A new recipe for teamwork in primary care

Jordi Varela
Editor

 

Primary care teams in Spain are under pressure from the schedules of daily visits, which sends multidisciplinary teamwork to the background. To understand each other, the sessions are held whenever possible and the level of attendance and participation is often irregular, given that nothing encourages them. The core aspect of a primary care centre today is that each doctor and each nurse is assigned a contingent of citizens -presumed to be patients-, who, when requested, must be attended to as soon as possible.

Baker's Decalogue for high-performance healthcare organizations

Jordi Varela
Editor

 

Americans trust that competitiveness is the essence of human activity, which has made them the world's leading power, with China's permission. This principle, however, has not worked for them when they have applied it, without palliative, to their health care system, which is showing clear signs of poor performance: it’s very costly, it’s inequitable and it’s showing poor results. For this reason, some public health care organizations such as Veterans Affairs and Medicare, or private, such as Mayo Clinic, Cleveland Clinic or Kaiser Permanente, are trying to put sanity, analyzing what are the keys to improve the performance of the system.

Family medicine confined into an individualistic practice

88% of the demand for assistance requires some kind of coordination

If we glimpse at the memories of the primary care centres, we will notice they all attach great importance to the number of visits, especially family doctors, in the sense that the more visits, the less waiting time. Unhappy with this, I have clicked on the primary care document of the AQuAS Results Centre, one of the most advanced evaluation systems in the world, and I have observed that, in addition to efficiency, data on effectiveness, quality, and value practices and information technology development are collected. The indicators of adequacy warrant separate mention since they are the only ones that, although indirectly, give an estimate of the collaborative work of the primary care teams, implying that if the preventable hospitalizations and the number of multi-medicated patients are in low levels, should be an indicator that in that team there is some form of integrated model of clinical work.

Primary care: reforms based on innovation

The primary care reform initiated in Spain in 1985 was inspired by the Alma-Ata statement that WHO had proclaimed a few years earlier. The need for change was evident since the previous model was characterized by access difficulties, the predominance of curative care, medical orientation focused on diseases and the absolute lack of teamwork. Thirty years later, primary care is in a crisis of exhaustion due to multiple factors, of which the lack of budgetary endowment, the ageing of the population and the rigidities and bureaucracies of which it has been endowed stand out, and for a long time the call for reforming the reformed has been heard and create a new model more appropriate to the present day.

Strategies for the integration of services

King's Fund has published a timely and in depth document "Acute Hospitals and Integrated Care" where they question what role should hospitals play in the integration of services. Given the approach, one could ask: What role should primary care play? How about community services? And the social health services? However it may be best, King's Fund has focused on it in this way and I believe it has its reasons for doing so because, right now, the organizational model that everyone tends to is that of territorial management or that of integrated health organizations, all of which are intended to integrate services from a hospital-centred position.

Who should lead the integration of services?

According to the document, it’s fundamental to generate the network of services on a territorial basis and the question of leadership should depend on the nature of each clinical process. Let's take a few examples: a) A remote dermatology project should be led by specialized care, b) An infarct ought to be led by cardiologists, intensive carers and emergency specialists, c) Care for type 2 diabetes mellitus, should be led by the primary care, d) Individualized therapeutic plans of complex chronic patients, should be led by primary care with the community nurse and the social worker taking a high profile role, e) Complex end-of-life processes should be led by community-based multidisciplinary palliative teams.

Integration of social and health services: 3 issues and 3 solutions

Aging population has many interpretations, some of them very positive such as the fact that more and more people are fortunate that they live for longer with a fairly healthy life. The other side of the coin is that there are also problems such as increased multiple combined chronic diseases, social deprivation and the fact that many people reach an advanced stage of geriatric frailty. And this is where service delivery models that have been consolidated in recent decades are still struggling to give satisfactory answers. Governments know it and, for this reason, are launching initiatives to address chronic disease and frailty in a more effective manner but these programs often face political difficulties, resistance to change and difficult to overcome bureaucracies.

From everything I've seen in this issue, I think the British are the most daring, so I chose the report of the "Commission on the future of health and social care in England" published by King's Fund, because it synthesizes very well what the problems of current models are and what are the solutions to be put on the table.

First problem: the current model is unfair. The health system is universal and free, while access to social services is restricted. Let's say two examples: people affected by cancer enjoy global coverage, regardless of process costs and economic level of the patient, while Alzheimer's patients suffer from limited access to services, especially in more advanced stages when their needs are more social than medical.

Second problem: funding sources are different. The health system feeds directly from the public budget, while social funding source is hybrid, with participation of different administrations, including the local, and with a variety of complex management copayments.

Population’s health beyond service integration

All health systems in the world are immersed in service integration projects aiming to meet the challenge posed by the increased chronic disease and geriatric frailty. Based on this circumstance, King's Fund has published a document, "Population health systems. Going beyond integrated care" wondering how difficult could the integration of public health services be, given that improving health determinants  and risk prevention can most effectively affect the way in which many people grow older and healthier. 

