrupt core public health infrastructure and overwhelm health services.2 Alternatively, if global emissions peak soon and quickly fall to net zero, consistent with the IPCC’s low-emissions scenario, (RCP 2.6), temperatures will remain steady from 2040 onwards.4 Measures needed to accomplish this, such as increasing clean energy, improving Figure 1: Examples of impacts of Climate Change on Health and Health Systems in Canada Indicators of climate-related health impacts and adaptation This year’s policy brief presents information on three key indicators of climate-related health impacts and adaptive responses. Additional recommendations can also be found in the 2017 and 2018 policy briefs.6,24 Wildfires Lancet Countdown data indicates that the number of daily population wildfire exposure events increased from an average of 35,300 in 2001-2004 to 54,100 in 2015-2018, not including those subjected to wildfire smoke. Canadian data supports increasing impacts: more than half of the 448,444 Canadians evacuated due to wildfires between 1980-2017 were displaced in the last decade.35 These exposures not only pose a threat to public health, but also result in major economic and social burdens. 2019 marks a crux point for humanity: choices and policies made in the lead up to the 2020 UNFCCC Nationally Determined Contribution submissions will determine whether the world follows the disastrous high-emissions scenario, or the safer low-emissions path. Children are taking to the streets to demand a livable world. It is the task of today’s political leaders and other adults to exert maximal effort within their spheres of influence in order to set a course for a healthy response to climate change. public transit, cycling and walking rates, and adhering to a plantrich diet in accordance with Canada’s new food guide, decrease emissions, and also improve health and decrease healthcare costs.30 Canada is not on track: in 2016, total Canadian GHG emissions were 704 Mt CO2e, an increase of more than 100 Mt since 1990.31 Policies and measures currently under development but not yet implemented are forecast to reduce national emissions to 592 Mt CO2e by 2030,32 79 Mt CO2e above Canada’s 2030 target of 513 MtCO2e 32—a goal which is itself too weak to represent a fair contribution by Canada to the emissions reductions necessary to meet the goals of the Paris Climate Change Agreement. The Earth as a whole is warming less quickly than Canada—but still far too fast. The IPCC and the World Health Organization have emphasized that keeping global surface temperature warming to 1.5oC is key to obtaining the best outcomes now possible for human health.33,34 To do so would require global net human-caused emissions to fall by about 45% from 2010 by 2030, reaching ‘net zero’ by 2050.34 Updated Nationally Determined Contributions to the Paris Agreement are due to be submitted by 2020: policymakers must integrate health considerations through proposed interventions. Figure 2: Number of Wildfire Evacuees in Canada 1980-2017.* Source: Wildland Fire Evacuation Database, Natural Resources Canada.35 (used with permission) *N.B. Reporting for 2017 only includes evacuations up to and including July In a mid-range GHG emissions scenario, wildfires in Canada are projected to rise 75% rise by the end of the 21st century,36 necessitating a strong adaptive response. Human health impacts of fire include death, trauma, and major burns,37 anxiety during wildfire periods,35,38 and post-traumatic stress disorder, anxiety and depression related to evacuations.39,40 Wildfire smoke also travels vast distances41 and increases asthma and chronic obstructive pulmonary disease exacerbations, with growing evidence of an association with all-cause mortality.41 Impacts on health systems can be severe: during the Fort McMurray fire hospital staff evacuated 103 patients in a matter of hours,10,42 and the 2017 British Columbia wildfires resulted in 700+ staff displaced, 880 patients evacuated, and 19 sites closed by the Interior Health Authority, at a cost of $2.7 million.12 Such devastating events also generate significant emissions, contributing to climate change, and helping to generate conditions conducive to future blazes.43 Much can be done to lessen the health impacts of wildfires. Qualitative data indicates that populations who are better-briefed on the local evacuation plan, as well as ways to lessen the risk of fire to their property, are not only more prepared but also less anxious.35,38 Building codes can be changed to help keep smoke out, primary care practitioners can ensure vulnerable patients receive at-home air filtration systems and respiratory medications prior to wildfire season,44 public health professionals can collaborate with municipal officials to maximize smoke forecast-informed outdoor and well-ventilated indoor recreation opportunities,38 and health personnel can help ensure evacuation plans are clearly communicated.45 Sustainable and healthy transport since 2000, they account for less than 4% of the energy used in transport (Figure 3). This rate of change is inconsistent with the emissions pathway required to keep today’s and future children safe. Support is therefore required for investments in public transit,47 and cycling infrastructure,48 creating win-wins for health by increasing physical activity levels and improving community cohesion, while reducing chronic disease, healthcare costs and GHG emissions.49,50 Zero emissions vehicles also reduce air pollution and are increasingly affordable: the up-front cost of electric vehicles is forecast to become competitive on an un-subsidized basis from 2024 onwards.51 British Columbia recently passed legislation requiring all new cars sold to be zero-emission by 2040.52 Other provinces would benefit from matching this ambition. Figure 3: Per Capita Fuel Consumption for Transport in Canada. Source: Lancet Countdown Transport-related pollution is harming the health of Canadians. Fine particulate matter (PM2.5) air pollution related to land-based transportation was responsible for approximately 1063 deaths in 2015 in Canada, resulting in a loss of economic welfare for Canadians valued at approximately $8 billion dollars.24 Additionally, Canada has the highest pediatric asthma rate amongst countries of comparable income level, with nitrogen dioxide (NO2) from traffic responsible for approximately 1 in 5 new cases of asthma in children.46 With transport responsible for 24% of national GHG emissions in 2017,31 decarbonizing this sector must be prioritized. Progress is entirely too slow: total fuel consumption for road transport per capita decreased 5.4% from 2013 to 2016. While per capita use of electricity and biofuels for transport increased by 600% Healthcare sector emissions Though Canadians are proud of the care they provide for one another with this country’s system of universal healthcare,53 Lancet Countdown analysis reveals an area which should give pause to all who endeavor to “do no harm”: Canada’s healthcare system has the world’s third highest emissions per capita. Previous analysis showed healthcare sector emissions to be responsible for 4.6% of the national total,54 as well as more than 200,000 tons of other pollutants, resulting in 23,000 disability-adjusted life years (DALYs) lost annually.54 Emissions from the health sector represent a strategic mitigation target in a single-payer healthcare system straining under the weight of an inexorably increasing burden of disease. While Canadian healthcare sector emissions are increasing, the world-leading Sustainable Development Unit in England reported an 18.5% decrease in National Health Service, public health and social care system emissions from 2007-2017 despite an increase in clinical activity.55 Despite healthcare being a provincial jurisdiction, there is a role for pan-Canadian sustainability initiatives to unite diverse experts spanning public health and the spectrum of clinical disciplines, economics, sustainability science and beyond. This demands health sector-wide education, consistent with existing efforts to increase environmental literacy for health professionals.56 1. Costello A, Abbas M, Allen A, Ball S, Bell S, Bellamy R, et al. Managing the health effects of climate change: Lancet and University College London Institute for Global Health Commission. Lancet 2009;373(9676):1693-733. 2. Watts N, Amann M, Arnell N, et al. The 2018 report of The Lancet Countdown on health and climate change: shaping the health of nations for centuries to come. Lancet 2018; vol. 392: 2479–514. 3. Watts N, Amann M, Arnell N, et al. The 2019 report of The Lancet Countdown on health and climate change: ensuring that the health of a child born today is not defined by a changing climate. Lancet 2019; vol. 394: 1836–78. 4. Government of Canada. Canada’s Changing Climate Ottawa, Ontario,; 2019. 5. Government of the Northwest Territories. Climate Observations in the Northwest Territories (1957-2012) Inuvik * Norman Wells * Yellowknife * Fort Smith. 6. Howard C, Rose C, Hancock T. Lancet Countdown 2017 Report: Briefing for Canadian Policymakers. Lancet Countdown and Canadian Public Health Association; 2017 October 31st, 2017. 7. Rosol R, Powell-Hellyer S, Chan HM. Impacts of decline harvest of country food on nutrient intake among Inuit in Arctic Canada: impact of climate change and possible adaptation plan. Int J Circumpolar Health 2016;75(1):31127. 8. Cunsolo A, Ellis N. Ecological grief as a mental health response to climate change-related loss. Nature Climate Change 2018;8:275-81. 9. Yao J, Eyamie J, Henderson SB. Evaluation of a spatially resolved forest fire smoke model for population-based epidemiologic exposure assessment. J Expo Sci Environ Epidemiol 2016;26(3):233-40. 10. Hampshire G. Hospital heroes get patients to safety during Fort McMurray fire: 17 buses took 105 patients to safety in dramatic evacuation. CBC News. 2016. Available from: http://www.cbc.ca/news/canada/edmonton/hospital-heroesget- patients-to-safety-during-fort-mcmurray-fire-1.3574416. 11. Kirchmeier-Young M, Zwiers F, Gillett N, Cannon A. Attributing extreme fire risk in Western Canada to human emissions. Climatic Change 2017;144(2):365-79. 12. British Columbia Interior Health Authority. Wildfire Emergency Response 2017. 2018. 