The role of Health Professions Socio-economic determinantns · CVD 4. Nurse practitioners 5. Nurse-led cardiac clinics 6. Nurse-led education 7. Home care Mental health 8. Case managers

European Observatory on Health Systems and Policies

The role of Health ProfessionsSocio-economic determinants / focus on primary healthcare

Dr Matthias Wismar


Key messages

• Non-physician health professions almost all play a role tackling the social determinants of health;

• those professions are becoming increasingly important in primary care;

• non-medical professions play increasingly a role acquiring health awareness in settings

• overall there is sufficient evidence on the effectiveness taking up roles in health promotion and prevention;

• tackling the socio-economic determinants is, however, limited to the direct setting/community and lacks general political clout addressing e.g. the commercial determinants of health


Health professionals tackling the socio-economic determinants of health


PT

FR

DEBE

AT

RS

PL

DK

FI

IE

NL

Background: Patient, peers, professionals: skill-mix innovations for primary and chronic care.

17 country case studies (forthc.)

UK

CANADA

CH

MT

SI

NO

Vol I: Country case studies

• Skill-mix innovations for primary and chronic care

• A wide concept of the health workforce

• What have countries done so far?

Vol II: Innovation and implementation• Keeping healthy / health

promotion and prevention

• Specialized acute care

• Helping chronically ill, in particular multi morbid patients to lead an independent life.

• Supporting those who cannot lead an independent life

• Primary / chronic care in rural areas

• Primary / chronic care in deprived areas

European Observatory on Health Systems and Policies 5

Non-physician health professionals in primary care

NURSING ASSOCIATEA support role to bridge the gap between healthcare assistants and nurse practitioners and enable registered nurses to focus on more complex clinical duties

HEALTHCARE ASSISTANTSupport role working under guidance of (usually) registered nurses to undertake routine tasks previously undertaken by nurses

NURSE PRACTITIONERAdvanced practice nurses educated to Master’s level that provide care in an advanced and extended clinical role

PHYSICIAN ASSISTANTMedically trained generalist healthcare professionals who are supervised by GPs and provide medical care as part of multi-disciplinary teams

MEDICAL ASSISTANTSupport doctors by reducing administrative workload pressures by handling routine administration and some basic clinical duties enabling the GP to focus on the patient.

PRACTICE BASED PHARMACISTWork in-practice in a patient focused role to clinically assess and treat patients, particularly managing long-term conditions, medication adherence and health promotion

SPECIALIST PARAMEDICDeployment of paramedics in-hours GP practices to triage, run clinics and manage minor illnesses to provide continuity of care to patients with complex needs


New roles in nursing: what they do and how they work together

HEALTHCARE ASSISTANT NURSING ASSOCIATE NURSE PRACTITIONER

Typical job

duties

• Sterilise equipment• Do basic health checks• Restock consulting rooms• Process lab samples• Take blood samples• Health promotion, prevention,

health education

• Clinical tasks (e.g. cannulation, venepuncture and ECGs)

• Social care support • Performing and recording

clinical observations (blood pressure, temperature, respirations, pulse)

• Ordering, performing, interpreting diagnostic tests

• Diagnosing, treating acute and chronic conditions

• Prescribing medications and other treatments.

• Managing patients' overall care.• Health promotion, health education

Practice areas Hospitals, GP practices Hospitals, GP practices, social

care providers

Hospitals, outpatient clinics, GP

practices, schools, long-term care

facilitiesPrerequisite

education

level

Often no formal requirements (UK

- may require previous work in

healthcare)

Secondary school maths and

English

Bachelor’s degree

Education

level

Vocational Vocational Master’s degree

Regulation No Yes YesSupervision Usually registered nurse Usually registered nurse Can work autonomously in some

countries


An introduction to physician assistants and medical assistants

Physician

Assistant

Medical

Assistant

Prospects

MEDICAL ASSISTANT PHYSICIAN ASSISTANT

Typical Job

duties

Clerical: Handle phone calls, manage front desk duties, process mail, assist with paperwork Administrative: update patient files, process claim forms, coordinate referrals and medical testsClinical: Review medical history, routine procedures (e.g. draw blood, process lab specimens, call in pharmacy refills, sterilize equipment, remove sutures, perform ECGs) health promotion, health education, prevention.

