integrated healthcare systems for family physicians

Integrated Healthcare Systems for Family Physicians ผศ.นพ.บวรศม ลีระพันธ์

FM Academic Activities For Medical Residents28 October 2016

Pix source: Rattanaphibunkun C., Chantaragomol C, Wongsin A., PMAC 2016 Art Contest

Seminar Outline

Pix source: online.wsj.com

Q1: What do we know about

“PHC” in Thailand?

Q2: What do we know about “Healthcare

Systems”in Thailand?

Q3: What policies are needed for the future of PHC and

“Integrated Healthcare

Management”?

Q1: What do we know about PHC in Thailand?

(“Myths and Facts About PHC in Thailand”)


What Do You Mean by “Primary Care”?

1. Basic medical services

2. Self-care, and health for all

3. First-contact, continuous, coordinated, and comprehensive care

4. Health promotion practices, and actions on social determinants of health

(=What a layman usually thinks of primary care)

(The Declaration of Alma-Ata 1978)

(Starfield 1992, 1998)

(Ottawa Charter 1986, The 66th World Health Assembly 2013)

Source: http://www.who.int/publications/almaata_declaration_en.pdf

Source: http://www.who.int/social_determinants/B_132_14-en.pdf?ua=1

Source: Stange KC. Barbara Starfield: Passage of the Pathfinder of Primary Care. The Annals of Family Medicine. 2011 July 1, 2011;9(4):292-6; Pix source: practiceimprovement.com.au;

Action on Social Determinants of Health

(การสร้างเสริมสุขภาพ)

Community-based Primary Healthcare

(การสาธารณสุขมูลฐาน)

Primary Care Medicine,Family Medicine

(เวชศาสตร์ปฐมภูม,ิ เวชศาสตร์ครอบครัว)

Basic Medical Care(บริการการแพทย์ระดบัพืDนฐาน)

• Health promotion practice at the population health level

• “Health in All Policies”

• Self-care• Community health worker• Community health volunteer• “Health for All”• First-contact care• Continuous care• Coordinated care• Comprehensive Care

•Health center (สอ./รพ.สต.)•OPD, physician office•Mobile medical units

What Do You Mean by “Primary Care”?

Community-basedPrimary Healthcare

Clinical Practicesat Primary Care

Level

“The Doughnut Hole” of Primary Care

• Primary care services in developed countries

• Medical facilities in urban settings• Medical facilities in private-sector

(without public health functions)

• Primary care services in developing countries

• Medical facilities in rural settings• Medical facilities in public-sector

(with public health functions)

ØWhat exactly policies & systems are we talking about?

Figure source: Thailand Health Profile 2008-2010.

“Primary” & “General”

Primary GeneralPrimary School

Primary Data

Primary Election

Primary Tumor

Primary Stage [of projects, etc]

Director-General

Attorney-General

Surgeon-General

General Hospital

General [Prayuth Chan-ocha]

Ø How do you feel about the “Primaries” and “Generals” listed above”?

Ø How’s about “Primary Healthcare” and “General Practitioner”?

Structure of Urban Health Services(City of Chanthaburi)

Pix source: สาํนกังานวจิยัและพฒันาระบบสุขภาพชุมชน (2555)

Structure of Urban Health Services(City of Chanthaburi)

Pix source: Office of Community Based Health Care Research and Development (2012)

Telecare Clinic(Bangkok General Hospital)

Pix source: http://www.bangkokhospital.com/

Q2: What do we know about Healthcare Systems in Thailand?


Source: W. Simpson del.; E. Walker lith.; Day & Son, Lithrs. to the Queen.Pix source: http://en.wikipedia.org/wiki/History_of_hospitals#mediaviewer/File:Hospital_at_Scutari_2a.jpg

“Hospital at Scutari” - A ward of the hospital at Scutari where Florence Nightingale worked and helped to restructure the modern hospital

Disability-Adjusted Year Lost (2004)

InjuryNCD

Infection

0-45-1415-2930-4445-5960-6970-7980+0-45-1415-2930-4445-5960-6970-7980+

MalesFemales

1,600

1,400

1,200

1,000

800

600

400

200

0

SourSource: Adapted from: WHO (2008), http://www.who.int/healthinfo/global_burden_disease

Pix source: www.sotaravej.net; www.med.chula.ac.th; www.phassociation.org

Living With Diseases?

Primary Care vs. Chronic Care

FigureSource:www.improvingchroniccare.org

FigureSource:InstituteforHealthcareImprovement(2012).PartneringinSelf-ManagementSupport:AToolkitforClinicians.

Institute for Healthcare Improvement Page 9 Partnering in Self-Management Support: A Toolkit for Clinicians

Collaborative Care: Cycle of Self-Management Support

Self-Management Supports

CCM Elements

Source: Coleman et al. (2009)

Primary Care vs. Palliative Care

“Palliative care is care provided based on patient & family needs & goals and independent of prognosis.”