13. Kirchmeier-Young M, Gillett N, Zwieres F, Cannon A, Anslow F. Attribution of the Influence of Human-Induced Climate Change on an Extreme Fire Season. Earth’s Future: American Geophysical Union 2018. 14. Alberta Health. Impact of Wildfires on the Mental Health of Fort McMurray Residents: Neurotic Disorders, Daily Physician Visits within an Emergency Department 2015 vs. 2016. Alberta Health, Health Standards, Quality and Performance Division, Analytics and Performance Reporting Branch,; 2016. 15. Teufel B, Diro GT, What K, Mildrad SM, Jeong DI, Ganji A, et al. Investigation of the 2013 Alberta flood from weather and climate perspectives. Climate Dynamics 2017:2881-99. 16. Canadian Broadcasting Corporation. Alberta Flood 2013: The five people we lost. 2014. Available from: https://www.cbc.ca/calgary/features/albertaflood2013/ alberta-flood-deaths/. 17. United Nurses of Alberta. UNA Calgary office closed, many health facilities affected by southern Alberta flooding. 2013 June 21, 2013. 18. Yusa A, Berry P, J JC, Ogden N, Bonsal B, Stewart R, et al. Climate Change, Drought and Human Health in Canada. Int J Environ Res Public Health 2015;12(7):8359-412. 19. Smoyer-Tomic KE, Klaver JD, Soskolne CL, Spady DW. Health Consequences of Drought on the Canadian Prairies. EcoHealth 2004. 20. Government of Canada Agriculture and Agri-Food Canada. Impact of Climate Change on Canadian Agriculture. 2015 [Oct 22, 2017]; Available from: http:// www.agr.gc.ca/eng/science-and-innovation/agricultural-practices/agriculture- and-climate/future-outlook/impact-of-climate-change-on-canadian-agriculture/? id=1329321987305 21. Cryderman K. Drought in Western Canada is becoming an agricultural nightmare for farmers. 2018. Available from: https://www.theglobeandmail.com/ canada/alberta/article-drought-in-western-canada-is-becoming-an-agricultural- nightmare-for/. 22. Ziska LH, Makra L, Harry SK, Bruffaerts N, Hendrickx M, Coates F, et al. Temper-ature-related changes in airborne allergenic pollen abundance and seasonality across the northern hemisphere: a retrospective data analysis. Lancet Planet Health 2019;3(3):e124-e31. 23. Nelder MP, Wijayasri S, Russell CN, Johnson KO, Marchand-Austin A, Cronin K, et al. The continued rise of Lyme disease in Ontario, Canada: 2017. Canadian Communicable Disease Review 2018;44(10):231-6. 24. Howard C, Rose C, Rivers N. Lancet Countdown 2018 Report: Briefing for Canadian Policymakers. Canadian Medical Association, Canadian Public Health Association, The Lancet Countdown; 2018 November. 25. a. Regional Public Health Department of Montreal. Epidemiological Investigation Heat Wave Summer 2018 in Montréal - Summary. 2019. b. Vogel MM, Zscheischler J, Wartenburger R, et al. Concurrent 2018 hot extremes across Northern hemisphere due to human-induced climate change. Earth's Future, 2019; vol. 7, 692–703. https://doi.org/10.1029/ 2019EF001189 26. Fenech A. Yes, Mr. Premier, Your Province is Shrinking! 2014 [cited 2019 Sept 20, 2019]; Available from: http://projects.upei.ca/climate/2014/02/16/ yes-mr-premier-your-province-is-shrinking/ 27. Kelleya C, Mohtadib S, Canec M, Seagerc R, Kushnirc Y. Climate change in the Fertile Crescent and implications of the recent Syrian drought. Proceedings of the National Academy of Science 2015;112 no 11: 3241–6,. 28. Berry HL, Bowen K, Kjellstrom T. Climate change and mental health: a causal pathways framework. Int J Public Health 2010;55(2):123-32. 29. Walpole SC, Rasanathan K, Campbell-Lendrum D. Natural and unnatural synergies: climate change policy and health equity. Bull World Health Organ 2009;87(10):799-801. 30. Watts N, Adger WN, Agnolucci P, Blackstock J, Byass P, Cai W, et al. Health and climate change: policy responses to protect public health. Lancet 2015;386(10006):1861-914. 31. Government of Canada. Greenhouse Gas Emissions. 2018 [June 13, 2018.]; Available from: https://www.canada.ca/en/environment-climate-change/ services/environmental-indicators/greenhouse-gas-emissions.html 32. Environment and Climate Change Canada. Canadian Environmental Sustainability Indicators: Progress Towards Canada’s Greenhouse Gas Emissions Reduction Target. 2019 [Sept 3, 2019]; Available from: https://www.canada. ca/content/dam/eccc/documents/pdf/cesindicators/progress-towards-canada- greenhouse-gas-reduction-target/2019/progress-towards-ghg-emissions- target-en.pdf 33. Ebi K, Campbell-Lendrum D, Wyns A. The 1.5 Health Report--Synthesis on Health and Climate Science in the IPCC SR1.5. 2018 2018. 34. Intergovernmental Panel on Climate Change. Global Warming of 1.5C--Summary for Policymakers. 2018 October 8, 2018. 35. Christianson A. Wildland Fire Evacuations in Canada. Natural Resources Canada; 2017. 36. Wotton M, Nock C, Flannigan M. International Journal of Wildland Fire 2010;19(3):253-71. 37. Cameron PA, Mitra B, Fitzgerald M, Scheinkestel CD, Stripp A, Batey C, et al. Black Saturday: the immediate impact of the February 2009 bushfires in Victoria, Australia. Med J Aust 2009;191(1):11-6. 38. Dodd W, Scott P, Howard C, Scott C, Rose C, Cunsolo A, et al. Lived experience of a record wildfire season in the Northwest Territories, Canada. Can J Public Health 2018;109(3):327-37. 39. McDermott BM, Lee EM, Judd M, Gibbon P. Posttraumatic stress disorder and general psychopathology in children and adolescents following a wildfire disaster. Can J Psychiatry 2005;50(3):137-43. 40. Papanikolaou V, Adamis D, Mellon RC, Prodromitis G. Psychological distress following wildfires disaster in a rural part of Greece: a case-control population- based study. Int J Emerg Ment Health 2011;13(1):11-26. 41. Reid CE, Brauer M, Johnston FH, Jerrett M, Balmes JR, Elliott CT. Critical Review of Health Impacts of Wildfire Smoke Exposure. Environ Health Perspect 2016;124(9):1334-43. 42. Matear D. The Fort McMurray, Alberta wildfires: Emergency and recovery management of healthcare services. J Bus Contin Emer Plan 2017;11(2):128- 50. 43. Liu Y, Goodrick S, Heilman W. Wildland fire emissions, carbon, and climate: Wildfire–climate interactions. Forest Ecology and Management 2014;317:80- 96. 44. Barn PK, Elliott CT, Allen RW, Kosatsky T, Rideout K, Henderson SB. Portable air cleaners should be at the forefront of the public health response to landscape fire smoke. Environ Health 2016;15(1):116. 45. Maguet S. Public Health Responses to Wildfire Smoke Events. BC Center for Disease Control; 2018. 46. Achakulwisut P, Brauer M, Hystad P, Anenberg SC. Global, national, and urban burdens of paediatric asthma incidence attributable to ambient NO2 pollution: estimates from global datasets. Lancet Planet Health 2019;3(4):e166-e78. 47. Besser LM, Dannenberg AL. Walking to public transit: steps to help meet physical activity recommendations. Am J Prev Med 2005;29(4):273-80. 48. United Kingdom Department of Transport. Value for Money Assessment for Cycling Grants. 2014. 49. Woodcock J, Tainio M, Cheshire J, O’Brien O, Goodman A. Health effects of the London bicycle sharing system: health impact modelling study. BMJ 2014;348:g425. 50. Maizlish N, Woodcock J, Co S, Ostro B, Fanai A, Fairley D. Health cobenefits and transportation-related reductions in greenhouse gas emissions in the San Francisco Bay area. Am J Public Health 2013;103(4):703-9. 51. Willett W, Rockstrom J, Loken B, Springmann M, Lang T, Vermeulen S, et al. Food in the Anthropocene: the EAT-Lancet Commission on healthy diets from sustainable food systems. Lancet 2019. 52. Zussman R. Legislation introduced to require all new cars sold in B.C. to be zero-emission by 2040. Global News Online. 2019. Available from: https:// globalnews.ca/news/5152429/legislation-introduced-electric-cars/2019. 53. Thompson N. More Canadians take pride in symbols of the country’s present than its past: survey. 2019. 54. Eckelman MJ, Sherman JD, MacNeill AJ. Life cycle environmental emissions and health damages from the Canadian healthcare system: An economic- environmental-epidemiological analysis. PLoS Med 2018;15(7):e1002623. 55. National Health System Sustainable Development Unit. Reducing the use of natural resources in health and social care 2018 report. 2018. 56. Parkes M, Poland B, Allison A, Cole DC, Culbert I, Gislason MK, et al. In press-Preparing for the future of public health: Ecological determinants of health and the call for an eco-social approach to public health education. Canadian Journal of Public Health 2019. DOI: 10.17269/s41997-019-00263-8. References Organisations and acknowledgements The concept of this brief was developed by the Lancet Countdown on Health and Climate Change. This brief was written by Courtney Howard, MD; Chris Buse, PhD; Caren Rose, PhD; Andrea MacNeill, MD, MSc; and Margot Parkes, MBChB, MAS, PhD. Review was provided by Owen Adams, PhD; Ian Culbert; and Sandy Buchman, MD. Thanks to Sarah Henderson, PhD; Peter Barry, PhD; Brian Wiens, PhD; Robin Edger, LLB, LLM; Jeff Eyamie, and Ashlee Cunsolo, PhD for their assistance. Contributions and review on behalf of the Lancet Countdown were provided by Jess Beagley and Nick Watts, MBBS. THE LANCET COUNTDOWN The Lancet Countdown: Tracking Progress on Health and Climate Change is an international, multi-disciplinary collaboration that exists to monitor the links between public health and climate change. It brings together 35 academic institutions and UN agencies from every continent, drawing on the expertise of climate scientists, engineers, economists, political scientists, public health professionals, and doctors. Each year, the Lancet Countdown publishes an annual assessment of the state of climate change and human health, seeking to provide decision-makers with access to high-quality evidence-based policy guidance. For the full 2019 assessment, visit www.lancet countdown.org/2019-report . THE CANADIAN MEDICAL ASSOCIATION The Canadian Medical Association (CMA), formed in Quebec City in 1867, has led some of Canada’s most important health policy changes. As we look to the future, the CMA will focus on advocating for a healthy population and a vibrant profession. THE CANADIAN PUBLIC HEALTH ASSOCIATION The Canadian Public Health Association (CPHA) is a national, independent, non-governmental organization that advances public health education, research, policy and practice in Canada and around the world through the Canadian Journal of Public Health, position statements, discussion documents and other resources.

