Future impact of continuity on quality
of care
within Primary Care
Disposition
16.30
Introduction - Continuity in primary care - background and evidence
16.45
(C.Björkelund)
Enhancing continuity in future primary care in Europe – impact on
multi-morbidity, goal- oriented care and equity (Jan de Maeseneer)
17. 10
Continuity of care through the patient's eyes - focusing on patient
experience.
(Anna Maria Murante)
17.30
Continuity of care – national examples
17.40
Workshop discussion on continuity:
17.55
Summary and conclusions
(Kathryn Hoffman
A. Maun
Zsuzanna Farkas-Pall )
Continuity in primary care background and evidence
Cecilia Björkelund
Department of Primary Health Care
University of Gothenburg
and Region VästraGötaland
Continuity of care –
One of the cornerstones of primary care
Evidence from community and
provider perspective
• Lower health care costs
• Lower hospitalization and
emergency room use
• Greater efficiency of services
• Associated with substantial
reductions in long-term
mortality
• More effective prevention of
diabetes
• Increased quality of care in
primary care depression
treatment
Patients’ perspective
• Patients identified both factors
that promote as well as factors
that divide continuity of care
across boundaries
• Chronic ill patients valued being
attended regularly and over time
by one physician
while
• Young patients valued convenient
access.
“variations in perceived importance
seem to depend on both individual
and contextual factors which
should be taken into account
during healthcare provision “
Waibel S, Henao D, Aller M-B, Vargas I, Vazquez M-L. What do
we know about patients' perceptions of continuity of care? A
meta-synthesis of qualitative studies. International Journal for
Quality in Health Care 2011
Chronic conditions
• 100 000 primary care patients
182 general practices in
England.
• 58 % of the patients had
chronic conditions
• accounting for 78% of the
consultations
• received lower continuity.
“patients with multi-morbidity
are, are less likely to receive
continuity although they
should be more likely to gain
from it
Evidence seems to recognize continuity as one of the
cornerstones of high quality primary care
BUT - there is no sign of decreasing lack of continuity
in primary care in Europe.
• Synthesis of quality of care
for patients with complex
care needs in eleven
European countries showed
that all countries needed
improvements by
development of care teams
in primary care, managing
among other things
transitions and medication
• The complexity of operationalizing
continuity in the context of multidisciplinary team-based primary care
of today and tomorrow, with the
desirable effects on care both from
patients’ perspectives, from medical
and health economic perspectives as
well as political perspectives is a
great challenge.
• The challenge will also be how to
measure and how to compare
between primary care centers,
organizations and between countries,
as this will be the best way to
stimulate the desired development.
• There is great need of further
developing methods to assess
and promote continuity in
primary care
• There is great need of research
to better understand and
operationalize continuity and
how development of
continuity should be
stimulated and incentivized
• There is great need of studying
the effects – including costs
and benefits – of today’s
general practice as well as the
costs of diminishing continuity.
EFPC Position paper
Impact of continuity on
quality of care within
Primary Care –
with focus on the
perspective of preferences
of citizens
• Does interpersonal
continuity lead to improved
medical outcomes?
• Does interpersonal
continuity of
practitioner/nurse/team aid
in the management of
problems?
• Which organizational
structures improve
interpersonal continuity in
primary care of today?
Enhancing continuity in future
primary care in Europe – impact on
multimorbidity, goal-oriented care
and equity
Prof. Dr. J. De Maeseneer, MD, PhD
Family Physician, Community Health Centre ,
Ledeberg-Ghent (Belgium)
Head of department of Family Medicine and PHC- Ghent University (Belgium)
Chair European Forum for Primary Care
Gothenburg, 03.09.2012
http://www.primafamed.ugent.be
http://www.euprimarycare.org
http://www.wgcbotermarkt.be
http://www.the-networktufh.org
Continuity in future primary care
1.
2.
3.
4.
