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Future impact of continuity on quality of care within Primary Care.

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Presentation on theme: "Future impact of continuity on quality of care within Primary Care."— Presentation transcript:

1 Future impact of continuity on quality of care within Primary Care

2 Disposition 16.30 Introduction - Continuity in primary care - background and evidence (C.Björkelund) 16.45 Enhancing continuity in future primary care in Europe – impact on multi-morbidity, goal- oriented care and equity (Jan de Maeseneer) 17. 10 Continuity of care through the patient's eyes - focusing on patient experience. (Anna Maria Murante) 17.30 Continuity of care – national examples (Kathryn Hoffman A. Maun Zsuzanna Farkas-Pall ) 17.40 Workshop discussion on continuity: 17.55 Summary and conclusions

3 Continuity in primary care - background and evidence Cecilia Björkelund Department of Primary Health Care University of Gothenburg and Region VästraGötaland

4 Continuity of care – One of the cornerstones of primary care

5 Evidence from community and provider perspective Lower health care costs Lower hospitalization and emergency room use Greater efficiency of services Associated with substantial reductions in long-term mortality More effective prevention of diabetes Increased quality of care in primary care depression treatment

6 Patients’ perspective Patients identified both factors that promote as well as factors that divide continuity of care across boundaries Chronic ill patients valued being attended regularly and over time by one physician while Young patients valued convenient access. “variations in perceived importance seem to depend on both individual and contextual factors which should be taken into account during healthcare provision “ Waibel S, Henao D, Aller M-B, Vargas I, Vazquez M-L. What do we know about patients' perceptions of continuity of care? A meta-synthesis of qualitative studies. International Journal for Quality in Health Care 2011

7 Chronic conditions 100 000 primary care patients 182 general practices in England. 58 % of the patients had chronic conditions accounting for 78% of the consultations received lower continuity. “patients with multi-morbidity are, are less likely to receive continuity although they should be more likely to gain from it

8 Evidence seems to recognize continuity as one of the cornerstones of high quality primary care Synthesis of quality of care for patients with complex care needs in eleven European countries showed that all countries needed improvements by development of care teams in primary care, managing among other things transitions and medication BUT - there is no sign of decreasing lack of continuity in primary care in Europe.

9 The complexity of operationalizing continuity in the context of multi- disciplinary team-based primary care of today and tomorrow, with the desirable effects on care both from patients’ perspectives, from medical and health economic perspectives as well as political perspectives is a great challenge. The challenge will also be how to measure and how to compare between primary care centers, organizations and between countries, as this will be the best way to stimulate the desired development.

10 There is great need of further developing methods to assess and promote continuity in primary care There is great need of research to better understand and operationalize continuity and how development of continuity should be stimulated and incentivized There is great need of studying the effects – including costs and benefits – of today’s general practice as well as the costs of diminishing continuity.

11 EFPC Position paper Impact of continuity on quality of care within Primary Care – with focus on the perspective of preferences of citizens Does interpersonal continuity lead to improved medical outcomes? Does interpersonal continuity of practitioner/nurse/team aid in the management of problems? Which organizational structures improve interpersonal continuity in primary care of today?

12 Enhancing continuity in future primary care in Europe – impact on multimorbidity, goal-oriented care and equity Prof. Dr. J. De Maeseneer, MD, PhD Family Physician, Community Health Centre, Ledeberg-Ghent (Belgium) Head of department of Family Medicine and PHC- Ghent University (Belgium) Chair European Forum for Primary Care Gothenburg, 03.09.2012


14 Continuity in future primary care 1.Continuity of care: a catch-all term 2.Typology 3.Multimorbidity, goal-oriented care and equity 4.The future of continuity: threats and opportunities in patients with multimorbidity 5.Conclusion: from the patient, the provider, the practice towards the community, the team, the system

15 1. Continuity of care: a catch-all term “A sustained partnership between patients and clinicians” (IOM) Process or outcome? Relationship Contextual Cost-effective?


