Recruitment and Retention of Health Care Providers in Remote Rural areas
Status Report for Northern Ontario, Canada
Dr. Roger Strasser
Dr. David Marsh
Dr. Karim Remtulla
Table of Contents
List of Figures ........................................................................................................................................................ 4
1
Introduction .................................................................................................................................................. 6
2
Geography .................................................................................................................................................... 7
3
Demography ................................................................................................................................................. 9
North East Ontario ...................................................................................................................................................10
North West Ontario ..................................................................................................................................................12
4
The Organization of Health Care Services ................................................................................................. 13
Local Health Integration Networks (LHINs) ...........................................................................................................13
Health Care services for Aboriginal communities. ........................................................................................ 13
Primary Care ............................................................................................................................................................13
Hospitals/Specialized Services ................................................................................................................................14
Inflow/Outflow Ratio (2010/2011). ............................................................................................................... 17
5
Health Care Professionals ........................................................................................................................... 18
Physicians in Northern Ontario ................................................................................................................................18
Demographics of Physicians ....................................................................................................................................18
Turnover of Physicians ............................................................................................................................................20
6
Urban Area: Toronto Central LHIN ........................................................................................................... 21
Demographics ..........................................................................................................................................................21
Primary Care ............................................................................................................................................................22
Hospitals/Specialized Services ................................................................................................................................23
Inflow/Outflow Ratio (2010/2011). ............................................................................................................... 23
7
Education and Training ............................................................................................................................... 26
Medical Education ...................................................................................................................................................26
Practice of Medicine in Ontario. .................................................................................................................... 26
Northern Ontario School of Medicine (NOSM). ............................................................................................ 26
Nursing ....................................................................................................................................................................27
Nursing in Ontario. ........................................................................................................................................ 27
Roles in Nursing............................................................................................................................................. 28
Primary Health Care NPs. .............................................................................................................................. 28
2
Adult and Pediatric NPs. ................................................................................................................................ 28
Nursing Programs in Northern Ontario. ......................................................................................................... 29
Pre-hospital Education .............................................................................................................................................29
Other Health Care Education ...................................................................................................................................29
Physician Assistants in Ontario (PA). ............................................................................................................ 29
Northern Ontario Dietetic Internship Program (NODIP). .............................................................................. 30
Rehabilitation Studies/Northern Studies Stream (NSS). ................................................................................ 30
Northern Ontario Electives Program. ............................................................................................................. 31
Interprofessional Education Program (IPE). .................................................................................................. 31
Northern Ontario Summer Studentship Program (SSP). ................................................................................ 31
Continuing Education ..............................................................................................................................................31
8
Recruitment / Retention Problems .............................................................................................................. 32
Projected Shortages ..................................................................................................................................................32
Programmatic Responses .........................................................................................................................................33
9
Summary..................................................................................................................................................... 35
A Chronic Shortage .................................................................................................................................................35
Five Key Northern Centres ......................................................................................................................................36
Dramatic Demographic Shifts. ....................................................................................................................... 36
Innovative Policy Instruments. ....................................................................................................................... 36
Supporting Small Hospitals. ........................................................................................................................... 37
10
Bibliography ............................................................................................................................................... 38
Appendix A: Preliminary Inventory of Government-Funded Northern and Rural Health Care Programs................40
3
List of Figures
Figure 1. Map of the Province of Ontario. .....................................................................................................................7
Figure 2. Key urban, rural, and remote populations in Northern Ontario (2006 Census). .............................................9
Figure 3. Average life expectancy at birth (in years). ....................................................................................................9
Figure 4. Infant mortality (average number of deaths per 1, 000 births). .................................................................... 10
Figure 5. The North East region of Northern Ontario. ‘LHIN’ stands for ‘Local Health Integration Network’. This
concept will be elaborated in more detail in Section 4 of the Status Report. ............................................................... 10
Figure 6. North East region 2011 estimates and 2036 projections of population distribution, by age......................... 11
Figure 7. The North West region of Northern Ontario. ‘LHIN’ stands for ‘Local Health Integration Network’. This
concept will be elaborated in more detail in Section 4 of the Status Report. ............................................................... 12
Figure 8. North West region 2011 estimates and 2030 projections of population distribution, by age and sex. The
line represents the projected population distribution in 2030. ..................................................................................... 12
Figure 9. Proportion and 95% confidence interval of adults in Ontario who have family doctors, by LHIN, 2008.... 13
Figure 10. Northern Ontario communities with 30,000 or fewer residents that are beyond 30 and 60 minutes travel
time by car to the nearest primary care provider. ........................................................................................................ 14
Figure 11. Northern Ontario communities with 30,000 or fewer residents that are beyond 30 and 60 minutes travel
time by car to the nearest emergency department. ....................................................................................................... 15
Figure 12. Northern Ontario communities with 30,000 or fewer residents that are beyond 30 and 60 minutes travel
time by car to the nearest hospital providing obstetrical delivery care. ....................................................................... 15
Figure 13. Northern Ontario communities with 30,000 or fewer residents that are beyond 30 and 60 minutes travel
time by car to the nearest hospital providing obstetrical delivery care. ....................................................................... 16
Figure 14. Northern Ontario communities with major economic hubs highlighted. ................................................... 16
Figure 15. Relative distribution of medical health care workers across Ontario. Large northern centres are Timmins,
Thunder Bay, North Bay, Sudbury and Sault Ste. Marie. ............................................................................................ 18
Figure 16. Demographic profile of Northern Ontario General Practitioners and Family Physicians (GP/FPs)
practising in large centres, 2001/02. Large northern centres are Timmins, Thunder Bay, North Bay, Sudbury and
Sault Ste. Marie. .......................................................................................................................................................... 19
Figure 17. Demographic profile of Northern Ontario specialists practising in large centres, 2001/02. Large northern
centres are Timmins, Thunder Bay, North Bay, Sudbury and Sault Ste. Marie. ......................................................... 19
Figure 18. Physicians per 100,000 population practising in large centres in Northern Ontario, by physician type,
1996/97 and 2001/02. Large northern centres are Timmins, Thunder Bay, North Bay, Sudbury and Sault Ste. Marie.
..................................................................................................................................................................................... 19
Figure 19. Turnover of physicians in large centres in Northern Ontario, by physician type, 1993–1996 and 1997–
2001. Large northern centres are Timmins, Thunder Bay, North Bay, Sudbury and Sault Ste. Marie. ....................... 20
Figure 20. Map of Toronto Central LHIN. .................................................................................................................. 21
Figure 21. Northern Ontario School of Medicine’s undergraduate medical education curriculum. ............................ 27
4
Figure 22. Summary of key inputs and assumptions: Base case simulation 3. ............................................................ 32
Figure 23. Summary of key inputs and assumptions: Base case simulation 3-continued. ........................................... 32
Figure 24. Simulation results by specialty for North East LHIN: Base case simulation 3. ......................................... 33
Figure 25. Simulation results by specialty for North West LHIN: Base case simulation 3. ........................................ 33
Figure 26. Programmes to address physician shortages in Northern Ontario introduced by the Ontario government
by policy instrument type and year, 1969 – 2004. ....................................................................................................... 34
5
1
Introduction
The purpose of this report is to provide general information on the region of Northern Ontario, including geography,
demography, the organization of the health care services, and health care staff, and finally, some discussion about
the pertinent problems with respect to the recruitment and retention of health care workers.
6
2
Geography
Northern Ontario encompasses almost 400,000 square miles (over 800,000 square kilometres) accounting for nearly
90% of Ontario’s land area. Northern Ontario is comprised of 10 territorial districts (144 municipalities): Kenora,
Rainy River, Thunder Bay, Cochrane, Algoma, Sudbury, Timiskaming, Nipissing, Manitoulin, and Parry Sound.
This includes five key ‘urban’ centres: North Bay, Sault Ste. Marie, Sudbury, Timmins, and Thunder Bay.
Figure 1 portrays Northern Ontario’s 10 territorial districts. This includes the two large ‘urban’ centres of Sudbury
and Thunder Bay. As depicted by the legend, population density increases with intensity of colour:
Figure 1. Map of the Province of Ontario.
From “Rural and northern health care framework/plan: Stage 1 report-Final report,” by Government of Ontario, 2008, p. 59. Copyright 2008 by
Queen’s Printer for Ontario.
7
Despite its large geographical size, Northern Ontario has a relatively small population (approximately 800, 000
based on the 2006 Census). Sixty per cent of the population lives in rural and remote communities. Thirty per cent
of the population lives in the two larger urban centres of Thunder Bay (approximately 123, 000) and Sudbury
(approximately 150, 000). The remaining 10% of the population lives in small urban or small or large rural
communities. According the to the Government of Ontario, ‘rural’ communities in Ontario are those with a
population of less than 30,000 and 30 minutes or more commuting from a community with a population of more
than 30,000. ‘Remote’ communities are those without year-round road access, or which rely on a third party (e.g.
train, airplane, ferry) for transportation to a larger centre.
Northern Ontario's many lakes and waterways are appreciated for their environmental benefits, as popular
community and tourism attractors, and for their contribution to commercial and recreational fishing. Northern
Ontario includes two of North America’s Great Lakes: Lake Superior and Lake Huron. The Great Lakes are not only
a cherished environmental feature, but they also provide Northern Ontario with innumerable economic advantages.
Fertile agricultural areas, freshwater aquaculture industry, the emergent bio-economy, and global demand for new,
environmentally sustainable sources of fish represent future areas of economic growth for Northern Ontario.
Tourism also contributes to employment, development, and growth. This includes gaining an appreciation of the
histories and cultures of Aboriginal peoples and French-speaking populations, reconnecting with nature, and
enjoying the diversity and vibrancy of urban communities.
The forestry and minerals sectors are vital to Northern Ontario's economy and Ontario’s economy as a whole.
Mining includes the extraction of gold, nickel, copper, uranium, and zinc, and represents a multi-billion-dollar
business. Ninety-one per cent of the forest land is owned by the Government of Ontario, which licenses logging
rights. The forest industry accounts for 5.8% of Ontario's exports. Northern Ontario is home to advanced
manufacturing industries, including steel and equipment manufacturing, that gain advantage, in part, from proximity
to resources and the shipping channels of the Great Lakes. The Great Lakes form a major inland waterway,
providing an efficient means of bulk commodity transport.
Ontario's climate ranges from the south, with chilly winters, warm summers and lots of humidity, to subarctic in the
north. The presence of the Great Lakes have a moderating effect on climate, making summer and winter
temperatures less extreme, delaying autumn frosts, and reducing the differential between day and night
temperatures. On average the coldest month of the year is January and the warmest is July. Ontario's weather is
marked by considerable rain or snow throughout the year, caused by cold polar air from the north meeting warm
moist air from the south. Annual precipitation in Northern Ontario varies from 70 cm (28 in) to 97 cm (38 in). In
Southwestern Ontario, precipitation averages about 95 cm (37 in) per year. The heaviest snowfalls occur in a
‘snowbelt’ lying inland to the east from Lake Huron and Georgian Bay, including Owen Sound where annual
snowfall can exceed 339 cm (134 in).
The challenges of providing appropriate access to health care in these communities stem from multiple factors:
geographic remoteness; long distances with low density populations; lesser availability of health care services
providers; and, inclement weather conditions. Access to health care, especially for Northern Ontario, is
characterized by a notably sparse population distributed across vast distances.
8
3
Demography
Northern Ontario, with an approximate overall population of 800, 000 (based on the 2006 Census), is home to 106
First Nations, Metis communities, and more than 150 other diverse communities. These communities range from
remote settlements of just a few hundred people to large cities. The population includes approximately 140,000 of
Ontario's Francophone people. Northern Ontario includes nearly half of Ontario's Aboriginal population, including
both on- and off-reserve residents.
More than half of Northern Ontarians live in the cities of Sudbury, North Bay, Sault Ste. Marie, Timmins, and
Thunder Bay. These cities are economic hubs that benefit all of Northern Ontario, and in some cases have a large
bilingual population. They possess the critical mass of skilled people, as well as regional assets such as colleges and
universities, innovation centres, media centres, and commerce and cultural facilities. These economic hubs anchor
many of Northern Ontario’s existing and emerging priority economic sectors. People of many cultures and
backgrounds have also migrated, and continue to migrate, to the region.
Figure 2 captures the relative population sizes of key remote, rural, and urban centres in Northern Ontario. As
depicted by the legend, population density increases by the shade of colour:
Figure 2. Key urban, rural, and remote populations in
Northern Ontario (2006 Census).
From “Rural and northern health care framework/plan: Stage 1 reportFinal report,” by Government of Ontario, 2008, p. 25. Copyright 2008 by
Queen’s Printer for Ontario.
Figure 3 depicts life expectancy at birth that identifies the average lifespan of residents across Ontario. Average life
expectancy at birth in Ontario is 79 years. In rural Northern Ontario (for example, Porcupine, Northwestern, and
Timiskaming), average life expectancy ranges from 75 to 77 years. Urban Northern Ontarians (for example
Sudbury, Thunder Bay, North Bay, and Parry Sound) have an average life expectancy between 77 to 78 years.
Figure 3. Average life expectancy at birth (in
years).
From “Rural and northern health care framework/plan:
Stage 1 report-Final report,” by Government of Ontario,
2008, p. 30. Copyright 2008 by Queen’s Printer for
Ontario.
Figure 4 shows infant mortality that identifies the average number of deaths per 1,000 live births, for infants under 1
year of age. In rural Northern Ontario (for example Porcupine, Northwestern, and Timiskaming), average infant
mortality ranges from 4 to 7. Urban Northern Ontarians (for example Sudbury, Thunder Bay, North Bay, and Parry
Sound) have the highest infant mortality, ranging from 5 to 8.
9
Figure 4. Infant mortality (average number
of deaths per 1, 000 births).
From “Rural and northern health care framework/plan:
Stage 1 report-Final report,” by Government of
Ontario, 2008, p. 31. Copyright 2008 by Queen’s
Printer for Ontario.
North East Ontario
The North East is an area of approximately 400,000 square kilometres (approximately 44% of Ontario’s geography)
and with a 2006 population of approximately 560, 000 persons (about 4.5% of Ontario’s population in 2006). Please
see Figure 5:
Figure 5. The North East region of
Northern Ontario. ‘LHIN’ stands for
‘Local Health Integration Network’.
This concept will be elaborated in more
detail in Section 4 of the Status Report.
From “North East LHIN: Population health
profile-August 2012,” by Government of Ontario,
2012, p. 1. Copyright 2012 by Queen’s Printer
for Ontario.
10
Furthermore, according to the 2006 census, the North East represents:
•
•
•
•
•
•
•
•
•
higher proportions of Aboriginals than Ontario as a whole, 10% and 2% respectively;
higher proportions of Francophones compared to Ontario as a whole, 24% and 4% respectively;
higher proportions of people aged 65 and over compared to Ontario as a whole, 17% and 14% respectively;
life expectancy at birth for males is 76 years and females is 81 years, as compared to Ontario as a whole for
males is 79 years and females is 84 years;
infant mortality (per 1, 000 births) is 6 as compared to Ontario as a whole which is 5 (based on 2007 statistics);
an overall lower education status than the rest of Ontario (only 50.3% of the North East population aged 25+
have completed post-secondary education vs. the provincial rate of 56.8% and only 25.9% of the North East
population age 25+ do not have a high school (or equivalent) certificate vs. the provincial rate of 18.7%);
a lower employment status (an overall unemployment rate in the North East which is higher than the provincial
rate, 8.4% vs. 6.4% respectively, a participation rate (the proportion of the population in the labour force) which
is lower than Ontario’s, 60.1% vs. 67.1% respectively, and a youth (age 15-24) unemployment rate in the North
East of 18.6% vs. the provincial rate of 14.5%);
population is projected to change dramatically over the next 25 years where the proportion of the population age
65 and over is projected to increase from 18% to 30% by 2036 and the estimated number of seniors (65+) is
projected to increase by 42%, from just over 100,000 to over 172,000; and,
overall population is projected to increase by approximately 1% between 2011 and 2036.
Figure 6 shows the projected change in the population structure over a 25 year period (2011 population Census):
Figure 6. North East region 2011 estimates and
2036 projections of population distribution, by age.
From “North East LHIN: Population health profile-August
2012,” by Government of Ontario, 2012, p. 1. Copyright 2012
by Queen’s Printer for Ontario.
11
North West Ontario
The North West region represents approximately 46% of the geographic area of Ontario. This region contains only
2% of Ontario’s population at approximately 240,000 (based on the 2006 Census). This region represents the largest
proportion of Aboriginal people at 19%. Based on the 2006 Census, North West region of Northern Ontario
includes:
•
•
•
•
•
•
Kenora District with population 65, 000 comprising 38.4% Aboriginal and 2.5% Francophone;
Rainy River District with population 23, 000 comprising 21.7% Aboriginal and 1.7% Francophone;
Thunder Bay City with population 123, 000 comprising 8.3% Aboriginal and 2.8% Francophone;
Thunder Bay District with population 27, 000 comprising 19.9% Aboriginal and 10.8% Francophone;
Infant mortality per 1, 000 births of 6 as compared to 5 for Ontario as a whole; and
Life expectancy at birth of 76 years for males and 81 years for females, as compared to 78 years for males and
83 years for females for Ontario as a whole.
Figure 7. The North West region of Northern Ontario.
‘LHIN’ stands for ‘Local Health Integration Network’. This
concept will be elaborated in more detail in Section 4 of the
Status Report.
From “North West LHIN: Population health profile-Updated Summer
2011,” by Government of Ontario, 2011, p. 1. Copyright 2011 by Queen’s
Printer for Ontario.
Figure 8. North West region 2011 estimates and 2030
projections of population distribution, by age and sex. The
line represents the projected population distribution in 2030.
From “North West LHIN: Population health profile-Updated Summer
2011,” by Government of Ontario, 2011, p. 1. Copyright 2011 by Queen’s
Printer for Ontario.
12
4
The Organization of Health Care Services
Within the Province of Ontario, the Ministry of Health and Long-Term Care (hereafter ‘MOHLTC’) governs health
care. The ministry works to establish a publicly funded health system by:








