PowerPoint-presentation

Future impact of continuity on quality of care within Primary Care

1Disposition16.30 Introduction - Continuity in primary care - background and evidence (C.Bjrkelund)16.45 Enhancing continuity in future primary care in Europe impact on multi-morbidity, goal- oriented care and equity(Jan de Maeseneer)17. 10Continuity of care through the patient's eyes - focusing on patient experience. (Anna Maria Murante)17.30 Continuity of care national examples(Kathryn Hoffman A. Maun Zsuzanna Farkas-Pall )17.40 Workshop discussion on continuity:17.55 Summary and conclusions

Continuity in primary care - background and evidenceCecilia BjrkelundDepartment of Primary Health CareUniversity of Gothenburgand Region VstraGtaland

Continuity of care One of the cornerstones of primary care

Evidence from community and provider perspectiveLower health care costsLower hospitalization and emergency room useGreater efficiency of services Associated with substantial reductions in long-term mortalityMore effective prevention of diabetesIncreased quality of care in primary care depression treatment

Patients perspective

Patients identified both factors that promote as well as factors that divide continuity of care across boundariesChronic ill patients valued being attended regularly and over time by one physician while Young patients valued convenient access. variations in perceived importance seem to depend on both individual and contextual factors which should be taken into account during healthcare provision Waibel S, Henao D, Aller M-B, Vargas I, Vazquez M-L. What do we know about patients' perceptions of continuity of care? A meta-synthesis of qualitative studies. International Journal for Quality in Health Care 2011

Chronic conditions100 000 primary care patients 182 general practices in England. 58 % of the patients had chronic conditions accounting for 78% of the consultationsreceived lower continuity.

patients with multi-morbidity are, are less likely to receive continuity although they should be more likely to gain from it

Evidence seems to recognize continuity as one of the cornerstones of high quality primary careSynthesis of quality of care for patients with complex care needs in eleven European countries showed that all countries needed improvements by development of care teams in primary care, managing among other things transitions and medication

BUT - there is no sign of decreasing lack of continuity in primary care in Europe.

The complexity of operationalizing continuity in the context of multi-disciplinary team-based primary care of today and tomorrow, with the desirable effects on care both from patients perspectives, from medical and health economic perspectives as well as political perspectives is a great challenge. The challenge will also be how to measure and how to compare between primary care centers, organizations and between countries, as this will be the best way to stimulate the desired development.

There is great need of further developing methods to assess and promote continuity in primary care There is great need of research to better understand and operationalize continuity and how development of continuity should be stimulated and incentivized There is great need of studying the effects including costs and benefits of todays general practice as well as the costs of diminishing continuity.

EFPC Position paperImpact of continuity on quality of care within Primary Care with focus on the perspective of preferences of citizens Does interpersonal continuity lead to improved medical outcomes? Does interpersonal continuity of practitioner/nurse/team aid in the management of problems? Which organizational structures improve interpersonal continuity in primary care of today?

http://www.primafamed.ugent.behttp://www.euprimarycare.orghttp://www.the-networktufh.orghttp://www.wgcbotermarkt.be

Continuity in future primary careContinuity of care: a catch-all termTypologyMultimorbidity, goal-oriented care and equityThe future of continuity: threats and opportunities in patients with multimorbidityConclusion: from the patient, the provider, the practice towards the community, the team, the system1. Continuity of care: a catch-all termA sustained partnership between patients and clinicians (IOM)Process or outcome?RelationshipContextualCost-effective?

Table 3. Provider Continuity (0/1) in a Multivariate Approach With Total Health Care Cost (LogarithmicTransformation) as the Dependent Variable:Standardized Regression Coefficients Explaining VariablesStandardized Regression Coefficient P ValueOlder age.086< .001Sex (male)-.036.008Health locus of control: internal-.030.029Physical functioning-.1568< .001Mental functioning-.056< .001Multiple morbidity.116< .001Number of regular encounters.296< .001Provider continuity-.105< .001R27.6%De Maeseneer, J. , De Prins, L., Gosset, C. and Heyerick, J. (2003). Annals of Family Medicine, 1(3): 148.

