Community health centres: Potential opportunities for community paediatrics. From interprofessional clinical care to board governance

Fifty years ago, health care for low-income children and families was described as “episodic, fragmented, crisis oriented, and anonymous” (1). Currently, children continue to face similar challenges, and conventional medical care only begins to address a small portion of these concerns. The ‘third era’ of public health will need to focus on optimizing health and well-being through primary prevention, health promotion and community-integrated delivery systems (2). As community paediatricians, we remain powerful advocates for children, families and communities because of respect from parents, altruism and knowledge of resources (3). We understand that advocating for an integrated and high-quality community health system with ‘upstream’ health promotion and prevention requires collaboration with community agencies, multisectorial partners and health care providers (3). By directly addressing social determinants with positive health-promoting influences – such as early childhood education, family support, primary health care and behaviour/mental health services – we can achieve optimal population health and health equity by breaking pathways of social risk and poor health outcomes (4). The Canadian model of community health centres (CHCs), in alliance with the evolving role of the community paediatrician, provides an ideal place-based community setting to create innovative solutions and address ongoing concerns, while not attempting to fulfill all characteristics of the community paediatrician (Table 1). This CHCs-community paediatrician model can create a broad gamut of services that range from clinical consultation, school-based health care, child-, adolescent- and family-based programming, to board governance and policy, building needed child health infrastructure. Characteristics of community paediatrics within the Canadian context Enlarging the paediatrician’s focus from one child to all children in the community. A recognition that the social determinants of health act favourably or unfavourably, but always significantly, on the health and functioning of children. An amalgamation of clinical practice and public health principles that provide health care to a given child and promote the health of all children within the context of the family, school and community. A commitment to use a community’s resources in collaboration with other professionals, agencies, and parents to achieve optimal quality of services. An integral part of the professional role and duty of the paediatrician. To advocate especially for those who lack access to care because of social, cultural, geographic or economic needs. Enlarging the paediatrician’s focus from one child to all children in the community. A recognition that the social determinants of health act favourably or unfavourably, but always significantly, on the health and functioning of children. An amalgamation of clinical practice and public health principles that provide health care to a given child and promote the health of all children within the context of the family, school and community. A commitment to use a community’s resources in collaboration with other professionals, agencies, and parents to achieve optimal quality of services. An integral part of the professional role and duty of the paediatrician. To advocate especially for those who lack access to care because of social, cultural, geographic or economic needs. Adapted from the American Academy of Pediatrics (15) Characteristics of community paediatrics within the Canadian context Enlarging the paediatrician’s focus from one child to all children in the community. A recognition that the social determinants of health act favourably or unfavourably, but always significantly, on the health and functioning of children. An amalgamation of clinical practice and public health principles that provide health care to a given child and promote the health of all children within the context of the family, school and community. A commitment to use a community’s resources in collaboration with other professionals, agencies, and parents to achieve optimal quality of services. An integral part of the professional role and duty of the paediatrician. To advocate especially for those who lack access to care because of social, cultural, geographic or economic needs. Enlarging the paediatrician’s focus from one child to all children in the community. A recognition that the social determinants of health act favourably or unfavourably, but always significantly, on the health and functioning of children. An amalgamation of clinical practice and public health principles that provide health care to a given child and promote the health of all children within the context of the family, school and community. A commitment to use a community’s resources in collaboration with other professionals, agencies, and parents to achieve optimal quality of services. An integral part of the professional role and duty of the paediatrician. To advocate especially for those who lack access to care because of social, cultural, geographic or economic needs. Adapted from the American Academy of Pediatrics (15) Across Canada, >700 CHCs and Aboriginal Health Access Centres provide care to two million clients (5). An idea ahead of its time, CHCs have been in existence in Canada since the 1920s as community clinics (Saskatchewan) and local community service centres (Quebec), and were formalized with federal recommendations in the 1972 Hastings Report (6). CHCs are increasing in number but vary according to region and community: currently Quebec has 257, Ontario 153, British Columbia 64, and other provinces and territories have fewer (5). Common features of all CHCs include: Not-for-profit, publicly funded primary health care organization; Collaborative approach to care with interprofessional care; Integrate primary care, health promotion and community development with an emphasis on community health; and Relevant local priorities addressed through community engagement (5). CHCs provide an integrated, interprofessional, culturally sensitive model of care working in partnership with other agencies – responding to the specific and diverse needs of their community, where the individuals and families have a sense of belonging and participate in decision making and planning (5). Aboriginal Health Access Centres deliver culturally oriented programs and services ranging from clinical care to traditional healing, health promotion, illness prevention and community development programs. CHCs fill many high-priority gaps by providing primary health care services and health promotion programs, often outperforming other primary care models (7). They are non-profit organizations described as an interprofessional model of health care delivery. CHCs are governed either by a majority