Continuity and Coordination in Primary Care

In the past century, there has been a transition in healthcare from focusing on diseases and their pathology to focusing instead on a variety of socio-environmental factors that influence health outcomes. This transition has called for a comprehensive primary care approach that provides services in a continuous and coordinated manner in order to meet the health needs of the patient. In this Database at a Glance we investigate how innovators in the CHMI database are improving coordinated care through the continuity of health services they provide. These programs broadly fall into 3 categories:

Relational Continuity is a tactic used by programs to establish long term relationships between patients and clinicians leading to care consistent with the patient’s needs. [1]

This strategy is central to programs like Our Family Clinic, a low cost chain of primary care clinics in Kerala, India. Our Family Clinic’s comprehensive services and ‘family-centric’ model have led to high rates of patient retention, with over 90% of consumers returning to the clinic more than once. Similarly, the health service chain Ross Clinics of India places an emphasis on the personal relationships established by clinic staff and their patients to build trust between the two parties. Ross Clinics has operationalized and launched outreach initiatives such as health checkup camps in the community and the workplace.[2]  These initiatives promote positive health behaviors and create awareness on preventive care. Approximately 40%[3] of the people who visit the camps go on to seek consistent care from the clinics. The frequency with which the checkup camps occur and general societal requirements such as school and employment physicals help drive people to seek care and especially care with physicians working within this network of clinics.

Management Continuity emphasizes the coordination of healthcare delivery across multiple clinicians and providers to ensure that care is never interrupted.

Strategic Hospital Alliance Program (SHAP) of the Philippines is a program that was designed to share services offered by Makati Medical Center (MMC)—a tertiary care center in Manila— with a group of smaller hospitals. SHAP focuses on establishing partnerships between MMC and local hospitals to enable these hospitals/clinics to have access to advanced diagnostic and treatment options and technology located at MMC that on their own they are unable to provide. Once partner clinics are signed as MMC affiliates, SHAP institutes a strict multi-level referral system that outlines the conditions for patient referral to the MMC. By sharing the overall burden of care associated with high volumes of patients at both the MMC and the smaller hospitals, providers are able to ensure timely delivery of quality care. Since their opening SHAP has signed on 70 new partner hospitals/clinics around the Philippines and one in Kuwait.

The BroadReach Healthcare Down Referral program in South Africa coordinates care across various providers through a similar referral system between its wellness center where patients are stabilized, and public and private clinics for follow-up care. The program’s main aim is to reduce over-reliance on South Africa’s public health system, which currently caters to approximately 84% of the population and is pressed for resources, by leveraging private sector resources to triage healthcare service delivery to patients, with a special emphasis on HIV/AIDS patients. Broadreach uses a traditional hub and spoke model with a centrally located community wellness center where patients are stabilized before they are moved to other hospitals or clinics. While at the wellness center, patients are registered with their closest general practitioner for follow up.  Adherence interventions rely on community outreach programs to tailor follow up of care based on the individual’s needs. Some commonly used outreach programs range from workshops, SMS treatment reminders, to house calls from community health workers.

The model has managed to reach over 2500 patients and reported higher adherence rates to ARV treatments (94% compared to 75% at control clinics) and viral load suppression rate[4] of 96% among their patients.[5] This shows how effective a combination of facility and community-based care can be on improving health outcomes. [6]

Informational Continuity relies on the sharing of information from previous care found primarily in patient medical records, to inform decisions for current care.  This form of continuity of care is promoted through various structures including health information systems or technologies that enable providers to access patient medical records pertinent for treatment directives, affecting quality and cost-efficiency of care provided.

The Integrated Community Case Management (eCCM) program in Malawi, for example, equips community health surveillance assistants (HSAs) with android phones used to assess treatment protocols for children under five during village clinic visits. Also integrated in the android phones is an HSA supervisory tool that feeds data to a main database allowing HSA supervisors to view all patient and summary notes documented by the HSAs during visits; a decision support tool for consultations with physicians/experts in larger hospitals to guide treatment of children and possibly recommend referrals; and a logistics management tool that curates vaccination records and facilitates easier monthly reporting of patient records and health outcomes. [7]

Though not representative of all programs in the database, the highlighted programs serve as reminders of the existing resources and innovation in the private sector capable of addressing and supporting how care can be coordinated to ensure consistent access to quality health services for all.  

As we gather more information about the universe of health market innovations, we will continue to track trends and highlight new insights gleaned from analysis of the aggregate. We invite you to do the same by downloading the CHMI Database and sharing your findings with us.

 

[1] Haggerty, J, F. Burge, R. Pineault, M.-D. Beaulieu, F. Bouharaoui, J.-F. Lévesque, C. Beaulieu, D. Santor. 2011. “Management Continuity from the Patient Perspective: Comparison of Primary Healthcare Evaluation Instruments.” Healthcare Policy Vol 7 (Special Issue):154-166
[2] An industrial tie-up is an event organized in collaboration with formal employers, who sponsor primary care consultations for their employees.
[3] http://healthmarketinnovations.org/sites/default/files/Ross%20Clinics%20Case%20Study_0.pdf
[4] Measurement of the reduced amount of a virus in the bloodstream.
[5] http://healthmarketinnovations.org/program/broadreach-healthcare-down-referral-model
[6] Also worth noting is Broadreach is primarily funded by PEPFAR but they have a MOU with South Africa’s Department of Health, who are willing and able to absorb the costs of the program should their funding decrease or be halted, presenting a unique private-public partnership.
[7] It is estimated that the HSAs have accurately assessed, diagnosed and treated over 7,700 patients since the launch of the program in 2010 to January 2015.