Introduction
This chapter provides a very brief and highly selective picture of some of the landscape of multidisciplinary family services in Ontario with a view to providing a context for the vision of layering on low-level legal services to a multidisciplinary family services delivery model. The discussion is divided into three main sections. The first section identifies some basic features of multidisciplinary family service delivery models and provides some general reasons for why they should be utilized. The second section reviews the history of Community Health Centres in Ontario, which pioneered in the province multidisciplinary family service delivery. The third section reviews the very recent innovations in early learning and early childhood education (ECE) in Ontario. The two types of sites for multidisciplinary family services described in this chapter – health-oriented and ECE-oriented – are promising illustrations of the potential for realizing the vision of multidisciplinary paths to family justice in Ontario.
Reasons for Multidisciplinary Family Services Teams
In a multidisciplinary service delivery team, different professionals with distinct skill sets provide services holistically whilst respecting professional boundaries and roles. This sort of multidisciplinary team operates through a division of labour that corresponds to professional expertise. It allows professionals from different fields – physicians, nurses, teachers, social workers, lawyers, early childhood educators, family mediators – to work collaboratively in teams focused on the multi-dimensional needs of families without transgressing the their own professional boundaries. Individuals who join these multidisciplinary teams retain their own identity as an expert in a given profession and bring that perspective to bear on the challenges that are facing the team.
A multidisciplinary service model should be distinguished from service delivery models where each member of the team performs tasks that blend into the tasks of others without rigorous role differentiation. There are some examples of the latter type of delivery model in Ontario, for instance, some of the shelters for victims of domestic violence operate in this way as do some of the shelters for the homeless. These teams are effective and well suited for some areas of social service delivery. The focus throughout this paper, however, is on multidisciplinary family services delivery models.
The principal rationale for the establishment of multidisciplinary family services teams are the needs of the clients or families being serviced by these teams, as opposed to the needs of the professionals providing these services.[8] Often, the challenges and problems facing Ontario’s families are neither simple nor one-dimensional. Employment issues may bleed into problems paying the rent or create health problems. Marital problems at home may affect educational achievements at school. Domestic violence might affect relationships with otherwise supportive extended family. As others have noted, when families are in crisis, they experience clusters of problems, problems that are different in nature but interrelated.[9] Multidisciplinary teams of professionals create a problem-solving space that allows for the collaboration of individuals with diverse skill sets and multiple perspectives to address these clusters of problems. The single most compelling reason for multidisciplinary family services teams is precisely that they reflect the complexity of the family problems they are designed to address.
These teams also have the capacity to respond to the cause and effect dynamics of family needs in ways that are proactive. In this way, by addressing problems earlier or indeed preventing new problems from emerging, these teams can result in considerable cost savings. Moreover, because the family is not dealing with a series of individual professionals but rather a team working together, it is less likely that the remedies and solutions will overlap and be redundant.
Another reason for multidisciplinary family services teams is that they make it easier for families to access services. Instead of telling their stories again and again and shuttling from one place to another, these sorts of teams offer families in Ontario a one-stop facility that they can rely on to identify their needs and address them.
In practice, effective multidisciplinary family services teams are characterized by two common features. One feature is some sort of co-location of the different team members. The sharing of physical space or some sort of central space combined with satellite spaces enable collaboration among professionals in ways that are rarer when geographical boundaries exist. Numerous individuals reported to us the value of informal interactions in the lunch room or over coffee. Others emphasized the ease of following up referrals to other professionals when it simply involved walking a client down a corridor to someone else’s office.
The second feature is the manner in which the services provided by the multidisciplinary team are expanded. Teams predominantly layer on more services by adding on programs, which are lead by professionals with the appropriate expertise. In this respect, multidisciplinary delivery models involve a series of programs. Effective teams are ones that integrate these programs into a mosaic rather than a mere patchwork.
Community Health Centres in Ontario
Community Health Centres in Ontario date back to the 1970s. At present, there are 74 Community Health Centres in the province.[10] These centres utilize the broad definition of health offered by the World Health Organization (WHO):
Health is the extent to which an individual or group is able, on one hand, to realize aspirations and satisfy needs; and, on the other hand, to change or cope with the environment. Health is therefore seen as a resource for everyday life, not the objective of living; it is a positive concept emphasizing social and personal resources, as well as physical capacity.[11]
The basic mandate of the Community Health Centres is to provide primary health care. However, because of their commitment to the WHO’s definition of health, the understanding of what constitutes primary health care and how it should be delivered makes Community Health Centres distinctive within Ontario’s health care delivery system.
