Patricia Leahy Warren, Senior Lecturer School of Nursing and Midwifery, UCC


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Primary and Secondary Healthcare: Challenges at the Interface

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  • Primary health care is reducing exclusion and social disparities in health (universal coverage reforms);organizing health services around people's needs and expectations (service delivery reforms);integrating health into all sectors (public policy reforms);pursuing collaborative models of policy dialogue (leadership reforms); andincreasing stakeholder participationHealth - the wider Dimensions (DOH, 1986) The process of enabling people to increase control over the determinants of health and thereby improve their health.As health care professionals our role is therefore one of mediating, enabling and facilitating the processes and systems that are required to achieve health goals.
  • The environment, lifestyle factors, human biology, and the health care provision. The effects of change are evident in the ways in which health care is being reorganised, with a shift from hospital-based care toward community-based health care and population health. A population focus intends to narrow the gap between different sections of the population, thereby improving the health of the population overall.This reorientation of health services toward community-based health care and population health will have an impact on the practice and role development of nurses working in the community, A wide range of factors – such as poverty, inequality, social exclusion, employment, income, education, housing conditions, transport access to health care, lifestyle, stress – all impact significantly on an individual’s health and wellbeing. Because good health is socially, economicallyand environmentally determined, policy choices implemented by all departments not just the Department of Health can significantly impact on a person’s health.
  • McCallion said that there was a strong case for change in the health services in view of the changing demands on our health and social care system which would increase the burden on services.  Our population was aging, there was an increase in demand from higher-dependency segment of the population, the number of cancer cases was predicted to increase, there was an increasing prevalence of conditions such as diabetes, obesity, heart disease and asthma and there was an increased requirement for prevention and specialist treatment. The public and patients were also more demanding and had higher expectations. There were stories of people coming into hospital with five pages printed off the internet and a diagnosis already in their head.The advantages of Primary health care are well documented. A strong Primary care system isassociated with better health outcomes, equity of access, more appropriate utilisation of services,cost effectiveness and increased patient Despite the known advantages of PrimaryCare no new funding has been provided to support the Government’s Programme of reform forPrimary Care and in fact any funding provision made has been withdrawn and diverted back toaddress shortfalls elsewhere in the system.(IMO, 2014)What this should mean for staff is that there will be more opportunities to work across boundaries
  • 25,000 older people live in residential care in IrelandChange in delivery of services…early discharge…complex care the need for increased home visiting, the care may be more complex and therefore takes longer to complete, and the requirement for additional services such as aids and appliances and is likely to be higherthe absence of a National Framework for Children and Young People’s Continuing Care.Older adults resident in nursing homes was 20,802 while the number of elderly recorded as being usually resident in hospitals across the country was 4,873
  • There is now a substantial body of evidence that demonstrates the value, both economic and developmental, of investing in early years. The right investment at this point in the life cycle has been shown to be effective in preventing poverty and disadvantage and can therefore, interrupt the intergenerational cycle of poor outcome.(Heckman, 2009). The Prevention and Early Intervention programme, led by the Department of Children and Youth Affairs, shows promising results in the validity and applicability of this international research for children, families and communities in Ireland. Results from the programme, for example, demonstrate the importance of both targeted and universal parenting programmes, recognising that family circumstances and families’ needs are different (Centre for Effective Services, 2012 a). Programmes implemented in terms of children's behavioural and learning outcomes have also been shown to be effective in the Irish context, thus providing a backdrop for adopting an evidence-informed approach to the delivery of services in these areas. (Centre for Effective Services, 2012 b). These findings can help to guide professional practice across a range of areas, including public health nursing.
  • These are the health issues that require interfacing between primary and secondary care…can these be managed in the community?Commitment to early intervention and prevention…
  • Delivery of health servicesEarly dischargeComplex careChanges in the delivery of health services focusing on shorter hospital stays and a new approach to the well being of children with long term health needs has a consequence for an increase in clinical nursing services provided in the home setting. In addition to problems around discharge planning and the successful transition of ventilated children to home the earlier discharge of clients means that the care of client has become more intensive, more complex, more specialised and more sustained. This is problematic because of the need for increased home visiting, the care may be more complex and therefore takes longer to complete, and the requirement for additional services such as aids and appliances and is likely to be higherthe absence of a National Framework for Children and Young People’s Continuing Care.
