Integrating prevention into primary healthcare - Jan Savage

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Presentation from the AFAO National Symposium on Prevention, held in Sydney, Thursday 27 May, 2010.

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  • Asked to discuss tertiary prevention and the primary health care sector, Will be focusing on MACSD project done last year by ASHM and NAPWA for the ministerial advisory committee
  • I’ll highlight findings of the MACSD project related to service access and delivery and workforce consequences and how these approaches are relevant to tertiary prevention in primary health care
  • I’m not going to be talking about the Commonwealth and states and health reform and funding
  • Nor will I talk about novel approaches to preventing cigarette smoking
  • So I’ll start by talking about tertiary prevention.Tertiary prevention aims to improve the QoL of people with a particular condition. For HIV it includes interventions such as ART, but definitions become a bit blurry if you then consider the prevention of side effects of tertiary prevention, such as managing cardiovascular risk – smoking, lipids etc There is a context here: tertiary interventions are inextricably and irrevocably linked to other aspects of our clients’/populations’ lives. For example ART use involves a series of steps: decision to initiation and continued use can be complex Generally applied to medical interventions however obviously has a non-medical, non-clinical component
  • Turn now to the health care component. This definition has been around for a while - 22 years old. Here, primary healthcare describes a continuum from maintenance and promotion of health to the management of illness of individuals and populations.It is provided by general practice, and our health system places GPs at the heart of services, in superclinics; it’s provided through community health centres and these vary across the country, through allied health professionals, within CBOs and advocacy organisationsThese groups all have roles to play in providing tertiary prevention and communication within and across these agencies is essential
  • This report addresses the provision of HIV clinical services in the face of the anticipated change to the demographics and clinical situation of people with HIV in Australia. The number of people with HIV is increasing due to continuing occurrence of new infections and diagnoses and the increased life expectancy of people with HIV as a result of improved therapies. The pattern of HIV as a disease is changing too, as a result of medical advances. It can be viewed as a chronic condition, with an initial and brief acute component at the time of seroconversion, a protracted, asymptomatic stage with minimal therapeutic intervention and a period of more intensive and complex clinical intervention. Death may be related to HIV, to co-morbidities, to a combination of both or, of course, to unrelated events.The report also considered what responses were needed from the health workforce to deal effectively with these changes
  • These qualities were consistently identified in the national and international literature as critical to effective service access and delivery.The national chronic disease strategy sets this out well, such as the integration of targeted and general preventative activities into primary care and the pathway to service coordination and communication and they were echoed in the national mental health plan and other jurisdictional strategies
  • Much of this developed from chronic care models and chronic disease strategies in Australia and internationally.From the chronic disease strategySelf management is a care model where the patient is actively engaged in and takes responsibility their healthcare. This model requires an informed, motivated and skilled patient with very good negotiation and communication skills: patients, providers and carers must be trained in roles and responsibilitiesFrom the Primary healthcare strategybetter rewarding prevention. promoting evidence-based management of chronic disease. supporting patients with chronic disease to manage their condition. supporting the role GPs play in the health care team. addressing the growing need for access to other health professionals, including practice nurses and allied health professionals like physiotherapists and dieticians. encouraging a greater focus on multidisciplinary team-based care. Wagner’s chronic care modelSelf management, coordination, evidence based, supportive delivery, information and health systems, community involvement
  • Nationally and internationally there is v little evidence about the factors that affect access to and delivery of HIV services and their relationship to outcomes (cf process). These factors were found to be positively associated with improved ART uptake by clients.
  • Need to consider all of client: HIV and ART and ageing and cardiovascular risk factors, lifestyle, social determinants etc and how to offer effective services and where these needs will be well metDifferent processes of engagement and referralImportance of support and ongoing professional development for all workersSystem change: culture etc for primary health care, secondary, community cased care and supportService re-orientation – what do non-clinical services have to consider? Do they want a (different) role providing clinical supportRole of mainstreamWorkforce issues
  • Shared care and exploration. What are features: define client and provider need and develop community supportsHigh caseload support – evaluate with respect to recruitment and retentionNurses: practice nurses, nurse practitioners (specialist), community based nursesTime of diagnosisEnabling – nat strategies, data, ministerial advisory committee etc
  • Integrating prevention into primary healthcare - Jan Savage