Documents

Less detail

Proposed approach to the regulation of cannabis

https://policybase.cma.ca/en/permalink/policy13838

Date
2018-01-19
Topics
Pharmaceuticals/ prescribing/ cannabis/ marijuana/ drugs
  1 document  
Policy Type
Response to consultation
Date
2018-01-19
Topics
Pharmaceuticals/ prescribing/ cannabis/ marijuana/ drugs
Text
The Canadian Medical Association appreciates this opportunity to respond to Health Canada's public consultation on the proposed regulatory approach for the proposed Cannabis Act, Bill C-45. Our approach to cannabis is grounded in broad public health policy. It includes promotion of health and prevention of drug dependence and addiction; access to assessment, counselling and treatment services; and a harm reduction perspective. The CMA endorsed the Lower-Risk Cannabis Use Guidelines1 and has expressed these views in our recommendations to the Task Force on Cannabis Legalization and Regulation,2 recommendations regarding Bill C-453 and submission on the cannabis excise duty framework.4 Therefore, we are limiting our response to those consultation questions that pertain to that approach and relate to our expertise and knowledge base. We are providing responses to questions 9, 10 and 11. Consultation questions Packaging and labelling 9. What do you think about the proposed rules for the packaging and labelling of cannabis products? Do you think additional information should be provided on the label? The CMA concurs with the proposed regulations. Packaging and labelling of cannabis products should include measures such as:
a requirement for plain and standard packaging,5 6
prohibition of the use of appealing flavours and shapes,
a requirement for adequate content and potency labelling,
a requirement for comprehensive health warnings,
a requirement for childproof packaging, and
a requirement that the content in a package should not be sufficient to cause an overdose. Education is required to develop awareness among Canadians of the health, social and economic harms of cannabis use especially in young people. In that regard, the regulations with respect to packaging and labelling should be viewed as an opportunity to maximize educational opportunities. Package inserts must outline and reinforce the health risks involved; they must also be designed by governments and health professionals, not cannabis producers or distributors. Package inserts should include:
information on securing the product in the home to prevent access by youth and children,
recommendations not to drive or to work with hazardous chemicals or operate equipment while using the contents of the package,
information on the health and social consequences (including legal penalties) of providing cannabis to those under a designated minimum age for purchasing, and
contact information for hotlines for poison control and for crisis support. In addition, the regulations for the marketing and advertising of cannabis should use an approach similar to those in place for tobacco and cigarettes.7 8 9 Cannabis for medicinal purposes 10. What do you think about the proposed approach to providing cannabis for medical purposes? Do you think there should be any specific additional changes? CMA maintains its position that there should be one system with one set of regulations for medical and recreational cannabis. The CMA believes that once the Act and regulations are in force, there will be no need for two systems. Cannabis will be available for those who wish to use it for medicinal purposes, either with or without medical authorization, and for those who wish to use it for other purposes. The medical profession does not need to authorize use once cannabis is legalized, especially given that cannabis has not undergone Health Canada's usual pharmaceutical regulatory approval process, and its anticipated removal as a controlled substance from the Controlled Drugs and Substances Act. Those who have experienced a two-system approach in Washington and Colorado have remarked on the challenges of having dual standards and regulations (e.g., purchase and possession quantities, taxation levelsa 4) and the contribution to the grey market.b 11 Consistent with the advice it received from the Task Force on Legalization and Regulation of Cannabis,12 the government intends on pursuing both a medicinal and retail cannabis system at this time. In this instance the CMA supports regulations for each system being as similar as possible. Furthermore, the CMA strongly supports the need for appropriate and relevant data collection (e.g., interaction of individuals between the medicinal and retail systems) to provide the necessary evidence for the future legislative review, anticipated in three years' time. The CMA would expect to be involved and looks forward to participating in the criteria development, evaluation and performance review of the systems. Sale of health products containing cannabis 11. What do you think about the proposed restrictions on the sale of health products containing cannabis authorized by Health Canada? Do they strike an appropriate balance between facilitating access to safe, effective and high quality health products, and deterring illegal activities and youth access? Health products include prescription health products, non-prescription drugs, natural health products, cosmetics and medical devices. Although all these products are regulated by Health Canada, they undergo different levels of scrutiny for safety, efficacy and quality, and in some cases industry does not need to provide scientific evidence to support the claims made on the label. The level of proof required to obtain a Drug Identification Number (DIN) for prescription drugs is considerably higher than the level of proof required for a Natural Product Number (NPN); rigorous scientific evidence is needed for a DIN but not for a NPN. Consumers generally do not know about this distinction, believing that Health Canada has applied the same level of scrutiny to the health claims made for every product. As a result, consumers presently do not have sufficient information to choose appropriate products. Health Canada launched a consultation in 201613 on the approval process of the categories of non-prescription drugs, natural health products and cosmetics ("self-care products") with the intent of modernizing the present regulations. The CMA fully supports this work and hopes it will be brought to a timely conclusion.14 With respect to all health products, the CMA supports a risk-based approach in which higher risk products, for example, those for which health claims are made, must meet a higher standard of review. Rigorous scientific evidence is needed to support claims of health benefits and to identify potential risks and adverse reactions. All health products containing cannabis must meet a high standard of review for safety, efficacy and quality, equivalent to that of the approval of prescription drugs (e.g., Marinol(r) and Sativex(r)), to protect Canadians from further misleading claims. Prescription drugs are subject to Health Canada's pharmaceutical regulatory approval process, based on each drug's specific indication, dose, route of administration and target population. Health claims need to be substantiated via a strong evidentiary process. With respect to the sale of cannabis products to youth, the CMA recommends the adoption of strict controls as outlined in the proposed regulations; as per the proposal, "All health products would be subject to provisions that control against practices that may appeal to youth, or the use of testimonials, real or fictional characters or animals, or lifestyle branding. Tamper-evident and child-resistant packaging requirements would also apply."15 We also support the additional precautions around medical devices, especially those sold to young persons. The CMA urges caution around the exemption for paediatric formulations that would allow for traits that would "appeal to youth." The CMA understands that these products, used under strict health professional supervision, should be child friendly, for example, regarding palatability, but we do not support marketing strategies that would suggest their use is recreational (e.g., producing them in candy or animal formats). There will be a need for careful monitoring of the health products released in the market and the health claims made. Experience has shown that regulations can and will be circumvented, and these activities will have to be addressed. Various examples have been reported in the media highlighting the need to be vigilant, as illustrated in Switzerland regarding health and other products with cannabis and high cannabidiol content.16 17 a The CMA supports similar taxation treatment of cannabis products for medical and non-medical purposes. b Grey market refers to products produced or distributed in ways that are unauthorized or unregulated, but not strictly illegal. 1 Fischer B, Russell C, Sabioni P, et al. Lower-risk cannabis use guidelines: A comprehensive update of evidence and recommendations. AJPH 2017 Aug;107(8):e1-e12. Available: http://ajph.aphapublications.org/doi/abs/10.2105/AJPH.2017.303818?url_ver=Z39.88-2003&rfr_id=ori%3Arid%3Acrossref.org&rfr_dat=cr_pub%3Dpubmed& (accessed 2017 Jul 27). 2 Canadian Medical Association (CMA). Legalization, regulation and restriction of access to marijuana. CMA submission to the Government of Canada - Task Force on cannabis, legalization and regulation. Ottawa: The Association; 2016 Aug 29. Available: www.cma.ca/Assets/assets-library/document/en/advocacy/submissions/2016-aug-29-cma-submission-legalization-and-regulation-of-marijuana-e.pdf (accessed 2017 Jul 27). 3 Canadian Medical Association (CMA). Bill C-45: The Cannabis Act. Submission to the House of Commons Health Committee. Ottawa: The Association; 2017 Aug 18. Available: http://www.cma.corp/dbtw-wpd/Briefpdf/BR2017-09.pdf (accessed 2018 Jan 17). 4 Canadian Medical Association (CMA). Excise duty framework for cannabis products. Submission to the Government of Canada consultation on the proposed excise duty framework for cannabis products. Ottawa: The Association; 2017 Dec 7. Available: http://www.cma.corp/dbtw-wpd/Briefpdf/BR2018-06.pdf (accessed 2018 Jan 17). 5 Vardavas C, Filippidis F, Ward B, et al. Plain packaging of tobacco products in the European Union: an EU success story? European Respiratory Journal 2017;50:1701232 Available: http://erj.ersjournals.com/content/erj/50/5/1701232.full.pdf (accessed 2018 Jan 17). 6 Torjesen I. Standardised packs cut adult smoking as well as discouraging young people, evidence indicates BMJ 2015;350:h935. Available: http://www.bmj.com/content/350/bmj.h935 (accessed 2018 Jan 17). 7 Hughes N, Arora M, Grills N. Perceptions and impact of plain packaging of tobacco products in low and middle income countries, middle to upper income countries and low-income settings in high-income countries: a systematic review of the literature. BMJ Open 2016;6:e010391. doi:10.1136/bmjopen-2015-010391. Available: http://bmjopen.bmj.com/content/bmjopen/6/3/e010391.full.pdf (accessed 2018 Jan 17). 8 White V, Williams T, Wakefield M. Has the introduction of plain packaging with larger graphic health warnings changed adolescents' perceptions of cigarette packs and brands? Tob Control 2015;24:ii42-ii49. Available: http://tobaccocontrol.bmj.com/content/tobaccocontrol/24/Suppl_2/ii42.full.pdf (accessed 2018 Jan 17). 9 Smith C, Kraemer J, Johnson A, Mays D. Plain packaging of cigarettes: do we have sufficient evidence? Risk Management and Healthcare Policy 2015;8:21-30. Available: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4396458/pdf/rmhp-8-021.pdf (accessed 2018 Jan 17). 10 Canadian Centre on Substance Use and Addiction (CCSA). Cannabis regulation: Lessons learned in Colorado and Washington State. Ottawa: CCSA; 2015 Nov. Available: http://www.ccsa.ca/Resource%20Library/CCSA-Cannabis-Regulation-Lessons-Learned-Report-2015-en.pdf (accessed 2018 Jan 18). 11 Task Force on Cannabis Legalization and Regulation. A framework for the legalization and regulation of cannabis in Canada: final report. Ottawa: Health Canada; 2016. Available: https://www.canada.ca/content/dam/hc-sc/healthy-canadians/migration/task-force-marijuana-groupe-etude/framework-cadre/alt/framework-cadre-eng.pdf (accessed 2018 Jan 18). 12 Government of Canada. Consultation on the regulation of self-care products. Ottawa: Government of Canada; n/d. Available: https://www.canada.ca/en/health-canada/programs/consultation-regulation-self-care-products.html (accessed 2018 Jan 17). 13 Canadian Medical Association (CMA). Regulation of self-care products in Canada. Ottawa: The Association; 2016. Available: http://www.cma.corp/dbtw-wpd/Briefpdf/BR2017-11.pdf (accessed 2018 Jan 17). 14 Health Canada. Proposed approach to the regulation of cannabis [consultation]). Ottawa: Health Canada; 2017 Nov. Available: https://www.canada.ca/content/dam/hc-sc/documents/programs/consultation-proposed-approach-regulation-cannabis/proposed-approach-regulation-cannabis.pdf (accessed 2018 Jan 17). 15 Knodt M. In Switzerland, high-CBD cannabis being sold legally as 'Tobacco Substitute'. Seattle: Leafly; 2018. Available: https://www.leafly.com/news/politics/switzerland-high-cbd-cannabis-sold-legally-tobacco-substitute (accessed 2018 Jan 17). 16 Wiley C. Could a legal quirk bring cannabis tourism to Switzerland? The Telegraph 2017 Jul 28;Travel Section. Available: http://www.telegraph.co.uk/travel/destinations/europe/switzerland/articles/cannabis-tourism-has-arrived-in-switzerland/ (accessed 2018 Jan 17).