pursuing a patient-focused, results-driven, integrated approach;
setting overall direction and leadership for the system;
focusing on planning and guiding resources to where they are most needed;
less involved when it comes to the actual delivery of health so as to maximize patient care and efficiency;
establishing overall strategic direction and provincial priorities;
developing legislation, regulations, standards, policies, and directives;
monitoring and reporting on the performance of the health system and the health of Ontarians; and,
designing funding models and levels of funding.
Local Health Integration Networks (LHINs)
In March, 2006, the Ministry of Health and Long-term Care divided the province into 14 regions or Local Health
Integration Networks (hereafter ‘LHINs’). Ontario’s LHINs are assigned the accountability to coordinate health care
services that meet the needs of local communities. LHINs bring together health care partners from hospitals,
community care, community support services, mental health and addictions services, community health centres and
long-term care, leading to more timely access to health care by Ontarians. Northern Ontario consists of the North
East LHIN and the North West LHIN.
LHINs were legislated in to existence by way of the Local Health System Integration Act, 2006. LHINs operate as
not-for-profit organizations governed by boards of directors who are appointed by the Government of Ontario. Each
LHIN has nine board members. Each LHIN’s board of directors is responsible for the management and control of
the affairs of the LHIN and is the key point of interaction with the MOHLTC. Each of the LHIN’s CEOs reports
directly to their respective LHIN board. In total, the LHIN boards oversee approximately $20 Billion CAD dollars
for health care across Ontario.
Health Care services for Aboriginal communities.
According to the 2011 Auditor General’s Report, in addition to the provincially funded health care services overseen
by the LHIN’s, there is a distinct system of funding and accountability for health care services provided to
Aboriginal communities. Because of the distinct constitutional relationship between Aboriginal Peoples and the
Government of Canada, these services are funded directly by the federal government through Health Canada. Many
of the remote communities in Northern Ontario fall into the category of Aboriginal communities under the
responsibility of Health Canada with considerable health care challenges.
Primary Care
Figure 9 illustrates the proportion of adults in Ontario who have family doctors, by LHIN, 2008. Northern Ontario
comprises the North East and North West LHINs:
Figure 9. Proportion and 95%
confidence interval of adults
in Ontario who have family
doctors, by LHIN, 2008.
From “Access to Primary Care in
Ontario: 2008,” by Government of
Ontario, 2009, p. 1. Copyright 2009
by Queen’s Printer for Ontario.
13
According to the Institute for Clinical Evaluative Sciences (ICES), in 2009 the number and proportion of people in
Ontario living in communities with populations of 30,000 or fewer people comprised 2, 600, 000 people, or
approximately 23% of Ontario’s overall population. This included approximately 347, 000 people in Northern
Ontario (or about half the population of Northern Ontario). The population of remote communities in Ontario was
about 26, 000. Recall that according the to the Government of Ontario, ‘rural’ communities in Ontario are those with
a population of less than 30,000 and 30 minutes or more commuting from a community with a population of more
than 30,000. ‘Remote’ communities are those without year-round road access, or which rely on a third party (e.g.
train, airplane, ferry) for transportation to a larger centre.
Primary care services that were likely to be available 24 hours a day, seven days a week (‘24/7’) include primary
care providers (general practitioner/family physician or nurse in an independent remote nursing station):


