FM Academic Activities For Medical Residents 2016.10.28

1. Integrated Healthcare Systems for Family Physicians
ผศ.นพ.บวรศม ลีระพันธ์
FM Academic Activities For Medical Residents
28 October 2016
Pix source: Rattanaphibunkun C., Chantaragomol C, Wongsin A., PMAC 2016 Art Contest

2. Seminar Outline
Pix source: online.wsj.com
Q1: What do we
know about
“PHC”
in Thailand?
Q2: What do we
know about
“Healthcare
Systems”
in Thailand?
Q3: What policies
are needed for the
future of PHC and
“Integrated
Healthcare
Management”?

3. Q1: What do we know about
PHC in Thailand?
(“Myths and Facts About PHC in Thailand”)
Pix source: online.wsj.com

4. What Do You Mean by “Primary Care”?
1. Basic medical services
2. Self-care, and health for all
3. First-contact, continuous, coordinated, and
comprehensive care
4. Health promotion practices, and actions on social
determinants of health
(=What a layman usually thinks of primary care)
(The Declaration of Alma-Ata 1978)
(Starfield 1992, 1998)
(Ottawa Charter 1986, The 66th World Health Assembly 2013)

5. Source: http://www.who.int/publications/almaata_declaration_en.pdf

6. Source: http://www.who.int/social_determinants/B_132_14-en.pdf?ua=1

7. Source: Stange KC. Barbara Starfield: Passage of the Pathfinder of Primary Care. The Annals of Family
Medicine. 2011 July 1, 2011;9(4):292-6; Pix source: practiceimprovement.com.au;

8. Action on Social
Determinants of Health
(การสร้างเสริมสุขภาพ)
Community-based
Primary Healthcare
(การสาธารณสุขมูลฐาน)
Primary Care Medicine,
Family Medicine
(เวชศาสตร์ปฐมภูมิ, เวชศาสตร์ครอบครัว)
Basic Medical Care
(บริการการแพทย์ระดับพืDนฐาน)
• Health promotion practice at
the population health level
• “Health in All Policies”
• Self-care
• Community health worker
• Community health volunteer
• “Health for All”
• First-contact care
• Continuous care
• Coordinated care
• Comprehensive Care
•Health center (สอ./รพ.สต.)
•OPD, physician office
•Mobile medical units
What Do You Mean by “Primary Care”?

9. Community-based
Primary Healthcare
Clinical Practices
at Primary Care
Level
“The Doughnut Hole” of Primary Care
• Primary care services in developed
countries
• Medical facilities in urban settings
• Medical facilities in private-sector
(without public health functions)
• Primary care services in
developing countries
• Medical facilities in rural settings
• Medical facilities in public-sector
(with public health functions)
Ø What exactly policies & systems are we talking about?

10. Figure source: Thailand Health Profile 2008-2010.

11. Figure source: Thailand Health Profile 2008-2010.

12. “Primary” & “General”
Primary General
Primary School
Primary Data
Primary Election
Primary Tumor
Primary Stage [of projects, etc]
Director-General
Attorney-General
Surgeon-General
General Hospital
General [Prayuth Chan-ocha]
Ø How do you feel about the “Primaries” and “Generals” listed above”?
Ø How’s about “Primary Healthcare” and “General Practitioner”?

13. Structure of Urban Health Services
(City of Chanthaburi)
Pix source: สํานักงานวิจัยและพัฒนาระบบสุขภาพชุมชน (2555)

14. Structure of Urban Health Services
(City of Chanthaburi)
Pix source: Office of Community Based Health Care Research and Development (2012)

15. Telecare Clinic
(Bangkok General Hospital)
Pix source: http://www.bangkokhospital.com/

16. Q2: What do we know about
Healthcare Systems in Thailand?
Pix source: online.wsj.com

17. Source: W. Simpson del.; E. Walker lith.; Day & Son, Lithrs. to the Queen.
Pix source: http://en.wikipedia.org/wiki/History_of_hospitals#mediaviewer/File:Hospital_at_Scutari_2a.jpg
“Hospital at Scutari” - A ward of the hospital at Scutari where
Florence Nightingale worked and helped to restructure the modern hospital

18. Disability-Adjusted Year Lost (2004)
Injury
NCD
Infection
0-4 5-14 15-29 30-44 45-59 60-69 70-79 80+ 0-4 5-14 15-29 30-44 45-59 60-69 70-79 80+
Males Females
1,600
1,400
1,200
1,000
800
600
400
200
0
Sour
Source: Adapted from: WHO (2008), http://www.who.int/healthinfo/global_burden_disease

19. Pix source: www.sotaravej.net; www.med.chula.ac.th; www.phassociation.org
Living With Diseases?

20. Primary Care vs. Chronic Care
Figure Source: www.improvingchroniccare.org

21. Figure Source: Institute for Healthcare Improvement (2012). Partnering in Self-Management Support: A Toolkit for Clinicians.
Collaborative Care: Cycle of Self-Management Support
Self-Management Supports

22. CCM Elements
Source: Coleman et al. (2009)

23. CCM Elements
Source: Coleman et al. (2009)

24. Primary Care vs. Palliative Care
“Palliative care is care provided based on patient & family needs &
goals and independent of prognosis.”

