Continuity Care.......

Wahyudi Istiono
Departemen Kedokteran Keluarga dan
Komunitas FK UGM
Wonca Euract
 3.2. Person-centred Care
Includes the ability:
to adopt a person-centred approach in dealing with patients
and problems in the context of patients circumstances;

to develop and apply the general practice consultation to bring

about an effective doctor-patient relationship, with respect
for the patients autonomy;

to communicate, set priorities and act in partnership;

to promote the goals of patient empowerment;

to provide longitudinal continuity of care as determined by

the needs of the patient,
referring to continuing and co-ordinated care management.
Patient Centered
Dimana continuity care berada...?
Apa komponen utama DLP....?
 The burden of disease
The burden is measured by combining two
indicators; the number of years of life lost to
disease and the number of years lived with
disability as a result of disease:
Change/ Perubahan Beban Penyakit di Indonesia 1990
2015
(beban dihitung sebagai Disability-Adjusted Life Years = DALYS)

Sumber: Global Burden of

Disease, 2010 dan
Health Sector Review (2014)

9
Perjalanan kehidupan vs penyakit..
Future impact of continuity on quality
of care
within Primary Care
 Disposition
16.30 Introduction - Continuity in primary care - background and evidence

(C.Bjrkelund)
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

Continuity in primary care -
background and evidence

Cecilia Bjrkelund
Department of Primary Health Care
University of Gothenburg
and Region VstraGtaland
 Continuity of care
One of the cornerstones of primary care
 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
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
 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
 Evidence seems to recognize continuity as one of the
cornerstones of high quality primary care
BUT - there is no sign of decreasing lack of continuity
in primary care in Europe.
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
 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.
 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 todays
general practice as well as the
costs of diminishing continuity.
 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?
 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
http://www.primafamed.ugent.be http://www.wgcbotermarkt.be

http://www.euprimarycare.org http://www.the-networktufh.org
 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
 1. Continuity of care: a catch-all
term
A sustained partnership between patients
and clinicians (IOM)
Process or outcome?
Relationship
Contextual
Cost-effective?
 Table 3. Provider Continuity (0/1) in a Multivariate
Approach With Total Health Care Cost (Logarithmic
Transformation) as the Dependent Variable:
Standardized Regression Coefficients

Standardized
Regression
Explaining Variables Coefficient P 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

R 27.6%

De Maeseneer, J. , De Prins, L., Gosset, C. and Heyerick, J. (2003). Annals of Family Medicine, 1(3): 148.
 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
 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
 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
 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.
 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
The ageing society
 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
(Eur Respir J 2008;32:962-69)

50 % of 65+ have at least 3 chronic conditions

20 % of 65+ have at least 5 chronic conditions

(Anderson 2003)
 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 2.7 4.9
Women 1.1 5.1
Belgium
Men 1.5 4.4
Women 1.2 4.6
Estonia
Men 2.0 5.3
Women 4.1 8.2
Wagner EH. Effective Clinical Practice 1998;1:2-4
EMPOWERMENT
But
 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,
 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.
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 dont 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 Jennifers goals. I visit Jennifer again with
pleasure ever since: I know what she wants, and how much I can
(merely) contribute to her life.
 Sum of the guidelines Time Medications

7:00 AM Ipratropium dose inhaler

Alendronate 70 mg/wk
Patient tasks Referrals
8:00 AM Calcium 500 mg
Joint protection Physical therapy
Vit D 200 IU
Lisinopril 40mg
Energy conservation Ophtalmologic examination
Glyburide 10mg
Self monitoring of blood glucose Pulmonary rehabilitati
Aspirin 81mg
Exercise Metformin 850 mg
Naproxen 250 mg
Non weight-bearing if severe foot disease is Omeprazol 20mg
present and weight bearing for osteoporosis
1:00 PM Ipratropium dose inhaler
Aerobic exercise for 30 min on most days Calcium 500 mg
Muscle strenghtening Vit D 200 IU
Range of motion 7:00 PM Ipratropium dose inhaler
Avoid environmental exposures that might exacerbate Metformin 850 mg
Calcium 500 mg
COPD Vit D 200 IU
Wear appropriate footwear Lovastatin 40 mg
Limit intake of alcohol Naproxen 250 mg
Maintain normal body weight 11:00 PM Ipratropium dose inhaler

As needed Albuterol dose inhaler

Paracetamol 1g

Clinical tasks Patient education

Administer vaccine Foot care
Pneumonia Oeseoartritis
Influenza annually COPD medication and delivery system
Check blood pressure at all clinical visits and training
sometimes at home Diabetes
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

Boyd et al. JAMA, 2005

 Problem-oriented versus goal-oriented care

Problem-oriented Goal-oriented

Definition of Health Absence of disease as Maximum desirable

defined by the health and achievable quality
care system and/or quantity of life
as defined by each
individual
 Problem-oriented versus goal-oriented care

Problem-oriented Goal-oriented

Purposes of Health Eradication of Assistance in

Care disease, achieving a maximum
prevention of death individual health
potential
 Problem-oriented versus goal-oriented care

Problem-oriented Goal-oriented

Measures of success Accuracy of diagnosis, Achievement of

appropriateness of individual goals
treatment, eradication
of disease, prevention
of death
 Problem-oriented versus goal-oriented care

