9 minute read
From fragmentation to people-centered integration
In some settings, where dedicated care teams are not yet the norm, narrowly constructed care teams have been set up to support patients with specific health needs. In Kazakhstan, for example, pregnant women are supported by a multidisciplinary team that includes social workers and psychologists in addition to health professionals; financial incentives help reinforce strong team performance, as evidenced by maternal and newborn health outcomes (Sukhanberdiyev and Tikhonova 2017).
Multidisciplinary care teams are the preferred standard of care for the human immunodeficiency virus (HIV). In the United States, the inclusion of pharmacists, care coordinators, social workers, nurses, and non-HIV primary care providers within the team has been associated with higher adherence to antiretroviral therapy (Horberg et al. 2012), while extensive international evidence associates inclusion of a pharmacist specifically with better adherence and clinical outcomes (Saberi et al. 2012). In the long run, these teams would ideally be “de-verticalized” from a single disease area/health need and integrated with generalist primary care for all health needs across the life course.
The literature distinguishes between three types of care continuity (Haggerty et al. 2003): + Informational continuity refers to the providers’ accumulated understanding of patient history, values, and preferences. Such information can be vested in provider memory, written or electronic medical records, or some combination of the two—but it must be easily accessible and applicable at the point of care.
+ Management continuity refers to the coherent and coordinated planning and execution of patient care for complex or chronic disease.
+ Relational continuity refers to established interpersonal relationships between specific providers or care teams and the patients they serve (Haggerty et al. 2003).
Empanelment to dedicated care teams provides a strong foundation for all three types of care coordination and continuity. The effects span patients’
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health needs and life courses, both within PHC service delivery and across the health system. Empanelment enables continuity by creating a single PHC hub for each patient’s care and disease management; offering an opportunity to build trusted long-term relationships with PHC providers; and building both written and informal repositories of information about patients. This matters because patients with access to continuous care have been shown to receive better quality care (Romano, Segal, and Pollack 2015), report higher satisfaction with health services (Reddy et al. 2015), and incur lower health expenditures (Hussey et al. 2018). In the United States, increases in the continuity of care have been linked to reductions in the utilization of specialist care (Nyweide et al. 2013), reductions in hospitalizations and emergency department use (Pourat et al. 2015), as well as reductions in medical errors (Gandhi et al. 2006). In Brazil, in areas with stronger PHC systems, a greater proportion of the population reported having a usual source of care, particularly in the poorest regions in the north and northeast (Dourado, Medina, and Aquino 2013).
Care continuity is clearly enhanced by the retention of care providers, and it is compromised by staff (or practice) attrition. High-staff turnover has been shown to reduce the probability of receiving preventive care services, weaken the coordination across different levels of care (Juliani, MacPhee, and Spiri 2017), and lower patient satisfaction scores (Reddy et al. 2015). PHC disruptions due to the retirement of primary care practitioners also lead to declines in the use of PHC services and increases in the number of medical tests and hospitalizations (Zhang, Salm, and van Soest 2018). In Denmark, the closure of primary care practices has been linked to increased utilization of emergency care (Simonsen et al. 2019), suggesting challenges in the transition of patients to new PHC providers.
When team-based networks function optimally, nonemergency access to higher levels of care is based on referrals from local PHC teams. PHC teams are accountable for prompt and appropriate referrals based on a patient’s health needs and their informed clinical judgment. In turn, regional referral centers accept the responsibility and accountability for health outcomes within their catchment areas; they willingly receive requests for assistance and transfers when judged necessary by local care and take responsibility for communicating the results of a referral back to the PHC team. This approach fosters respectful and trusting relationships between PHC team members and specialist service providers. This is a true collaborative health system model that endorses the preeminence of cost-effective local comprehensive PHC services and preserves high-cost specialist services for those who need this level of care. It also recognizes the expertise of local PHC teams and their
communities as being of equal value to the specialist expertise in regional referral centers.
Better two-way referrals: From primary care to specialists, and back into the community
The most effective PHC systems operate not as dysfunctional gatekeepers—a chokepoint before patients can access “real” care from secondary and tertiary providers—but as traffic dispatchers, triaging patients across different levels of care in an agile manner and in accordance with their health needs. The care coordination function helps direct patients to the appropriate care providers within the PHC team, and, as necessary, to external specialists. Equally important, it tracks the results of specialist consultations or hospitalizations and ensures appropriate follow-up care upon return to the community.
In some cases, specialist providers may physically co-locate with a PHC team on a part- or full-time basis. In theory, physical co-location of general practitioners with specialist providers extends the benefits of the PHC care team to a broader range of care—helping streamline referral processes, integrate medical records, and create better continuity of care across multiple types of health providers. In Canada, for example, a primary care physician can refer patients to a mental health counselor and/or psychiatrist, who are preferably physically co-located; the different providers then work collaboratively to provide whole-of-person care for low-acuity mental health needs (OECD 2020a). Cross-country survey data in Organisation for Economic Co-operation and Development (OECD) countries finds highly variable rates of co-location between general practitioners and other health professionals; rates of co-location can be as low as 5 or 6 percent (Czech Republic, Denmark, Germany, and Slovak Republic) and as high as 90–99 percent (Iceland and Lithuania) (Bonciani et al. 2018). Evidence on the results of co-location is limited and mixed. Analysis of survey data suggests that the co-location of general practitioners with specialists, midwives, physiotherapists, dentists, or pharmacists is significantly associated with improved coordination with secondary care; however, in countries with weak primary care systems, co-location is significantly associated with worse patient perceptions of care continuity, accessibility, and comprehensiveness (Bonciani et al. 2018).
