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Role of Family Physicians in
fighting the health risks;
Home Care as a tool
Professor Faisal Abdul Latif Alnasir FPC, FRCGP, MICGP, FFPH,
PhD
Chairman; Dept of Family & Community Medicine
Arabian Gulf University. Bahrain
President; Scientific Council Family & Com. Medicine
Arab Board for Medical Specializations
General Secretary: Inter. Society for the History of Islamic Medicine
F. Alnasir 2012
‫ا‬‫هي‬ ‫الطب‬ ‫صناعة‬ ‫ن‬"‫أقدم‬ ‫بها‬ ‫والعلم‬ ‫الصنائع‬ ‫أشرف‬
‫العلوم‬"‫سائر‬ ‫على‬ ‫المرتبة‬ ‫في‬ ‫تتقدم‬ ‫أن‬ ‫ويجب‬
‫والمهن‬ ‫الصنائع‬.
(‫في‬‫الطبيب‬ ‫أدب‬)
(‫الرهاوي‬ ‫علي‬ ‫بن‬ ‫اسحق‬)
(‫الهجري‬ ‫الرابع‬ ‫القرن‬)
F. Alnasir 2012
3
• Family Practice / Primary Health Care
• Effect of PHC on Health Of the Nation
• Why PHC
• Cost Health Care
• Home Health Care as an example
F. Alnasir 2012
4
Family Practice is the medical specialty
which provides continuing,
comprehensive health care for the
individual and family. It is a specialty in
breadth that integrates the biological,
clinical and behavioral sciences. The
scope of family practice encompasses
all ages, both sexes, each organ system
and every disease entity.
F. Alnasir 2012
5
Family Medicine is centered on lasting,
caring relationships with patients and
their families. Family physicians
integrate the biological, clinical and
behavioral sciences to provide
continuing and comprehensive health
care. The scope of family medicine
encompasses all ages, sexes, each
organ system and every disease entity.
Dept Of Family Medicine University of Chicago
F. Alnasir 2012
6
FM: One place you could go for all
your health concerns.
Primary health care refers to health
care services that are provided
outside the hospital.
F. Alnasir 2012
7
Family medicine is a person-focused
and should not be disease-focused
discipline; i.e., based on the health of
people and populations.
The World Health Report 2008,
Primary Health Care – Now More Than
Ever, indicates that this requires a
renewed universal emphasis on
primary health care – i.e., person-
focused care over time, not disease-
focused care.
World Health Organization. The World Health Report 2008F. Alnasir 2012
8
Why Family Medicine is needed in
every nation:
• Invading serious healthcare
challenges
• Family medicine is the answer to the
health care challenges facing nations
• PC is the foundation of any
successful health system
F. Alnasir 2012
9
WHO as well as a number of other
international commissions, reflect the
widespread acceptance of the
importance of primary health care.
Barbra Starfield, 2012
Both People's Health Movement and
WHO agree that primary healthcare
makes a considerable contribution to
reducing the adverse impact of social
inequalities on health.
Sanders D, et al 2011, Rasanathan K, et al 2011F. Alnasir 2012
10
Primary healthcare-oriented health systems
have been shown to be generally more
effective in achieving better health (particularly
at young ages) at lower costs than is the case
for systems more oriented to disease
management and specialty care.
Even in the USA, “one of the most inequitable
societies in the industrialized world”, better
primary care resources preferentially improve
health more in socially disadvantaged
populations than in the majority population.
Starfield B. Shi L, Macinko J. 2005
F. Alnasir 2012
11
Strong primary care health systems
are more likely to provide better
population health, better distribution
(more equity) in health throughout the
populations, and greater economy in
the use of resources.
Barbra Starfield, 2012.
F. Alnasir 2012
12
Stronger primary care should
produce better outcomes than
weaker primary care
F. Alnasir 2012
13
It is known that, “within certain
bounds, neither the wealth of a
country nor the total number of health
personnel are related to health
levels”.
What counts is the existence of key
features of health policy (Primary
Health Care)
Barbra Starfield, 2012.
F. Alnasir 2012
14
It's very well documented:
“That a system that is based on
primary care can provide higher
quality care,"
said Dr. Minal Kale, of the Mount Sinai School of Medicine in New York.2012
F. Alnasir 2012
F. Alnasir 2012
Tertiary
Secondary
PRIMARY CARE
F. Alnasir 2012
Tertiary
Secondary
Primary
17
Studies consistently find that the supply
of primary care physicians is associated
with:
•better quality of care
•better population health
•lower cost of care
Stange KC, Ferrer RL. Paradox of primary care. Ann Fam Med 2009
F. Alnasir 2012
18
In USA a study in 2011, found that
seniors living in areas with more primary
care doctors were less likely to be
hospitalized with a preventable disease
and had lower death rates.
Reuters Health story of May 24, 2011. http://reut.rs/O2itHr
F. Alnasir 2012
19
In Thailand after primary care reform was
initiated in the early 1990s, there was marked
improvement in under-5 mortality
Vapattanawong P, et al, 2007
In Ontario, Canada, populations in areas with
greater primary care physician supply have
better experiences with a wide variety of
healthcare access and outcome indicators—
even more so in lower income areas than in
higher income ones.
Guttmann A, et al.2010
F. Alnasir 2012
20
Brazil in 1990 built health services system based on
strong PHC. During the period 1990-2007, the following were
found:
• Improvements in maternal education
• Large reductions in post-neonatal mortality and under-5
mortality.