Continuity of care: a catch-all term
Typology
Multimorbidity, goal-oriented care and equity
The future of continuity: threats and
opportunities in patients with multimorbidity
5. Conclusion: from the patient, the provider,
the practice towards the community, the
team, the system
1. Continuity of care: a catch-all term
• “A sustained partnership between patients
and clinicians” (IOM)
• Process or outcome?
• Relationship
• Contextual
• Cost-effective?
Table 3. Provider Continuity (0/1) in a Multivariate
Approach With Total Health Care Cost (Logarithmic
Transformation) as the Dependent Variable:
Standardized Regression Coefficients β
Standardized
Regression
Coefficient β
P Value
Older age
.086
< .001
Sex (male)
-.036
.008
Health locus of control: internal
-.030
.029
Physical functioning
-.1568
< .001
Mental functioning
-.056
< .001
Multiple morbidity
.116
< .001
Number of regular encounters
.296
< .001
Provider continuity
-.105
< .001
R²
27.6%
Explaining Variables
De Maeseneer, J. , De Prins, L., Gosset, C. and Heyerick, J. (2003). Annals of Family Medicine, 1(3): 148.
Continuity in future primary care
1.
2.
3.
4.
Continuity of care: a catch-all term
Typology
Multimorbidity, goal-oriented care and equity
The future of continuity: threats and
opportunities in patients with multimorbidity
5. Conclusion: from the patient, the provider,
the practice towards the community, the
team, the system
• Informational
An organized collection of medical and
social information about each patient is
readily available to any health care
professional caring for the patient. A systemic
process also allows accessing and
communicating about this information among
those involved in the care
• Longitudinal
In addition to informational continuity,
each patient has a "medical home" where the
patient receives most health care, which
allows the care to occur in an accessible and
familiar environment from an organized team
of providers. This team assumes
responsibility for coordinating the quality of
care, including preventive services
• Interpersonal
In addition to longitudinal continuity, an
ongoing relationship exists between each
patient and a personal physician. The patient
knows the physician by name and has come
to trust the physician on a personal basis.
The patient uses this physician for basic
health services and depends on the
physician to assume personal responsibility
for the patient's overall health care. When the
personal physician is not available, a
coverage arrangement assures that
longitudinal continuity occurs.
Continuity in future primary care
1.
2.
3.
4.
Continuity of care: a catch-all term
Typology
Multimorbidity, goal-oriented care and equity
The future of continuity: threats and
opportunities in patients with multimorbidity
5. Conclusion: from the patient, the provider,
the practice towards the community, the
team, the system
The ageing society
Multimorbidity becomes the rule, not the
exception
•
More than half of the patients with COPD have either
cardiovascular problems, or diabetes
•
Patients with COPD have a 3- to 6-fold risk to have all
these problems
(Eur Respir J 2008;32:962-69)
•
50 % of 65+ have at least 3 chronic conditions
•
20 % of 65+ have at least 5 chronic conditions
(Anderson 2003)
Age-standardised prevalence and prevalence ratio of
diabetes by educational level in men and women, 30-64 years
of age in selected countries (source: Eurothine, 2007)
Country
Tertiary
education
Lower secundary
education
2.7
1.1
4.9
5.1
1.5
1.2
4.4
4.6
2.0
4.1
5.3
8.2
Spain
Men
Women
Belgium
Men
Women
Estonia
Men
Women
Wagner EH. Effective Clinical Practice 1998;1:2-4
EMPOWERMENT
But…
Jennifer is 75 years old. Fifteen years ago she lost her husband.
She is a patient in the practice for 15 years now. During these last
15 years she has been through a laborious medical history:
operation for coxarthrosis with a hip prothesis, hypertension,
diabetes type 2, COPD and osteoartritis. Moreover there is
osteoporosis. She lives independently at her home, with some help
from her youngest daughter Elisabeth. I visit her regularly and
each time she starts saying: “Doctor, you must help me”. Then
follows a succession of complaints and unwell feeling: sometimes
it has to do with the heart, another time with the lungs, then the
hip, …
Each time I suggest – according to the guidelines - all sorts of
examinations that did not improve her condition. Her requests
become more and more explicit, my feelings of powerlessness,
insufficiency and spite, increase. Moreover, I have to cope with
guidelines that are contradictory: for COPD she sometimes needs
corticosteroids, which worsens her glycemic control.
