1. Rural & Remote PRACTICE Manitoba
Physician Assistant Opportunities in Primary
& Acute Care

2. OBJECTIVES Why now? Challenges Demographic Issues Key Health Issues
*DM, HTN, TB, ID, CKD…
NRHA
Population and Community Demographics in the NRHA
Local Health Care Resources and Breakdown
Comparison
What can we offer
Considerations/Input/Discussions
Highlights

3. Why Now? 5 years of physician assistant presence
Currently participating in roles including:
Emergency Care
Acute Care (inpatient and outpatient)
Surgical Assist
Primary Care
Rural/Remote Fill In
Leaf Rapids, Lynn Lake, Flin Flon, Gillam, Snow Lake
Administrative Process

4. Why Now? Increasing familiarity
Patients and staff are engaging in dialogues more
Recognizing that we can gather information and stream line communication and formulate treatment plans with less distraction
Improved continuity
Diagnostics, treatment plans, documentation are high calibre.

5. Challenges Health care is highly politicized internally
Communities are highly politicized
Social and historical context
Resource paucity - materials, staff, skills and transience of staff and populations

6. Demographic Issues Remoteness and Isolation Jurisdictional Education
Unemployment
Income Inequality
Government transfers
Families
Housing
Healthy foods
Transportation and community infrastructure

7. Key Health Issues Chronic disease prevention and treatment
Disparity in Health Status
Maternal Infant and Child Health
Injury, Premature Death and Life Expectancy
Youth Health
Communicable Disease Prevention
Accessibility and Effectiveness
Health System Utilization
Social Determinants of Health

8. HEalth care challenges
Chronic Disease DM
HTN
Vasc Dx
CKD
Infectious Disease -
MRSA TB
Antibiotic overuse

9. Diabetes, HTN, Vascular disease
Poor glycemic control & uncontrolled HTN very common
Significant complications and end-organ disease associated with the above.
Tremendous impact on quality of life.
Poor access to primary care physicians allows disease states to evolve over years
Causes considerable stress for individuals, communities and those that care for them.
Amplified by a disorganized approach to health care
Confusion, frustration limits ability for self advocacy
Often under estimate the value of care they get and could potentially access.

10. INFECTIOUS Disease - MRSA
Normalization of MRSA in northern communities
Emergence early 2000’s, by rates 10x higher than southern MB
By x higher
Heavily influenced by policies and practices that are racist
Downstream = Access to timely & adequate care and relationships with health care works (accessibility, consistency, reliability)
Upstream = water and sewage, over-crowding, ownership, education
Polices that have attempted to address these concerns: UNDRIP, TRC, Jordans Principle

11. MRSA
Limited studies about MRSA in northern communities with respect to HA and CA; colonization vs symptomatic
Estimated that 1/30 are affected
Strain of MRSA has specific virulence factors that contribute to tissue necrosis
Predominant clinical presentation is with skin and soft tissue infections; secondary are sepsis and necrotizing pneumonia

12. INfectious disease - MRSA

13. TB in Manitoba Twice the national average
Canada 4.9/100,000 & is improving; vs,
MB 12.8/100,000 & getting worse
First Nations are more affected, those in remote communities even more so; but.. this has been a more recent trend
in 2000: rates of TB were almost equivocal between First Nations, Canadian-borne residents, and immigrants
Since then, the latter two groups have both improved, while First Nations communities have not (from 41% in 2000 to 61% 2012)
Remote communities are particularly affected within the NRHA - rates are 7 x higher
rate was 300/100,000 (from 10 communities in the NRHA) - astronomical by epidemiological standards
In Wpg the rate of pulmonary TB is higher than Calgary, Saskatoon, Regina and Edmonton combined
Wpg rates are 158 x higher than these cities

14. NRHA 60% of Manitobas land mass 396,000 square kilometres
Population of 74,983
Population density
NRHA 0.19
Winnipeg

15. Population Demographics
Census Population
CITIES
POP.
COMMUNITIES
Thompson
13,678
Norway House
5360
Wabowden
442
Flin Flon
5,185
Cross Lake
4643
Gods Lake Narrows 89
TOWN
Nelson House
5089
Pikwitonei 64
The Pas
5369
Opaskwayak Cree Nation
3034
Thicket Portage
126
Gillam
1265
Split Lake
2945
South Indian Lake
981
Snow Lake
2662
Oxford House
2559
Ilford
106
Leaf Rapids
582
Pukatawagon
1724
Bakers Narrows
Lynn Lake
494
York Landing
1239
Cranberry Portage
771
Grand Rapids
268
Lac Brochet
1134
Wanless
(RM) Kelsey (Flin Flon)
2492
Shamattawa
1425
Cormorant
244
Tadoule
772
Sherridon
108
Brochet
789
Moose Lake
1124
Gods River
643

