Final emerging primary health care strategy for ontario july 23 2012

Emerging Primary Health Care Strategy For Ontario A Discussion Paper

July 2012

This is a draft discussion paper prepared by the Association of Ontario Health Centres designed to contribute to the ongoing discussion about revitalizing primary health care in Ontario.

We hope the ideas and innovations we recommend encourage dialogue. We welcome feedback from AOHC members, partners and primary health care decision-makers, academics and policy makers. Please send your feedback to Jacquie Maund, Policy and Government Relations Lead: jacquie@aohc.org The Association of Ontario Health Centres (AOHC) is the voice of community-governed primary health care. AOHC members provide primary health care in communities across Ontario through 122 Community Health Centres (CHC), Aboriginal Health Access Centres (AHAC), Community Family Health Teams (CFHT), and Nurse Practitioner-led Clinics (NPLC).

I.

INTRODUCTION

This past year has featured much discussion and debate about the future of Ontario’s health care system with many stakeholders releasing position papers that offer ideas for positive change. This discussion paper reflects the Association of Ontario Health Centre’s (AOHC) contribution to this ongoing dialogue.

Our specific focus is primary care and how to develop a strong primary care delivery model within a primary health care frameworki. Many of our recommendations build on Ontario’s Action Plan for Health Care (2012) and the five Strengthening Primary Care reports (2011) commissioned by the MOHLTC. We have also incorporated input from the AHAC/CHC Executive Director Network as well as the CFHT Executive Director Network. It is also important to note that the content is very closely aligned with AOHC’s new strategic plan for 2012-2015.

We thank everyone who has contributed to date and look forward to engaging with other health care partners and decision makers about the ideas and innovations we propose. It is our firm belief that by working together, we can achieve a revitalized primary health care system for Ontario ---a system that supports health and well-being for all.

An important note: this paper does not address the full scope of primary health care related to health and well-being of individuals, families and communities and only marginally addresses the social determinants of health. A future report, with detailed recommendations on how to develop a comprehensive community health strategy within a primary health care framework will soon be released to cover this ground.

II.

A STRONG VISION FOR PRIMARY HEALTH CARE IN ONTARIO

Primary health care must be the foundation of a high performing health care system. Given the current fragmented state of the primary care ‘non-system’, this is an ambitious but not unreachable goal.

To begin to reach this goal, Ontario needs a strong Primary Health Care vision to drive the development of a Primary Health Care Strategy.

Without a clear vision and supporting strategy, there is no roadmap for change – and more importantly the LHINs will not have a common understanding on how to fulfil their new role to plan primary health care in their region.

As stewards of the health care system, MOHLTC must lead the development of this vision and strategy in partnership with the LHINs and with the leadership of primary health care.

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Key Elements of a bold Primary Health Care Vision: A bold primary health care vision must:   



 

III.

support the best possible health and well-being for everyone living in Ontario with a focus on reducing health inequities; be people-and community-centred, designed around the needs of the individuals and communities being served; build towards a future in which individuals, families and communities are served by, and are able to actively participate in, trusted healthcare systems that respond to people’s and communities’ needs in coordinated and comprehensive ways; shift emphasis from solely treating illness to promoting a complete state of physical, mental and social well-being with a strong emphasis on health promotion, early detection and disease prevention; focus on addressing the root causes of illness and injury by addressing the social determinants of health; and contribute towards an efficient and sustainable people-centered health system.

THE BEGINNING OF THE TRANSFORMATION

While it may take some time to articulate a clear primary health care vision and strategy for Ontario, we believe there are some actions that can be implemented immediately that will begin the transformation of the primary health care system in an evolutionary way.

Most of these key elements and actions are consistent with the recommendations in the Strengthening Primary Care reports which indicate that there is already significant support among primary health care leaders, academics and policy leadersii. CHCs, AHACs and CFHTs are willing partners to implement these key elements.

Key Elements for a Primary Health Care Strategy: 1.

A population needs based and health equity planning approach.  According to the Health Disparities Task Group of the Federal/Provincial/Territorial Advisory Committee, lowest income groups use the health care system twice as much as higher income Canadiansiii. For these reasons, a primary health care strategy must target lowincome Ontarians.  This plan should include a province wide Aboriginal and Francophone strategy and three integrated regional sub-plans: northern remote; southern rural; and urban with a focus on new immigrants and racialized communities.  The result should be a mix of models to meet the diverse needs of communities.

