The Role of Primary Care in Healthcare Integration. Associate Professor Lee Kheng Hock President College of Family Physicians Singapore

Transcription

1 The Role of Primary Care in Healthcare Integration Associate Professor Lee Kheng Hock President College of Family Physicians Singapore

2 下 醫 治 病 The inferior doctor treats the disease 中 醫 治 人 The average doctor treats the person 上 醫 治 制 The superior doctor treats the system

3 IF INTEGRATION IS THE CURE, WHAT IS THE SICKNESS? Integrated care also known as coordinated care, comprehensive care, seamless care and transmural care is a worldwide trend in health care reforms and new organizational arrangements focusing on more coordinated and integrated forms of care provision. Integrated care may be seen as a response to the fragmented delivery of health and social services being an acknowledged problem in many health systems. Source: last accessed 7 Nov 2013!Disclaimer! Integration is used by different people to mean different things. Combined with the fact that this is an issue which arouses strong feelings, there is clearly much scope for misunderstanding and fruitless polarization. WHO Technical Brief No

4 80 YEARS AGO. AMA Flexner report Development of specific areas of medicine 1908 Concept of specialty board proposed with training and exams 1933 Advisory Board of Medical Specialties 1970 American Board of Medical Specialties

5 The General Practitioner The Prototype Doctor [In the early 1900s], most graduates of America s medical schools went into general practice, providing their enhanced skills in surgery, maternity care, care of children and other fields to people throughout the nation. They delivered most of the babies, and maternal and infant mortality rates dropped sharply as care improved. Through dedication to their patients continuing care every day, these general practitioners (GPs) established a public image that remains symbolic of what people expect from their physicians. Stanard. Caring for America: The story of family practice. Donning Company Publishers 1997

6 The first specialist

7 Flexner Report 1910 Higher standards in admission and graduation Standardized curriculum Adhere to mainstream science in teaching and research Medical schools affiliate with universities Academic faculty Promote biomedical research

8 Counterculture 1960 In the mid-1960s, a series of reports focused concern on the rapid decline in the availability of general physicians (the general practitioner, or GP ), who before the 1950s had provided the majority of care in solo practices (Millis, 1966; Lee, 1992). An explosion of new medical knowledge and new technologies had resulted in an increasing number of specialties and specialists. Primary care is the provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community. Defining primary care. Institute Of Medicine 1994

9 Counterculture 1960s Millis Commission Report 1966 Willard Report 1966 Folsom Report 1966

10 A physician who focuses not upon individual organs and systems but upon the whole man, who lives in a complex setting knows that diagnosis or treatment of a part often overlooks major causative factors and therapeutic opportunities Millis Commission: The Citizens Commission on Graduate Medical Education Every individual should have a personal physician who is the central point for integration and continuity of all medical services to his patient. Such physician will emphasize the practice of preventive medicine He will be aware of the many and varied social, emotional and environmental factors that influence the health of his patient and his family His concern will be for the patient as a whole, and his relationship with the patient must be a continuity one The Folsom Report: The National Commission of Community Health Services established by the American Public Health Association and the National Health Council The American public does want and need large numbers of qualified Family Physicians The Willard Committee: an Ad Hoc Committee on Education for Family Practice

11 Era of Specialization Ophthalmology 1917 ENT 1924 O&G 1930 Pediatrics 1933 Radiology 1934 Colorectal surgery 1934 Orthopedics 1934 Urology 1934 Internal Medicine 1936 Anesthesiology 1937 Plastic surgery 1941 Thoracic Surgery 1948 Preventive medicine 1949 Family Practice 1969 Allergy & Immunology 1971 Emergency Medicine 1979

12 Confusing Ourselves On balance, I judge that we have squandered some public credibility in our evolution despite our success in having created a specialty. We probably confused the public early on when we changed our name from General Practice to Family Practice, and we confused ourselves in drawing finer distinctions with the addition of Family Medicine, Community Medicine and Primary Care. We all know the reasons for these changes, but they held no interest for the public, conveyed no weight of meaning, and sometimes allowed us to mistake the cart for the horse.... We took a hit to our public credibility when we were suckered into gatekeeping by managed care organizations.. Stephens GG. Family practice and social and political change. In: Keystone III: the role of family practice in a changing health care environment: a dialogue. Washington, DC: Robert Graham Center, 2001: G. Gayle Stephens, MD, during his tenure as chair of the Family Practice Department at the University of Alabama, Birmingham, from 1977 to 1982.

