Challenges of providers: training and specialists

Blog: Key messages and reflections from ‘Coffee with Latin America: The challenges of providers: training and specialists'

‘Coffee with Latin America’ and ‘Tea with Africa’ are part of The George Institute’s initiative aimed to promote discussion around various health-related topics to foster partnership and collaboration.

Caring for chronic conditions and multimorbidity has many challenges at many levels of the health systems. In collaboration with colleagues in Latin America, this ‘Coffee with Latin America’ edition brought together international expert voices in primary healthcare to share experiences around improving healthcare systems to ensure continuity of care for people with chronic conditions and multimorbidity.

On this occasion, as well as swapping stories of success from different regions to see what might be adopted elsewhere, this series invited speakers and audiences to explore and reflect on multiple challenges across actors, settings, and systems.

Key points from speakers

Dr Jacqueline Seiglie: ‘Diabetes in the U.S. Latino population: challenges and opportunities.’

Jacqueline presented the project REACH Spanish which is an adaptation of an existing text message platform with content tailored to patient-reported barriers such as information barriers, motivation and even the high cost of medications.

  • A longitudinal study evidenced that REACH reduced barriers of adherence to diabetes controlling drugs, improved glycaemic control and diet within an English-speaking population.
  • The platform will be adapted for the Spanish-speaking population using qualitative methodologies that incorporate Latino patients’ feedback during the adaptation phase and the pilot testing.
  • The objective is to include elements from the different social and cultural contexts to reduce inequities in diabetes care within Latino patients.

Dr Belinda Ford : ‘Exploring vertical and horizontal integration strategies for the management of chronic eye disease in Australia’

Belinda presented a collaborative eye care program which was developed and evaluated as part of her PhD and  has now been running in Westmead hospital for over 5 years.

  • The program is a vertical integration strategy aiming to improve access to specialist care for patients by identifying patients with low-risk referrals who go into the hospital and diverting these patients out to a community-based optometrist who then conducts standardized testing and makes the clinical decision accordingly.
  • The community-based optometrist sends a report for these patients back to the hospital where an ophthalmologist reviews it in a virtual clinic so patients don’t need to go physically into the clinic. In case a patient is identified as being at high risk, they will have an appointment organised with an ophthalmologist.
  • The pilot testing of the program showed a reduction in waiting times for patients from 9 months to 53 days and up to 68% of patients avoided a hospital appointment facilitating access to an appointment with an ophthalmologist for those patients with higher clinical needs.

After presenting this program Belinda also talked about some horizontal strategies implemented by other researchers that relate to her study. She presented as an example another two programs aiming to identify high-risk patients to link them with specialised eye care. Belinda then highlighted that there is an intersection between horizontal and vertical streams of care and that therefore communication and information sharing between providers is absolutely crucial for integrated care and to support timely decision-making.

Finally, Belinda discussed some challenges that need to be considered when incorporating technology such as virtual clinics. Challenges include the possibility of overlooking patients since the clinician is not able to physically assess each patient and medico-legal issues regarding who is ultimately responsible for the patients if something goes wrong.

Maoyi Tian: ‘ Strengthen Chinese Primary Health Care System to Improve the Management of Hypertension and Diabetes’

Maoyi presented a project that is currently being conducted in China with the aim of improving the management of hypertension and type 2 diabetes at the primary healthcare level.

  • The project is named the SAPPHIRE study and aims to strengthen the primary healthcare system in China to support the maximum uptake of the essential public health service package for hypertension and type 2 diabetes in three provinces of China.
  • The study is being conducted in phases. Phase one is a comprehensive assessment of the primary healthcare system. Phase two is to co-create an intervention that will be implemented at the primary healthcare level and tailored to each local context. Phase three will be using implementation science to evaluate the interventions implemented in the previous phase and the last phase of the study is to develop economic modelling and a policy conceptual framework to support the implementation pf such interventions
  • The study is currently in its initial phase which has multiple components. The research team is reviewing the national policies related to private healthcare, conducting a survey at multiple facilities to assess availability and readiness and conducting questionnaires and interviews with stakeholders to identify barriers and facilitators to delivering high-quality services for hypertension and type 2 diabetes management. Another component is evaluating routinely collected data from the electronic house medical record to determine healthcare gaps.

Maoyi explained that results from the policy review have identified multiple health system flaws including a lack of emphasis on multi-sectorial collaboration, underuse of non-health professionals, lack of quality-oriented primary health care service evaluations, gaps in the availability of medicines and equipment and resident’s low trust and utilization of primary healthcare services among others.

Sofia Cuba-Fuentes: ‘The challenge of training in caring for a complex health system’

Sofia started her presentation by highlighting the importance of the training provided to General Practitioners and Family and Community practitioners since they are the ones who focus not only on the disease but also consider patient’s social contexts and provide a more integral approach of care.

Dr Sofia also talked about the importance of considering the political context in particular in Latin American countries where poor management of resources by governments has continued to create injustice and inequities for the population. In light of these inequities, Sophia stressed the importance of training primary healthcare workers to deliver person-centred health services with a more holistic and humanitarian approach that considers and integrates the different contexts and narratives that each patient has as a background.

Finally, she reflected on the need to focus research on building systems that are more centred in the communities and the primary healthcare level. Sofia stated that those who work closely with communities are able to have a different understanding of the way chronic health problems should be approached along the life course. Therefore, she argues that training and education of the new generation of doctors should be focused on allowing them to think differently and doing things differently.

Concluding remarks from the speakers

After the presentations, the speakers provided some concluding remarks and reflections. All speakers agreed on the need of developing models of care that are more integral, patient-centred and consider the different cultural and social contexts that are essential determinants of people’s health. In addition, Maoyi and Belinda stressed the importance of including patients and community members in our conversations and discussions to design programs so that they can also understand the way the system works.

Questions from the audience

Q: I would like to see an example of how the REACH platform could contribute to improving treatment adherence for a patient with diabetes.

A: Jacqueline Seiglie -  REACH is an interactive text messaging platform that is personalised according to each patient’s profile and that profile includes the medication that the patient is taking for diabetes control. There is a function where the patient is asked through text messages if he/she has taken the medication today and serves as a mechanism to remind the patient to take the medication. The platform also provides information according to the barriers that the patient has previously identified, for example, a common barrier is a myth that insulin damages organs so, in that case, they would receive information about the importance of insulin to prevent damage to the organs.

Q: How does pre-diabetes screening fit in the diabetes management?

A: Jacqueline Seiglie -  prediabetes and type 2 diabetes are both conditions that are reversible with changes in lifestyle, diet and weight loss. In my opinion diabetes management starts from managing prediabetes because at that stage we can also identify patients that are at high risk of progressing to type 2 diabetes and prediabetes screening allows us to connect high-risk patients with primary and also specialised healthcare services.

Q: How could collaborations support the prototypes or experiment ideas in the sense of understanding all these complexities that have been described today?

A: Belinda Ford – In terms of collaboration, the model that I presented was developed in UK and the clinician leadership was really crucial to getting that off the ground in Westmead. It was very important to get ideas from the people on the ground who are delivering the services because they often know a lot more about the context and the local population and other information which is not published in the journals.

Q: Does anyone have experience using these strategies/ tools with infectious chronic diseases for instance chagas, Cystic Echinococcosis, or Cysticercosis?

A: Jaime Miranda -  This is why this event was not focussed on specific diseases but more on the continuity of care and many of your patients, I would imagine, have also these requirements to engage repeatedly with the system and that is why is very important to address the needs and expectations of peo