Continuity in future primary careContinuity of care: a catch-all termTypologyMultimorbidity, goal-oriented care and equityThe future of continuity: threats and opportunities in patients with multimorbidityConclusion: from the patient, the provider, the practice towards the community, the team, the systemInformationalAn organized collection of medical and social information about each patient is readily available to any health care professional caring for the patient. A systemic process also allows accessing and communicating about this information among those involved in the careLongitudinalIn addition to informational continuity, each patient has a "medical home" where the patient receives most health care, which allows the care to occur in an accessible and familiar environment from an organized team of providers. This team assumes responsibility for coordinating the quality of care, including preventive servicesInterpersonalIn addition to longitudinal continuity, an ongoing relationship exists between each patient and a personal physician. The patient knows the physician by name and has come to trust the physician on a personal basis. The patient uses this physician for basic health services and depends on the physician to assume personal responsibility for the patient's overall health care. When the personal physician is not available, a coverage arrangement assures that longitudinal continuity occurs.Continuity in future primary careContinuity of care: a catch-all termTypologyMultimorbidity, goal-oriented care and equityThe future of continuity: threats and opportunities in patients with multimorbidityConclusion: from the patient, the provider, the practice towards the community, the team, the systemThe ageing society

24Multimorbidity becomes the rule, not the exceptionMore than half of the patients with COPD have either cardiovascular problems, or diabetesPatients with COPD have a 3- to 6-fold risk to have all these problems

50 % of 65+ have at least 3 chronic conditions20 % of 65+ have at least 5 chronic conditions(Eur Respir J 2008;32:962-69)(Anderson 2003)26De huisarts, zal samen met de patint tot een besluit moeten komen over "wat er echt toe doet": de huisarts doet aan "patient mangement". Hierbij zullen afwegingen, gemaakt op basis van de continue relatie en longitudinale informatie over hoe de patint keuzen heeft gemaakt en maakt rond gezondheid, in het gesprek worden opgenomen.

Age-standardised prevalence and prevalence ratio of diabetes by educational level in men and women, 30-64 years of age in selected countries (source: Eurothine, 2007)CountryTertiary educationLower secundary educationSpainMenWomen2.71.14.95.1BelgiumMenWomen1.51.24.44.6EstoniaMenWomen2.04.15.38.2RemarksThe prevalence ratio (PR) can be interpreted as the ratio between the prevalence of diabetes in the upper/lower secondary educational group and the prevalence of diabetes in the tertiary educational group. If the PR is larger than 1, this means that the prevalence of diabetes is higher in the upper/lower secondary educational group than in the tertiary educational group.The classification of the educational groups used in the figure above is adapted from the ISCED. Data apply to the 1990s and the early 2000s.Also see Age-standardised prevalence ratio of diabetes by educational level in men and women, 30-64 years of age in selected countries.

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Wagner EH. Effective Clinical Practice 1998;1:2-4 31Het CCM is als referentiekader gebruikt bij de ontwikkeling van De interventie. Dit model wordt ook internationaal vaak gebruikt bij het opzetten van zorgvernieuwingsprojecten. Het model is voor het eerst beschreven in 1998 door Wagner op basis van de evidentie uit onderzoek, ervaringen uit best practicesvoorbeelden en expertopinie. Centraal in dit model staat de interactie tussen depatint en het team in de eerste lijn. Het model beschrijft 6 essentile pijlers die bijdragen tot een betere kwaliteit van zorg.Eerste 2 pijlers zijn vooral van belang op macro- en mesoniveau:1.Een gezondheidszorgsysteem met aandacht voor een chronische zorg, gereflecteerd in een globale visie met duidelijke doelstellingen en voldoende middelen. Zichtbare betrokken zijn van beleidsmensen en lokale senior leaders in de zorgvernieuwing. 2.Het inbedden van de chronische zorg in de lokale gemeenschap.Bvb door intensifiren van de samenwerking met patintenorganisaties, partnerships met andere organisaties die programmas aanbieden 4 volgende pijlers zijn vooral van toepassing op de praktijkorganisatie:3.Ondersteuning van de zelfzorg van de patint door het aanbieden van educatieprogrammas complementatir aan de informatie die de artsen zelf geven in de praktijk; meest effect al aangeboden worden gentegreerd in de reguliere zorg4.Het beschikken over een team van goed opgeleide zorgverleners met duidelijke taak-en werkafspraken, een organisatie van de praktijk die een nauwgezette opvolging van chronische zorg toelaat: afspraaksysteem, eventueel opzetten van Diabetesspreekuren, ..5.Integratie van guidelines in de praktijkvoering, ondersteuning vanuit de nascholing, betrekken van de tweede lijn als coach bij kwaliteitsverbetering6.Informatiesysteem dat chronsche zorg ondersteunt; praktijkregister met mogelijkheden voor call en recall (specifieke groepen), reminders vanuit Softwareprogramma, uitwerken mogelijkehden voor audit en feedback