The Association of Ontario Health Centres identifies the following as basic principles that inform its approach to primary health care:
“Effective primary health care must address the determinants of health, including shelter, education, food, income, a stable eco-system, sustainable resources, social justice, equity and peace. It therefore encompasses primary care, illness prevention, health promotion, health education, community development, social action, building healthy public policy, and creating supportive environments.”
Community governance ensures that the health of a community is enhanced by providing leadership through effective partnerships of individuals and community and the staff of health centres. Community governance allows the skills, expertise, knowledge, and life experience of all partners to be shared to contribute to the health of their community.
[Multidisciplinary] teams of health professionals are the most effective and efficient means for providing quality services in an appropriate manner. These multidisciplinary teams include physicians, nurse practitioners, nurses, dieticians, health promoters, counsellors and other staff and volunteers who contribute to the health of the community.[12]
Community Health Centres receive their basic funding from the Ministry of Health and do not bill OHIP on a fee-for-service basis.
Although Community Health Centres began in the mid-1970s, they remained experimental until the early 1980s. They remained controversial among medical professionals until a decade ago for three principal reasons.[13] One reason is that the idea of delivery of primary health care through a multidisciplinary team ran counter to the dominant ethos of the family doctor as a sole practitioner. There were concerns about the sharing of information, patient confidentiality, and the patient-physician relationship.
The second reason is that Community Health Centres introduced the practice of paying salaries to physicians to provide primary health care services as opposed to fee-for-service payment. However, because so few physicians were employed in the centres in the early years, this form of payment had very little impact on the broader provision of primary health care in the province, which relied on individual practitioners providing fee-for-service delivery. It is however difficult to develop an accurate billing scheme for multidisciplinary primary health care services.
The third reason is that the governance structure of Community Health Centres threatens the professional autonomy of individual physicians. The administrators who run the centres are perceived to have ultimate decision making powers that can override the judgements and decisions that physicians might make about their patient’s care.
In response to these concerns, the Community Health Centres developed standards for the professionals working on their multidisciplinary teams that for the most part exceed the standards set by the regulatory bodies for the professions. The result is that these teams are characterized by corresponding role differentiation among professionals working on these teams. In other words, this sort of professional role differentiation developed in Community Health Centres because of the resistance to the centres within the medical profession and in particular the Ontario Medical Association.
Although the Ministry of Health funds directly the primary health care services provided by Community Health Services, these centres typically receive significant funding from other sources in order to provide other programs. For example, virtually all of the centres in Ontario offer the Healthy Babies Healthy Children program and the Pre-Natal Nutrition program funded by the Federal Government through its Community Action Program for Children (CAPC).
Within Ontario’s health care system, the especially distinctive function Community Health Centres fulfill is the provision of primary health care for marginal or vulnerable groups. A clear illustration of this pertains to the provision of primary health care for individuals and families who lack legal residency status. For these individuals and families, the Ontario Health Insurance Plan (OHIP) does not provide coverage. Fee-for-service delivery requires all individuals to present an OHIP number for billing. Community Health Centres do not bill OHIP on a fee-for-service basis and thus do not require OHIP numbers from their patients. In the case of one Community Health Centre in the Greater Toronto Area, it was reported to us that more than fifty percent of its patients lack legal residency status.
The Early Years Learning Initiative in Ontario
Over the past decade, the Government of Ontario has sought to become a leader internationally in the development of a multidisciplinary family services model that focuses on early years learning. The focal point for this initiative is the establishment of a new continuum of services for children from the early years to the end of elementary school. As Charles Pascal – the principal architect of the early years learning initiative in Ontario – describes it, the goal is, “for a seamless and integrated system to support children from 0 to 12 years old and their families.”[14] Much of the policy development has concentrated on children to the age of 8 and their families.
This initiative challenges what Pascal calls, “the historic divide between education and childcare.”[15] This divide is a reflection of legislation, funding, and delivery structures. Traditionally, for example, kindergarten in Ontario is part of the public school system, regulated by the Education Act, and funded by the Ministry of Education through property taxes. Kindergarten is taught by university-educated teachers certified by the Ontario College of Teachers. Day care and preschool, in contrast, is overwhelmingly delivered through private providers, paid for by parents with some public subsidies, and regulated by the Day Nurseries Act. Traditionally, workers in daycares and preschools have had a patchwork of qualifications. In 2008, the Ontario College of Early Childhood Educators was established, which began to require that daycare and preschool workers be certified as early childhood educators.
