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Jan Savage ASHM

AFAO National Symposium on Prevention May 2010

Integrating prevention into primary healthcare

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Integrating prevention into primary healthcare

• Models of access to and delivery of clinical services for people with HIV project

• Models for delivery• Workforce issues• Suggested approaches to integration and some

issues arising

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Tertiary prevention in HIV

• Interventions which improve the quality of life for people with existing diseases and disabilities– ART– OI prophylaxis– Prevention of therapeutic side effects etc.

• Intermeshed with other aspects of wellbeing– Co-morbidities, age related, mental health, social

determinants and other preventative activities etc

• Traditionally medicalised in various settings

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Primary healthcare

Primary Health Care (PHC):

“seeks to extend the first level of the health system from sick care to the development of health. It seeks to protect and promote the health of defined communities and to address individual and population health problems at an early stage. PHC services involve continuity of care, health promotion and education, integration of prevention with sick care, a concern for population as well as individual health, community involvement and the use of appropriate technology.”

Australian Health Ministers’ Council (1988) from the National Primary Health Care Partnership website http://www.nphcp.com.au/site/index.cfm?display=30987

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Models of access to and delivery of clinical services for people with HIV project

• In response to changes to population of people with HIV: demographics, health and well being, treatment improvements

• Recognition of ongoing and emerging workforce issues: supply, recruitment retention and training across all professional groups

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Recurrent themes – big picture

• Policy and funding support and change• Patient and carer centred models• Spectrum of responses from prevention of condition to end-

of-life• Key role of community • Health systems

– Responsive, integrated, coordinated, flexible, evidence based and supported by• Effective and strategic planning• Information management systems and communication technology

• Workforce – GP, development• Evaluation and research

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Recurrent themes - services

• Service access: geographical and cultural• Service delivery: re-oriented, patient centred,

integrated, coordinated, multi-disciplinary• Delivered through:

– Self management, supported or comprehensive care– Shared care, nurse practitioners– Strong and clear referral pathways– Access to primary, specialist and multidisciplinary

teams based care etc

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Evidence base and HIV

• Access– Service and delivery models – multi-disciplinary, dedicated

case managers– Integrated information systems– Physical access and cost

• Delivery– High case loads– Case management

• Workforce– Mostly untested. Need financial and ‘lifestyle’ incentives,

need system change and support for change

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Services in Australia

• Specialist hospital and sexual health clinics• Specialist general practices• Low case load general practices • Other services: medical, social and community

• Service requirements defined by individual state of health

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Issues for tertiary prevention in primary healthcare• What tertiary prevention is required and when; what else is required to support an individual

with HIV eg other aspects of prevention ‘tertiary plus’ (age related and HIV prostate etc)?

• Process– Client group – engagement and support– Providers – introducing and maintaining engagement and skills, avoiding burnout

• Applying system change, service access and delivery change and re-orientation, for example: – Continuum from diagnosis to end-of life– Self managed care– Multi-disciplinary teams– Necessary system supports eg planning, IT, communication etc

• Consider re-orientation of services to address medical aspects of tertiary prevention (eg adherence, side effects, smoking, exercise). How to manage?

• Using mainstream services, expertise and funding including shared care between eg specialist and GPs, nurses, specialist nurses, nurses managers

• Workforce re-orientation in content and system: doctors, nurses, health educators, community workers etc

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Demonstration projects

• Deliver shared care in the community• Support individual high caseload general practices through

tailored solutions • Explore, implement and evaluate a range of nurse based

strategies aimed at increasing access to clinical service delivery• Implement and evaluate

– strategies aimed at increasing the linkage between laboratory and clinical settings

– innovative strategies for linking with patients and with doctors at time of diagnosis

• Support, implement and evaluate– e-health strategies– communication between services– self management strategies and exploring these in tandem with above

priorities

• Supportive and enabling recommendations

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Conclusion

• Delivery of appropriate clinical services including tertiary prevention can be improved and integrated into primary healthcare with roles for providers beyond the clinic.

• Effective management of the major changes to health system(s) and access and delivery of clinical services is critical.

• Response to consequent changes to community sector and the HIV health workforce will be required.