Bulletin of the Alliance's Learning Health System |
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Safer Supply: Emerging Evidence |
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RCT: Chiropractic Care for Pain Management |
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The BPSO Journey Continues at Quest |
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Get Involved: Research & Sharing |
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Learning Events & Programs |
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Emerging Evidence on Safer Supply
Research Demonstrates that Safer Supply Saves Lives
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In the two years that the National Safer Supply Community of Practice (NSS-CoP) has existed, it’s been exciting to see how evidence for prescribed safer supply has grown – along with our membership, which is now over 1300 doctors, nurse practitioners, nurses, pharmacists, people who use drugs, social care workers, program managers, researchers, journalists, and others.
It’s become increasingly clear that safer supply is an intervention that advances health outcomes and health equity for people who use substances. NSS-CoP Program Manager Rebecca Penn says “the research that’s happening is invaluable. As the opioid crisis unfolded, we knew prescribed safer supply was a promising innovation that could save lives – now, the body of evidence that’s accumulating really supports it as a critical option on the continuum of care for people who use drugs, particularly for those who haven’t had success with more traditional approaches to care.”
To help people keep up with the evidence, the National Safer Supply Community of Practice has put together an evidence brief. This living document is updated with every new evaluation or research paper – sometimes several times a month.
Recent additions to the evidence brief include data from coroners’ reports in BC and Ontario, which clearly show that prescribed hydromorphone from safer supply programs is not contributing to drug-related deaths. Quite the opposite: a growing list of program evaluations of prescribed safer supply programs and articles in peer-reviewed journals have found that safer supply clients have a reduced risk of death and many fewer overdoses. Safer supply clients also benefit from:
- High engagement and retention in programs and care
- Improvements in physical and mental health
- Fewer emergency department visits and hospitalizations
- Decrease in hospitalizations for infectious complications
- Reduced use of drugs from the unregulated street supply
- Improved control over drug use
- Improvements in social well-being and stability.
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All of this results in lower health care costs aside from medications & primary care, so there are system-level benefits as well as benefits to the individual receiving safer supply.
Safer supply programs have been learning from their initial efforts and those of others, and are using evaluation findings to improve their services. They have found that success factors include comprehensive health and social supports delivered alongside safer supply; a low-barrier, client-centred program design; program flexibility; a community-centred approach; and the ability to provide a range of drug options to meet people’s needs.
The NSS-CoP also holds regular Research Spotlight webinars in which researchers present their new findings directly to Community of Practice members. Because their membership base is interdisciplinary and not siloed, the CoP is able to disseminate knowledge quickly to a broad spectrum of stakeholders. This advances the adoption of promising practices, allows health care providers to respond to the changing environment, and fuels advocacy to make safer supply more accessible.
The evidence is increasingly clear: Safer supply saves lives.
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Contributed by Robyn Kalda, Knowledge Mobilization Specialist with the National Safer Supply Community of Practice. |
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Study: Managing chronic pain
Can chiropractic care help reduce opioid use?
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When people experience chronic spinal pain, they often rely on prescription opioids for relief. The escalating opioid crisis underscores the need for other options. Those options exist, but unfortunately they are inaccessible to many people. For instance, observational studies have shown that adding chiropractic care to the usual course of treatment in primary care can reduce the need to prescribe opioids, or enable existing opioid prescriptions to be tapered. But chiropractic care is not covered by OHIP, and most CHC clients don’t have supplemental insurance or the means to pay out of pocket. To effectively advocate for making allied health services such as chiropractic care for chronic spinal pain more accessible, we need robust evidence demonstrating effectiveness. Dr. Peter Emary, a chiropractor and clinician-researcher based at Langs CHC and McMaster University, spoke to EPIC News about how he plans to build such evidence through an innovative randomized controlled trial (RCT) in Ontario CHCs.
Low-Barrier Study Design
The trial Dr. Emary is proposing is a “cluster RCT,” in which groups (or “clusters”), rather than individuals, are sorted into the different arms of a study. In this case, each cluster will consist of clients at one CHC who are receiving care for chronic spinal pain. The CHCs assigned to the control group will continue to provide the usual standard of care to their chronic spinal pain clients. Those assigned to the intervention group will provide usual care plus eight weeks of chiropractic care. Outcomes for clients in both groups will be measured using EMR data and client feedback. To ensure that participating in this trial does not place a financial burden on CHCs, Dr. Emary is seeking funding from the Canadian Institutes of Health Research and others for funds to cover all research-related costs, including chiropractic services, equipment, and additional reception staff time. Centres will only need to provide part-time access to a small examination room. However, the chiropractic services could be provided offsite at a community-based clinic if needed.