  • Contributing factors to delay in carrying out of health checks include; an inefficient information system in relation to communication of the birth notification form, no standardisation of the notification form, waiting lists for community nursing care, and limited time allocated to the child cohort for PHNs due to the more immediate demands of other care groups. If information is not adequate…risk factors not identified…transfer of information …KPI between 48 hours and 72 hours…chancing KPIs be cautious/prudent shown problematic in relation to safe care…learning disability/stillbirth/downs syndrome…at what cost…CFHNA Midlands Decreased medication discrepancies were associated with communication by Primary care physicians (PCP) with patients within 24 hours of discharge(Lindquist et al., 2013). Lindquist, L.A., Yamahiro, A., Garrett, A., Zei, C. & Feinglass, J.M. (2013) Primary care physician communication at hospital discharge reduces medication discrepancies. Journal of Hospital Medicine,8(12), 672-677Written Information and instructions needs to be in appropriate language and reading level and high quality care is linked to communication (Samuels-Kalowet al., 2012). Samuels-Kalow M.E., Stack A.M. & Porter S.C. (2012) Effective Discharge Communication in the Emergency Department. Annals of Emergency Medicine,60(2), 152-159.
  • VhiHomeCare is available in Dublin, Kildare, Meath and specific areas in Wicklow, Louth and Wexford. As far south as Gory and as far north as Dundalk.patients covered within the 180 bed days of their policyDo not do nursing care/personal care…work with PHNs Palliative careLiaise with GP and Consultants via letter/emailNo their IT systems do not ‘communicate’ with othersWill accept patients from A&E reduce trolley numbersOPATH –public patients…early discharge e.g. IV medications at home covered by hospital consultantsLaya TCP Nurse-led services byCREST
  • I welcome the publication of the Healthy Ireland A Framework for improved health and wellbeingadoption of a Health in All Policies (HiAP) approach to addressing the socio-economic determinantsof health. If we can get health and care systems and services right for our older population – thosewith the highest complexity, activity, spend, variability, and use of multiple services – weshould help get it right for other service users. The twin challenges of demography andfunding demand no less.
  • Patricia Leahy Warren, Senior Lecturer School of Nursing and Midwifery, UCC

    1. 1. Patricia Leahy-Warren PhD, Senior Lecturer School of Nursing and Midwifery, UCC
    2. 2. Primary & Secondary Health Care: Challenges at the Interface Dr P. Leahy-Warren National Healthcare Conference April 2nd 2014
    3. 3. Objectives • Health Strategy and Policy • Challenges – Changing demographic profiles in population – Changes in delivery of services – Primary Care Teams – Information/communication – Economics/Resources • Innovations • Conclusion Dr P. Leahy-Warren
    4. 4. Determinants of Health At least 30% of cancers and 80% of heart disease, stroke and Type 2 diabetes can be prevented through regular physical activity, a healthy diet and non use of tobacco products
    5. 5. Primary Care 2001 • Vision for 520 teams Dr P. Leahy-Warren 90-95% of care will take place in the community
    6. 6. Demographics • Population: 4.593M • Population ≥65: 535,393 • Projected increase: 20-25% by 2036 • The population of older adults increased by 14.4% • Aged ≥100: 389 - an increase of 100 persons since 2006 • Life expectancy: 80.6 yrs • Chronic morbidities: – cardiovascular – cancer – chronic respiratory disease – diabetes – Mental health (dementia, depression, suicide etc.) (CSO, 2011, 2012; NSP, 2014)
    7. 7. Demographics…contd • Highest birth rate in EU with 71,986 in 2012 • Population of children aged 0-4 years is 356,329, by 18% • Population of Primary school-aged (5-12) children is 504,267, by 12% • Number of children eligible for PHN service is 860,596
    8. 8. Children & Young People • 1: 100 infants are sometimes or often unwell and 17% infants have some minor problems • 13% of infants admitted to hospital since their birth & spend ̴ 6 nights in hospital. • A total of 153,905 hospital discharges in 2012 of which 14,085 were due to accidents • More than half of the total hospital discharges in 2011 among children were children < 5 years • 25% of three year old children are either overweight or obese (GUI; TSNC)