• Take medical histories• Carry out physical examinations• See patients with undifferentiated diagnoses• See patients with long-term chronic conditions• Formulate differential diagnoses and

management plans• Perform diagnostic and therapeutic procedures• Develop and deliver appropriate

treatment+management plans• Request and interpret diagnostic studies• Provide health promotion and disease prevention

advicePractice areas GP practices, outpatient clinics, long-term care

facilities, hospitals

GP practices, outpatient clinics, long-term care

facilities, hospitals, correctional institutions, military

Prerequisite

Education

High school diploma Bachelor’s Degree

Education Vocational Master’s Degree (usually)

Regulation No Sometimes

Supervision Usually physician Physician


Analysing the reported cases

Primary care segments 73* Professions 73

Keeping people healthy 10 Nurses (all sorts including medical assistants)

29

Acute care 30 Pharmacists 8

Chronic care, multi-morb. 26 Physiotherapists 5

Long-term and palliative care 12 (Social) care workers 4

Rural a/o deprived areas 3 Volunteers 5

GPs 3

Physician assistant 3

Paramedic 3

Oral dental Hygienist 1

Other prof. 12

10 x teams


WHAT:

Skill Mix Innovation

HOW:

Innovation Process

WHO:

Professional, Volunteer,

Peer, Patient, Citizen,

Team

SCALE

(name where available)

COUNTRY

6** Prevention, patient counselling

(e.g. diabetes, cardiovascular risk

management, COPD, dementia

screening)

Role

expansion

and

introduction

of team

model

Public health nurse Nationwide: ASALÉE involves ca.

2% of GPs (>1000), 300 FTE

nurses, 300 000 patients

France

7 Prevention, screening diagnostics in

primary care-based mental health

care

Introduction

of new role

and team

model

Mental health practice nurse

(nurse or other professional with

1-year additional training)

Nationwide, 81% of GP practices

employ a mental health practice

nurse ca. 1,5 days/week

The

Netherlands

8 Essential public health operations Introduction

of new

profession

Public health professionals Nationwide Serbia

10 Prevention and health promotion in

GP practices

Introduction

of new job

Registered nurse with additional

training in prevention of NCDs

Nationwide, 75% of all GP

practices employed an additional

0.5FTE nurse in 2017 (model

practices)

Slovenia

51** Routine care-related tasks for

chronic patients (home visits,

geriatric assessments, patient

education, vaccination, prevention)

Role

expansionMedical assistants, nurses Federal States; initially especially

in rural or under-served areas but

has since been expanded

Germany

73 - Daily personal care

- Prevention

- Psycho-social support

- Housekeeping

Introduction

of home-

based care

Home care assistants Nationwide: 85% of local

governments provide geronto

service to ca. 16.000 residents

(1.2% of population over 65 years)

(2012)

Serbia


Non-health professionsWHAT:

Skill Mix Innovation

HOW:

Innovation Process

WHO:

Professional, Volunteer, Peer,

Patient, Citizen, Team

SCALE

(name where available)

COUNTRY

Prevention and health promotion

2 Carry out ‘safe and well

visits’ as part of broader

health and wellbeing

approach

Introduction of new

role

Fire service Local: Manchester England

3 - Identify mental health

problems among tenants

- Signpost to (specialist)

services

Introduction of new

role

Sheltered housing

professionals

Multiple local experiments England

4 Rapid HIV and HVC testing Introduction of new

role

Volunteers

(associations) or social

workers specially trained

and certified

Nationwide France

5 HIV auto-testing Introduction of new

role

Citizens Nationwide France


Records identified through database searching

(n = 8,300)

TI/A

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clu

ded

Elig

ibili

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fica

tio

n

Additional records identified through other sources

(n = 316, ongoing)

Records after duplicates removed(n =3,983)

Title/abstract screened (n = 3,983)

Records excluded(n = 3,310)

Full-text articles assessed for eligibility

(n = 673)

Full-text articles excluded, reasons:

- skill-mix not main intervention n = 71, - year (prior 2010) = 163, - no relevant outcome measure n=7, - not SR/ME n=46, - Not primary/ambulatory care (inpatients included) n=197, - no EU/OECD country n=4, - not English n=1- reasons tbc n=11

Reviews included

(n = 144,pending final results from

snowballing)

