Innovative Service Models

Health services are more difficult and costly to deliver in rural areas, where populations are sparse with a greater distance between them. Models of care in rural and remote areas must differ from those in urban communities using strategies unique to the rural context.

Also, medical care has shifted to a greater focus on community-based care and more up-stream population health and early interventions such as screening, health teaching, family planning, or injury prevention. This has made way for new service delivery models closer to home that better meet the needs of rural communities.

Several service delivery models are common in rural areas, such as:

• local and regional integrated services
• outreach services
• mobile services
• virtual health services.

These models can improve health care access, continuity of care, and the quality of service delivery in rural areas. Below you find a description of each of these service models with some rural examples.

Local integration: one-stop shops

Integrated health models are located within local communities and offer a range of services. The most common example is the community health centre, where health providers from different backgrounds work together to offer the services. These centres are often referred to as “one stop health shops”. Services may include primary clinical care, preventive and health promotion activity, as well as education. For two great Alberta examples, check out the Slave Lake Family Care Clinic and the Vulcan Community Health Centre.

Integrated local services aim to improve health outcomes through better access to services and by addressing underlying social determinants of health. They also direct people to the most appropriate form of care and avoid costly duplication. Apart from offering convenient access, health centres may help to de-stigmatized some services (e.g. sexual health, mental health) as they are included as part of the general health service. Integrated health services fit in with the modern emphasis on primary and preventive care.

Regional integration: health networks and integrated care pathways

Another form of an integrated service model is a rural health network. Different from local community health centres, rural health networks are designed to achieving larger-scale, region-wide integration. Integration can occur between different kinds of providers, such as a primary care practice and a geriatric (seniors) health team, or between different levels of services, such as a rural hospital and an urban hospital or specialist care services.

Rural health networks allow sharing of resources and the provision of specialist services that individual communities could not support by themselves. Most importantly, networks allow the formation of an “integrated care pathway”, which is a well-defined approach to delivering all necessary services to a population, irrespective of their location.

An integrated pathway describes the route that a patient will take from their first contact with their primary care provider to a transfer to the hospital for specialized care. It also covers the period from hospital admission to discharge back home for follow-up care.

The Specialist Link, Alberta Health Services describes care pathways for different conditions. These integrated care pathways ensure that Albertans have timely access to specialist and hospital care, no matter where they live.

Outreach services

Outreach models offer periodic services from one location which has services to other locations which do not. They often use a “hub and spoke” approach where the main service or clinic is centrally located but will visit satellite communities on a regular basis. For example, a general practitioner residing in one community may visit a second community for short periods, or services are supplied on a fly-in fly-out basis.

Specialist outreach models are also emerging. They are often part of multifaceted interventions involving collaboration with primary care, education or other services. For example, Extension for Community Healthcare Outcomes (ECHO) is a unique “hub and spoke” model where rural practitioners can work with and learn from academic specialists using video conferencing. The use of outreach models is associated with improved health outcomes, more efficient and guideline consistent care, and less use of inpatient services.

Mobile health services

Mobile health services bring services, including specialist equipment, to rural communities through mobile units, such as a health bus or mobile clinic.

Mobile mammogram and prostate cancer screening services are two examples. These mobile services travel through the province according to posted schedules. They bring health services out of the medical, “institutional” setting into one that may be more attractive to populations that do not typically access regular preventive health care checks and tests. Mobile services may overcome a variety of barriers to access of health services, including distance, social isolation, lack of time, and cultural issues.

Despite improved access offered by mobile services, they may be less acceptable to consumers who prefer local, fixed services. Many mobile services operate as projects or pilots, which may have difficulty getting ongoing funding and providing continuity of care. Due to their periodic nature, mobile services may not be available when most needed.

Virtual health services

Virtual health services, also called virtual care, is a broad term that describes the use of information and communication technologies to provide health care to patients when the health provider and patient are not in the same location. One example is real-time virtual visits between patients and health providers using videoconferencing and mobile apps. Alberta Health Services has a comprehensive Telehealth program that supports 37 clinical programs.

Virtual health has been on the rise over the past decade as a means of overcoming problems of access to health care and the shortage of health professionals in rural and remote areas. In many cases, virtual health is used to augment other service delivery models.

Because virtual health is so important for rural communities, we have dedicated an entire section to this topic.

A stroke is a sudden loss of brain function caused by a brain blood vessel blockage (also known as an ischemic stroke) or rupture (also known as a hemorrhagic stroke).  Stroke is a one of the leading causes of death in Canada and can result in considerable long-term disability.