Documents

Less detail

Federal monitoring of medical assistance in dying regulations

https://policybase.cma.ca/en/permalink/policy13856

Date
2018-02-13
Topics
Ethics and medical professionalism
  1 document  
Policy Type
Response to consultation
Date
2018-02-13
Topics
Ethics and medical professionalism
Text
The Canadian Medical Association (CMA) is pleased to provide input on the proposed regulations of the federal monitoring of Medical Assistance in Dying in Canada. The CMA fully supports the proposed intent of the regulations, in particular, public accountability and transparency and safeguards for vulnerable patient populations. Tracking trends and carrying out research is very important to monitor the implementation and implications of medical assistance in dying. The CMA further supports the intent to provide electronic reporting and guidance documents, and to leverage any synergies between the federal and provincial/territorial governments, especially to prevent duplication and to promote consistency in reporting across the country. The CMA would like to raise the following critical areas for your consideration: 1. Definitions/parameters of terms There continues to be a need to more clearly define several terms to ensure consistency of reporting. For example: a. Who constitutes a “practitioner”? One can argue that there is a broad scope of who is “a medical practitioner or nurse practitioner”. Is it the practitioner who provides MAiD? Or he practitioner who first reads a patient’s request for MAiD? Or is the first practitioner? Or second practitioner who assesses the patient? b. What constitutes a therapeutic relationship (as one of the eight proposed items to be collected about the practitioner)? A therapeutic relationship is not required to access MAiD. This criterion should be removed and if not, given the differences in opinion in the health professions as to what constitutes a therapeutic relationship includes, it should be clearly defined. c. What constitutes a request, a written request, the receipt of a request? If reporting obligations are “triggered” by a patient’s “written request”, at what point is that request actually triggered? The very first practitioner who receives the patient’s written request? Or the practitioner who conducts the eligibility assessment upon receipt of the written request? Or the practitioner who provides the prescription or carries out the procedure? d. On a related point, without clear definitions, any future comparative analysis of research or trends will be difficult as there will be no common starting point. e. There continues to be confusion on how to count or when to start counting the required 10 clear days. There are many reasons why this requires more clarity. 2. Collection and protection of data We applaud Health Canada for further reducing and revising data requirements. We submit, however, that further reductions are required for several reasons, including adherence to privacy best practices that require the collection of the least amount of data necessary to achieve reasonable purposes. In particular: a. In view of the quantity and highly personal and sensitive data that will be collected about patients and practitioners, data sharing agreements should be required; for example, agreements between the federal government and provincial/territorial governments or between researchers and others requesting use of the data to facilitate the appropriate sharing of data. b. Collection of personal information should be limited to what is relevant to the purpose of monitoring medical assistance in dying. Personal information, such as the patient’s full postal code, marital status, or principal occupation is beyond the scope of the eligibility criteria outlined in the legislation and thus beyond the scope of the purpose of monitoring the impact of the legislation. c. Any “characteristics” of the patient should refer only to the eligibility criteria. If other data will be collected beyond that scope, the justification for doing so, and the characteristics themselves, should be clearly outlined. d. The scope of the information collected about the practitioner could be narrowed. As is, it is very broad – a list of eight items – while the Quebec regulations, as a comparator, have only three-four items that must be collected in relation to the physician who administers MAiD. 3. Additional requirements Schedule 4 [section 2(i)] of the proposed regulations requires that the practitioner opine as to whether the patient met, or did not meet, all of the eligibility criteria outlined in the legislation – with two significantly expanded requirements; the requirements that the practitioner: 1) provide an estimate as to the amount of time MAiD shortened the patient’s life; and 2) indicate the anticipated likely cause of natural death of the patient. These additional requirements are beyond the letter and spirit of the legislation and, in many ways, are in direct contradiction to the legislation. The Legislature was not unaware when it drafted the Act that it did not follow other jurisdictions’ criteria requiring either a terminal illness or a prognosis of time within which the practitioner believed the patient would die, e.g., “within the next 6 months”. It is specifically the lack of a timeframe that makes the legislation unique and provides flexibility for both patients and practitioners. By adding these two additional criteria for reporting, in effect, they become additional criteria for eligibility which is, as stated above, beyond the scope, and in contradiction to, the legislation. 4. Lack of clarity of reasons for ineligibility There is a potential for misunderstanding as to whether reasons are required when the patient does not meet the criteria under Schedule 4, section 2(a) – (h). The introduction to section 2 speaks to the practitioner giving an indication as to (a) whether the patient met or (b) did not meet the criteria. However, in the itemized criteria [2(a)-(h)] it only speaks to the practitioner having to provide reasons when the patient meets the criteria (and not when the patient has not met the criteria). It would be helpful to specify that reasons should be required when the patient does and does not meet the criteria. This is also crucial for the publication of the Minister of Health’s annual report requiring that the reasons, and which eligibility criteria were not met, be addressed. Conclusion The CMA recognizes the importance of regulations to capture the provision, collection, use, and disposal of information for the purpose of monitoring MAiD. The CMA cautions against introducing reporting requirements that are beyond the scope of the legislation. As noted in the legislation, practitioners who fail to provide information under the regulations may be found guilty under the Criminal Code and subject to possible imprisonment. It is thus imperative that the federal government drafts clear regulations that respect the legislation, privacy, research ethics, and a de minimus approach. .

Documents

Less detail

Consultation on proposed front-of-package labelling

https://policybase.cma.ca/en/permalink/policy13882

Date
2018-04-23
Topics
Health care and patient safety
Pharmaceuticals/ prescribing/ cannabis/ marijuana/ drugs
  1 document  
Policy Type
Response to consultation
Date
2018-04-23
Topics
Health care and patient safety
Pharmaceuticals/ prescribing/ cannabis/ marijuana/ drugs
Text
Dear Mr. Rodrigue: The Canadian Medical Association is pleased to have this opportunity to participate in the consultation on the proposed front-of-packaging labelling (FOP) as posted in the Canada Gazette Part One on February 9, 2018.1 This new requirement will “provide clear and consistent front-of-package information and updated nutrient content claims to help protect Canadians from the risks of chronic diseases” related to the intake of foods high in sugar, sodium, saturated fats and trans fat.2 1 Canada Gazette Part One. Regulations Amending Certain Regulations Made Under the Food and Drugs Act (Nutrition Symbols, Other Labelling Provisions, Partially Hydrogenated Oils and Vitamin D) Department of Health Vol. 152, No. 6 — February 10, 2018 2 Ibid pg.1 3 Presentation to the House of Commons Standing Committee on Health, Nutrition Labelling, Canadian Medical Association, March 3, 2011 accessed at http://policybase.cma.ca The CMA believes that governments have a responsibility to provide guidance on healthy eating that can be easily incorporated into daily lives, and that the federal government has a continuous obligation to promulgate policies, standards, regulations and legislations that support healthy food and beverage choices; provide user-friendly consumer information including complete nutritional content and accurate advertising claims; and increase the amount of information provided on product labels. We also commend Health Canada for its current work on revising the Canada Food Guide. Front-of-Packaging Labelling The CMA has supported a standard “at a glance” approach to FOP food labelling that can reduce confusion and help consumers make informed dietary choices since 2011.3 FOP labelling on packaged foods will help Canadians make healthier food and beverage choices. It will draw attention to those ingredients to be avoided in higher levels and can reinforce public health messaging on healthy eating. An added benefit may be an incentive to the food industry to reformulate processed foods with lower amounts of those nutrients highlighted in FOP labelling. The CMA supports the placement of the proposed symbol on the upper and/or right hand side of the packaging, covering 25% of the principal display surface. The symbol must be clearly delineated from the product packaging so that it stands out and can be located with relative ease. It is important for the symbol to convey to the consumer that there is a certain degree of risk involved in consuming these foods, hence the colours used and the shape will be important. Of the four symbols proposed by Health Canada, our preference is for the one displayed here but with a more defined, thicker border, that includes a small outer buffer (in white). It will be essential for Health Canada to ensure that the symbol design has been tested thoroughly with consumers and is effective in conveying the intended “high in” message. As such, manufacturers will need clear guidance about the constraints on the use and placement of these symbols to ensure they cannot be misconstrued and to prevent the use of configurations that will diminish their effectiveness. Manufacturers must not be permitted to place voluntary nutrient content or health claims below or near the main symbol that would distort the message and create confusion. Foods to be exempted from front-of-package nutrition labelling There will be foods that are exempt from the labelling requirements and consumers will need clear explanations with respect to those that are exempt and why; some will be obvious, some will not. The CMA supports the proposed exemptions for eggs, fruits, vegetables and unsweetened, unsalted plain milk, and whole milk. However, we do not believe flavoured and/or seasoning salts and “sea salts” should be exempted from the requirement to have an FOP symbol on the package. Health Canada will need to undertake an education program to explain to consumers that these products are actually high in sodium. Nutrient thresholds for sodium, sugar & saturated fat CMA policy has encouraged governments to continue to work to reduce the salt, sugar, saturated fat, trans-fat and calorie content of processed foods and prepared meals.4 The nutrient levels chosen will therefore be critical in that regard. The CMA supports the proposed levels to identify foods high in sugar, salt or saturated fats. The CMA believes that it is important that there is consistency across all nutritional and healthy eating information and advice for Canadians. Ensuring consistency between the “high in” threshold and the 15% “a lot” daily value (DV) message delivers a clear message of concern. 4 Healthy Behaviours: Promoting Physical Activity and Healthy Eating, Canadian Medical Association Policy, 2014, accessed at http://policybase.cma.ca. While we understand the rationale behind increasing the nutrient threshold for prepackaged meals to 30% of the DV, we recommend that the threshold for “high in” sugar of 30 grams or more total sugars per serving of stated size may be too high and should be reconsidered. It should also be noted that the different thresholds on prepackaged foods and prepackaged meals may cause confusion for consumers and should be introduced with some consumer education. Nutrient content claims, in relation to Front-of-Packaging Labelling symbol Allowing a food that qualifies for a “high in” sugar FOP symbol to also display a “no added sugars” claim would be very confusing to consumers. The product label information would appear as quite contradictory; therefore the CMA does support not allowing “no added sugar” claims on these foods. The CMA would suggest that a food that is high in two or more of sugar, sodium or saturated fats not be allowed to display any content claims to avoid any consumer confusion. High-intensity sweetener labelling Canadians have come to rely on easy-to-recognize information that alerts them that food may contain artificial sweeteners. Therefore, we do not support the elimination of the labelling requirement for artificial sweeteners on the principal display panel. For products that have high intensity sweeteners added and which bear claims such as “unsweetened” or “no sugar added,” a declaration of “artificially sweetened” should be clearly visible on the FOP. The specific sweetener does not need to be identified so long as it is declared in the list of ingredients. As long as quantity is displayed on the nutrition facts table it doesn’t need to be on the principal display. Further, while we recognize that harmonizing with USA labelling regulations is desirable, we recommend strongly against the use of the term “phenylketonurics.” The proper approach would be to use the phrase “people with phenylketonuria” for any warnings on products containing aspartame, which contains phenylalanine. Consumer education For many Canadians, their diet can have a negative rather than positive impact on their overall health. There is a particular concern for children and youth who are growing up in increasingly obesogenic environments that reinforce practices that work against a healthy diet and healthy lifestyle. Determined action is required for children and youth to learn and acquire healthy behaviours that they will maintain throughout their life. The CMA supports the government’s Healthy Living Strategy and their efforts to create a healthier food environment. The addition of FOP nutrition labelling is an important tool to make the healthy choice the easy choice. Sincerely, Jeff Blackmer, MD, MHSc, FRCPC Vice-president, Medical Professionalism