• Infant mortality declined 40% between 1990 and 2002;
controlling for other impacts on infant mortality.
• A 10% increase in primary care coverage was associated
with an average 4.6% decline in infant mortality.
• Decrease in absolute rich-poor differences in infant and
child mortality across different areas.
• Large decline in hospitalizations for primary care sensitive
conditions and for chronic diseases by 25-30%, especially
(cardiovascular diseases, asthma, hypertension, stroke).
• In general hospitalizations that would be prevented by
good primary care declined by over 5% annually.
Macinko J, et-al.2006, 2010, 2011F. Alnasir 2012
21
In Bahrain
After adopting the primary Health Care
Policy and start of the Family Residency
Program in 1983, there were;
• Decrease in AE attenders
• Decrease in unnecessary referral
• Decrease in the prevalence of
hereditary blood diseases
• Increase health awareness
Alnasir,Faisal
F. Alnasir 2012
22
Among 90 countries with Gross National
Income of less than $10,000 per person,
30 have moved toward primary health
care. Of these 30, 14 moved to
comprehensive primary care (defined as
skilled attendance at birth).
These 14 have achieved much lower
under-five mortality rates along with
greater equity in health care as well as
more equitable distribution of health
services.
Rohde J, et al 2008F. Alnasir 2012
23
In the United States
An increase of one primary care doctor
(PCP) per 10,000 population (approximately a
15% increase) (after controlling for income inequality, education, unemployment,
racial/ethnic composition, urban/rural location, percentage elderly, percentage living in poverty
and/or low income) is associated with:
• 1.44 fewer deaths per 10,000 population
• a 2.5% reduction in infant mortality
• a 3.2% reduction in low birth weight
Shi L, Macinko J, Starfield B, et-al. 2004.
F. Alnasir 2012
24
In the United States
An increase of one primary care doctor
(PCP) per 10,000 population (approximately a
15% increase) (after controlling for income inequality, education, unemployment,
racial/ethnic composition, urban/rural location, percentage elderly, percentage living in poverty
and/or low income) is associated with reduction:
• Inpatient admissions by an estimated 6%,
• Outpatient visits by 5%,
• Emergency room visits by 10%
• Surgeries by over 7%.
Kravet SJ, Shore AD, Miller R, et-al.2008
F. Alnasir 2012
25
A nationally representative USA study
showed that adults and children with a
Family Physician (rather than a general
internist, pediatrician, or sub-specialist)
as their regular source of care had:
• reported less difficulty in accessing
care
• lower annual cost of care
• made fewer visits
• had 25% fewer prescriptions
Phillips RL, et-al. 2009
F. Alnasir 2012
Starfield Barbra
No equity in Health
Care
• Budget allocated is on
an average of 70% to
80% to Secondary and
tertiary care.
• Health care human
resources are allocated
more to secondary and
tertiary care (80% to
20%)
0
10
20
30
40
50
60
70
80
PC SC TC
F. Alnasir 2012
27
Primary health care can now be
measured and assessed; all innovations
and enhancements in it must serve its
essential features in order to be useful.
Barbra Starfield, 2012
F. Alnasir 2012
28
Two in five adults in the U.S.
are getting general
healthcare from specialist
doctors, according to a new
study.
Researchers found that in
1999 and 2007,
approximately 59% of visits
family physicians and 41%
were to specialists, such as
internists and obstetricians-
gynecologists.
Andrew M. Seaman, (Reuters Health) 2012
0
10
20
30
40
50
60
FP Specialist
F. Alnasir 2012
29
In USA Specialists now provide a significant
percentage of primary care services.
A 2012 Archives of Internal Medicine study
found that 41% of primary care office visits
were provided by specialists.
The Wrong Battles
Brian Klepper, Sep 20, 2012
F. Alnasir 2012
30
A study examined more than a billion patient
encounters between 2002-2004 in USA
found:
46.3% of specialist visits were for preventive
care or routine follow-up of patients who the
specialist had previously seen.
New referrals accounted for only 30.4% of all
visits. Many of these visits could be handled
competently and far more cost-effectively by a
generalist.
The Wrong Battles
Brian Klepper, Sep 20, 2012
F. Alnasir 2012
Shi. Jam Board Fam Practic 2003;16:412-22
Mortality Outcome
• Specialists:
Increase of 1 Specialists/10000 (8%more)
increases mortality by 16 per 100000
(2% more deaths)
• Primary Care Physicians:
Increase of 1 PCP/10000 (20%) would
decreases mortality by 40 per 100000
(5% fewer deaths)
• Family Physicians;
Increase of 1 FP/10000 (33%more) results
in decrease mortality by 70 per 100000
(9% fewer deaths)
-80
-70
-60
-50
-40
-30
-20
-10
0
10
20
30
SP PCP FP
F. Alnasir 2012
Baicker et al.,2004
Cost implication
Increasing 1 physicians/10000
population would:
Specialists;
-Increase costs $526/beneficiary
and decrease quality
Primary care;
-Decrease costs
$684/beneficiary and increase
quality
-800
-600
-400
-200
0
200
400
600
SP FP
F. Alnasir 2012
33
In 2010 a study found
that primary care
doctors in the USA earn
about $60 per hour,
which is much less than
the $92 per hour and
$85 per hour rates for
surgeons and ob-gyns,
respectively.
