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Community Oriented Primary Care
 

Community Oriented Primary Care

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    Community Oriented Primary Care Community Oriented Primary Care Presentation Transcript

    • Community-Oriented Primary Care ( ) January 25, 2008 R2 / VS
    • Community-Oriented Primary Care ( ) January 25, 2008 R2 / VS
    • Content What you have to know to be a family physician Primary Health Care COPC Something else... I want to share with all of you
    • Primary Health care ( Declaration of Alma-Alta Sept 12, 1978 Essential health care Appropriate technology Affordable and sustainable Community based Water, housing, sanitation, nutrition, traditional medicine
    • Primary Health Care 2A3C (Accessibility) (Accountability) (Continuity) (Comprehensiveness) (Coordination)
    • Primary Health Care First contact care 2A3C (Accessibility) (Accountability) (Continuity) (Comprehensiveness) (Coordination)
    • Primary Health Care regardless of the presence or First contact care absence of disease 2A3C (Accessibility) (Accountability) (Continuity) (Comprehensiveness) (Coordination)
    • Primary Health Care regardless of the presence or First contact care absence of disease 2A3C Integrationist (coordinating role) (Accessibility) (Accountability) (Continuity) (Comprehensiveness) (Coordination)
    • COPC is..... A systemic approach to the practice of medicine in the community built on principles of epidermiology and community organizing
    • COPC blends.. Public health vs. Personal health Care Epidermiology and Primary care Community empowerment Medical services, housing, water supplies,sanitation... Preventive medicine Health promotion
    • COPC Process COPC: Health Care for the 21st Century, Rhyne et al, 1998
    • COPC Process Geographic Special population Health care coverage “community” COPC: Health Care for the 21st Century, Rhyne et al, 1998
    • COPC Process Quantitative Geographic Qualitative Special population Health care coverage “community” COPC: Health Care for the 21st Century, Rhyne et al, 1998
    • COPC Process Quantitative Geographic Qualitative Special population Health care coverage “community” COPC: Health Care for the 21st Century, Rhyne et al, 1998
    • COPC Process Quantitative Geographic Qualitative Special population Health care coverage “community” COPC: Health Care for the 21st Century, Rhyne et al, 1998
    • Challenges to COPC The cost of doing business Reimbursement favors clinical services and technologic procedures Precise definition of COPC Chasm between clinical practice and public health Fragmented health care system Medical education
    • Future Roles Eliminate inequity Consumer empowerment Family physician
    • Medicine is a social science and politics is a medicine on a grand scale Dr. Rudolf Virchow 1821~1902
    • Context of Primary Care USA late 1960s ~early 1970s Vertical health approach in Malaria eradication Technology + doctors ≠ health Medical missionary: basic health service Christian Medical Commission 1970, it created this term “primary health care” Communist China
    • Context of Primary Care USA late 1960s ~early 1970s Vertical health approach in Malaria eradication Technology + doctors ≠ health Medical missionary: basic health service Christian Medical Commission 1970, it created this term “primary health care” Communist China Rural, not urban preventive not curative combined Western and traditional medicines
    • Alma-Ata China vs. Soviet Union Soviet Union will offer $US 2 million Cold war Western technology decline Grossroots, and socio-political alternatives Approved by acclamation A victim of the ideological clash between communism and capitalism
    • Root of COPC Sidney and Emily Kark, South Africa Society for the Study of Medical Conditions Among the Bantu Pholea, Kwazulu-Natal, 1940 Institute of Family and Community Health, University of Natal at Durban 1948, apartheid restriction
    • COPC: A Path to Community Development H. Jack Geiger Late 1960s~early 1970s Northern Bolivar County in the Mississippi Deltas Medical services, housing, water supplies, sanitation Community empowerment program Self-perpetuating
    • Primary care in the driver’s seat? Rising health expenditure Multiple disease and different disciplines Better health outcome Lower costs Greater equity in health