North East LHIN: approximately 94 General/Family Physicians per 100,000 and 65 Specialized Physicians per
100, 000, circa 2010; and,
North West LHIN: about 107 General/Family Physicians per 100,000, and 62 Specialized Physicians per 100,
000, circa 2010.
Figure 10 shows that in 2009, 68 communities were more than 30 minutes from a source of primary care, including
59 in Northern Ontario. Of the 68 communities, 57 had populations of less than 250 people, 10 had populations of
between 250 and 1,000, and one had a population of between 1,000 and 5,000 people. There were 25 communities
lacking access to any source of primary care within 60 minutes. Eighteen of these communities were in Northern
Ontario. All but three of the 18 communities had populations of less than 250 people, and none of these
communities had more than 1,000 people. Of these communities, three were remote (defined as not being on the
road network):
Figure 10. Northern Ontario communities with
30,000 or fewer residents that are beyond 30 and
60 minutes travel time by car to the nearest
primary care provider.
From “Geographic access to primary care and hospital
services for rural and northern communities: Report to the
Ontario Ministry of Health and Long-Term Care January
2011,” by Institute for Clinical Evaluative Sciences (ICES),
2011, p. 5. Copyright 2011 by the Institute for Clinical
Evaluative Sciences (ICES).
Hospitals/Specialized Services
Figure 11 illustrates that 131 communities in Northern Ontario were more than 30 minutes travel time from an
emergency department, and 27 were remote. Fifty-five communities in Northern Ontario did not have access to an
emergency department within 60 minutes, none had more than 5,000 people, and 27 were remote:
14
Figure 11. Northern Ontario communities with
30,000 or fewer residents that are beyond 30 and
60 minutes travel time by car to the nearest
emergency department.
From “Geographic access to primary care and hospital services
for rural and northern communities: Report to the Ontario
Ministry of Health and Long-Term Care January 2011,” by
Institute for Clinical Evaluative Sciences (ICES), 2011, p. 7.
Copyright 2011 by the Institute for Clinical Evaluative
Sciences (ICES).
Figure 12 shows that hospitals providing obstetrical delivery care were more than 60 minutes away from over 75
communities within Northern Ontario:
Figure 12. Northern Ontario communities with
30,000 or fewer residents that are beyond 30
and 60 minutes travel time by car to the nearest
hospital providing obstetrical delivery care.
From “Geographic access to primary care and hospital
services for rural and northern communities: Report to the
Ontario Ministry of Health and Long-Term Care January
2011,” by Institute for Clinical Evaluative Sciences (ICES),
2011, p. 9. Copyright 2011 by the Institute for Clinical
Evaluative Sciences (ICES).
Figure 13 portrays that hospitals with specialized services (trauma centres, burn units, interventional cardiology
centres and neurosurgical centres), were over 60 minutes away from more than 130 communities in Northern
Ontario. Highly specialized services were concentrated in major centres and were less accessible to Ontario’s
population, especially in the north. Communities without access within 240 minutes were found only in Northern
Ontario. Of note, air transportation (helicopter or fixed wing) is commonly available in areas with no roads or where
travel times are too long for patient safety. For those reasons, the long travel times seen to many Ontario
communities by road may not correspond with actual travel times, especially in remote communities in emergency
situations or in inclement weather:
15
Figure 13. Northern Ontario communities
with 30,000 or fewer residents that are
beyond 30 and 60 minutes travel time by
car to the nearest hospital providing
obstetrical delivery care.
From “Geographic access to primary care
and hospital services for rural and
northern communities: Report to the
Ontario Ministry of Health and LongTerm Care January 2011,” by Institute for
Clinical Evaluative Sciences (ICES),
2011, p. 11. Copyright 2011 by the
Institute for Clinical Evaluative Sciences
(ICES).
Figure 14 includes the names of some of the affected communities illustrated in Figures 10, 11, 12, and 13:
Figure 14. Northern Ontario
communities with major
economic hubs highlighted.
From “ Physician services in rural and
Northern Ontario: ICES investigative
report.,” by Institute for Clinical
Evaluative Sciences (ICES), 2005, p. 6.
Copyright 2005 by the Institute for
Clinical Evaluative Sciences (ICES).
16
Inflow/Outflow Ratio (2010/2011).
North East LHIN ratio is 0.93. Similarly, the North West LHIN ratio is 0.91. This ratio represents the number of
discharges from relevant facilities (acute care/same-day surgery) within a given region divided by the number of
discharges generated by residents of that region.
An overall ratio is calculated for discharges associated with any diagnosis or procedure for acute care discharges
only. A ratio of less than one indicates that health care utilization by residents of a region exceeded care provided
within that region resulting in an ‘outflow’ effect. A ratio of greater than one indicates that care provided by a region
exceeded the utilization by its residents, thereby resulting in an ‘inflow’ effect. A ratio of one indicates that care
provided by a region is equivalent to the utilization by its residents, suggesting that inflow and outflow activity, if it
exists at all, is balanced. A ratio of zero is an indication that none of the institutions in the region provided the
service and residents received care outside of their region.
Table 1 lists the hospitals in Northern Ontario, classification by services. There are approximately 93 hospital sites
in Ontario considered small hospitals. They are located in small, rural, and remote communities throughout Ontario.
They are community governed facilities for the coordination and delivery of a broad range of primary care and
selected secondary care. There are 28 small hospitals located in Northern Ontario:
Table 1. Hospitals in
Northern Ontario.
Retrieved from
http://www.oha.com/AboutUs/Re
gionalAffairs/Region1/Pages/Reg
ion1Hospitals.aspx
17
5
Health Care Professionals
Physicians in Northern Ontario
Ontario has extensive rural and northern regions. These areas face significant and unique challenges in the
recruitment and retention of physicians. The data in this section compare the years 1996/97 and 2001/02.
According to the Institute for Clinical Evaluative Services (ICES), in 2001/02, 14% of Ontario General Practitioners
and Family Physicians (hereafter ‘GPs’ and ‘FPs’, respectively) and 2.5% of Ontario specialists who were practising
in rural areas cared for almost 20% of the Ontario population. Most of these rural GP/FPs and specialists lived in the
southern parts of the Province.
In Ontario in 2001/02, 52% of all physicians were specialists. Specialists represented 55% of the physicians in urban
areas, 51% in large northern centres, and 16% of the physicians in rural areas. Physicians overwhelmingly practiced
in urban centres. In 2001/02, 82% of GP/FPs and 93% of specialists were located in urban areas, with the remainder
in the rural communities and the large northern centres.
This is captured in Figure 15:
Figure 15. Relative distribution of medical
health care workers across Ontario. Large
northern centres are Timmins, Thunder Bay,
North Bay, Sudbury and Sault Ste. Marie.
From “Physician Services in Rural and Northern Ontario,”
by Institute for Clinical Evaluative Sciences (ICES), 2005,
p. 23. Copyright 2005 by the Institute for Clinical
Evaluative Sciences (ICES).
Demographics of Physicians
A stronger presence of women in northern areas may have implications for service delivery. More women in the
physician workforce may be beneficial for several reasons. Some studies note that patients report higher satisfaction
with care offered by female physicians. For patients who express a preference for female physicians, having more
females in the physician workforce represents greater choice. Female physicians are noted to be better
communicators, more focused on preventive care, and have higher quality of care assessments.
18
Figure 16. Demographic profile of Northern
Ontario General Practitioners and Family
Physicians (GP/FPs) practising in large centres,
2001/02. Large northern centres are Timmins,
Thunder Bay, North Bay, Sudbury and Sault Ste.
Marie.
From “Physician Services in Rural and Northern Ontario,” by
Institute for Clinical Evaluative Sciences (ICES), 2005, p. 45.
Copyright 2005 by the Institute for Clinical Evaluative
Sciences (ICES).
Figure 17. Demographic profile of Northern
Ontario specialists practising in large centres,
2001/02. Large northern centres are Timmins,
Thunder Bay, North Bay, Sudbury and Sault
Ste. Marie.
From “Physician Services in Rural and Northern Ontario,”
by Institute for Clinical Evaluative Sciences (ICES), 2005, p.
46. Copyright 2005 by the Institute for Clinical Evaluative
Sciences (ICES).
Figure 18. Physicians per 100,000 population
practising in large centres in Northern Ontario,
by physician type, 1996/97 and 2001/02. Large
northern centres are Timmins, Thunder Bay,
North Bay, Sudbury and Sault Ste. Marie.
From “Physician Services in Rural and Northern Ontario,”
by Institute for Clinical Evaluative Sciences (ICES), 2005,
p. 36. Copyright 2005 by the Institute for Clinical
Evaluative Sciences (ICES).
19
Turnover of Physicians
The five large centres in Northern Ontario had the highest levels of turnover compared to all other settings for both
specialists and GP/FPs. This was true for the periods 1996/97 and 2001/02. Northern Ontario had the highest
consistent rates of turnover among all LHINs. This speaks to the relative instability of the physician workforce in
these areas. This means that rural GP/FPs were more likely to be less than five years in practice, while their urban
counterparts were more likely to be female and trained outside of Canada. Among rural family physicians, those in
the North West LHIN area were much more likely to be more recent graduates and female. A greater proportion of
rural specialists have been in practice more than 30 years compared to all other settings. This is shown in Figure 19:
Figure 19. Turnover of physicians in large
centres in Northern Ontario, by physician
type, 1993–1996 and 1997–2001. Large
northern centres are Timmins, Thunder
Bay, North Bay, Sudbury and Sault Ste.
Marie.
From “Physician Services in Rural and Northern
Ontario,” by Institute for Clinical Evaluative
Sciences (ICES), 2005, p. 52. Copyright 2005 by the
Institute for Clinical Evaluative Sciences (ICES).
GP/FPs in rural communities are known to offer a broader scope of practice than their urban counterparts, a
difference that seems to increase the farther a physician practises from an urban setting. Northern Ontario GP/FPs
are more likely to work in the Emergency Department (ED), handle obstetrics, perform minor surgical procedures
and care for patients in the hospital than those GP/FPs in other parts of the Province. They also function with fewer
resources, less on-site back-up, greater on-call frequency, and their patients have less recourse to after-hours or
walk-in clinics.
20
6
Urban Area: Toronto Central LHIN
Demographics
The Toronto Central LHIN is Ontario’s only fully urban LHIN and is the most densely populated:

