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Rama Nurse Public Policy

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public policy development for caring chronic diseases

public policy development for caring chronic diseases

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  • ผาสุก พงษ์ไพจิตร (2536) แบ่งคนชั้นกลางเป็น 4 กลุ่มคือ (1) นักวิชาชีพผู้จัดการ ผู้บริหาร (2) กลุ่มพี่น้อง (3) คนงาน คอปกขาวระดับล่าง (4) นักคิดและนักวิชาการ

Rama Nurse Public Policy Rama Nurse Public Policy Presentation Transcript

  • Public Policy and Health Policy
    นพ.ชูชัย ศรชำนิ
    chuchai.s@nhso.go.th
    chuchai.sn@gmail.com
    Facebook , Twitter : Morchuchai
    1
  • What is ‘policy’?
    a course of action or inaction (Heclo 1972)
    a course of action adopted and pursued by a government, party, rulers, statesman (Oxford English Dictionary)
    a set of interrelated decisions … concerning the selection of goals and the means of achieving them within a specified situation … (Jenkins 1978)
    decisions taken by those with authority and responsibility for a given policy area (Buse et al 2005)
    any course of action followed primarily because it is expedient or advantages in a material sense
    2
  • นโยบายสาธารณะ ( Public Policy ) กับสุขภาวะของประชากร
    นโยบายด้านสาธารณสุข (Public Policy) นโยบายเพื่อการดำเนินสาธารณสุข ที่เป็นเรื่องที่เกี่ยวข้องทางด้านสุขภาพโดยตรง
    นโยบายสาธารณะเพื่อสุขภาพ (Healthy Public Policy) นโยบายสาธารณะที่แสดงความห่วงใยอย่างชัดเจนในเรื่องสุขภาพ พร้อมที่จะรับผิดชอบต่อผลกระทบทางสุขภาพ ที่อาจเกิดขึ้นจากนโยบายนั้น ขณะเดียวกันก็เป็นนโยบายที่มุ่งสร้างเสริมสิ่งแวดล้อมทั้งทางสังคม และกายภาพที่เอื้อต่อการมีชีวิตที่มีสุขภาพดี และมุ่งให้ประชาชนมีทางเลือก และสามารถเข้าถึงทางเลือกที่ก่อให้เกิดสุขภาพดีได้
  • 4
    ระดับของนโยบาย
    • นโยบายของรัฐบาล-แถลงการณ์ของนายกฯ
    • กฎหมาย พรบ พรก กฎกระทรวง ประกาศ
    • แผนพัฒนาเศรษฐกิจและสังคมแห่งชาติ
    • แผนแม่บทแห่งชาติ
    • บัญชียาหลักแห่งชาติ
    • ชุดสิทธิประโยชน์ของระบบประกันสุขภาพ
    นโยบายระดับชาติ
    • กฎหมาย กฎระเบียบในระดับจังหวัด
    • แนวทางระดับเขตตรวจราชการ
    • มติของคณะกรรมการจังหวัด อำเภอ
    นโยบายระดับพื้นที่
    • แนวทางการคัดเลือกเวชภัณฑ์ของโรงพยาบาล
    • Clinical Practice Guidelines, Standard Operating Procedures (SOP) เช่น Laboratory manuals
    • การจัดงานประชุมวิชาการ
    นโยบายระดับองค์กร
  • 5
    Output
    Effect
    Impact
    Outcome
    Long term
    Short term
    Policy diagram
    Input
    Process
    By product
    Input
    Human resources
    Financial resources
    Instruments
    Technical knowledge
  • 6
    The Policy Triangle
    Context
    Actors
    Content
    Process
    Walt G and Gilson L, Reforming the health sector in developing countries: the central role of policy analysis, Health Policy and Planning 1994; 9: 353-70
  • แนวทางการสร้างนโยบายสาธารณะเพื่อสุขภาพ : 8 Elements
    วัยรุ่น
    ภาคีสุขภาพ
    มูลนิธิสาธารณสุขแห่งชาติ 2553
  • Relationships between the functions and objectives of health systems
    Performance framework (WHO, 2000)
  • Global Attention to Health Systems
  • ‘6 Building Blocks’
    Source: World Health Organization. Everybody’s Business: Strengthening health systems to improve health outcomes—WHO’s Framework for Action. Geneva: WHO, 2007, page 3.