The adaptation of the medication for the blood pressure (at one
time too high, at another time too low), cannot meet with her
approval, as does my interest in her HbA1C and lung function
test-results.
After so many contacts Jennifer says: “Doctor, I want to tell you
what really matters for me. On Tuesday and Thursday, I want to
visit my friends in the neighbourhood and play cards with them.
On Saturday, I want to go to the Supermarket with my daughter.
And for the rest, I want to be left in peace, I don’t want to change
continually the therapy anymore, … especially not having to do
this and to do that”.
In the conversation that followed it became clear to me how
Jennifer had formulated the goals for her life. And at the same
time I felt challenged how the guidelines could contribute to the
achievement of Jennifer’s goals. I visit Jennifer again with
pleasure ever since: I know what she wants, and how much I can
(merely) contribute to her life.
Sum of the guidelines
Patient tasks
• Joint protection
• Energy conservation
• Self monitoring of blood glucose
• Exercise
• Non weight-bearing if severe foot disease is
present and weight bearing for osteoporosis
• Aerobic exercise for 30 min on most days
• Muscle strenghtening
• Range of motion
• Avoid environmental exposures that might
exacerbate COPD
• Wear appropriate footwear
• Limit intake of alcohol
• Maintain normal body weight
Clinical tasks
• Administer vaccine
• Pneumonia
• Influenza annually
• Check blood pressure at all clinical visits and
• sometimes at home
• Evaluate self monitoring of blood glucose
• Foot examination
• Laboratory tests
• Microalbuminuria annually if not present
• Creatinine and electrolytes at least 1-2 times a
year
• Cholesterol levels annually
• Liver function biannually
• HbA1C biannually to quarterly
Time
Medications
7:00 AM
Ipratropium dose inhaler
Alendronate 70 mg/wk
Referrals
8:00 AM
Calcium 500 mg
Vit D 200 IU
• Physical therapy
Lisinopril 40mg
• Ophtalmologic examination
Glyburide 10mg
• Pulmonary rehabilitati
Aspirin 81mg
Metformin 850 mg
Naproxen 250 mg
Omeprazol 20mg
1:00 PM
Ipratropium dose inhaler
Calcium 500 mg
Vit D 200 IU
7:00 PM
Ipratropium dose inhaler
Metformin 850 mg
Calcium 500 mg
Vit D 200 IU
Lovastatin 40 mg
Naproxen 250 mg
11:00 PM
Ipratropium dose inhaler
As needed
Albuterol dose inhaler
Paracetamol 1g
Patient education
• Foot care
• Oeseoartritis
• COPD medication and delivery
system training
• Diabetes
Boyd et al. JAMA, 2005
“Problem-oriented versus goal-oriented care”
Problem-oriented
Definition of Health
Goal-oriented
Absence of disease as Maximum desirable
defined by the health
and achievable quality
care system
and/or quantity of life
as defined by each
individual
“Problem-oriented versus goal-oriented care”
Problem-oriented
Purposes of Health
Care
Eradication of
disease,
prevention of death
Goal-oriented
Assistance in
achieving a maximum
individual health
potential
“Problem-oriented versus goal-oriented care”
Problem-oriented
Goal-oriented
Measures of success Accuracy of diagnosis, Achievement of
appropriateness of
individual goals
treatment, eradication
of disease, prevention
of death
“Problem-oriented versus goal-oriented care”
Problem-oriented
Evaluator of success Physician
Goal-oriented
Patient
What really matters for patients is
• Functional status
• Social participation
Evolution from
‘Chronic Disease Management’
towards
‘Participatory Patient Management’
Puts the patient centrally in the process.
Changes the perspective from ‘problem-oriented care’.
towards ‘goal-oriented’ care.