In the case of a stroke, it is critical that patients get medical attention right away. Administering the clot‐busting drug ‘tissue-type plasminogen activator’ (tPA) within 60 minutes of a stroke has been shown to reduce death rates and treatment complications, lessen disabilities, and shorten inpatient hospital stays. These treatments occur best in specialized stroke units according to standardized protocols.

Rural communities are at a disadvantage when it comes to stroke care. Few rural hospitals have dedicated stroke units with the expertise and equipment (for example, a CT scanner) for proper clinical assessment and brain imaging. This has prompted some provincial action.

In 2013, Alberta Health Services has implemented a province-wide stroke action plan to help stroke patients in small urban and rural settings receive the same level of care that can be delivered in urban centres. The plan included the creation of stroke units (or stroke unit-equivalent care) within rural hospitals, as well as Early Supported Discharge teams for in-home rehabilitation following discharge. The project was awarded the 2014 Co-Chairs’ Award for Impact by the Canadian Stroke Congress.

As of 2017, Alberta had 17 stroke centres including in rural areas. See backgrounder on this page for zone information.

 Thanks to a year-long quality improvement initiative, the average time it takes from a patient’s arrival at hospital to being diagnosed with stroke and injected with tPA (known as door-to-needle time) has been halved from about 70 minutes to 36 minutes. – AHS, 2017

In February 2017, Edmonton Stroke Program introduced the mobile stroke unit in Canada to focus on a rural setting. The catchment area for the mobile stroke unit is within a 250 km radius of the University of Alberta Hospital in Edmonton.

The mobile stroke unit allows patients to have a rapid diagnosis and immediate treatment, which could save lives and decrease disability.

First responders frequently encounter harrowing situations when rushing to a place of emergency. These repeated events take a physical and mental toll. It is well documented that first responders are at higher risk for Acute Stress Disorder and Post Traumatic Stress Disorder (PTSD). Studies show that as many as 20-30% of law enforcement officers, paramedics and fire fighters develop PTSD throughout their career. Symptoms of PTSD may include flashback of the stressful event, nightmares and insomnia, memory loss, jumpiness, or detachment from others. PTSD increases the risk for long-term depression, social isolation, and suicide – the suicide rate among first responders is tragically high.

After experiencing a traumatic incident, it is critical to reduce the impact of the event, help first responders to recover and offer additional psychological support to reduce the likelihood of PTSD developing from the incident.

To this end, Alberta Health Services EMS launched PAWS (Psychological Awareness and Wellness Support) in 2017. This unique provincial peer support program uses a specialized paramedic/dog team to support Emergency Medical Service responders who experience work-related stress. Delray, the black lab, has been carefully trained to connect with staff, socialize, and interact in a playful way. While Delray interacts with staff, Erica Olson, who is Delray’s handler and a fellow paramedic, offers information on what affects first responders’ mental wellness. She also provides some simple practices for self-care. Knowing how psychological trauma affects the human nervous system can help first responders see why they need to be proactive about managing their stress levels.

The calming effect of dogs and the benefits of canine-human interactions have been drawn on in many different contexts. For example, a play session with dogs has been found to reduce stress levels in college students before an exam. Service dogs have been used for persons with mental health disorders and veterans with PTSD. Studies with veterans found that service dogs reduced hypervigilance, disrupted nightmares, and helped veterans turn their attention away from trauma-related thoughts. Veterans also reported improved emotional connections with others, increased community participation and physical activity, and reduced suicidal impulses and medication use.

A British study introduced dogs into therapy sessions in three prisons as a way to reduce the risk of self-harm or self-inflicted death in prison. The therapy dogs had a calming influence on participants, helped increase their coping skills, and supported engagement. Participants felt that the therapy dogs formed a special bond with them and introduced some ‘normality’ into their lives, particularly for those who had left dogs behind when they had come into prison.

For now, the PAWS program is unique in North America. Hopefully it will be adopted and spread to more communities so that more first responders can benefit from safe and supportive environments. Read more about PAWS or listen to the “pawscast”.

A couple of years ago, Alberta Health Services introduced the Community Paramedic program. Originally just serving seniors in Calgary and Edmonton, the program now works across the province, including rural areas. The program provides services in the resident’s home to help reduce the number of potentially preventable or inappropriate emergency department visits and hospital admissions.

Data from three provinces (Alberta, Ontario and Yukon) shows that one in three seniors living in long-term care residences visited the emergency department in a given year. This rate is similar for seniors living in the community.

