Future impact of continuity on quality of care within Primary Care

1. Future impact of continuity on quality of care within Primary Care

2. Disposition 16.30 Introduction - Continuity in primary care - background and evidence   (C.Björkelund) 16.45 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          (Kathryn Hoffman A. Maun ZsuzannaFarkas-Pall ) 17.40 Workshop discussion on continuity: 17.55  Summary and conclusions

3. Continuity in primary care - background and evidence Cecilia Björkelund Department of Primary Health Care University of Gothenburg and Region VästraGötaland

4. Continuity of care –One of the cornerstones of primarycare

5. Evidence from community and providerperspective • Lowerhealthcarecosts • 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

6. 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

7. Chronicconditions • 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

8. 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

9. The complexity of operationalizing continuity in the context of multi-disciplinary 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.

10. 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.

11. EFPC Position paper 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? Impact of continuity on quality of care within Primary Care – with focus on the perspective of preferences of citizens

12. Enhancingcontinuity 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 FamilyMedicine and PHC- GhentUniversity (Belgium) Chair European Forum forPrimaryCare Gothenburg, 03.09.2012

13. http://www.primafamed.ugent.be http://www.wgcbotermarkt.be http://www.the-networktufh.org http://www.euprimarycare.org

14. Continuity in futureprimary care • Continuity of care: a catch-all term • Typology • Multimorbidity, goal-oriented care andequity • The future of continuity: threatsandopportunitiesin patientswithmultimorbidity • Conclusion: from the patient, the provider, the practicetowards the community, the team, the system

15. 1. Continuityof care: a catch-allterm • “A sustained partnership betweenpatientsandclinicians” (IOM) • Process or outcome? • Relationship • Contextual • Cost-effective?

17. De Maeseneer, J. , De Prins, L., Gosset, C. andHeyerick, J. (2003). Annals of Family Medicine, 1(3): 148.

19. Continuity in futureprimary care • Continuity of care: a catch-all term • Typology • Multimorbidity, goal-oriented care andequity • The future of continuity: threatsandopportunities in patientswithmultimorbidity • Conclusion: from the patient, the provider, the practicetowards the community, the team, the system

20. 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

21. 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

22. 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.

23. Continuity in futureprimary care • Continuity of care: a catch-all term • Typology • Multimorbidity, goal-oriented care andequity • The future of continuity: threatsandopportunities in patientswithmultimorbidity • Conclusion: from the patient, the provider, the practicetowards the community, the team, the system

24. The ageing society

26. 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 • 50 % of 65+ have at least 3 chronic conditions • 20 % of 65+ have at least 5 chronic conditions (EurRespir J 2008;32:962-69) (Anderson 2003)

28. 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)

31. Wagner EH. Effective Clinical Practice 1998;1:2-4

32. EMPOWERMENT

34. But…

35. Jennifer is 75 yearsold. Fifteenyearsagoshe lost her husband. She is a patient in the practicefor 15 yearsnow. During these last 15 yearsshe has been through a laboriousmedicalhistory: operationforcoxarthrosiswith a hip prothesis, hypertension, diabetes type 2, COPD and osteoartritis. Moreoverthere is osteoporosis. She lives independently at her home, withsome help from her youngestdaughter Elisabeth. I visit her regularly and each time she starts saying: “Doctor, you must help me”. Thenfollows a succession of complaints and unwell feeling: sometimesit has to do with the heart, another time with the lungs, then the hip, …

36. Each time I suggest – according to the guidelines - all sorts of examinationsthatdidnotimprove her condition. Her requestsbecome more and more explicit, myfeelings of powerlessness, insufficiency and spite, increase. Moreover, I have to copewithguidelinesthat are contradictory: for COPD shesometimesneedscorticosteroids, whichworsens her glycemiccontrol. The adaptation of the medicationfor the bloodpressure (at one time too high, at another time too low), cannot meet with her approval, as does my interest in her HbA1C and lungfunctiontest-results.

37. AftersomanycontactsJennifer says: “Doctor, I want to tellyouwhatreallymattersfor me. OnTuesday and Thursday, I want to visitmyfriends in the neighbourhood and playcardswiththem. OnSaturday, I want to go to the Supermarketwithmydaughter. And for the rest, I want to beleft in peace, I don’t want to changecontinually the therapyanymore, … especiallynothaving to do this and to do that”. In the conversationthatfolloweditbecameclear to me howJennifer had formulated the goals for her life. And at the same time I feltchallengedhow the guidelinescouldcontribute to the achievement of Jennifer’sgoals. I visitJennifer againwithpleasure ever since: I knowwhatshe wants, and howmuch I can (merely) contribute to her life.

38. Sum of the guidelines • Patient tasks • Joint protection • Energy conservation • Self monitoring of blood glucose • Exercise • Non weight-bearing if severe foot diseaseispresent and weightbearing for osteoporosis • Aerobicexercise for 30 min on mostdays • Muscle strenghtening • Range of motion • Avoidenvironmentalexposuresthatmightexacerbate COPD • Wear appropriatefootwear • Limitintake of alcohol • Maintain normal body weight • Referrals • Physicaltherapy • Ophtalmologicexamination • Pulmonaryrehabilitati • Clinicaltasks • Administer vaccine • Pneumonia • Influenza annually • Check blood pressure at all clinicalvisits and • sometimesat home • Evaluate self monitoring of blood glucose • Foot examination • Laboratory tests • Microalbuminuriaannually if not present • Creatinine and electrolytesat least 1-2 times a year • Cholesterollevelsannually • Liverfunctionbiannually • HbA1C biannually to quarterly • Patient education • Foot care • Oeseoartritis • COPD medication and delivery system training • Diabetes Boyd et al. JAMA, 2005

40. “Problem-oriented versus goal-oriented care”

41. “Problem-oriented versus goal-oriented care”

42. “Problem-oriented versus goal-oriented care”

43. “Problem-oriented versus goal-oriented care”

44. What really matters for patients is • Functional status • Social participation

45. 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.

47. F R A G M E N T A T I O N

48. The challenge: vertical disease- oriented programs and multimorbidity Create duplication Lead to inefficient facility utilization May lead to gaps in patients with multiple co-morbidities Lead to inequity between patients