Documents

Less detail

Canada's Food Guide

https://policybase.cma.ca/en/permalink/policy13920

Date
2018-06-06
Topics
Population health/ health equity/ public health
  1 document  
Policy Type
Response to consultation
Date
2018-06-06
Topics
Population health/ health equity/ public health
Text
The Canadian Medical Association (CMA) is pleased to provide this submission to the House of Commons Standing Committee on Health with respect to its study of Canada’s Food Guide. The CMA supports access to healthy foods to improve individual health and well-being and the overall health status of the population.1 1 Canadian Medical Association (CMA). Obesity in Canada: Causes, consequences and the way forward. Ottawa: CMA; 2015. Available: http://policybase.cma.ca/dbtw-wpd/Briefpdf/BR2015-12.pdf (accessed 2018 Feb 5). 2 Colapinto C, Graham J, St. Pierre S. Trends and correlates of frequency of fruit and vegetable consumption, 2007 to 2014. Health Reports. 2018 January;29(1):9-14. Available: http://www.statcan.gc.ca/pub/82-003-x/2018001/article/54901-eng.pdf (accessed 2018 Feb 5). 3 Van Vliet B, Campbell N. Efforts to reduce sodium intake in Canada: Why, what, and when? Can J Cardiol. 2011;27(4):437–445. 4 Canadian Medical Association (CMA). Early childhood development. Ottawa: CMA; 2014. Available: http://policybase.cma.ca/dbtw-wpd/Policypdf/PD15-03.pdf (accessed 2018 Feb 2). 5 Canadian Medical Association (CMA). Health equity and the social determinants of health: A role for the medical profession. Ottawa: CMA; 2013. Available http://policybase.cma.ca/dbtw-wpd/Policypdf/PD13-03.pdf (accessed 2018 Jan 30). 6 Health Canada. Eating well with Canada’s food guide. Ottawa: Health Canada; 2007. Available: https://www.canada.ca/content/dam/hc-sc/migration/hc-sc/fn-an/alt_formats/hpfb-dgpsa/pdf/food-guide-aliment/view_eatwell_vue_bienmang-eng.pdf (accessed 2018 Jan 30). 7 Collier R. Calls for a better food guide. CMAJ. 2018 November 18;186(17):1281. Available: https://doi.org/10.1503/cmaj.109-4911 (accessed 2018 Jan 30). 8 Ministry of Health of Brazil. Dietary guidelines for the Brazilian population. 2nd ed. Brazil: Ministry of Health of Brazil; 2014. Available: http://www.foodpolitics.com/wp-content/uploads/Brazilian-Dietary-Guidelines-2014.pdf (accessed 2018 Feb 1). 9 Report of the Standing Committee on Social Affairs, Science and Technology. Obesity in Canada. A whole-of-society approach for a healthier Canada. Ottawa: Senate of Canada; 2016 March. Available: https://sencanada.ca/content/sen/committee/421/soci/rms/01mar16/Report-e.htm (accessed 2018 Feb 2). 10 Health Canada. Evidence review for dietary guidance: summary of results and implications for Canada’s food guide. Ottawa: Health Canada; 2015. Available: https://www.canada.ca/content/dam/canada/health-canada/migration/publications/eating-nutrition/dietary-guidance-summary-resume-recommandations-alimentaires/alt/pub-eng.pdf (accessed 2018 Feb 2). 11 Government of Canada. Guiding principles [Canada’s food guide consultation]. Ottawa: Government of Canada; 2017 April 5. Available: https://www.foodguideconsultation.ca/guiding-principles-detailed (accessed 2018 Feb 5). The CMA has been active on nutritional issues for many years, both directly through its policy and government advocacy as well as through membership in various coalitions. Some of the issues addressed include the nutrition facts table, front-of-package labelling, a ban on the marketing of food and beverages to children younger than 16 years of age, and a levy on the manufacturers of sugar-sweetened beverages. Canadians’ self-reported dietary intakes do not meet national dietary recommendations despite public education efforts concerning healthy eating and healthy diets. Children and adults are consuming fewer than the recommended number of servings of vegetables and fruits, an established proxy for healthy eating habits, and they are exceeding daily recommended intakes of sodium.2,3 The protection of vulnerable populations including children is of paramount concern to the CMA. Access to nutritious food is essential in early childhood development in support of later adult health.4 The availability of food security programs is a key element in preventing children from developing dietary deficiencies that would lead to an increased risk of chronic disease and greater difficulty in disease management later in life.5 The Food Guide has historically been a valued resource for Canadians, and physicians have found it useful in counselling their patients about healthy eating. However, there are serious concerns with the present Food Guide,6 which was released in 2007, and physicians have increasingly called for it to be reviewed.7 Other countries have made significant changes to their dietary guidelines. Brazil, for example, has developed a guideline that incorporates simple-to-follow, common-sense messaging, such as encouraging Brazilians to prepare meals from scratch and promoting the value of family meals.8 A new, modern Canadian guide is needed. Witnesses appearing before the Senate Committee on Social Affairs, Science and Technology characterized the current version as being “at best ineffective, and at worst enabling, with respect to the rising levels of unhealthy weights and diet-related chronic diseases in Canada.”9 Health Canada is in the process of revising the Food Guide, having done an extensive review of the evidence10 and releasing Guiding Principles.11 Recommendations for a revised Food Guide A new approach to a food guide that addresses the larger picture, beyond daily nutrient consumption recommendations, is fundamental to the effort to improve the health of all Canadians and to the larger goal of developing a food policy for Canada. Indeed, “coordinated investments in health promotion and disease and injury prevention, including attention to the role of the social determinants of health, are critical to the future health and wellness of Canadians and to the viability of the health care system.”12 12 Canadian Medical Association (CMA) and Canadian Nurses Association (CNA). Principles for health care transformation in Canada. Ottawa: CMA and CNA; 2011. Available: http://policybase.cma.ca/dbtw-wpd/Policypdf/PD1113.pdf (accessed 2018 Jan 30). 13 Nexus H. Primer to action: Social determinants of health. Toronto: Ontario Chronic Disease Prevention Alliance; 2007. Available: http://www.ocdpa.ca/sites/default/files/publications/PrimertoAction-EN.pdf (accessed 2018 Feb 1). 14 Tarasuk V, Mitchell A, Dachner N. Household food insecurity in Canada. Toronto: PROOF; 2016. Available: http://proof.utoronto.ca/resources/proof-annual-reports/annual-report-2014/ (accessed 2018 Feb 5). 15 Rao M, Afshin A, Singh G, et al. Do healthier foods and diet patterns cost more than less healthy options? A systematic review and meta-analysis. BMJ Open. 2013;3:e004277. Available: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3855594/pdf/bmjopen-2013-004277.pdf (accessed 2018 Feb 5). 16Lee A, Mhurchu CN, Sacks G, et al. Monitoring the price and affordability of foods and diets globally. Obes Rev. 2013 Oct;14 Suppl 1:82–95. 17 Food Banks Canada. Hungercount2016: A comprehensive report on hunger and food bank use in Canada, and recommendations for change. Toronto: Food Banks Canada; 2016. Available: https://www.foodbankscanada.ca/hungercount2016 (accessed 2018 Jan 30). 18 Raine K. Improving nutritional health of the public through social change: Finding our roles in collective action. Can J Diet Pract Res. 2014;75(3):160-164. Available: https://doi.org/10.3148/cjdpr-2014-017 (accessed 2018 Feb 2). 19 Canadian Medical Association (CMA). CMA’s Support for Bill S-228: An Act to amend the Food and Drugs Act (prohibiting food and beverage marketing directed at children).Ottawa: CMA; 2017.Available: http://policybase.cma.ca/dbtw-wpd/Briefpdf/BR2017-07.pdf (accessed 2018 Feb 2). 20 Howard, C., Culbert I., Food Guide revamp encouraging plant-based, low-meat diet is good for people and the planet CBC February 11, 2018 Available: http://www.cbc.ca/news/canada/manitoba/opinion-canada-food-guide-1.4530058 (accessed 2018 Feb 12) CMA recommendations: 1. The Food Guide must go hand in hand with efforts to increase access to affordable, healthy food Food insecurity does not affect all Canadians equally, and there are very clear social patterns of vulnerability.13 Analyses of population survey data consistently identify low income as a predictor of household food insecurity. In addition, rates of food insecurity are highest among Aboriginal Canadians, households reliant on social assistance, households headed by single mothers, and those renting rather than owning a home.14 More research is needed to understand decisions surrounding the purchase of healthy foods versus unhealthy foods.15,16 Food Banks Canada reported that in March 2016, 863,492 people received food from a food bank, an increase of 1.3% over 2015, with eight of 10 provinces showing an increase.17 As the report notes, “approximately 1.7 million Canadian households, encompassing 4 million people, experience food insecurity each year” with 340,000 of them experiencing severe food insecurity.17 Other determinants of healthy eating include a wide range of contextual factors, such as the interpersonal environment created by family and peers, the physical environment, which determines food availability and accessibility, the economic environment, in which food is a commodity to be marketed for profit, and the social environment. Within the social environment, social status (income, education and gender) and cultural milieu are determinants of healthy eating that may be working "invisibly" to structure food choice.15 2. The Food Guide must be based on sound nutritional research With unhealthy diets consistently linked with chronic disease such as cardiovascular diseases (heart disease, stroke, hypertension, diabetes, dyslipidemia) and with an estimated 60% of Canadian adults and close to one-third of children being overweight or obese, there is a need for evidence-based approaches in the development of healthy eating policies and practices in Canada. As the links between nutrition and disease and other impacts of nutrition on the health of our society are revealed and better understood, it is more important than ever to identify what influences healthy eating behaviours.18 Food choices are structured by a variety of individual determinants of behaviour, including one's physiological state, food preferences, nutritional knowledge, perceptions of healthy eating and psychological factors. The Food Guide needs to incorporate emerging research on nutrition and health, for example, by emphasizing the need to replace saturated fats with unsaturated fats, as opposed to focusing on total fats. It also must take into account the changes in consumer behaviour and in the food supply. 3. The Government of Canada must assure Canadians that the revision process is evidence based Canadians must be able to trust Canada’s Food Guide as a source of unbiased information, based on evidence. The Food Guide must be part of a larger coordinated approach that also looks at other critical issues, such as the role of the marketing of unhealthy foods and beverages to children.19 CMA is concerned that conflict-of-interest situations have arisen in the past where recommendations might favour certain products or food groups over others.20 Canadians must have confidence that their health and wellness is the primary focus of an evidence-based revision process. 4. The Food Guide must reflect changing eating patterns reflective of our evolving and increasingly multicultural society Canadian society is more ethnically diverse than in the past, so it is necessary to keep in mind cultural preferences. The current food groups do not always take into account an understanding of traditional foods and cultural eating practices. These are intrinsically linked to identity and culture and contribute to overall health. Advice needs to be tailored to different ages and cultural groups. There is also a need to emphasize patterns of eating, as opposed to a focus almost exclusively on nutrient requirements. It is important to promote eating as a social undertaking, recognizing the essential role that food has in bringing people together. It is also important to support the development of basic, practical culinary skills, which will reduce Canadians’ dependence on restaurant meals and ultra-processed foods. 5. The Food Guide must encourage Canadians to reduce their reliance on processed foods The production and consumption of ultra-processed foods has increased drastically in the last decades in both higher and lower income countries. Highly or ultra-processed food tends to contain less protein and dietary fibre than less processed foods and include high proportions of free sugar, total saturated fat, trans fat and salt. Typically, processed foods are energy dense (high in calories) but have fewer beneficial nutrients such as vitamins and proteins. Most processed foods encourage unhealthy ways of eating and have become popular because of their accessibility and convenience. These features have changed the way food and in particular these products are consumed compared with unprocessed foods: increased “grazing,” eating alone or eating while carrying out other activities such as work or driving. In addition, many calories consumed come in liquid form. Physicians are concerned with the Food Guide’s support for fruit juices, given the plethora of sugar-sweetened beverages, including milk and milk alternatives. There should be a maximum amount of juice recommended for children, and the Food Guide should instead support the consumption of actual fruit. 6. The Government of Canada must produce simple, practical products for Canadians and clear dietary guidance for health professionals Reliable, trustworthy sources of information are essential to support healthy eating. However, the new Food Guide must not be just another set of rules and lists or a long, cumbersome document. The challenge will be to take the evidence around nutrition and health and make it meaningful and useful. This is the only way that the Food Guide will actually be able to support and even provoke change. To do that it must focus on the needs of the Canadians, with tools that personalize information for different age and cultural groups. It should also be useful to people with certain health conditions who require regulation of their diet to improve health (e.g., people with diabetes or hypertension). It should support couples during pregnancy and breastfeeding. There can’t be only one set of guidance; rather, various versions should be produced that are adapted to different audiences. The Food Guide needs to be practical and simple to use. The concept of the number and size of servings of different foods, for example, has been very confusing. Research has shown that Canadians do not weigh or measure their foods and serving sizes are often underestimated, promoting overconsumption. The Food Guide must support Canadians in deciphering food labels and making informed choices about what they consume. The use of technology will allow information to be more accessible. The guidance must be sensitive to issues related to the social determinants of health and food security, with attention to the cost and accessibility of foods. A focus on good sources of proteins, for example, as opposed to red meats and dairy, could allow for more choice. The Food Guide should provide guidance to food banks and other programs that seek to provide food to low-income families in terms of what foods they should procure for their clients. As one of the most trusted sources of health information, physicians also need to be able to access the latest evidence in a user-friendly manner. Resources must be succinct and easy for physicians to access in a busy practice. They should allow a physician to go into more depth should that be required. As well, point-of-care tools that help clinicians explain technical facts to their patients in an accessible manner are needed. Recommendations 1. The Food Guide must go hand in hand with efforts to increase access to affordable, healthy food 2. The Food Guide must be based on sound nutritional research 3. The Government of Canada must assure Canadians that the revision process is evidence based 4. The Food Guide must reflect changing eating patterns reflective of our evolving and increasingly multicultural society 5. The Food Guide must encourage Canadians to reduce their reliance on processed foods 6. The Government of Canada must produce simple, practical products for Canadians and clear dietary guidance for health professionals

