Embedding Surgery into Primary and Community Health Care and

Embedding Surgery into Primary and Community Health Care and Services
Didi Bertrand Farmer
CHW
Sharing Objectives
1. Discuss the importance of integrating surgical care management with PHC and community health worker programs. 1.
Explore how surgical care and outcomes might be improved through “health systems strengthening” to better meet the surgical needs of patients and communities. 2. Share lessons learned from Partners In Health in strengthening health systems to deliver NCDs care (including surgical disease) in Rwanda. 4. Introduce patients’ voices to Lancet Commission project
Voice of Patient
“I live very far from the nearest health center. If CHW are able to visit my home, then that would be much better for me. Also, due to my leg injury, transport is challenging. At the same time, I would be concerned that the health personnel that visit my home may have low capacity.”
“Ideally, I would prefer to go home only after I am completely recovered, as I do not like having to visit the health center on a daily basis for wound care. If the doctor insists on discharging me then I do not think it's possible for a nurse or other health personnel to visit my home. It seems too strange”.
Who are the CHWs?
• CHWs powerful and essential component for an effective Health system. • CHWs working both with households and health care facilities • CHWs are members of their communities and agents of community development.
Working Together
Training, Supervision, Outreach, & Accompaniment
Patient/
Communities
CHW
Health Sector Structure
National Referral Hospital
Tertiary care
District Hospital : Secondary care and Services
Health Center : Primary Care and Services
Communities and Community Health Worker Services
Guiding Principles
Foundation for Building Strong Health Systems
PHC provides general medical care, health promotion, and education, based on Primary Health Care principles of “equity, collaboration, affordability, effectiveness, efficiency, acceptability” of services. Benefits of Strong PHC System
Gaps and Challenges Address Health workforce gaps;
Improve access
Decentralized care and services closer to people;
Ensure continuum of care in a coordinated manner.
Better management of chronic illnesses
Accelerating progress in achieving MDG’s
High quality patient care;
Improved health outcomes;
Reduced costs
Barriers to accessing care at the health facility level.
Health insurance coverage barriers. High out of pocket expenditures for families. Higher health care spending for the system to address individual patient needs.
Difficulties coordinating patient care.
Holistic Approach to Primary Health Care Clinical Care
10
Social Determinants
Prevention & Promotion
Household environment
Diagnosis
Social support networks
Treatment
Economic status
Health & Wellness
Primary Health Care and Community Health Prevention & Promotion
Trust
Continuous Care
11
Collaboration and coordination
Community
Infrastructure
Task sharing
Individual
Family
Cost
Comprehensive Care
2 ways of addressing gaps
• 1‐Strengthening and Decentralizing services
– Decentralize services by integrating them at all levels from community to district levels.
– Implement Interventions to strengthen health facilities at different levels to Improve access, quality delivery, and health outcomes.
– promote quality improvement and strengthen community health. • 2‐Innovative partnerships for patient centered care through:
– Better collaboration between health providers at # levels – Advocacy to build political commitment for appropriate policy development and allocation of funding
– Promotion of community engagement in needs identification and management of services.
Three Approaches to strong Partnership
‐ Utilize “community‐based participatory approaches ”:Sanders et al., 2013
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Build “communities of solutions”: Ferrer et al., 2013; Griswold et al., 2013
– Create “community‐oriented primary care” Mullan et al., 2002
Linking Surgical Care with Primary and Community Health
The Community Health Worker as a complementary WORKFORCE • Past decade: growing interest in CHW’s worldwide.
• Network of CHWs engaged in:
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TB, HIV
NCDs
Maternal and Neonatal Health
Child Health
Family Planning access
Health prevention and Promotion
Etc….