    9. 9. Children & Young People…Contd • At age 3 years 16% of were reported as having at least one longstanding illness, condition or disability (asthma (5.8%), eczema (3.9%), and digestive problem (1.2%) • The average age for detection of severe hearing loss is over 3 years of age, which is above the acceptable age by international standards • 31,626 referrals to the Social Work Services related to child protection concerns in 2012 • Nearly 10% of children aged 9-17 reported smoking cigarettes every day • Over 20% of children aged 10-17 reported that they had been drunk at least once in the last 30 days • There were 21 suicides of children aged 10-17 in 2009 (GUI; TSNC)
    10. 10. Changes in Health Service Delivery • >1.8 million Medical Cards (40.6%) 46% since 2008 • 61% of adults are overweight & cost of obesity per annum is aprox €1.13 billion • Chronic disease is due to by 40% by 2020 • Advances in the development of medical technologies are cost-intensive • Early discharge & more complex discharges • Complex care in the community • Backdrop of reduced resources (NSP, 2014) Dr P. Leahy-Warren
    11. 11. Patient/Client Palliative Care Chronic Sick People with disabilities Mental Health CHILDREN Older persons Client Groups in Population
    12. 12. Communication Nothing is so simple that it cannot be misunderstood. — Freeman Teague, Jr • Means of communication as barrier to smooth, safe, satisfactory transitioning – Inefficient information systems – Absence of Health Information legislation – Incompatible/insufficient access to IT systems – No standardisation of documentation/records e.g. notification of births/CFHNA (O’Dwyer, 2012) – Lack of consistent data for auditability • Need for a shared understanding of integrated care Dr P. Leahy-Warren
    13. 13. Primary Care Teams in Ireland • Many GPs (41.6%) (N=423)not part of a primary care team at present but 10.1% will be part of team shortly (ICGP, 2011) • Primary Care Teams report that GPs in 54% of PCTs regularly attend team meeting (Office of the Comptroller & Auditor General (OCAG) 2011). • Presence of local primary care manager has Improved communications & team concept (ICGP 2011) • Many GPs (64.6%) say that PCT are not functioning well (ICGP OCAG) 2011). • GPs use computerised medical records……other PCT members (PHNS, RGNs, etc) have limited access and do not use computerised assessment. • Major problems in team communications linked to lack of IT structures (OCAG 2011).
    14. 14. Innovations • Cois Ti Maternity Care • Community Rehabilitation and Support Team (CRST) • Hospital at Home • Standardised assessment e.g. Child and Family Health Needs Assessment • Child Health Information Technology App (CHeITA) • Promotion of self-care management of chronic illness • Increase in nurse-Led care and clinics • Further research to demonstrate concrete outcomes and measures of success of primary care in Irish context Dr P. Leahy-Warren
    15. 15. Conclusion • Policy …challenges of demography and funding • Individual and collective responsibility for health • Shift from high-cost, reactive and bed-based care to care that is preventive, proactive and centred closer to people’s homes with main focus on wellness as well as an effective and efficient response to ill health • Research and innovation with clear positive patient outcomes Dr P. Leahy-Warren
    16. 16. CCli Integrated Primary Care Team Single Assessment Process Specialist Services Social Supports Integrated Technology Regulation of Quality & Standards Integrated Care Client/Patient
    17. 17. References • Begley, C., et al. (2013) Differences between clinical specialist and advanced practitioner clinical practice, leadership, and research roles, responsibilities, and perceived outcomes (the SCAPE study). Journal of Advanced Nursing 69 (6), 1323- 1337 • Central Statistics Office (CSO) 2012) Census 2011 Stationery Office, Dublin • Department of Health (2013) Healthy Ireland A Framework for Improved Health and Well Being, Dublin: Stationery Office • Department of Health (2010) Primary Care Dublin: DoH • Department of Health (2010) Qualoity and Fairness Care Dublin: DoH • Department of Health (2012) Future Health A Strategic Framework for Reform of the Health Service 2012 – 2015, Dublin: DoH • Growing up in Ireland • Health Service National Service Plan 2014 Dublin HSE • IMO Budget Submission 2014 • Office of the Comptroller and Auditor General Corporate Report (2011) Dublin OCAG • O’ Riordan, M (2011) ICGP Report on Primary Care Teams: A GP Perspective • • The State of the Nation's Children (2006) Dr P. Leahy-Warren