By: Kirsten Pavelich, PT and Denise Taylor, PT
Out the airplane window, the scenery shifted from long finger-like lakes running parallel through stretches of boreal forest, to deep blue lines of rivers winding through marshland. The students and Kirsten took up five of six seats on the small propeller plane heading to Sandy Lake First Nation, a host community for part of the Community Rehabilitation Worker training program. Mesh straps separated the group from the cargo section behind them – filled with supplies to support the program. As the plane descended, the roads and buildings along Sandy Lake came into view before touching down on the gravel runway.
The Community Rehabilitation Worker (CRW) program serves Treaties 5 and 9, which cover two-thirds of Ontario and are home to approximately 45,000 people in 49 communities. These are the traditional lands of the Ojibwe, Oji-Cree, and Cree peoples. Sandy Lake First Nation is on Treaty 5 lands, in the far north of the province, close to the Manitoba border.
Like many Northern Indigenous communities, Sandy Lake can only be accessed by road for a short period in the winter when the ice on the waterways is thick enough to drive on. Many essential supplies are shipped into communities only in the winter. In communities with year-round road access, like North Caribou Lake First Nation, it can take up to 10 hours to get to an urban centre. Travelling out of the community is expensive and time-consuming, but when it comes to accessing services, including specialized healthcare and rehabilitation, travel out of the community is a necessity.
The CRW program is a recent initiative, based on need. Statistics Canada reports that the First Nations, Métis and Inuit populations 65 years of age and older could more than double by 2036, and Indigenous seniors aged 75+ are 45-55% more frail than the average senior in Ontario.
While some communities have access to a physiotherapist who may visit up to once a month, essential rehabilitation programs are simply not available. Indigenous people must travel to urban communities where they may experience a sense of isolation, cultural and language barriers, and incidents of systemic and individual racism. Some choose to forgo out-of-town rehabilitation altogether. A lack of access to care puts Indigenous Elders at greater risk of frailty and compromised health, making it more challenging to stay in their home community as they age.
In 2017, the Northwest region identified significant gaps in rehabilitative services throughout remote Indigenous communities, and a need to focus on preventative, and rehabilitative self-management programming to support healthy aging to reduce chronic disease. In her role as the North West Regional Rehabilitative Care Program Manager, Denise worked with partners to start to tackle this gap in access to rehabilitation. Based on an initial needs assessment and literary review, four communities, along with three Indigenous health organizations, three rehabilitation health organizations, and two academic institutions, obtained funding to develop and evaluate the CRW program in Northwestern Ontario. The CRW project team included Health Directors from each of the First Nations and was guided by an Advisory Committee, which included an Elder from each First Nation throughout the project.
The program trains local CRWs, familiar with local languages and cultures, to provide rehabilitative services in their own communities to help Elders as they age, while supporting their health, wellbeing, and quality of life. The program builds local capacity, supports culturally safe care, supports the Truth and Reconciliation Calls to Action (specifically 19 and 23) and the United Nations Declaration on the Rights of Indigenous Peoples, and affirms the rights to self determination. It’s a big project with a lot of partners, a lot of moving parts, and the potential to make a big difference.
When Kirsten and the team visited Sandy Lake for the CRW training program, they brought nine cases of water. Like many remote northern communities, Sandy Lake is under a boil water advisory, and has been for more than 20 years.
The week in Sandy Lake was full of learning, problem solving, camaraderie and adventures. The team set up in the empty church turned classroom, with pews for seats around the fold out table and a white sheet on the wall for the projector.
Six students worked with Kirsten to make sure everything went smoothly – from setting up the Wi-Fi, to finding a space heater and extension cord, to pooling together personal hand sanitizers because the bathroom sink had no running water. Someone found a wheelchair in a closet that the team used to practice transfers outside. By the end of the week, everyone was tired, full of new knowledge and experience from the week, and feeling like part of a community.
Community plays a big role in the success of the program. CRWs are identified as eligible for participation in the program by the Health Director in their community, rather than applying directly. CRWs are trained in rehabilitation principles and skills to support Elders and Home and Community Care (HCC) clients. They are employed as members of the local HCC team.
CRWs often see their clients twice a week, developing trusting relationships with them, and optimizing their ability to quickly identify changes to clients’ wellbeing. CRWs work closely with physiotherapists and other rehabilitation professionals who visit the community or provide virtual care, as well as healthcare staff at their Home and Community Care office. They may find themselves supporting clients with their exercise programs, installing bathroom equipment, helping a client get outside, transporting clients to community events, monitoring a client’s blood pressure or oxygen saturation, ensuring that a client with diabetes has appropriate footwear, and communicating with other healthcare providers.
The in-person portions of the CRW program are led by a rehabilitation professional and a local Elder, who grounds the material in real life experiences and local culture. Each week of training includes a half day dedicated to language re-vitalization and culture, guided by the students and the Elder. There’s a lot of discussion and hands-on practice, and students complete assignments and participate in supervised clinical practice in the homecare setting.
The students bring many strengths to the program – lived experience, resourcefulness, resilience, hard work, support for their fellow students, and a full understanding of the culture and how things work in their community, which helps reduce barriers to care.
After the first group of students graduated in November 2022, the program was evaluated to understand it’s impact and opportunities for growth. Interviews, focus groups and conversations with Elders in the communities help the collaborative planning group identify the local impact of the program.
The first graduating class of CRWs has stayed in touch and shared their questions, struggles, and successes. “I wish they had this program five years ago,” says one CRW named Margaret. “On a personal note, my mother was paralyzed from a stroke, and she did have an exercise program from St. Joe’s [hospital], but there was nobody to help her continue her exercises at home [in Sandy Lake]. So, I’m glad this program is ongoing... I’m working here now, to help people get motivated.”
The CRWs are eager for the next training session to run so the group can continue to grow. Ten communities in Treaties 5 and 9 are ready to participate in the program, which would graduate 20 more CRWs. The collaborative planning group is currently in the process of applying to different funding streams for the program.
For more information about the Community Rehabilitation Worker Program, contact: Denise Taylor, Manager North West Regional Rehabilitative Care Program, St. Joseph’s Care Group
Denise.taylor@tbh.net, rrcp.sjcg.net
We are all treaty people. If you care about equitable access to healthcare, there are things you can do. First, identify what you need to learn. Did anything in this article surprise you or leave you with more questions? Resources from Indigenous people and organizations are a great place to start. Here are some you might want to check out, but there are many more:
The First Nations Principles of OCAP (Ownership, Control, Access, and Possession)
Indigenous Health Resources: Canadian Physiotherapy Association Global Health Division
Read the TRC Calls to Action for healthcare and follow their progress with websites like Indigenous Watchdog.