Community Health Centre Partnerships
Some midwifery practices have established formal partnerships with CHCs, which entail writing a Memorandum of Understanding (MOU) with the CHC. These MOUs state the nature of the referral relationships and the responsibilities of the midwives and the CHC.
There are several models by which midwifery practice groups can establish partnerships with local CHCs:
Reciprocal Referral Model
All pregnant people who are patients of the CHC are referred to midwives. In the case where a client is already a patient of the CHC, they are referred to a midwife for the duration of the pregnancy, intrapartum and postpartum care. At six weeks postpartum, the midwife discharges the client and baby back to the CHC. This “reciprocal referral” model produces a seamless process of client care for both the CHC and midwifery practices. Clients who are already in CHC care have access to the midwifery model of care and are taken back into care at the CHC when midwifery care is finished.
In this arrangement, the CHC will refer clients to the midwifery clinic. CHC offers clients choice of which practitioner they want to see. For many clients in CHC care, they already have an established relationship with caregivers at the CHC. Hence, they may find the idea of having a known care provider for most of their pregnancy more appealing than going to a midwife for their care. The number of referrals from the CHC can be sporadic; as a result, this can made caseload planning more difficult for a midwifery practice. For CHCs that are taking new patients, any uninsured clients or clients who do not have a primary care provider who are taken into care by the midwifery practice are also taken into care by the CHC. As a result, clients must go to the CHC and have an appointment with the designated provider (e.g. intake worker, nurse practitioner, or family physician). Clients who only want midwifery care may see this as an additional burden—additional appointments, additional travel time, additional people to see etc. However, most clients see this step as beneficial as it also allows them to have access to care for other needs and have a long-term provider when they are discharged from midwifery care.
Ad Hoc CHC Referral
There are several Ontario CHCs that refer clients to midwifery practices on an ad-hoc basis. In these cases there are no Memorandums of Understanding in place. The biggest challenge with this model is there is no established flow of patient referrals, so the system does not allow for effective caseload planning for the midwifery practice. In addition, such clients are often taken in later into care and so their accommodation at the practice is contingent on whether or not the midwifery practice has vacancy.
Midwifery Clinic within CHC
In this model, a practice was established and funded in partnership with a CHC. This practice functions out of the CHC, much like an independent midwifery practice funded by the TPA. However, they are physically in the same space and all low risk pregnant clients are seen by midwives at the CHC. The practice partners perform all administrative work, including booking of appointments and lab collection. The practice's caseload encompasses CHC referrals of all low-risk pregnant clients and community referrals. This arrangement may pose a challenge for a larger practice or a practice that wants to grow since the midwifery clinic space is limited by the physical space available at the CHC.
Midwives Conduct Clinic Visits at CHC
Midwives from a practice in the community hold a weekly clinic at a CHC where nurse practitioners and other providers are very knowledgeable and supportive of midwifery. The CHC serves a community with a very large pregnant population. This model is extremely beneficial to clients as they can receive midwifery care at the CHC, a centre with familiar services and providers. As well, all CHC services are available to midwifery clients, including interpretation, social work, and settlement. After discharge from midwifery care the CHC takes on clients in its catchment area who do not have a primary care provider. The midwives who work at the CHC take all clients from the CHC and then fill up any spaces in caseload from their midwifery practice's wait list. Their combined caseload requires close administrative cooperation between the CHC and the practice. One barrier to this model is it relies significantly on effective administration collaboration between the CHC and midwifery practice and personal commitment of midwives to attend to clients at multiple clinic locations.