17 Table 3. Provider Continuity (0/1) in a Multivariate Approach With Total Health Care Cost (Logarithmic Transformation) as the Dependent Variable: Standardized Regression Coefficients β Explaining Variables Standardized Regression Coefficient βP Value Older age.086<.001 Sex (male)-.036.008 Health locus of control: internal-.030.029 Physical functioning-.1568<.001 Mental functioning-.056<.001 Multiple morbidity.116<.001 Number of regular encounters.296<.001 Provider continuity-.105<.001 R²27.6% De Maeseneer, J., De Prins, L., Gosset, C. and Heyerick, J. (2003). Annals of Family Medicine, 1(3): 148.


19 Continuity in future primary care 1.Continuity of care: a catch-all term 2.Typology 3.Multimorbidity, goal-oriented care and equity 4.The future of continuity: threats and opportunities in patients with multimorbidity 5.Conclusion: from the patient, the provider, the practice towards the community, the team, the system

20 Informational An organized collection of medical and social information about each patient is readily available to any health care professional caring for the patient. A systemic process also allows accessing and communicating about this information among those involved in the care

21 Longitudinal In addition to informational continuity, each patient has a "medical home" where the patient receives most health care, which allows the care to occur in an accessible and familiar environment from an organized team of providers. This team assumes responsibility for coordinating the quality of care, including preventive services

22 Interpersonal In addition to longitudinal continuity, an ongoing relationship exists between each patient and a personal physician. The patient knows the physician by name and has come to trust the physician on a personal basis. The patient uses this physician for basic health services and depends on the physician to assume personal responsibility for the patient's overall health care. When the personal physician is not available, a coverage arrangement assures that longitudinal continuity occurs.

23 Continuity in future primary care 1.Continuity of care: a catch-all term 2.Typology 3.Multimorbidity, goal-oriented care and equity 4.The future of continuity: threats and opportunities in patients with multimorbidity 5.Conclusion: from the patient, the provider, the practice towards the community, the team, the system

24 The ageing society


26 Multimorbidity becomes the rule, not the exception More than half of the patients with COPD have either cardiovascular problems, or diabetes Patients with COPD have a 3- to 6-fold risk to have all these problems 50 % of 65+ have at least 3 chronic conditions 20 % of 65+ have at least 5 chronic conditions (Eur Respir J 2008;32:962-69) (Anderson 2003)


28 Age-standardised prevalence and prevalence ratio of diabetes by educational level in men and women, 30-64 years of age in selected countries (source: Eurothine, 2007)Country Tertiary education Lower secundary education Spain Men Women 2.7 1.1 4.9 5.1 Belgium Men Women 1.5 1.2 4.4 4.6 Estonia Men Women 2.0 4.1 5.3 8.2



31 Wagner EH. Effective Clinical Practice 1998;1:2-4



34 But…

35 Jennifer is 75 years old. Fifteen years ago she lost her husband. She is a patient in the practice for 15 years now. During these last 15 years she has been through a laborious medical history: operation for coxarthrosis with a hip prothesis, hypertension, diabetes type 2, COPD and osteoartritis. Moreover there is osteoporosis. She lives independently at her home, with some help from her youngest daughter Elisabeth. I visit her regularly and each time she starts saying: “Doctor, you must help me”. Then follows a succession of complaints and unwell feeling: sometimes it has to do with the heart, another time with the lungs, then the hip, …

36 Each time I suggest – according to the guidelines - all sorts of examinations that did not improve her condition. Her requests become more and more explicit, my feelings of powerlessness, insufficiency and spite, increase. Moreover, I have to cope with guidelines that are contradictory: for COPD she sometimes needs corticosteroids, which worsens her glycemic control. The adaptation of the medication for the blood pressure (at one time too high, at another time too low), cannot meet with her approval, as does my interest in her HbA1C and lung function test-results.