Documents

Less detail

Health Canada consultation on restriction of marketing and advertising of opioids

https://policybase.cma.ca/en/permalink/policy13921

Date
2018-07-18
Topics
Pharmaceuticals/ prescribing/ cannabis/ marijuana/ drugs
  1 document  
Policy Type
Response to consultation
Date
2018-07-18
Topics
Pharmaceuticals/ prescribing/ cannabis/ marijuana/ drugs
Text
The Canadian Medical Association (CMA) is pleased to provide this submission to Health Canada in response to the publication of the Notice of Intent to restrict the marketing and advertising of opioids.1 The CMA is very concerned with the high rates of overdose deaths due to opioids2 and supports a comprehensive, multi-pronged approach to address this public health crisis.3 As part of the Government of Canada's strategy, the Minister of Health's 2017 mandate letter committed to "consult with provinces, territories, and professional regulatory bodies to introduce appropriate prescribing guidelines to curb opioid misuse, ensure prescriptions are appropriately tracked in a consistent and patient-centred way, and increase transparency in the marketing and promotion of therapies."4 Health Canada is proposing to further restrict drug manufacturers' advertising of opioids and is consulting on the scope and intent of the restrictions. The Food and Drugs Act defines advertisement as "any representation by any means for the purpose of promoting, directly or indirectly, the sale of any drug or device".5 Opioids are important therapeutic tools and serve legitimate purposes, when prescribed in an appropriate manner with proper assessment, and as part of a comprehensive therapeutic strategy and monitoring. These medications have been essential in areas such as palliative and cancer care and have contributed to the alleviation of suffering.3 Any measures to address advertising must not restrict appropriate access. Limiting access without appropriate alternatives and careful tapering can lead to undue suffering and seeking of drugs, potentially tainted, on the illegal market. However, of great concern, opioid dispensing levels have been shown to be strongly correlated with increased mortality, morbidity and treatment admissions for substance use.6,7 Many patients were prescribed these medications and developed dependence.8 Since the 1990s, opioids have been recommended for longer-term treatment of chronic non-cancer pain, and have become widely used due in part to aggressive promotion and marketing for this indication.9,10 However, there is evidence for pain relief in the short term but insufficient evidence regarding maintenance of pain relief over longer periods of time, or for improved physical function.11,12,13 There was also a concerted effort by industry to minimize the risk of addiction in the use of opioids for the treatment of chronic non-cancer pain. While stating that the risk of addiction was less than one percent, many studies have shown that the risk varies from 0 to 50% depending on the criteria used and sub population studied.14 Marketing significantly influences the type and amount of opioids consumed.15 Substantial tension exists between the competitive pressures that manufacturers face to expand product sales and support for limited, evidence-based use of most cost-effective available alternatives.16 Choices made by prescribers are subject to a number of influences, including education (undergraduate, residency and continuing); availability of useful point of care information; drug marketing and promotion; patient preferences and participation, and drug cost and coverage.17 Important contributing factors for the increase in opioid prescriptions are also the lack of supports and incentives for the treatment of complex cases, including availability and funding for treatment options for pain and addictions. Alternate approaches to pain management require more time with patients. Prescriptions also increased due to the availability of new, highly potent opioid drugs.18,19 Addressing advertising is only one component of the issue, and significant efforts need to be made to address issues such as access to alternatives for pain management and treatment of addiction. Presently, advertising of opioids is prohibited to the public, and only permitted to health care professionals if the claims are consistent with the terms of market authorization by Health Canada. Pharmaceutical industry's marketing practices to health care practitioners "can take many forms of direct and indirect activities and incentives, including, for example, manufacturer-sponsored presentations at conferences, continuing education programs, advertisements in medical journals, and personal visits from sales representatives. It can also include use of promotional brochures, fees for research, consulting or speaking, reimbursement for travel and hospitality expenses to attend industry-sponsored events, and gifts of meals, equipment, and medical journals and texts."1 As well, industry has sponsored advocacy organizations dedicated to the treatment of pain and key opinion leaders.15,20 Studies have shown that marketing influences prescribing patterns.21 Initiatives to regulate advertising and the promotion of prescription drugs have come from industry, nongovernmental organizations and government. The pharmaceutical industry itself is voluntarily self-regulated in Canada through the Pharmaceutical Advertising Advisory Board (PAAB), pre-clearing marketing initiatives based on a Code of Advertising.22 The CMA recommends that marketing initiatives could be vetted for accuracy and truthfulness through a pre-clearance mechanism such as PAAB. Faced with multiple legal challenges in the U.S., some opioid manufacturers have limited marketing, however, such measures had not been taken in Canada. The federal government has a complaints-based system and hasn't been proactive in the regulation and monitoring of advertising and marketing of opioids. In recently published regulations amending the Food and Drug Regulations,23 the Minister of Health can require companies to develop and implement risk management plans, which include the preclearance of opioid-related materials to be provided to health care professionals. Product information prepared by manufacturers, summarizing scientific evidence on effects and setting out conditions for use, as well as promotional activities are subject to regulatory approval. The authority conferred to the Minister has the objective of allowing Health Canada to "appropriately monitor, quantify, characterize, and mitigate the risks associated with post-market use" of opioids. CMA supports such actions. As Van Zee has noted in the case of the United States, "modifications of the promotion and marketing of controlled drugs by the pharmaceutical industry and an enhanced capacity of the Food and Drug Administration to regulate and monitor such promotion can have a positive impact on public health".14 This approach would confer a similar benefit for Canada in that, if effective, could contribute to unbiased, evidence-based prescribing. There are important guidelines and standards in place, developed by physicians, to guide relationships with the pharmaceutical industry. CMA's "Guidelines for Physicians in Interactions with Industry"24 were developed as a resource tool both for physicians, medical students and residents, as well as medical organizations, to support decisions as to appropriate relationships with industry, in conjunction with CMA's Code of Ethics.25 In summary, physicians have a responsibility to ensure that their interaction with the pharmaceutical industry is in keeping with their primary obligation to their patients and duties to society, and to avoid situations of conflict of interest where possible, appropriately managing these situations when necessary. These guidelines include principles for continuing medical education and continuing professional development (CME/CPD) and are the basis for the National Standard for Support of Accredited CPD Activities, developed by the Royal College of Physicians and Surgeons of Canada (RCPSC), the College of Family Physicians of Canada (CFPC) and the Collège des médecins du Québec. According to the Standard, "the interests of organizations that provide financial and in-kind support for the development of accredited CPD activities cannot be assumed to always be congruent with the goal of addressing the educational needs of the medical profession. Therefore, it is essential that the medical profession define and assume their responsibility for setting standards that will guide the development, delivery, and evaluation of accredited CPD activities."26 Physicians must complete CPD credits to maintain their professional license, and the accreditation bodies (such as CFPC, RCPSC) have processes in place to assure that these courses are evidence-based and free from industry bias. In recognition of the importance of opioid prescribing, and the key role that physicians play in this field, the CMA recommends that the government fund certified / accredited CPDs on pain management addressing non-pharmacologic and pharmacologic options, including opioids. This funding could include unconditional contribution from the opioid manufacturers, to ensure independence. The CMA appreciates the role that Health Canada has had in funding evidence-based guidelines.27 This has been a key initiative, which sought to provide physicians with unbiased information. Ongoing funding to maintain their currency would be warranted. The CMA supports long overdue actions related to the restriction of the marketing of opioids and looks forward to collaboration between Health Canada and the physician community. Recommendations The CMA supports Health Canada's efforts to place significant restrictions on the ability of drug manufacturers to advertise opioids to health care practitioners. Marketing initiatives should be vetted for accuracy and truthfulness through a pre-clearance mechanism. The CMA recommends that the measures chosen to constrain advertising do not unduly restrict access to opioids for appropriate use. The CMA recommends that the government fund certified / accredited CPDs on pain management addressing non-pharmacologic and pharmacologic options, including opioids, and consider unconditional funding from opioid manufacturers. The CMA recommends that the government support keeping the 2017 Opioid Prescribing Guidelines current through ongoing funding. The CMA recognizes that restricting advertising is only one, overdue, measure to address the opioid crisis, and recommends that issues such as access to alternatives for pain management and addiction treatment urgently be addressed. 1 Government of Canada. Notice of intent to restrict the marketing and advertising of opioids. Ottawa: Government of Canada; 2018. Available: https://www.canada.ca/en/health-canada/services/drugs-health-products/drug-products/announcements/restrict-advertising-opioids.html (accessed 2018 Jul 17). 2 Public Health Agency of Canada. National report: apparent opioid-related deaths in Canada (released June 2018). Ottawa: Public Health Agency of Canada; 2018. Available: https://www.canada.ca/en/public-health/services/publications/healthy-living/national-report-apparent-opioid-related-deaths-released-june-2018.html (accessed 2018 Jul 17). 3 Canadian Medical Association. Harms associated with opioids and other psychoactive prescription drugs. Ottawa: Canadian Medical Association; 2009. Available: http://policybase.cma.ca/dbtw-wpd/Policypdf/PD15-06.pdf (accessed 2018 Jul 17). 4 Trudeau J. Minister of Health mandate letter. Ottawa: Office of the Prime Minister; 2017 Oct 4. Available: https://pm.gc.ca/eng/minister-health-mandate-letter (accessed 2018 Jul 17). 5 Government of Canada. Food and Drugs Act. Ottawa: Government of Canada; 1985. Available: http://lois-laws.justice.gc.ca/eng/acts/F-27/index.html (accessed 2018 Jul 17). 6 Fischer B, Jones W, Rehm J. High correlations between levels of consumption and mortality related to strong prescription opioid analgesics in British Columbia and Ontario, 2005-2009. Pharmacoepidemiol Drug Saf 2013;22(4):438-42. 7 Gomes T, Juurlink DN, Moineddin R, et al. Geographical variation in opioid prescribing and opioid-related mortality in Ontario. Healthc Q 2011;14(1):22-4. 8 Brands B, Blake J, Sproule B, et al. Prescription opioid abuse in patients presenting for methadone maintenance treatment. Drug Alcohol Depend 2004;73(2):199-207. 9 Manchikanti L, Atluri S, Hansen H, et al. Opioids in chronic noncancer pain: have we reached a boiling point yet? Pain Physician 2014;17(1):E1-10. 10 Dhalla IA, Persaud N, Juurlink DN. Facing up to the prescription opioid crisis. BMJ 2011;343:d5142 DOI: 10.1136/bmj.d5142. 11 Franklin GM. Opioids for chronic noncancer pain. A position paper of the American Academy of Neurology. Neurology 2014;83:1277-84. 12 Chou R, Ballantyne JC, Fanciullo GJ, et al. Research gaps on use of opioids for chronic noncancer pain: Findings from a review of the evidence for an American Pain Society and American Academy of Pain Medicine clinical practice guideline. J Pain 2009;10:147-59. 13 Noble M, Treadwell JR, Tregear SJ, et al. Long-term opioid management for chronic noncancer pain. Cochrane Database Syst Rev 2010;(1):CD006605. 14 Van Zee A. The promotion and marketing of OxyContin: Commercial triumph, public health tragedy. Am J Public Health 2009;99:221-27. 15 Hamunen K, Paakkari P, Kalso E. Trends in opioid consumption in the Nordic countries 2002-2006. Eur J Pain 2009;13:954-962. 16 Alves TL, Lexchin J, Mintzes B. Medicines information and the regulation of the promotion of pharmaceuticals. Sci Eng Ethics 2018:1-26. 17 Canadian Medical Association. Optimal prescribing. Ottawa: Canadian Medical Association; 2011. Available: http://policybase.cma.ca/dbtw-wpd/Policypdf/PD11-01.pdf (accessed 2018 Jul 17). 18 Fischer B, Goldman B, Rehm J, et al. Non-medical use of prescription opioids and public health in Canada. Can J Public Health 2008;99(3):182-4. 19 Fischer B, Keates A, Buhringer G, et al. Non-medical use of prescription opioids and prescription opioid-related harms: why so markedly higher in North America compared to the rest of the world? Addiction 2013;109:177-81. 20 Dyer O. OxyContin maker stops marketing opioids, as report details payments to advocacy groups. BMJ 2018;360:k791. 21 Katz D, Caplan AL, Merz JF. All gifts large and small: toward an understanding of the ethics of pharmaceutical industry gift-giving. Am J Bioethics 2003;3(3):39-46. 22 Pharmaceutical Advertising Advisory Board. PAAB Code. Ottawa: PAAB; 2018. Available: http://code.paab.ca/ (accessed 2018 Jul 17). 23 Regulations Amending the Food and Drug Regulations (Opioids), SOR/2018-77. Canada Gazette, Part II 2018 May 2;152(9). Available: http://gazette.gc.ca/rp-pr/p2/2018/2018-05-02/html/sor-dors77-eng.html (accessed 2018 Jul 17). 24 Canadian Medical Association. Guidelines for physicians in interactions with industry. Ottawa: Canadian Medical Association; 2007. Available: http://policybase.cma.ca/dbtw-wpd/Policypdf/PD08-01.pdf (accessed 2018 Jul 17). 25 Canadian Medical Association. CMA Code of Ethics (Update 2004). Ottawa: Canadian Medical Association; 2004. Available: https://www.cma.ca/Assets/assets-library/document/en/advocacy/policy-research/CMA_Policy_Code_of_ethics_of_the_Canadian_Medical_Association_Update_2004_PD04-06-e.pdf (accessed 2018 Jul 17). 26 Royal College of Physicians and Surgeons of Canada. National standard for support of accredited CPD activities. Ottawa: Royal College of Physicians and Surgeons of Canada; 2017. Available: http://www.royalcollege.ca/rcsite/cpd/providers/tools-resources-accredited-cpd-providers/national-standard-accredited-cpd-activities-e (accessed 2018 Jul 17). 27 Busse JW, Craigie S, Juurlink DN, et al. Guideline for opioid therapy and chronic noncancer pain. CMAJ 2017;189:E659-66.