EMPOWERMENT3232Het CCM-model is een theoretisch model dat in 1998 ontwikkeld is door Wagner op basis van de bestaande evidentie rond zorgorganisatie voor chronisch zieken & in de meesteonderzoeken rond zorgvernieuwing als onderbouwing wordt gebruikt.Centraal in goede zorgverlening staat de interactie tussen een goed gestructureerd team en een genformeerde & gemotiveerde patint.6 elementen dragen er toe bij om dit te realiserenVoldoende aandacht vanuit maatschappij en beleid voor de uitbouw van een chronisch zorgbeleidOrganisatie van de gezondheidszorg: doelstellingen voorop stellen, aangepaste financiering van de zorg (targets),Aandacht voor zelfzorg: continue evaluatie zelfzorg, centrale rol van patint benadrukken, Organisatie zorgverlening: taakafspraken, call/recall, afspraaksysteem, Ondersteuning in medisch handelen: beschikken over aanbeveling, navorming, ondersteuning door de tweede lijn Aangepaste informatietechnologie: ondersteuning bij registratie & feedback, gedeeld dossier, ..

ButJennifer is 75 years old. Fifteen years ago she lost her husband. She is a patient in the practice for 15 years now. During these last 15 years she has been through a laborious medical history: operation for coxarthrosis with a hip prothesis, hypertension, diabetes type 2, COPD and osteoartritis. Moreover there is osteoporosis. She lives independently at her home, with some help from her youngest daughter Elisabeth. I visit her regularly and each time she starts saying: Doctor, you must help me. Then follows a succession of complaints and unwell feeling: sometimes it has to do with the heart, another time with the lungs, then the hip, Each time I suggest according to the guidelines - all sorts of examinations that did not improve her condition. Her requests become more and more explicit, my feelings of powerlessness, insufficiency and spite, increase. Moreover, I have to cope with guidelines that are contradictory: for COPD she sometimes needs corticosteroids, which worsens her glycemic control.

The adaptation of the medication for the blood pressure (at one time too high, at another time too low), cannot meet with her approval, as does my interest in her HbA1C and lung function test-results.36After so many contacts Jennifer says: Doctor, I want to tell you what really matters for me. On Tuesday and Thursday, I want to visit my friends in the neighbourhood and play cards with them. On Saturday, I want to go to the Supermarket with my daughter. And for the rest, I want to be left in peace, I dont want to change continually the therapy anymore, especially not having to do this and to do that.In the conversation that followed it became clear to me how Jennifer had formulated the goals for her life. And at the same time I felt challenged how the guidelines could contribute to the achievement of Jennifers goals. I visit Jennifer again with pleasure ever since: I know what she wants, and how much I can (merely) contribute to her life.