    1. 1. Integrating prevention into primary healthcare<br />Jan Savage ASHM<br />AFAO National Symposium on Prevention May 2010<br />
    2. 2. Integrating prevention into primary healthcare<br />Models of access to and delivery of clinical services for people with HIV project <br />Models for delivery<br />Workforce issues<br />Suggested approaches to integration and some issues arising<br />
    3. 3.
    4. 4.
    5. 5. Tertiary prevention in HIV<br />Interventions which improve the quality of life for people with existing diseases and disabilities<br />ART<br />OI prophylaxis<br />Prevention of therapeutic side effects etc.<br />Intermeshed with other aspects of wellbeing<br />Co-morbidities, age related, mental health, social determinants and other preventative activities etc<br />Traditionally medicalised in various settings<br />
    6. 6. Primary healthcare<br />Primary Health Care (PHC): <br /> “seeks to extend the first level of the health system from sick care to the development of health. It seeks to protect and promote the health of defined communities and to address individual and population health problems at an early stage. PHC services involve continuity of care, health promotion and education, integration of prevention with sick care, a concern for population as well as individual health, community involvement and the use of appropriate technology.” <br />Australian Health Ministers’ Council (1988) from the National Primary Health Care Partnership website http://www.nphcp.com.au/site/index.cfm?display=30987<br />
    7. 7. Models of access to and delivery of clinical services for people with HIV project <br />In response to changes to population of people with HIV: demographics, health and well being, treatment improvements<br />Recognition of ongoing and emerging workforce issues: supply, recruitment retention and training across all professional groups<br />
    8. 8. Recurrent themes – big picture<br />Policy and funding support and change<br />Patient and carer centred models<br />Spectrum of responses from prevention of condition to end-of-life<br />Key role of community <br />Health systems<br />Responsive, integrated, coordinated, flexible, evidence based and supported by<br />Effective and strategic planning<br />Information management systems and communication technology<br />Workforce – GP, development<br />Evaluation and research<br />
    9. 9. Recurrent themes - services<br />Service access: geographical and cultural<br />Service delivery: re-oriented, patient centred, integrated, coordinated, multi-disciplinary<br />Delivered through:<br />Self management, supported or comprehensive care<br />Shared care, nurse practitioners<br />Strong and clear referral pathways<br />Access to primary, specialist and multidisciplinary teams based care etc<br />
    10. 10. Evidence base and HIV<br />Access<br />Service and delivery models – multi-disciplinary, dedicated case managers<br />Integrated information systems<br />Physical access and cost<br />Delivery<br />High case loads<br />Case management<br />Workforce<br />Mostly untested. Need financial and ‘lifestyle’ incentives, need system change and support for change<br />
    11. 11. Services in Australia<br />Specialist hospital and sexual health clinics<br />Specialist general practices<br />Low case load general practices <br />Other services: medical, social and community<br />Service requirements defined by individual state of health<br />
    12. 12. Issues for tertiary prevention in primary healthcare<br />What tertiary prevention is required and when; what else is required to support an individual with HIV eg other aspects of prevention ‘tertiary plus’ (age related and HIV prostate etc)?<br />Process<br />Client group – engagement and support<br />Providers – introducing and maintaining engagement and skills, avoiding burnout<br />Applying system change, service access and delivery change and re-orientation, for example: <br />Continuum from diagnosis to end-of life<br />Self managed care<br />Multi-disciplinary teams<br />Necessary system supports eg planning, IT, communication etc<br />Consider re-orientation of services to address medical aspects of tertiary prevention (eg adherence, side effects, smoking, exercise). How to manage?<br />Using mainstream services, expertise and funding including shared care between eg specialist and GPs, nurses, specialist nurses, nurses managers<br />Workforce re-orientation in content and system: doctors, nurses, health educators, community workers etc<br />
    13. 13. Demonstration projects<br />Deliver shared care in the community<br />Support individual high caseload general practices through tailored solutions <br />Explore, implement and evaluate a range of nurse based strategies aimed at increasing access to clinical service delivery<br />Implement and evaluate <br />strategies aimed at increasing the linkage between laboratory and clinical settings<br />innovative strategies for linking with patients and with doctors at time of diagnosis<br />Support, implement and evaluate<br />e-health strategies<br />communication between services<br />self management strategies and exploring these in tandem with above priorities<br />Supportive and enabling recommendations<br />
    14. 14. Conclusion<br />Delivery of appropriate clinical services including tertiary prevention can be improved and integrated into primary healthcare with roles for providers beyond the clinic. <br />Effective management of the major changes to health system(s) and access and delivery of clinical services is critical.<br />Response to consequent changes to community sector and the HIV health workforce will be required.<br />

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