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 w...
Primary Health care
          (
Declaration of Alma-Alta
 Sept 12, 1978
 Essential health care
 Appropriate technology
 Af...
Primary Health Care


2A3C
       (Accessibility)

       (Accountability)

       (Continuity)

       (Comprehensiveness...
Primary Health Care
  First contact care




2A3C
       (Accessibility)

       (Accountability)

       (Continuity)

  ...
Primary Health Care          regardless of the presence or
  First contact care             absence of disease




2A3C
  ...
Primary Health Care             regardless of the presence or
  First contact care                absence of disease




2...
COPC is.....
A systemic approach to the practice of
medicine in the community built on
principles of epidermiology and
com...
COPC blends..
Public health vs. Personal health Care
Epidermiology and Primary care
Community empowerment
Medical services...
COPC Process




   COPC: Health Care for the 21st Century, Rhyne et al, 1998
COPC Process
  Geographic
  Special population
  Health care coverage
“community”




                         COPC: Healt...
COPC Process
                                                       Quantitative
  Geographic                             ...
COPC Process
                                                       Quantitative
  Geographic                             ...
COPC Process
                                                       Quantitative
  Geographic                             ...
Challenges to COPC
The cost of doing business
  Reimbursement favors clinical services and
  technologic procedures

Preci...
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 + doc...
Context of Primary Care
 USA late 1960s ~early 1970s
   Vertical health approach in Malaria eradication

 Technology + doc...
Alma-Ata
China vs. Soviet Union
Soviet Union will offer $US 2 million
Cold war
  Western technology decline
  Grossroots, ...
Root of COPC
Sidney and Emily Kark, South Africa
Society for the Study of Medical Conditions
Among the Bantu
Pholea, Kwazu...
COPC: A Path to Community
      Development
H. Jack Geiger
Late 1960s~early 1970s
Northern Bolivar County in
the Mississip...
Primary care in the driver’s
          seat?

Rising health expenditure
Multiple disease and different disciplines
Better ...
Better Health outcome




          Policy relevant determinants of health- an international
          perspective. Health...
Better Health outcome




          Policy relevant determinants of health- an international
          perspective. Health...
Lower cost
Poorer primary
care, spend more
Stronger the
primary care, the
lower the total
health care
expenditures
       ...
USA




      WHO, Countries
USA




Cuba




       WHO, Countries
Consultorio: 600 pts or 150
families

Consultori--> Poclinico

Each poclinico ser ves 30-40
consultorio
                  ...
Consultorio: 600 pts or 150
families

Consultori--> Poclinico

Each poclinico ser ves 30-40
consultorio
                  ...
Major effecting factor




     Policy relevant determinants of health- an international
     perspective. Health Policy 2...
Density of GPs in Europe
First contact
First contact

                 Acute problem: burnt
            hand, first symptoms of
            convulsion, sprained a...
Comprehensiveness

                 Tx and F/U:
            hyperthyroidism, acute CVA, UC,
            MI
               ...
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
...
Exodus
Money
  Pay subspecialist 5-40 times more to perform a
  procedure than pays a primary care physician
  to discuss ...
Exodus

Hamster Health Care
  “Across the globe doctors are miserable because they
  feel like hamsters on a treadmill. Th...
Running Hamster
Time require to deliver all highly
recommended chronic care services:
10.6 hours/day     Is there time for...
Time is enough?
Duration of visit
  US: 16.5 min

  Australia: 15 min

  New Zealand: 14.9 min

Mean time spent
per year
 ...
Saving Primary Care
Discarding the Artisan model
Promoting a New Vision
 As quarterback,rather than decathlete

Changing M...
Saving Primary Care
Improving professional lifestyles
  Predictable work hours, less call, more
  flexibility

Financial in...
Raising Health Expenditure
2005
Community Oriented Primary Care
Community Oriented Primary Care
Community Oriented Primary Care
Community Oriented Primary Care
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Community Oriented Primary Care

  1. 1. Community-Oriented Primary Care ( ) January 25, 2008 R2 / VS
  2. 2. Community-Oriented Primary Care ( ) January 25, 2008 R2 / VS
  3. 3. 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
  4. 4. 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
  5. 5. Primary Health Care 2A3C (Accessibility) (Accountability) (Continuity) (Comprehensiveness) (Coordination)
  6. 6. Primary Health Care First contact care 2A3C (Accessibility) (Accountability) (Continuity) (Comprehensiveness) (Coordination)
  7. 7. Primary Health Care regardless of the presence or First contact care absence of disease 2A3C (Accessibility) (Accountability) (Continuity) (Comprehensiveness) (Coordination)
  8. 8. Primary Health Care regardless of the presence or First contact care absence of disease 2A3C Integrationist (coordinating role) (Accessibility) (Accountability) (Continuity) (Comprehensiveness) (Coordination)
  9. 9. COPC is..... A systemic approach to the practice of medicine in the community built on principles of epidermiology and community organizing
  10. 10. COPC blends.. Public health vs. Personal health Care Epidermiology and Primary care Community empowerment Medical services, housing, water supplies,sanitation... Preventive medicine Health promotion
  11. 11. COPC Process COPC: Health Care for the 21st Century, Rhyne et al, 1998
  12. 12. COPC Process Geographic Special population Health care coverage “community” COPC: Health Care for the 21st Century, Rhyne et al, 1998
  13. 13. COPC Process Quantitative Geographic Qualitative Special population Health care coverage “community” COPC: Health Care for the 21st Century, Rhyne et al, 1998
  14. 14. COPC Process Quantitative Geographic Qualitative Special population Health care coverage “community” COPC: Health Care for the 21st Century, Rhyne et al, 1998
  15. 15. COPC Process Quantitative Geographic Qualitative Special population Health care coverage “community” COPC: Health Care for the 21st Century, Rhyne et al, 1998
  16. 16. 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
  17. 17. Future Roles Eliminate inequity Consumer empowerment Family physician
  18. 18. Medicine is a social science and politics is a medicine on a grand scale Dr. Rudolf Virchow 1821~1902
  19. 19. 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
  20. 20. 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
  21. 21. 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
  22. 22. 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
  23. 23. 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
  24. 24. Primary care in the driver’s seat? Rising health expenditure Multiple disease and different disciplines Better health outcome Lower costs Greater equity in health
  25. 25. Better Health outcome Policy relevant determinants of health- an international perspective. Health Policy 2002; 60(3):201-218.
  26. 26. Better Health outcome Policy relevant determinants of health- an international perspective. Health Policy 2002; 60(3):201-218.
  27. 27. 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.
  28. 28. USA WHO, Countries
  29. 29. USA Cuba WHO, Countries
  30. 30. 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
  31. 31. 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
  32. 32. Major effecting factor Policy relevant determinants of health- an international perspective. Health Policy 2002; 60(3):201-218.
  33. 33. Density of GPs in Europe
  34. 34. First contact
  35. 35. 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
  36. 36. 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
  37. 37. Collaboration
  38. 38. Low satisfication
  39. 39. Low satisfication Some Parts of my work do not really make sense
  40. 40. 2004: Primary care The Future of Primary Medicine NEJM (2004) 351;7, 710~712
  41. 41. 2006: Will it Survive? Primary Care-Will It Survive? NEJM 355;9, 861-864, 2006
  42. 42. 2006: Will it Survive? Primary Care-Will It Survive? NEJM 355;9, 861-864, 2006
  43. 43. 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
  44. 44. 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
  45. 45. 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
  46. 46. 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
  47. 47. 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
  48. 48. 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
  49. 49. 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
  50. 50. Raising Health Expenditure
  51. 51. 2005

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