2. Innovation in integrated community- based care through the life-span Prof Jan De Maeseneer, MD, PhD, (Hon)FRCGP Chair European Forum for Primary Care Chair Expert Panel on Effective Ways of Investing in Health (EC) Head of Department of Family Medicine and PHC, Ghent University, BE Family Physician, Community Health Centre Botermarkt, Ghent

3. Innovation in integrated community- based care through the life-span ° The challenge: increasing chronic conditions, multi-morbidity and inequity in health ° Accessible Comprehensive Primary Care contributes to better health outcomes and more equity ° Experiences in integrated community-oriented primary care

7. Socio-economic inequalities in health Healthy life expectancy in Belgium (Bossuyt, et al. Public Health 2004)

8. Sum of the guidelines Patient tasks Joint protection Energy conservation Self monitoring of blood glucose Exercise Non weight-bearing if severe foot disease is present and weight bearing for osteoporosis Aerobic exercise for 30 min on most days Muscle strengthening Range of motion Avoid environmental exposures that might exacerbate COPD Wear appropriate footwear Limit intake of alcohol Maintain normal body weight Clinical tasks Administer vaccine Pneumonia Influenza annually Check blood pressure at all clinical visits and sometimes at home Evaluate self monitoring of blood glucose Foot examination Laboratory tests Microalbuminuria annually if not present Creatinine and electrolytes at least 1-2 times a year Cholesterol levels annually Liver function biannually HbA1C biannually to quarterly Referrals Physical therapy Ophtalmologic examination Pulmonary rehabilitati Patient education Foot care Oesteoartritis COPD medication and delivery system training Diabetes TimeMedications 7:00 AMIpratropium dose inhaler Alendronate 70 mg/wk 8:00 AMCalcium 500 mg Vit D 200 IU Lisinopril 40mg Glyburide 10mg Aspirin 81mg Metformin 850 mg Naproxen 250 mg Omeprazol 20mg 1:00 PMIpratropium dose inhaler Calcium 500 mg Vit D 200 IU 7:00 PMIpratropium dose inhaler Metformin 850 mg Calcium 500 mg Vit D 200 IU Lovastatin 40 mg Naproxen 250 mg 11:00 PMIpratropium dose inhaler As neededAlbuterol dose inhaler Paracetamol 1g Boyd et al. JAMA, 2005

10. “Problem-oriented versus goal-oriented care” Problem-orientedGoal-oriented Definition of HealthAbsence of disease as defined by the health care system Maximum desirable and achievable quality and/or quantity of life as defined by each individual

11. “Problem-oriented versus goal-oriented care” Problem-orientedGoal-oriented Measures of successAccuracy of diagnosis, appropriateness of treatment, eradication of disease, prevention of death Achievement of individual goals

12. “Problem-oriented versus goal-oriented care” Problem-orientedGoal-oriented Evaluator of successPhysicianPatient

13. What really matters for patients is Functional status Social participation

14. Vertical Disease Oriented Approach Mono-disease-programs? Or… Integration in comprehensive PHC HYPERTENSION COPDAIDSOSTEOPOROSIS DIABETES HYPERCHOLESTEROL OBESITY

15. F R A G M E N T A T I O N

16. The challenge: vertical disease- oriented programs and multimorbidity Create duplication Lead to inefficient facility utilization May lead to gaps in patients with multiple co- morbidities Lead to inequity between patients

17. “Inequity by disease” becomes an increasing problem both in developed and developing countries [ see www.15by2015.org ]www.15by2015.org

20. Resolution WHA62.12 “Primary Health Care, including health systems strengthening” The World Health Assembly, urges member states: … (6) to encourage that vertical programmes, including disease-specific programmes, are developed, integrated and implemented in the context of integrated primary health care.

21. Innovation in integrated community- based care through the life-span ° The challenge: increasing chronic conditions, multi-morbidity and inequity in health ° Accessible Comprehensive Primary Care contributes to better health outcomes and more equity ° Experiences in integrated community-oriented primary care

24. Opinion on Definition primary care – Definition Core-definition 'The Expert Panel considers that primary care is the provision of universally accessible, integrated person-centered, comprehensive health and community services provided by a team of professionals accountable for addressing a large majority of personal health needs. These services are delivered in a sustained partnership with patients and informal caregivers, in the context of family and community, and play a central role in the overall coordination and continuity of people’s care The professionals active in primary care teams include, among others, dentists, dieticians, general practitioners/family physicians, midwives, nurses, occupational therapists, optometrists, pharmacists, physiotherapists, psychologists and social workers.’

