HLN004 Lecture 3 Primary healthcare and introduction to strategies and approaches for prevention and management
Lecture 3 Primary Health Care and major frameworks
„Essential health care based on practical, scientifically sound and socially acceptable methods and technology made universally accessible to individuals and families in the community through their full participation and at a cost that the community and the country can afford to maintain at every stage of their development in the spirit of self- reliance and self-determination‟
The WHO Alma-Ata Declaration defined Primary Health Care (PHC) as incorporating curative treatment given by the first contact provider along with promotional, preventive and rehabilitative services provided by multi- disciplinary teams of health-care professionals working collaboratively (Anderson, Bridges-Webb and Chancellor, 1986)
PHC is socially appropriate, universally accessible, scientifically sound first level care provided by a suitable trained workforce supported by integrated referral systems and in a way that gives priority to those most in need, maximises community and individual self-reliance and participation and involves collaboration with other sectors. It includes the following: - Health promotion - Illness prevention - Care of the sick - Advocacy - Community Development (Australian Primary Health Care Research Institute, Australian University. Cited in Primary Health Care-2006. Available http://www.ama.com.au/node/2502
Within Australia, the primary health care services are a complex combination of State and Commonwealth funded initiatives with both public and private providers Services include General Practitioners, community health care centres, private allied health professionals such as dietitians, pharmacies and complimentary therapists GPs provide majority of primary health care services ◦ 85% of the population see a GP at least once a year ◦ average Australian person would visit a GP 6.5 times per year.
Broader population health focus than hospital and specialist care ◦ population health activities better delivered through primary care eg immunisation, health promotion and screening More continuity of care- people receiving ongoing care from a trusted doctor or other health professional achieve better health outcomes than those receiving care from a number of doctors Greater accessibility (financially, geographically, culturally) (Doggett, 2007)
International evidence suggests strength of a country‟s primary care system is associated with improved population health outcomes for all-cause mortality from respiratory and cardiovascular disease Health systems that include strong primary medical care are more efficient and have lower rates of hospitalisation. Continuity of care with the same primary care provider or service has been associated with lower use of hospitals and greater patient satisfaction with all care (Harris, Kidd and Snowdon, 208; WHO Regional Office for Europe‟s Health Evidence Network (HEN), 2004)
Conventional Disease control People-centredambulatory medical programs` primary carecare in clinics oroutpatientdepartmentsFocus on illness and cure Focus on priority diseases Focus on health needsRelationship limited to the Relationship limited to Enduring personalmoment of consultation program implementation relationshipEpisodic curative care Program-defined disease Comprehensive, control interventions continuous and person- centredResponsibility limited to Responsibility for disease- Responsibility for the healtheffective and safe advice to control interventions of all in the communitythe patient at the moment along the life cycle;of consultation responsibility for tackling determinants of ill healthUsers are consumers of the Population groups are People are partners incare they purchase targets of disease-control managing their own health interventions and that or their community (WHO, 2008, p.43)
Primary Health Care‟s focus is on providing “health for all” through health systems that put “people at the centre of their own care” WHO Primary Health Care- Now More than Ever (2008) ◦ evaluates events that have been undertaken to address health over the last 30 years ◦ provides recommendations to decrease global health inequalities Available at: http://www.who.int/whr/2008/whr08_en.pdf
Disproportionate focus on narrow offer of specialized curative care Command and control approach to disease control focused on short-term results Hands-off approach to governance allowing unregulated commercialization of health to flourish
Inverse care – people with the most means and often less needs consume the most care Impoverishing care – where lack of social protection and payment for care is largely out-of-pocket and can result in poverty Fragmented and fragmenting care – excessive specialization of health care providers and narrow focus discourage a holistic approach
Unsafe care – poor system design cannot ensure safety and hygiene standards leading to hospitalized infections and other errors Misdirected care – resources allocation clusters around curative services at great cost, neglecting potential of primary health care and health promotion to prevent up to 0% of disease burden.