FRAGMENTATION
The challenge: vertical disease- oriented
programs and multimorbidity
• Create duplication
• Lead to inefficient facility utilization
• May lead to gaps in patients with multiple comorbidities
• Lead to inequity between patients
Problems with guidelines in multimorbidity
•
“Evidence” is produced in patients with 1
disease
•
Guidelines may lead to contradictions (e.g. in
therapy)
“Treat the patient”
“Treat-to-target”
Resolution WHA62.12 “Primary Health
Care, including health systems
strengthening”
The World Health Assembly, urges
member states: … (6) to encourage that
vertical programmes, including
disease-specific programmes, are
developed, integrated and implemented
in the context of integrated primary
health care.
Multi-morbidity, goal-oriented care and equity:
•
The way goals are formulated by patients is
determined by social class
•
“contextual evidence” : how to deal with an
“unhealthy” and “inequitable” context?
Community Health Centre:
- Family Physicians; nurses;
dieticians; health promotors;
dentists; social workers; …
- 6000 patients; 60 nationalities
- Capitation; no co-payment
- COPC-strategy
• Diabetes
clinic: horizontal
approach to chronic conditions
• Objectives:
– Improving the care for diabetes type 2 patients
through a structured multidisciplinary follow-up
and health education
– Improve self-efficacy of patients
– To tackle social inequalities in relation to
chronic diseases
Diabetes clinic: horizontal
approach to chronic conditions
• Programme:
– biomedical and behavioural follow-up by
nurse, diabetes educator,dietician and family
physician, implementing guidelines in the
context of the patient
– exchange of experiences by the patients
(groups)
– “diabetes-cooking” (3 x / year)
Integration of personal and community health care
The Lancet 2008;372:871-2
Intersectoral action for health: the community
Ledeberg (8.700 inh.)
•
Platform of stakeholders
•
Implementing COPC-strategy, taking different
sectors on board
•
Accessible, comprehensive, quality local health care
facility: a multidisciplinary Primary Health Care
Centre
Platform of stakeholders:
• 40 to 50 people
• 3 monthly
• Exchange of information
• “Community diagnosis”
Intra-family violence
Continuity in future primary care
1.
2.
3.
4.
Continuity of care: a catch-all term
Typology
Multimorbidity, goal-oriented care and equity
The future of continuity: threats and
opportunities in patients with multimorbidity
5. Conclusion: from the patient, the provider,
the practice towards the community, the
team, the system
4. The future of continuity: threats and
opportunities in patients with
multimorbidity
• Threats:
– Anonimous care – dilution of information
– Dilution of responsebility
– Outsourcing
– Fragmentation
4. The future of continuity: threats and
opportunities in patients with
multimorbidity
• Opportunities
– The patient in the driver’s seat
– Increased comprehensiveness –
complementary frames of reference
– Including context
– Task-sharing
– Interprofessional feedback
– Sustainability
4. The future of continuity: threats and
opportunities in patients with
multimorbidity
• Requirements
– Culture of cooperation
– Patient’s choice: limits?
– E-health system: interprofessional
electronic patient record
– Interprofessional education
– Case-load
– Comprehensive financing mechanisms:
integrated needs based capitation
Continuity in future primary care
1.
2.
3.
4.
Continuity of care: a catch-all term
Typology
Multimorbidity, goal-oriented care and equity
The future of continuity: threats and
opportunities in patients with multimorbidity
5. Conclusion: from the patient, the provider,
the practice towards the community, the
team, the system
Assessment over time
Informational: improvement
Longitudinal: PHC team
Interpersonal: the challenge
Thank you…
jan.demaeseneer@ugent.be
WHO
Collaborating
Centre on PHC
We thank Lynn Ryssaert, MA, PhD-student for her valuable input
Continuity of care
through the patient's eyes focusing on patient experience
Anna Maria Murante,
Laboratorio Management e Sanità
Istituto di Management
Scuola Superiore Sant’Anna - Pisa (Italy)
Before we start...
Before we start...