2.

A commitment to interprofessional team Primary Health Care Organizations (PHCOs) as the models of the future for all Ontarians.  A ten year plan should be developed to migrate all Ontarians from fee- for -service models to interprofessional PHCOsiv. The Ontario College of Family Physicians in their report Vision 2020 stated that all Ontarians should have access to multidisciplinary teams by 2020v.

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3.

A direction to LHINs to develop a network of PHCOs with a plan to ensure everyone has access to the appropriate mix of models pending the needs of the community. The PHCOs should be mandated to work in partnership to provide co-ordinated and specialty services (e.g. psychiatric services, diabetes education).  The MOHLTC to direct the LHINs to conduct a needs-based analysis by sub-LHIN to capture the unique attributes of communities, and then map this data against current models of primary care to determine the appropriate fit and the gaps. A plan should be developed to ensure the appropriate PHCO model is implemented to meet the needs of the communities.  The MOHLTC to establish a provincial target that 22% of Ontarians facing the greatest barriers to accessing care are prioritized in any resource allocationvi. These include: people living in poverty, Aboriginal populations, Francophone populations, new immigrants and refugees, racialized groups, rural and remote populations, people with chronic complex care needs, lesbian, gay, bisexual and transgendered (LGBT) Ontarians, and people with physical and mental disabilities/limitations.  Future resource allocation should be informed by this equity-oriented planning approach, with a focus on strategies to address the needs of populations who most lack access to care: the medically complex; the 1% who use the system the most; and those communities with high poverty levels.  Immediately announce more community governed primary health care models in communities where the need is clearly proven and none exist (e.g. Richmond Hill, Thornhill, Markham and Mississauga).  The MOHLTC to reaffirm the mandates of CHCs and AHACs to address the needs of populations facing barriers to access. Many CFHTs are already serving clients with barriers and are willing to expand their mandate.

4.

A strong and accountable primary care governance model under the authority of the LHINs to oversee planning, development and delivery of services.  In order to plan the full health care system, the LHINs must be responsible for planning and implementing primary care services within a provincially mandated primary care vision and strategy.  However, primary care as the foundation of the health care system must have its own strong primary care governance model. Primary care governance must not be under the direction of the hospitals and must not be incorporated into large regional omnibus health care entities.  AOHC and its members are open to discussing options for primary care governance models including regional networks of PHCOs. However, any primary care governance models must include the following principles: o Be accountable to the community it serves. o Ensure the appropriate mix of models is informed by population needs based planning and health equity, and be open to transforming from current fragmented provider models to an appropriate mix of models that meet the needs of the communities.  Appropriate governance models must be developed for the Aboriginal and Francophone populations in Ontario.  The CFHT ED Network has agreed in principle to begin discussions as early as possible to transfer from the MOHLTC to the LHINs as early adopters. AHACs are also prepared to consider transferring to the LHINs once their operational base funding issues have been addressed and stabilized and there is a guarantee for Aboriginal governance. They already

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sign accountability agreements with the LHINs for community support and/or mental health funding.

5.

A commitment to community-governed primary health care models.  Increased access to community–governed primary health care models should be strongly considered by the MOHLTC and the LHINs as they develop their primary health care plans.  PHCOs must identify and respond to the changing needs of the communities they serve. We believe this can be optimally achieved through primary health care organizations that are community-governed with accountability to and dialogue with the community.  CHCs, AHACs and CFHTs are very experienced in community governance. Community members have a voice through representation on the board of directors, advisory committees, and community engagement processes. They set strategic directions for the development of programs and services that reflect community needs.  The recent ICES report noted that community engagement is one of the possible factors why CHCs have lower than expected Emergency Department visitsvii.

6.

