from policy to practice and back to policy
DESCRIPTION
From Policy to Practice and back to Policy. Prof. Dr. J. De Maeseneer, MD, PhD Department of Family Medicine and PHC- Ghent University , Belgium General Practitioner ( part-time ), Community Health Centre , Ledeberg-Ghent ( Belgium ) Chairman European Forum for Primary Care - PowerPoint PPT PresentationTRANSCRIPT
From Policy to Practice and back
to PolicyProf. Dr. J. De Maeseneer, MD, PhD
Department of Family Medicine and PHC- Ghent University, BelgiumGeneral Practitioner (part-time), Community Health Centre ,
Ledeberg-Ghent (Belgium)Chairman European Forum for Primary Care
Chairman Expert Panel on Effective Ways of Investing in Health-EC
Director International Centre for PHC and FM – Ghent University, BelgiumWHO-Collaborating Centre on PHC
Paris, 9.04.2014
• No conflict of interest
1. Expert Panel on Innovative Ways of Investing in Health
2. The model of PHC-Centres in Belgium
3. Policy:strategies for change
From Policy to Practice and back to Policy
Expert Panel on effective ways of investing in Health (EXPH)
• * To provide independent non-binding advice on matters related to health care modernisation, responsiveness, and sustainability
• * Set up by Commission Decision of 5 July 2012• http://ec.europa.eu/health/healthcare/docs/dec_panel2012_en.pdf
• * 12 members, nominated for 3 years, by Decision 21 May 2013• http://ec.europa.eu/health/healthcare/docs/dec_members_expert_panel_20
13_en.pdf
• * Started its activities on 11 July 2013
The public consultation has been launched (deadline: 11 May 2014).http://ec.europa.eu/health/expert_panel/consultations/primarycare_en.htm
Opinion on Definition primary care – Definition
• History• Alma-Ata / Vuori / Tarimo / Starfield / IOM
• Core-definition• 'The Expert Panel considers that primary care is the provision of
universally accessible, person-centered, comprehensive health and community services provided by a team of professionals accountable for addressing a large majority of personal health needs. These services are delivered in a sustained partnership with patients and informal caregivers, in the context of family and community, and play a central role in the overall coordination and continuity of people’s care.'
Opinion on Definition primary care – Main points
• 3. Referral systems (including gatekeeping)
- Emphasises the importance of using primary care as the preferred entry point into the health system
- To be effective, referral systems (gatekeeping) must involve:• - a strong and responsive high-quality primary care system
- a patient-centered approach- timely access to medical imaging results (by primary care providers)- a prompt response by secondary care- maximal subsidiarity to avoid long waiting terms- electronic referral processes as much as possible- interactions between referral and payment systems
Opinion on Definition primary care –Main points
• 4. Financing primary care
• The opinion recommends- to ensure an adequate level of financing for primary care,- to promote equitable access to primary care(when user charges -> protecting mechanisms needed for people with low incomes or regular users)- to provide incentives for efficiency and quality in primary care delivery, including care coordination
• (trend towards blended provider payment systems can be effective when financial incentives are integrated)
1. Expert Panel on Innovative Ways of Investing in Health
2. The model of PHC-Centres in Belgium
3. Policy:strategies for change
From Policy to Practice and back to Policy
The changing society
a. Demographical and epidemiological developments
b. Scientific and technological developments
c. Cultural developments
d. Socio-economical developments
e. Globalisation and “glocalisation”
‘By 2030, 70% of the world population will live in an urban context’ (Castells, 2002)By 2100, 85%?
