Primary Health CareChallenges and Opportunities…

Jennifer Leuschner RN, BScN

Manager, Primary Health Care

GASHA

Lost in Translation…

Primary HealthCare

PrimaryCare

PopulationHealth

Chronic DiseasePrevention and

Management

Primary, SecondaryTertiary

Prevention

HealthPromotion

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 preventableWe are using our human resources poorlyThe 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 HealthAccessibilityAppropriatenessIntersectoral/InterprofessionalContinuity of CareCommunity ParticipationEfficiencyAffordable & 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 Carefocus on individual

Selective Primary Health Care

Population Health through individuals

Comprehensive Primary Health Caretackles social determinants

of health

-Individualized clinical services-Secondary & Tertiary disease prevention-Health Education

Examples:

General Practice

Diabetic Clinic

Heart Health Clinic

Screening Programs

-Screening and surveillance-Immunization-Primary prevention -Health education

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 wellnessProviders working in teamsElectronic 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 startedRecommendations 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 NPsGASHA hired first NP in 2005 – both clinical and

community components

Approx 40 initiatives in our DHA in the first few yearsLHCW, EMR, Cardiac Clinic, YHC Arichat

Our GASHA PHC team

4 NPs1 RNDietitianBehaviour MotivatorCoordinatorAHTF coordinatorClerical supportPhysiotherapist

…team is growing

Role of the nurse in PHC

Population HealthAccessibilityAppropriatenessIntersectoral/InterprofessionalContinuity of CareCommunity ParticipationEfficiencyAffordable & 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.)

CancerCOPD (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 cancerSecond highest rate of diabetesChronic Disease account for 75% of all deaths in

NSMedical costs alone for chronic diseases in NS

account for $1.2 billion/yearWhen combined with productivity losses they

account for over $3 billion/year

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

U.S.A. Projected toll resulting from Quality Gap

Chronic Disease Prevention & Management Continuum (across the lifespan)

Well Population

Primary Prevention

At Risk Population

Secondary Prevention

Established Chronic Disease

Controlled Chronic Disease

Surveillance of diseases & risk factorsBuilding healthy public policyCreating supportive environmentsStrengthening community actionsDeveloping personal skillsUniversal & targeted approaches

Population-based screeningCase findingPeriodic health examinationsEarly interventionMedication to controlUniversal & targeted approachesSelf-managementSurveillance and monitoringCreating supportive environments

Treatment and acute care (exacerbation of chronic condition)Complications managementSelf-managementCreating supportive environmentsMonitoring

Ongoing careMaintenanceRehabilitationSelf-ManagementCreating supportive environmentsMonitoring

Health Promotion Health Promotion Health Promotion Health Promotion

Prevent movement to at-risk group

Prevent progressionTo established disease

Prevent progression to complications and/orhospitalizations

Tertiary Prevention

Draft – April 11, 2008

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

1.5

4.42

1.51

2.23

1.45

4.27

1.41

2.16

1.4

4.05

1.39

2.03

0

0.5

1

1.5

2

2.5

3

3.5

4

4.5

5

Triglycerides Total Cholesterol HDL LDL

mm

ol/

L Initial

3 months

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 29.85

Waist Circumference 102.7 cm 99 cm 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 hourVisits to specialists = 1 hourPT, OT, Dietitian = 10 hoursTotal = 12 hours with professionals364.5 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 WomenMen’s Health CentreHealth ConnectionsCollaborative Practice TeamsElectronic Medical RecordWell Women’s strategyDo I Need to See a Dr. BooksPatient Teaching Guides (Angina, COPD, Heart

Failure, Heart Attack, Diverticular disease)Health LiteracyMidwifery ProgramStaff 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