26. “ The analysis showed that strong primary care was associated with better population health; lower rates of unnecessary hospitalizations; and relatively lower social inequality, as measured by an indicator linking education levels to self-rated health.” (Kringos et al, Health Affairs 2013;32(4):686-694)

27. Innovation in integrated community- based care through the life-span ° The challenge: increasing chronic conditions, multi-morbidity and inequity in health ° Accessible Comprehensive Primary Care contributes to better health outcomes and more equity ° Experiences in integrated community-oriented primary care

28. GHENT UNIVERSITY TEACHING PLATFORM WELCOME to the Community Health Centre Botermarkt Hundelgemsesteenweg 145 9050 Ledeberg www.wgcbotermarkt.be Tel 0032 9 232 32 33 Info@wgcbotermarkt.be Fax 0032 9 230 51 89

29. Improving health and primary health care around the world through Community Health Centres Learn more at: www.ifchc2013.org

30. A Community Health Centre is… An accessible multidisciplinary primary health care centre, Community-oriented, in an integrated needs-based capitation system

31. INTEGRATED NEEDS- BASED CAPITATION Contract between health care workers and insurance companies in the framework of the National Social Security System (RIZIV-INAMI)

32. Commitment : free access to service for patients on the list (for family medicine; nursing; physiotherapist) patients are only allowed to contact providers from the health centre for family medicine and nursing care INTEGRATED NEEDS- BASED CAPITATION

33. INTERDISCPLINARY TEAM Family physiciansNursesDietician Health promotion worker Social workers Administrative staff and receptionist Ancillary staff Dentists External health care workers: physiotherpists, psychologists,…

34. Competency Sharing Care is provided by the person most equipped for the task and most knowledgeable about the subject. Each discipline works based on their own competencies!

35. Shared Electronic Patient Record

36. Social Work 2 FTE social workers Social work in the health centre includes : –first intake, exploring the problem –information and counseling –advocating, mediating –supporting, psychosocial guidance –referral to specialised services –administrative support, application for allowances, budgetplanning –establishing patient centered networks of care

37. Integrated care Physical, mental and social well-being Taking environment/home situation into account! Assigned GP and nurse

39. Local Welfare Meetings In order to work together on a local level to tackle poverty 1986: first community welfare meeting in Ledeberg Approx 40 community workers from different organisations Tri-monthly meetings

40. Networking Obtaining local congruence on welfare themes Sharing warning signs on the local level and tackling them by working together, making new initiatives,… Signalising to policy makers Sharing information Sharing expertise Education Local Welfare Meetings GOALS

41. Integration of personal and community health care The Lancet 2008;372:871-2

42. Created in 2005 The European Forum for Primary Care is situated at the NIVEL institute in the Netherlands. The European Forum for Primary Care is situated at the NIVEL institute in the Netherlands. Board members from Belgium, UK, Italy, Sweden, Slovenia, Hungary, the Netherlands, Greece, Latvia, etc Board members from Belgium, UK, Italy, Sweden, Slovenia, Hungary, the Netherlands, Greece, Latvia, etc The patient perspective as a starting point for service delivery! The patient perspective as a starting point for service delivery! Membership network Membership Membership (110 institutional & 60 individual members) Members from the 3 levels: Policy, Research & Practice Membership is multi-professional Membership is multi-professional

43. www.euprimarycare.org Amsterdam 30 August /1 September 2015 "Integrated Primary Care: Research, Policy & Practice“ 10 th EFPC conference at the: Conference fees Students € 150 Early bird EFPC members € 150 Early bird Non members € 300 EFPC members € 250 Non members € 400 Pre-conference Sunday 30/8+ € 75 Early bird ends June 15 Local partners: Sponsored by: www.tobacco.nl

44. Thank you… jan.demaeseneer@ugent.be WHO Collaborating Centre on PHC

45. Ghent University Jan.DeMaeseneer@ugent.be