37 After so many contacts Jennifer says: “Doctor, I want to tell you what really matters for me. On Tuesday and Thursday, I want to visit my friends in the neighbourhood and play cards with them. On Saturday, I want to go to the Supermarket with my daughter. And for the rest, I want to be left in peace, I don’t want to change continually the therapy anymore, … especially not having to do this and to do that”. In the conversation that followed it became clear to me how Jennifer had formulated the goals for her life. And at the same time I felt challenged how the guidelines could contribute to the achievement of Jennifer’s goals. I visit Jennifer again with pleasure ever since: I know what she wants, and how much I can (merely) contribute to her life.

38 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 strenghtening 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 Oeseoartritis 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


40 “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

41 “Problem-oriented versus goal-oriented care” Problem-orientedGoal-oriented Purposes of Health Care Eradication of disease, prevention of death Assistance in achieving a maximum individual health potential

42 “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

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

44 What really matters for patients is Functional status Social participation

45 Evolution from ‘Chronic Disease Management’ towards ‘Participatory Patient Management’ Puts the patient centrally in the process. Changes the perspective from ‘problem-oriented care’. towards ‘goal-oriented’ care.


47 F R A G M E N T A T I O N

48 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



51 Problems with guidelines in multimorbidity “Evidence” is produced in patients with 1 disease Guidelines may lead to contradictions (e.g. in therapy)

52 “Treat the patient” “Treat-to-target”


54 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.


56 Multi-morbidity, goal-oriented care and equity: The way goals are formulated by patients is determined by social class “contextual evidence” : how to deal with an “unhealthy” and “inequitable” context?

57 Community Health Centre: -Family Physicians; nurses; dieticians; health promotors; dentists; social workers; … -6000 patients; 60 nationalities -Capitation; no co-payment -COPC-strategy

58 Diabetes clinic: horizontal approach to chronic conditions Objectives: –Improving the care for diabetes type 2 patients through a structured multidisciplinary follow-up and health education –Improve self-efficacy of patients –To tackle social inequalities in relation to chronic diseases

59 Diabetes clinic: horizontal approach to chronic conditions Programme: –biomedical and behavioural follow-up by nurse, diabetes educator,dietician and family physician, implementing guidelines in the context of the patient –exchange of experiences by the patients (groups) –“diabetes-cooking” (3 x / year)

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

61 Intersectoral action for health: the community Ledeberg (8.700 inh.) Platform of stakeholders Implementing COPC-strategy, taking different sectors on board Accessible, comprehensive, quality local health care facility: a multidisciplinary Primary Health Care Centre

62 Platform of stakeholders: 40 to 50 people 3 monthly Exchange of information “Community diagnosis” Intra-family violence

63 Continuity in future primary care 1.Continuity of care: a catch-all term 2.Typology 3.Multimorbidity, goal-oriented care and equity 4.The future of continuity: threats and opportunities in patients with multimorbidity 5.Conclusion: from the patient, the provider, the practice towards the community, the team, the system

64 4. The future of continuity: threats and opportunities in patients with multimorbidity Threats: –Anonimous care – dilution of information –Dilution of responsebility –Outsourcing –Fragmentation

65 4. The future of continuity: threats and opportunities in patients with multimorbidity Opportunities –The patient in the driver’s seat –Increased comprehensiveness – complementary frames of reference –Including context –Task-sharing –Interprofessional feedback –Sustainability

66 4. The future of continuity: threats and opportunities in patients with multimorbidity Requirements –Culture of cooperation –Patient’s choice: limits? –E-health system: interprofessional electronic patient record –Interprofessional education –Case-load –Comprehensive financing mechanisms: integrated needs based capitation

67 Continuity in future primary care 1.Continuity of care: a catch-all term 2.Typology 3.Multimorbidity, goal-oriented care and equity 4.The future of continuity: threats and opportunities in patients with multimorbidity 5.Conclusion: from the patient, the provider, the practice towards the community, the team, the system

