Primary Health Care
Challenges and Opportunities…
Jennifer Leuschner RN, BScN
Manager, Primary Health Care
GASHA
Lost in Translation…
Primary
Care
Primary,
Secondary
Tertiary
Prevention
Primary Health
Care
Population
Health
Chronic Disease
Prevention and
Management
Health
Promotion
Health…
…is a state of complete
physical, mental and social
well-being and not merely the
absence of disease or infirmity.
World Health Organization 1948
….is a resource for everyday life,
not the object of living. It is a
positive concept emphasizing
social & personal resources as
well as physical capability
evolution?
We Can’t focus on Risk Factors Alone
Poverty and Inequity
Challenges - What ‘s wrong with the
system?
 Too many patients are in acute care beds who
should be receiving care elsewhere
 Too many patients with chronic illnesses
develop preventable complications
 Too many people develop illnesses which are
totally preventable
 We are using our human resources poorly
 The only determinant of health we seem to
address is the health care services one
Every system is perfectly designed…
To achieve the results it gets.
W. Edwards Deming
Early Days of Primary Health Care
Primary Health Care Definition
 Primary Health Care (PHC) is concerned with all the factors that
promote health as they apply to a given population, not just personal
health services. It addresses the factors that determine health such
as income, social status, social support networks, education,
employment, working conditions, social and physical environment,
biology and genetic endowment, personal health practices and
coping skills, healthy child development, gender, culture and health
services
 These factors are addressed within a system that has appropriate
linkages. PHC is developed with the full participation of the people it
serves. It empowers people to take care of their own health and to
take an active part in planning, policy making and delivering health
care services in their community
Principles of Primary Health Care
Population Health
Accessibility
Appropriateness
Intersectoral/Interprofessional
Continuity of Care
Community Participation
Efficiency
Affordable & Sustainable
Primary Care Definition
 Primary Care is an important part of Primary
Health Care and is a term used for the activity of
a health care provider who acts as a first point of
consultation for all patients. The aims of primary
care are to provide the patient with a broad
spectrum of care, both preventative and
curative, over a period of time and to coordinate
all of the care the patient receives.
Primary Care
focus on individual
Selective Primary
Health Care
Comprehensive
Primary Health Care
Population Health through
individuals
tackles social determinants
of health
-Individualized clinical
services
-Secondary & Tertiary
disease prevention
-Health Education
-Screening and
surveillance
-Immunization
-Primary prevention
-Health education
Examples:
General Practice
Diabetic Clinic
Heart Health Clinic
Screening Programs
Examples:
Healthy Heart Programs
Well child clinics
Flu Clinics
-Provision of housing,
shelter, social support,
food and nutrition, safe
environments
-Capacity building and
health promotion
-Health impact
awareness
-Harm minimization
approaches
-Advocacy for
sustainable social and
system change
Examples:
Youth Health Centres
Healthy Public Policies
Food Security work
The WHO recognizes that only a
comprehensive primary health care
approach will actually improve the quality of
life and health outcomes of people in any
society and that Primary Health Care must
be modified to suit the differing needs of
population groups.
Nova Scotia Priorities
Improving access to PHC services
 Increase the emphasis on health
promotion and wellness
Providers working in teams
Electronic Patient Record (EPR)
Opportunities
• Primary prevention to avert illness entirely
• Screening initiatives
• Chronic disease management to decrease
acute episodes
• Chronic Disease Self Management
• New Providers
• Success
Opportunities cont’d
PHCTF – paid to get change started
Recommendations of a $1.0 M report in
NS ….PHSOR report
…..(many more)
PHC in GASHA: the history
 Sheila Sears hired in 2003 (PHC Transition
Fund)
 GASHA is innovative in finding money for
projects – (AHTF, Drug Company $, Literacy $)
 Roll out of NPs
GASHA hired first NP in 2005 – both clinical and
community components
 Approx 40 initiatives in our DHA in the first few
years
LHCW, EMR, Cardiac Clinic, YHC Arichat
Our GASHA PHC team
 4 NPs
 1 RN
 Dietitian
 Behaviour Motivator
 Coordinator
 AHTF coordinator
 Clerical support
 Physiotherapist
…team is growing
Role of the nurse in PHC
Population Health
Accessibility
Appropriateness
Intersectoral/Interprofessional
Continuity of Care
Community Participation
Efficiency
Affordable & Sustainable
PHC: What’s Cookin’ in GASHA?
• Focus on Chronic Disease Prevention and
Management
We are in the midst of crisis…..chronic
disease is the cause. Our health system is
not sustainable. We need a whole of
community response to health, chronic
disease and inequity
Chronic Disease in Nova Scotia
5800 people die per year from 4 chronic
diseases
Cardiovascular Disease (Heart disease, stroke etc.)