13 Taking a Wrong Turn Some had proposed that the future family physician confine his practice exclusively to the ambulatory care setting while serving in a triage role as the entry point to the health-care system. Such an approach would in the long run compromise the continued clinical competence of these physicians and their ability to provide primary care of high quality to their patients. The sharp separation of medical careers into community-oriented and hospital-based would involve serious problems for both medical practice and medical education. The creation of a system with built in discontinuity between ambulatory and hospital patient care could be expected to jeopardize the quality of care and depersonalize care further. Geyman J P. Family practice in evolution. Progress, problems and projections. NEJM Vol 298. No

14 Broken Promise The initial promise of family medicine was that it would rescue a fragmented health care system and put it together again, and return it to the people. Taylor RB. The promise of family medicine: history, leadership and the age of Aquarius. JABFM, Mar-Apr Vol 19 No Prof Robert B Taylor Author and Editor Family Medicine: Principles and Practice

15 Defining Ourselves Family Medicine as a discipline has her roots in a generalist ethos and was birthed as a counter culture movement to the increasing sub-specialisation of medicine. The aim was to train and develop more generalist physicians so as to promote holistic care. Family physicians are the largest pool of generalists who are trained to provide general medical care to patients in the context of the person, the family and the community that they live in. Source: Position statement on the principles and practice of family medicine in Singapore. College of Family Physicians Singapore, November 2011

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17 Shifting Healthcare Landscape From Third World to First 1950s-1960s - High Infant Mortality - Main cause of Death: Infectious Disease Develop a basic and effective primary healthcare system - GPs, Maternal and Child Health Clinics and Government-run dispensaries 1970s-1980s - Decrease in Infant Morality rate - Infectious disease no longer main cause of death Built Tertiary Healthcare Institutions - Tertiary referral centers for specialized medical services. 1990s - Low Infant Mortality rate - Increasing Life expectancy Built Specialised Centres - National Cancer Centre, Singapore National Eye Centre, National Heart Centre etc Rapidly Aging and Growing Population - Increasing Life Expectancy - Increase in Lifestyle Related Diseases Formation of Public Healthcare Clusters -Started with Singapore Health Services and National Healthcare group - Evolved into 6 Regional Health Clusters Beyond Rapidly Aging and Growing Population - Increasing Life Expectancy - Management of Rising Chronic Diseases Implement Regional Health System -Development & Improvement of Intermediate and Long term Care and Community Health -Growth in National Healthcare Infrastructure & Services 17 Source: Ministry of Health

18 The Neglect of Primary Care The strong guiding hand and deep pockets of the state have brought about the growth of hospitals and national specialist centres while leaving the primary care sector largely to free market forces. Thus, it is not surprising that the evolution of Singapore s healthcare system has largely favoured specialisation and tertiary care Gerald Koh CH Jeremy Lim FY. Bridging the Gap between Primary and Specialist Care: Formidable Challenges Ahead. Annals of Academy of Medicine. February 2008, Vol. 37 No. 2

19 Source: MOH Singapore

20 Source: MOH Singapore

21 This issue of primary care physicians is absolutely critical, and it has the promise of making such a big difference in the overall health of everybody, from children to seniors. It used to be that most of us had a family doctor. You would consult with that family doctor. They knew your history. They knew your family. They knew your children. They helped deliver babies. Now in these big medical systems, so often, what happens is that you're shuttled around from (sub)specialist to (sub)specialist. Oftentimes, people don't have a primary care physician that they're comfortable with, so they don't get regular checkups. They don't get regular consultations. Preventable diseases end up being missed, and you don't have the kind of coordination that's necessary between all these different specialists.