A mandate that all PHCOs are required to provide system navigation and care coordination for their clients – including as they transition in and out of other parts of the health, community and social service systems.  The role of system navigation, care coordination and case management should not be embedded in one organization or one person. Every organization should ensure that clients receive the care they need. For example, if someone has a complex medical situation, an RN may be well positioned for the role. If a person faces complex social issues, a health promoter or social worker may be better suited. If the person has a trusting relationship with a mental health worker in supportive housing this may be the best person to ensure they get the services they need.  The breadth of system navigation, case management and care coordination provided for CHC and AHAC clients far exceed the health system, expanding to include access to social services, food, OHIP cards, immigrant services, employment, education, housing and other services.  System navigation/care coordination/case management for the people and communities they serve is already a required mandate for CHCs and AHACs. CHCs report that they fulfill this role, especially outside the health care system. Information management systems need to be improved to enable better care coordination with the health care system.  AOHC is committed to working with the CHCs, AHACs and CFHTs to measure how well they are doing system navigation and care coordination and to set benchmarks for improvement.  CHCs, AHACs and CFHTs do not generally rely on CCACs to do system navigation or case management for their clients. They utilize Community Care Access Centres (CCACs) to access services under the mandate of CCACs.  CCACs are not set up to meet the complex social, cultural and medical needs of clients from birth to death and do not perform the breadth of system navigation with social services, education and other services that are required by socially complex clients.  As PHCOs increasingly have the capacity to fulfill their full mandate and have the information management systems for system navigation and case management, the current responsibilities of CCACs for this role should be reviewed.

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7.

A requirement that all interprofessional teams work to full scope of practice.  A study should be conducted to determine the appropriate mix and ratio of interprofessional teams in PHCOs if everyone worked to full scope of practice. The mix and ratio would vary depending on the people served by the Primary Health Care Team. AOHC is very interested in participating in such a study.  Depending on the specific needs of the community being served, these teams should be equipped to address the social and environmental determinants of health. For example, community development workers should be part of interprofessional teams in low income neighbourhoods.

8.

A requirement that PHCOs provide extended hours, implement advanced access, and provide 24/7 coverage whenever possible.  Extended hour coverage should immediately require three hours of after hour care per physician and NP per week.  PHCOs should also work in partnership to provide 24 hour 7 days per week coverage wherever possible. Unique solutions would need to be negotiated in some rural and remote areas.  Bench marks for 3rd next available appointment or appointment of choice should be established as a measure of timely access.

9.

Immediately legislate PHCOs under the Excellent Care for All Act.  A performance measurement framework for primary health care should be developed in alignment with Health Quality Ontario’s attributes of a high performing health system.  PHCO sector-wide stretch quality improvement targets should be established and benchmarked.  PHCOs should be required to be accredited.  PHCOs should be required to have clear mechanisms for patient/client grievances and complaints that include open and transparent reporting to the public for accountability.

10.

Mandate PHCOs to sign accountability agreements with the LHINs. Key elements of this agreement should require PHCOs to:  provide comprehensive, high-quality, equitable, timely, and continuous services and programs that are evidence-informed, anti-oppressive, culturally competent and appropriate;  ensure all members of the interprofessional team are working to full scope of practice;  ensure system navigation and care coordination across the health and social continuum; and  provide advanced access and extended hours.

Implementing these key strategic directions will lead to significant transformation in Ontario’s primary health care system.

AOHC urges the MOHLTC and the LHINs to start with willing partners who are ready to be early adopters – including CHCs, AHACs, and CFHTs. The required changes are transformational in nature, but can be introduced in an evolutionary way. By implementing these strategic directions, over time Ontario’s primary health care system will truly become the foundation of the health care system. It will also lead to better health, better value and better care for all Ontarians as well as increased sustainability of our health care system July 23, 2012

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III.

COMMITMENTS BY COMMUNITY HEALTH CENTRES (CHCs), ABORIGINAL HEALTH ACCESS CENTRES (AHACs) AND COMMUNITY FAMILY HEALTH TEAMS (CFHTs)

CHCs, AHACs and CFHTs have committed to moving forward on several key platforms in the Minister’s 2012 Action Planviii. The AHAC and CHC ED Network established sector wide commitments that are in alignment with the Minister’s Action Plan and where CHCs and AHACs felt they were well positioned to address system problems. CFHT Executive Directors have made similar commitments. Individual CHCs, AHACs and CFHTs may rank these commitments in different orders depending on their individual circumstances and on regional and LHIN priorities.

These commitments are in the context that CHCs and AHACs work with vulnerable and complex populations including: Aboriginal, Francophone, people living in poverty, complex mental health, homeless, rural and remote areas, seniors, LGBT, new immigrants, racialized communities, people with disabilities and other priority populations as identified by the community they serve. CFHTs also work with some of these same populations.

1.