68 Assessment over time Informational: improvement Longitudinal: PHC team Interpersonal: the challenge

69 Thank you… WHO Collaborating Centre on PHC We thank Lynn Ryssaert, MA, PhD-student for her valuable input

70 Continuity of care through the patient's eyes - focusing on patient experience Anna Maria Murante, Laboratorio Management e Sanità Istituto di Management Scuola Superiore Sant’Anna - Pisa (Italy)

71 Before we start...

72 Patient satisfaction vs patient experience (Avedis Donabedian, 1988) Patient satisfaction as a quality-outcome indicator The complexities of modern health care and the different expectations and experiences of patients cannot be measured by asking ‘How satisfied are you with your care/service?’

73 Before we start... Patient satisfaction vs patient experience Patient experience measures coming from questions like ‘What was your experience with…’ report (through the patient perspective/perception) whether a certain events occurred. However, patient tend to be more positive in evaluating care than in reporting their experience with specific events. (Fitzpatrick et al, 2009)

74 Adler R, Vasiliadis A, Bickell N. The relationship between continuity and patient satisfaction: a systematic review. Fam Pract 2010;27(2):171-8. Continuity of care & patient satisfaction

75 Let's move on!

76 Continuity of care is a dimension of patient satisfaction (Ware and Snyder, 1975) Interpersonal continuity Longitudinal continuity Informational continuity (Saultz,2003)

77 Interpersonal Continuity & patient satisfaction (1992)

78 « […] ‘overfamiliarity’ or seeing the same physician too frequently could lead to missed diagnosis or fed beliefs that the physician could become complacent with the patient’s problems, so that his or her concerns were no longer taken seriously. » Interpersonal Continuity & patient satisfaction

79 Interpersonal and Longitudinal Continuity & patient satisfaction 2001

80 «[…] patients expected from their GPs to exchange information with specialists regarding their health situation, treatment options and care facilities » Informational Continuity & patient satisfaction

81 Other Continuity & patient satisfaction (2006)

82 (Naithani et al, 2006) Adjusting services to the needs of the individual over time. « The nurse … always makes time for me. If I phone […] she will always call me back on the same day. I have been able to see her when I’ve needed to. » « They’re very good here you know, whenever I need to see the doctor I can just phone up and get a appointment when you want, you don’t have to wait long and they ask you, you know, what’s it about so if you need more time then they will book you a double appointment. » Flexible Continuity & patient satisfaction

83 (Naithani et al, 2006) « Just recently I have had to change doctors because the doctor that I have been seeing has retired. When I went to the new practice and registered and went to see the nurse, they told me they didn’t have any information on me and my medical records hadn’t turned up. » Team and cross-boundary Continuity & patient satisfaction

84 (Naithani et al, 2006) «[…] Patients responses to their perception of a serious lack of experienced continuity of care were sometimes to seek alternative care and advice, non-compliance with advice or treatment, or withdrawal from formal services and attempting to monitor and manage their condition themselves.» Team and cross-boundary Continuity & patient satisfaction

85 What happens when patients have a chronic disease?

86 Patients with chronic conditions prefer to see their GPs regularly to check the progress even when they were not feeling sick (Infante et al, 2004). Patients with multiple long-term conditions report that several professionals know them equally well (Cowie et al, 2009). Chronicity & continuity & patient satisfaction

87 According to the experience of some patients with diabetes: GPs might lose interest, when they were referred to secondary care (Infante et al, 2004) GPs and specialist have to exchange information on health situation, treatment options and care facilities (Michielson et al, 2007) Chronicity & continuity & patient satisfaction Patients with co-morbidities perceived that specialists did not interact with their colleagues. (Williams, 2004) Patients with chronic conditions report to be frustrated when they had to repeat their antecedents to doctors, who had not informed themselves in advance. (Von Bültzingslöwen et al, 2006)