Next Steps
This trial will unfold in two stages. The first, a pilot study, will take place in four CHCs – two in the intervention arm, and two in the control arm – and involve a total of 60 clients. It is intended to address four feasibility questions:
- Will patients want to join?
- Can they follow the care plans?
- Is the data-collection sufficient?
- Will patients be available for follow-up?
The pilot is scheduled to begin in April 2024. Recruitment is already underway; it is focused on a small number of CHCs with similar characteristics. Learnings from the pilot will help refine the protocol for the second stage, a definitive RCT involving many clients at a large number of CHCs. Recruitment for this phase will take place across Ontario in 2025.
Long-Term Goals
Dr. Emary hopes this study will lead to better access to chiropractic care for CHC clients in Ontario and that this, in turn, will benefit not only those who live with chronic pain, but also their families and communities, health care organizations, and the health care system in general. With additional options for pain management, particularly within CHCs, reliance on opioids may be reduced. Some people will experience sufficient pain relief to return to their normal daily activities, work, and community engagement. Connecting clients with appropriate interprofessional care can also free up clinicians’ time, leading to cost savings and making clinical care more efficient and accessible.
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If you are interested in getting involved, now is the time to start talking to your team.
Dr. Emary will also be happy to answer your questions about this study and the intervention it is evaluating; you can email him here.
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The BPSO Journey Continues at Quest CHC
Advances in Health Equity and a Palliative Approach to Care
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Two years ago, EPIC News shared the story of how Quest CHC, in St. Catharines, became the first CHC in Ontario to receive Best Practice Spotlight Organization (BPSO) designation from the Registered Nurses Association of Ontario (RNAO). This was not the end of a journey, but the beginning of one. We caught up with three of Quest’s staff members to reflect on the last year, share where they are now, and look ahead to what’s next.
To be designated as a BPSO, an organization must implement five of RNAO’s Best Practice Guidelines (BPGs) and commit to upholding them and sharing their learnings with peers. They also commit to continuing this cycle by implementing additional BPGs every two years. Quest started by implementing BPGs for pain management, nicotine interventions, suicidality, substance use, and crisis intervention. Over the last two years, they have been implementing BPGs for 2SLGBTQ+ health care and palliative approaches to care.
Palliative Approach to Care
Whereas end of life care is focused on easing the end of life, a palliative approach to care is an adaptive response to an ever-evolving disease process. It is interprofessional and woven throughout an organization’s practices. Extending beyond clinical care for an individual, it is a holistic approach that includes social and family support. Instead of a single conversation about end-of-life decisions, it includes multiple conversations about how to respond to changing needs. Jenny Stranges, the Program Director of Quest, notes that it’s particularly important when clients are vulnerable. “We need to look at palliative care with a social determinants of health lens. We need to understand the clients’ wishes and how their disease is going to impact the rest of their life. How are you going to maintain your home? What if you lose the ability to take care of your pet? Conversations like these need to start early, because people may not have ready access to the necessary resources.”
To build their organizational capacity for this work, a team of Quest staff members participated in a variety of efforts including a randomized controlled trial of CAPACITI, a web-based learning program designed to support primary care teams to provide early palliative care. In one arm of the trial, participating teams were supported by a QI facilitator; in the other, their learning was self-directed. The Quest team was assigned to the facilitated-learning arm. Stranges notes that her team valued having the guidance of a facilitator and opportunities to network with peers from other organizations, but that it was sometimes challenging to coordinate schedules so everyone could participate together.
Quest’s work on implementing these BPGs continues. They are adding a palliative care registry to their EMR; so far, they’ve implemented it with clients who have life limiting chronic diseases, and they will soon be adding it for those at risk of overdose or suicidal ideation. They plan to implement specialized palliative approaches for people from marginalized populations, who often lack a next of kin to support them, including those at risk of overdose or suicidal ideation.
Promoting 2SLGBTQ+ Health Equity
An early step in adopting the BPG for 2SLGBTQI+ health equity was adding pronouns to staff name badges. Quest also updated their intake forms on their EMR. They are now working with the Alliance, the Canadian Association of Community Health Centres, and other community partners to advocate for the ability to use inclusive pronouns and change gender markers, including use of ‘x’, on their EMR.