Documents

Less detail

Proposed UN Convention on the rights of older persons

https://policybase.cma.ca/en/permalink/policy13925

Last Reviewed
2020-02-29
Date
2018-07-25
Topics
Population health/ health equity/ public health
  1 document  
Policy Type
Policy endorsement
Last Reviewed
2020-02-29
Date
2018-07-25
Topics
Population health/ health equity/ public health
Text
Dear Minister Freeland: We are a national consortium of experts who serve and advocate for the needs and rights of older people. We are delighted by the recent appointment of a new Minister of Seniors, and send our congratulations to the Honourable Filomena Tassi. We are also encouraged by our Government’s commitment to support the health and economic well-being of all Canadians, and heartened by your promise to listen to, and to be informed by feedback from Canadians. It is in this spirit that we are writing today regarding the need for Canada to provide support and leadership with a goal of developing and ratifying a United Nations (UN) Convention on the Rights of Older Persons. In the context of massive global demographic shifts and an aging population, insightful and careful reflection by the leaders of our organizations has led to universal and strong support for the creation and implementation of a UN Convention to specifically recognize and protect the human rights of our older persons. A UN Convention on the Rights of Older Persons will:
enshrine their rights as equal with any other segment of the population with the same legal rights as any other human being;
categorically state that it is unacceptable to discriminate against older people throughout the world;
clarify the state’s role in the protection of older persons;
provide them with more visibility and recognition both nationally and internationally, which is vitally important given the rate at which Canadian and other societies are ageing;
advance the rights of older women at home and as a prominent factor in Canada’s foreign policy;
have a positive, real-world impact on the lives of older citizens who live in poverty, who are disproportionately older women, by battling ageism that contributes to poverty, ill-health, social isolation, and exclusion;
support the commitment to improve the lives of Indigenous Peoples; members of the LGBTQ community, and visible and religious minorities; and,
provide an opportunity for Canada to play a leadership role at the United Nations while at the same time giving expression to several of the Canadian government’s stated foreign policy goals. We have projected that the cost and impact of not having such a Convention would have a significant negative impact on both the physical and mental health of older Canadians. The profound and tragic consequence would have a domino effect in all domains of their lives including social determinants of health, incidence and prevalence of chronic diseases, social and psychological functioning, not to mention massive financial costs to society. There is recognition of this need internationally and ILC-Canada, along with other Canadian NGOs and organizations have been active at the UN to help raise awareness of the ways a UN Convention on the Rights of Older Persons would contribute to all countries. Changes have already been implemented by our Government that are consistent and aligned with a UN Convention, such as improving the income of vulnerable Canadian seniors, funding for long term care and support for community based dementia programs. These initiatives are all in keeping with support for a Convention on the Rights of Older Persons. They are also reflective of our country’s commitment to engage more fully with the United Nations and provide Canada the stage to demonstrate leadership on a vital international issue. It is an opportunity to champion the values of inclusive government, respect for diversity and human rights including the human rights of women. Scientific evidence demonstrates that human rights treaties help to drive positive change in the lives of vulnerable groups of people. In many countries in the world, older people are not adequately protected by existing human rights law, as explicit references to age are exceedingly rare. Even in countries like Canada, where there are legal frameworks that safeguard older people, a Convention would provide an extra layer of protection, particularly if the Convention has a comprehensive complaints mechanism. Older adults need to be viewed as a growing but underutilized human resource. By strengthening their active role in society including the workforce, they have tremendous capacity, knowledge, and wisdom to contribute to the economy and general well-being of humankind. We are requesting you meet with our representatives, to discuss the vital role of a UN Convention on the Rights of Older Persons and the role your government could play in improving the lives of older people in Canada and around the world. The fact that Canada is ageing is something to celebrate. We are all ageing, whether we are 20 or 85. This is a ”golden opportunity” to showcase Canada as a nation that will relentlessly pursue doing the “right thing” for humanity by supporting a UN Convention that ensures that our future is bright. Please accept our regards, and thank you for your attention to this request. We await your response. Sincerely, Margaret Gillis, President, International Longevity Centre Canada Dr. Kiran Rabheru, Chair of the Board, International Longevity Centre Canada Linda Garcia, Director, uOttawa LIFE Research Institute cc: The Right Honourable Justin Trudeau Prime Minister of Canada The Honourable Filomena Tassi Minister of Seniors The Honourable Jean Yves Duclos Minister for Families, Children and Social Development Ambassador Marc-Andre Blanchard Permanent Representative to Canada at the United Nations The Honourable Ginette Petitpas Taylor Health Minister Margaret Gillis President International Longevity Centre Canada Dr. Kiran Rabheru Chair of the Board, International Longevity Centre Canada Linda Garcia, PhD Director LIFE Research Institute Dr. Laurent Marcoux President Canadian Medical Association Andrew Padmos, BA, MD, FRCPC, FACP Chief Executive Officer Dani Prud’Homme Directeur général FADOQ Peter Lukasiewicz Chief Executive Officer Gowling WLG Dr. Dallas Seitz, MD, FRCPC President, CAGP Dr. Frank Molnar President, Canadian Geriatrics Society Dr. David Conn Co-Leader Canadian Coalition for Senior’s Mental Health Claire Checkland Director - Canadian Coalition for Seniors’ Mental Health Joanne Charlebois Chief Executive Officer, Speech-Language & Audiology Canada Claire Betker President Canadian Nurses Association Janice Christianson-Wood, MSW, RSW Title/Organization: President, Canadian Association of Social Workers / Présidente, l’Association canadienne des travail- leurs sociaux François Couillard Chief Executive Officer/Chef de la direction Ondina Love, CAE Chief Executive Officer Canadian Dental Hygienists Association Jean-Guy Soulière President/Président National Association of Federal Retirees /Association nationale des retraités fédéraux Sarah Bercier Executive Director Laura Tamblyn Watts National Initiative for the Care of the Elderly Dr. Keri-Leigh Cassidy Founder Fountain of Health Dr. Beverley Cassidy Geriatric Psychiatris Seniors Mental Health Dalhousie University Dept of Psychiatry Jenny Neal and Janet Siddall CO Chairs, Leadership Team Grandmothers Advocacy Network (GRAN) Kelly Stone President and CEO Families Canada Dr. Becky Temple, MD, CCFP, CCPE President, CSPL Medical Director Northeast, Northern Health Medical Lead Privilege Dictionary Review, BCMQI J. Van Aerde, MD, MA, PhD, FRCPC Clinical Professor of Pediatrics - Universities of Alberta & British Columbia, Canada Associate Faculty - Leadership Studies - Royal Roads Univ, Victo- ria, BC, Canada Past-President - Canadian Society of Physician Leaders Editor-in-Chief / Canadian Journal of Physician Leadership Dr. Rollie Nichol, MD, MBA, CCFP, CCPE Vice-President, CSPL Associate Chief Medical Officer, Alberta Health Services Dr. Shannon Fraser, MSc, FRCSC, FACS Secretary / Treasurer, CSPL Chief General Surgery Jewish General Hospital Linda Gobessi MD FRCPC Medical Director Geriatric Psychiatry Community Services of Ottawa Ottawa Vickie Demers Executive Director / Directrice générale Services communautaires de géronto- psychiatrie d’ Ottawa Geriatric Psychiatry Community Services of Ottawa Ging-Yuek Robin Hsiung, MD MHSc FRCPC FACP FAAN Associate Professor Ralph Fisher and Alzheimer Society of BC Professor Director of Clinical Research Director of Fellowship in Behavioural Neurology UBC Hospital Clinic for Alzheimer and Related Disorders Division of Neurology, Department of Medicine University of British Columbia Adriana Shnall Senior Social Worker Baycrest Health Sciences Harinder Sandhu, D.D.S., Ph.D Professor and Past Director Schulich Dentistry & Vice Dean, Schulich School of Medicine & Dentistry Western University Dr. Christopher Frank, Chair of Geriatric Education and Recruitment Initiative Jennie Wells, MD Associate Professor, University of Western Ontario Department of Medicine Chair/Chief Division of Geriatric Medicine Parkwood Institute Laura Diachun, MD Program Director, Undergrad Geriatric Education University of Western Ontario Department of Medicine, Division of Geriatric Medicine Parkwood Institute Sheri-Lynn Kane, MD Program Director Internal Medicine Dept of Medicine Education Office Victoria Hospital Niamh O’Regan, MB ChB, Assistant Professor, University of Western Ontario Parkwood Institute Michael Borrie, MB ChB, FRCPC Professor, University of Western Ontario Department of Medicine, Division of Geriatric Medicine Parkwood Institute Jenny Thain, MRCP (Geriatrics) Assistant Professor, University of Western Ontario Department of Medicine, Division of Geriatric Medicine Victoria Hospital Peter R. Butt MD CCFP FCFP Assoc. Professor, Department of Family Medicine, College of Medicine, University of Saskatchewan Mamta Gautam, MD, MBA, FRCPC, CCPE Dept of Psychiatry, University of Ottawa Psychiatrist, Psychosocial Oncology Program, The Ottawa Hospital President and CEO, PEAK MD Inc. Dr. Shabbir Amanullah Chair, ICPA Arun V. Ravindran, MBBS, MSc, PhD, FRCPC, FRCPsych Professor and Director, Global Mental Health and the Office of Fellowship Training, Department of Psychiatry, Graduate Faculty, Department of Psychology and Institute of Medical Sciences, University of Toronto Sarah Thompson, MD, FRCPC Geriatric Psychiatrist Seniors’ Mental Health Team Addictions and Mental Health Program Louise Plouffe, Ph.D. Director of Research, ILC Canada (retired) Kimberley Wilson, PhD, MSW Assistant Professor, Adult Development & Aging, Department of Family Relations & Applied Nutrition, University of Guelph Andrew R. Frank M.D. B.Sc.H. F.R.C.P.(C) Cognitive and Behavioural Neurologist Medical Director, Bruyère Memory Program Bruyère Continuing Care Ottawa, Canada Diane Hawthorne Family Physician BSc, MD, CCFP, FCFP Dr. Ken Le Clair Prof Emeritus Queens University and. Lead Policy Physician Consultant to Ontario. Seniors Behavioral Support Initative Queens University