Patient satisfaction vs patient experience
Patient satisfaction as
a quality-outcome indicator
(Avedis Donabedian, 1988)
The complexities of modern health
care and the different expectations and
experiences of patients cannot be
measured by asking ‘How satisfied are
you with your care/service?’
Before we start...
Patient satisfaction vs patient experience
Patient experience measures coming from questions like
‘What was your experience with…’ report
(through the patient perspective/perception)
whether a certain events occurred.
However, patient tend to be more positive in
evaluating care than in reporting their experience with
specific events.
(Fitzpatrick et al, 2009)
Continuity of care & patient satisfaction
Adler R, Vasiliadis A, Bickell N. The relationship between continuity and
patient satisfaction: a systematic review. Fam Pract 2010;27(2):171-8.
Let's move on!
Continuity of care is a dimension of
patient satisfaction
(Ware and Snyder, 1975)
Interpersonal continuity
(Saultz,2003)
Informational continuity
Longitudinal continuity
Interpersonal Continuity & patient satisfaction
(1992)
Interpersonal Continuity & patient satisfaction
«[…] ‘overfamiliarity’ or seeing the same physician
too frequently could lead to missed diagnosis
or fed beliefs that the physician could become
complacent with the patient’s problems, so
that his or her concerns were no longer
taken seriously. »
Interpersonal and Longitudinal Continuity
& patient satisfaction
2001
Informational Continuity & patient satisfaction
«[…] patients expected from their GPs to exchange
information with specialists regarding their health situation,
treatment options and care facilities »
Other Continuity & patient satisfaction
(2006)
Flexible Continuity & patient satisfaction
(Naithani et al, 2006)
Adjusting services to the needs of the individual over time.
«The nurse … always makes time for me. If I phone […] she
will always call me back on the same day. I have been able
to see her when I’ve needed to. »
«They’re very good here you know, whenever I need to see
the doctor I can just phone up and get a appointment when
you want, you don’t have to wait long and they ask you, you
know, what’s it about so if you need more time then they
will book you a double appointment . »
Team and cross-boundary Continuity
& patient satisfaction
(Naithani et al, 2006)
«Just recently I have had to change doctors because the
doctor that I have been seeing has retired. When I went to
the new practice and registered and went to see the nurse,
they told me they didn’t have any information on me and
my medical records hadn’t turned up. »
Team and cross-boundary Continuity
& patient satisfaction
(Naithani et al, 2006)
«[…] Patients responses to
their perception of a serious
lack of experienced
continuity of care were
sometimes to seek
alternative care and advice,
non-compliance with advice
or treatment, or withdrawal
from formal services and
attempting to monitor and
manage their condition
themselves.»
What happens when patients
have a chronic disease?
Chronicity & continuity & patient satisfaction
Patients with chronic conditions prefer to see their GPs
regularly to check the progress even when they were not
feeling sick (Infante et al, 2004).
Patients with multiple long-term conditions report that several
professionals know them equally well (Cowie et al, 2009).
Chronicity & continuity & patient satisfaction
According to the experience of some patients with diabetes:
• GPs might lose interest, when they were referred to
secondary care (Infante et al, 2004)
• GPs and specialist have to exchange information on health
situation, treatment options and care facilities (Michielson et
al, 2007)
Patients with co-morbidities perceived that specialists did not
interact with their colleagues. (Williams, 2004)
Patients with chronic conditions report to be frustrated when
they had to repeat their antecedents to doctors, who had not
informed themselves in advance. (Von Bültzingslöwen et al, 2006)
Chronicity & continuity & patient satisfaction
«Young and employed patients with a minor, acute health
problem preferred convenient access, although achieved at the
cost of seeing different healthcare professionals. In urgent
cases, an immediate intervention became a priority for patients
with diabetes or other long-term conditions.»
The point of...
Continuity of care & patient satisfaction
• Several and different measures are used to extimate the
relationship between PS and CoC
• Many evidences exist about a positive relationship
• But also anyothers report a weak or not significant
relationship.
• Among patients with chronic condition different results
could be observed (e.g. depending on severity), however
sharing information among professionals is a common
need.