Sum of the guidelinesPatient tasksJoint protectionEnergy conservationSelf monitoring of blood glucose ExerciseNon weight-bearing if severe foot disease is present and weight bearing for osteoporosisAerobic exercise for 30 min on most daysMuscle strenghtening Range of motion Avoid environmental exposures that might exacerbate COPDWear appropriate footwearLimit intake of alcohol Maintain normal body weight Clinical tasksAdminister vaccinePneumoniaInfluenza annually Check blood pressure at all clinical visits and sometimes at homeEvaluate self monitoring of blood glucoseFoot examinationLaboratory testsMicroalbuminuria annually if not present Creatinine and electrolytes at least 1-2 times a year Cholesterol levels annually Liver function biannually HbA1C biannually to quarterly ReferralsPhysical therapy Ophtalmologic examination Pulmonary rehabilitatiPatient education Foot careOeseoartritisCOPD medication and delivery system training DiabetesTime Medications7:00 AM Ipratropium dose inhalerAlendronate 70 mg/wk8:00 AM Calcium 500 mgVit D 200 IU Lisinopril 40mgGlyburide 10mg Aspirin 81mgMetformin 850 mgNaproxen 250 mgOmeprazol 20mg 1:00 PM Ipratropium dose inhalerCalcium 500 mgVit D 200 IU7:00 PM Ipratropium dose inhalerMetformin 850 mgCalcium 500 mgVit D 200 IULovastatin 40 mgNaproxen 250 mg 11:00 PM Ipratropium dose inhalerAs neededAlbuterol dose inhalerParacetamol 1g Boyd et al. JAMA, 2005

Problem-oriented versus goal-oriented careProblem-orientedGoal-orientedDefinition of HealthAbsence of disease as defined by the health care systemMaximum desirable and achievable quality and/or quantity of life as defined by each individualProblem-oriented versus goal-oriented careProblem-orientedGoal-orientedPurposes of Health CareEradication of disease,prevention of deathAssistance in achieving a maximum individual health potentialProblem-oriented versus goal-oriented careProblem-orientedGoal-orientedMeasures of successAccuracy of diagnosis, appropriateness of treatment, eradication of disease, prevention of deathAchievement of individual goalsProblem-oriented versus goal-oriented careProblem-orientedGoal-orientedEvaluator of successPhysicianPatientWhat really matters for patients is Functional status

Social participation

Evolution fromChronic Disease Management towardsParticipatory Patient ManagementPuts the patient centrally in the process.Changes the perspective from problem-oriented care. towards goal-oriented care.

F R A G M E N T A T I O NThe challenge: vertical disease- oriented programs and multimorbidityCreate duplicationLead to inefficient facility utilizationMay lead to gaps in patients with multiple co-morbiditiesLead to inequity between patients48

Problems with guidelines in multimorbidityEvidence is produced in patients with 1 diseaseGuidelines may lead to contradictions (e.g. in therapy)

53Resolution WHA62.12 Primary Health Care, including health systems strengtheningThe World Health Assembly, urges member states: (6) to encourage that vertical programmes, including disease-specific programmes, are developed, integrated and implemented in the context of integrated primary health care.54

Multi-morbidity, goal-oriented care and equity:The way goals are formulated by patients is determined by social classcontextual evidence : how to deal with an unhealthy and inequitable context?

Community Health Centre:Family Physicians; nurses; dieticians; health promotors; dentists; social workers; 6000 patients; 60 nationalitiesCapitation; no co-paymentCOPC-strategy

Diabetes clinic: horizontal approach to chronic conditionsObjectives:Improving the care for diabetes type 2 patients through a structured multidisciplinary follow-up and health educationImprove self-efficacy of patientsTo tackle social inequalities in relation to chronic diseases58Diabetes clinic: horizontal approach to chronic conditionsProgramme:biomedical and behavioural follow-up by nurse, diabetes educator,dietician and family physician, implementing guidelines in the context of the patientexchange of experiences by the patients (groups)diabetes-cooking (3 x / year)

59Integration of personal and community health care

The Lancet 2008;372:871-2Continuity in future primary careContinuity of care: a catch-all termTypologyMultimorbidity, goal-oriented care and equityThe future of continuity: threats and opportunities in patients with multimorbidityConclusion: from the patient, the provider, the practice towards the community, the team, the system4. The future of continuity: threats and opportunities in patients with multimorbidityThreats:Anonimous care dilution of informationDilution of responsebilityOutsourcingFragmentation

4. The future of continuity: threats and opportunities in patients with multimorbidityOpportunitiesThe patient in the drivers seatIncreased comprehensiveness complementary frames of referenceIncluding contextTask-sharingInterprofessional feedbackSustainability

4. The future of continuity: threats and opportunities in patients with multimorbidityRequirementsCulture of cooperationPatients choice: limits?E-health system: interprofessional electronic patient recordInterprofessional educationCase-loadComprehensive financing mechanisms: integrated needs based capitationContinuity in future primary careContinuity of care: a catch-all termTypologyMultimorbidity, goal-oriented care and equityThe future of continuity: threats and opportunities in patients with multimorbidityConclusion: from the patient, the provider, the practice towards the community, the team, the system Assessment over time Informational: improvement