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174 health service providers, including 18 hospitals, 17 community health centres, 37 long-term care homes,
one Community Care Access Centre, 67 community support agencies, and 68 mental health and addictions
organizations (some health service provider organizations deliver more than one service, for example,
community support services and addictions services);
1.15 million residents or 8.6 per cent of Ontario’s population;
41% immigrants;
more than 160 languages and dialects;
2% Aboriginal or Aboriginal ancestry (about 25, 000);
2.9% Francophone and French-speaking (approximately 53, 400);
almost 22% with physical or mental condition or health problem;
people 85+ growing faster than any group;
5, 000 homeless representing 30% of homeless in Ontario;
largest Lesbian Gay Bisexual Transgendered (LGBT) community in Canada;
51 per cent of patients are from other areas of Ontario;
Only 24% of patients requiring a primary care physician are attached; and,
2.4 million commuters daily, many of whom receive health care within the Toronto Central LHIN.
Toronto Central LHIN had a budget of $4.378 billion in 2010/11, $4.36 billion of which was provided to health
service providers for day-to-day operations. Toronto Central LHIN is also home to 44% of Ontario’s teaching
hospitals, including some of the largest teaching hospitals in the country such as Hospital for Sick Children; Centre
for Addictions and Mental Health; and, the Princess Margaret Hospital (part of University Health Network).
Figure 20 presents a map of the Toronto Central LHIN:
Figure 20. Map of Toronto
Central LHIN.
From “Toronto Central LHIN:
Diversity at a glance,” by Government
of Ontario, 2008, p. 1. Copyright 2008
by Queen’s Printer for Ontario.
21
Primary Care
Toronto Central LHIN is home to approximately 1,400 primary care physicians and other primary care providers:

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

Approximately 160 General/Family Physicians and 296 Specialist Physicians per 100,000 circa 2010.
Many different practice models: family health teams, family health groups, community health centres, solo
practices and many other models. These models serve diverse urban and inner city populations and
neighbourhoods, some ethno-culturally specific.
Team-based delivery: Many of the organized primary care models promote collaborative practices and services
to address the complex needs of their populations.
The University of Toronto with tis world class Family Medicine program.
Hospitals that have cultivated strong family medicine departments with significant expertise in primary care for
inner city, marginalized populations.
Table 2 presents additional population characteristics based on the 2006 Census for the Toronto Central LHIN:
Table 2: Population characteristics of the Toronto Central
LHIN (2006 Census).
From “Toronto Central LHIN: Diversity at a glance,” by Government of
Ontario, 2008, p. 1. Copyright 2008 by Queen’s Printer for Ontario.
22
Toronto Central LHIN has a fragmented primary care system both because of the mix of practice types and the
relatively high number of solo practitioners – the highest of any region within the province. This fragmentation
makes patient transitions between primary care and specialty care and other providers a challenge:

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Targeted investments by the government: enabled a number of innovations in programming which provided
accessible and effective primary care support to complex, at-risk populations; and also to increase the number
of people attached to primary care providers, increase availability of EMRs in primary care, and growth in the
number of Family Health Teams providing comprehensive and accessible primary care.
Many primary care practitioners are isolated from hospitals and other parts of the system.
Many solo practitioners serving Toronto’s ethno-cultural communities are entering retirement age, but there is
no plan to ensure those populations are transitioned to other culturally appropriate primary care practices.
There are particular gaps in primary care for high-needs populations such as people with mental illness and
addictions, frail seniors, and those with complex chronic conditions. There is also evidence that those with the
highest rates of chronic diseases such as diabetes have fewer primary care services in their local communities.
Hospitals/Specialized Services
Inflow/Outflow Ratio (2010/2011).
The Toronto Central LHIN ratio is 1.88. Recall, North East LHIN ratio is 0.93. Similarly, recall the North West
LHIN ratio is 0.91. This ratio represents the number of discharges from relevant facilities (acute care/same-day
surgery) within a given region divided by the number of discharges generated by residents of that region.
An overall ratio is calculated for discharges associated with any diagnosis or procedure for acute care discharges
only. A ratio of less than one indicates that health care utilization by residents of a region exceeded care provided
within that region resulting in an ‘outflow’ effect. A ratio of greater than one indicates that care provided by a region
exceeded the utilization by its residents, thereby resulting in an ‘inflow’ effect. A ratio of one indicates that care
provided by a region is equivalent to the utilization by its residents, suggesting that inflow and outflow activity, if it
exists at all, is balanced. A ratio of zero is an indication that none of the institutions in the region provided the
service and residents received care outside of their region.
Table 3 compares activity of hospitals in North East, North West, as well as Toronto Central LHINs with respect to
Acute Care, Emergency Departments, Rehabilitation, and Complex Continuing Care for the period 2005-2006.
Table 4 lists the hospitals in Toronto Central LHIN, classification by services circa 2009.
23
Acute Care Hospitals in Ontario
LHIN
7
Toronto Central
13 Nor th East
14
Percent of Ontario
Discharges
Small
Hospitals
Community
Hospitals
Teaching
Hospitals
Total
14.2
0
2
5
7
6.2
14
7
1
22
9
2
1
12
43
65
15
123
Nor th West
2.7
Ontario
100
Percent of Ontario ED
Visits
Small
Hospitals
Emergency Departments in Ontario
LHIN
7
Toronto Central
13 Nor th East
14 Nor th West
Ontario
Community
Hospitals
Teaching
Hospitals
Total
7.6
0
2
5
7
8.6
14
7
1
22
3.9
9
2
1
100
44
65
15
12
124
Inpatient Rehabilitation in Ontario
LHIN
7
Toronto Central
13 Nor th East
14
Nor th West
Ontario
Percent of Inpatient
Specialty
Rehabilita- tion Clients in Hospitals
Ontario
General
Hospitals
Hospitals With Both
Facility Types
Total
21.6
3
5
0
2.0
1
3
0
1
58
2.3
0
0
1
100
8
46
4
8
4
Hospitals Providing Complex Continuing Care in Ontario
Percent of Ontario CCC
Patients
LHIN
Free-Standing
Hospitals
Small/ Medium
Large
Acute Care Hospitals
With CCC Units/Beds
Large
Medium
Small
Total
7
Toronto Central
20
7
0
1
1
0
9
13
Nor th East
3
0
0
0
2
16
18
14
Nor th West
6
1
0
0
0
10
11
100
12
4
7
20
64
107
Ontario
Notes: The Percent of Ontario CCC Patients adds to 101% due to rounding.
Small: less than or equal to 10,000 patient days in 2005–2006.
Medium: between 10,001 and 30,000 patient days in 2005–2006.
Large: over 30,000 patient days in 2005–2006.
Table 3. Comparing hospital activity for North East, North West, and Toronto Central LHINs: Acute care,
emergency department, rehabilitation, and complex continuing care-2005-2006.
Retrieved from http://www.oha.com/KnowledgeCentre/Library/HospitalReports/Documents/
24
Organization
LHIN
LHIN #
Classification
Baycrest Centre for Geriatric
Care
Toronto Central
7
General Rehabilitation, Chronic > 200 beds
Bridgepoint Hospital
Toronto Central
7
General Rehabilitation, Continuing Care
Centres
Centre for Addiction & Mental
Health
Toronto Central
7
Psychiatric/Teaching, Alcoholism/Drug
Addiction with Teaching
Holland Bloorview Kids Rehab
Toronto Central
7
General Rehabilitation
Hospital for Sick Children
Toronto Central
7
General / Teaching, Computerized Axial
Tomography (CTs), Magnetic Resonance
Imaging - MRI scan, Transplantation,
Biosynthetic Growth Hormone, Cystic
Fibrosis, Thalassemia
Mount Sinai Hospital
Toronto Central
7
General / Teaching, Computerized Axial
Tomography (CTs), Magnetic Resonance
Imaging - MRI scan, In vitro
General / Teaching
Providence Healthcare
Toronto Central
7
General Rehabilitation, Chronic > 200 beds
Runnymede Healthcare Centre
Toronto Central
7
Continuing Care Centres
St. Joseph's Health Centre
(Toronto)
Toronto Central
7
General > 100 Beds, General Rehabilitation,
Computerized Axial Tomography (CTs),
Magnetic Resonance Imaging - MRI scan
St. Michael's Hospital
Toronto Central
7
General / Teaching, Computerized Axial
Tomography (CTs), Magnetic Resonance
Imaging - MRI scan, Transplantation,
Lithotripsy, Cystic Fibrosis
Sunnybrook Health Sciences
Centre
Toronto Central
7
General / Teaching, Cancer Care, General
Rehabilitation, Chronic > 200 Beds,
Computerized Axial Tomography (CTs),
Magnetic Resonance Imaging - MRI scan
The Toronto East General
Hospital
Toronto Central
7
General > 100 Beds, General Rehabilitation,
Chronic < 200 Beds, Computerized Axial
Tomography (CTs), Magnetic Resonance
Imaging - MRI scan, In vitro
University Health Network
Toronto Central
7
General / Teaching, Cancer Care,
Computerized Axial Tomography (CTs),
Magnetic Resonance Imaging - MRI scan,
Transplantation, Cystic Fibrosis, Thalassemia
West Park Healthcare Centre
Toronto Central
7
General Rehabilitation, Chronic < 200 Beds,
Special Rehabilitation
Women's College Hospital
Toronto Central
7
General / Teaching, Computerized Axial
Tomography (CTs), Magnetic Resonance
Imaging - MRI scan, Ambulatory Care Centres
Table 4. Hospitals in Toronto Central LHIN.
Retrieved from http://www.oha.com/KnowledgeCentre/Library/HospitalReports/Documents
25
7
Education and Training
Medical Education
Practice of Medicine in Ontario.
The College of Physicians and Surgeons of Ontario is the body that regulates the practice of medicine to protect and
serve the public interest. The role of the College and its authority and powers are set out in the Regulated Health
Professions Act (RHPA), the Health Professions Procedural Code under the RHPA, and the Medicine Act.
All doctors in Ontario must be members of the College in order to practise medicine. The duties of the College
include:
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registration of physicians to practise medicine in Ontario;
quality assurance to continuously improve the quality of care provided by physicians;
education guidelines and courses to assist physicians in their practice;
patient relations to prevent and deal with sexual abuse of patients;
investigating concerns and complaints from members of the public about doctors; and,
disciplinary action when a physician does not appear capable of remediation.
Northern Ontario School of Medicine (NOSM).
As a medical school for the whole of Northern Ontario, the Northern Ontario School of Medicine (hereafter
‘NOSM’) is a joint initiative of Lakehead University in Thunder Bay and Laurentian University in Sudbury.
The entire undergraduate medical curriculum is organized around the following five integrated themes:
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Northern and Rural Health: the teaching of cultural competency especially in relation to populations in Northern
Ontario including Aboriginal peoples and Francophone health.
Personal and Professional Aspects of Medical Practice: professionalism, medical ethics, medico-legal issues and
historical developments related to the practice of medicine and health in Northern Ontario.
Social and Population Health: concepts of health and illness, public and community health, social determinants
of health, research skills, public health policy, and the organization of health care in Canada.
Foundations of Medicine: all of the basic sciences in medicine including the disciplines of anatomy, physiology,
pathology, pharmacology, genetics, microbiology, and biochemistry, and immunology.
Clinical and Communication Skills in Health Care: communication skills, components of the health history and
physical examination of body systems related to various aspects of the life cycle.
The five themes are integrated into every module and clerkship of the MD program for both teaching and
assessment.
Seven key academic principles guide the development and delivery of all NOSM academic programs:
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Interprofessionalism
Integration
Community Orientation
Inclusivity
Generalism
Continuity
Dedication to Inquiry
Figure 21 provides an overview of undergraduate medical education at NOSM:
26
Figure 21. Northern Ontario
School of Medicine’s
undergraduate medical education
curriculum.
From “Canada's new medical school: The
Northern Ontario School of MedicineSocial accountability through distributed
community engaged learning, by R.P.
Strasser et al., Academic Medicine, 84(10),
p. 1461. Copyright 2009 by Academic
Medicine.
Phase 1 encompasses the first two years of the program. Phase 1 is organized around eleven Case Based Modules
(CBMs), each of which covers a major body system. Each CBM also has either a remote, regional, rural, or
Aboriginal setting focus. Learners experience a mix of small and large group sessions, labs, and community-based
clinical experiences (including a 4-week placement in an Aboriginal community at the end of year 1 and two small
community placements in year 2). Learners also undertake a longitudinal program of community and
interprofessional learning.
Phase 2 (year 3) of the MD program is dedicated to a single Comprehensive Community Clerkship (CCC) that takes
place in medium-sized communities across Northern Ontario. Learners undertake a wide range of clinical learning
activities throughout the community as well as engaging in group teaching sessions including virtual academic
rounds (VARs) and distributed topic sessions (DTS). Learners also undertake a reflective research project based in
the needs and dynamics of their host communities.
Phase 3 (year 4) takes place in the academic health science centres in Thunder Bay and Sudbury and is organized
around a series of specialist clerkship rotations: Surgery, Internal Medicine, Children’s Health, Women’s Health,
Mental Health, Emergency Medicine, and Family Medicine. The integrated exposure to various specialties and
subspecialties in Phase 3 provides learners with the opportunity to assess various specialties which they may choose
to pursue as career choices. There are also opportunities to experience medicine in different settings through
electives.
The curriculum is clinically driven, while ensuring students gain a strong grounding in core knowledge and skills
including the basic sciences. In keeping with these seven academic principles, the undergraduate program involves
students learning in small groups, much of the time in distributed community-engaged learning sites supported by
information communication technologies.
Nursing
Nursing in Ontario.
The College of Nurses of Ontario (CNO) is the governing body for Registered Nurses (RNs), Registered Practical
Nurses (RPNs), and Nurse Practitioners (NPs) in Ontario.
The College fulfils its role by:

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establishing requirements for entry to practice;
articulating and promoting practice standards;
administering its quality assurance program;
enforcing standards of practice and conduct;
27


participating in the legislative process; and,
sharing statistical information about Ontario’s nurses.
The College works in partnership with employers, educators, and government.
Roles in Nursing.
In Ontario, nursing includes Registered Nurses (RNs) (which includes Nurse Practitioners (NPs)) as well as
Registered Practical Nurses (RPNs). RPNs obtain a 2- or 3-year diploma in Practical Nursing. RNs obtain a 4-year
bachelor’s degree in Nursing.
NPs are Registered Nurses (RNs) with additional education and experience. They are able to order and interpret
diagnostic tests; communicate diagnoses; prescribe pharmaceuticals; and, perform specific procedures. Nurse
Practitioners work in a variety of settings such as community health centres, clinics, urgent care centres, public
health units, long-term care facilities, and hospital in-patient and outpatient units.
NPs are expected to complete courses in pathophysiology; advanced health assessment and diagnosis; therapeutics;
professional roles and responsibilities; advanced nursing practice; and, clinical reasoning. NPs must complete a 700hour clinical placement in an acute care clinical area of their choice. The clinical courses are focused on primary
health care service delivery, and the program involves a 13-week, full-time clinical placement in which the NP
student works alongside an experienced NP and/or FP and other team members. NPs are required to consult with a
physician if they encounter patient care needs that are beyond their scope of practice.
Primary Health Care NPs.
Primary Health Care NPs generally work in community settings and provide general primary health care services to
people of all ages. For many people, primary health care NPs are their first and most frequent point of contact with
the health care system.
Examples of the types of health care services provided by primary health care NPs include:
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annual physicals;
patient counselling (e.g., mental health, family planning, medication compliance);
health promotion (e.g., smoking cessation);
immunization against disease, screening for diseases;
treatment for short-term acute illnesses (e.g., infections, minor injuries);
monitor patients with stable chronic illnesses (e.g., diabetes);
referrals to other health care services (e.g, home care services); and,
referrals to social services (e.g., housing supports).
Adult and Pediatric NPs.
Adult and Pediatric NPs tend to work in hospital settings and provide specialized health services to people who have
specific health conditions (e.g., neonatal care, cardiovascular disease, diabetes, or cancer). Although many of these
NPs provide health services to patients who are hospitalized with acute and/or critical illness, they also monitor and
treat patients who are ambulatory and living with chronic illnesses.
Examples of the types of health care services provided by Adult and Pediatric NPs include:
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
patient counselling (e.g., understanding illness progression, treatments);
health promotion (e.g., infection control);
treatment for acute / critical / urgent illness;
procedures (e.g., de-fibrillation);
monitor patients with chronic conditions (e.g., diabetes); and,
referrals to other health and social services (e.g. social work, dieticians, pharmacists).
28
Nursing Programs in Northern Ontario.
NOSM does not offer programs in Nursing. Both Laurentian University and Lakehead Unviersity, NOSM’s two
governing universities, offer Nursing programs.
The School of Nursing at Lakehead University offers:
•
•
•
•
•
four year Bachelor of Science in Nursing Degree program;
three year compressed Bachelors of Science in Nursing Degree program ;
Nurse Practitioner postgraduate program;
Master’s Degree in Public Health with a Specialization in Nursing; and ,
Native Nurses Entry program.
The School of Nursing at Laurentian University offers:

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Bachelor of Science in Nursing, BScN;
Bachelor of Science in Nursing Collaborative College Partnerships;
Bachelor of Science in Nursing Program for Registered Nurses (RNs) via Distance Education;
Master of Science in Nursing; and,
Primary Health Care Nurse Practitioner (PHCNP) Program.
Pre-hospital Education
The Postgraduate Education Unit of NOSM is responsible for the provision, administration, and support of all
postgraduate residency training programs in Northern Ontario. NOSM offers residency training in eight major
general specialties, as well as the Family Medicine Residents of the Canadian Shield (RoCS) program – the newest
Family Medicine program in Canada. PGY3 programs are also offered to those Family Medicine residents wishing
to further their knowledge and training in specific specialty areas. NOSM PGY3 programs include Emergency
Medicine, Anesthesia, Enhanced Skills Maternity Care, Care of the Elderly, and Self-Directed Enhanced Skills.
Royal College Specialty training available at NOSM includes Public Health and Preventive Medicine, General
Surgery, Pediatrics, Internal Medicine, Orthopedic Surgery, Psychiatry, and Anesthesiology (beginning July, 2013).
The Obstetrics/Gynecology Northern Training program is also available through a partnership with the University of
Ottawa through which this program is accredited.
All of NOSM’s residency programs combine learning within the major academic centres with clinical rotations
throughout rural Northern Ontario health care settings.
Other Health Care Education
Physician Assistants in Ontario (PA).
The Canadian Association of Physician Assistance (CAPA) is the national governing body for the profession, which
has developed the National Competency Profile (NCP) and a Scope of Practice documents. The Physician Assistant
Certification Council provides and monitors the certification process.
Physician Assistants (PAs) are skilled health professionals who support physicians in a range of health care settings.
They work alongside physicians, nurses, nurse practitioners, and other members of the interprofessional health care
team. The PA role is currently being introduced to the Ontario health care system through a 2-year demonstration
project taking place in selected hospitals, community health centres, community-based diabetes care clinics, and
long-term care homes. The initiative is being co-led by the MOHLTC and the Ontario Medical Association
(hereafter ‘OMA’).
29
The Bachelor of Science Physician Assistant degree (BScPA) is a full-time professional, second-entry
undergraduate degree program, based in the Department of Family and Community Medicine (DFCM) in the
Faculty of Medicine at the University of Toronto (U of T). The BScPA is a University of Toronto degree delivered
in collaboration with NOSM and The Michener Institute for Applied Health Sciences (Michener). The three
institutions have formed the Consortium of PA Education to collaboratively contribute in the development,
administration, and delivery of the BScPA degree. The aim of the program is to equip graduates with the
competencies necessary to establish the foundation for a sustainable Canadian Physician Assistant profession.
The Physician Assistant (PA) duties and responsibilities fall directly under the supervision of a licenced physician.
PAs are not presently licensed and are not a regulated health profession in Ontario. However, the Canadian Medical
Association (CMA) has accorded the BScPA Program a 2 year accreditation status until December 2013:
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Year 1 (3 semesters) is academically focused: completion of 15 courses in total, including 120 hours of
longitudinal clinical experience.
Year 2 (3 semesters) is clinically focused: 40 weeks of supervised direct clinical contact in rural and urban
settings.
Northern Ontario Dietetic Internship Program (NODIP).
NODIP is administered by NOSM in collaboration with multiple preceptors, communities, and facilities throughout
Northern Ontario. NODIP is a comprehensive internship program that offers a wide range of challenging learning
experiences in a variety of practice settings including hospitals, family health teams, public health units, community
health centres, long-term care facilities; as well as, in Aboriginal and Francophone communities in Northern
Ontario.
Distributed experiences in the provision of nutrition care across the health-care continuum form a key part of the
curriculum. Emphasis is on self-directed learning. Interns are actively involved in planning and directing their own
learning within the structure of the program. Learning occurs within placements and established professional
development sessions, such as case presentations, journal clubs, as well as the NODIP newsletter and workshops.
Within NODIP there is a comprehensive balance of clinical, food service, administration and community-based
learning opportunities, as well as practice-based research. At completion of the program, graduates will acquire the
entry-level competencies specified by Dietitians of Canada. The complete program includes:
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