FP Obgyn Surgeon
0
20
40
60
80
100
Earn
(Reuters Health story of October 25, 2010.
http://reut.rs/O2mVG9)
F. Alnasir 2012
34
Why do people get worse with specialists:
-Outside areas of expertise1
-Late stage diagnosis of cancers (Breast 2 or
Colorectal3)
-Excessive utilization4
-Communication errors5
1. Weingarton et al Arch int Med 2002: 162:627-532
2. Ferrante et al J Am Board Fam Pract 2000;13;408-414
3. Rotezheim et al J Fam Pract 1999:48:850-858
4. Greenfield et al. JAMa 1992:367; 1024-1030
5. Skinner et al Health Affairs 2006; 25;w34-w37
F. Alnasir 2012
35
Care during family physician visits is
more complex per hour than the care
during visits to cardiologists or
psychiatrists. This may account for a
lower rate of completion of process items
measured for quality of care.
The complexity of care provided per hour
in general/family practice is 33% more
relative to cardiology and 5 times more
relative to psychiatry.
David K ,Robert W,Carlos J, 2011
F. Alnasir 2012
36
Policy for success of any PHC:
1. Any reform of health system must ensure equity
2. Ensure quality and safety
3. Continuity of care is the corner stone of any PC
4. Ensure the sustainability of PC services
5. Community engagement is an essential
component of PC policy development
6. Health promotion and prevention are core
components of the work carried out in PC
7. Strengthen the role of PC in chronic disease
management
8. Support and grow PC workforce
9. Exploit new technologies
10.Address the specialist needs of each group of
people within the community.
F. Alnasir 2012
37
F. Alnasir 2012
‫ممم‬‫م‬‫عل‬‫ممب‬‫م‬‫الط‬"‫ممي‬‫م‬‫له‬ ‫ا‬ ‫ممم‬‫م‬‫العل‬ ‫ممد‬‫م‬‫بع‬ ‫مموم‬‫م‬‫العل‬ ‫ممرف‬‫م‬‫أش‬"‫ألن‬
‫موضوعه‬“‫نسان‬ ‫ا‬ ‫بدن‬”‫أشرف‬ ‫هو‬ ‫الذي‬‫الخلق‬
(‫الفارسي‬ ‫مصلح‬ ‫بن‬ ‫سعود‬ ‫بن‬ ‫محمود‬)
(710‫هجرية‬)
F. Alnasir 2012
39
Home Health Care Services
F. Alnasir 2012
40
Delivery of various items and
services directly to the home has
mushroomed since the beginning of
this century.
The philosophy behind home delivery
is to reduce the hassle of getting the
service from its source, requiring
effort, causing stress and costing
money.
F. Alnasir 2012
41
WHO Define Home Care as:
Provision of health services by formal and
informal caregivers in the home.
This includes physical psychological,
palliative and spiritual activities.
Home care services can be classified into
preventive, promotive, therapeutic,
rehabilitative long term and palliative
care.
F. Alnasir 2012
F. Alnasir 2012
43
The medical home is conceptualized
as an approach which provides
comprehensive primary care, fosters
a close partnering relationship
between patient and provider and,
when appropriate, their family as
well.
F. Alnasir 2012
44
Home care are offered by
interdisciplinary team, but due to
many reasons, doctors, most of the
time are not part of this.
Boling quoted that “there are still
policies that make it difficult for a
physician to be part of the
interdisciplinary team providing home
care”
Peter A. Boling, 1997
F. Alnasir 2012
45
To be able to offer these services
within the patient’s home, special
characteristics, skills and attitude are
required from each team member.
Since home is considered the
patient’s safe haven, many factors,
whether familial, social or
environmental, factors interact,
affecting the well-being of the
individual.
Alnasir F, 2009
F. Alnasir 2012
46
The role of this team:
Providing the required services to
patients within their home
environment without the hassle of
moving the patient to primary,
secondary, or tertiary care units to
meet their needs.
F. Alnasir 2012
47
Why there is demand for home care?
•Demographic trends with ageing population.
•Changes in family structures and role of
women
•Increased focus on person-centred services
•Availability of new support technologies
•Need to redesign health systems to improve
responsiveness, continuity, efficiency and
equity.
Home care in Europe, WHO European office (2008) Copenhagen WHO
F. Alnasir 2012
48
Advantages of HHC:
• provision of care in the home environment where
patients are surrounded by their beloved ones
giving the patient a positive element of support,
reducing strain and anxiety induced by separation.
• Decreasing the risk of noso-comial infection, due to
shorter periods of hospital stay.
• When HHC is provided in a professional, well-
planned way, it could replace some non-urgent
hospital stay.
• HHC could reduce patients’ hospital stays by
allowing earlier discharge.
• Offers an opportunity for home health nurses to
provide vital home care which is complex using a
high technology approach.
Humphrey, Carolyn J. 2009.F. Alnasir 2012
49
F. Alnasir 2012
50
The medical role should be well-
organized and known before the
home visit. For this reason, the
American Medical Association (AMA)
developed guidelines for physicians
when they practice home care
American Medical Association, 1992.
F. Alnasir 2012
51
As part of the medical care provided
to patients in the UK, the Department
of Health has recommended
replacing hospital admissions by
offering in home treatment for acute
problems.