This work builds on Quest’s existing strengths. In our 2021 article, we featured Steven Athanasas, an RN at Quest who had just completed an advanced nursing fellowship focused on prescribing pre-exposure prophylaxis (PrEP) medication for HIV prevention. Since then, Quest has leveraged that expertise to partner with Positive Living Niagara, Niagara Falls CHC, and Bridges CHC in developing the Niagara PrEP clinic. Each of the participating CHCs receives referrals from Positive Living Niagara and provides PrEP prescriptions along with wraparound care and supports. Last year, the Niagara PrEP clinic won the Niagara Pride Unity Award, and were nominated for it again this year.
Quest is also advancing 2SLGBTQI+ health care in their region by sharing expertise with other sectors. Recently, they hosted a train-the-trainer learning series for home and community care providers about how to provide inclusive post-operative care for people recovering from gender-affirming surgery.
When it comes to 2SLGBTQI+ care, Stranges notes that while Quest is “ahead of the game” in many ways, they recognize the need for continual learning and improvement, and the importance of always evaluating the accessibility and safety of their programs and services. They are now developing processes to make cancer screening safer and more comfortable for 2SLGBTQI+ clients.
Join the Journey
As the first CHC in Ontario to become a BPSO, Quest has demonstrated that it is feasible for others, and they have begun to blaze a trail. They worked with RNAO to fine-tune the BPGs to work in a CHC setting, and they believe more CHCs should be adopting the BPGs and should consider becoming BPSOs. Stranges notes that the fundamental enablers of success in becoming a BPSO are “universal CHC-isms,” such as understanding mental health and substance use, recognizing the impacts of racism and colonialism, being committed to equity, and recognizing the need for continuous learning and improvement.
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Many thanks to Jenny Stranges, Program Director; Ailish Westaway, Health Promoter;
and Steven Athanasas, Registered Nurse at Quest CHC
for sharing their time and their stories with EPIC News for this article.
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Funding Opportunities
Deadline November 1, 2023 | Harkness Fellowships in Health Care Policy and Practice Innovations. Successful applicants will spend a year in the US conducting internationally comparative research with mentorship from leading US experts. Learn more here. Apply here.
Join anytime between now and April 24, 2024 | Health Workforce Innovation Challenge | Do you want to earn funds for your organization while testing new ideas and solutions for retaining and supporting your workforce? Healthcare Excellence Canada is offering a 12-month Open Innovation Challenge, and participating teams can earn up to $112,000 to develop and implement their ideas. The sooner you join, the more you can earn! All participants will be supported through peer networking, expert coaching, and learning events. Learn more here and here, and sign up here for a virtual Q&A on July 19.
In Case You Missed It: Recent Webinars and Podcasts
Strategies and Tools to Support Equity, Safety, and Quality in Virtual Care Delivery | June 22, 2023 | A panel of experts in primary health care quality and virtual care delivery from the Alliance and partner organizations presented an overview of some virtual care resources and helped us understand how they can be used together when planning and delivering care. Recording, slide deck, and resources available here.
FNIM Data and Indigenous Data Sovereignty Webinars. This two-part webinar series was presented by the IPHCC and hosted by the POPLAR Network.
CBC's White Coat, Black Art features Centretown CHC. This episode of the CBC podcast, broadcast on May 20, showcases Centretown Community Health Centre. The CHC is presented as an example of what our model of comprehensive primary health care looks like and the value it offers to people with complex health and social needs. It also describes how the model benefits providers and its potential to make the health system more sustainable.
Spotlight on Climate Change and Health: This webinar, hosted by The Lancet, took place on June 29. It explores the crucial roles of health care professionals and health systems in mitigating their contributions to climate change and in advocating for collective action to protect the populations they serve. It’s still available on demand; register here for free access.
Tools for Improvement and Highest-Quality Care
Educational Support for Clinicians on Anxiety and Depression. The Centre for Effective Practice is offering Mainpro+ accredited educational support (academic detailing) for primary care clinicians from a trained clinical pharmacist. These can integrate the most up-to-date evidence and quality standards to help clinicians identify comprehensively assessing anxiety and depression in adults, and enable a stepped approach to therapies.
These apps use gamification to build vaccine confidence. Digital Public Square is a non-profit organization that uses digital media to support healthy communities. With funding from the Public Health Agency of Canada, they’ve just published two apps that can help build vaccine confidence using a “choose your own adventure”—style conversation structure.
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Our Medicine Path was created in partnership with two Indigenous-led companies to address concerns frequently experienced by Indigenous people and communities.