  • Care Management for Chronic Diseases
    Health Policy and Healthy Public Policy Development
    • Diseases or Service Response
    • Health System Response
  • Care Management : Chronic illness
    Insurance Model
    Utilization review, quality assurance function
    Compliance and access orientation
    No integration
    Care Delivery Model
    Develop standard tools: CPG, care map
    Linear integration
    Security (Continuum Care) Model
    Community health care, optimum care site
    Continuous quality improvement
    Promote wellness and community health status
    Multidimensional integration
    12
  • พัฒนาการทางเศรษฐกิจ สังคม เทคโนโลยี กับ การพัฒนานโยบายความเข้มแข็งระบบสาธารณสุข “โรคเรื้อรัง”
  • ประเทศไทยที่เปลี่ยนแปลง
    โครงสร้างประชากรที่เปลี่ยนแปลง
    2005
  • Prevalence Hypertension: 23% male, 21% female
    All samples are hypertensive, >140/90 mmHg,
  • Prevalence DM: 6% male, 7% female
    All samples have FBS, >126 mg/dl
  • 19
    ประเทศไทยที่เปลี่ยนแปลง
    จำนวนครัวเรือนชั้นกลาง แยกตาม 2 นิยามจำนวนคนชั้นกลางอยู่ระหว่างนิยามทั้งสอง คือ 12-15 ล้านครัวเรือน
    คนชั้นกลางในไทยปี 2533-2549
  • 20
    ประเทศไทยที่เปลี่ยนแปลง
    ร้อยละครัวเรือนทุกกลุ่มทีมีอุปกรณ์อำนวยความสะดวก
    ความต้องการสิ่งอำนวยความสะดวกทำให้ตลาดสินค้าอุปโภคบริโภคใหญ่และขยายตัว เช่น เครื่องใช้ไฟฟ้า ยานพาหนะ อาหารแปรรูป เกิดการผลิตและการจ้างงานในประเทศ
    นอกเทศบาล
    เทศบาล
    ครัวเรือนมีค่าใช้จ่ายที่เกี่ยวข้องกับการเรียนรู้เพิ่มมากขึ้น เช่น ด้านการสื่อสาร และการเดินทางในโอกาสพิเศษ รวมทั้งการลงทุนด้านคอมพิวเตอร์และเชื่อมต่ออินเทอร์เน็ต
  • ประเทศไทยที่เปลี่ยนแปลง
    เศรษฐกิจไทยขึ้นกับเศรษฐกิจโลก
    ที่มา : สศช.