    • Better Health outcome Policy relevant determinants of health- an international perspective. Health Policy 2002; 60(3):201-218.
    • Better Health outcome Policy relevant determinants of health- an international perspective. Health Policy 2002; 60(3):201-218.
    • Lower cost Poorer primary care, spend more Stronger the primary care, the lower the total health care expenditures Policy relevant determinants of health- an international perspective. Health Policy 2002; 60(3):201-218.
    • USA WHO, Countries
    • USA Cuba WHO, Countries
    • Consultorio: 600 pts or 150 families Consultori--> Poclinico Each poclinico ser ves 30-40 consultorio How Cuba Achieve? GPs spend spend half-day per week joining their patients for specialist visits in policlinico 2001, 35% residency graduates specialized further Consultorio➙Policlinico
    • Consultorio: 600 pts or 150 families Consultori--> Poclinico Each poclinico ser ves 30-40 consultorio How Cuba Achieve? GPs spend spend half-day per week joining their patients for specialist visits in policlinico Complementary and Alternative medicine 2001, 35% residency Herbal medicine, acupuncture, graduates specialized further homeotherapy, floral/essence therapy... Green Medicine Consultorio➙Policlinico Natural Medicine Clinics
    • Major effecting factor Policy relevant determinants of health- an international perspective. Health Policy 2002; 60(3):201-218.
    • Density of GPs in Europe
    • First contact
    • First contact Acute problem: burnt hand, first symptoms of convulsion, sprained ankle, paralysis Children Woman: OCP, irregular menstruation, lump in breast Psycho-social problems: relationship problems, suicidal ideation, work-related stress
    • Comprehensiveness Tx and F/U: hyperthyroidism, acute CVA, UC, MI Technique procedure: removal of warts, IUD, removal of rusty spots on cornea, joint injection Cervical screen Health education: smoking, diet or alcohol intake Family planning
    • Collaboration
    • Low satisfication
    • Low satisfication Some Parts of my work do not really make sense
    • 2004: Primary care The Future of Primary Medicine NEJM (2004) 351;7, 710~712
    • 2006: Will it Survive? Primary Care-Will It Survive? NEJM 355;9, 861-864, 2006
    • 2006: Will it Survive? Primary Care-Will It Survive? NEJM 355;9, 861-864, 2006
    • 2007: Saving Primary Care Graduating Family physician decreased by 12% since 1998 35% of physicians are aged >55y/o March 2007 FM programs: 100 fewer positions (500 fewer than 2000) 88% of those were filled; only 42% from US AM J Med 2007;120:99-102
    • Exodus Money Pay subspecialist 5-40 times more to perform a procedure than pays a primary care physician to discuss whether the precedure is consistent with the patient’s goal Payment system do not recognize the value of avoiding more expensive care Telephone, e-mail, coordinate Lifestyle: controllable life
    • Exodus Hamster Health Care “Across the globe doctors are miserable because they feel like hamsters on a treadmill. They must run faster just to stay still.” Morrison and Smith, BMJ, 2000; 321;1541-1542 Substantial work outside the office Administrative paperwork
    • Running Hamster Time require to deliver all highly recommended chronic care services: 10.6 hours/day Is there time for management of patients with chronic diseases in primary care? Ann Fam Med 3:209-214 (2005) Time require to deliver all highly recommended preventive services: 7.4 hours/working day Primary Care: Is There2003 Time for Prevention?? AJPH 93(4): 635-641 Enough Raised expectation
    • Time is enough? Duration of visit US: 16.5 min Australia: 15 min New Zealand: 14.9 min Mean time spent per year US: 29.7 min Australia: 83.4 min New Zealand: 55.5 min Diagnostic scope of and exposure to primary care physicians in Australia, New Zealand, and the United States: cross sectional analysis of results from three national surveys BMJ 2007;334;1261-1267
    • Saving Primary Care Discarding the Artisan model Promoting a New Vision As quarterback,rather than decathlete Changing Medical Groups information system Training Programs Schedule patients examination AM J Med 2007;120:99-102
    • Saving Primary Care Improving professional lifestyles Predictable work hours, less call, more flexibility Financial incentives Reimbursement system too heavily weighted procedure Zero-sum game AM J Med 2007;120:99-102
    • Raising Health Expenditure
    • 2005