Longitudinal: PHC team

Interpersonal: the challengeThank you jan.demaeseneer@ugent.be

WHO CollaboratingCentre on PHC

We thank Lynn Ryssaert, MA, PhD-student for her valuable inputContinuity of care through the patient's eyes - focusing on patient experienceAnna Maria Murante, Laboratorio Management e SanitIstituto di ManagementScuola Superiore SantAnna - Pisa (Italy)

Before we start...Before we start...Patient satisfaction vs patient experience

(Avedis Donabedian, 1988)Patient satisfaction as a quality-outcome indicatorThe complexities of modern health care and the different expectations and experiences of patients cannot be measured by asking How satisfied are you with your care/service?

Before we start...Patient satisfaction vs patient experiencePatient experience measures coming from questions like What was your experience with report (through the patient perspective/perception) whether a certain events occurred. However, patient tend to be more positive in evaluating care than in reporting their experience with specific events.(Fitzpatrick et al, 2009)Adler R, Vasiliadis A, Bickell N. The relationship between continuity and patient satisfaction: a systematic review. Fam Pract 2010;27(2):171-8.

Continuity of care & patient satisfactionLet's move on!Continuity of care is a dimension of patient satisfaction

(Ware and Snyder, 1975)Interpersonal continuityLongitudinal continuityInformational continuity(Saultz,2003)Interpersonal Continuity & patient satisfaction

(1992)[] overfamiliarity or seeing the same physician too frequently could lead to missed diagnosis or fed beliefs that the physician could become complacent with the patients problems, sothat his or her concerns were no longer taken seriously.

Interpersonal Continuity & patient satisfaction

Interpersonal and Longitudinal Continuity & patient satisfaction

2001[] patients expected from their GPs to exchange information with specialists regarding their health situation, treatment options and care facilities

Informational Continuity & patient satisfaction

Other Continuity & patient satisfaction

(2006)(Naithani et al, 2006)Adjusting services to the needs of the individual over time.

The nurse always makes time for me. If I phone [] she will always call me back on the same day. I have been able to see her when Ive needed to.

Theyre very good here you know, whenever I need to see the doctor I can just phone up and get a appointment when you want, you dont have to wait long and they ask you, you know, whats it about so if you need more time then they will book you a double appointment . Flexible Continuity & patient satisfaction(Naithani et al, 2006)Just recently I have had to change doctors because the doctor that I have been seeing has retired. When I went to the new practice and registered and went to see the nurse, they told me they didnt have any information on me andmy medical records hadnt turned up.

Team and cross-boundary Continuity & patient satisfaction(Naithani et al, 2006)[] Patients responses to their perception of a serious lack of experienced continuity of care were sometimes to seek alternative care and advice, non-compliance with advice or treatment, or withdrawal from formal services and attempting to monitor andmanage their condition themselves.Team and cross-boundary Continuity & patient satisfaction

What happens when patients have a chronic disease?Patients with chronic conditions prefer to see their GPs regularly to check the progress even when they were not feeling sick (Infante et al, 2004).

Patients with multiple long-term conditions report that several professionals know them equally well (Cowie et al, 2009).

Chronicity & continuity & patient satisfactionChronic ill patients valued being attended regularly and over time by one physician while young patients valued convenient access. The authors concluded that variations in perceived importance seem to depend on both individual and contextual factors which should be taken into account during healthcare provision (4).

86According to the experience of some patients with diabetes:

GPs might lose interest, when they were referred to secondary care (Infante et al, 2004)GPs and specialist have to exchange information on health situation, treatment options and care facilities (Michielson et al, 2007)

Chronicity & continuity & patient satisfactionPatients with co-morbidities perceived that specialists did not interact with their colleagues. (Williams, 2004)Patients with chronic conditions report to be frustrated when they had to repeat their antecedents to doctors, who had not informed themselves in advance. (Von Bltzingslwen et al, 2006)Young and employed patients with a minor, acute health problem preferred convenient access, although achieved at the cost of seeing different healthcare professionals. In urgent cases, an immediate intervention became a priority for patients with diabetes or other long-term conditions.