Functional CHW Infrastructure •
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Support systems for:
Training Supervision
M&E and reporting
Referral and counter‐referral
Compensation/Motivation Operational research
Etc…
Role of CHWs in transforming surgical care and services (1)
CHWs plays a critical role in facilitating access to surgical care and in the continuum of care for patients needing follow‐up;
• CHWs provide links between the home, community, and health facility through: – routine home visits; community education and mobilization on
surgical issues; perform active case finding; follow-up of patients
returning from health facility; follow-up of target groups with specific
conditions; perform DOT drug administration, pain management,
perform some post-op care such as wound care etc..
• CHWs can also link patients and families to health facilities through referrals, accompaniment to appointments and counter‐referrals etc…
Role of CHWs in transforming surgical care and services (2)
• CHWs bring the humanistic and relational dimension that is needed to the patient care; • CHWs empower the community to better engage in their health and seek their rights;
• CHW advocate for patients with specific needs.
EXAMPLE of Innovative Partnerships to Improve Service Delivery: NCD Care in Rwanda
National Referral Centers
District Hospitals
Specialty Physicians
General Physicians
NCD Nurses
HIV & TB Nurses
Health Centers
Integrated Chronic Care Nurses
Community Health Workers
Integrated Chronic Care CHW
19
Neuro‐
psychiatric nurses
Role of CHWs Hospital Health Center
Village with 40‐60 HH
Community Health Worker SUPERVISOR
Role of CHWs (2)
HOSPITAL
HEALTH CENTER 20 TO 25 CHWS
CHW SUPERVISOR
CHALLENGES
• Overburdened CHWs
• Access to support and equipment needed to do the work • Functional system • Respect from hospital‐based professionals (nurses, doctors, administrators)
• Credentialing • Political and health system priority Unpleasant Topics for Consideration
• Effects of power dynamic, culture and structure in promoting a shared vision of patient‐centered care . • How best to collaborate and communicate toward provide the best care experience for patients?
• Power dynamic among different staff levels:
– Low level versus high level providers
– Across specialties and gender
– Equal consideration, respect and trust among health providers.
Key recommendations for integration of Surgery care into CHW systems
• Recruitment;
• Defined package of activities and follow‐up indicators;
• Appropriate training curriculum;
• Additional tools, equipment and supplies;
• Adequate compensation;
• Functional and integrative system • Advocate for this new package Integration into national policies and strategic plans • Identify financial mechanisms References 1.
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Drobac PC, Basinga P, Condo J et al. (2013). Comprehensive and integrated district health system strengthening: The Rwanda Population Health Implementation and Training partnership. BMC Health Services Research, 13(Suppl 2):S5. Ferrer RL, Schlenker CG, Romero RL. (2013). Advanced primary care in San Antonia: Linking practice and community strategies to improve health. Journal of the American Board of Family Medicine, 26: 288‐298. Griswold KS, Lesko SE, Westfall JM. (2013). Communities of solution: Partnerships for population health. Journal of the American Board of Family Medicine, 26:232‐238. Groenewegen PP, Dourgnon P, GrebS, Jurgutis A, Willems S. (2013). Strengthening weak primary care systems: Steps towards stronger primary care in selected Western and Eastern European countries. Health Policy, doi:10.1016/j.healthpol.2013.05.024.
Kringos DS, Boerma WGW, Hutchinson A, vn der Zee J, Groenewegen PP. (2010). The breadth of primary care: A systematic literature review of its core dimensions. BMC Health Services Research, 10:65. Phaswana‐Mafuya N, Petros G, Peltzer K et al. (2008) Primary health care service delivery in South Africa. International Journal of Health Care Quality Assurance, 21(6):611‐624.
Sander J, Solberg B, Gauger M. (2013). Breaking barriers to care: A community of solution for chronic disease management. Journal of the American Board of Family medicine, 26:311‐315. Starfield B. (1994). Is primary care essential? Lancet, 344(8930):1129‐1133. WHO (1978), Primary Health Care: Report of the International Conference on Primary Care. Alma Ata, USSR, 6‐12 September, World Health Organization, Geneva. Thank You Questions and Comments