Healthy life expectancy in Belgium, 25 years, men
28,1
3842,6
45,9
2025303540455055
basic secundaryschool: 1st cycle
secundaryschool: 2nd
cycle
university/highereducation
Socio-economic inequalities in health
Healthy life expectancy in Belgium
(Bossuyt, et al. Public Health 2004)
http://www.who.int/social_determinants/resources/csdh_media/primary_health_care_2007_en.pdf
Primary Care delivery in Belgium: type IIPrimary Health Care Centres
Type of Services:• Patient-list: territorial; “referral”• Reactive care: broad-spectrum: physical, mental, social,…• Diagnostic (Imaging, lab): outsourced, GP-controlled• Comprehensive home care (incl. palliative)• Prevention and screening: call-recall; contract for health promotion towards the local community• Community Oriented Primary Care (COPC)• Training of GPs
16
Primary Care deliveryin Belgium: type II
Primary Health Care CentresTypes of payment:• Integrated mixed needs-based capitation (since 01.05.2013) negotiated PHC-Insurance companies• Allowances (informatics, GMR, Impulseo, care trajectories diabetes and CRF,…)• No co-payment for patients• Incentives for prevention (regions, municipalities)
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Integrated mixed needs-based capitation: the “needs-variables” Demographic variables Social-economic variables Morbidity variables Contextual variables
Age/sex (41 combinations) Widow Low income: < 15 000,00EUR Self-employed workers Deceased in that year Disability Urbanization index in the
neighbourhood Medical supply index in the
neighbourhood Handicap Help from public welfare centres Impaired functional status Cardiac diseases COPC Asthma Cystic Fibrosis Diabetes combined with chronic
cardiac condition IDD
NIDD Exocrine pancreatic diseases Psoriasis Rheumatoid arthritis, Crohn’s disease,
ulcero-hemorragic recto-colitis Psychosis: young adults Psychosis: elderly people Parkinson’s disease Epilepsy HIV Chronic hepatitis B & C Multiple sclerosis Post-transplant immunosuppression Alzheimer Thyroid diseases Thrombosis Coagulation disorders Protected habitat
ImplementationBased on an (electronic) “photograph” of the population on the list of the different PHCC’s
→ photograph made annuallyEach PHCC receives a specific “capitation” for the patients on the list
The integrated needs-based mixed capitation system:stimulates prevention, health promotion and self-reliance of the people,
as there is a global payment for all disciplines, there is an incentive to task-shifting and subsidiarity,
Prevents risk selectionStimulates a global approach to a broad range of problems, avoiding the fragmentation and disease-orientation
Study: comparison payment systems
Study: comparison payment systems2008: Federal Knowledge Center for Health Care
Fee-for-service ↔ Capitation
Strengths capitation system high degree of accessibility, especially for
vulnerable groups no risk selection patients in the capitated system use:
• less resources in the secondary care• less medications
the quality of care was at least as good or better
Primary Health Care Centre:
- Family Physicians; nurses; dieticians; health promotors; social workers; …
- 5800 patients; 60 nationalities
- Integrated needs based mixed capitation; no co-payment
- COPC-strategy
• 1978 family practice in poor neighbourhood
• 1980 first nurse and foundation of the community health centre
• 1986 interprofessional team• 1995 capitation financed system
Community Health Care Centre Botermarkt: history
ACCESSIBLE• Geographical context• Notwithstanding ethnicity, culture,
income, administrative status,…• No risk selection <> high prevalence of
multiproblem patients• Patients on the list
The 19th
century “belt” around Ghent
The 19th
century “belt” around Ghent
Wgc Kapellenberg
WGC Watersportbaan 01.04.2010
WGC Rabot
INTERPROFESSIONAL TEAM
• Family physicians
• Nurses
• Social work
• Health Promotion
• Dietician
• Administratieve staff and receptionist
• Ancillary staff
• Podologist
• External health care workers : physiotherapists,
psychologists
INTERPROFESSIONAL ELECTRONIC PATIENT
RECORD
• Family physicians
• Nurses
• Social work
• Dieticians
International Classification of Primary Care (ICPC-2);
Future: + International Classification of Function (ICF)
Family Physicians• During the day
– consultations – appointments– home visits
• At night (from 19.00 until 08.00)
– Cooperation with local GP-service
• During the weekend (Friday 19.00 pm to Mo 08.00 a.m.)
– Three “on call” GP-posts in Ghent
Nursing
• Appointments at the health centre– Daily direct access – Referral by GPs or receptionists
• Home visits– Daily – Referral by GPs or receptionists– Only when indicated by the medical and
functional condition
Nursing
Prevention• Follow – up blood pressure• Family-planning management• Participatory patient management
– Diabetic consultation: 3-monthly– COPD, asthma: Spirometry
• Diabetes clinic
• Objectives:– Improving the care for diabetes type 2 patients
through a structured multidisciplinary follow-up and health education
– To help patients to cope with their condition (“empowerment”)
– Improve self-efficacy of patients– To tackle social inequalities in relation to chronic
diseases
• Diabetes clinic• Programme:
– biomedical and behavioural follow-up by nurse and family physician, following guidelines
– exchange of experiences by the patients– contact with dietician (2 x / year)– “diabetes-cooking” (3 x / year)
Social Work
• social workers• Social work in the health centre includes :
– first intake, exploring the problem– information and counseling– advocating, mediating– supporting, psychosocial guidance– referral to specialised services– administrative support, application for allowances,
budgetplanning– establishing patient centered networks of care
Social Work
• Problems situated on different domains of life
• Multiproblem cases• Not (yet) reached by other social
services • Undocumented residents• On appointment or crisis intervention• No waiting lists
Dietician
• Gives information about healthy food and counsels :– Patients with general dietary problems– Patients with gastro-intestinal problems– Patients with cardiovascular problems– Patients with diabetes– Patients with kidney-problems– Children with obesity
• Only on appointment
Reception and administration
• First contact of patients
• Organisation of the surgery
• Dispatching of incoming phone-
calls
• Information to the patients
• General administration
• Handling of the capitation-system
Health promotion
• Health as a resource for social, economic and personal development / important aspect of quality of life
• Achieving equity in health and reducing socioeconomic differences in health.