Orientation (2 weeks)
Food Service and Management (8 weeks)
Clinical Nutrition (17 weeks)
Community Nutrition (10 weeks)
Research Project Development (4 weeks)
Staff Relief (3 weeks)
Vacation (2 weeks)
Total (including vacation) (46 weeks)
Rehabilitation Studies/Northern Studies Stream (NSS).
The Rehabilitation Studies program is a pan-northern initiative administered by NOSM. Learners from audiology,
occupational therapy, physiotherapy, and speech language pathology, are offered a wide range of challenging
clinical learning experiences in equally challenging health care settings across Northern Ontario.
Clinical placements expose learners to health care practice and delivery in remote, rural, and northern settings.
Learners work closely with other health care professionals in a variety of practice settings including large hospitals,
small rural hospitals and community practices, community care access centres (CCAC), private clinics and solo
practices. Community-based placements are located across Northern Ontario.
30
Rehabilitation Studies also encompasses the Northern Studies Stream Program. NSS is specifically designed for
Occupational Therapy (OT) and Physiotherapy (PT) rehabilitation learners and provides OT and PT learners with
the opportunity to learn about the unique health care needs and diverse populations of Northern Ontario.
NSS was created 20 years ago. Originally a partnership between McMaster University, Lakehead University, and
MOHLTC, NSS is now administered by NOSM. Travelling from McMaster University to Thunder Bay, students
complete a clinical placement or a combined academic semester plus clinical placement. The program often results
in graduates who remain in Northern Ontario or relocate to other rural locations in Canada upon completion of their
studies.
Northern Ontario Electives Program.
This program provides a variety of rural, remote, and small urban clinical learning opportunities in Northern Ontario
to undergraduate medical students and postgraduate residents from both family medicine and specialty programs.
All medical trainees from any medical university in the world can gain access to northern community-based clinical
learning opportunities by registering in the electives program.
Each learner works closely with a clinical facilitator to meet his/her objectives, with regular feedback and
evaluations. Electives are available in Family Medicine, Rural Family Medicine, Emergency Medicine, as well as in
many of the specialty disciplines.
Interprofessional Education Program (IPE).
NOSM’s IPE program introduces learners to the skills necessary to function as a member of a quality health care
team and develop the competencies needed to be a team member. The program addresses recruitment and retention
with a focus on education that highlights the geographic, demographic, linguistic, and cultural realities of Northern
Ontario. Utilizing a variety of learning strategies within a community-oriented curriculum, teams of health
professional learners experience a learner-centred approach to collaboration and problem solving.
Teams of learners including audiology, dietetics, health promotion, kinesiology, midwifery, medicine, nursing,
occupational therapy, pharmacy, physiotherapy, social work and speech language pathology are brought together for
weekly tutorial sessions.
Northern Ontario Summer Studentship Program (SSP).
The SSP provides paid jobs for four to eight weeks in health care settings across Northern Ontario. The intent of the
SSP is to enhance the learners’ knowledge of healthcare in the North. The learner becomes the employee of the
agency/institution and abides by their policies and procedures.
Continuing Education
NOSM’s Office of Continuing Education and Professional Development (NOSM CEPD) is dedicated to the
provision of innovative, learner driven, continuing medical education and continuing professional development
opportunities (CME/CPD) that meets the needs of all Northern Ontario health care professionals, including NOSM
faculty currently supporting under and postgraduate medical education and health sciences programs.
The CEPD Office is committed to the guidelines and policies of the College of Family Physicians of Canada
(CFPC), The Royal College of Physicians and Surgeons of Canada (RCPSC), the Canadian Medical Association
(CMA), the Association of the Faculties of Medicine of Canada (AFMC), the Committee on Accreditation of
Continuing Medical Education (CACME), the Accreditation Council of Continuing Medical Education (ACCME),
and NOSM. The CEPD Office collaborates with educational partners on the development and delivery of
innovative and accredited programming.
31
8
Recruitment / Retention Problems
Projected Shortages
In January 2007, the MOHLTC and OMA decided to jointly initiate a process for the development of a Population
Needs-Based Physician Simulation Model for Ontario. The model compares various health needs of the population
to the supply of physician services, quantifies the variance and converts the variance into a physician requirement.
The Population Needs-Based Physician Simulation Model is a strategic tool for planners and policy makers to
understand the impacts of health population trends and health policies on physician supply and need.
Figure 22 and Figure 23 outline the basic assumptions taken into account for the simulation model:
Figure 22. Summary of key inputs and
assumptions: Base case simulation 3.
From “Ontario population needs-based physician simulation
model October 2010,” by Government of Ontario, p. 24.
Copyright 2010 by the Queen’s Printer for Ontario.
Figure 23. Summary of key inputs and
assumptions: Base case simulation 3-continued.
From “Ontario population needs-based physician simulation
model October 2010,” by Government of Ontario, p. 25.
Copyright 2010 by the Queen’s Printer for Ontario.
Figure 24 and Figure 25 present the projected shortages for the North East and North West LHIN, respectively:
32
Figure 24. Simulation results by specialty for
North East LHIN: Base case simulation 3.
From “Ontario population needs-based physician
simulation model October 2010,” by Government of
Ontario, p. 38. Copyright 2010 by the Queen’s Printer for
Ontario.
Figure 25. Simulation results by specialty for
North West LHIN: Base case simulation 3.
From “Ontario population needs-based physician
simulation model October 2010,” by Government of
Ontario, p. 39. Copyright 2010 by the Queen’s Printer for
Ontario.
Programmatic Responses
In the context of a growing shortage of doctors in Northern Ontario and across the entire province, the Ontario
government commissioned a ‘fact finder report’ in 1999. A number of initiatives ensued which included a formal
recommendation that a medical school be established in Northern Ontario with campuses in the cities of Sudbury
and Thunder Bay, which are home to Laurentian University and Lakehead University, respectively.
On the basis of this report, the Government of Ontario announced in 2001 its decision to establish a new medical
school in Northern Ontario (i.e. NOSM) with a social accountability mandate of improving the health of the people
and communities of Northern Ontario.
One key series of initiatives that has been shown to be effective involves rural-based medical education. Studies
conducted in a number of different countries have shown that the three factors most strongly associated with
entering rural practice are:



a rural background;
positive clinical and educational experiences in rural settings as part of undergraduate medical education; and,
targeted training for rural practice at the postgraduate level.
Over the years, the Government of Ontario has used a number of policy initiatives in response to physician shortages
in Northern Ontario, including:
33









Financial incentives: Providing incentives to medical students or physicians willing to work in Northern
Ontario.
Physician recruitment: "Marketing" Northern Ontario to physicians.
Alternative providers: Using non-physician practitioners such as nurse practitioners where physicians are not
available.
Rural medical education/training: Training physicians in rural or northern areas.
Medical practice support: Making northern practice less onerous in order to enhance its attractiveness.
Service outreach: Bringing services to areas where they are not locally available.
Patient travel assistance: Providing financial assistance to patients who have to travel long distances to access
medical care.
Telemedicine: Linking patients and physicians via telecommunications technology.
Research: Using research to support rural health workforce planning.
Figure 26 captures the frequency of utilization of these policy efforts over a 35 year period:
Figure 26. Programmes to address physician shortages in Northern Ontario introduced by the Ontario government
by policy instrument type and year, 1969 – 2004.
From “Strategies to overcome physician shortages in Northern Ontario: A study of policy implementation over 35 years,” by R. Pong, 2008,
Human Resources for Health 6(24), p. 4. Copyright 2008 by Pong.
Appendix A presents a non-exhaustive listing of additional programs sponsored by the Government of Ontario in
response to the projected shortage of health care professionals in Northern Ontario.
34
9
Summary
A Chronic Shortage
Northern Ontario has a chronic shortage of doctors and other health care providers. Circa 2010, there were 18.9
physicians per 10,000 population in Canada overall, whereas for Northern Ontario, the figure was 14.9 physicians
for every 10,000 people. Producing more physicians and other allied health care professionals in urban settings and
expecting the excess to spill over from the cities into remote and rural areas has been shown to be ineffective in
solving the rural medical workforce shortage.
Recruiting health care professionals is continuing to be a challenge for a number of reasons, including: limited
enrolment health education programs and schools; increased timeframes for training; trends in education towards
specialists versus generalists; limited incentives to work in rural, remote, and northern areas as compared to urban
areas and abroad; concentration of training and education centres in urban versus rural communities; limited family
support strategies for professionals; and, the need for increased mentorship.
Other challenges to recruitment and retention include:













Scarcity of resources (e.g. health human resources, infrastructures, technologies, etc.), and varied enablement of
health professionals to work at the full scope of practice, limit the capacity of the system to deliver care at an
acceptable standard.
Demand for rural health provider organizations and professionals to take on a broader and more diverse set of
care responsibilities than is required in urban settings.
Limited capacity within rural and remote communities in Northern Ontario to respond to health care challenges,
engage in planning, pursue special grant opportunities, raise capital to support local share requirements for new
infrastructure, or to support on-going capital equipment renewal.
Fragmentation of the funding, management, coordination, and decision-making across different components of
the health system (e.g. emergency medical services, public health, primary care), with limited consideration of
the impact of related changes on local community health care access.
Varying degrees of funding transfer between the health and other sectors when service changes are made, that
then impacts the ability of new service models to be successful.
Political challenges in implementing strategies to improve access, which may result in sub-optimal service
delivery models and access.
Limited coordination and clarity on the roles, accountabilities, funding, and service models for health care
services across federal, provincial, and Aboriginal governments.
Different perspectives and varying alignment on the role of the LHINs in planning and service delivery for First
Nations, relative to the role of the federal and provincial governments, and existing agreements between First
Nations and different levels of government.
Limited availability of non-urgent transportation in some northern remote and rural areas, which impacts the
access to physician clinics, dialysis, chemotherapy, and other services. Public transportation options are being
curtailed in many rural areas, and particularly in Northern Ontario, made worse by poor roads and inclement
weather conditions.
Limited availability of emergency, inter-facility, and non-urgent transportation that require a patient to be
accompanied by a health professional is limited. Long distances between services in the north can result in an
ambulance or health professional(s) being needed for over a day for a single patient transport, limiting the
availability of those services to others in the community.
Geographic placement of service and travel distance can make access to services difficult, and influences which
services individuals choose to seek – limited non-urgent transportation; inflexible travel grants (e.g. one-way
trip minimum requirement versus accumulated transportation over a time period).
Lack of rural perspective applied in planning at the provincial or LHIN levels, and the need for increased
flexibility at the local level to drive innovations related to scope of practice, funding, system integration, and
other aspects.
Recognition that health care access challenges and needs in rural communities differ between Northern Ontario
and other regions of Ontario, and that challenges are typically accentuated in the north.
35
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