Harrison, Judy et al 2003.
F. Alnasir 2012
52
In the USA, an estimated three
million Americans receive home
health care, which is fast becoming
the preferred method of meeting the
social and medical challenges of
patients especially the elderly
Steven R. Eastaugh, 2001.
F. Alnasir 2012
53
In Sweden a study showed that
patients were pleased with HHC
most of the time and satisfied when
they were not being forced to leave
their home for nursing and medical
care.
They thought it is safer to be at
home to receive care rather than in
the hospital. The patients also
admitted advantages other than
medical care.
Öresland Stina, Määttä Sylvia, 2009
F. Alnasir 2012
F. Alnasir 2012
55
Family-centered care rests on a
foundation of a collaborative partnership
between health care providers and
families to provide the best care possible.
It facilitates communication and respects
the diversity and individuality within
families. Recognizing family needs and
ensuring that services and support
systems are available is essential in the
provision of family-centered care.
Lewandowski & Tesler, 2003.
F. Alnasir 2012
56
The quality of the physician-patient
therapeutic relationship is a key factor in
the effectiveness of care. Social
competence is a process based on
knowledge, skills and attitudes that
support effective interaction between the
physician and patient despite the
intervening social distance. It enables
physicians to better understand their
patients' living conditions and to adapt
care to patients' needs and abilities.
Loignon, et al, 2010.
F. Alnasir 2012
57
The physician-patient relationship is part of the
patient's larger social system and is influenced
by the patient's family.
The patient-centered medical home, a patient
care concept that helps address this dynamic,
often involves a robust partnership among the
physician, the patient, and the patient's family.
Omole et al,2011.
For the medical house to be a home requires
physicians to demonstrate a personal touch
that communicates caring to the patient.
Egnew TR, 2010.
F. Alnasir 2012
58
Having a health care home has been
shown to be associated with positive
health outcomes for children with special
health care needs.
The health care home represents a
process of care that may help families
manage the daily demands of caring for
such children through family-centered
care, provider-to-provider communication,
and provision of care coordination.
Angela D, Wendy L, Abby P, 2012
F. Alnasir 2012
59
HHC decreases the financial burden
on hospitals and patients by
preventing longer stays in hospital.
Eastaugh stated that, within HHC, a
good saving could be accomplished
by better case management and by
avoiding expensive hospital stays.
Steven R. Eastaugh, 2001.
F. Alnasir 2012
60
A study done in the USA found that the
marginal cost of a day stay in the hospital
could range from US $315 to US $472, but
each dollar invested in HHC shows a benefit
reduction of US $1.78 in hospital costs.
Steven R. Eastaugh, 2001.
F. Alnasir 2012
61
They also reported that “these were
the largest cost savings ever reported
due to reductions in hospital
readmission days and to use of
lower-intensity hospital beds for a
hospital stay”.
Humphrey, Carolyn J.,2009
F. Alnasir 2012
62
In Bahrain;
Each HHC visit would cost on an average
US $50 (about 10% of each day’s hospital
stay cost or 40% of the hospital’s
outpatient visit cost).
Alnasir, Faisal 2009.
0 200 400 600
HHC
OPD
Admission
F. Alnasir 2012
63
In Bahrain;
A very successful practice adopted by the
Ministry of Social Affairs in the Kingdom is
utilizing the Mobile Unit Services to
provide limited services to the elderly in
their own homes. However, this does not
cover all patients on the Island.
Alnasir, Faisal 2009.
F. Alnasir 2012
‫ال‬ ‫طريق‬ ‫عن‬ ‫إال‬ ‫تأتى‬ ‫ال‬ ‫القصوى‬ ‫السعادة‬ ‫ان‬‫علم‬
‫ابن‬‫سينا‬
‫سينا‬ ‫ابن‬ ‫على‬ ‫بن‬ ‫الحسن‬ ‫بن‬ ‫هلل‬ ‫عبدا‬ ‫بن‬ ‫الحسن‬ ‫ابن‬(980–1027‫م‬(
F. Alnasir 2012
65
The Patient Centered Medical
Home is a health care setting that
facilitates partnerships between
individual patients, and their
personal physicians, and when
appropriate, the patient’s family.
F. Alnasir 2012
66
Why home care in PHC
- Home health Care has a natural appeal
- Home is a place of emotional and
physical associations, memories and
comfort.
- Home care offers a mix of services
associated with health promotion,
prevention, ageing and chronic
conditions in familiar environment.
- It improves access to health care such
as thorough home visits,
telemedicine/telenursing.