The King's Fund document selects 5 experiences from different countries, that beyond the integration of services, are reaching community action: a) Kaiser Permanente, USA, focused on promoting physical activity and healthy eating; b) Nuka System of Care, Alaska, focused on community work to reduce domestic violence; c) Gesund Kinzigtal, Germany, focused on community groups that promote sport and health; d) Manukau Counties, New Zealand, created programs that emphasize healthy improvements in social housing; and e) Jönköping County Council, Sweden, formed discussion groups to promote health (life cafés, learning cafés, etc.)

Integration of social and health services: a must!

Integration matters, but so too does additional money into #socialcare: @MMitchMS gives her response to #barkercomm http://t.co/Inpgt4zEUa

— The King's Fund (@TheKingsFund) May 27, 2014

King's Fund, through this tweet, offers us access to an interim report of an independent commission that is working for the unification of the social and health services for complex chronic patients and patients with disabling degenerative processes. The report's proposal is clear: one organization and one budget with the aim of promoting access to social and health services tailored to the needs.

According to the Commission, in the UK, with regard to chronic disease care, there’s a misuse due to different barriers to access to services, with little public money on social services and waste in health services. The question is whether it’s possible to redistribute public funds to meet the real needs of this ever-growing population group.

Leadership: difficulties and challenges

Managers from National Health Service consortiums now seem an endangered species, according to the King's Fund. Politicians have demanded cuts and they have fought greatly so that their centres can maintain the required levels of care. The result: the leakage of first level managers disappearing from the public system.

The first reference documents, which has as its subtitle "No More Heroes" (the green one), describes the new leadership style beyond the mandatory compliance to the objectives imposed from above. It said that Managers who have an inside perspective are essential if we want to get the doctors, nurses and other health professionals to do their work with quality. The new leadership should not only correspond to the manager, the heroism no longer makes sense. Therefore, now we need to have leaders throughout the organization, leaders who are present in every corner of all processes and, above all, know how to involve professionals in the management of resources, but also know how to facilitate the participation of patients in the decisions that affect them.

Complex Chronic Patients: UK progress in funding

good article by Sam Everington on general practice http://t.co/Qk0iIs2ZZQ

— Chris Ham (@profchrisham) marzo 13, 2014

Director of King'sFund, Chris Ham’s tweet, takes us to Sam Everington’s article in The Guardian, about new experiences of financing (commissioning) towards community services deployed to address chronic complex patients in their own homes, even in episodes of clinical exacerbations, and thus avoiding likely unwise hospitalizations.

Frail elderly patients: the case of Torbay

The health and social care for elderly people in Torbay (England) is fully integrated today (see the King's Fund document). In 2004 a pilot in one of the county’s districts was launched and soon spread to the entire area. Each of the 5 teams that were set up serves a population in a range from 25,000 to 40,000 inhabitants. In 2005 Torbay Care Trust was created.

The main objective of the service integration:

Maintaining the frail patients at home or in a community setting for as long as possible.

Key elements to achieve the objectives:

• Integration of health and social care professional teams
• Team budgets’ fusion
• Deployment (or purchase if appropriate) of a wide range of intermediate services that facilitates home support
• The enthusiastic support of family doctors (even though they have not been integrated)
• Institutional support, especially local support

Can unnecessary hospitalizations be avoided?

It is said that the best savings in health is in avoidable hospitalisation that doesn’t occur, especially since the use of a hospital bed is the most expensive health resource of all the health offers, but also because if one person, let’s imagine an elderly one with several chronic conditions, can avoid being admitted in hospital, his/her health will suffer less compromising situations. For this reason, all health systems are very active in trying to launch all kinds of measures to reduce the admission of chronic and frail patients.

Dr. Sara Purdy, family physician and Senior Consultant at the University of Bristol, published under the auspices of the King’s Fund, in late 2010, an analysis of what actions reduce the unnecessary hospital admissions and which ones do not. The work of Dr. Purdy is focused only on organisational actions such as home hospitalisation or case management, and, in contrast, does not include strictly clinical factors such as the impact of a new drug for asthma conditions.

See below what actions have been proven to reduce unnecessary hospitalisations (for the source of evidence, consult the King’s Fund paper):

Preference sensitive health care: the causes of variations

There is a case-mix part (25% according to Wennberg) such as inguinal hernia, cataracts, metrorrhagia or knee osteoarthritis, for which modern medicine has an effective surgical response, although in the application of the technique there is often a margin for the doctor’s interpretation, another margin for the subjectivity of the patient, such as pain perception or adaptation to the lack of visual acuity, as well as a very important factor: the decision of the patient himself. There are men who prefer to wear a brace to hernia surgery and women who prefer to live with their uterus, provided that the degree of the discomfort and metrorrhagy allows them to.

After this introduction, let’s see the Variations in Health Care, the good, the bad and the inexplicable report by John Appleby and his collaborators, published by King's Fund in 2011, which states that variations in hospitalization rates are pervasive and persistent, and even affect common interventions known to be effective such as hip replacement for advanced osteoarthritis cases.

                Distribution rates of hip replacement in England 2009/10