16. Local Health RESOURCES
CITIES
POP.
COMMUNITIES
Thompson (13678) H
Norway House (5369)
Wabowden (442) HC
Flin Flon (5185)
Cross Lake (4643) NS
Gods Lake Narrows (89)
TOWN
Nelson House (5089)
Pikwitonei (64)
The Pas (5369)
Opaskwayak Cree Nation (3034)
Thicket Portage (126)
Gillam (1265)
Split Lake (2945)
South Indian Lake (981)
Snow Lake (2662)
Oxford House (2559)
Ilford (106)
Leaf Rapids (582)
Pukatawagon (1724)
Bakers Narrows
Lynn Lake (494)
York Landing (1239)
Cranberry Portage (771)
Grand Rapids (268)
Lac Brochet (1134)
Wanless
(RM) Kelsey (Flin Flon) (2492)
NOT RHA
Shamattawa (1425)
Cormorant (244)
Tadoule (772)
Sherridon (108)
Brochet (789)
Moose Lake (1124)
Gods River (643)
HOSPITALS (H) NURSING STATIONS (NS) - 17+
HEALTH CENTERS (HC) - 8

17. BREAKDOWN OF LOCAL RESOURCES
HOSPITALS
THOMPSON
FLIN FLON/THE PAS
Gillam
Lynn Lake
COMMUNITY HOSPITALS
NORWAY HOUSE
NURSING STATIONS (23)
HEALTH CENTERS (9)

18. Breakdown of local resources/Barriers
Physician presence (potentially only 1 week/month)
Barriers to referrals, acceptance to tertiary care
Limited onsite pharmaceuticals from pain management, anti-microbial
Multiple jurisdictions and organizations involved in policies
PICC management
long term antibiotics (e.g. Vancomycin)
excessive displacement for patients from home communities
Telephone consultation (volume in ED)

19. Comparison (updated numbers still pending)
THOMPSON/FLIN FLON/PAS
SEVEN OAKS
CATCHEMENT
74983
75553
ED VOLUME
~35000
45000
ED BED
e.g. clinics for IV/Cast 36
INPATIENT BED
40/42/21 (103)
304
SCU/ICU
3/1
OBS
18/#/1
PACU
10/0/8 19

20. WHAT CAN WE OFFER?
Improve access to primary care services that has more financial sustainability.
Help promote effective utilization of services and formulate an organized approach to healthcare.
Acute care and interventions.
Infant, child, youth, maternal and elder health issues.
Chronic disease prevention and management.
Improve referral process and specialist care.

21. CONSIDERATIONS… PGY TRAINING CURRICULUMS Interventions/specialization
Familiarization with available technology - e.g. XR
Contact points (onsite physicians/remote physician contact)
Financial sustainability
INPUT? DISCUSSION? IDEAS? INTERESTS?

22. Highlights Health Care across the lifespan
Infants, children, adolescents, adults, seniors
Interdisciplinary
Complex Case Management
Fishing, kayaking, hiking, endless boreal forests
Complete 4 monthly EMRAPs simply by driving to Winnipeg and back.

23. further information
5th Estate - “This is where I live” - Mental Health Crisis in Cross Lake
N’we Jinan - nonprofit organization that brings a mobile recording studio into schools and community centres across North America. Youth are able to express themselves musically and creatively under the guidance of a professional music producer.
Night Spirits - Book about the survival of the Sayisi Dene following the forced relocation to Churchill and their subsequent personally initiated move to Tadoule Lake in the 1970s told by survivors

24. References
Northern Regional Health Authority. (2017). Annual Report 2016/2017. Retrieved from 17_NRHA_Annual_Report_(Final).pdf
Northern Regional Health Authority. (2014). Community Health Assessment Retrieved from
Welch, M. A. (2014). TB rates of aboriginals soar. Chiefs contend provincial report fails to capture the extent of the problem. Retrieved from
Winnipeg Regional Health Authority. (2015). Seven Oaks Community Area Profile, Retrieved from
Statistics Canada. (2016.) Census Profile, 2016 Census. Retrieved from
Walkty, A. & Hoban, D. (2009). DSM Micronotes Clinical Microbiology Discipline Publication: Methicillin Resistant Staphylococcus aureus (MRSA) Retrieved from
Alfa, M., Mhanickam, K. & Simner, P. (2011). DSM Micronotes Clinical Microbiology Discipline Publication: TB in Manitoba. Retrieved from content/uploads/2014/09/MicroNotes pdf
Northern Health Region TB program and partners. (2015). Tuberculosis cases diagnosed in persons using a northern MB shelter. [PowerPoint slides]. Received 06 June 2018.
Isaac, M. & Waruk, J. (2017). MRSA in Northern MB. [PowerPoint slides]. Received 10 October 2017.