Chronicity & continuity & patient satisfactionContinuity of care & patient satisfactionThe point of...Several and different measures are used to extimate the relationship between PS and CoC

Many evidences exist about a positive relationship

But also anyothers report a weak or not significant relationship.

Among patients with chronic condition different results could be observed (e.g. depending on severity), however sharing information among professionals is a common need.

Timely access to services may be preferred to continuity of careThanks for your attention!Anna Maria Murantea.murante@sssup.itLaboratorio Management e SanitIstituto di ManagementScuola Superiore SantAnna di Pisa (Italy)A country report Austria

Kathryn Hoffmann, MD, MPHEFPC Conference Gothenburg 2012

Impact of continuity on quality of care within PC

91The three sisters of continuityFist Contact: Free, region-wide and full covered access for everybodyCoordination: Structural preconditions for continuity: 1) System level: E.g. single vs. group practices, financial incentives 2) Process level: E.g. gate-keeping-system, list-system, appointment-system, ...Comprehensiveness: Knowledge about the predominant diseases in the related region/county (adequate staff with adequate education and equipment): E.g. morbidity registers, sentinel offices for surveillance, ...Continuity

Barbara Starfields 4 cardinal Cs of PC92First of all a few thoughts related to continuity of care that express the complexity of this issue. First I wanted to write instead of sisters mothers because I thought without these three continuity is not possible at all. Then I shifted to children because without the basis and aim continuity the three would grow into strange directions. But at the end I stayed with sisters because they are have to be at the same level to make the picture ready for equity in health comming across.92Austrian situation (excerpt)First Contact: Free access, overall good availability, for more than 98% of population fully covered BUT free and covered access with some exceptions (e.g. radiologist) also to the secondary level of careCoordination: No gate-keeping system, no list system, ~95% single-handed practices, fee-for-service mainly, GPs are self-employed Comprehensiveness: Very high standard of equipment, nearly no knowledge about the morbidity situation in the primary care sector: mainly hospital based data, no incentives for community-orientation, 3-year hospital based postgraduate education to become a GP

93The idea of an ideal pathway and the possibility of referrals are existing (first GP, then specialist) but only theoretically; in practice it depends on the patients decision. 93Some preliminary results from Austria>70% of patients said they have a certain GP but >60% of them visited a specialist without referral at least once in the last year QUALICOPC data

Rate of patients who visited a specialist within the last 4 weeks with referral from GP is low (~26%). Chronic disease is not a predictor for a higher referral rate in women - part of the Ecohcare-study; will be submitted soon

9494Continuity in Austria: Attempt of a summerySingle handed practices: Good for continuity, bad for GPs satisfaction?Choice of physician as patients decision High satisfaction with system in 2004 (Euro health consumer index) vs. publication cost of satisfaction(Fenton, 2012)High health care expenditures, high hospital admission rates, high utilisation of specialists (e.g. Austria 71.1% vs. the Netherlands 37.8% - own research project), low referral rates, low healthy life years for 65+

How to measure the impact of continuity on quality of care alone to highlight its importance? 9595

Continuity of care national examples Sweden

Andy Maunmember of quality council SFAM Q GP Trainee, Primary Healthcare Gothenborg, PhD student96Healthcare systems in SwedenIn health care and certainly primary healthcare:21 counties and regions differing in: payment systems IT systemsfollowup of quality

Reform on Choice of Care 2008Aim: Increase the number of healthcare centresPatients can choose a centre but not personal GP - centres compete!

Resulted in a lot of new centres mostly run by great companies owned by risk capitalists.