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Moving at the Speed of Trust was created in partnership with a Black-led organization to address concerns frequently experienced by Black people and communities.
Curious about clinical trials? These public-facing resources from Clinical Trials Ontario were developed with the help of people who have different experiences related to clinical trials as well as people who are part of patient organizations and health charities. They can help health care clients and their providers make informed choices about participating in clinical trials, including how to find opportunities to participate, how to understand and evaluate the risks and benefits of participating, what participants can expect during and after the trial, and what rights they have. If have accessed these resources, please consider sending feedback here.
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2SLBGTQ Emotional & Mental Health. This live training explores how social stigma and discrimination can affect 2SLGBTQ people’s mental and emotional health.
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2SLGBTQ Older Adults and Inclusive Care. This modular, self-directed online course is an introduction to providing clinically and culturally competent care to 2SLGBTQ seniors, elders, and older adults.
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Fondemonts 2SLGBTQ. RHO’s flagship Foundations course is now available in French. It can help bridge the gaps faced by Francophone 2SLGBTQ service users in Ontario who struggle to find culturally safe and inclusive care in their native language.
New in our Library
Progress Report: Alliance EQ-5D PROMs Pilot. Since the fall of 2022, the Alliance has been piloting the use of a Patient Reported Outcome Measures (PROMs) tool known as EQ-5D at 6 Community Health Centres. The project will evaluate the tool's usability and effectiveness to support collaborative care planning and program evaluation, and it will identify the processes involved in implementing the tool across our sector. This progress report summarizes how each participating centre is implementing and using the EQ-5D tool and their experiences so far. Also available in French.
“Can you hear me now?”: a qualitative exploration of communication quality in virtual primary care encounters for patients with intellectual and developmental disabilities. Dr. Jennifer Rayner is a co-author of this paper published in BMC Primary Care. It explores how the use of virtual modalities, including telephone and video, affects communication in primary care interactions for patients with IDD. clients with intellectual and developmental disabilities.
A Bridge to Universal Healthcare: The Benefits of Ontario’s Program to Make Hospital Care Accessible to All Residents of the Province. This report, published by the Health Network for Uninsured Clients, describes and measures the impacts of the Ontario Ministry of Health's directive to extend funding for all medically necessary hospital care to residents without health insurance.
The Benefits and Challenges of Precepting Pharmacy Students Virtually in Interprofessional Primary Care Teams. Dr. Jennifer Rayner contributed to this article along with other experts in interprofessional primary health care. Published in the American Journal of Pharmaceutical Education.
Rapid hepatitis C virus point-of-care RNA testing and treatment at an integrated supervised consumption service in Toronto, Canada: a prospective, observational cohort study. This article describes a research study at South Riverdale CHC (SRCHC) in which low low-barrier testing and linkage to care for Hepatitis C (HCV) were provided to supervised consumption service (SCS) clients. The outcomes confirm that SCS clients are a high-risk population for HCV and demonstrate that SCS sites are an important a point of care for HCV testing and treatment with this population. Published in The Lancet Regional Health in May 2023. This study and its findings were covered by Global TV.
Considerations for collecting data on race and Indigenous identity during health card renewal across Canadian jurisdictions. This article, published in the Canadian Medical Assocation Journal, describes the importance of standardized practices for collecting data on race and Indigenous identity from health care clients. It also points out the potential for harms if this is done incorrectly. Honouring principles such as Engagement, Governance, Access, and Protection (EGAP), Ownership, Control, Access, and Possession (OCAP), and Indigenous data governance and data sovereignty can reduce the risk of harm. It is also essential that this data is only collected where there is a corresponding commitment to using it to advance health equity.
Experiences and Needs of Young Black Canadian Mothers in Toronto: A Community-Based and Black-Centered Research. This report from researchers at TAIBU CHC and Brock University focuses on the experiences of young Black mothers in navigating the challenges of motherhood while facing systemic racism. This research project is the first of its kind in Canada to explore this topic in a significant way.
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Looking for more?
Consider subscribing to these newsletters to receive regular updates from Alliance system partners:
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Learning Events & Programs |
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August
August 15-17 | CMA Health Summit – What Health Care Should Be: Time for Bold Solutions. This hybrid conference will be held in Ottawa and online. Clinicians, interprofessional health care workers, learners, health system leaders, and people with lived experience will be participating. Register here.
August 4-25 | 4-part Hybrid Workshop Series on female genital mutilation/cutting (FGM/C) for health, social, and community service providers. Learn how to safeguard and support those who are living with or at risk of FGM/C. Register here by July 28. See flyer here.
