The Interim Board of Health reports having approved the implementation of the Healthy Babies, Healthy Children Program for Toronto.

Purpose:

This report seeks approval of and outlines the critical issues and timelines for implementation of the Healthy Babies, Healthy Children Program, which is a new Ministry of Health, public health initiative program to begin in early 1998. This report is being submitted in tandem to the January 12, 1998, meeting of the Interim Board of Health and the January 15, 1998, meeting of the Community and Neighbourhood Services Committee (the Committee), in order to expedite a Council decision on these matters. The Board of Health=s recommendations will be reported to the Committee and then forwarded to Council for approval.

Funding Sources, Financial Implementations and Impact Statement:

Operating funds for direct service delivery of this new mandatory public health program are 100 percent provincial:

1997/98 $2,611,491 (approved)

1998/99 $3,072,341 (tentative).

Management and other support functions for the program will be absorbed from the current public health budget and staff complement.

Recommendations:

It is recommended that:

(1) the Interim Board of Health:

(a) approve implementation of the Healthy Babies, Healthy Children Program for Toronto;

(b) recommend that the City of Toronto enter into contracts for lay home visitors and public health nurses as set out in this report, so that the program can be properly implemented;

(2) the City of Toronto contract for lay home visiting services with the seven agencies referred to in this report;

(3) Human Resources Department staff work with Healthy Babies, Healthy Children Program managers to recruit and hire lay home visitors and public health nurses as needed to ensure timely start-up of this program;

(4) the contracts referred to in Recommendation No. (2) be satisfactory in form and content to the City Solicitor.

Background:

Overview:

The Healthy Babies, Healthy Children Program is a prevention and early intervention initiative announced in April 1997 (see Appendix A, Mandatory Program, Province of Ontario, draft standard). Funding for program planning and development was flowed to the former six health units beginning October 1997.

This joint Ministry of Health/Ministry of Community and Social Services initiative is designed to screen all families prenatally or at birth, to link families with identified needs with community services, and to provide Alay home visiting services@ for high risk families who would benefit from such services. The provincial Office of Integrated Services for Children is co-ordinating implementation of the program and issued Implementation Guidelines in September 1997. Across the Province, implementation is scheduled for January 2, 1998. An evaluation plan is being developed.

The Implementation Guidelines for the Healthy Babies, Healthy Children Program required that planning for the program be collaborative and that it builds on community resources and existing networks of service providers for families of children prenatal to age six. For Toronto=s planning process, groups were formed both City-wide and in all six former municipalities. Since July 1997, over 250 participants from community agencies, hospitals and municipalities have worked with staff from public health and the Ministry of Community and Social Services, Toronto Area Office, to assess current services for families. Their recommendations about how best to support those families assessed as being Aat risk@ or Ahigh risk@ formed the basis for a comprehensive Implementation Plan submitted to the Province in December 1997. Networks of service providers will continue to meet, to identify gaps in service and to support families in need. To accommodate for amalgamation, the Toronto plan recommended a delayed start date of March 2, 1998.

There are over 44,000 births a year in 14 Toronto hospitals, over 35,000 being to City residents. The goal of the program is to screen each family and, with their consent, to refer those with identified needs to public health. Provincial estimates predict that about 4,000 Toronto families a year will be referred for lay home visiting services. Actual numbers will only be available after implementation (see Appendix B, Estimates of Caseload).

A detailed program budget for the 1997/1998 fiscal year was submitted to the Office of Integrated Services for Children as part of Toronto=s Implementation Plan (see Appendix C, Program Budget Submission). Approval of that budget has not yet been received. However, the total amount to be flowed to the City of Toronto for this fiscal period has been confirmed at $2,611,491.00. Details about funding and budget parameters for the 1998/1999 fiscal year have not yet been received. The Province=s April 1997 estimate of annualized funding for the City of Toronto was $3,072,341.00.