Trends in most CountiesPayment by individual capitation based onage socio-economy morbidity burden (ACG - adjusted clinical groups)

The centre pays all costs for laboratory services, x-ray and drugs

Development of a register for Quality Improvement of the Western RegionAim: regional primary healthcare register with the potential for a national registerTarget group:Healthcare centres - internal improvementsAcademy - scientific researchPolitical management - results, paymentPatient choice of healthcare centre

Get a new

perspective

IndicatorsFive chronic diseases: (< age 75)Diabetes (National Diabetes Register)Ischemic heart diseaseHypertensionAsthma COPD

Medical variabelsDiagnosisSmokingWeightLengthWaistlines

Age / GenderSpirometryHbA1cBlood lipidsBlood pressure

Results can be linked to other registers e.g. stroke registerprescription registersocioeconomic data

Effects?Diabetes diagnosisPrimary Healthcare, Western RegionBefore/after ACG(Payment for morbidity burden)010 00020 00030 00040 00050 00060 00070 000200520062007200820092010Number of individualsStaffan Bjrck, Analysis Unit Western Region Pilot study - continuityAim: to examine the feasibility of a larger study, where the correlation between provider continuity and health outcomes is to be exploredMethod: retrospective study (Oct 2009-Febr 2012) four primary care centres (33485 individuals)health outcomes (blood pressure, HbA1c) usual provider continuity (UPC) and continuity of care index (COC) for physician/nurse

continuityResults No distinct correlationsNo distinct correlations could be found between interpersonal continuity with physician/nurse and blood pressure and HbA1c values

A timeline-study on the whole population of the region (1,5 million inhabitants) is feasible and necessary to gain more knowledge

ChallengesTransformation? From interpersonal continuity towards team continuity in primary care?The big challenge: collaboration cross organizational borders?What actions are required to improve medical outcomes?

Thank you for your attention!

Dr. Zsuzsanna Farkas-PallContinuity of care,a way to reduce healthinequalitiesThe Future of Primary Health Care in Europe IV , September 2012 The Future of Primary Health Care in Europe IV , September 2012 BackgroundIn Romania, no or little efforts were made at policy making levels to address socio-economic determinants of health and tackle health inequalities emerging from reduced access to health care, lack of local health services, povertyNo feasible solutions are offered to bridge the gap between sporadic and continuous access to health care servicesLocal primary care team can play a key role in maintaining continuity and offering tailored health services in the communityThe Future of Primary Health Care in Europe IV , September 2012 AimsTo give an example of good practice in reliable, continuous health service delivery and gather evidence about the importance of it To act locally, use local resources and emphasize the importance of team approachTo offer integrated health services locally and monitor the impact on health indicators in the communityThe Future of Primary Health Care in Europe IV , September 2012 The national contextApprox. 11000 GPs working in mostly solo practicesNr. of patients/GP 1545,practice nurse/GP rate1.2Nr. of settlements without any health care provider 88, with a total of 153904 inhabitantsNr. of settlements without access to out of hours service 2330Percentage of people without health insurance 16.10%Amongst EU states Romania has the most reduced percentage of GDP spent on health care- 5.5%

The Future of Primary Health Care in Europe IV , September 2012 Our experience Our health centre is located in the north-western region of RomaniaWe provide the community with the possibility of having ultrasound, ECG examinations, lab tests, physiotherapy, family planning services and access to prevention programs performed locally During the years we developed educational programs targeting different groups in the community, have done research activities to gather evidences in order to prove the importance of our activitiesThe activites are ongoing and continuity helped developing partnership with the community

The Future of Primary Health Care in Europe IV , September 2012 ResultsContinuity in access to high standard sustainable and reliable health services, health promotion will result in improved health indicators, healthier and more satisfied population, decreased needs of secondary care services, efficient utilization of the existent resourcesPrimary care team equipped with appropriate tools and empowered with knowledge is well positioned to reduce health inequalities Continuity in patient education, establishing partnership will induce a more responsible and self conscious population

a ativitii, invitaii personalizate, intervenii consecvente accesibile pentru populaie.

The Future of Primary Health Care in Europe IV , September 2012 114ConclusionsIntegrated health services like ultrasounds, ECG, lab tests and ongoing population based health education and screening programs has to be delivered locally and the service must be reliable to build trust and engagementgaps in health care provision will negatively influence patient behavior and will lead to setbacksOur approach towards continuity in primary care service delivery in the community has helped to improve the relationship between our staff and the population in our area: trust has lowered the threshold for contactThe model is sustainable as it uses local resources and is based on a partnership with the community The Future of Primary Health Care in Europe IV , September 2012 Thank you for your attention!

The Future of Primary Health Care in Europe IV , September 2012