F. Alnasir 2012
‫وبما‬‫من‬ ‫منحة‬ ‫هي‬ ‫الطب‬ ‫صناعة‬ ‫أصول‬ َ‫أن‬‫هللا‬
‫تعالى‬,‫أو‬ ‫إلهي‬ ‫علم‬ ‫فالطب‬ ،‫األقدمين‬ ‫اق‬َ‫ف‬‫بات‬‫قريب‬
‫منه‬
«‫ال‬‫عقل‬ ‫يدركه‬ ‫أن‬ ‫العلم‬ ‫هذا‬ ‫في‬ ‫يمكن‬‫إنسان‬»
‫أب‬‫و‬‫ق‬‫ـ‬‫راط‬
‫ابن‬‫اقليدس‬‫بن‬‫أبقراط‬‫الذي‬‫ولد‬‫ب‬‫كوس‬ ‫جزيره‬‫حوال‬‫ي‬‫سنة‬460‫قبل‬‫الميالد‬
F. Alnasir 2012
68
Thank you
F. Alnasir 2012

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Role of Family medicine in fighting illness by Prof Faisal Alnaser /Alnasir د. فيصل عبداللطيف الناصر

  • 1. 1 Role of Family Physicians in fighting the health risks; Home Care as a tool Professor Faisal Abdul Latif Alnasir FPC, FRCGP, MICGP, FFPH, PhD Chairman; Dept of Family & Community Medicine Arabian Gulf University. Bahrain President; Scientific Council Family & Com. Medicine Arab Board for Medical Specializations General Secretary: Inter. Society for the History of Islamic Medicine F. Alnasir 2012
  • 2. ‫ا‬‫هي‬ ‫الطب‬ ‫صناعة‬ ‫ن‬"‫أقدم‬ ‫بها‬ ‫والعلم‬ ‫الصنائع‬ ‫أشرف‬ ‫العلوم‬"‫سائر‬ ‫على‬ ‫المرتبة‬ ‫في‬ ‫تتقدم‬ ‫أن‬ ‫ويجب‬ ‫والمهن‬ ‫الصنائع‬. (‫في‬‫الطبيب‬ ‫أدب‬) (‫الرهاوي‬ ‫علي‬ ‫بن‬ ‫اسحق‬) (‫الهجري‬ ‫الرابع‬ ‫القرن‬) F. Alnasir 2012
  • 3. 3 • Family Practice / Primary Health Care • Effect of PHC on Health Of the Nation • Why PHC • Cost Health Care • Home Health Care as an example F. Alnasir 2012
  • 4. 4 Family Practice is the medical specialty which provides continuing, comprehensive health care for the individual and family. It is a specialty in breadth that integrates the biological, clinical and behavioral sciences. The scope of family practice encompasses all ages, both sexes, each organ system and every disease entity. F. Alnasir 2012
  • 5. 5 Family Medicine is centered on lasting, caring relationships with patients and their families. Family physicians integrate the biological, clinical and behavioral sciences to provide continuing and comprehensive health care. The scope of family medicine encompasses all ages, sexes, each organ system and every disease entity. Dept Of Family Medicine University of Chicago F. Alnasir 2012
  • 6. 6 FM: One place you could go for all your health concerns. Primary health care refers to health care services that are provided outside the hospital. F. Alnasir 2012
  • 7. 7 Family medicine is a person-focused and should not be disease-focused discipline; i.e., based on the health of people and populations. The World Health Report 2008, Primary Health Care – Now More Than Ever, indicates that this requires a renewed universal emphasis on primary health care – i.e., person- focused care over time, not disease- focused care. World Health Organization. The World Health Report 2008F. Alnasir 2012
  • 8. 8 Why Family Medicine is needed in every nation: • Invading serious healthcare challenges • Family medicine is the answer to the health care challenges facing nations • PC is the foundation of any successful health system F. Alnasir 2012
  • 9. 9 WHO as well as a number of other international commissions, reflect the widespread acceptance of the importance of primary health care. Barbra Starfield, 2012 Both People's Health Movement and WHO agree that primary healthcare makes a considerable contribution to reducing the adverse impact of social inequalities on health. Sanders D, et al 2011, Rasanathan K, et al 2011F. Alnasir 2012
  • 10. 10 Primary healthcare-oriented health systems have been shown to be generally more effective in achieving better health (particularly at young ages) at lower costs than is the case for systems more oriented to disease management and specialty care. Even in the USA, “one of the most inequitable societies in the industrialized world”, better primary care resources preferentially improve health more in socially disadvantaged populations than in the majority population. Starfield B. Shi L, Macinko J. 2005 F. Alnasir 2012
  • 11. 11 Strong primary care health systems are more likely to provide better population health, better distribution (more equity) in health throughout the populations, and greater economy in the use of resources. Barbra Starfield, 2012. F. Alnasir 2012
  • 12. 12 Stronger primary care should produce better outcomes than weaker primary care F. Alnasir 2012
  • 13. 13 It is known that, “within certain bounds, neither the wealth of a country nor the total number of health personnel are related to health levels”. What counts is the existence of key features of health policy (Primary Health Care) Barbra Starfield, 2012. F. Alnasir 2012
  • 14. 14 It's very well documented: “That a system that is based on primary care can provide higher quality care," said Dr. Minal Kale, of the Mount Sinai School of Medicine in New York.2012 F. Alnasir 2012
  • 17. 17 Studies consistently find that the supply of primary care physicians is associated with: •better quality of care •better population health •lower cost of care Stange KC, Ferrer RL. Paradox of primary care. Ann Fam Med 2009 F. Alnasir 2012
  • 18. 18 In USA a study in 2011, found that seniors living in areas with more primary care doctors were less likely to be hospitalized with a preventable disease and had lower death rates. Reuters Health story of May 24, 2011. http://reut.rs/O2itHr F. Alnasir 2012
