Despite the fact that health care in Canada is universal, marginalized populations such as refugees and immigrants continue to face barriers to accessing health-care services. Barriers may include: low educational level, language, low socioeconomic status, cultural differences, discrimination (e.g. race, sex, ethnicity and religion), geography, mental and physical disabilities and more.
Many provinces in Canada recognize that navigation is a key component of an integrated system for cancer care. In 2012, the “Person-Centered Cancer Care Initiative” aimed to enhance the delivery of cancer care by supporting the implementation of navigation programs in all provinces and one territory and services are still expanding. In its guide, the Canadian Partnership Against Cancer (CPAC) highlighted the benefits of navigator programs in bridging cultures to achieve equity of access to health services, increasing efficiency of delivery of care and enhancing the patient experience.
What benefits should we expect outside of health care?
This is a difficult question to answer with certainty but it seems very likely that if resources are dedicated to removing barriers and helping newcomers navigate Canadian institutions, complex organizations — whatever they are — should expect more successful outcomes.
Canadian cities should anticipate that, with help, newcomers will better understand and make use of city services like transit, libraries, parks, recreation, arts and culture. Newcomers are likely to better understand bylaws, licensing and permits and, thus, be more compliant. This reduces conflict and demand on other city services.
Provinces may find that newcomers will better understand driving regulations and licensing, increasing mobility and safety for their families.
Community police programs like >Crime Stoppers may be better understood and utilized, helping to protect newcomers from unscrupulous fraudsters.
Children arriving from very different education systems are more likely to be enrolled with the most suitable board of education, in the proper grade.
Navigator program development toolkit
This toolkit is designed to help you assess the need, design, implement and evaluate a navigator program with the best chance of reducing the disparities and improving the outcomes of refugees and other newcomers arriving at your organization.
It provides tools, information and links to resources that will be useful in developing a navigator program. While this toolkit contains many tools and resources specific to navigation in health care, it is designed so that much of the guidance and many of the resources will be relevant to navigation outside of health care.
Should your organization have a navigator program? A five-step decision tool
The decision to add a navigator program to your organization is an important one. There will need to be staff training, budgets, support materials, accountability, performance evaluation and more. The following five questions will help you conduct a general needs assessment for a newcomer navigator program in your organization.
1. Problem analysis
The initial steps in the needs assessment are to identify the problem the navigator program will help you solve, to deepen your understanding of that problem, and identify the resources that will help you solve it. You should be able to clearly answer the following:
What is the immigrant population served by my organization?
In the early part of 2016, 4,088 Syrians settled in Toronto. Compared to Toronto’s population of 6.4 million people, this number is small, however Toronto organizations may still need specialized help serving these new Canadians. A general service offered by the City of Toronto in a particular neighbourhood, may serve a high percentage of immigrants who do not speak English nor French.
What services does your organization offer to newcomers?
Are your services something that newcomers are likely to rely on? Public health-care institutions can expect heavy uptake from immigrants arriving from locations with little or no access to health care.
What is the rate of client flow through your organization?
It is essential to know the number of newcomers served by your organization per day, week, month and year. How many clients were seen in the previous year? Know the number of no-shows for appointments, lost clients for follow-ups, and complex clients with multiple needs. Calculate the percentage of clients who are illiterate and cannot speak English nor French to ensure you have the proper resources to meet their needs.
What are the barriers to obtaining your services?
Navigators help clients overcome a variety of barriers related to: logistics, finances, communication, education, employment, linguistics, service coordination, psychosocial challenges, and cultural, religious and spiritual issues. Because of the wide range of barriers that newcomers face, it is crucial to support clients and identify individual barriers and customize solutions.
Are there already resources available to address these barriers?
Once you have identified barriers, carefully check available resources — both within and outside your organization — to help address these barriers. Make a list of all organizations that provide the needed supportive services. Contact them to learn what they are offering and who is eligible to receive them.
What are the gaps that remain which a navigator program can fill?
The service delivery process must be examined to identify gaps and identify ways that the navigator can address them. To enhance and streamline service delivery, while avoiding overlap with any other member of the team.
Calculate the cost of implementing a program and assess the availability of continuous funding. Possible expenses include:
Interpreter services, including telephone interpreter services for as many languages as needed
3. Organizational and process analysis
No matter how small the population you are serving, you will need to coordinate and plan with appropriate departments and support staff. Your navigator will build trust and clout in your organization by providing valuable, expert information where needed. Over time, the navigator will become an important internal resource for helpful, informative content.
