Primary Healthcare

One of the most effective and valuable principles to promote health in all countries has been adoption of Primary Health Care (PHC) as a fundamental strategy. In September 1978, an international conference was held in Alma-Ata, whose great achievement was declaring PHC as a roadmap for “Health for All” by the year 2000 (HFA 2000). Indeed, as a new approach beyond the traditional system of health care, PHC insisted on justice in the delivery and distribution of services in the health sector (1).


HEAVY BURDEN OF DISEASE
Nova Scotia has some of the country's highest rates of cancer, heart disease, diabetes and other chronic diseases.

RISING RATES OF FRAILTY
Nova Scotia has higher rates of frailtythe accumulation of health deficits to the point of extreme vulnerability-than any other province in Canada.

POOR MENTAL HEALTH
One in five people in Nova Scotia has some form of mental illness, affecting their ability to work, care for their family, attend school or otherwise function in daily life.

SOCIAL VULNERABILITY
Nova Scotia has the highest poverty rate in Atlantic Canada and the highest rate of food insecurity in Canada-two factors with major impact on health outcomes.

UNATTACHED PATIENTS
More than 10 per cent of Nova Scotians over the age of 12 lacked a regular health care provider in 2014a percentage researchers believe is rising; meanwhile, the number of providers accepting new patients is declining.
In its initial proposal, CoR PHC set six objectives: 1. bring together researchers from different faculties at Dalhousie University who are already conducting their own primary health care research into a new "primary health care research collaborative" 2. focus researchers' activities on health system decision makers' needs for information to guide them in the positive transformation of primary health care 3. gather  In Nova Scotia, we face a number of converging trends that threaten to overwhelm our health care system.

%
The top 5% of health care users account for nearly two-thirds of health spending in N.S.* q q q q q q Spending on health care services already consumes 40 per cent of Nova Scotia's annual budget. Most of this goes to hospital-based care and physician services, delivered to a relatively small number of people. In fact, a recent study found that 64 per cent* of Nova Scotia's health care spending goes to just 5 per cent of the population-the sickest, most vulnerable members of our communities. Their needs might be served better by community-based services and a variety of providers, integrated more seamlessly with the health care system. Since that time, CoR PHC has expanded to involve more than 40 investigators, from the faculties of Medicine, Dentistry, Health, Science, Computer Science and Arts. Researchers from other universities have also joined in the collaborative, which continues to expand as more new projects take shape. Health system and government leaders, health care professionals who've never been involved in research before, students, patients and interested members of the general public have also joined in.
The fact that so many disciplines, professions and organizations are involved is a core strength of CoR PHC. It allows complex problems to be addressed from all anglesincluding the perspective of patients who, until CoR PHC, had little opportunity to contribute to health care improvement efforts. As a result, research questions are focused on the most relevant issues, with an eye to creating the most practical and effective solutions.

Growth and diversity of CoR PHC
CoR PHC launched in 2013 with just 13 individuals. All of them were academic researchers, representing 3 faculties and 8 disciplines.
Since then, CoR PHC has expanded to involve 40 researchers, representing 6 faculties and 20 disciplines. The researchers now include not only academics, but clinicians, learners, health system managers, government decision-makers, patients and members of the public. This diversity ensures that the research addresses the relevant issues and puts the findings into practice.

Dr. Fred Burge and Dr. Ruth Martin-Misener
NSHA's senior director of Primary Health Care and Chronic Disease Management, Lynn Edwards, says integrated primary health care research efforts are providing the health authority and provincial government with essential data. "We need solid evidence to guide our decision-making as we address the extraordinary health care challenges we face in this province," she says. "Involving our directors and managers as research team members allows us to shape the research agenda to provide the answers we need to address priority issues."