The study estimated that one third of emergency department visits of seniors (that is more than 21,600 visits observed in the study) could have been avoided:

• 24% of visits were for potentially preventable conditions such as urinary tract infections, pneumonia, chronic obstructive pulmonary disease, and others. Urinary tract infections and pneumonia alone accounted for more than half (56%) of unnecessary visits.
• 10% of visits were for non-urgent reasons that did not require a senior to stay at the hospital. Falls were the reason for one-quarter (25%) of these non-urgent visits.

Care in the emergency department is very costly and capacity limited, and should be reserved for the most urgent cases. Also, visits to the emergency department are stressful for seniors as dementia or delirium can make it difficult for them to express their symptoms.

It is possible to prevent conditions such as urinary tract infections, pneumonia, or dehydration through close monitoring of the health of seniors. Once residents at risk are identified, they can be well managed by their primary health care team to avoid worsening of their health. Similarly, there are many excellent falls prevention programs that help seniors to move around safely.

It is estimated that the AHS Community Paramedic program has prevented thousands of unnecessary emergency department visits. Community paramedics have additional education in gerontology, pharmacology, social determinants of health and more. They are trained to give short-term treatments to seniors for non-urgent conditions. Similar programs have been introduced in other provinces.

To find out more about the program check out this fact sheet. You can read more about the work of paramedics in Grand Prairie and Rainbow Lake and watch the video below on the advanced care paramedic in Fort Chipewyan.

Given all we know about the social determinants of health and the specific issues faced by Indigenous Albertans, it is important to support innovative health services to meet their unique health care needs. Research tells us that Indigenous Peoples in Canada benefit from strengthening traditional cultural ways of life, particularly in relation to health and healing practices. Evidence further indicates that Indigenous-led health services and partnerships improve holistic health that is inclusive of mind, body, emotion, and spirit. This, in turn supports improved access to care and better health outcomes for Indigenous Peoples. 

There are some great examples of health services and patient care models in Alberta that are tailored to the needs of Indigenous Albertans. Below are three examples. 

Indigenous Health Care Patient Navigator

Since October 2020, Indigenous Peoples in the Alberta Health Services (AHS) South Zone can receive one-on-one help to access the health services they need through an Indigenous Patient Navigation service. During AHS community engagement sessions held a year ago, many Indigenous patients and families in the South Zone expressed frustration that they were both unaware of and overwhelmed by the range of health services that AHS offers. In response, AHS and Indigenous stakeholders co-designed the navigation service. Click the link to watch a video about this unique program.

Awasisak Indigenous Health Program 

The Awasisak Program is offered at The Stollery Children’s Hospital in Edmonton. It is designed to provide effective, patient-centered care to First Nations, Métis and Inuit peoples and communities through culturally safe specific service delivery. 

 Maskwacis Elder Support Program 

Prior to the COVID-19 pandemic, the Maskwacis Elder Support Program operated out of the Wetaskiwin Primary Care Network. This innovative program connects expectant mothers and fathers who are members or residents of Maskwacis with an elder for support. COVID brought unexpected safety concerns of having elders present in the clinic; however, the program has now re-launched in virtual form and through phone calls. The elders provide a cultural connection to support strong and healthy families. The Elders Mentoring Program was recognized with an HQCA Patient Experience Award in 2020. Click this link to view a video about the program. 

Older persons with serious chronic illnesses living in rural communities often experience symptoms that affect their mobility and quality of life. Tasks like grocery shopping or cooking meals may become a burden. They also might be unable to leave the house, which puts them at risk of social isolation. Many seniors are not aware of the services offered in their communities to help them.

Nav-CARE (Navigation: Connecting Accessing Resourcing and Engaging) was developed to support rural seniors living with severe chronic illness and help them manage their daily lives. The program is a success story made in Alberta that started as a pilot research study led by two nursing professors.

The program builds on a partnership between nurses and community volunteer navigators. Community volunteers are trained for their new navigator roles and receive ongoing support from a volunteer coordinator. Since the volunteers are people who live in the seniors’ communities, they know the resources that are available, which makes wayfinding easier.

Volunteers visit their clients on a regular basis and assume a wide range of roles. For example, they help their client access health care services, transportation, or meal options; assist with completing forms; encourage them to renew old hobbies; or engage them in conversations and leisure activities. They basically tailor their support to their clients’ needs.

The program was first trialed in the rural Alberta communities of Camrose and Killam. Over the course of a year, nine volunteer navigators supported by one specially trained nurse navigator worked together to successfully connect 23 older rural adults with serious illnesses to the appropriate resources, information, and people to address their needs.

The support from volunteer navigators has enhanced seniors’ experience of living with chronic conditions and their community connections.