The navigator will need to know your organization’s administrative procedures (e.g. appointment scheduling, referrals, application forms, timelines, information communication, consultations, payments)
Creating new processes might be required to accommodate implementation of your navigator program
4. Internal and external resource mapping
Every organization is different, you will need to consider:
Existing resources in your organization
A stakeholder needs assessment to identify who will be impacted by the program, their needs and priorities
Developing a community resource directory, what is available outside your organization but close at hand
Promotion of the navigator program by means such as posters, broadcast news, social media and newspapers
5. Accountability of your navigator program
Your navigator program should have a system for data collection and analysis. This will enable:
Qualitative and quantitative analysis of the value of the program services
Support for senior management decision making through collected data that reflects navigation effects, problems solved, client satisfaction and persistent barriers
Pressed by the urgent need, the early weeks in 2016 were essentially a problem analysis. A multi-disciplinary hospital-based committee was formed to look at the needs of the refugees.
Based on their cumulative knowledge of refugee health combined with their experiences with the refugees to date, the committee supported the concept of a navigator for these vulnerable children.
The role would go beyond merely sorting out interpretation services and coordinating care within the hospital walls. They began to think proactively, to build relationships with agencies in the community, like family medicine clinics and settlement agencies. They began to consider everything they could think of to both help newcomers access CHEO services and how CHEO could help community service providers.
A literature review and reach out to an Aboriginal Peoples cultural navigator led to a job description. The group’s preference was someone who understood the hospital and spoke Arabic. Some children might need coordination of their assessments by several disciplines like orthopedics, endocrinology and infectious diseases. As such, the navigator preferably would be someone intimately familiar with CHEO’s various departments.
After building a business case, money was secured from CHEO’s administration to fund a newcomer navigator position for one month while they assessed the true impact of the refugees and to determine whether a refugee navigator would help. Administration reached out to the Ministry of Health and Long-Term Care to reimburse this short-term commitment for additional support for interpretation and navigation services. [See step two of the five-step decision tool]
Suelana Taha, the patient services clerk who was coincidentally in the Emergency Department on January 6 when the crush began, applied and was offered the position. Taha started as the CHEO newcomer navigator on Monday, March 7, 2016.
“For the first two weeks I followed Gerardo everywhere he went,” Taha says. “He taught me everything he could as quickly as he could.”
Taha began to build simple internal resources. She created a 10-page binder for the Emergency Department that listed the most critical Arabic words, written phonetically in English, to simplify basic communication and triage. The binder also included a pain-location diagram of the human body and a pain scale, labelled in English and Arabic, to facilitate description of symptoms.She learned about policies and procedures in the hospital that might help these new Syrian-Canadians. [See step three of the five-step decision tool] She assisted setting up a one-time dental screening clinic for the refugee children with health issues (many of whom had significant dental decay due to lack of regular access to running water) by having on-site interpretation, having the community arrange group transportation, diversionary activities for the children and on-going support for the parents. With the assistance of the team at Healthy Smiles Ontario, the dental clinic at CHEO was able to facilitate and assist more than 15 children who had advanced dental-care issues.
Taha worked particularly closely with the Multicultural Health Navigator Program implemented by the Somerset West Community Centre. She worked identify any gaps and challenges in the continuum of the health care and respond better to the needs the Syrian refugees. This program delivered community services in the community like referring clients to health-care providers, paying home visits, referring clients to various organizations, educating clients about the Canadian health-care system and advocating for the needs of refugees.
In doing so, she was able to orient CHEO’s partners to her new role, gain a better understanding of available resources for this vulnerable population, as well as assist community providers in navigating the hospital’s services. [See step four of the five-step decision tool]
CHEO also set about developing a way to evaluate what intuitively was felt to be tremendously important work. [See step five of the five-step decision tool] The CHEO Decision Support Department’s mission is to turn data into information useful for informed decision making. Patient health records, for instance, can be examined for information like how many of the refugees were coming to the Emergency inappropriately, missing appointments or having long length of admissions as compared to more typical patients. CHEO also developed an experience survey in Arabic and English for the families to provide direct feedback on their perceptions of the care experience. This is the sort of information that the Patient Experience team is now looking at to determine exactly where Taha’s work makes the biggest difference.