The home visit is a crucial responsibility of family doctors. By doing home visits the physician and the team become more aware of the nature of the illness and other factors that playing role in either increasing the burden or decreasing the severity of the disease 9Such as the home environment, the family members interactions, and others...)

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

15. F. Alnasir 2012
Tertiary
Secondary
PRIMARY CARE

16. F. Alnasir 2012
Tertiary
Secondary
Primary

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

37. 37
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

42. 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

49. 49
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

54. 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

68. 68
Thank you
F. Alnasir 2012