22 .. developing new models of primary care such as the Family Medicine Clinics (FMCs). FMCs are team-based practices geared towards handling chronic cases, enabling the acute hospitals to have their stable patients cared for by the GPs in the community.at the National Heart Centre Singapore New Building Topping Out Ceremony. 21 March 2013 We have taken steps to make primary care more accessible and affordable for patients. We introduced the Community Health Assist Scheme, or CHAS, to help lower- to middle-income patients receive subsidised treatment at GP clinics Committee of Supplies Speech. Better Health for All (Part 1 of 2) at the Parliament, 12 March 2013 Singapore is ramping up capacity across the healthcare value chain to prepare for a growing and ageing population. With the building of at least two new acute and four sub-acute hospitals, we will be adding more than 4,000 beds by the end of this decade. We are also looking to add 10 new nursing homes in the next few years. However, building in-patient capacity alone is not a sustainable strategy to tackle chronic conditions which are best managed in the community. The private sector delivers the majority of primary care in Singapore. As such, we are working with them to develop new care models such as the Family Medicine Clinic, which provides comprehensive team-based care to better manage chronic diseases. Through the Community Health Assist Scheme (CHAS), we provide portable subsidies at participating private GP clinics for Singaporeans with low and middle incomes. We are also developing more options for seniors to be cared for in the community through home care services and better caregiver support. Speech at the World Health Summit Regional Meeting Asia s Asian Ministers Panel Discussion, 9 April 2013

23 The State of Primary Care in Singapore 18 government polyclinics 75% subsidy for >65 or <18 50% subsidy for all > 2400 private medical clinics 0% subsidy All primary care attendances 19% public 81% private Chronic care attendances: 45% public 55% private Primary care physician workforce 14% public 86% private Source: Source: Primary Care Survey 2010

24 Perspective of Primary Care Physicians in Canada Prior to the development of primary care networks (PCNs) in Alberta, the primary care system was isolated and functioned independently from other components of the healthcare system. Primary care consisted of disparate components; more specifically, the care provided by family physicians was disconnected from other primary care services and the system as a whole. This marginalized family physicians from their specialist colleagues and the healthcare system, resulting in poor or non-existent relationships with health authorities Oekle et al. Healthcare Quarterly Vol.13 Special Issue October 2009

25 Perspective of UK GPs Across all of the five case study programmes, the apparent disengagement of general practitioners (GPs) was a cause for concern; it made information exchange more problematic and limited the ability to bring their general knowledge of the patient/family into discussions about care. All sites agreed that the lack of general practitioner (GP) engagement had contributed to slower than anticipated progress, in terms of the ability both to provide effective care co-ordination and to ensure referrals into their programmes. A variety of strategies to improve GP engagement have been used for example, financial incentives, information sessions and attending regular GP meetings. However, none of the programmes had yet achieved the desired level of engagement with GPs other than in south Devon, where virtual wards were hosted by GP practices. Goodwin N et al. Co-ordinated care for people with complex chronic conditions: Key lessons and markers for success. King s Fund 2013.

26 Activating Primary Care General practice needs to see itself at the hub of a wider system of care, and must take responsibility for co-ordination and signposting to services beyond health care in particular, social care, housing and benefits General practice needs to move from being the gatekeeper for specialist care to being the navigator that helps steer patients to the most appropriate care and support. The skill-mix in general practice will need to evolve, to include a wider range of professionals working within and alongside it. The GP should no longer be expected to operate as the sole reactive care giver, but should be empowered to take on a more expert advisory role, working closely with other professionals

27 Changing with the Times 2006: CDMP Launched 1960s: Decentralization of outpatients from hospitals 1970: Formation of specialists departments in SGH 1981: Tertiary Hospital expansions 1989 Corporatization of Hospitals 2000 Clustering of Heatlhcare Services 2008: Agency for Integrated Care 2011: Primary Care Masterplan : Founding of CFPS 1974: MCFPS Recognised 1985: Vocational Training in FM proposed 1993: MMed Family Medicine Exams 2012: Family Physician Register CHAS 1988: Tripartite Body Formed 2000 Fellowship by Assessment 2006: The first hospital based family medicine department

28 Bridging the Hospital-Primary Care Divide 34 Beds General Medicine Ward Family physicians led teams Comparison to usual care by specialist led teams 1 Jan 2008 to 31 Dec 2008 Others = 2892 FMCC = 601 (17.2%) Lee KH et al. Bringing generalist into the hosptial: Outcomes of a family medicine hospitalist model in Singapore. Journal of Hospital Medicine 2011;6: VC 2011