Main Reforms Recommended include: Universal coverage reforms Public policy reforms Leadership reforms Service delivery reforms
Main Areas of Concern Provides many of the required services, however there are still many people with multiple and complex health conditions receiving inadequate care There is a general lack of GPs in some areas Poor access to GP services for some groups in the community eg rural/remote, indigenous communities
High out of pocket expenses for many allied health services and some pharmaceuticals Many people require a variety and number of health professional services and the lack of coordination of health care can ultimately contribute to poor health outcomes and an in emergency and hospital admissions, placing a great burden on the health system
An insufficient focus on prevention and population health Inflexible funding system that does not always allow consumers to gain access to the most suitable form of care for their condition Primary Health Care has been regarded in Australia as being fragmented, difficult to navigate and prone to gaps and inequities in access to services- A REFORM of the system including a coordinated and universal approach to Primary Health Care is required. (Doggett, 2007)
The National Primary Health Care Strategy confronts the challenges relating to health care in the present and the future. The priorities of the Primary Health Strategy:
Better 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 eg dietitians and physiotherapists Encouraging a greater focus on multidisciplinary team based care (Department of Health and Ageing, 2008)
Regional integration Information and technology, including eHealth Skilled workforce Infrastructure Financing and system performance
Key Priority Area 1: Improving access and reducing inequity Key Priority Area 2: Better management of chronic conditions Key Priority Area 3: Increasing the focus on prevention Key Priority Area 4: Improving quality, safety, performance and accountability
Research from the USA and New Zealand suggest that primary health care is contributing to a in the life expectancy gap for indigenous peoples Indigenous Australians continue to experience poor access to primary health care, despite the higher levels of morbidity and the large gap in life expectancy.
Developed in the USA by Edward Wagner Describes the essential elements for improvements in the care of people with chronic conditions with a focus on primary care Aim of the CCM is to develop well informed patients and a healthcare system that is prepared for them
Epping-Jordan, J E et al. Qual Saf Health Care 2004;13:299-305
Delivery System Design ◦ Create teams with a clear division of labour ◦ Separated acute care from the planned care ◦ Planned visits and follow up are important features Self-management support ◦ Collaboratively helping patients and families to acquire the skills and confidence to manage their condition ◦ Provide self management tools, referrals to community resources and routinely assessing progress
Decision Support ◦ Integration of evidence based clinical guidelines into practice and reminder systems Clinical Information Systems ◦ Reminder system to improve compliance with guidelines, feedback on performance measures and registries for planning the care for chronic diseases
Community Resources ◦ Linkages with hospitals providing patient education classes or home care agencies to provide case managers ◦ Linkages with community based resources- exercise programs, self help groups and senior centres Health Care Organisation ◦ The structure, goals and values of the provider organisation. Its relationship with purchaser, insurers and other providers underpins the model
Harris, Kidd and Snowdon (2009) have adapted Wagner‟s CCM to address issues relating the PHC in Australia Provides a framework for an effective and accessible national primary health care system Evidence that this model will provide a more effective way of ensuring access, quality and equity of care for all people in Australia
Model for Primary and Community Care to meet the challenges of chronic disease prevention and management • Reengineering the organisation of health care • Modification of primary care organisations • Engaging the community • Monitoring performance and accountability • Self management and health literacy support • Redesign of the primary health care team • Shared information systems • Decision support Informed patients Proactive Team Better Prevention and management of chronic disease Harris, Kidd and Snowdon, 2008, p. 7
Developed by the WHO in response to the increasing prevalence of chronic diseases in both developed and developing countries. Adapted from CCM ◦ Shift from acute care for chronic disease to a more preventative and long-term health care management model. Composed of fundamental components at the patient (micro), organisation/ community (meso) and policy (macro) levels
Macro Level - governments developing and implementing policies to prevent and manage chronic disease. Meso Level - systems to manage care over time. This will include education of health professionals, evidence based guidelines, prevention strategies, information systems and linking with community resources. Micro Level – The micro level of the model elevates the role of patients and their families, and partners them with communities and healthcare organisations.