  • คนไทยบริโภคน้ำตาลเพิ่มขึ้น
    ข้อมูล สำนักงานคณะกรรมการอ้อยและน้ำตาล คัดจากรายงานการสาธารณสุขไทย พ.ศ. 2544-2547
  • Top ten: DALYs
    % of Total 52.61 42.83
  • Burden attributable to risk factors, 1999-2004
    ลำดับปัจจัยเสี่ยงที่ก่อให้เกิดภาระโรคจากมากไปหาน้อย ได้แก่ การมีเพศสัมพันธ์ที่ไม่ปลอดภัย แอลกอฮอล์ บุหรี่ ความดันเลือดสูง การไม่สวมหมวกและคาดเข็มขัดนิรภัย ภาวะน้ำหนักเกินและโรคอ้วน ระดับโคเลสเตอรอลในเลือดสูง การบริโภคผักและผลไม้น้อย การขาดการออกกำลังกาย การใช้สารเสพติด มลพิษทางอากาศ การขาดน้ำสะอาด การสุขาภิบาลและสุขอนามัยที่ไม่เหมาะสม และภาวะทุพโภชนาการ
  • โลกที่เปลี่ยนแปลง
  • Information medicine
    “Knowledge is power”
    Medical process: information process
    Delocalised, distributed and direct
    Decision support, information management, identity technology,imaging, visualisation, sensors,telemedicine
    The home as treatment location
    The Internet Patient
  • Decision Support Systems
    Diagnosis, data analysis, reminders, memory empowerment, ”second opinion”
    Interactive broschures, simulations, smart objects, ”the digital doctor”
    Benefits patient participation, handle information overload
    Problems: conservative, silent knowledge,integration with patients and organisation
  • Imaging
    Scanning + fast visualization+ information fusion
    Non-invasive exploration
    Direct information to doctors
    Shorten the treatment chain, reduce sidetracks
    Requires change in routines
  • Sensors and Telemedicine
    Trends
    More conditions measurable, smaller, cheaper, plentiful, more functions per chip
    More intimate and biological, both non-invasive and implanted
    Active ”smart” sensors/actuators, wireless communication
    Pathogen sensors, automated medication
    Moves the location of diagnosis and treatment to the periphery
    Information overload, privacy, security, training
  • Cybersurgery
    Surgery supported by information technology
    Remote surgery
    Direct visualisation
    Augmented reality
    Robotics
    Economy? Stumbles on organisation issues
  • Minimal Access Surgery
    More and more applications
    Faster recovery
    Faster surgery redistributes medical personell
    Need of a new kind of operating theatre?
    Strong link to VR and robotic surgery
  • Biotech medicine
    Regenerative medicine
    Rational drug design
    Bionics
    Genetic testing
    Vaccines
    Enhancing medicine
  • The New Pharmacology
    Rational design
    Based on genomics, simulation and knowledge of basic processes
    Generics threatened, business models in pharma threatened
    Blurs the borders between palliative, curative, preventative and enhancing medicine
  • Prosthetics and Neurointerfaces
    Neurointerfaces rapid development (~300 electrodes, permanent)
    Prosthetic research underfinanced
    Large gains for small groups
  • Genetic Testing
    Cheap, fast genetic tests many conditions
    How many wants to test? How does the health system respond?
    Benefits: More individually adapted, good for preventative medicine and pharmacogenomics
    Problems: Interpretation, too much faith in genetics, diagnosis develops faster than treatment, breaks information monopolies
  • Reproductive Medicine
    Reproduction as a right?
    We are willing to spend enormous sums on our children and their health
    Genetic testing, preventative medicine
    Perinatal medicine
  • The New Vaccines
    Vaccines for treatment instead of just prevention
    Immune system control
    Vaccines against
    Allergies
    Diabetes
    Autoimmune illnesses
    Metabolic illnesses
    Cancer
    Narcotics
  • Neurotechnology
    The brain/mind increasingly visible
    New pharmacology + understanding of brain leads to treatment of many mental disorders
    Hybrid therapies
  • Nanotech medicine
    NBIC convergence
    Enhancement of previous technologies
    Reduced price
    Increased effectiveness
    Increased portability
    Active and smart devices and drugs
    Development gradual and enabled byprevious technologies.
  • Chronic Care Modelกับการพัฒนานโยบายสาธารณะ
    Epping-Jordan, J E et al. Qual Saf Health Care 2004;13:299-305 Copyright ©2004 BMJ Publishing Group Ltd.