To expand the number of people CHCs, AHACs and CFHTs serve in their community with a focus on the 22% of the population with the highest barriers to health care. a. Individual CHCs are reviewing their clients to see who they are serving and to ensure new clients include the most vulnerable in their communities. b. AOHC is completing a provincial population needs based study with a focus on the 22% of the population who most need services, including Aboriginal, Francophone, low income, racialized, new immigrants and those with disability under the age of 65. The study examines Ontario from five population segments: Aboriginal, Francophone, northern remote, rural and urban. The findings are divided by sub-LHINix.

2.

To commit to work with the health care system to identify and serve the “1%” of the population who represent the truly complex and expensive cases as identified in the Drummond report. a. CHCs are examining their client lists to determine if any of their clients are falling into the 1% category and to provide wrap around services to address the issues. b. CHCs are committed to work with partners in hospitals and CCACs to identify the 1% in their communities and to provide primary health care services for these clients. A preliminary review of a few CHCs has indicated that they can accept more high need clients without additional services. If the numbers are large then additional resources would be required. c. AOHC has approached ICES to understand the profile of the 1% population in order to determine if CHC, AHAC and CFHT services are already preventing people from falling into the 1%. (i.e. avoidance of use of the system through effective PHC)

3.

To continue to work with partners in community support and mental health and addictions to review and coordinate services and reduce duplication. a. At the local level there are many examples of CHCs working with partners to provide peopleand community-centered care. These extend well beyond the services funded through the LHINs and include social and immigrant services, child support, justice, and supportive housing, to name a few.

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b. Through Community Health Ontario, AOHC, Ontario Federation of Community Mental Health and Addictions Programs (OFCMHAP) and Ontario Community Support Association (OCSA) have received funding from the Trillium Foundation to enhance these discussions at the local and provincial levels.

4.

To ensure all members of the interprofessional teams are working to full scope of practice. a. RNAO released its report on full scope of practice for RNs and RPNsx. AOHC is committed to working with these role descriptions and to conduct a base line review of the status of RNs and RPNs working to full scope in CHCs, AHACs and CFHTs. AOHC will work with our members over the next three years to ensure all RNs and RPNs work to full scope. b. RNs and RPNs are only a part of the interprofessional teams and this same review will occur with all members of the team.

5.

To ensure all clients receive system navigation and care coordination across the health and social services systems. a. System navigation and care coordination is inherent in the models of care for CHCs and AHACs. System navigation goes well beyond the health system and includes many other agencies and resources that address the root causes of an illness (e.g. low income, lack of housing, lack of employment, etc). Most CHCs and AHACs report that they are generally doing a good job but this has never been measured. b. AOHC is working with all our members, in consultation with academics and other decision makers, to determine a common definition and metric for system navigation and care coordination. Phase II will include a base line study with our members to measure current status, establish benchmarks and set targets for quality improvement.

6.

To implement advanced access and extended hours. a. CHCs are already required to provide the minimum of 3 hours per NP/Physician. Some CHCs are looking at extended hours beyond the minimum. b. 33 CHCs, 3 AHACs and several CFHTs have participated in the Office Efficiency Waves at Health Quality Ontario. The remaining members are being encouraged to participate in future Waves. c. AOHC is conducting a baseline review of all members to determine the current status of 3rd next available appointment or appointment of choice for clients. d. Many members will set improvement targets for 3rd next available appointment or appointment of choice in their Quality Improvement Plans.

IV.

“VALUE FOR MONEY”

AOHC recognizes that “Value for Money” is very important in this time of financial constraint. Every study where CHCs have been included has indicated that CHCs produce better health outcomes than other primary health care models. (Note: To date AHACs and CFHTs have not been included in studies quoted) Comparison of Models of Primary Care in Ontario: Studies completed at the Elisabeth Bruyère Research Institute found that CHCs outperform other primary health care models in providing a comprehensive approach to health promotion and illness July 23, 2012

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prevention. They provide better chronic disease management, and do a better job in orienting their services to the needs of the communities servedxi. The Bruyère studies reported a limitation that they did not adjust for the complexity of the clients served by CHCs and stated that if they had, the results would have been more marked.

FHT Evaluation: Anecdotal reports of the preliminary five year results of the FHT model evaluation indicate that CHCs are performing favourably in comparison.

ICES Study- Comparison of Primary Care Models in Ontario by Demographics, Case Mix and Emergency Department Use: This ICES study confirmed that CHCs see more complex clients than other primary health care models, and found that these same complex clients use the emergency room less than expectedxii.