The historic trend toward centralization in health system design, which limits local responsiveness and reduces
access; need to create local capacity to focus on synergies across the continuum of care and sectors.
Although shifts in the nature of health services delivered in a local community may need to occur, current
planning for rural, remote, and Northern Ontario is insufficient with respect to: the level of community
engagement in the decision-making process, examination of the impacts on health human resources and other
health sectors, and consideration of the economic impact and sustainability of the community.
Inconsistent implementation of potential interprofessional models across local communities, which are
considered an important element of improved access to local health care (e.g. varied levels of investment in
primary care models such as Family Health Teams across local communities).
Limited sharing of health records and information across professionals within the system.
Increasing expectations by individuals/families/communities, which are changing access demands.
Limited availability of cultural and linguistically appropriate services (e.g. for Aboriginal and Francophone
populations), which impacts access and outcomes.
Five Key Northern Centres
The five large Northern Ontario centres of Timmins, Thunder Bay, North Bay, Sudbury, and Sault Ste. Marie, all
play an important role in northern health care delivery. The vast majority of the northern specialist physician
population is located in these key centres. Also, these communities have profiles (demographic, turnover levels,
physician to population ratios) that are typically different from both urban and rural communities. Programs
specifically addressing these five centres, with enough flexibility to reflect the differences among them, may be
helpful:



Physician workforce strategies: There has been a wide range of initiatives. However, the fact that many of these
are focused more on recruitment than on retention may be contributing to higher turnover rates in northern and
rural communities. More research needs to be done to identify ways of reducing turnover.
Rural specialists are diminishing in numbers: The number of rural specialists is small and declining.
Furthermore, rural specialists tend to be older and many are approaching retirement age. If this trend continues,
then the model of care that provides rural physicians with local access to specialist back-up may gradually
disappear.
Role of alternate payment models for primary care: The increase in the numbers of both young and female
family physicians in areas where new alternate payment models have been introduced suggests that these new
models of remuneration may be important recruitment tools. Governments should consider expanding these
successful models to other rural areas.
Dramatic Demographic Shifts.
The number of seniors in Ontario will double in the next 20 years by 2030. In Northern Ontario where the
proportion of seniors is greater than the rest of Ontario, this shift will be more pronounced. Focus and training must
be provided health care learners to address the needs of the 1% of the population that accounts for 34% of health
costs and the 5% of the population that are at risk but are able to maintain independence with the right services and
support. This results in the need for a comprehensive, system-wide primary care strategy as well as the recruitment,
retention, training, and education of GPs and FPs.
Innovative Policy Instruments.
The Government of Ontario and MOHLTC may continue to leverage policy instruments that fully exploit global
knowledge, interprofessional health education, and interprofessional health collaboration, technology, and
transportation including:




Service outreach: Bringing services to areas where they are not locally available.
Alternative providers: Using non-physician practitioners such as nurse practitioners where physicians are not
available.
Telemedicine: Linking patients and physicians via telecommunications technology.
Research: Using research to support rural health workforce planning.
36
Supporting Small Hospitals.
Small and rural hospitals also face critical recruit and retention challenges, exacerbated by a unique set of
geographic, demographic, and resource constraints, including:








Geographical remoteness and isolation.
Low-density populations – few economies of scale to be gained.
Demographics – aging population and special needs populations.
Lack of physicians (including specialists), nurses and other health care providers.
Reduced access to medical and other professional health care services.
Limited or no alternatives to essential services.
Decreased availability of community-based services and non-acute care resources.
Fiscal challenges where the options to cut/reduce costs are extremely limited, including decreased opportunity
to manage patients on an ambulatory basis.
While not considered small hospitals, Thunder Bay Regional Health Sciences Centre, St. Joseph's Care Group
(Thunder Bay), Sudbury Regional Hospital, Sault Area Hospital, Timmins and District Hospital, and North Bay
General Hospital, are all deemed regional northern sites and are located in one of the five key northern centres.
37
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health status and health determinants. Toronto, CAD: Canadian Institute for Health Information (CIHI),
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Toronto, CAD: Queen's Printer for Ontario Retrieved from
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Government of Ontario. (2009). Access to Primary Care in Ontario: 2008. Toronto, CAD: Queen's Printer for
Ontario.
Government of Ontario. (2010). Ontario population needs-based physician simulation model October 2010.
Toronto, CAD: Queen's Printer for Ontario Retrieved from
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Government of Ontario. (2011). Growth plan for Northern Ontario 2011. Toronto, CAD: Queen's Printer for
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CAD: Queen's Printer of Ontario.
Government of Ontario. (2011). Toronto Central LHIN: 2010/11 Annual Report-Improving access to care for
healthier people and communities. Toronto, CAD: Queen's Printer for Ontario.
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Printer for Ontario.
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Institute for Clinical Evaluative Sciences (ICES). (2011). Geographic access to primary care and hospital services
for rural and northern communities: Report to the Ontario Ministry of Health and Long-Term Care January
2011. Toronto, CAD: Institute for Clinical Evaluative Sciences (ICES),.
Laurentian University. (2012). Laurentian University: Learning, it's in our nature. Retrieved August 22, 2012, from
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Lin, E. , Durbin, J. , Zaslavska, N. , Teed, M. , Veldhuizen, S. , Daniel, I. , . . . Goering, P. . (2008). Hospital Report
2007: Mental Health. Toronto, CAD: Hospital Report Research Collaborative, University of Toronto
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http://www.oha.com/KnowledgeCentre/Library/HospitalReports/Documents/Hospital%20Reports%202007
/Mental%20Health.pdf.
Northern Ontario School of Medicine (NOSM). (2010). Overview of the four year Undergraduate Medical
Education Program at the Northern Ontario School of Medicine. Greater Sudbury, CAD: Lakehead
University and Laurentian University.
Ontario Hospital Association (OHA). (2007). Hospital Report 2007: Acute Care. Toronto, CAD: Canadian Institute
for Health Information (CIHI) Retrieved from
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/Acute%20Care.pdf.
Ontario Hospital Association (OHA). (2007). Hospital Report 2007: Complex Continuing Care. Toronto, CAD:
Canadian Institute for Health Information (CIHI) Retrieved from
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/Complex%20Continuing%20Care.pdf.
Ontario Hospital Association (OHA). (2007). Hospital Report 2007: Emergency Department Care. Toronto, CAD:
Canadian Institute for Health Information (CIHI) Retrieved from
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/Emergency%20Department%20Care.pdf.
Ontario Hospital Association (OHA). (2007). Hospital Report 2007: Rehabilitation. Toronto, CAD: Canadian
Institute for Health Information (CIHI) Retrieved from
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/Rehabilitation.pdf.
Pong, R.W. (2008). Strategies to overcome physician shortages in Northern Ontario: A study of policy
implementation over 35 years. [Y]. Human Resources for Health 2008, 6(24), 1-9.
Pong, R.W. , DesMeules, M. , Heng, D. , Lagacé, C. , Guernsey, J.R. , Kazanjian, A. , . . . Luo, W. . (2011). Patterns
of health services utilization in rural Canada. [Y]. Chronic Diseases and Injuries in Canada, 31(Suppl 1),
1-36.
Strasser, R. P., Lanphear, J. H., McCready, W. G., Topps, M. H., Hunt, D. D., & Matte, M. C. (2009). Canada's new
medical school: The Northern Ontario School of Medicine-Social accountability through distributed
community engaged learning. [Y]. Academic Medicine, 84(10), 1459-1464. doi:
10.1097/ACM.0b013e3181b6c5d7
Tepper, Joshua D. , Schultz, Susan E. , Rothwell, Deanna M. , & Chan, Benjamin T.B. (2005). Physician services in
rural and Northern Ontario: ICES investigative report. Toronto, CAD: Institute for Clinical Evaluative
Sciences (ICES).
39
Appendix A: Preliminary Inventory of Government-Funded Northern and Rural Health Care Programs
40
Program
Description/objectives
Northern Health Travel Grant
Helps to defray medical related travel costs for residents of Northern Ontario who must travel long distances within Ontario, or
Manitoba to access medical specialist, or designated health care facility (e.g. hospital for MRI) services unavailable locally
within 100km radius.
Northern Health Travel Grant
enhancements
On July 4, 2007 the Premier of Ontario announced the following enhancements to the NHTG program:



An increase in the per kilometre reimbursement rate from 34.25 cents to 41 cents per kilometre; effective July 1, 2007
(completed);
An accommodation allowance of $100.00 per eligible trip; effective October 1, 2007 (completed); and
Upgrades/redesign of the NHTG claims processing system; implementation scheduled for Q4 2008/09 (underway and ontrack).
The business drivers for the NHTG Program Enhancements are to improve the delivery of this Program to Northern Residents
by:


Small hospital funding initiative
Deferring costs for Northern Residents seeking specialty medical services not available locally; and
Assuring that applicants receive this compensation in as timely a fashion as possible in order to offset these travel costs.
To recognize the unique challenges small hospitals face as a result of isolation, transportation, limited efficiencies from
economies of scale and lack of services in the community.
The ministry defines hospitals as 'small' for a given funding year:
If it had less than or equal to 2,500 equivalent weighted cases of service for that funding year. This also includes those multi-site
hospitals with small sites that meet this criteria (less than or equal to 2,500 weighted cases).
Northern Ontario School of
Medicine