• Timely access to services may be preferred to continuity
of care
Thanks for your attention!
Anna Maria Murante
a.murante@sssup.it
Laboratorio Management e Sanità
Istituto di Management
Scuola Superiore Sant’Anna di Pisa (Italy)
Impact of continuity on
quality of care within PC
A COUNTRY REPORT
AUSTRIA
KATHRYN HOFFMANN, MD, MPH
EFPC CONFERENCE GOTHENBURG 2012
The three sisters of continuity
92
• Fist Contact: Free, region-wide and full covered access
for everybody
• Coordination: Structural preconditions for continuity:
1) System level: E.g. single vs. group practices, financial
incentives 2) Process level: E.g. gate-keeping-system,
list-system, appointment-system, ...
• Comprehensiveness: Knowledge about the
predominant diseases in the related region/county
(adequate staff with adequate education and
equipment): E.g. morbidity registers, sentinel offices for
surveillance, ...
• Continuity
Barbara Starfields´ 4 cardinal “C”s of PC
Austrian situation (excerpt)
93
• First Contact: Free access, overall good availability, for
more than 98% of population fully covered BUT free and
covered access with some exceptions (e.g. radiologist)
also to the secondary level of care
• Coordination: No gate-keeping system, no list system,
~95% single-handed practices, fee-for-service mainly,
GPs are self-employed
• Comprehensiveness: Very high standard of
equipment, nearly no knowledge about the morbidity
situation in the primary care sector: mainly hospital
based data, no incentives for community-orientation, 3year hospital based postgraduate education to become a
GP
Some preliminary results from Austria
94
 >70% of patients said they have a certain GP but
>60% of them visited a specialist without referral at
least once in the last year– QUALICOPC data
 Rate of patients who visited a specialist within the
last 4 weeks with referral from GP is low (~26%).
Chronic disease is not a predictor for a higher
referral rate in women - part of the Ecohcare-study;
will be submitted soon
Continuity in Austria: Attempt of a summery
95
• Single handed practices: Good for continuity, bad for
GPs satisfaction?
• Choice of physician as patients decision
• High satisfaction with system in 2004 (Euro health
consumer index) vs. publication “cost of
satisfaction”(Fenton, 2012)
• High health care expenditures, high hospital admission
rates, high utilisation of specialists (e.g. Austria 71.1% vs.
the Netherlands 37.8% - own research project), low
referral rates, low healthy life years for 65+
• How to measure the impact of continuity on quality of
care alone to highlight its importance?
Continuity of care – national examples
Sweden
Andy Maun
member of quality council SFAM Q
GP Trainee, Primary Healthcare
Gothenborg, PhD student
Healthcare systems in Sweden
In health care and certainly primary healthcare:
21 counties and regions
differing in:
payment systems
IT – systems
follow–up of quality
Reform on Choice of Care 2008
Aim: Increase the number of healthcare centres
• Patients can choose a centre but not personal GP centres compete!
• Resulted in a lot of new centres mostly run by
great companies owned by risk capitalists.
Trends in most Counties
• Payment by individual capitation based on
– age
– socio-economy
– morbidity burden (ACG - adjusted clinical groups)
• The centre pays all costs for laboratory
services, x-ray and drugs
Development of a register for Quality
Improvement of the Western Region
• Aim: regional primary healthcare register with
the potential for a national register
• Target group:
– Healthcare centres - internal improvements
– Academy - scientific research
– Political management - results, payment
– Patient – choice of healthcare centre
Get a new…
…perspective
Indicators
• Five chronic diseases: (< age 75)
– Diabetes (National Diabetes Register)
– Ischemic heart disease
– Hypertension
– Asthma
– COPD
Medical variabels
•
•
•
•
•
Diagnosis
Smoking
Weight
Length
Waistlines
•
•
•
•
Spirometry
HbA1c
Blood lipids
Blood pressure
• Age / Gender
Results can be linked to
- other registers e.g. stroke register
- prescription register
- socioeconomic data
Effects?