Problem-oriented Goal-oriented

Evaluator of success Physician Patient

What really matters for patients
is

Functional status

Social participation
 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.
FRAGMENTATION
 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
 Problems with guidelines in
multimorbidity
Evidence is produced in patients with 1
disease
Guidelines may lead to contradictions (e.g. in
therapy)
Treat the patient

Treat-to-target
 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.
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?
Community Health Centre:
- Family Physicians; nurses; dieticians;
health promotors; dentists; social
workers;
- 6000 patients; 60 nationalities
- Capitation; no co-payment
- COPC-strategy
 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
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)
Integration of personal and community health care

The Lancet 2008;372:871-2

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
Platform of stakeholders:

40 to 50 people
3 monthly
Exchange of information
Community diagnosis

Intra-family violence
 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
 4. The future of continuity:
threats and opportunities in
patients with multimorbidity
Threats:
Anonimous care dilution of information
Dilution of responsebility
Outsourcing
Fragmentation
 4. The future of continuity:
threats and opportunities in
patients with multimorbidity
Opportunities
The patient in the drivers seat
Increased comprehensiveness complementary
frames of reference
Including context
Task-sharing
Interprofessional feedback
Sustainability
 4. The future of continuity:
threats and opportunities in
patients with multimorbidity
Requirements
Culture of cooperation
Patients choice: limits?
E-health system: interprofessional electronic
patient record
Interprofessional education
Case-load
Comprehensive financing mechanisms: integrated
needs based capitation
 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
 Assessment over time
Informational: improvement

Longitudinal: PHC team

Interpersonal: the challenge

 Thank you
jan.demaeseneer@ugent.be

WHO
Collaborating
Centre on PHC

We thank Lynn Ryssaert, MA, PhD-student for her valuable input

 Continuity of care
through the patient's eyes -
focusing on patient experience

Anna Maria Murante,

Laboratorio Management e Sanit
Istituto di Management
Scuola Superiore SantAnna - Pisa (Italy)
Before we start...
 Before we start...
Patient satisfaction vs patient experience

Patient satisfaction as
a quality-outcome indicator
(Avedis Donabedian, 1988)

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?
 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)
 Continuity of care & patient satisfaction
Adler R, Vasiliadis A, Bickell N. The relationship between continuity and
patient satisfaction: a systematic review. Fam Pract 2010;27(2):171-8.
Let's move on!
 Continuity of care is a dimension of
patient satisfaction

(Ware and Snyder, 1975)

Interpersonal continuity Informational continuity

Longitudinal continuity
(Saultz,2003)
Interpersonal Continuity & patient satisfaction

(1992)
Interpersonal Continuity & patient satisfaction

[] overfamiliarity or seeing the same physician

too frequently could lead to missed diagnosis
or fed beliefs that the physician could become
complacent with the patients problems, so
that his or her concerns were no longer
taken seriously.
Interpersonal and Longitudinal Continuity
& patient satisfaction

2001
Informational Continuity & patient satisfaction

[] patients expected from their GPs to exchange

information with specialists regarding their health situation,
treatment options and care facilities
Other Continuity & patient satisfaction

(2006)
 Flexible Continuity & patient satisfaction
(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 Ive needed to.

Theyre 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 dont have to wait long and they ask you, you
know, whats it about so if you need more time then they
will book you a double appointment .
 Team and cross-boundary Continuity
& patient satisfaction
(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 didnt have any information on me and
my medical records hadnt turned up.
Team and cross-boundary Continuity
& patient satisfaction
(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.
What happens when patients
have a chronic disease?
 Chronicity & continuity & patient satisfaction

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

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)

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 Bltzingslwen et al, 2006)
 Chronicity & continuity & patient satisfaction

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.
 The point of...
Continuity of care & patient satisfaction

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
Thanks for your attention!

Anna Maria Murante

a.murante@sssup.it
Laboratorio Management e Sanit
Istituto di Management
Scuola Superiore SantAnna di Pisa (Italy)
Impact of continuity on quality
A country report Austria
of care within PC

Kathryn Hoffmann, MD, MPH

EFPC Conference Gothenburg 2012
 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, ... 103
 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 104
 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 105
 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

106
 Continuity of care national examples
Sweden

Andy Maun
member of quality council SFAM Q
GP Trainee, Primary Healthcare
Gothenborg, PhD student
 Healthcare systems in Sweden
In health care and certainly primary healthcare:
21 counties and regions
differing in:
payment systems
IT systems
followup of quality
 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.
 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
 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
 Get a new

perspective
 Indicators
Five chronic diseases: (< age 75)
Diabetes (National Diabetes Register)
Ischemic heart disease
Hypertension
Asthma
COPD
 Medical variabels
Diagnosis Spirometry
Smoking HbA1c
Weight Blood lipids
Length Blood pressure
Waistlines

Age / Gender
Results can be linked to
- other registers e.g. stroke register
- prescription register
- socioeconomic data
 Effects?
70 000
Before/after ACG
60 000 (Payment for
Number of individuals

50 000 morbidity burden)

40 000

30 000
Diabetes diagnosis
20 000

10 000 Primary Healthcare,

0 Western Region

Staffan Bjrck, Analysis Unit Western Region

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
 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
 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?
Thank you for your attention!
 Continuity of care,
a way to reduce health
inequalities
Dr. Zsuzsanna Farkas-Pall
 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
 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
 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
 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
 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
 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
THANK YOU FOR YOUR
ATTENTION!