Development of Primary Care Systems in Bangkok:Opportunities and Challenges

ผศ.นพ.บวรศม ลีระพันธ์การอบรมเชิงปฏิบัติการขับเคลื่อนการดำเนินงานทีมหมอครอบครัวในกรุงเทพมหานคร

โรงแรมมิราเคิล แกรนด์ คอนเวนชั่น 1 กันยายน 2559

Pix source: ra.mahidol.ac.th

Outline

Pix source: online.wsj.com

Q1: What do we mean by “PHC”

in the contexts of BKK/Thailand?

Q2: What are the “care designs” for

PHC in BKK?

Q3: What canwe do (or try to do)

in the next year?

Q1: What do we mean by “PHC” in the contexts of BKK/Thailand?

(ปฐมภูมิหมายถึงอะไร?)

Pix source: online.wsj.com

What Do You Mean by “Primary Care”?

1. Basic medical services

2. Self-care, and health for all

3. First-contact, continuous, coordinated, and comprehensive care

4. Health promotion practices, and actions on social determinants of health

(=What a layman usually thinks of primary care)

(The Declaration of Alma-Ata 1978)

(Starfield 1992, 1998)

(Ottawa Charter 1986, The 66th World Health Assembly 2013)

Action on Social Determinants of Health

(การสร้างเสริมสุขภาพ)

Community-based Primary Healthcare

(การสาธารณสุขมูลฐาน)

Primary Care Medicine,Family Medicine

(เวชศาสตร์ปฐมภูมิ, เวชศาสตร์ครอบครัว)

Basic Medical Care(บริการการแพทย์ระดับพืDนฐาน)

• Health promotion practice at the population health level

• “Health in All Policies”

• Self-care• Community health worker• Community health volunteer• “Health for All”• First-contact care• Continuous care• Coordinated care• Comprehensive Care

•Health center (สอ./รพ.สต.)•OPD, physician office•Mobile medical units

What Do You Mean by “Primary Care”?

Community-basedPrimary Healthcare

Clinical Practicesat Primary Care

Level

“The Doughnut Hole” of Primary Care

• Primary care services in developed countries

• Medical facilities in urban settings• Medical facilities in private-sector

(without public health functions)

• Primary care services in developing countries

• Medical facilities in rural settings• Medical facilities in public-sector

(with public health functions)

ØWhat exactly policies & systems are we talking about?

Q2: What are the “Care Designs”for PHC in BKK?

(การออกแบบบริการระดับปฐมภูมิเก่ียวข้องกับอะไรบ้าง?)

Pix source: online.wsj.com

“Level” of Healthcare Delivery Systems: (Only Acute Care?)

Primary Health Care (population-level, public health-type functions)

What’s probably missing?• How’s about Sub-acute Care?• How’s about Emergency Care?• How’s about Long-term Care?• How’s about Palliative Care?• How’s about Hospice Care?

Community(Self-care)

Primary Care Services(family doctor-type services)

Secondary Care Services

Tertiary Care ServicesSupra-tertiary/Quaternary Care Services

2

3

1

Source: W. Simpson del.; E. Walker lith.; Day & Son, Lithrs. to the Queen.Pix source: http://en.wikipedia.org/wiki/History_of_hospitals#mediaviewer/File:Hospital_at_Scutari_2a.jpg

“Hospital at Scutari” - A ward of the hospital at Scutari where Florence Nightingale worked and helped to restructure the modern hospital

Dealing with the Care Cycle

Source: Tishihiko Hasegawa (2013)

Source: Macagba, R. L. (1985). Hospitals and Primary Health Care: An International Study from the International Hospital Federation. In M. Hardie (Ed.), World-wide survey on the Role of Hospitals in Primary Health Care. London: International Hospital Federation.

Q3: What can we do in the next year?(แนวทางการทำงานในระยะส้ันคืออะไร?)

Pix source: online.wsj.com

Delivery of PHC Services

Pix source: www.free-ed.net/free-ed/HealthCare/Physiology/default.asp

Structure & Organizations of primary care services • Patient Care Teams• PCUs/Clinics• Systems/Networks• Governance policies

Four Cardinal Functions of primary care services • First Contact/Access• Continuity• Coordination• Comprehensiveness

“Anatomy of Primary Care” “Physiology of Primary Care”

First Contact/Access

Continuity Coordination Comprehensiveness

• Cost sharing• Distance to PC

practice • Distribution of

PC physicians • List size • Home visits in

PC • Electronic access

• Computerization of the practice

• Patient habits with first contact visits/referrals

• Endurance of patient–provider relationship

• PC practice management

• Collaboration among practitioners

• Referral system• Shared care

arrangements

• Premises, equipment

• Medical procedures

• Preventive, rehabilitative, educational activities

• Disease management

• Community links• Technical skills

Desirable PHC Functions

Source: WHO/Europe (2010)

Ø Selected proxy measures from WHO/Europe’s Primary Care Evaluation Tool (PCET)

Traditional Work Flow in Clinics(Cambridge Health Alliance, US)

Pix source: Southcentral Foundation & Institute of Healthcare Improvement (2010)

Redesign: Parallel Work Flow in Clinics(Cambridge Health Alliance, US)

Pix source: Southcentral Foundation & Institute of Healthcare Improvement (2010)

Pre-visit Work in Geriatric Care

Pix source: Harvard Vanguard Medical Associates & Institute of Healthcare Improvement (2010)

Care Coordination: EMR

Pix source: Bates et al. (2003). A Proposal for Electronic Medical Records in U.S. Primary Care

Care Coordination Innovations(UnitedHealth Group, US)

Pix source: Lewis G. Sandy (2010). AcademyHealth 2010 Annual Research Meeting June 29, 2010

Pix source: www.noogenesis.com/pineapple/blind_men_elephant.html

Integrated Healthcare & Systems Thinking

John Godfrey Saxe's ( 1816-1887) version of the famous Indian legend

Pix source: www.simoncamilleri.com/the_truth_of_the_elephant/

Integrated Healthcare & Systems Thinking

Source: alumni.harvard.edu (2010).

Pix source: www.davidco.com

“You can do anything, but not everything.”

--David Allen, Getting Things Done