Health promotion
• Mission statement Health Centre Botermarkt“Prevention of illness and health promotion as very important aspects in the daily routine of a primary health care centre”
• 2 levels:– Patient – centred– Community - centred
Interdisciplinary work -Internal meetings
• Weekly disciplinary teams• Interdisciplinary meeting for care-providers
with • case-discussions• worker-oriented discussions• community and policy oriented themes
• Monthly planning-meeting with the whole team
• Executive committee
External meetings
• Platform of providers and services – 3-monthly meetings, trainings, lunchdebates,…– Meeting, detecting problems, signalize problems
to stakeholders, working on projects,…
• Committee of Flemish Health Centres
• Local medical quality circle
• City Committee on health problems of asylum seekers and ‘people without papers’
• Local Social Policy Advisory board (city of Ghent)• ...
COMMUNITY ORIENTED
COPC-example: dental problems: periodontal disease in childhood
Risk factor for:
• Diabetes
• Coronary Heart Disease
• Preterm birth and low birth weight
• Osteoporosis
Identifying health problem: Family physicians/nurses: problematic oral condition of todlers, leading to feeding problems, crying, not
sleeping,...
COPC-project : from individual care to community health care
Results research children 30 months old:
• 18,5 % early symptoms of childhood caries (7,4 % – 29,6 %)
• 100% need for treatment!
Correlation with• deprivation
• nationality (Eastern-Europe)• no previous dentist consultations
COPC-project : DENTAL FITNESS
Childhood caries:
• Information and Sensibilisation
• Involving providers, social workers, parents, schools…
Strategies:
Community oriented, intersectoral, participation.
Educational platform for students in dentistry
COPC-project : DENTAL FITNESS
Accessible primary dental care
Centre for Primary Oral Health Care
Botermarkt Ledeberg (CEMOB)Started 01/09/2006
Towards accessible oral health care !
Ghent University
COPC-project : DENTAL FITNESS
Integration of personal and community health care
The Lancet 2008;372:871-2
Education and training
• Training for :– undergraduatie medical students
– family physician trainees
– nursing students
– social work students
– ...
The future: WHO-six star provider
- assess and improve the quality of care
- make optimal use of new technologies
- promote healthy lifestyles
- reconcile individual and community health
requirements
- work efficiently in teams
THE SIX STAR PROVIDER
- leadership attributes and acts as change agent
The Lancet 2010;376:1923-58
Universitiesshould investin strong departments offamily medicineand PHC
Integrationof family medicinein the undergraduatecurriculum
1. Expert Panel on Innovative Ways of Investing in Health
2. The model of PHC-Centres in Belgium
3. Policy:strategies for change
From Policy to Practice and back to Policy
Created in 2005
EFPC Multi-CountryStudy-Visits
Barcelona 2014 September 1/2
Website: www.euprimarycare.org
Tel: +31 30 272 96 11E-mail: [email protected]
Improving health and primary health care around the world
through Primary Health Care Centres
Learn more at: www.ifchc2013.org
Debate:SCORE the PHC-practice in your country/region in comparison with the PHC-centres model in Belgium: use a comparative score (--;-;0;+;++) looking at:
°RELEVANCE (CARE THAT REALLY MATTERS…)
°EQUITY (INCL. ACCESSABILITY)
°QUALITY
°COST-EFFECTIVENESS
°PERSON- AND PEOPLE- CENTREDNESS
°SUSTAINABILITY
Debate:What would be the most important policy-measure to improve the quality of PHC in your country/region?
What is/are the most important obstacle(s) to make change happen?
What could be appropriate advocacy-strategies?
Management versus leadership
Management versus Leadership
• Planning and budgetting • Establishing direction
• Organizing and staffing • Aligning people
• Controlling and problem solving
• Motivating and inspiring
Source: J.P. Kotter. A force for change: How leadership differs from management (1990)
Ghent University [email protected]