  • Components of Chronic Diseases Management
  • Full Integration: Population Based and Chronic Care Case Based Model
    HEALTH IMPROVEMENT
    DISEASE MANAGEMENT
    Lifestyle interventions
    Low risk
    At risk
    Disease
    Management
    Disease
    Symptoms
    Early Signs
    Preventive Services
    Case Management
    Screening
    Acute
    treatment
    Disease
    Management
    Primary and Secondary
    Prevention
    HEALTH MANAGEMENT
    POPULATION-BASED
    CASE-BASED
  • Chronic Illness and Medical Care
    Primary care dominated by chronic illness care
    Clinical and behavioral management increasingly effective BUT increasingly complex
    Inadequate reimbursement and greater demand forcing primary care to increase throughput—the hamster wheel
    Unhappy primary care clinicians leaving practice; trainees choosing other specialties
    Loss of confidence in primary care by policy-makers and funders
    But, there are new models of primary care and growing interest in changing physician payment to encourage and reward quality
  • People-centred care
    World Health Report: 2008
  • โรงพยาบาลส่งเสริมสุขภาพตำบล Tambon Health Promotion Hospital
    Coordinate with other partners - central government + local authority + community + private sector,
    Working in community – home ward,
    Proactive, outreach services based on community health needs,
    Care coordination – horizontal and vertical levels and case management system
  • What Patients with Chronic Illnesses Need
    A “continuous healing relationship” with a care team and practice system organized to meet their needs for:
    • Effective Treatment (clinical, behavioral, supportive),
    • Information and support for their self-management,
    • Systematic follow-up and assessment tailored to clinical severity,
    • More intensive management for those not meeting targets, and
    • Coordination of care across settings and professionals
  • Toward a chronic care oriented system
    Reviews of interventions in other conditions show that practice changes are similar across conditions
    Integrated changes with components directed at:
    • use of non-physician team members,
    • plannedencounters,
    • modern self-management support,
    • Intensification of treatment
    • care management for high risk patients
    • electronic registries
  • Chronic Care Model
    Health System
    Community
    Health Care Organization
    Resources and Policies
    ClinicalInformationSystems
    DeliverySystem
    Design
    Self-Management Support
    Decision
    Support
    Prepared,
    Proactive
    Practice Team
    Informed,
    Activated
    Patient
    Productive
    Interactions
    Improved Outcomes
  • What distinguishes good chronic illness care from usual care?
    Prepared
    Practice
    Team
    Informed,
    Activated
    Patient
    Productive
    Interactions
  • Prepared
    Practice
    Team
    Informed,
    Activated
    Patient
    Productive
    Interactions
    How would I recognize a
    productive interaction?
    Assessment of self-management goal attainment and confidence as well as clinical status
    Adherence to guidelines
    Tailoring of clinical management by stepped protocol (Treat to target)
    Collaborative goal-setting and problem-solving resulting in a shared care plan
    Planning for active, sustained follow-up
  • Informed,
    Activated
    Patient
    What characterizes an “informed, activated patient”?
    They have goals and a plan to improve their health, and the motivation, information, skills, and confidence necessary to manage their illness well.
  • Self-Management Support
    Goal
    To help patients take a more active role and be more competent managers of their health and healthcare.
  • Community Resources and Policies
    Goal
    To help patients access effective and useful services and resources in the surrounding community.
  • What characterizes a “prepared” practice team?
    Prepared
    Practice
    Team
    Practice team and interactions with patientsorganized to help patients reach clinical targets and self-management goals..
  • Delivery System Design
    Goal
    To organize practice staff, schedules and other systems to assure that all patients receive planned, evidence-based care.
  • Decision Support
    Goal
    To assure that clinicians and other staff have the training, scientific information and system support to routinely provide evidence-based (adhere to guidelines) and patient-centered care.
  • ClinicalInformation System
    Goal
    To assure that clinicians and other staff have ready access to patient information on individuals and populations to help plan, deliver and monitor care.
  • Health Care Organization
    Goal
    To assure that practices within the organization have the motivation, support and resources needed to redesign their care systems.
  • Challenges in Implementing the CCM
    Practices spent considerable time searching for/developing tools
    Some practices felt intimidated by taking on the whole model – asked for a sequence
    Many changes were made in ways that were not sustainable logistically or financially (e.g., double data entry)
    CCM elements implemented as “special events” rather than part of routine care
    Many achieve process improvements but outcomes don’t change
  • Self-Management Supportand Community Resources
  • Ecological Model of Health Behavior
  • Clinical Information Systems and Decision Support
  • A Model for Effective Chronic Illness Care
    Health System
    Organization of Health Care
    Community
    Resource and Policies
    Self-Management
    Support
    Decision
    Support
    Clinical
    Information
    System
    Delivery
    System
    Design
    Informed,
    Activated Patient
    Prepared,
    Proactive
    Practice team
    Productive
    Interaction
    Functional and Clinical Outcomes
  • ClinicalInformation Systems
    Provide reminders for providers and patients.
