COMMUNITY ORIENTED PRIMARY HEALTH CARE

1. COMMUNITY ORIENTED PRIMARY HEALTH CARE Manfred Maier Chairman, Department for General Practice Head, Center for Public Health Medical University of Vienna Dept. Gen.Practice, CPH, Medical University of Vienna

2. CONTENT • Roots of COPC • Determinants of Health- public health approach • Duties and opportunities for Primary Care - clinical duties - education – training – teaching - mutual interaction with „Public Health – programs“ Dept. Gen.Practice, CPH, Medical University of Vienna

3. COPC - YESTERDAY Pieter Brueghel, 1563, KHM Vienna Dept. Gen.Practice, CPH, Medical University of Vienna

4. COMMUNITY ORIENTED PRIMARY CARE HISTORY • South Afrika 1940 • „Homelands“, rural areas • Nutritional deficits, Syphilis, Malaria, Bilharziosis, Tuberkulosis, ... • Health Centres - Prevention und treatment - health education - inclusion / activation of the „community“ Dept. Gen.Practice, CPH, Medical University of Vienna

5. HEALTH CENTERS • methods - demography - influence on health - assessing morbidity - „community health status“ - monitoring • implementation - physicians - nurses - social workers Pieter Brueghel, 1568, Musée du Louvre Dept. Gen.Practice, CPH, Medical University of Vienna

6. Incidence of new cases of syphilis in the Pholela defined area Dept. Gen.Practice, CPH, Medical University of Vienna

7. COPC - TODAY Dept. Gen.Practice, CPH, Medical University of Vienna

8. COMMUNITY ORIENTATION • Community • A group of people, which live in a certain region and under the same circumstances (politics, environment, occupation, social system,…). • Characteristics • socioeconomic status • religious groups • ethnic – cultural groups • occupational groups • age groups Dept. Gen.Practice, CPH, Medical University of Vienna

9. CONTENT • Roots of COPC • Determinants of Health- public health approach • Duties and opportunities for Primary Care - clinical duties - education – training – teaching - mutual interaction with „Public Health – programs“ Dept. Gen.Practice, CPH, Medical University of Vienna

10. POPULATION HEALTH MODEL • societies that enjoy a higher level and relatively equitable distribution of wealth enjoy a higher level of health status • at the individual level, health status is determined by the social and economic environment and the way in which this environment interacts with individual psychological resources and coping skills. Evans, 1994 Dept. Gen.Practice, CPH, Medical University of Vienna

11. Dept. Gen.Practice, CPH, Medical University of Vienna NEJM 2007; 357:1221-1228

12. PUBLIC HEALTH - STRUCTURES AND STRATEGIES • addressing all determinants of health • vaccinations, disease management programs, health checks, … • working with different professionals and organisations to improve health • influencing policy and plans for improving public health • gaining visibility/awareness for public health Dept. Gen.Practice, CPH, Medical University of Vienna

13. Dept. Gen.Practice, CPH, Medical University of Vienna

14. EXAMPLE FOR COPC: SUBSTITUTION PROGRAMM VIENNA • appr. 10 000 drug addicts • withdrawal - substitution • goal: decent life in society • legal basis: SMG • agreement city – ÄK – WGGK • approx. 70 % cared for by GP´s Dept. Gen.Practice, CPH, Medical University of Vienna

15. EVALUATION • increase in patients and attendance • advantages of treatment by GP • low threshold- easy access • existing relationship • „difficult“ patients • GP is „flexible“ • decentralized care Dept. Gen.Practice, CPH, Medical University of Vienna

16. GLOBAL HEALTH 2005 • One child dies of malaria in Africa every 29 seconds • One person is infected with HIV every 6.4 seconds • Someone in the world dies of TB every 18 seconds • One pregnant woman dies of complications every 60 seconds nature 2007 Dept. Gen.Practice, CPH, Medical University of Vienna

17. FACTS ARE NOT APPRECIATED: • 95% of health care economy spent for direct medical care • 5% invested in population - wide approaches to health improvement Dept. Gen.Practice, CPH, Medical University of Vienna

18. Dept. Gen.Practice, CPH, Medical University of Vienna

19. CITIZENS PER PHYSICIAN: Austria 212 Belgium 299 Denmark 372 France 328 Germany 333 Netherlands 420 USA 472 Malawi 158000 Dept. Gen.Practice, CPH, Medical University of Vienna

20. POOR COUNTRIES WITH SUPERIOR OUTCOME • Emphasis on educational attainment • Empowerment of women • Well organized Primary Health Care System Dept. Gen.Practice, CPH, Medical University of Vienna

21. CONTENT • Roots of COPC • Determinants of Health - public health approach • Duties and opportunities for Primary Care - clinical duties - education – training – teaching - mutual interaction with „Public Health – programs“ Dept. Gen.Practice, CPH, Medical University of Vienna

22. THE PRIMARY CARE PHYSICIAN IN THE COMMUNITY • Clinical responsibility • Role model – educator, teacher ? • Research opportunities ? • Initiator of change ? • goal: improving the health status in the community Dept. Gen.Practice, CPH, Medical University of Vienna

23. CLINICAL RESPONSIBILITIES • Epidemiology in the community • documentation of health problems / diseases • identification of risks and needs • Vulnerable groups / people in the community • psychiatric diseases, drug dependency, homeless people, minorities, violence, … • Allocation of resources / possibilities • rationalisation - rationing • overuse – misuse – underuse Dept. Gen.Practice, CPH, Medical University of Vienna

24. BARRIERS FOR RECEIVING ADEQUATE HEALTH CARE • financial reasons ? • distances, transportation ? • competing needs, priorities ? • educational level ? • psychiatric diseases ? • social context ? • fear, sense of shame ? • access to health care services ? • attitude of health care personnel ? Dept. Gen.Practice, CPH, Medical University of Vienna

25. ACCESS TO HEALTH CARE • Dependant on - Availability in a community - Personal care seeking behavior • Having an usual source of care improves • Continuity of care • Preventive care • Prenatal care • Management of chronic diseases Dept. Gen.Practice, CPH, Medical University of Vienna

26. THE PRIMARY CARE PHYSICIAN AS ROLE MODEL – EDUCATOR - TEACHER • medical students, trainees, colleagues • patients • disease specific information / education • general patient information • industry, schools, institutions, associations, ... Dept. Gen.Practice, CPH, Medical University of Vienna

27. RESEARCH OPPORTUNITIES • participation in „community based projects“ • population based studies • evaluation of research results / recommendations / guidelines for daily practice • monitoring – documentation - registry for morbidity Dept. Gen.Practice, CPH, Medical University of Vienna

28. INITIATIVES FOR CHANGE • implementation of public health strategies • environment • drugs • alcohol • obesity • vaccinations • health checks Dept. Gen.Practice, CPH, Medical University of Vienna

29. INITIATIVES FOR CHANGE - 2 • Feedback to health politics on health care aims or health care reforms • social disadvantages • social isolation • drug policy • violence • interface problems • injustice / inequity Dept. Gen.Practice, CPH, Medical University of Vienna

30. Politics, Public Health Programms disease centered implementation ? PHC Patient GP Patient centered Family, Community, Population Dept. Gen.Practice, CPH, Medical University of Vienna

31. THANK YOU FOR YOUR ATTENTION ! Dept. Gen.Practice, CPH, Medical University of Vienna