September
September 26, 4-6 pm | Safeguarding Girls at Risk in Canada Webinar on female genital mutilation/cutting for health and social care providers, teachers, and caregivers. Register here. See flyer here.
Ongoing Training and Collaborative Learning
ECHO at UHN: ECHO is a virtual community that links primary care providers across Ontario with peers and specialists. Through lessons and case studies, participants gain knowledge, skills, and support. Participation is free, and providers earn professional development credits. Learn more about UHN’s ECHO program and about all 25+ Ontario ECHO projects.
SPIDER Learning Collaborative: De-prescribing dangerous medications. Can data-driven QI activities help de-prescribe potentially harmful medications, for medically complex senior clients? Help answer this question and improve health outcomes for your clients by participating in a 12-month learning collaborative. EMR queries will be provided to help participating Alliance members identify clients who would benefit. Contact Jennifer Rayner for more information.
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Research & Sharing Opportunities |
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Calls for Abstracts
Deadline July 22 | Social Prescribing Virtual Conference 2023. This year’s virtual social prescribing conference takes place on October 19, as part of Community Health and Wellbeing Week. Share your stories, research, best practices, and more with healthcare and community-based professionals from across Canada and beyond! Fill out the call for proposals here.
Deadline August 18 | Submit your abstracts for the 4th Annual London & Region FASD Conference. Event takes place on October 24 & 25. Registration opens August 2023.
Research Partners Needed
Looking for primary health care organizations who help vulnerable people get ID. Not having ID is a significant barrier to many of the social and structural determinants of health including shelter, income, and health care. The Thunder Bay ID Action Group, a collective of organizations in Thunder Bay who are working together to help low-income and other vulnerable individuals to get ID. They’re looking for other organizations doing similar work in order to exchange knowledge. If this is you, please email Anita Jean, Manager of Community Digital Health Equity. Want to learn more? Check out their research-informed calls to action regarding access to birth certificates.
Clinical Trials and Participatory Research
Survey for Healthcare Providers: Supporting Young People who Use Drugs. Get Sensible, a project by Canadian Students for Sensible Drug Policy, has partnered with the Canadian Public Health Association to conduct a survey on the experiences of health and social service providers supporting youth (aged 16-25) who use drugs. Participation in this bilingual survey will help inform the development of a guide for service providers on how to better engage with and support youth who use drugs. Complete the survey here.
Need help with client engagement and communication? Get access to the Canadian Primary Care Information Network (CPIN), tailored messages for your vaccine-hesitant clients, and up to three additional communications and survey campaigns on topics of your choice. Family physicians at the University of Ottawa and Monfort Hospital are studying how automated patient engagement systems like CPIN can improve communications with clients about COVID-19 vaccines. Get more information here or email the study team.
Interviews and Focus Groups
Racialized stroke survivors and family members/caregivers: Your lived-experience expertise can help develop knowledge about the needs and goals of racialized people after a stroke, as well as the gaps in support and services available to them. Researchers at the University of Toronto are looking for people who are Black/African, South Asian, or Chinese to share their experiences in meetings and through photovoice. Participants will be compensated. See the flyers linked above or email Hardeep Singh for more information.
Surveys
Survey for your older adult clients: A graduate student at the University of Toronto is surveying older adults about how they use the Internet for health information, and how they would like to learn new information for their health maintenance and improvement. Anyone aged 55+ is welcome to participate, especially those who are Indigenous, racialized, 2SLGBTQ+; have disabilities; or live in rural/remote areas. Consent form and survey here. For further information, please reach out to Mary Hynes by email or at (416) 597-3422 ext. 7775.
Does your organization provide health care or other supports to refugees and asylum seekers? Researchers at the University of Calgary are looking for people working in clinical, public health, or settlement organizations to answer some questions via an online survey. They want to understand who provides care to refugees and asylum seekers in Canada, how this care is coordinated and delivered, how it differs among jurisdictions, and how COVID-19 has impacted it. Participate by completing this short survey. In lieu of an honorarium, the research team will donate $10 to support refugee student scholarships. See flyer (English or French) for more information.
Advocacy
Action for Safer Supply, a working group composed exclusively of people who use drugs who are all members of the National Safer Supply Community of Practice, is submitting an open letter to the federal government about the sustainability of safer supply and harm reduction programs across the country. The working group invites all people who use drugs, drug user organizations, associations, and groups, and any community-led harm reduction initiatives to sign on.
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