National strategic policy approach to chronic disease prevention and carein the Australian population. Overarching framework which encourages coordinated action nationally. Five supporting National Service Improvement Frameworks (asthma; cancer; diabetes; heart, stroke and vascular disease; osteoarthritis, rheumatoid arthritis and osteoporosis).Primary objectives of the NCDS are to: Prevent/delay the onset of chronic conditions Reduce the progression and complications of chronic conditions Maximize the wellbeing and quality of life of individuals living with chronic disease and their families and carers Reduce avoidable hospital admissions and health care procedures Implement best practice in the prevention, detection and management of chronic disease Enhance the capacity of the health workforce to meet population demand for chronic disease prevention and care into the future
Key principles ◦ Adopt a population health approach ◦ Prioritise health promotion and illness prevention ◦ Achieve person-centred care and optimise self- management ◦ Provide the most effective care ◦ Facilitate coordinated and integrated multidisciplinary care across services setting and sectors ◦ Achieve significant and sustainable change ◦ Monitor progress
Action areas 1)Prevention across the continuum 2)Early detection and early treatment 3)Integration and continuity of prevention and care 4)Self-management Action implementation areas1) Building workforce capacity2) Developing strategic partnerships3) Enhancing investment and funding opportunities4) Developing infrastructure and information technology support
National agreement between the Commonwealth and the States and Territories. Clarifies the roles and responsibility of Commonwealth and State governments to guide the delivery of health services Defines objectives for chronic condition prevention, primary and community care, hospital and related care and aged care Provides a description of the outputs and performance indicators to measure success.
National preventative task force National partnership on closing the gap in Indigenous health outcomes Australian Better Health initiative National Health Priority Area initiative
GPs play a major role in the prevention and management of chronic diseases ◦ First point of contact ◦ First to diagnose conditions ◦ Can provide counseling services, prescription & referral ◦ Strategies to support and facilitate role of GP in PHC essential Enhanced Primary Care Plan Lifescripts (discussed later in semester) SNAP methodology (discussed later in semester)
MBS items were introduced for health assessments and care planning ◦ GPs could receive a MBS rebate for initiating and participating in health assessments and care planning Other EPC initiatives ◦ Healthy Kids Check ◦ 45 year old Health Check ◦ Type 2 Diabetes Risk Evaluation ◦ Incentive Programs ◦ Practice Nurses
In the 2005-2006 Budget, the Australian Government announced funding for the Healthy for Life program The objectives are to : ◦ improve the availability of child and maternal health care; ◦ improve the prevention, early detection and management of chronic disease; ◦ improve men‟s health; ◦ improve long term health outcomes for Aboriginal and Torres Strait Islander Australians; ◦ increase the capacity of the Aboriginal and Torres Strait Islander health workforce through the Puggy Hunter Memorial Scholarship Scheme. ◦ http://www.health.gov.au/internet/h4l/publishing.n sf/Content/home-1
Anderson, N., Bridges-Webb, C. and Chancellor, A. (1986). General practice in Australia. Sydney University Press, Sydney cited in Primary Health Care-2006. AMA. Available at http://www.ama.com.au/node/2502- Australian Primary Health Care Research Institute, Australian University. Cited in Primary Health Care-2006. Available http://www.ama.com.au/node/2502- Department of Health and Ageing (2008). Primary Health Strategy. Available at: http://www.health.gov.au/internet/main/publishing.nsf/Content/D66FEE14F736A789CA2574E3001783C0/$File/Discussio nPaper.pdf- Doggett, J. (2007). A New Approach to Primary Care for Australia. Centre for Policy Development, Sydney.- Harris, M., Kidd, M. and Snowdon, T. (2008). New models of Primary and Community Care to meet the challenges of chronic disease prevention and management: a discussion paper for the NHHRC.- Harris, M., Laws, R. and Amoroso, C. (2008). Moving towards a More Integrated Approach to Chronic Disease Prevention in Australian General Practice. Australian Journal of Primary Health. 14(3), 112-118.- National Heart Foundation and Kinect Australia for Lifescripts Consortium. (2005). Lifescript in your Division: supporting lifestyle risk factor management in general practice. A guide for Division of General Practice. Canberra, Commonwealth of Australia.- World Health Organisation. (2008). Primary Health Care: Now More than Ever. Available at:http://www.who.int/whr/2008/whr08_en.pdf- WHO Regional Office for Europe‟s Health Evidence Network (HEN). (2004). What are the advantages and disadvantages of restructuring a health care system to be more focused on primary care services. Cited in Primary Health Care- 2006. AMA. Available at http://www.ama.com.au/node/2502.