  • 19. 19 In Thailand after primary care reform was initiated in the early 1990s, there was marked improvement in under-5 mortality Vapattanawong P, et al, 2007 In Ontario, Canada, populations in areas with greater primary care physician supply have better experiences with a wide variety of healthcare access and outcome indicators— even more so in lower income areas than in higher income ones. Guttmann A, et al.2010 F. Alnasir 2012
  • 20. 20 Brazil in 1990 built health services system based on strong PHC. During the period 1990-2007, the following were found: • Improvements in maternal education • Large reductions in post-neonatal mortality and under-5 mortality. • Infant mortality declined 40% between 1990 and 2002; controlling for other impacts on infant mortality. • A 10% increase in primary care coverage was associated with an average 4.6% decline in infant mortality. • Decrease in absolute rich-poor differences in infant and child mortality across different areas. • Large decline in hospitalizations for primary care sensitive conditions and for chronic diseases by 25-30%, especially (cardiovascular diseases, asthma, hypertension, stroke). • In general hospitalizations that would be prevented by good primary care declined by over 5% annually. Macinko J, et-al.2006, 2010, 2011F. Alnasir 2012
  • 21. 21 In Bahrain After adopting the primary Health Care Policy and start of the Family Residency Program in 1983, there were; • Decrease in AE attenders • Decrease in unnecessary referral • Decrease in the prevalence of hereditary blood diseases • Increase health awareness Alnasir,Faisal F. Alnasir 2012
  • 22. 22 Among 90 countries with Gross National Income of less than $10,000 per person, 30 have moved toward primary health care. Of these 30, 14 moved to comprehensive primary care (defined as skilled attendance at birth). These 14 have achieved much lower under-five mortality rates along with greater equity in health care as well as more equitable distribution of health services. Rohde J, et al 2008F. Alnasir 2012
  • 23. 23 In the United States An increase of one primary care doctor (PCP) per 10,000 population (approximately a 15% increase) (after controlling for income inequality, education, unemployment, racial/ethnic composition, urban/rural location, percentage elderly, percentage living in poverty and/or low income) is associated with: • 1.44 fewer deaths per 10,000 population • a 2.5% reduction in infant mortality • a 3.2% reduction in low birth weight Shi L, Macinko J, Starfield B, et-al. 2004. F. Alnasir 2012
  • 24. 24 In the United States An increase of one primary care doctor (PCP) per 10,000 population (approximately a 15% increase) (after controlling for income inequality, education, unemployment, racial/ethnic composition, urban/rural location, percentage elderly, percentage living in poverty and/or low income) is associated with reduction: • Inpatient admissions by an estimated 6%, • Outpatient visits by 5%, • Emergency room visits by 10% • Surgeries by over 7%. Kravet SJ, Shore AD, Miller R, et-al.2008 F. Alnasir 2012
  • 25. 25 A nationally representative USA study showed that adults and children with a Family Physician (rather than a general internist, pediatrician, or sub-specialist) as their regular source of care had: • reported less difficulty in accessing care • lower annual cost of care • made fewer visits • had 25% fewer prescriptions Phillips RL, et-al. 2009 F. Alnasir 2012
  • 26. Starfield Barbra No equity in Health Care • Budget allocated is on an average of 70% to 80% to Secondary and tertiary care. • Health care human resources are allocated more to secondary and tertiary care (80% to 20%) 0 10 20 30 40 50 60 70 80 PC SC TC F. Alnasir 2012
  • 27. 27 Primary health care can now be measured and assessed; all innovations and enhancements in it must serve its essential features in order to be useful. Barbra Starfield, 2012 F. Alnasir 2012
  • 28. 28 Two in five adults in the U.S. are getting general healthcare from specialist doctors, according to a new study. Researchers found that in 1999 and 2007, approximately 59% of visits family physicians and 41% were to specialists, such as internists and obstetricians- gynecologists. Andrew M. Seaman, (Reuters Health) 2012 0 10 20 30 40 50 60 FP Specialist F. Alnasir 2012
  • 29. 29 In USA Specialists now provide a significant percentage of primary care services. A 2012 Archives of Internal Medicine study found that 41% of primary care office visits were provided by specialists. The Wrong Battles Brian Klepper, Sep 20, 2012 F. Alnasir 2012
  • 30. 30 A study examined more than a billion patient encounters between 2002-2004 in USA found: 46.3% of specialist visits were for preventive care or routine follow-up of patients who the specialist had previously seen. New referrals accounted for only 30.4% of all visits. Many of these visits could be handled competently and far more cost-effectively by a generalist. The Wrong Battles Brian Klepper, Sep 20, 2012 F. Alnasir 2012
  • 31. Shi. Jam Board Fam Practic 2003;16:412-22 Mortality Outcome • Specialists: Increase of 1 Specialists/10000 (8%more) increases mortality by 16 per 100000 (2% more deaths) • Primary Care Physicians: Increase of 1 PCP/10000 (20%) would decreases mortality by 40 per 100000 (5% fewer deaths) • Family Physicians; Increase of 1 FP/10000 (33%more) results in decrease mortality by 70 per 100000 (9% fewer deaths) -80 -70 -60 -50 -40 -30 -20 -10 0 10 20 30 SP PCP FP F. Alnasir 2012
