Promoting Community Health: The Integration of Public Health and Primary Care Professor Sian Griffiths Director, School of Public Health Chairman, Department of Community and Family Medicine The Chinese University of Hong Kong 14 March 2008 Primary care • “Primary healthcare is usually taken to mean the first point of contact individuals and the family have with a continuing healthcare process and constitutes the first level of care in the context of the healthcare system” Healthcare Reform Consultation Document 2008 Primary Care: 5 Family Medicine Principles • Context of Care – Evidence-based • Continuity of Care – Continuous Healing Relationships • Comprehensive Care – Whole Person Care • Coordination of Care – Integration of complex care • Bio-psychosocial Approach – Patient Centred Public health “The science and art of preventing disease, prolonging life and promoting health through the organised efforts of society” Sir Donald Acheson “What we as a society do collectively to assure the conditions in which people can be healthy” Institute of Medicine Three domains Occupational health Environmental health Infectious diseases International health Health economics Health Protection Psychosocial Care groups aspects of health Healthcare management Health education Health Health Global health improvement Services Healthcare Impact of wider systems & policy determinants & international Primary care perspectives Evidence based Epidemiology, biostatistics, clinical trials, medicine 5 law & ethics Patient Centred Care • “ … providing care that is respectful of and responsive to individual patient preferences, needs and values and ensuring that patient values guide all clinical decisions.” (Institute of Medicine 2001) 6 A shift in focus … • “The essence of care is to centre on the patient. This is a shift from traditional, provider focused practice, and it requires the workforce to develop communication skills that empower patients through seeing health from the patient’s perspective, and motivating and training patients in health-related self- management.” – Core Competencies of the Health Care Workforce for the 21st Century: The Challenge of Chronic Conditions (WHO 2005 ) 7 Different focus • Individual level – Doctor-patient relationship; consultation & communication style – Collaborative definition of problem – Supporting patient self-care • Systems & Organizational level – System re-design – Team-based care – Coordination & integration of care 8 Case Study 1 • Mr. A is a 52-years old manual worker. He has history of back strain and recurrent back pain. He is unable to resume his normal duties, and he has also stopped joining gatherings of his friends. • He has been seeing different doctors (GOPC, private GPs, A/E and SOPC) but only getting symptomatic relief so far. He has attended several physiotherapy sessions, occasionally takes over-the-counter self-medication and is now also seeing Chinese medicine practitioner for acupuncture. He suffered from acute gastrointestinal bleeding last month after taking pain-killers prescribed by 3 different doctors whom he consulted over one week. Doctor Chinese medical practitioner Pharmacist Acupuncture Medical for back pain treatment for back pain Physiotherapy; Mr. A: Counseling Physiotherapist strengthening Recurrent Services back pain Behavioral Financial Labour modification assistance Department Healthy Living Programme Social worker Concerns / problems • Physical : recurrent back pain needing pain control • Job performance and social activities affected • Financial problems arising from difficulties in fully returning to work • Doctor shopping : unnecessary exposure to duplicating tests / investigations • Lack of continuity : Different providers each keeping their own records, no information sharing • Multiple medications : prescribed by different doctors > potential problem of iatrogenic reactions Future • Integrated record: sharing of medical information > continuity of care • Ongoing care from a multi-disciplinary team at the primary care practice, which would review the progress together with Mr. A and discuss his concerns • Pharmacist: regularly reviews the pharmacy records and discuss with the doctor and Mr. A for medication adjustment • Mr. A attends the “healthy living programme” at the practice which offers support on behavioral modification (e.g. postures, weight reduction, muscle strengthening exercise), as well as information on services/ facilities available • The practice nurse coordinates with the social worker and labour department to arrange for financial aid and counseling services Case Study 2 • Little boy-B is two years old. He has been in hospital several times with gastroenteritis. He also has frequent asthmatic attacks and chest infections. His vaccination schedule is not up to date. • He lives with his mother, Ms B, who is an 18-years old single mother. Ms B is a heavy smoker. She left school at age 15 and is now working part-time at a convenience store. Little B stays home on his own when his mother is at work, and eats fast food which his mother brings home after work. Concerns / problems • Child: – Recurrent attacks of asthma and chest infection; constantly exposed to environmental tobacco smoke at home – Repeated attacks of gastroenteritis due to poor food and environmental hygiene > – Frequent episodes of infections with repeated hospitalizations > postponing vaccination – Doctors at OPD and hospitals do not know the child’s vaccination status; while doctors at maternal & child health centres do not have update information on the investigations and treatment at OPD / hospital • Teenage and single mother: – Lack of social support; no child care support and child being left uncared for at home – Unhealthy diets and smoking problems GOPC Doctor Smoking cessation MCHC doctor programme Mother heavy smoker: Recurrent asthma environmental and chest infection tobacco smoke Childhood Home and food vaccination 2-yr old Little B hygiene; living with 18-yr gastroenteritis old single mother Child care Poor diet Healthy living support programme Financial aid Social worker Dietitian Future • Little B: – A single integrated record – “Reminder system” automatically for outstanding vaccinations; recalled by the practice staff to receive vaccination – All providers access updated information about medical problems and family background. • Ms. B: – smoking cessation advice – Information to raise awareness of health risks (e.g. smoking, diet) from the primary care team,enrolling in the healthy living programmes offered at the primary care practice, – Obtains information and advice about the facilities and services available, including enquiry hotlines for childcare advice, child care facilities and support services offered by NGOs – The practice nurse coordinates with the social worker to arrange for financial aids for Ms B Case Study 3 • Mrs. C is 67 years old and lives with her daughter. She has hypertension, diabetes mellitus and history of minor stroke. Her blood pressure and glucose control are not good and she suffers from recurrent chest infections requiring hospital admissions. • She has several episodes of fall and once broke her wrist. She now seldom goes out on her own due to fear of falls, and avoids physical exercise. She stays alone in her apartment while her daughter is at work during the day. Doctor Pharmacist Nurse Lifestyle modification Medication for & self-monitoring for HT & DM control HT, blood glucose control Financial support Frequent falls Social worker Mrs. C, 67 yr, DM, HT, minor stroke, frequent falls Rehabilitation & physical Care at home exercise programmes Physiotherapist Transport Social assistance interactio n NGO outreach programme NGO day centre Concerns / problems • Multiple medical problems poorly controlled leading to repeated admissions/ re-admissions • Insufficient community support resulting in discharge problems (and/ or frequent re-admissions) • Problems with transition from hospital care to community and continuity of care, as community physicians cannot access Mrs C’s hospitalization records • Multiple medical conditions followed up at different clinics, each focusing on a specific body system: lacking a comprehensive picture of the patient’s needs • Problems with poly-pharmacy • Physical health problems and difficulties with traveling becoming a barrier to access health services • Real and perceived barriers to adopting behaviour changes (e.g. physical exercise) for controlling disease conditions and promoting wellness Future • Different care providers access and update through her integrated electronic medical record • ongoing care from a multi-disciplinary team. • The team provides support for self-management by Mrs. C, sharing with her information about her diseases and advice on dietary modification. She also learns how to self-monitor her blood pressure and glucose levels • Pharmacy record is regularly reviewed by the pharmacist in the team, who also provides advice to Mrs. C about drug management. • The practice nurse refers Mrs. C to attend an NGO’s day centre facilities, where she can enjoy social interactions, and also join exercise classes which are tailored to her physical conditions • The practice nurse coordinates with the social worker to arrange for transport assistance and (if necessary) financial aid • “Currently, primary medical care is predominantly provided by the private sector, by solo practitioners or group practices, mainly on out‐patient curative care with some preventive elements.” • “Health education and promotion is often perceived as the sole responsibility of the government” Enhance Primary Care • Promoting the family doctor concept which emphasizes continuity of care, holistic care and preventive care. • Putting greater emphasis on prevention of diseases and illnesses through public education and through family doctors. • Encouraging and facilitating medical professionals to collaborate with other professionals to provide co‐ordinated services. • Develop basic models for primary care services • Establish a family doctor register • Subsidize patients for preventive care • Improve public primary care • Strengthen public health functions Explore future public primary care models • “Preventive care services should be incorporated alongside existing curative care services in GOPCs, having regard to the basic models of primary care services.” Need for • Education – Politicians – Public – Professions • Systems change – Focus on patient and increase flexibility • Professional pathways – That interrelate • Team working – Between professionals • Patient participation in primary care Thank you!