    Identify relevant patient subpopulations for proactive care.
    Facilitate individual patient care planning.
    Share information with providers and patients.
    Monitor performance of team and system.
  • Barriers to CIS use
    Lack of perceived value
    Competing business and productivity demands
    Lack of office flow expertise
    Lack of information support
    Lack of leadership support
  • What is the Issue?
    Functionality!
    Whatever you use should be able to deliver information that supports:
    population planning
    clinical summaries at the visit
    individual care planning
    reminders
    performance feedback
  • Necessary functions for chronic care
    be organized by patient; not disease, but responsive to disease populations
    contain data relevant to clinical practice
    assist with internal and external performance reporting
    guide clinical care first, measurement second!
  • Everyone, including senior leadership understands the clinical utility and supports the time involved in upkeep.
    Data forms are clear, data entry role is assigned, data review time allotted.
    Data entered and retrieved are clinically relevant, and used for patient care first, and measurement second.
    Data can be shared with patient to improve understanding of treatment plan.
    Keys to Success from Others That Have Implemented Registries
  • The Implications of Social Media
  • The Networked World
    Influencers
    Potential Employees
    Investors
    Employees
    MESSAGES
    Customers
    Competitors
    Prospects
    Partners
    Press/Analysts
  • ศูนย์เทคโนโลยีสารสนเทศและการสื่อสาร
    สำนักงานปลัดกระทรวงคมนาคม
    Facebookusage statistics - March 2010 (with 12 month increase figures)
  • ศูนย์เทคโนโลยีสารสนเทศและการสื่อสาร
    สำนักงานปลัดกระทรวงคมนาคม
    Facebookusage statistics - March 2010
    จำนวนผู้ใช้ Facebookทั่วโลก 465,562,160คน
    จำนวนผู้ใช้ Facebookในประเทศไทย 3,757,340 คน คิดเป็น 0.81% ของทั่วโลก
    Thailand Male / Female
    Female
    2,069,440
    55.8%
    Male
    1,636,040
    44.2%
  • ศูนย์เทคโนโลยีสารสนเทศและการสื่อสาร
    สำนักงานปลัดกระทรวงคมนาคม
    Facebookusage statistics - March 2010
    Thailand Age Distribution
    <= 13 36,220 (1.8%)
    14 – 17 271,980 (13.1%)
    18 – 24 778,400 (37.6%)
    25 – 34 714,840 (34.5%)
    35 – 44 189,680 (9.2%)
    45 – 54 54,820 (2.6%)
    55 – 64 13,660 (0.7%)
    65+ 9,780 (0.5%)
  • 2 side to consider
    18 file and OPD individual record
    HCIS , JHCIS, HosXP, etc.
    Report for claim
    New media , Social network
    Tele consultation
  • The Social Media Ecosystem
    Tools that facilitate:
    Communication
    Engagement
    Transparency
    Trust
    Tools that are:
    Complementary to traditional communication activities
    Used by organizations who recognize the social characteristics of effective communication
    Blogs
    Wikis
    Facebook , twitter
    Podcasts
    Videocasts / Vlogs
    Moblogs
    MMS
    Internet telephony i.e. skype™
  • What’s Social About Health Behavior?
    Asymptomatic Screenings
    Lifestyle Modifications
    Cessation of Addictive Behaviors
    Medical Regimen Compliance
    Precaution Adoption
  • e-Health Tools and Functions
    Health Information
    Behavior change
    Self-management
    On-line communities
    Decision support
    Disease management
    Healthcare tools
    Office of Disease Prevention and Health Promotion, DHHS. Expanding the Reach and Impact of Consumer e ‑Health Tools. 2006.