88 « Young and employed patients with a minor, acute health problem preferred convenient access, although achieved at the cost of seeing different healthcare professionals. In urgent cases, an immediate intervention became a priority for patients with diabetes or other long-term conditions.» Chronicity & continuity & patient satisfaction

89 Continuity of care & patient satisfaction The point of... Several and different measures are used to extimate the relationship between PS and CoC Many evidences exist about a positive relationship But also anyothers report a weak or not significant relationship. Among patients with chronic condition different results could be observed (e.g. depending on severity), however sharing information among professionals is a common need. Timely access to services may be preferred to continuity of care

90 Thanks for your attention! Anna Maria Murante Laboratorio Management e Sanità Istituto di Management Scuola Superiore Sant’Anna di Pisa (Italy)


92 The three sisters of continuity Fist Contact: Free, region-wide and full covered access for everybody Coordination: Structural preconditions for continuity: 1) System level: E.g. single vs. group practices, financial incentives 2) Process level: E.g. gate-keeping-system, list-system, appointment-system,... Comprehensiveness: Knowledge about the predominant diseases in the related region/county (adequate staff with adequate education and equipment): E.g. morbidity registers, sentinel offices for surveillance,... Continuity Barbara Starfields´ 4 cardinal “C”s of PC 92

93 Austrian situation (excerpt) First Contact: Free access, overall good availability, for more than 98% of population fully covered BUT free and covered access with some exceptions (e.g. radiologist) also to the secondary level of care Coordination: No gate-keeping system, no list system, ~95% single-handed practices, fee-for-service mainly, GPs are self-employed Comprehensiveness: Very high standard of equipment, nearly no knowledge about the morbidity situation in the primary care sector: mainly hospital based data, no incentives for community-orientation, 3- year hospital based postgraduate education to become a GP 93

94 Some preliminary results from Austria >70% of patients said they have a certain GP but >60% of them visited a specialist without referral at least once in the last year– QUALICOPC data Rate of patients who visited a specialist within the last 4 weeks with referral from GP is low (~26%). Chronic disease is not a predictor for a higher referral rate in women - part of the Ecohcare-study; will be submitted soon 94

95 Continuity in Austria: Attempt of a summery Single handed practices: Good for continuity, bad for GPs satisfaction? Choice of physician as patients decision High satisfaction with system in 2004 (Euro health consumer index) vs. publication “cost of satisfaction”(Fenton, 2012) High health care expenditures, high hospital admission rates, high utilisation of specialists (e.g. Austria 71.1% vs. the Netherlands 37.8% - own research project), low referral rates, low healthy life years for 65+ How to measure the impact of continuity on quality of care alone to highlight its importance? 95

96 Continuity of care – national examples Sweden Andy Maun member of quality council SFAM Q GP Trainee, Primary Healthcare Gothenborg, PhD student

97 Healthcare systems in Sweden In health care and certainly primary healthcare: 21 counties and regions differing in: payment systems IT – systems follow–up of quality

98 Reform on Choice of Care 2008 Aim: Increase the number of healthcare centres Patients can choose a centre but not personal GP - centres compete! Resulted in a lot of new centres mostly run by great companies owned by risk capitalists.

99 Trends in most Counties Payment by individual capitation based on – age – socio-economy – morbidity burden (ACG - adjusted clinical groups) The centre pays all costs for laboratory services, x-ray and drugs

100 Development of a register for Quality Improvement of the Western Region Aim: regional primary healthcare register with the potential for a national register Target group: – Healthcare centres - internal improvements – Academy - scientific research – Political management - results, payment – Patient – choice of healthcare centre

101 Get a new… …perspective

102 Indicators Five chronic diseases: (< age 75) – Diabetes (National Diabetes Register) – Ischemic heart disease – Hypertension – Asthma – COPD

103 Medical variabels Diagnosis Smoking Weight Length Waistlines Age / Gender Spirometry HbA1c Blood lipids Blood pressure Results can be linked to -other registers e.g. stroke register -prescription register -socioeconomic data