  • 32. Baicker et al.,2004 Cost implication Increasing 1 physicians/10000 population would: Specialists; -Increase costs $526/beneficiary and decrease quality Primary care; -Decrease costs $684/beneficiary and increase quality -800 -600 -400 -200 0 200 400 600 SP FP F. Alnasir 2012
  • 33. 33 In 2010 a study found that primary care doctors in the USA earn about $60 per hour, which is much less than the $92 per hour and $85 per hour rates for surgeons and ob-gyns, respectively. FP Obgyn Surgeon 0 20 40 60 80 100 Earn (Reuters Health story of October 25, 2010. http://reut.rs/O2mVG9) F. Alnasir 2012
  • 34. 34 Why do people get worse with specialists: -Outside areas of expertise1 -Late stage diagnosis of cancers (Breast 2 or Colorectal3) -Excessive utilization4 -Communication errors5 1. Weingarton et al Arch int Med 2002: 162:627-532 2. Ferrante et al J Am Board Fam Pract 2000;13;408-414 3. Rotezheim et al J Fam Pract 1999:48:850-858 4. Greenfield et al. JAMa 1992:367; 1024-1030 5. Skinner et al Health Affairs 2006; 25;w34-w37 F. Alnasir 2012
  • 35. 35 Care during family physician visits is more complex per hour than the care during visits to cardiologists or psychiatrists. This may account for a lower rate of completion of process items measured for quality of care. The complexity of care provided per hour in general/family practice is 33% more relative to cardiology and 5 times more relative to psychiatry. David K ,Robert W,Carlos J, 2011 F. Alnasir 2012
  • 36. 36 Policy for success of any PHC: 1. Any reform of health system must ensure equity 2. Ensure quality and safety 3. Continuity of care is the corner stone of any PC 4. Ensure the sustainability of PC services 5. Community engagement is an essential component of PC policy development 6. Health promotion and prevention are core components of the work carried out in PC 7. Strengthen the role of PC in chronic disease management 8. Support and grow PC workforce 9. Exploit new technologies 10.Address the specialist needs of each group of people within the community. F. Alnasir 2012
  • 38. ‫ممم‬‫م‬‫عل‬‫ممب‬‫م‬‫الط‬"‫ممي‬‫م‬‫له‬ ‫ا‬ ‫ممم‬‫م‬‫العل‬ ‫ممد‬‫م‬‫بع‬ ‫مموم‬‫م‬‫العل‬ ‫ممرف‬‫م‬‫أش‬"‫ألن‬ ‫موضوعه‬“‫نسان‬ ‫ا‬ ‫بدن‬”‫أشرف‬ ‫هو‬ ‫الذي‬‫الخلق‬ (‫الفارسي‬ ‫مصلح‬ ‫بن‬ ‫سعود‬ ‫بن‬ ‫محمود‬) (710‫هجرية‬) F. Alnasir 2012
  • 39. 39 Home Health Care Services F. Alnasir 2012
  • 40. 40 Delivery of various items and services directly to the home has mushroomed since the beginning of this century. The philosophy behind home delivery is to reduce the hassle of getting the service from its source, requiring effort, causing stress and costing money. F. Alnasir 2012
  • 41. 41 WHO Define Home Care as: Provision of health services by formal and informal caregivers in the home. This includes physical psychological, palliative and spiritual activities. Home care services can be classified into preventive, promotive, therapeutic, rehabilitative long term and palliative care. F. Alnasir 2012
  • 43. 43 The medical home is conceptualized as an approach which provides comprehensive primary care, fosters a close partnering relationship between patient and provider and, when appropriate, their family as well. F. Alnasir 2012
  • 44. 44 Home care are offered by interdisciplinary team, but due to many reasons, doctors, most of the time are not part of this. Boling quoted that “there are still policies that make it difficult for a physician to be part of the interdisciplinary team providing home care” Peter A. Boling, 1997 F. Alnasir 2012
  • 45. 45 To be able to offer these services within the patient’s home, special characteristics, skills and attitude are required from each team member. Since home is considered the patient’s safe haven, many factors, whether familial, social or environmental, factors interact, affecting the well-being of the individual. Alnasir F, 2009 F. Alnasir 2012
  • 46. 46 The role of this team: Providing the required services to patients within their home environment without the hassle of moving the patient to primary, secondary, or tertiary care units to meet their needs. F. Alnasir 2012
  • 47. 47 Why there is demand for home care? •Demographic trends with ageing population. •Changes in family structures and role of women •Increased focus on person-centred services •Availability of new support technologies •Need to redesign health systems to improve responsiveness, continuity, efficiency and equity. Home care in Europe, WHO European office (2008) Copenhagen WHO F. Alnasir 2012
  • 48. 48 Advantages of HHC: • provision of care in the home environment where patients are surrounded by their beloved ones giving the patient a positive element of support, reducing strain and anxiety induced by separation. • Decreasing the risk of noso-comial infection, due to shorter periods of hospital stay. • When HHC is provided in a professional, well- planned way, it could replace some non-urgent hospital stay. • HHC could reduce patients’ hospital stays by allowing earlier discharge. • Offers an opportunity for home health nurses to provide vital home care which is complex using a high technology approach. Humphrey, Carolyn J. 2009.F. Alnasir 2012