Focus research on decision makers' needs
From the beginning, CoR PHC aimed to ensure that its members' research activities were focused on serving the information needs of decision makers in the health care system.
This strategic decision coincided with other moves to make primary health care research a priority in Nova Scotia. The amalgamation of the province's nine health authorities into a single Nova Scotia Health Authority (NSHA)-with a priority mandate to improve primary health care-created the ideal opening for what has become a highly productive partnership between the university-based research community and the provincial health care system. Creating new research teams -Regular "incubator meetings" bring people together to form new collaborations focused on key issues of common concern.

Leadership connections-Leading
Learning and sharing ideas-Monthly "Brewing Ideas" sessions bring CoR PHC members and learners together to share ideas, solve problems and learn from each other over coffee. The collaborative also hosts events where learners can present a project or thesis, network with mentors and peers, and broaden their knowledge of primary health care research.
Mentorship-Members provide ongoing mentorship to learners, including graduate and undergraduate students, whom they supervise in a large number and variety of projects. Several CoR PHC researchers are mentors in a CIHR strategic training initiative that mentored more than 120 new primary health care researchers in Canada, New Zealand and the United Kingdom.
" There used to be a chasm between policy and research, but not anymore."

-Lynn Edwards
Since the inception of CoR PHC, 24 lead investigators have acquired funding to launch 28 collaborative research projects. These projects span a wide range of high-impact themes, including:

OBESITY AND LIFESTYLE
Addressing the role of excess pregnancy weight gain on offsprings' BMI and future risk of obesity; integrating behavior change interventions; evaluating key aspects of the built environment and their impact on physical activity and overall health

ACCESS TO PRIMARY HEALTH CARE
Mapping access to primary health care across Nova Scotia; understanding the experience of unattached patients; creating a framework for collaborative interprofessional practice

ORAL HEALTH
Providing culturally appropriate population health interventions to improve oral health in First Nations communities

COMPLEX PATIENTS
Assessing case management as a means of improving outcomes among heavy system users with chronic conditions; exploring the meaning of "patient-centred" care for people with multiple chronic conditions

MEDICATION MANAGEMENT
Launching an interprofessional research effort to find ways of reducing unnecessary and potentially risky use of medications (polypharmacy, opioids)

END-OF-LIFE CARE
Educating physicians to initiate advance care planning with seriously ill patients; integrating hospice, respite care, spiritual care and other community-based services with primary health care services provided by family physicians and nurse practitioners; improving the quality of palliative care in the community

MENTAL HEALTH
Increasing capacity of community pharmacists to provide information, advice and referrals to people with mental illness and addictions; exploring rates of child and youth mental health presentations to emergency as a proxy for access to helpful community mental health and primary health care services

EXPANDED ROLE OF PARAMEDICS
Evaluating new role of paramedics in assessing and treating palliative patients at home in a crisis, to reduce unnecessary transports to hospital

SYSTEM ISSUES
Characterizing high system use; understanding regional variations in system use; discussing fairness issues related to primary health care in Nova Scotia

Create useful knowledge Taking men's mental health head on
"Headstrong-taking things head-on" takes advantage of pharmacists' knowledge of medications and their street-level location to connect with men about mental health.
"Research shows men are less likely to seek help for mental health problems, but more likely to commit suicide, than women," says CoR PHC member Dr. Andrea Murphy, associate professor in Dalhousie's College of Pharmacy. As Headstrong's lead investigator, she's working with community pharmacists across Nova Scotia to see if men will be willing to talk to their pharmacist about depression, anxiety, insomnia, problems with alcohol and drugs, or suicidal thoughts and feelings.
Funded by the Movember Foundation, Headstrong uses displays in pharmacies to encourage men to talk to their pharmacist. It's also educating pharmacists to provide the best-possible information, guidance and support to the men who seek help.

