Photo Credit: Teckles Photography Inc
Looking at the whole picture
Gina Browne’s research shows how health and social services can work together to improve people’s lives and contain health-care costs.
While working as a family therapist in southern Ontario in the late 1970s, Gina Browne made an observation that would change the focus of her life’s work. While working as a family therapist in southern Ontario in the late 1970s, Gina Browne made an observation that would change the focus of her life’s work.
“I noticed that frequent users of primary care had many more social, emotional and cognitive problems,” says Browne in her distinctive Kentucky drawl. “The ones who kept coming back to our clinic had something else bothering them. I’ve been interested in that ever since.”
The renowned researcher and educator is a native of Louisville. After obtaining a BSN from Catherine Spalding College in Kentucky and an M.Sc. from Boston University, she accepted a position as a lecturer in the school of nursing at McMaster University in Hamilton, Ont., in 1971. She came to Canada, she says, because she saw the potential for a broader scope of nursing practice and had taken some inspiration from the independent lead character on the TV show That Girl.
At the University of Toronto, she completed her M.Ed. and PhD in educational theory and sociology of health. In 1978, she began work as a registered nurse family therapist in the Halton Region, just outside Toronto, and conducted her first research into chronic illness and service utilization at McMaster. A decade later, she founded the Health and Social Service Utilization Research Unit. Browne is the director of the unit, which brings together McMaster researchers and local service agencies in examining and implementing cross-sectoral interventions for vulnerable populations in the region.
The Ontario Association of Community Care Access Centres reported in 2010 that one per cent of the province’s population accounted for 49 per cent of hospital and home care costs, with just five per cent accounting for a whopping 84 per cent of these expenditures.
“The report dramatized a point nurses have known for a long time,” says Browne. “Only a few people use the system frequently. Everybody talks about the effects on the system of the greying tsunami and of people with chronic illnesses, but I think that spin diverts our attention from the costly few.”
“The vast majority of people with chronic illnesses cope and adjust without being high users of health services,” Browne explains. “The repeat users do generally have some kind of organ dysfunction, but the real culprit isn’t heart disease, diabetes or high blood pressure. It’s the challenges of a lifetime of adversity and stress that drive their help-seeking behaviour.”
In Better Care: An Analysis of Nursing and Healthcare System Outcomes, a research synthesis prepared for CNA’s National Expert Commission, Browne and her colleagues highlighted the fact that the small proportion of the population that use a disproportionate amount of health-care services are usually those with chronic illnesses. “But within that group, it is the poor with co-existing mental health and social issues who are the most frequent health-care seekers. These people have lost the ability to problem solve, which requires organization, focus, prioritizing and follow through.”
The report’s recommendations included using proactive nurse-led interdisciplinary community care that focuses on self-management for people with chronic disease. Overall, the research showed that models of nursing interventions that address the various determinants of a person’s health were either more effective and equally or less costly, or equally effective and less costly, than on-demand, episodic, acute models of care.
The problem, says Browne, is that the health system hasn’t adapted to the complexity of what people need. “The policies in place work against change. Often, nothing can happen in emergency departments until the physician sees the patient. Acute exacerbations of chronic illnesses are addressed, but the accompanying mental and social circumstances leading to crises and driving help-seeking behaviour go unaddressed. Other studies and our own work have established that when we take care of these people more completely, repeat hospital visits are significantly reduced.”
Her team’s research on measuring integrated care and the relationship to health outcomes was the first to appear in the published literature. They focused on care teams put together by the Children’s Treatment Network and the 47 agencies in York Region and Simcoe County to serve severely disabled children and their families.
“Everyone likes to say they’re doing integrated care, but no one had been measuring whether it was actually happening. We found that only half the people who were supposed to get integrated care actually received it. The teams — none of which had nurses, by the way — weren’t always caring for the people with the greatest need; they were caring for those who were nicest. However, we saw that when teams actually worked with the more challenging families, the children’s functional outcomes improved significantly.”
“Right now, we have separate silos of funding and fragmented services,” says Browne. “What we need are incentives to encourage more collaboration between health-care and social service interventions, which we have demonstrated do save health-care and crisis-care dollars.” Also required, she says, is a new teaching focus in nursing and medical schools: “less emphasis on anatomy and physiology courses and more on coping strategies such as mindfulness. Otherwise, health-care professionals are just going to keep dealing with the health consequences of stress, having to pull patients out of rivers versus keeping them from being pushed in.”
Browne envisions an integrated “ministry of well-being” in Ontario that would bring together all aspects of human wellness. She is clearly frustrated by the lack of political will to implement that change. “We act like health care is illness care, with half of Ontario’s $48-billion health-care budget going to hospitals. We have policies that are antiquated, that serve personal and professional interests. There’s definitely collusion between some medical associations, elected governments and CEOs of hospitals to perpetuate the expensive status quo.” She continues, “I really believe we need to do things differently, especially for those repeat health-care users. If interdisciplinary teams, led by nurses, served this clientele more completely, we could really help the one per cent who need more than just acute medical care and be able to release funds for better care in the community.”
Although she is proud of her professional successes, Browne points to her sons as her crowning achievements: Joe is studying music at Concordia University, and Dillon, a Vanier Scholar, is enrolled in clinical psychology at the University of Toronto.
Currently on sabbatical, Browne says she is re-evaluating her personal and professional goals and has promised herself “to go where the water takes me.” She finds more time these days to play her piano (a long-time passion) and to relax at her renovated log cabin in Burlington. Browne keeps fit by splitting wood for the cabin’s four fireplaces. She maintains that the competencies required for this task are embedded in leadership principles: going with the grain; avoiding the knots; using a wedge when the knots are unavoidable (“for leverage, two wedges are better than one”); and accepting that the wood is probably old if the bark is falling off it.
Reprinted by permission of the publisher. With gratitude to Canadian Nurse for allowing the publication of their nurse stories and photographs. For more information, including ways to subscribe, please visit canadian-nurse.com/en/contact-us
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