of locally representative directors or a broader health network with a community advisory committee of local representatives (5). Participation provides a locally relevant and place-based approach to health care, with an advocacy opportunity to build stronger communities supporting the basic foundations of health, education and family support needed to achieve optimal well-being and life trajectories (8). The interprofessional components of the community paediatrician’s involvement in CHCs are as follows: Paediatric consultations are conducted as a component of the interprofessional team approach, consisting of family physicians, nurse practitioners, registered nurses and allied health care workers (such as early childhood educators, lactation consultants, dietitians and respiratory therapists). Social workers, child and youth workers, health promoters and the vitally important community health workers support this integrated approach through their knowledge of local community resources, not only about food security, legal aid and language services, but community context and social-cultural needs. Paediatric consultation provides a component of interprofessional, nonsilo health care that aligns with future health care transformation, breaking down barriers to access, improving interprofessional communication and providing ‘wrap-around’ care. In addition to CHCs, the school system provides an additional community setting for children facing access barriers to health care. Innovative partnerships between CHCs and school boards help to reduce barriers and increase family involvement within the community and neighbourhood (9). High school-based clinics provide at-risk adolescents with immediate medical attention, prevention through immunizations, and screening for physical and mental health disorders. The integration of the interprofessional CHC with a paediatrician and local board of education provide this place-based infrastructure. Community paediatricians can facilitate the implementation of successful programs, with active CHCs staff and community participation by establishing appropriate outcome measures and methods for evaluating program success. This engagement fulfills the participatory concept of engaging the community in program development and responding to the specific needs of the community. With increasing recognition of the importance of community health and child advocacy activities by paediatricians, CHCs play an important role in providing new sites of training for both medical students and residents. Medical education within CHCs enhance the CanMEDS physician competency framework of specialist physicians needed for improved patient outcomes – health advocate, medical expert, communicator and collaborator (10). In addition to educating students and residents, community paediatricians may create clinical educational opportunities for CHC clinicians. CHCs provide an ideal setting to conduct child- and family-centred outcomes research. Community paediatricians can foster community-academic partnerships to generate and implement evidence into practice to improve health care delivery for children (11). They can influence how children and families participate in research and how findings are shared with families. Practice-based research networks that include CHCs offer a powerful platform for child health research, especially in early childhood, when children have frequent contact with the health care system (12). CHCs’ strong commitment to health equity will assure that population-level child health research will be representative and relevant to all Canadian children. The Canada Not-for-profit Corporations Act requires CHCs to have a board of directors who oversee its health and sustainability (13) and can effectively improve community environments (14). As members, community paediatricians have an extraordinary opportunity to advocate for social determinants that affect child and family health and help to create sustainable collaborations between health care, public health and the social sector. Community paediatricians have developed many qualities of a desired board member, through formal training and working with children and families, such as: Knowledge of the health care system; Understanding of the community demographics and health concerns of families; Experience in collaborating with community organizations; Skill in consensus building, communication skills and decision making; and Conviction as advocates in clinical roles and as responsible citizens. In addition, board governance can enhance the community paediatrician’s clinical practice by providing: Community context of promoting health and well-being within a high-quality medical home, such as the built environment, food security or youth violence; Reinforcement of the importance of community partner collaboration; Knowledge of a model of interprofessional care; and Knowledge of board governance with exposure to finance, quality assurance and community engagement. As integrated health care models transform to focus on building stronger communities and neighbourhoods, community paediatricians may face barriers to participate in CHCs. Common barriers include lack of remuneration, lack of time, family and personal commitments, opportunity cost (lost income) while pursuing CHC participation, and lack of knowledge and interest in the CHC-community paediatrician model of care. Overcoming barriers begins with the recognition by community paediatricians and funders that participation provides a place-based advocacy opportunity to build stronger neighbourhoods and to achieving optimal population health and health equity. Strategies are required to increase knowledge, interest and participation in this innovative model of care. The CHC-community paediatrician model of care has limitations. First, this proposed model of practice is untested, with little evidence to support effectiveness. Second, suitable outcome measures for monitoring have not been developed. Third, cost effectiveness has not been established. Finally, future directions should be aimed at evaluation of the proposed CHC-community paediatrician model with development of specific metrics for both clinical care and population health. Community paediatricians are powerful advocates for children, families and communities. By developing relationships with and participating in the multiple aspects of CHCs, community paediatricians are well positioned to address population health and well-being through primary prevention, health promotion and community-integrated delivery systems. We have an exciting opportunity to optimize population health and health equity, and influence the social determinants of health. Safia Ahmed, Executive Director, Rexdale Community Health Centre, Rexdale; Cheryl Prescod, Executive Director, Black Creek Community Health Centre, Toronto, Ontario.

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