104 Effects? Diabetes diagnosis Primary Healthcare, Western Region Before/after ACG (Payment for morbidity burden) 0 10 000 20 000 30 000 40 000 50 000 60 000 70 000 200520062007200820092010 Number of individuals Staffan Björck, Analysis Unit Western Region

105 Pilot study - continuity Aim: to examine the feasibility of a larger study, where the correlation between provider continuity and health outcomes is to be explored Method: – retrospective study (Oct 2009-Febr 2012) – four primary care centres (33485 individuals) – health outcomes (blood pressure, HbA1c) – usual provider continuity (UPC) and continuity of care index (COC) for physician/nurse

106 Results – No distinct correlations No distinct correlations could be found between interpersonal continuity with physician/nurse and blood pressure and HbA1c values A timeline-study on the whole population of the region (1,5 million inhabitants) is feasible and necessary to gain more knowledge

107 Challenges Transformation? From interpersonal continuity towards team continuity in primary care? The big challenge: collaboration cross organizational borders? What actions are required to improve medical outcomes?

108 Thank you for your attention!

109 The Future of Primary Health Care in Europe IV, September 2012 Dr. Zsuzsanna Farkas-Pall Continuity of care, a way to reduce health inequalities

110 The Future of Primary Health Care in Europe IV, September 2012 Background  In Romania, no or little efforts were made at policy making levels to address socio-economic determinants of health and tackle health inequalities emerging from reduced access to health care, lack of local health services, poverty  No feasible solutions are offered to bridge the gap between sporadic and continuous access to health care services  Local primary care team can play a key role in maintaining continuity and offering tailored health services in the community

111 The Future of Primary Health Care in Europe IV, September 2012 Aims  To give an example of good practice in reliable, continuous health service delivery and gather evidence about the importance of it  To act locally, use local resources and emphasize the importance of team approach  To offer integrated health services locally and monitor the impact on health indicators in the community

112 The Future of Primary Health Care in Europe IV, September 2012 The national context  Approx. 11000 GPs working in mostly solo practices  Nr. of patients/GP 1545,practice nurse/GP rate1.2  Nr. of settlements without any health care provider 88, with a total of 153904 inhabitants  Nr. of settlements without access to out of hours service 2330  Percentage of people without health insurance 16.10%  Amongst EU states Romania has the most reduced percentage of GDP spent on health care- 5.5%

113 The Future of Primary Health Care in Europe IV, September 2012 Our experience  Our health centre is located in the north-western region of Romania  We provide the community with the possibility of having ultrasound, ECG examinations, lab tests, physiotherapy, family planning services and access to prevention programs performed locally  During the years we developed educational programs targeting different groups in the community, have done research activities to gather evidences in order to prove the importance of our activities  The activites are ongoing and continuity helped developing partnership with the community

114 The Future of Primary Health Care in Europe IV, September 2012 Results  Continuity in access to high standard sustainable and reliable health services, health promotion will result in improved health indicators, healthier and more satisfied population, decreased needs of secondary care services, efficient utilization of the existent resources  Primary care team equipped with appropriate tools and empowered with knowledge is well positioned to reduce health inequalities  Continuity in patient education, establishing partnership will induce a more responsible and self conscious population a ativităţii, invitaţii personalizate, intervenţii consecvente accesibile pentru populaţie.

115 The Future of Primary Health Care in Europe IV, September 2012 Conclusions  Integrated health services like ultrasounds, ECG, lab tests and ongoing population based health education and screening programs has to be delivered locally and the service must be reliable to build trust and engagement  gaps in health care provision will negatively influence patient behavior and will lead to setbacks  Our approach towards continuity in primary care service delivery in the community has helped to improve the relationship between our staff and the population in our area: trust has lowered the threshold for contact  The model is sustainable as it uses local resources and is based on a partnership with the community

116 The Future of Primary Health Care in Europe IV, September 2012 Thank you for your attention!

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