70 000
Number of individuals
60 000
50 000
Before/after ACG
(Payment for
morbidity burden)
40 000
30 000
Diabetes diagnosis
20 000
10 000
0
Primary Healthcare,
Western Region
Staffan Björck, Analysis Unit Western Region
Pilot study - continuity
• Aim: to examine the feasibility of a larger study,
where the correlation between provider
continuity and health outcomes is to be explored
• Method:
–
–
–
–
retrospective study (Oct 2009-Febr 2012)
four primary care centres (33485 individuals)
health outcomes (blood pressure, HbA1c)
usual provider continuity (UPC) and continuity of care
index (COC) for physician/nurse
Results – No distinct correlations
• No distinct correlations could be found
between interpersonal continuity with
physician/nurse and blood pressure and
HbA1c values
• A timeline-study on the whole population of
the region (1,5 million inhabitants) is feasible
and necessary to gain more knowledge
Challenges
• Transformation? From interpersonal
continuity towards team continuity in primary
care?
• The big challenge: collaboration cross
organizational borders?
• What actions are required to improve medical
outcomes?
Thank you for your attention!
Continuity of care,
a way to reduce health
inequalities
Dr. Zsuzsanna Farkas-Pall
The Future of Primary Health Care in Europe IV , September 2012
The Future of Primary Health Care in Europe IV , September 2012
Background
 In Romania, no or little efforts were made at policy
making levels to address socio-economic determinants
of health and tackle health inequalities emerging from
reduced access to health care, lack of local health
services, poverty
 No feasible solutions are offered to bridge the gap
between sporadic and continuous access to health care
services
 Local primary care team can play a key role in
maintaining continuity and offering tailored health
services in the community
The Future of Primary Health Care in Europe IV , September 2012
Aims
 To give an example of good practice in reliable,
continuous health service delivery and gather evidence
about the importance of it
 To act locally, use local resources and emphasize the
importance of team approach
 To offer integrated health services locally and monitor
the impact on health indicators in the community
The Future of Primary Health Care in Europe IV , September 2012
The national context
 Approx. 11000 GPs working in mostly solo practices
 Nr. of patients/GP 1545,practice nurse/GP rate1.2
 Nr. of settlements without any health care provider 88,
with a total of 153904 inhabitants
 Nr. of settlements without access to out of hours service
2330
 Percentage of people without health insurance 16.10%
 Amongst EU states Romania has the most reduced
percentage of GDP spent on health care- 5.5%
The Future of Primary Health Care in Europe IV , September 2012
Our experience
 Our health centre is located in the north-western region
of Romania
 We provide the community with the possibility of
having ultrasound, ECG examinations, lab tests,
physiotherapy, family planning services and access to
prevention programs performed locally
 During the years we developed educational programs
targeting different groups in the community, have done
research activities to gather evidences in order to prove
the importance of our activities
 The activites are ongoing and continuity helped
developing partnership with the community
The Future of Primary Health Care in Europe IV , September 2012
Results
 Continuity in access to high standard sustainable and
reliable health services, health promotion will result in
improved health indicators, healthier and more satisfied
population, decreased needs of secondary care
services, efficient utilization of the existent resources
 Primary care team equipped with appropriate tools and
empowered with knowledge is well positioned to reduce
health inequalities
 Continuity in patient education, establishing partnership
will induce a more responsible and self conscious
population
The Future of Primary Health Care in Europe IV , September 2012
Conclusions
 Integrated health services like ultrasounds, ECG, lab tests
and ongoing population based health education and
screening programs has to be delivered locally and the
service must be reliable to build trust and engagement
 gaps in health care provision will negatively influence
patient behavior and will lead to setbacks
 Our approach towards continuity in primary care service
delivery in the community has helped to improve the
relationship between our staff and the population in our
area: trust has lowered the threshold for contact
 The model is sustainable as it uses local resources and is
based on a partnership with the community
The Future of Primary Health Care in Europe IV , September 2012
Thank you for your
attention!
The Future of Primary Health Care in Europe IV , September 2012