29 Outcome The Comorbid conditions of patients cared by hospitalist and usual care Usual care, n=2892 Hospitalist, n=601 Comorbidity condition, % Any malignancy, including leukemia and lymphoma Diabetes without organ damage Renal disease Diabetes with chronic complications Metastatic solid tumor Congestive heart failure Cerebrovascular accident Myocardial infarction Chronic pulmonary disease Mild liver disease Peripheral vascular disease Hemiplegia or paraplegia Peptic ulcer disease Moderate or severe liver disease Connective tissue disease Dementia Acquired immunodeficiency syndrome Charlson Comorbidity Index, % None Low Moderate High * p value was calculated using Chi-Square test P* 0.872

30 Outcome The length of stay, cost and outcomes of care of patients cared by hospitalist and usual care Difference Usual care, n=2892 Hospitalist, n=601 (%) P Length of stay, day 5.7 (5.4, 5.9) 4.6 (4.2, 5.0) 1.1(-19.3) <0.001 Cost, $ (3624.0, ) (3035.1, ) 502(-13.4) Unscheduled readmission, %* (-2.9) Hospital mortality, %* (-24.5) * p value was calculated using Chi-Square test Geometric mean (95% confidence interval); p value was calculated using Mann-Whitney U test

31 Integrating back to the Community: Adapted Virtual Ward Daily IT List of Patient readmissions (1 or more within 90 days) LACE Screening done by Medical Officer LACE Scoring Ward Assessment for Patients with LACE 10 Randomization after Consent INTERVENTION GROUP CONTROL GROUP Patients Enrolled into after Index Discharge Multidisciplinary Team Review Active Surveillance, Education and Community Support Patient discharged from after 3 months Data Analysis

32 Emerging primary care networks Subsidised Drug Delivery Programme whereby subsidised drugs are delivered to subsidized patients preferred address from SGH/NHCS pharmacies Free Diagnostic Tests, sponsored by SingHealth, to monitor patient s clinical outcome and to audit the programme Fast track referral to SOCs as subsidized patients when their conditions deteriorate and require specialist s attention Capped consultation fee at $25 for every GP visit Optional Shared Care model, ordered by SOC Clinicians, for patients who genuinely require yearly reviews at SOCs Follow-up support from SingHealth Right-Siting officer, as friendly and accessible point of contact between GPs and SingHealth Convenience of nearby GP

33 Bottom Up Networks Started in April Collaboration between Frontier Healthcare Group and Agency for Integrated Care (AIC). Started with 9 clinics (Frontier clinics) 2 other GP clinics subsequently joined > current size of 11 clinics. Woodlands Yishun Punggol Sengkang) Ang Mo Kio Buangkok Bukit Batok Jurong Ubi Havelock Bedok West

34 Primary Care Master Plan Community Health Centres (CHCs) which aim to provide off-site ancillary support services (such as health education, Diabetic Retinal Photography and Diabetic Foot Screening) to GPs; Family Medicine Clinics (FMCs) bringing together doctors, nurses, allied health professionals and other related services in an integrated service delivery model to enable resource sharing, economies of scale and team-based care; and Medical Centres (MCs) to provide ambulatory procedures (such as day surgery for cataract removal) in the community. Specialists will also work with GPs to co-manage patients with more complex but stable conditions as part of shared care programmes, to enable the rightsiting of stable patients from acute hospitals Specialist Outpatient Clinics (SOCs).

35 The Way Forward: A New Kind of Primary Care Resource Community Health Centres Community Health Assist Scheme Chronic Disease Management Program NEHR Re-skill Family Physician Register Graduate Diploma in Family Medicine Master in Medicine Family Medicine / ACGME (I) Residency Fellow of the College of Family Physician Singapore/ Advanced Family Medicine Training Re-unite Regional Health System Public Private Partnerships/ Family Medicine Clinics? Primary Care Network

36 The Specialist in De-fragmenting Health Care

37 The expert integrator of care across the continuum

38 Fulfilling the Promise of Family Medicine The initial promise of family medicine was that it would rescue a fragmented health care system and put it together again, and return it to the people. Taylor RB. The promise of family medicine: history, leadership and the age of Aquarius. JABFM, Mar-Apr Vol 19 No Prof Robert B Taylor Author and Editor Family Medicine: Principles and Practice