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From Policy to Practice and back to Policy

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

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From Policy to Practice and back to Policy

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  1. From Policy to Practice and back to Policy Prof. Dr. J. De Maeseneer, MD, PhD Department of FamilyMedicine and PHC- GhentUniversity, Belgium General Practitioner (part-time), Community Health Centre ,Ledeberg-Ghent (Belgium) ChairmanEuropean Forum forPrimaryCare Chairman Expert Panel on EffectiveWays of Investing in Health-EC Director International Centre for PHC and FM – GhentUniversity, Belgium WHO-Collaborating Centre on PHC Paris, 9.04.2014

  2. No conflict of interest

  3. From Policy to Practice and back to Policy 1.Expert Panel on Innovative Ways of Investing in Health The model of PHC-Centres in Belgium Policy:strategies for change

  4. 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_2013_en.pdf • * Started its activities on 11 July 2013

  5. The public consultation has been launched (deadline: 11 May 2014).http://ec.europa.eu/health/expert_panel/consultations/primarycare_en.htm

  6. 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.'

  7. 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

  8. 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 towardsblendedprovider payment systems can be effective when financial incentives are integrated)

  9. From Policy to Practice and back to Policy • 1.Expert Panel on Innovative Ways of Investing in Health • The model of PHC-Centres in Belgium • Policy:strategies for change

  10. a. Demographical and epidemiological developments b. Scientific and technological developments c. Cultural developments d. Socio-economical developments e. Globalisation and “glocalisation” The changing society ‘By 2030, 70% of the world population will live in an urban context’ (Castells, 2002) By 2100, 85%?

  11. Healthy life expectancy in Belgium (Bossuyt, et al. Public Health 2004) Socio-economic inequalities in health

  12. http://www.who.int/social_determinants/resources/csdh_media/primary_health_care_2007_en.pdfhttp://www.who.int/social_determinants/resources/csdh_media/primary_health_care_2007_en.pdf

  13. 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

  14. Primary Care deliveryin Belgium: type IIPrimary Health Care Centres Types 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) 17

  15. Integrated mixed needs-basedcapitation: the “needs-variables” • Demographic variables • Social-economic variables • Morbidity variables • Contextual variables

  16. Age/sex(41 combinations) Widow Low income: < 15 000,00EUR Self-employedworkers Deceasedin thatyear Disability Urbanization index in the neighbourhood Medical supply index in the neighbourhood Handicap Help from public welfare centres Impairedfunctional status Cardiacdiseases COPC Asthma Cystic Fibrosis Diabetes combined with chronic cardiac condition IDD NIDD Exocrinepancreaticdiseases Psoriasis Rheumatoidarthritis, Crohn’sdisease, ulcero-hemorragic recto-colitis Psychosis: youngadults Psychosis: elderlypeople Parkinson’sdisease Epilepsy HIV Chronic hepatitis B & C Multiple sclerosis Post-transplant immunosuppression Alzheimer Thyroiddiseases Thrombosis Coagulation disorders Protected habitat

  17. Implementation • Based on an (electronic) “photograph” of the population on the list of the different PHCC’s → photograph made annually • Each PHCC receives a specific “capitation” for the patients on the list

  18. 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 selection • Stimulates a global approach to a broad range of problems, avoiding the fragmentation and disease-orientation

  19. Study: comparisonpayment systems

  20. Study: comparisonpayment systems 2008: 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

  21. Primary Health Care Centre: • Family Physicians; nurses; dieticians; health promotors; socialworkers; … • 5800 patients; 60 nationalities • Integratedneedsbased mixed capitation; no co-payment • COPC-strategy

  22. Community Health Care Centre Botermarkt: history • 1978family practice in poorneighbourhood • 1980 first nurse andfoundation of the communityhealth centre • 1986interprofessional team • 1995 capitation financed system

  23. ACCESSIBLE The 19th century “belt” around Ghent • Geographical context • Notwithstandingethnicity, culture, income, administrative status,… • No risk selection <> high prevalence of multiproblempatients • Patients on the list

  24. The 19th century “belt” around Ghent Wgc Kapellenberg WGC Watersportbaan 01.04.2010 WGC Rabot

  25. INTERPROFESSIONAL TEAM • Family physicians • Nurses • Social work • Health Promotion • Dietician • Administratieve staff and receptionist • Ancillary staff • Podologist • External health care workers : physiotherapists, psychologists

  26. INTERPROFESSIONAL ELECTRONIC PATIENT RECORD • Family physicians • Nurses • Socialwork • Dieticians International Classification of Primary Care (ICPC-2); Future: + International Classification of Function (ICF)

  27. Family Physicians • During the day • consultations • appointments • home visits • At night(from 19.00 until 08.00) • Cooperation withlocal GP-service • During the weekend (Friday 19.00 pmto Mo 08.00 a.m.) • Three “on call” GP-posts in Ghent

  28. Nursing • Appointments at the health centre • Daily direct access • ReferralbyGPs or receptionists • Home visits • Daily • ReferralbyGPs or receptionists • Onlywhenindicatedby the medicalandfunctionalcondition

  29. Nursing Prevention • Follow – up blood pressure • Family-planning management • Participatory patient management • Diabetic consultation: 3-monthly • COPD, asthma: Spirometry

  30. 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

  31. 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)

  32. 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

  33. Social Work • Problemssituated on different domains of life • Multiproblem cases • Not (yet) reachedbyothersocial services • Undocumentedresidents • On appointment or crisis intervention • No waitinglists

  34. 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

  35. 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

  36. 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.

  37. 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

  38. 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

  39. 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) • ...

  40. COMMUNITY ORIENTED

  41. COPC-example: dental problems: periodontal disease in childhood • Risk factor for: • Diabetes • Coronary Heart Disease • Preterm birth and low birth weight • Osteoporosis

  42. COPC-project : from individual care to community health care Identifying health problem: Family physicians/nurses: problematic oral condition of todlers, leading to feeding problems, crying, not sleeping,...

  43. COPC-project : DENTAL FITNESS • 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

  44. COPC-project : DENTAL FITNESS • Childhoodcaries: • Information and Sensibilisation • Involving providers, socialworkers, parents, schools… • Strategies: • Communityoriented, intersectoral, participation. • Educational platform forstudents in dentistry

  45. Accessible primary dental care COPC-project : DENTAL FITNESS Centre for Primary Oral Health Care Botermarkt Ledeberg (CEMOB) Started01/09/2006 Towards accessible oral health care ! Ghent University

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