25. Source: NEJM 2014;370(26):2457-60.
Primary Care
vs.
End-of-Life Care
(Hospice Care)

26. Primary Care vs. Long-term Care
Source: Tishihiko Hasegawa (2013)
“Care Cycle”

27. Managing Long-Term Care
Source: Adapted from Feldman, Nadash & Gursen (2008)
1) Chronic Care
2) Palliative Care
3) Rehabilitative Services
• Activities of Daily Living (ADL)
• Instrumental Activities of Daily Living (IADL)
4) Supportive services
• Care plans, appointment arrangement
• Coordination between providers & patients-caregivers
• Logistics and supply of necessities
5) Care Management

28. Hospital Care vs. Primary Care:
Control Knobs Framework for Health Reform
Source: Adapted from Roberts et al. (2003).

29. Financing of Thai Healthcare System
CSMBS SSS UCS Motor Vehicle
Victim
Protection
Law
Private Health
Insurance
Feature State/Employer
welfare
Compulsory
heath insurance
with state
subsidies
State welfare Compulsory
heath insurance
for vehicle
owners
Voluntary health
insurance
Targeted groups
of beneficiaries
Civil servants,
state enterprise
employees and
dependents
Employees in
private sector and
temporary
employees in
public sector
Thai citizens
without the
coverage of
CSMBS & SSS
Victims of
vehicle accidents
General public
Source of
financing
Govt. budget Tri-party
(Employee,
employer and
govt. budget)
Govt. budget Vehicle owners Household
Method of
payment to
health facilities
Fee-for-service Capitation and
Fee-for-service
Capitation and
Fee-for-service
Fee-for-service Fee-for-service
Major problems Rapidly and
constantly rising
costs
Covering while
being employed
only
Inadequate
budget
Redundant
eligibility and
slow
disbursement
Redundant
eligibility and
slow
disbursement
Source: Adapted from Wibulpolprasert et al. (2011). Thailand Health Profile 2008-2010.

30. Major Mechanisms of
Healthcare Financing
Healthcare
Regulator(s)
2) Taxes
Payers
4)
Employer-
based private
health
insurance
3) Individual
private
health
insurance
Hospitals
Medical
Specialists
Generalists
& PCPs
1) Out-
of-pocket
Payments
Ambulatory
Facilities
Payment Mechanisms:
Salary, Fee-for-Service,
Global Budget,
Capitation, etc.

31. CGD
(CSMBS),
NHSO
(UCS)
Taxes Payers
Employer-based
private health
insurance
Individual &
Employer’s
private health
insurance
(Voluntary)
Hospitals
Medical
Specialists
Generalists
& PCPs
Patients paying out-of-pocket
Ambulatory
Facilities
Payment Mechanisms:
Salary, Fee-for-Service,
Global Budget,
Capitation, DRGs, etc.
Thai Healthcare Systems
Providers in
Public & Private Sector
Commercial
Insurance
Companies
Social
Security
Office (SSS)
Motor vehicle’s owners
(Mandatory by the Motor
Vehicle Victim Protection Law)

32. “Health System”
Pix source: WHO’s framework for action. (2007)

33. “Health System”
Source: who’s World Health Report (2000)

35. Pix source: www.noogenesis.com/pineapple/blind_men_elephant.html
Integrated Healthcare & Systems Thinking
John Godfrey Saxe's ( 1816-1887) version of the famous Indian legend

36. Pix source: www.simoncamilleri.com/the_truth_of_the_elephant/
Integrated Healthcare & Systems Thinking

37. Pix source: Don de Savigny and Taghreed Adam (2009).

38. Pix source: Don de Savigny and Taghreed Adam (2009).

39. Pix source: de Savigny & Adam (2009)
3 Major Levels of Health Systems

40. Performance of Thai Health System
Pix source: WHO (2000). World Health Report 2000.

41. Challenges of Thai Universal Health Coverage
Pix Source: www.hfocus.com

42. Q3: What policies are needed
for the future of PHC and
“Integrated Healthcare Management”?
Pix source: online.wsj.com

43. Major Issues in Thai Healthcare Systems
Frenk J, Chen L, Bhutta ZA, Cohen J, Crisp N, Evans T, et al.
Health professionals for a new century: transforming
education to strengthen health systems in an interdependent
world. The Lancet. 2010;376(9756):1923-58.

44. Thailand in 1960s
Pix Source: www.nationalguard.mil

45. Major Issues in Thai Healthcare Systems
• Thailand 1970s – Rural Health (“PHC")
• Thailand 2010s – ??
“Transformative education creates change agents.”
“But change agents create what?”