After the successful pilot study, Nav-CARE has been adapted and tailored across diverse social and geographic contexts across Canada. The model has been implemented in 21 locations in Canada and is available in Alberta in the communities of Camrose, Grand Prairie, Olds, and Vulcan as well as in Calgary.

Communities interested in implementing a Nav-CARE program can get in touch with the organization. They will first go through a series of steps to determine whether Nav-CARE is a good fit for their community, and they can also access support for implementation.

Extension for Community Healthcare Outcomes (ECHO) is a unique educational model that enables primary care providers in remote areas to better manage their patients’ chronic conditions. Rural practitioners can work with and learn from academic specialists using video conferencing.

Originating from the University of New Mexico in 2004, the project has grown into a global network of ECHO training centres and hubs to treat more than 70 chronic diseases and conditions. In Canada, Ontario has an ECHO training centre and many provinces have funded ECHO programs. The video below explains this innovative model.

The philosophy of ECHO is to move knowledge, not people, because the best care is local care.

ECHO uses a hub and spokes model, where groups of primary care practitioners from rural and urban areas are connected through videoconferencing to academic or tertiary care specialists. During educational sessions, specialists share best practices with local clinicians. Primary care providers present case studies that will be discussed during ECHO education sessions. After the case discussion, the hub members prepare a summary with all the recommendations and community resources that are relevant to the case discussed.

ECHO helps to build knowledge and competence in rural practitioners. Specialists also learn from primary care practitioners as local best practices emerge. ECHO attendees typically report improved clinical knowledge. They also felt a sense of community and better supported in their local practice. For rural patients, it means less travel to specialists and better local care.

British Columbia, Newfoundland & Labrador, Ontario, Quebec, and Saskatchewan all have active ECHO programs that cover chronic pain, substance use, mental health, and elder care. Some sites, such as ECHO Care of the Elderly for LTC in Ontario, make recordings of many of their sessions available.

Current breast cancer screening clinical practice guidelines from the Alberta Medical Association state that women should be screened for breast cancer regularly beginning at age 50. However, according to the Health Quality Council of Alberta, only 64% of eligible patients completed breast cancer screening in 2019.

In Manitoba, the use of mobile screening vans throughout the 1990s has successfully increased breast screening participation from 12.6% to 52.7% . These traveling clinics have helped to address barriers of distance and transportation for rural residents.  

The Alberta Breast Cancer Screening Program provides mammograms to 120 communities, including 26 First Nations and Metis communities – see their map for the locations across the Province. The program uses traveling mobile clinics in the form of two 50-foot trailers, as well as two stationary health centres to screen Alberta women aged 50-74 years old for early-stage breast cancer. Catching it early is when treatment is most effective. Approximately 16,500 patients are screened annually and over 2,700 patients have been diagnosed.  

Research has shown that promoting breast cancer screening in rural areas through programs like the mobile clinics may be one reason that breast cancer screening rates no longer show an urban-rural trend. This means that urban women and rural women are screened in similar numbers. However, research also shows that rural women are at higher risk to develop cancer – the reasons for this link back to the social determinants of health – so it is important to continue screening promotion and innovative service delivery efforts to ensure rural women can easily access early detection tools.  

Visit screeningforlife.ca for information on breast cancer, screening processes and locations, and how to interpret results. They also have a risk calculator to help individuals make screening decisions based on their personal circumstances. They also have the 2021 mobile mammography schedule on their site.

Typically, rural areas have fewer rehabilitation specialists than urban areas. This leads to a lack of treatment or long travels for rural residents to access rehab services. To tackle this issue, Tele-Rehab 2.0 was introduced as an innovative project aiming to improve access to specialist rehabilitation services for rural Albertans.

The initial pilot in the AHS North Zone outlined the processes and gathered technologies to virtually conduct specialist rehabilitation assessments in four key areas:

• shoulder pain
• hip and knee replacements
• vertigo and balance
• wheelchair special seating assessment

The project is now ready to expand beyond the initial North Zone sites to validate the program in other areas, and with more patients.

The project uses state of the art technology to communicate between the rural patient/clinician and an urban specialist. Technology allows capturing patient data such as range of motion and muscle activity. The data can be sent to the urban specialist who interprets the data.

Telerehabilitation has been increasingly implemented in health systems as a way to reach patients in rural areas. There is growing evidence that Telerehabilitation is as effective as conventional therapy for a number of conditions including stroke, physical functioning and pain in patients with disabilities, cardiac issues, chronic low back pain, and rehabilitation of post-surgical populations.