Cancer
COPD (Chronic Obstructive Pulmonary Disorder)
Diabetes
Nova Scotia Context cont’d
 68% of Nova Scotians 12 years of age and over
have at least one chronic condition (CCHS,
2002)
 70% of Health Care Costs related to Chronic
Diseases (GPI Atlantic, 2002)
Impact of Chronic Disease
In Canada:
NS highest death rate attributable to cancer
Second highest rate of diabetes
Chronic Disease account for 75% of all deaths in NS
Medical costs alone for chronic diseases in NS account
for $1.2 billion/year
 When combined with productivity losses they account for
over $3 billion/year




U.S.A. Projected toll resulting from Quality Gap
Condition
Shortfall in Care
Avoidable Toll
Diabetes
24% Blood sugar not
measured
29,000 kidney failures
Colorectal cancer
62% not screened
9,600 deaths
Pneumonia
36% elderly did not
receive vaccine
10,000 deaths
Heart attack
39-55% did not
receive needed
medications
37,000 deaths
Hypertension
<65% received
indicated care
68,000 deaths
Healthcare Papers, Vol. 7,
No. 4, 2007
Chronic Disease Prevention & Management Continuum
(across the lifespan)
Well Population
Primary Prevention
At Risk Population
Secondary Prevention
Established Chronic
Disease
Controlled Chronic
Disease
Tertiary Prevention
Surveillance of diseases
& risk factors
Building healthy public
policy
Creating supportive
environments
Strengthening
community actions
Developing personal
skills
Universal & targeted
approaches
Population-based screening
Case finding
Periodic health
examinations
Early intervention
Medication to control
Universal & targeted
approaches
Self-management
Surveillance and monitoring
Creating supportive
environments
Health Promotion Health Promotion
Prevent movement
to at-risk group
Draft – April 11, 2008
Treatment and acute care
(exacerbation of chronic
condition)
Complications
management
Self-management
Creating supportive
environments
Monitoring
Ongoing care
Maintenance
Rehabilitation
Self-Management
Creating supportive
environments
Monitoring
Health Promotion
Health Promotion
Prevent progression
To established disease
Prevent progression
to complications and/or
hospitalizations
T.E.A.M.
(Teaching Eating and Activity Management for Families)
Chronic Disease Prevention, Screening and Management
Pilot Project in Culturally Diverse and Geographically
Isolated Communities
Average Lipid Level
5
4.42
4.5
4.27
4.05
4
3.5
mmol/L
3
Initial
2.5
2.23
3 months
2.16
2.03
2
1.5
1.5
1.45
1.51
1.4
1.41 1.39
1
0.5
0
Triglycerides
Total Cholesterol
HDL
LDL
6 months
Initial
3 Months 6 Months
Blood Pressure
131/69.5 119/66.4 118/68.8
Weight
196.1 lbs 190.1 lbs 180.7 lbs
BMI
31.21
30.68
Waist Circumference 102.7 cm 99 cm
29.85
95.2 cm
Body Fat
36.66 % 34.98 % 34.51 %
Diabetes HbA1c
6.171
6.5
6.183
Your Way to Wellness (Chronic Disease
Self-Management Program)
Chronic Disease Self Management
• Self-management is what people do every day:
decide what to eat, whether to exercise, if and
when they will take their medications.
• Everyone self-manages; the question is whether
or not people make decisions that improve their
health-related behaviors and clinical outcomes.
Patient Contact with Health Professionals





GP visits per annum = 1 hour
Visits to specialists = 1 hour
PT, OT, Dietitian = 10 hours
Total = 12 hours with professionals
364.5 days managing on their own or 8748 hours
Barlow, J. Interdisciplinary Research Centre in Health, School of Health & Social Sciences,
Coventry University, May 2003.
Aboriginal Health Transition Fund
 Lindsay’s Health Centre for Women
 Men’s Health Centre
 Health Connections
 Collaborative Practice Teams
 Electronic Medical Record
 Well Women’s strategy
 Do I Need to See a Dr. Books
 Patient Teaching Guides (Angina, COPD, Heart
Failure, Heart Attack, Diverticular disease)
 Health Literacy
 Midwifery Program
 Staff development (Cultural Safety, Motivational
Interviewing
Tips For Better Health
(adapted from Donaldson, 1999)
1. Don't smoke.
2. Eat a balanced diet that includes plenty of fruit
and vegetables.
3. Keep physically active.
4. Manage stress by making time to relax.
5. If you drink alcohol, do so in moderation.
6. Cover up in the sun and avoid sunburns.
7. Practise safer sex.
8. Take up cancer screening opportunities.
9. Be safe on the roads: follow the Highway Code.
Tips for Staying Healthy
(adapted from Dave Gordon Townsend Centre for International
Poverty Research , University of Bristol)
1. Get yourself a good education. If you are illiterate, get
some help.
2. Avoid being poor. If you are, try not to be poor for long.
3. Don't work in a stressful, low paid manual job.
4. Don't become unemployed. If you are, try not to stay
unemployed for long.
5. Don't live in damp, low quality and crowded housing.
6. Don't live in a polluted environment.
What can you do now and in the future?
 To improve health outcomes:
Don’t just moan about things (more $$)
Think outside the “health” services box (food security,
literacy)
Be “p”olitical (lobby, join a board)
Ask “Why?”
“If you always do what you have always done, you’ll
always get what you always got”
- PB
Thank you 