Intelligent approaches to frailty
CoR PHC members are developing and testing assessment tools, practice guidelines and IT solutions to help health professionals identify when patients are frail and determine what kinds of interventions and approaches will be the most help.
"As people become frail, they're more vulnerable to sudden declines in their health," says one of the researchers, Melissa Buckler, Central Zone's project manager for Nova Scotia Health Authority's frailty strategy. "In advanced stages of frailty, interventions such as surgery can do more harm than good." The researchers aim to make frailty screening part of routine primary care, and to integrate information about a patient's frailty status and health care decisions into a central electronic record where professionals in every part of the health care system can see it.
"We want to avoid potentially harmful interventions and empower patients and professionals to have open discussions about frailty," Buckler says. "Proactive approaches will keep people healthier longer."

Empowering self-management
Half of all Canadians now live with one or more chronic conditions. "It requires skill, knowledge and confidence to manage everyday life with a chronic disease," says CoR PHC member Dr. Tanya Packer, a professor in Dalhousie's Faculty of Health. "Without them, people end up at the walk-in clinic or emergency department." Dr. Packer and her team are exploring how best to empower patients: "We've been interviewing Canadians, asking, 'what are you doing to manage your symptoms and control your disease, to be healthy and manage your day? What will help you manage better?'" They're using the input to develop computerized tools to provide patients with customized information, connect them to resources, and help them assess their state and course-correct-or know when it's time to get to their provider. "We want people to feel that they are in the driver's seat," Dr. Packer says, "so they can make the healthiest decisions day-to-day." Dr. Tanya  BRIC NS is part of projects that have received a combined total of nearly $4 million from CIHR. These funds were secured thanks to matching funds provided by non-federal sources. To date, 67 per cent of BRIC NS-led projects have successfully secured the requested funding from CIHR.
CIHR continues to offer tens of millions of dollars in funding to the SPOR PIHCI networks-but with stringent requirements for matching funds from local sources. Like CoR PHC, BRIC NS projects must secure matching commitments from other funding agencies and philanthropic organizations in order to receive CIHR SPOR PIHCI funding. BRIC NS welcomes such collaboration and support in its efforts to advance primary health care in Nova Scotia.
In 2017, CoR PHC responded to Dalhousie Medical School's "Wave" process, a competition to identify its leading research teams and strategic research priorities.
Recognizing the critical importance of primary health care to the health and wellbeing of Maritimers, the medical school identified this research area as high priority. In the process, CoR PHC became part of a larger Wave research group known as the Health Priorities Cluster.
The Wave adjudicators named the Health Priorities Cluster a "Wave 2" team, which means it has the potential to become internationally competitive within three to five years.
The Health Priorities Cluster brings together a diverse array of research groups in collaborative primary health care, frailty and aging, pain and back pain, emergency medical services, musculoskeletal health, and child and youth health. Although these groups address a great variety of very different health issues, there are strong common interests and themes that can be aligned to address pressing issues in population health and health services delivery.

Leading researchers
Dalhousie University researchers have been on the forefront of primary health care research in Canada for more than 20 years. We are recognized internationally for the quality and impact of our work.

Strong odds for success in funding competitions
Funding requirements for many of the large-scale collaborative grant programs are very stringent, resulting in a small pool of competitors and high chance of success. Almost all BRIC NS projects supported with local matching funds have succeeded in national funding competitions, for example. In the current research environment, CoR-PHC and BRIC NS researchers are well-positioned to continue their successful grant capture-provided they have local matching funds to support their applications.

Meaningful real-world impact
CoR PHC involves researchers, clinicians, policymakers, health system administrators and patients. This ensures the research is relevant to patients' and clinicians' concerns, while also being scientifically sound and practically feasible. This approach ensures that research results, when applied, will produce tangible improvements in practices, systems, outcomes and health.

Aimed at top priorities
CoR PHC researchers work hand-in-hand with the Nova Scotia Health Authority and Nova Scotia Department of Health and Wellness to shape a research agenda that addresses the most pressing patient and health system priorities-in particular, the need to improve access to high-quality care for people with (or at risk of developing) complex chronic health conditions.

Double your donation
Depending on the project and program, there is a good chance that your contribution to the research will be doubled.