This study will be repeated every six months with ICES and will include all our members (CHCs, AHACs, CFHTs and 4 NPLCs). The data set will include: a) Utilization of Emergency departments, readmissions after 30 days and ALC rates. b) More basic demographics, ACG extended Diagnostic Clusters, health status, utilization of services and testing/screening.

See Appendix A for more details.

As a result of these biannual reports, AOHC will be able to describe the clients served, monitor key client outcomes and determine the levels of utilization of the system by clients. The results will be used to determine areas for quality improvement.

The report will also continue to answer the question of “value for money”. With this data AOHC will be able to determine the effectiveness of the CHC, AHACs, CFHT and NPLC models of care in reducing avoidable use of the more expensive part of the health care system.

V.

INTEGRATION

CHCs, AHACs and CFHTs are committed to an integrated and coordinated health care system that provides people and community centered care. It is an attribute in the CHC Model of Care, and sustainability and efficiency of the health system are outcomes captured within the CHC Results Based Logic Modelxiii.

There are 73 CHCs, 10 AHACs and 25 CFHTs in the province. In 2004-05, the Liberal Government announced 21 new CHCs and 22 satellites. These new CHCs have been leaders in developing partnership with existing services to ensure no duplication. They have also developed hubs and colocations where possible.

In 2010, AOHC commissioned KPMG to do a study on the extent of integration in CHCs, entitled System Integration and Community Health Centresxiv. The summary of the key findings are:

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  

CHCs integrate services to benefit the client through increasing access, breaking down barriers to health and assisting with navigating the health and social systems.

CHCs are to a large extent actively involved in pursuing and implementing integration initiatives such as coordinating services, co-locating and, in a few cases, amalgamating or merging services.

CHCs are health system leaders in reaching out to non-health sector partners for integration initiatives (e.g. public health, municipalities and universities);

Because the focus of CHCs is on addressing the social determinants of health, most of the integrations were with providers and partners outside the health care system. The report found that CHCs needed to better connect with the rest of the health care system.

AOHC and its members know that there is room for improvement. It means continuing to find efficiencies among and with other primary care partners, community support agencies, mental health and addiction partners and with other service providers to ensure clients receive coordinated care for the services they need.

Ontario Community Support Association (OCSA), Ontario Federation of Community Mental Health and Addictions Programs (OFCMHAP) and AOHC have received Trillium funding to continue to explore value based integration at the local, regional and provincial level.

However, often in integration discussions, governance and structural integration become the focus. As stated earlier in this discussion paper, AOHC and its members do not support the structural integration of primary care models under the governance of hospitals or into one regional omnibus health care entity. If primary care is to become the foundation of the health care system, then primary care needs to develop strong primary care governance models.

VI.

CONCLUSION

The MOHLTC as steward of the health care system needs to set a clear vision for primary health care as the foundation of the health care system and to clearly articulate strategic directions to get there. The MOHLTC also needs to restate their commitment to community-governed primary health care models as key players in a revitalized primary health care system.

Specifically AOHC and our members are asking that the Ministry: 1. Articulate a clear vision, common set of principles and strategic directions for strengthened primary health care that will guide the LHINs in the planning and accountability of primary health care.

2. Mandate the LHINs to develop a population needs based primary health care plan that leads to an appropriate mix of interprofessional primary health care models to meet the diverse needs of the people in their communities.

3. Direct the LHINs to work with all primary health care organizations including CHCs, AHACs, CFHTs and NPLCS as key players in the development of a strong network of primary health care models.

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4. Develop governance models for primary care that are not under the governance of hospitals or regional omnibus health entities.

CHCs, AHACs and CFHTs are willing partners to develop a robust people and community centered primary health care system. We are eager to be early adopters and to set stretch goals through a quality improvement approach. We have already begun this journey and look forward to working with MOHLTC, LHINs and other decision makers on making this vision a reality.

