Primary Care Reform: Implications for Public Health

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So: system redesign is needed

  • Every system is perfectly designed to deliver the results it gets ‘- Berwick
  • First Ministers(2000): “planned provision of comprehensive services to a defined population…(with) …multidisciplinary teams..(and)…emphasis on health promotion, disease and injury prevention, and chronic disease management ..(and)..24/7 access to essential services”

The Expanded Chronic Care Model

Chronic Disease Management

  • Good early success with IHI collaborative model : diabetes, CHF
  • Challenge – many patients present with clusters of chronic disease e.g. ‘frail elderly’, DM,CHF, renal failure & mental health problems or chronic mental illness, addiction and HIV/hepatitis.
  • Urgent need for real system re-design

Primary Care Reform

Important New Concepts

  • PHC teams providing care for a defined population
  • System re-design: improved health of population
  • Partnerships – clinicians, community agencies
  • Communication, information, decision supports
  • Shared care
  • Self-management/self efficacy
  • Navigation- care maps, resource maps
  • Better prevention
  • Evidence-based care- guidelines, protocols, algorithms, care pathways
  • Better information & decision supports

But what health system model?

  • Existing model – acute episodic care
  • Best available Canadian evidence – if focus is onimproving the health of a defined population then an ‘integrated community health model’ holds the most promise
  • Means an expanded primary care team integrated with hospitals, public health, home care, mental health, etc serving a defined (geographic) population

Achieved anywhere?

  • UK – PCTs & regional authorities
  • New Zealand – all personal (face-to-face) public health services delivered in primary care. PHO model.
  • Both countries achieved the transition to a new system through:
    • Vision – bottom-up & top-down
    • Organisation change management
    • Increased income for family docs
    • Significant investments in an EHR