Improve access to needed medical services in the North
Recruit and retain physicians in communities in rural and Northern Ontario.
Transitional Physician Funding to help NOSM achieve their academic mission. Full Physician funding associated with NOSM
negotiated as part of the 2008 OMA Framework Agreement.
41
Program
Description/objectives
Underserviced Area Program
While the UAP has a single funding allocation, the program constitutes 18 program components. The UAP helps northern and
rural underserviced communities across the province improve access to health care services by providing a variety of integrated
initiatives aimed at attracting and retaining health care providers. In order to be eligible for the UAP's recruitment and retention
support, a community must be designated as underserviced.
(see Appendix for components including transfers to other programs proposed in 2009/10 RbP)
Family Health Teams
29 FHTs provide care to residents in North East and North West LHINs
49 FHTs provide care to over 336,000 rural Ontarians
• Implement 50 new FHTs across Ontario to improve access to comprehensive family health care for Ontarians.
• New FHTs will be located in areas of greatest unmet need (i.e. unattached patients) as identified through the Health Care
Connect program. This is anticipated to include rural and northern areas of the province.
• The first call for proposals is being targeted for spring 2009 with a second call targeted for winter 2010.
Ontario Telemedicine Network
The Ontario Telemedicine Network (OTN) is a telemedicine networks funded by the MOHLTC. OTN provides access to care for
patients in every hospital and hundreds of other health care locations across the province. Nearly 3,000 health care professionals in
more than 925 sites across the province use OTN to delivery more than 90,000 patient visits.
In addition to clinical care, OTN facilitates the delivery of distance education and meetings for health care professionals and
patients.
42
Program
Description/objectives
First Nations Agreement - Sioux
Lookout
Description
• Health Canada has withdrawn from directly funding physician services effective March 31, 2008
• MOH has assumed this responsibility effective April 01, 2008 by way of a Bridging Agreement that maintains status quo of
physician services in the region while introducing very basic elements of a MOH funded primary care physician services funding
model. Full PHC funding agreement to be negotiated in 2009/10.
Objective(s)
• Assume funding responsibility for primary care physician services in the Sioux Lookout region in order to ensure
comprehensive primary health care services available to residents of 28 isolated communities in northwestern Ontario
43
Program
Description/objectives
Group Health Centre (GHC) Sault Ste. Marie
Description
• The GHC agreement funds family and specialist physicians and allied health professionals to provide an integrated health care
service model to over 61,000 enrolled patients (approximately 60% of the population of Sault Ste Marie).
Objective(s)
• The GHC aims to provide an integrated health care service model (primary health care, health promotion, disease prevention,
diagnostic services, hospital care) to over 61,000 enrolled patients (approximately 60% of the population of Sault Ste Marie).
Northern Physician Retention
Initiative
Support recruitment and retention of physicians in Northern Ontario and to encourage physicians to maintain hospital privileges.
Established as a three year initiative under the 2000 OMA agreement and continued under the 2004 and 2008 agreements. The
NPRI provides eligible physicians in Northern Ontario with a $7,000 retention incentive paid at the end of each year in which
they continue to practice full-time in Northern Ontario. Eligible participants also have access to the Continuing Medical
Education (CME) Program, for benefits up to $2,500 in each year of eligibility.
The NPRI is targeted to general/family practitioners and specialists who have stayed, and maintained their practices, in Northern
Ontario for a minimum of four years. Northern Ontario is defined as the territorial districts of Algoma, Cochrane, Kenora,
Manitoulin, Nipissing, Parry Sound, Muskoka, Rainy River, Sudbury, Thunder Bay and Timiskaming.
Nurse Practitioner Demonstration
Project (NPDP)
The NPDP was implemented in 2002 by Nursing Secretariat to provide increased access to primary health care services in 12
small, rural and under-serviced communities.
Effective April 1, 2005, 19.44 FTE NP positions were transferred from the Nursing Secretariat to the PCNP program. As a result
of subsequent transfers of 9.84 FTEs to other TP programs, funds have been allocated for 9.6 NP FTEs through the 2009/10
RbP.
44
Program
Description/objectives
Rural Medicine Investment
Program
Recruitment and retention of physicians in Northern and Rural Areas with RIO scores of 45 or greater. (2004 OMA agreement)
Rural Northern Initiative (RNI)
Description
• This program brings physicians who are teaching at the University of Toronto and a PGY-3 (final year resident) to RNPGA
communities to provide additional short term locum coverage (beyond Group's contractual locum entitlements) for RNPGA
communities with a vacancy.
Objective(s)
• Exposes new graduates to rural medicine practice.
• Provides temporary relief to RNPGA communities in need
Rural Northern Physician Group
Agreement (RNPGA)
Description
• GP services funding model for provision of comprehensive care in isolated communities.
•At full complement : potential of having 114 full time physicians (approximately 99-105 currently participating)
Objective(s)
• Ensure comprehensive primary health care services available to residents of the currently 39 identified eligible northern
communities.
45
Program
Description/objectives
Rural Northern Physician Group
Agreement (RNPGA)
Description
Expansion
• RNPGA physician services funding model for additional underserviced communities (northern and southern) as mandated
through the 2004 MOH-OMA Memorandum of Understanding.
• RNPGA
for southern communities is a modified version of the existing RNPGA, with main difference being PHC base remuneration tied
to roster size.
• Full complement : potential of having 49 full time physicians (2 currently participating)
Objective(s)
• Expand availability of comprehensive primary health care services to residents of the 8 identified eligible northern communities
and 14 southern communities.
46
Program
Description/objectives
Thunder Bay Collaborative
Maternity Centre Alternate
Funding Plan
Description
• Interim funding for Allied Health Professionals providing maternity services pro-rated by FTE and overhead
• Sessional physician services to support collaborative maternity care – currently in discussions
Objective(s)
• Provide integrated multidisciplinary primary maternity services to patients in Thunder Bay
Trauma Team Lead AFA —
Sudbury
Provision of services by Trauma Team Leaders in regional Lead Trauma Hospital (Sudbury, Thunder Bay)
LTC homes – unorganized parts
grants
To assist Algoma District municipalities in defraying the cost of establishing new LTC beds based upon the proportion of costs
that are allocated to unorganized parts of the territorial districts in which the homes are established.
Northern Redevelopment Grants
Northern Redevelopment Grants represent the difference between the maximum amount that the operator can raise and a
minimum project cost as determined in consultation with the Ministry. Eligibility for the Northern Redevelopment Grant is
restricted to those operators who are building new awarded LTC beds or redeveloping ‘D’ LTC beds. Eligibility for the Northern
Redevelopment Grant is limited to Not-for-Profit organizations that can substantiate that the cost of developing their project
significantly exceeds what would be expected in more urban or southern communities, or that all avenues to access the necessary
equity have been exhausted.
47
Program
Description/objectives
Unorganized Territories Grant

The Ministry provides 100% grants to public health units for the delivery of mandatory programs in unorganized territories
(territories without municipal organization).

There are eight (8) public health units which receive funding for unorganized territories: District of Algoma, North Bay
Parry Sound District, Northwestern, Porcupine, Renfrew County & District, Sudbury & District, Thunder Bay District, and
Timiskaming Health Units. Seven (7) of these public health units are situated in the North.
CHCs
The CHC expansion plan includes 17 Community Health Centres and 7 satellite Community Health Centres whose catchment
areas include rural communities, providing access to primary health care and community health programs.
Other notes:
-
Some strategies, such as Aging at Home, can benefit these communities but are not targeted to them.
48
COMPONENTS OF UNDERSERVICED AREA PROGRAM
Incentive grants




$40,000 paid over four years to GP/FPs and psychiatrists who relocate to designated northern communities.
$15,000 paid over four years to GP/FPs who relocate to designated southern communities.
$20,000 paid over four years to physician specialists who relocate to designated communities in Northern Ontario plus a $20,000 grant if the specialist provides a
minimum of 12 days of outreach services per year.
$15,000 paid over three years to audiologists, chiropodists, occupational therapists, physiotherapists and speech-language pathologists who relocate to fill full-time,
MOHLTC fully-funded positions in UAP approved vacancies in Northern Ontario.
Community Assessment Visit Program
Provides reimbursement for travel and accommodation expenses within Ontario, for a physician or rehabilitation professional, and spouse, to visit ministry designated
underserviced communities for the purpose of exploring practice opportunities.
Rehab Outreach
To provide rehab outreach clinics in smaller and remote northern communities that have had long standing difficulties recruiting rehab professionals.
Dental Outreach
To provide regularly scheduled dental clinics, of up to three days per month, on an outreach basis to remote communities in Northern Ontario where there is no access to
dental care within 80-kilometre radius.
Physician Outreach
Family physicians provide regularly scheduled primary care outreach clinics to remote communities that have UAP-funded nursing stations. This program also funds
physicians for telephone back-up to the nurse/nurse practitioner working at the nursing station
49
Free Tuition Program
Provides up to $40,000 (or $10,000 per year) to final-year medical students, residents and new physician graduates, in exchange for full-time three or four-year return-ofservice commitment in an eligible underserviced/undersupplied community.
Visiting Specialist Clinic Program
Funds physician specialists to provide medical specialist services on an outreach basis in smaller, and remote Northern Ontario communities where the population base
does not warrant a full-time specialist, or where the recruitment has proved to be difficult.
Psychiatric Outreach Program
Provides clinical service, education, and support to Northern rural or remote communities underserviced in mental health care. The program emphasizes service delivery
and resident training in partnership with all five Ontario university departments of psychiatry.
CNIB Mobile Eye Van
The CNIB - Ontario Medical Mobile Eye Care Unit is a fully equipped medical eye care clinic, which brings professional eye care services to remote communities in
Northern Ontario. The unit has been an integral part of the "Prevention of Blindness" program for both the CNIB and the OMA section on ophthalmology. Northern
communities are visited by the Eye Van between March and November of each year.
Prevention of blindness through early diagnosis of eye disease is the main goal of the program. Educating local medical communities on issues related to eye diseases and
the prevention of blindness is also part of the Eye Van’s goal. The CNIB also provides patient counselling and referral; vision rehabilitation; orientation career
development and guidance; visual technical aids; and CNIB library services.
50
Specialist Locum Program
Provides temporary medical specialists services to designated underserviced communities in Northern Ontario until a permanent physician can be recruited. The program
also provides physicians with exposure to working in a northern community in order to assess their desirability of relocating to the north on a permanent basis. [2009/10
RbP: proposed to be transferred to HealthForceOntario - Marketing and Recruitment Agency (HFO-MRA) - ($5.7M)]
GP Locum Program
Provides temporary GP/FP services to designated underserviced communities in Northern Ontario until a permanent physician can be recruited. The program also
provides physicians with exposure to working in a northern community in order to assess their desirability of relocating to the north on a permanent basis. [2009/10 RbP:
proposed to be transferred to HFO-MRA ($1.0M)]
Nursing Stations
Provides operational funding to 21 Nursing Stations in order for them to render primary care services in rural and northern communities whose population is not able to
support a full-time family physician.
Nurse Practitioner
UAP funds and administers 81 NP positions across the province in order to improve access to primary health care services. [2009/10 RbP: proposed to be transferred to
CHC program ($1.56195M)]
Northern Ontario Health Professional Development
NOHP-Dev provides professional support, especially to rehabilitation practitioners working in northern underserviced areas as a means of promoting retention. NOHP is
a component of Northern Academic Health Science Network (NAHSN) which is designed to address northern recruitment and retention of physicians and other health
professionals from high school to career practice.
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Annual Health Professional Recruitment Tour
Co-sponsored by MOHLTC and MNDM, the annual tour enables underserviced communities and organizations to market themselves to current and future health care professionals
by providing information about practice, lifestyle and employment opportunities in their communities. This tour visits the province’s five Academic health science centres for a oneweek duration in September. It also includes an educational program to help communities in the recruitment and retention of physicians. The Tour is organized and administered by
PAIRO.
Tuition Support for Nurses
Offers tuition reimbursement to recent nursing graduates from rural and remote communities who are new College of Nurses of Ontario registrants and who choose to do a return-ofservice in an eligible underserviced community. The program is open to NPs, RNs and RPNs who have recently graduated from a Canadian University or College.
Resident Placement
Funded through UAP, but coordinated in partnership with PAIRO to help medical residents better understand the career opportunities available in the province and to select those
positions that best meet personal and professional needs.
From “Rural and northern health care framework/plan: Stage 1 report-Final report,” by Government of Ontario, 2008, pp. 69-84. Copyright 2008 by Queen’s Printer for Ontario.
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