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Appendix A: Data Elements for ICES bi-annual report for CHCs, AHACs and participating CFHTs and NPLCs Domain Basic Demographics

Information provided in Complexity of Care Report (2012) Age 0-18, 19-44, 45-64, 65+

Additional Information provided in new ICES Report (every six months) Age (0-4, 5-9, 10-18, 19-34,35-49, 50-64,65-74,75-84, 85+)

Sex Socioeconomic status (income quintiles) Recent OHIP registration % of clients on OW, ODB and Low income seniors Case mix (RUB, SAMI)

Health Status (based on 2 years)

Utilization of Services

RIO Band ICES Validated Cohorts (asthma, diabetes, COPD, mental health, Standardized ACG*Morbidity Index (SAMI) – unadjusted (measures health of the population SAMI (age and sex adjusted) – for assessing changes or differences in population health across time, geographies and settings – controlling for differences in the age and sex composition of the populations ED visits – Urgent (CTAS 1,2) Intermediate (CTAS 3) Less Urgent (CTAS 4, 5 and not admitted) Ambulatory care sensitive hospital admissions (overall) making use of the definition of ambulatory care sensitive conditions that OHQC and CIHI used

Profile of ACG Extended Diagnostic Clusters (useful for examining the epidemiology of disease within a population). Eg. Identifying a group of clients for inclusion in a targeted disease management group

ED visits -rate per population of total ED visits and of ED visits with a triage score (CTAS score) of 4 or 5 (less urgent clients) Ambulatory care sensitive hospital admissions (overall) making use of the definition of ambulatory care sensitive conditions that POWER used - rate per population Hospital admissions by condition (diabetes, asthma, COPD, CHF) rate per population Hospital readmissions within 30 days (total) and one year (total) - rate of readmissions per admissions

Testing/Screening

Specialist visits (overall and by selected specialties )  Proportion of clients with a specialist visit and rate of specialist visits Patients with diabetes:  HbA1C within the past 12 months - percent with at least 2 tests  Retinal examination within the past 24 months percent with at least 1 exam years  LDL cholesterol within the past 12 months - percent with at least one test  ACE or AARB - over the age of 65 only – percent prescribed Women:  

Pap smear within the past three years (age 20-69) Mammogram within the past two years (age 50-69)

Both Sexes: 

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FOBT within the past 2 years OR colonoscopy within the past 5 years (age 50-74)

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i

Primary Care “… is that level of a health services system that provides entry into the system for all new needs and problems, provides person-focused (not disease-oriented) care over time, provides care for all but very uncommon or unusual conditions, and coordinates or integrates care, regardless of where the care is delivered and who provides it”. Source: John Hopkins Primary Care Policy Centre. Definitions.

Baltimore: Johns Hopkins Bloomberg School of Public Health.

Primary Health Care as defined by the World Health Organization (WHO) is essential health care made universally accessible to individuals and families in the community by means acceptable to them, through their full participation and at a cost that the community and country can afford. It forms an integral part both of the country’s health system of which it is the nucleus and of the overall social and economic development of the community. Source: WHO. Primary Health Care: Report of the International Conference on Primary Health Care, September 1978 ii

See http://www.trilliumresearchday.com/documents/2012_PHPG_Overview%20of%20Process%20and%20R ecommendations_Final.pdf iii

Federal/Provincial/Territorial Advisory Committee on Population Health and Health Security, Health Disparities Task Force (2004). Reducing Health Disparities – Roles of the Health Sector: Recommended Policy Directions and Activities. www.phac-aspc.gc.ca iv

In this document Primary Health Care Organizations (PHCO) means organizations with interprofessional teams, including AHACs, CHCs, CFHTs, FHTs, NPLCs. v

Ontario College of Family Physicians. Vision 2020: Raising the Bar in Family Medicine and Ontario’s Primary Care Sector. January 2011. vi

A study by Steps to Equity commissioned by AOHC has identified 22% of Ontarians with barriers to accessing health care. The report, “Towards Closing the Gap in Equity in Access to Community-based Primary Health Care”, will be released in fall 2012. vii

ICES Investigative Report March 2012 see www.aohc.org/index.php?ci_id=9467&la_id=1

viii

4 NPLCs are members of AOHC. We will be meeting with member NPLCs to determine commitments to these priorities. ix

Steps to Equity, forthcoming report.

x

RNAO. Primary Solutions for Maximizing and Expanding the Role of the Primary Care Nurse in Ontario.

June 2012. xi

See for example, www.openmedicine.ca/article/view/233

xii

See www.aohc.org/index.php?ci_id=9467&la_id=1

xiii

Available from AOHC upon request.

xiv

See www.aohc.org/index.php?ci_id=3114&la_id=1

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