  • 50. 50 The medical role should be well- organized and known before the home visit. For this reason, the American Medical Association (AMA) developed guidelines for physicians when they practice home care American Medical Association, 1992. F. Alnasir 2012
  • 51. 51 As part of the medical care provided to patients in the UK, the Department of Health has recommended replacing hospital admissions by offering in home treatment for acute problems. Harrison, Judy et al 2003. F. Alnasir 2012
  • 52. 52 In the USA, an estimated three million Americans receive home health care, which is fast becoming the preferred method of meeting the social and medical challenges of patients especially the elderly Steven R. Eastaugh, 2001. F. Alnasir 2012
  • 53. 53 In Sweden a study showed that patients were pleased with HHC most of the time and satisfied when they were not being forced to leave their home for nursing and medical care. They thought it is safer to be at home to receive care rather than in the hospital. The patients also admitted advantages other than medical care. Öresland Stina, Määttä Sylvia, 2009 F. Alnasir 2012
  • 55. 55 Family-centered care rests on a foundation of a collaborative partnership between health care providers and families to provide the best care possible. It facilitates communication and respects the diversity and individuality within families. Recognizing family needs and ensuring that services and support systems are available is essential in the provision of family-centered care. Lewandowski & Tesler, 2003. F. Alnasir 2012
  • 56. 56 The quality of the physician-patient therapeutic relationship is a key factor in the effectiveness of care. Social competence is a process based on knowledge, skills and attitudes that support effective interaction between the physician and patient despite the intervening social distance. It enables physicians to better understand their patients' living conditions and to adapt care to patients' needs and abilities. Loignon, et al, 2010. F. Alnasir 2012
  • 57. 57 The physician-patient relationship is part of the patient's larger social system and is influenced by the patient's family. The patient-centered medical home, a patient care concept that helps address this dynamic, often involves a robust partnership among the physician, the patient, and the patient's family. Omole et al,2011. For the medical house to be a home requires physicians to demonstrate a personal touch that communicates caring to the patient. Egnew TR, 2010. F. Alnasir 2012
  • 58. 58 Having a health care home has been shown to be associated with positive health outcomes for children with special health care needs. The health care home represents a process of care that may help families manage the daily demands of caring for such children through family-centered care, provider-to-provider communication, and provision of care coordination. Angela D, Wendy L, Abby P, 2012 F. Alnasir 2012
  • 59. 59 HHC decreases the financial burden on hospitals and patients by preventing longer stays in hospital. Eastaugh stated that, within HHC, a good saving could be accomplished by better case management and by avoiding expensive hospital stays. Steven R. Eastaugh, 2001. F. Alnasir 2012
  • 60. 60 A study done in the USA found that the marginal cost of a day stay in the hospital could range from US $315 to US $472, but each dollar invested in HHC shows a benefit reduction of US $1.78 in hospital costs. Steven R. Eastaugh, 2001. F. Alnasir 2012
  • 61. 61 They also reported that “these were the largest cost savings ever reported due to reductions in hospital readmission days and to use of lower-intensity hospital beds for a hospital stay”. Humphrey, Carolyn J.,2009 F. Alnasir 2012
  • 62. 62 In Bahrain; Each HHC visit would cost on an average US $50 (about 10% of each day’s hospital stay cost or 40% of the hospital’s outpatient visit cost). Alnasir, Faisal 2009. 0 200 400 600 HHC OPD Admission F. Alnasir 2012
  • 63. 63 In Bahrain; A very successful practice adopted by the Ministry of Social Affairs in the Kingdom is utilizing the Mobile Unit Services to provide limited services to the elderly in their own homes. However, this does not cover all patients on the Island. Alnasir, Faisal 2009. F. Alnasir 2012
  • 64. ‫ال‬ ‫طريق‬ ‫عن‬ ‫إال‬ ‫تأتى‬ ‫ال‬ ‫القصوى‬ ‫السعادة‬ ‫ان‬‫علم‬ ‫ابن‬‫سينا‬ ‫سينا‬ ‫ابن‬ ‫على‬ ‫بن‬ ‫الحسن‬ ‫بن‬ ‫هلل‬ ‫عبدا‬ ‫بن‬ ‫الحسن‬ ‫ابن‬(980–1027‫م‬( F. Alnasir 2012
  • 65. 65 The Patient Centered Medical Home is a health care setting that facilitates partnerships between individual patients, and their personal physicians, and when appropriate, the patient’s family. F. Alnasir 2012
  • 66. 66 Why home care in PHC - Home health Care has a natural appeal - Home is a place of emotional and physical associations, memories and comfort. - Home care offers a mix of services associated with health promotion, prevention, ageing and chronic conditions in familiar environment. - It improves access to health care such as thorough home visits, telemedicine/telenursing. F. Alnasir 2012
  • 67. ‫وبما‬‫من‬ ‫منحة‬ ‫هي‬ ‫الطب‬ ‫صناعة‬ ‫أصول‬ َ‫أن‬‫هللا‬ ‫تعالى‬,‫أو‬ ‫إلهي‬ ‫علم‬ ‫فالطب‬ ،‫األقدمين‬ ‫اق‬َ‫ف‬‫بات‬‫قريب‬ ‫منه‬ «‫ال‬‫عقل‬ ‫يدركه‬ ‫أن‬ ‫العلم‬ ‫هذا‬ ‫في‬ ‫يمكن‬‫إنسان‬» ‫أب‬‫و‬‫ق‬‫ـ‬‫راط‬ ‫ابن‬‫اقليدس‬‫بن‬‫أبقراط‬‫الذي‬‫ولد‬‫ب‬‫كوس‬ ‫جزيره‬‫حوال‬‫ي‬‫سنة‬460‫قبل‬‫الميالد‬ F. Alnasir 2012