Documents

Less detail

Health Canada consultation on regulatory amendments regarding tramadol

https://policybase.cma.ca/en/permalink/policy13927

Date
2018-08-14
Topics
Pharmaceuticals/ prescribing/ cannabis/ marijuana/ drugs
  1 document  
Policy Type
Response to consultation
Date
2018-08-14
Topics
Pharmaceuticals/ prescribing/ cannabis/ marijuana/ drugs
Text
The Canadian Medical Association (CMA) is pleased to provide this submission in response to Health Canada's notice as published in the Canada Gazette, Part 1 for interested stakeholders to provide comments on Health Canada's intent to amend Schedule 1 to the Controlled Drugs and Substances Act (CDSA) and the Schedule to the Narcotic Control Regulations (NCR) to include tramadol, its salts, isomers and derivatives and the salts and isomers of its derivatives.1 Tramadol has been marketed in Canada since 2005 and is available only by prescription.1 The CMA is concerned that, despite tramadol being judged low-risk in terms of addiction, it is nevertheless an opioid and should be placed in the Controlled Drugs and Substances Act, under Schedule 1.2 The Canadian Institute for Health Information reports that tramadol is one of six opioids accounting for 96% of all opioid prescriptions between 2012 and 2016.3 The report noted that there was a significant increase in tramadol prescriptions and Defined Daily Doses (DDDs) in that same 2012 to 2016 timeframe that may have been due in part to a decrease in prescriptions and DDDs for codeine. Tramadol is considered a weak opioid and is used to treat "moderate pain that has not responded to first-line treatments."4 It is regarded as having a lower rate of overdose, misuse and addiction than more powerful opioids.4 However, it is not without risks. The addition of tramadol to the CDSA, Schedule 1, is important because, as with any opioid, dependence on tramadol can occur with use over prolonged periods. According to the World Health Organization "dependence to tramadol may occur when used within the recommended dose range of tramadol but especially when used at supra-therapeutic doses."5 Physical dependence is "distinct from addiction, which includes behavioural elements and harm despite continued drug use." Maintenance of patients on opioids sometimes is only to avoid withdrawal symptoms, caused by physical dependence, as opposed to being used to treat pain.6 Tramadol must be tapered under supervision from a health professional. In addition, tramadol's analgesic effect can be unpredictable depending on a person's genetic capacity to metabolize the drug. Success or failure will be predicated "on it being converted by CYP2D6 to an active metabolite, O-desmethyltramadol."7 If there is a CYP2D6 inhibitor present or if the person's genetic make-up is such that they do not metabolize the enzyme very well, "conversion can be blocked so that little or none of the metabolite is produced and little analgesic effect is achieved."7 These tramadol pathways may also be blocked which could lead to the drug being "present at higher concentrations for longer periods."7 As one expert has noted "when a doctor prescribes tramadol, he or she rolls the dice, not knowing whether the patient will get a bit of opioid, a lot of opioid or none at all."6 The risks associated with tramadol with respect to children are such that the United States Food and Drug Administration (FDA) recently recommended that tramadol (and codeine) should not be given to children under 12.8 Their concern stems from the potential for tramadol (and codeine) to "cause life-threatening breathing problems in children."9 The FDA also recommended that breast-feeding women not be given tramadol because of the potential harm to the child. As well, teens 12 to 18 should not be given the drug "if there is a history of obesity, obstructive sleep apnea, or severe lung disease."9 Further, it warned that it should not "be given to children or adolescents as a pain medication after surgery to remove the tonsils or adenoids."9 It is very important for the health and safety of Canadians that tramadol be placed on CDSA's Schedule 1. As described in the Notice of Intent for this consultation, this change will "prevent diversion of tramadol and protect Canadians from the health risks associated with unauthorized use."1 Further, pharmacists will not be able to follow verbal prescriptions and or provide refills of tramadol, and other controls outlined in the Narcotic Control Regulations within the Controlled Drugs and Substances Act.10 In conclusion, the CMA is concerned that, despite tramadol being judged low-risk in terms of addiction, it is nevertheless an opioid and carries dangers similar to its stronger counterparts. Doctors support patients in the management of acute and chronic pain, as well as addictions, and as such we have long been concerned about the harms associated with opioid use. Therefore, as part of our advocacy, the CMA supports Health Canada's intent to amend Schedule 1 to the Controlled Drugs and Substances Act (CDSA) and the Schedule to the Narcotic Control Regulations (NCR) to include tramadol, its salts, isomers and derivatives and the salts and isomers of its derivatives. By doing so it will "help dispel the perception that it's somehow safer than other opioids."6 The CMA continues to urge governments to increase access to services and treatment options for addiction and pain management, as well as harm reduction.11 1 Controlled Drugs and Substances Act: Notice to interested parties - Proposal to add tramadol to Schedule I to the Controlled Drugs and Substances Act and the Schedule to the Narcotic Control Regulations Canada Gazette, Part I, 2018 Jun 16 152(24) Available: http://www.gazette.gc.ca/rp-pr/p1/2018/2018-06-16/html/notice-avis-eng.html#ne2 (accessed 2018 Jun 25) 2 Young JWS, Juurlink DN. Five things to know about Tramadol. CMAJ May 2013 185(5) Available: http://www.cmaj.ca/content/cmaj/185/8/E352.full.pdf (accessed 2018 Jul 31) 3 Canadian Institute for Health Information. Pan-Canadian Trends in the Prescribing of Opioids, 2012 to 2016. Ottawa, ON: CIHI; 2017. 4 Kahan M, Mailis-Gagnon A, Wilson L, et al. Canadian guideline for safe and effective use of opioids for chronic noncancer pain; clinical summary for family physician. Part 1: general population. Can Fam Physician November 2011 011;57:1257-66. Available: http://www.cfp.ca/content/cfp/57/11/1257.full.pdf (accessed 2018 Jul 30) 5 World Health Organization. Tramadol Update Review Report Expert Committee on Drug Dependence. Thirty-sixth Meeting Geneva, 16-20 June 2014 Available: http://www.who.int/medicines/areas/quality_safety/6_1_Update.pdf (accessed: 2018 Aug 1) 6 Juurlink DN. Why Health Canada must reclassify tramadol as an opioid. The Globe and Mail November 27, 2017 7 Flint, A., Merali, Z., and Vaccarino, F. (Eds.). (2018). Substance use in Canada: improving quality of life: substance use and aging. Ottawa, Ont: Canadian Centre on Substance Use and Addiction. Available: http://www.ccsa.ca/Resource%20Library/CCSA-Substance-Use-and-Aging-Report-2018-en.pdf#search=all%28aging%29 (accessed 2018 Aug 1) 8 Jin J. Risks of Codeine and Tramadol in Children. JAMA 2017;318(15):1514. doi:10.1001/jama.2017.13534 Available: https://jamanetwork.com/journals/jama/fullarticle/2657378 (accessed: 2018 Aug 2) 9 United States Food and Drug Administration. Codeine and Tramadol Can Cause Breathing Problems for Children. Consumer Update April 20, 2017 Available: https://www.fda.gov/ForConsumers/ConsumerUpdates/ucm315497.htm (accessed: 2018 Aug 14) 10 Minister of Justice. Narcotic Control Regulations C.R.C., c. 1041. Current to July 5, 2018. Last amended on May 20, 2018 Available: http://laws-lois.justice.gc.ca/PDF/C.R.C.,_c._1041.pdf (accessed: 2018 Aug 14) 11 Canadian Medical Association. Harms Associated with Opioids and Other Psychoactive Prescription Drugs. CMA Policy, 2015. Ottawa: The Association; 2015. Available: https://www.cma.ca/Assets/assets-library/document/en/policies/cma_policy_harms_associated_with_opioids_and_other_psychoactive_prescription_drugs_pd15-06-e.pdf (accessed: 2018 Aug 2).

Documents

Less detail

54 records – page 1 of 3.