  • e-Health Tools: Behavior Changes
    Improve dietary habits
    Increase physical activity levels
    Reduce heavy drinking
    Decrease disordered eating behaviors
    Improve adherence to treatment protocols
    Impact on health care utilization and costs?
    Office of Disease Prevention and Health Promotion, DHHS. Expanding
    the Reach and Impact of Consumer e ‑Health Tools. 2006.
  • Mobile Technologies for Change: m-Change and Obesity
    The appropriate model for obesity and weight management is tailored information according to design principles suggested by Social Cognitive Theory and the Social Marketing Model.
    The health behaviors to target are self-monitoring of diet and physical activity.
    The devices are Web-enabled “smart” cellular telephones and wireless PDAs.
    JT Tufano & BT Karras. Mobile eHealth Interventions for Obesity:
    A Timely Opportunity to Leverage Convergence Trends. Journal
    of Internet Medical Research 2005;7(5):e58).
  • ลักษณะโปรแกรมสำหรับใช้งาน
    ข้อมูลผู้ป่วย
    หน้าต่างฟอร์มต่างๆ
    ฟอร์มในการลงข้อมูล
    ลำดับเตียงผู้ป่วย
  • Decision Support
    Embed evidence-based guidelines into daily clinical practice.
    Integrate specialist expertise and primary care.
    Use proven provider education methods.
    Share guidelines and information with patients.
  • What is evidence-based medicine?
    Evidence-based medicine is an approach to health care that promotes the collection, interpretation, and integration of valid, important and applicable evidence.
    The best available evidence, moderated by patient circumstances and preferences, is applied to improve the quality of clinical judgments.
    McMaster University
  • Evidence-based practice
    Customize guidelines to your setting
    Embed in practice: able to influence real time decision-making
    Flow sheets with prompts
    Decision rules in EMR
    Share with patient
    Reminders in registry
    Standing orders
    Have data to monitor care
  • Stepped Care
    Often begins with lifestyle change or adaptation (eliminate triggers, lose weight, exercise more)
    First choice medication
    Either increase dose or add second medication, and so on
    Includes referral guideline
  • Going beyond consultation: integrating specialist expertise
    Shared care agreements
    Alternating primary-specialty visits
    Joint visits
    Roving expert teams
    On-call specialist
    Via nurse case manager
  • Effective educational methods
    Interactive, sequential opportunities in small groups or individual training
    Academic detailing
    Problem-based learning
    Modeling (joint visits)
  • Effective educational methods
    Build knowledge over time
    Include all clinic staff
    Involve changing practice, not just acquiring knowledge
    Evans et al, Pediatrics 1997;99:157
  • The Patient as Partner
    Principles of CIS &DS
  • Other Choices for Patient Decision Support
    PBGH Evaluation of Consumer Decision Support Tools June 2007
  • Ways to share guidelines with patients
    Stoplight tools
    Expectations for care
    Wallet cards
    Web sites
    Workbooks
  • Chronic Care Model
    Health System
    Community
    Health Care Organization
    Resources and Policies
    ClinicalInformationSystems
    DeliverySystem
    Design
    Self-Management Support
    Decision
    Support
    Prepared,
    Proactive
    Practice Team
    Informed,
    Empowered
    Patient
    Productive
    Interactions
    Improved Outcomes
  • Specifics of System Design
    Workforce Development
    Up front training and Admin Support
    Professional development
    Integration of Complementary Medicine
    Micro system optimization
  • Micro System Optimization
    Clinical
    Doctor,
    Nurse Case Manager
    Support groups
    Behavorist
    Pharmacist, Nutrition, H. Ed.
  • Supply
    *Shortage of health
    care personnel, both
    quantity and quality
    *Malutilization especially
    nurse
    Demand
    * Complex
    health problem
    *Explosion of knowledge and technology
    *Health care reform
    *Expand the scope of nursing
    Unsafe both nurses and patients/clients
    Paradox