Contracted Services for Lay Home Visiting:

Planning for the provision of lay home visiting services to Toronto families included assessment of and discussion with agencies that currently provide lay home visiting services. The Implementation Plan recommends that lay home visiting services be purchased from seven agencies that currently provide these services in specific geographic areas, and that the new City of Toronto hire lay home visitors for families in other geographic areas of the City. The agencies are all incorporated and currently have some of their funding from the Federal Community Action Program for Children (CAP-C). They are:

- Babies Best Start B Scarborough;

- Better Beginnings Now B Eastern North York;

- Building Brighter Futures B Western North York;

- Community Parent Program B City of York;

- Native Child and Family Services Association B for Aboriginal clients city wide;

- Parents for Better Beginnings B Regent Park, Moss Park; and

- Growing Together B St. James Town.

The terms and conditions of these contracts would be drafted by legal counsel and could be ready for signature by the end of January. These contracted lay home visitor services would be purchased with provincial funds.

Direct Staffing for Lay Home Visits and Assessments:

The Implementation Plan recommends that about 17 lay home visitors be hired by the new City of Toronto to provide services to families who live in areas not serviced by the seven agencies listed above, i.e., former Etobicoke, former East York and large portions of former Toronto. There currently exists a CUPE job classification for lay home visitors in Toronto and new staff would be hired into that job class and wage grade. Job postings have been prepared but advertisement will be postponed until there is approval for these activities.

Public health nurses are required to do a detailed assessment of families referred to the program. Twenty-two additional public health nurse positions are required and would be funded through the program. Public health nurses currently belong to two union groups - CUPE and the Ontario Nurses Association (ONA). The Human Resources Department has committed to provide assistance in the posting and filling of these positions, and union representatives will be consulted in this process.

Discussion:

The timelines for implementation of this program are difficult as they overlap with the first months of the new City administration. Even under current timelines, Toronto families in need will not be assessed and linked to services until March. This is despite substantial pressure from the government for Toronto to implement in January, along with the rest of the Province.

The March start-up date requires Council approval at its February meeting. There are three main issues requiring an early decision, and these are discussed briefly below.

(1) Why should the program be implemented?

Healthy Babies, Healthy Children Program is a mandatory public health program for which there is a substantial need and well-researched evidence of effectiveness from other jurisdictions. The program is designed to support the healthy physical, cognitive and psychosocial development of young children who may be at risk of developmental delays and to assist in the prevention of child abuse. Similar programs in Hawaii and other parts of the U.S. have demonstrated a long-term reduction in school failure and drop-out rates, reduced costs to the child mental health and social services sectors, and reduced rates of child abuse and neglect. While these programs are funded for more intense interventions than is the Ontario program, nevertheless it is clearly a step in the right direction.

Failure to implement the program in a timely fashion would put the Board of Health in breach of its duty to deliver all provincially mandated programs. It would also leave young families in Toronto without assured access to needed supports and services. Failure to implement the program would also cause the Province to withhold new operating funds from the City until start-up could be assured. As well, the Department would still receive referrals from neighbouring jurisdictions that it would have difficulty managing without dedicated staff and financial support.

If implemented, this Program will be the first to be initiated on a City-wide basis with a consistent level of service for all residents of the new City. It will also require public health staff to work with families in ways that differ from most current program initiatives. Support of individual families around breast feeding and parenting issues is provided by most, but not all of the former health departments. Some health departments have been calling and or visiting all first time mothers, while others have not. It is difficult to integrate the Healthy Babies, Healthy Children Program with current services because of this variation in service levels. Therefore, it will be a stand alone program for the first year of implementation until decisions are made about levels of services in other areas. Once these program decisions are made, the program could be integrated with other, similar services.

It should be noted that provincial funding is limited to the costs of direct service delivery, i.e., it does not provide for management support to these additional front-line staff and does not provide for other administrative expenses. Negotiations have begun with the Province regarding the design and possible funding of an information system necessary to support this program.

The Interim Board of Health is urged to approve implementation of this program and to recommend to the Committee and Council that authority to approve the necessary contracts be granted.

(2) How Should Lay Home Visitor Services Be Provided?