Source: NEJM 2014;370(26):2457-60.

Primary Care vs.

End-of-Life Care(Hospice Care)

Primary Care vs. Long-term Care

Source: Tishihiko Hasegawa (2013)

“Care Cycle”

Managing Long-Term Care

Source: Adapted from Feldman, Nadash & Gursen (2008)

1) Chronic Care

2) Palliative Care

3) Rehabilitative Services

• Activities of Daily Living (ADL)• Instrumental Activities of Daily Living (IADL)

4) Supportive services

• Care plans, appointment arrangement • Coordination between providers & patients-caregivers• Logistics and supply of necessities

5) Care Management

Hospital Care vs. Primary Care:Control Knobs Framework for Health Reform

Source: Adapted from Roberts et al. (2003).

Financing of Thai Healthcare SystemCSMBS SSS UCS Motor Vehicle

Victim Protection Law

Private Health Insurance

Feature State/Employer welfare

Compulsory heath insurance with state subsidies

State welfare Compulsory heath insurance for vehicleowners

Voluntary health insurance

Targeted groups of beneficiaries

Civil servants, state enterprise employees and dependents

Employees inprivate sector and temporary employees in public sector

Thai citizens without the coverage of CSMBS & SSS

Victims of vehicle accidents

General public

Source of financing

Govt. budget Tri-party (Employee, employer and govt. budget)

Govt. budget Vehicle owners Household

Method of payment to health facilities

Fee-for-service Capitation and Fee-for-service

Capitation and Fee-for-service

Fee-for-service Fee-for-service

Major problems Rapidly and constantly rising costs

Covering while being employed only

Inadequate budget

Redundant eligibility and slow disbursement

Redundant eligibility and slow disbursement

Source: Adapted from Wibulpolprasert et al. (2011). Thailand Health Profile 2008-2010.

Major Mechanisms of Healthcare Financing

HealthcareRegulator(s)

2) Taxes Payers

4) Employer-

based private health

insurance

3) Individual private health

insurance

Hospitals

MedicalSpecialists

Generalists& PCPs

1) Out-of-pocket Payments

Ambulatory Facilities

Payment Mechanisms:Salary, Fee-for-Service,

Global Budget, Capitation, etc.

CGD (CSMBS),

NHSO (UCS)

Taxes Payers

Employer-based private health

insurance

Individual & Employer’s

private health insurance

(Voluntary)

Hospitals

MedicalSpecialists

Generalists& PCPs

Patients paying out-of-pocket

Ambulatory Facilities

Payment Mechanisms:Salary, Fee-for-Service,

Global Budget, Capitation, DRGs, etc.

Thai Healthcare Systems

Providers in Public & Private Sector

Commercial Insurance

Companies

Social Security

Office (SSS)

Motor vehicle’s owners (Mandatory by the Motor

Vehicle Victim Protection Law)

“Health System”

Pix source: WHO’s framework for action. (2007)

“Health System”

Source: who’s World Health Report (2000)

Pix source: www.noogenesis.com/pineapple/blind_men_elephant.html

Integrated Healthcare & Systems Thinking

John Godfrey Saxe's ( 1816-1887) version of the famous Indian legend

Pix source: www.simoncamilleri.com/the_truth_of_the_elephant/

Integrated Healthcare & Systems Thinking

Pix source: Don de Savigny and Taghreed Adam (2009).

Pix source: de Savigny & Adam (2009)

3 Major Levels of Health Systems

Performance of Thai Health System

Pix source: WHO (2000). World Health Report 2000.

Challenges of Thai Universal Health Coverage

Pix Source: www.hfocus.com

Q3: What policies are needed for the future of PHC and

“Integrated Healthcare Management”?


Major Issues in Thai Healthcare SystemsFrenk J,ChenL,Bhutta ZA,CohenJ,CrispN,EvansT,etal.Healthprofessionalsforanewcentury:transformingeducationtostrengthenhealthsystemsinaninterdependentworld.TheLancet.2010;376(9756):1923-58.

Thailand in 1960s

Pix Source: www.nationalguard.mil

Major Issues in Thai Healthcare Systems

• Thailand 1970s – Rural Health (“PHC")• Thailand 2010s – ??

“Transformative education creates change agents.”

“But change agents create what?”

Rural vs. Urban

18,972,330(31.1%)

29,133,829(44.2%)

41,944,111(68.9%)

36,847,830(55.8%)

0%10%20%30%40%50%60%70%80%90%

100%

2543 2553

ประชากรในเขตเทศบาล ประชากรนอกเขตเทศบาล

Source: สำมะโนประชากรและเคหะ สำนักงานสถิติแห่งชาติ, accessed from http://service.nso.go.th/nso/nsopublish/service/servstat.html

Poor vs. Middle-class

Source: สำมะโนประชากรและเคหะ สำนักงานสถิติแห่งชาติ, accessed from http://service.nso.go.th/nso/nsopublish/service/servstat.html

Thai vs. Global Citizens

Source: http://news.bbc.co.uk

Urban Lifestyle?