Some low- and middle-income countries (LMICs) currently lack the capacity to rapidly create dedicated PHC teams able to work with and track individuals across the life course. In these settings, end-to-end, same-day services across diagnosis and treatment may offer a stopgap to increase referral completions and limit attrition. Studies show potential applications of
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same-day services to eye care and to the diagnosis and treatment of sexually transmitted infections; however, the approach has not been systematically evaluated and may be difficult to finance and integrate within routine services. In India, outreach camps provided by the philanthropically funded Aravind Eye Care System offer comprehensive eye exams and same-day provision of nonsurgical treatment (for example, glasses or a medicine prescription); patients in need of cataract surgery or other specialty services are counseled and transported to a nearby hospital for immediate admission (Aravind Eye Care System 2015). In Cameroon, a pilot study for cervical cancer screening returned test results for the human papillomavirus (HPV) within one hour of sample submission, offering same-day coagulation treatment to eligible patients; loss to follow-up was only 1 percent (Kunckler et al. 2017). A similar approach in Tanzania yielded promising results for the diagnosis and treatment of syphilis; testing for syphilis jumped more than 12-fold, treatment rates for diagnosed cases increased from 46 to 95 percent, and women reported savings as a result of averted transportation costs (Nnko et al. 2016).
When specialist services are not co-located or provided as integrated single-day services, technological solutions can play a useful role in strengthening referral processes. Although evidence is limited, a few available studies suggest that direct appointment booking services, typically over an online portal, have been associated with substantial reductions in the waiting time for nonurgent specialist services, though not with cost reductions (Frandsen et al. 2015). Such platforms are increasingly being adopted at scale within countries in the OECD. In the United Kingdom, all National Health Service providers were required to adopt an e-referral system for specialist consultations (e-RS) by October 2018; the platform enables patients to book a specialist appointment from their general practitioner’s office at the time of referral or to do so from their personal computer after returning home (NHS 2018). An initial pilot study suggests that the new system can reduce waiting times for a specialist appointment by an average of eight days (Kripalani et al. 2007).
Electronic consultations (e-consults), defined as “asynchronous, consultative, provider-to-provider communications within a shared electronic health record (EHR) or web-based platform,” can allow general practitioners to directly access specialist expertise and avoid in-person referrals unless necessary (Vimalananda et al. 2015). Evidence shows generally high provider and patient satisfaction with e-consult platforms; shorter wait times than for traditional in-person referrals; a reduction in face-to-face specialist appointments; and potential for reduced cost (Liddy et al. 2019). Rigorous evidence for the effect of e-consults on health outcomes is limited (Liddy et al. 2019).
Alternatively, telemedicine can allow patients to remotely access medical services and complete referrals from PHC providers—particularly for specialist services that may not otherwise be locally accessible. These initiatives are still largely underdeveloped within LMICs, with many nascent (often donor-funded) efforts but few sustained programs (Mars 2013). A rare scaled and sustained use of telemedicine is in Brazil, where some states have routinized remote electrocardiogram (ECG) testing, chest x-ray analysis, and ultrasounds as part of the national Family Health Program (Maldonado, Marques, and Cruz 2016). By end-2015, just one Brazilian state had performed almost 2.5 million remote ECGs and 74,000 teleconsultations. Over a five-year period, the state reported net US$11 million in cost savings (Scott and Mars 2015). In addition, a handful of telehealth networks in LMICs for humanitarian purposes have been sustained at least five years; in some cases, they have offered general remote consultation for all specialties, and in others, they have offered targeted support for dermatology, HIV, or trauma. However, evidence in support of these initiatives is limited. Elsewhere, feasibility studies suggest potential, although not scale or sustainability (Mars 2013).
Where routine care coordination processes are lacking, dedicated patient navigators can also help patients engage with a complex web of health services. A systematic review defines the patient navigation approach as “trained personnel”—potentially nurses, social workers, CHWs, or volunteers—“who help patients overcome modifiable barriers to care and achieve their care goals by providing a tailored approach to addressing individual needs” (McBrien et al. 2018). Patient navigation services can be quite wide in scope, encompassing all aspects of clinical, logistical, administrative, and emotional support, typically for chronic or life-threatening conditions like cancer.3 The current evidence base is incomplete, but it generally suggests that patient navigators can be associated with more complete screening, faster diagnostic resolution, better mental health and quality of life among patients and their caregivers, lower A1C levels among diabetics, and higher clinical attendance and treatment adherence (Labrique et al. 2018). Information technology (IT) and digital platforms for integrated care
More developed integrated care and payment models, including those from OECD countries, require interoperable data systems among specialists, hospitals, primary care settings, social service providers, and patients. These systems are often in their infancy in LMICs, with several limitations that prevent such platforms from realizing their full potential. First, fragmented donor-supported initiatives and vertical programs have driven a proliferation