Overview of reviews: search results


For chapter 6 (chronic conditions): Reviews were of good quality, mostly focusing on pharmacists and nurses

Multi

Single condition

66%

62%51%

48%

38% UK

USA

Australia

Canada

Europe

Country coverage

13

109

3

9 Diabetes

Mental Health

Cardiovascular disease

Cancer

Multimorbidty

Chronic condition and multimorbidity

Profession

68%

32%

Meta-analysis

No meta-analysis

Quality

1

41

00

313

1122

2

13

Pharmacist

Nurse

Physician

Physcian assistant

CHW or peer educator

Multidisciplinary team


2115

65

137

1

1117

0

10

20

30

40

50

60

70

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Key areas of primary health care Implementation

Reviews by key areas of relevance to PHC


Preliminary results: main themes

Skill-mix changes

Details of skills/ roles? Professions? What patientgroups?

Outcomes

1 New divisionof work

Advanced clinical practice(e.g. prescribing, advancedhealth assessments, screenings, monitoring, advice)

I: Nurses,pharmacists(others)C: physicians/ GPs

• Patients with(stable) chronicconditions

• Minor conditions• Triage• Screenings, other

• At least equivalentquality of care

• May reduce costs• Improved access

(rural)

2 Outreach Pro-active outreachactivities, e.g. home visitsincl. tailored counselling, information, social servicecoordination

I: Nurses, assistants, layworkers (CHWs)C: SoC

• At risk groups(healthpromotion, prevention, chronicconditions, palliative care)

• Improved access(at risk)

• Improved healthliteracy

• Improved painmanagement


Preliminary results: main themes

Skill-mix Details of skills/ roles? Professions? What patient groups? Outcomes

3 Patient / peerempowerment

Lifestyle advice, coaching, monitoring, shareddecision making

I: Nurses, socialcare workers, assistants, GPsC: SoC

• All patient groups, but• Focus: risk /vulnerable

groups

• Improved access(at risk)

• Improved healthliteracy

4 Case manager role/ transitioncoordinator

Coordination of care, comprehensive needsassessments, navigationrole, information/coaching

I: Nurses, socialcare workers, GPs, pharmacistsC: SoC

• (High) need patients• Focus: chronic/

multimorbidity, LTC, Palliative care

• Improved quality• Reduced re-

admissions• Inconclusive

results in LTC

5 Collaboration/ shared care

Interprof. cooperation, shared care plans, jointcare

I: team-basedC: noteams/SoC

• Various patient groups • Inconclusiveresults


Patient outcomes

Nurse-led skill mix interventions generally provided better or equal care to physicians

Care

typeResource

Use

$

Professional outcomes

Diabetes1. Titration of medicines2. Nurse practitioners3. Nurse-led education

CVD4. Nurse practitioners5. Nurse-led cardiac

clinics6. Nurse-led education7. Home care

Mental health8. Case managers9. Nurse-led education

DiabetesAll: HbA1c levels, SBP, DBP (1-3)1. Medication adherence2, 3. Feet at risk, total mortalityPhysical activity, diet, patientsatisfaction

CVD4, 5. BP and cholesterol control5. Risk of major cardiac event4. Patient satisfaction7. All cause mortality, QoL

6. Medication adherence

Mental health8. Depression symptoms9. Self-management skills

Medication adherence

Diabetes1. Inpatient costs

1. Outpatient costs

2. Hospitalizations

CVD4,5 Hospitalizations

Mental health9. Use of crisis and

emergency services

$

Diabetes, CVD2, 4. job satisfaction

2, 4. Inappropriate demands for team work

±±

±

±

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The commercial determinants of health


Key messages

• Non-physician health professions almost all play a role tackling the social determinants of health;

• those professions are becoming increasingly important in primary care;

• non-medical professions play increasingly a role acquiring health awareness in settings

• overall there is sufficient evidence on the effectiveness taking up roles in health promotion and prevention;

• tackling the socio-economic determinants is, however, limited to the direct setting/community and lacks general political clout addressing e.g. the commercial determinants of health

Documents

The role of Health Professions Socio-economic determinantns · CVD 4. Nurse practitioners 5. Nurse-led cardiac clinics 6. Nurse-led education 7. Home care Mental health 8. Case managers