The model for the delivery of the early years learning initiative is a multidisciplinary professional team. As we saw in the previous chapter, Pascal imagines different professionals working together on a co-located site delivering services that families need. In this model, rather than having kindergarten teachers siloed in public schools and early childhood educators in daycares it is envisioned that certified teachers and registered early childhood educators will collaborate to provide a learning environment that reflects their knowledge of early childhood development and an effective parent engagement strategy. Layered on to this model will be community nurses, public health physicians, social workers, nutritionists, psychologists, and speech therapists, all bringing to the team their own particular set of professional skills.
Three distinct stages of the early learning initiative in Ontario can be distinguished. The first stage was the introduction of the Ontario Early Years Centres (OEYC) in 2002.[16] In these universally accessible drop-in centres, children up to the age of six and their parents/caregivers, can take part in a variety of programs and activities. They are staffed with people who have a range of expertise in child development. This includes early years professionals and volunteers. Parents/caregivers can talk to the staff and get answers to their questions, and find out information about programs and services they can access in their community. The centres offer several programs that include: early learning and literacy; early childhood development; pregnancy and parenting; links to other early years and outreach activities. There are 107 Early Years Centres in Ontario, one in each riding of the provincial legislature, that service all families including those living in rural or northern areas. Many of the centres also have satellite sites and mobile programs to better serve people in their own communities. The centres are open different hours and are designed to meet the needs of all children. They are also linked to child and family health and social services to help serve the needs of families better. Staff can refer parents to these other services as needed. These centres are designed to give children the best start in life. The early years are crucial to a child’s development and they set the stage for learning, behaviour and health. The OEYC receive their funding from the Government of Ontario and provide their services free of charge to families.
The second stage of the early learning initiative, which begins in September 2010, is the opening of all day kindergartens at 580 public schools across the province.[17] These schools were chosen based on several criteria including local need, space availability and the impact on existing child care. This initiative is part of Ontario’s plan to build a well-educated workforce and a stronger school system. Full-day learning for four and five year olds will be phased in until full implementation in 2015-16. It will improve children’s skills and better prepare them for the transition to Grade 1. The main idea is that for children in kindergarten, they will have a seamless day where daycare and school are not a separate experience. Teachers and Early Childhood Educators will work together during the school day. Extended day programs, before and after school, will be run by Early Childhood Educators. Other professionals will provide services that meet the needs of individual children.
The third stage, which is still in development, is for the province to establish a network of Best Start Child and Family Centres. These centres are envisioned to each house a wide range of existing family services under one management: Ontario Early Years Centre, Parenting and Family Literacy Centre, Healthy Babies Healthy Children, Early Screening and Intervention, Preschool Speech and Language, Child Care Special Needs Resourcing, and the Prenatal Nutrition Program. Other programs, like Aboriginal Head Start, could also be housed in the Best Start Child and Family Centre. Pascal states that,
The Best Start Child and Family Centres will provide:
· prenatal and postnatal information and support;
· home visiting;
· child and family playgroups;
· family literacy, information, and supports;
· full-time, part-time, and occasional early learning/care for children up to 4 years old;
· food and nutrition counselling programs;
· early identification and intervention resources and links to specialized treatment services;
· links to community resources such as libraries, recreation and community centres, health services, family counselling, employment training, settlement services, and housing.[18]
These centres could provide a more family friendly environment for other services delivered by agencies and specialized professionals such as Behaviour Management Programs. The Best Start Child and Family Centres offer, in Pascal’s view, “a strong foundation on which to build a comprehensive, integrated child and family service system that will become a model for other jurisdictions.”[19] From the perspective of this paper, given the comprehensive character of the Best Start Child and Family Centres that Pascal projects, it is notable that community legal services are not included. It is our suggestion that adding those legal services is an important piece of a comprehensive multidisciplinary family services model.
Conclusion
The general point of this chapter has been to provide a broader context for thinking about multidisciplinary family services in Ontario. The particular focus on community health centres and the early learning initiative has been strategic in the sense that they both provide sites where it is not difficult to imagine layering on early and multiple access points to legal services for families facing legal challenges or legal problems. And in this way suggests possibilities for realizing the vision of multidisciplinary paths to family justice.
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