Source: http://www.chaophya.com/index_th.php

Middle-class Lifestyle?(Consumerism)

Source: http://www.facebook.com/www.jantrai

Source: Macagba, R. L. (1985). Hospitals and Primary Health Care: An International Study from the International Hospital Federation. In M. Hardie (Ed.), World-wide survey on the Role of Hospitals in Primary Health Care. London: International Hospital Federation.

Features of Primary Care Providers

Focus Public Health Medicine &Public Health

Setting Rural Urban

Professional Perception

Generalist Specialist

Public Perception

Second-tier Doctors(“basic”)

Top-tier Doctors(“personal & exclusive”)

SystemDesign

MovingAssembly Lines

CustomizedServices Systems

Delivery of PHC Services

Pix source: www.free-ed.net/free-ed/HealthCare/Physiology/default.asp

Structure & Organizations of primary care services • Patient Care Teams• PCUs/Clinics• Systems/Networks• Governance policies

Four Cardinal Functions of primary care services • First Contact/Access• Continuity• Coordination• Comprehensiveness

“Anatomy of Primary Care” “Physiology of Primary Care”

First Contact/Access

Continuity Coordination Comprehensiveness

• Cost sharing• Distance to PC

practice • Distribution of

PC physicians • List size • Home visits in

PC • Electronic access

• Computerization of the practice

• Patient habits with first contact visits/referrals

• Endurance of patient–provider relationship

• PC practice management

• Collaboration among practitioners

• Referral system• Shared care

arrangements

• Premises, equipment

• Medical procedures

• Preventive, rehabilitative, educational activities

• Disease management

• Community links• Technical skills

Desirable PHC Functions

Source: WHO/Europe (2010)

Ø Selected proxy measures from WHO/Europe’s Primary Care Evaluation Tool (PCET)

Source:Vasan etal.BMCMedicine2014,12:6

How “integrated care” could advance primary care delivery?

Source:Vasan etal.BMCMedicine2014,12:6

Dealing with Complexity in Healthcare Systems (UnitedHealth Group, USA)

Pix source: Lewis G. Sandy (2010). AcademyHealth 2010 Annual Research Meeting June 29, 2010

Care Coordination Innovations(UnitedHealth Group, US)

Pix source: Lewis G. Sandy (2010). AcademyHealth 2010 Annual Research Meeting June 29, 2010

Traditional Work Flow in Clinics(Cambridge Health Alliance, US)

Pix source: Southcentral Foundation & Institute of Healthcare Improvement (2010)

Redesign: Parallel Work Flow in Clinics(Cambridge Health Alliance, US)

Pix source: Southcentral Foundation & Institute of Healthcare Improvement (2010)

Pre-visit Work in Geriatric Care

Pix source: Harvard Vanguard Medical Associates & Institute of Healthcare Improvement (2010)

Care Coordination: EMR

Pix source: Bates et al. (2003). A Proposal for Electronic Medical Records in U.S. Primary Care

Building Blocks of PHC Systems:Research Needed

Pix source: WHO’s framework for action. (2007)

New financing?• OOP?• Co-payment?• Membership fee?

New informatics?• Mobile app?• Personal health

data portal?• Disadvantaged

population’s data

New organizational model?• Team based providers?• Linkage with hospital care?

New kinds of providers?• MDs vs. non-MDs• Professional Manager?• Career path? • Linkage with academia?

New kinds of products?• Life-style modifications? • Preventive medicine?• Outlets of hospital ‘s

labs & pharmacy?

New governance?• Focus on personal services

vs. on public health services• Market vs. Central-planning

• Clinical outcomes of population-health-integrated PCUs vs. individual-health-oriented PCUs

• Satisfaction of patients receiving care from PCUs located in urban community vs. from PCUs attached to hospitals

• Satisfaction of primary care providers working in differently organized PCUs

• Comparison of comprehensiveness of care delivered in differently organized PCUs

• Financial risks of differently organized PCUs • Appropriateness of office hours of urban PCUs• Effectiveness of P&P programs in urban communities

Considerations for Further Study

Source: Leerapan (2012). Primary Care Services in Urban Settings: Lessons from International Experiences.

New Health Research Mapping?

Source: Hoffman et al. (2012).

New Health Research Mapping?

Source: Hoffman et al. (2012).

Different kinds of knowledge are needed

Source: alumni.harvard.edu (2010).

Food-for-Thought


“If I had asked people what they wanted, they would have said faster horses.”

--Henry Ford

[email protected]