46. Rural vs. Urban
18,972,330
(31.1%)
29,133,829
(44.2%)
41,944,111
(68.9%)
36,847,830
(55.8%)
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
2543 2553
ประชากรในเขตเทศบาล ประชากรนอกเขตเทศบาล
Source: สำมะโนประชากรและเคหะ สำนักงานสถิติแห่งชาติ, accessed from http://service.nso.go.th/nso/nsopublish/service/servstat.html

47. Poor vs. Middle-class
Source: สำมะโนประชากรและเคหะ สำนักงานสถิติแห่งชาติ, accessed from http://service.nso.go.th/nso/nsopublish/service/servstat.html

48. Thai vs. Global Citizens
Source: http://news.bbc.co.uk

49. Urban Lifestyle?
Source: http://www.chaophya.com/index_th.php

50. Middle-class Lifestyle?
(Consumerism)
Source: http://www.facebook.com/www.jantrai

51. Source: Macagba, R. L. (1985). Hospitals and Primary Health Care: An International Study from the International
Hospital Federation. In M. Hardie (Ed.), World-wide survey on the Role of Hospitals in Primary Health Care. London:
International Hospital Federation.

52. Features of Primary Care Providers
Focus Public Health Medicine &Public Health
Setting Rural Urban
Professional
Perception
Generalist Specialist
Public
Perception
Second-tier Doctors
(“basic”)
Top-tier Doctors
(“personal & exclusive”)
System
Design
Moving
Assembly Lines
Customized
Services Systems

53. Delivery of PHC Services
Pix source: www.free-ed.net/free-ed/HealthCare/Physiology/default.asp
Structure & Organizations
of primary care services
• Patient Care Teams
• PCUs/Clinics
• Systems/Networks
• Governance policies
Four Cardinal Functions
of primary care services
• First Contact/Access
• Continuity
• Coordination
• Comprehensiveness
“Anatomy of Primary Care” “Physiology of Primary Care”

54. First
Contact/Access
Continuity Coordination Comprehensivenes
s
• Cost sharing
• Distance to PC
practice
• Distribution of
PC physicians
• List size
• Home visits in
PC
• Electronic access
• Computerization
of the practice
• Patient habits
with first contact
visits/referrals
• Endurance of
patient–provider
relationship
• PC practice
management
• Collaboration
among
practitioners
• Referral system
• Shared care
arrangements
• Premises,
equipment
• Medical
procedures
• Preventive,
rehabilitative,
educational
activities
• Disease
management
• Community links
• Technical skills
Desirable PHC Functions
Source: WHO/Europe (2010)
Ø Selected proxy measures from WHO/Europe’s Primary Care Evaluation Tool (PCET)

55. Source: Vasan et al. BMC Medicine 2014, 12:6

56. How “integrated care” could advance
primary care delivery?
Source: Vasan et al. BMC Medicine 2014, 12:6

57. Dealing with Complexity in Healthcare
Systems (UnitedHealth Group, USA)
Pix source: Lewis G. Sandy (2010). AcademyHealth 2010 Annual Research Meeting June 29, 2010

58. Care Coordination Innovations
(UnitedHealth Group, US)
Pix source: Lewis G. Sandy (2010). AcademyHealth 2010 Annual Research Meeting June 29, 2010

59. Traditional Work Flow in Clinics
(Cambridge Health Alliance, US)
Pix source: Southcentral Foundation & Institute of Healthcare Improvement (2010)

60. Redesign: Parallel Work Flow in Clinics
(Cambridge Health Alliance, US)
Pix source: Southcentral Foundation & Institute of Healthcare Improvement (2010)

61. Pre-visit Work in Geriatric Care
Pix source: Harvard Vanguard Medical Associates & Institute of Healthcare Improvement (2010)

62. Care Coordination: EMR
Pix source: Bates et al. (2003). A Proposal for Electronic Medical Records in U.S. Primary Care

63. Building Blocks of PHC Systems:
Research Needed
Pix source: WHO’s framework for action. (2007)
New financing?
• OOP?
• Co-payment?
• Membership fee?
New informatics?
• Mobile app?
• Personal health
data portal?
• Disadvantaged
population’s data
New organizational model?
• Team based providers?
• Linkage with hospital care?
New kinds of providers?
• MDs vs. non-MDs
• Professional Manager?
• Career path?
• Linkage with academia?
New kinds of products?
• Life-style modifications?
• Preventive medicine?
• Outlets of hospital ‘s
labs & pharmacy?
New governance?
• Focus on personal services
vs. on public health services
• Market vs. Central-planning

64. • Clinical outcomes of population-health-integrated PCUs vs.
individual-health-oriented PCUs
• Satisfaction of patients receiving care from PCUs located in urban
community vs. from PCUs attached to hospitals
• Satisfaction of primary care providers working in differently
organized PCUs
• Comparison of comprehensiveness of care delivered in differently
organized PCUs
• Financial risks of differently organized PCUs
• Appropriateness of office hours of urban PCUs
• Effectiveness of P&P programs in urban communities
Considerations for Further Study
Source: Leerapan (2012). Primary Care Services in Urban Settings: Lessons from International Experiences.

65. New Health Research Mapping?
Source: Hoffman et al. (2012).

66. New Health Research Mapping?
Source: Hoffman et al. (2012).
Different kinds of
knowledge are needed

67. Source: alumni.harvard.edu (2010).

68. Food-for-Thought
Pix source: online.wsj.com

69. “If I had asked people what they wanted,
they would have said faster horses.”
--Henry Ford

70. borwornsom.lee@mahidol.ac.th