Three options were considered for provision of lay home visitor services in Toronto:

(a) Direct employment of all lay home visitors:

The City could hire all 33 lay home visitors and then try to co-ordinate these lay home visitor services with other similar services provided in some parts of the City. This option would duplicate services and create confusion for clients and current lay home visiting agencies.

(b) Contract-out all lay home visitors:

The City could contract out all lay home visiting services to agencies that currently provide similar services and that are willing to expand their services. About one half of the City=s geographic area currently has agencies that provide lay home visiting services for some families in their area. The other half of the City=s geographic area does not have lay home visiting services, and it is not feasible at this time to expand existing contracted services to those areas as well.

(c) Combination of both:

The third option combines options (a) and (b) described above. It is recommended that the City contract out for lay home visiting services for some portions of the City and hire lay home visitors to provide services in other parts of the City. This option will not duplicate current services and will permit programs and agencies to learn from one another as they participate together in Healthy Babies, Healthy Children Program implementation.

The issue of risk management regarding the purchase of contracted lay home visitor services has been raised and discussed with legal counsel. Indemnification and agency insurance coverage clauses will be included in the contracts. The hiring, training and supervision of the lay home visitors will be the responsibility of the contracting agencies.

(3) What are the direct staffing implications?

Management and administrative support for this program is not funded provincially. In the first year of implementation, three managers and two clerks will be reassigned from the current staff complement to the Healthy Babies, Healthy Children Program. Their current positions would remain vacant and their responsibilities redistributed among other staff.

Decisions about how to fill the 22 public health nurse positions funded by the Province for this program have not yet been made. The City=s Human Resources Commissioner has been consulted about the hiring of public health nurses and lay home visitors and will assign a labour relations consultant to assist with the posting and hiring process.

Conclusions:

The Healthy Babies, Healthy Children Program is a new mandatory public health program funded by the Province. It will require screening of all families prenatally or at birth and referral to public health of those families assessed Aat risk@. Public Health is to further assess these families and link them with appropriate services including lay home visitor services.

Toronto=s Implementation Plan includes the hiring of 22 public health nurses and 17 lay home visitors and contracting with seven agencies for lay home visitor services in specific geographic areas. The City=s Human Resources Commissioner is prepared to assist with the posting and hiring process for public health nurses and lay home visitors. Legal counsel is prepared to draft the contracts with lay home visiting agencies.

Implementation of this program in Toronto has been delayed by two months to accommodate for amalgamation. Council approval in February to proceed as recommended will mean that Toronto families will receive the early intervention supports and services they need by March 1998.

In conclusion, it is recommended that the Interim Board of Health approve the Implementation of the Healthy Babies, Healthy Children Program for Toronto and that the City enter into contracts for lay home visiting services and hire lay home visitors and public health nurses to ensure the effective implementation of this program.

Contact Name:

Linda Shortt,

Coordinating Director, Healthy Babies, Healthy Children Program

Tel: (416) 469-8566 Fax: (416) 461-8564

Appendix A

Mandatory Program, Province of Ontario

(draft standard)

Vision:

Every child at-risk (prenatal to age six) in Ontario will be provided with opportunities to achieve his/her optimal potential.

Every child at-risk in Ontario will have access to effective integrated programs and services that support healthy child development.

Principles:

The Healthy Babies, Healthy Children Program will:

Goal and Objectives (Draft):

The following goal and objectives are taken from the draft Public Health Mandatory Health Programs and Services Guidelines. These public health guidelines, which include the legal requirements of boards of health, are currently being revised and, once approved by the Ministry of Health, will be distributed to boards of health.

Goal:

To promote optimal physical, cognitive, communicative, and psychosocial development in children who are at risk.

Objectives:

The attainment of these objectives is linked to the Reproductive Health and Child Health Objectives in the Mandatory Health Programs and Services Guidelines.

Program Components:

The Healthy Babies, Healthy Children Program consists of five components:

Appendix B

Estimates of Caseload

Appendix C

Program Budget Submission