The educational material for Community-based Primary Care Project, made by the Ministry of Health and Welfare, has been adopted as the training manual for the World Health Organization’s Western Pacific Regional Office (WPRO).
The ministry conducted the project in several localities, including Jungnang District in Seoul, Wonju in Gangwon Province, and Jeonju and Muju in North Jeolla Province, from 2014 to 2016. Its purposes were to strengthen the quality of primary care and plans to expand it as a pilot program eligible for health insurance benefits from the latter half of this year.
It also developed the material to upgrade and standardize educational manuals about chronic illnesses used by neighborhood clinics. Twenty-five medical professionals, including professors of family medicine and internal medicine, took part in developing the material.
At the center of this pilot project is Professor Cho Jung-jin조정진 of Hallym University College of Medicine, also chairwoman of the Community-based Primary Care Committee. The Korea Biomedical Review met Professor Cho to hear about the project, including its background, accomplishment, process and future.
Question: Can you explain about the educational material for the community-based primary care project and the process through which it was selected by the WPRO?
|Chairwoman Cho Jung-jin explains the meaning of the WHO’s selection of the educational material for community-based primary care project as the training manual for its West Pacific chapter, during a recent interview with Korea Biomedical Review.|
Answer: Previously, private educational institutes or healthcare institutions used to conduct the education on how to manage chronic diseases using materials made on their own. Therefore it was difficult for the government to control contents that could directly harm patients’ health, including those with unproven scientific evidence or made for commercial purposes. It was also hard to provide same education not least because the quality of teaching differed depending on educators’ knowledge and experience.
Standardizing education on the management of chronic diseases is necessary for providing efficient primary care services. We must be able to provide high-quality, standard education for all patients regardless of the ability of doctors at primary medical institutions. For the material to be used in the field properly, it should also contain lots of clinical experiences. So I, as the head of the committee, selected professors with clinical experience of 10 years or more and had them produce the “Health Partner Doctor One Educational Manual.”
The material has so excellent content that it was selected as the WPRO manual. The manual comprises 15 sorts – seven related to high blood pressure, another seven on diabetes, and one on anti-smoking. It outlines diagnosis and management guidelines for hypertension and diabetes, the importance of healthy lifestyles, dietary guides for healthy life, complication prevention, quitting smoking, etc. The WRPO asked the Ministry of Health and Welfare to allow the use of this manual in 2015 to help its member nations prevent and manage chronic illnesses. After about a year of translation and editing, the ministry published it on March 9.
Q: What propelled community-based primary care pilot project?
|This is a part of the educational material for community-based primary care project, adopted by WPRO as the training manual for member nations.|
A: To reduce medical costs by lowering chronic illness risk and improving the quality of life in this era of rapid populating aging, we must focus on long-term prevention of chronic diseases and health promotion rather than on treating illnesses after they begun in old age. We can reduce disease risks and mortality in half by just changing life habits, such as smoking, drinking, exercise, and diet.
To this end, primary healthcare specialists should form a persistent and comprehensive relationship with their patients to motivate patients to reform lifestyles that will lower their health risks actively.
But Korea’s healthcare system unduly depends on hospitals and lacks in the primary healthcare system. From the viewpoint of prevention and primary care, previous government projects had clear limitations because it did not give meaningful roles to primary care doctors, relied on treatment in managing chronic illnesses, and were led by the government. Experts have also pointed out that communal resources were used in disconnected ways. It was apparent the nation needed more efficient chronic illness management, and so the government had to come to conduct the pilot project over three years.
Q: Can you explain the pilot project model in detail?
A: Once a primary care doctor selects and recommends a patient whose health conditions, like high blood pressure or diabetes, meet the qualifications, and the patient agrees, the doctor makes a personal health plan for the patient. Then the doctor can either give counsels directly to the patient or refer the latter to a local primary care center for education.
The regional centers are comprised of nurses, nutritionists, health trainers, and part-time physicians, and educate patients as requested by primary care doctors, provide counsels to motivate patients further and offer community-connected services. In this way, they help patients shape their health habits.
Q: What kinds of outcome have the pilot program yielded?
A: I would summarize primary care’s most important roles as gatekeeper and navigator of the medical world. Currently, the navigator role has become more important than that of gatekeeper because of changes in diseases and the composition of medical services. To cope with the increase in medical demand for the two primary changes resulting from population aging – complex and multiple comorbidities -- the primary care service also needs an integrated clinical ability and management skills.
However, the Korean healthcare system’s low-cost, low-fee and relative fee policies have hindered the division of functions for different medical institutions and have resulted in a situation in which clinics, hospitals, and general hospitals have to compete over patients. To resolve this problem, the health care system environment must help primary care physicians play the role of navigators from the standpoint of patients. The pilot project has made primate case specialists play a central role in preventing and managing chronic diseases, one of the original functions of the primary care medical institutions.
In other words, we shifted the frame of chronic illness management from treatment-oriented one to doctor-led one to create the basis for the Korean-type model. The existing frame regarded life habits as individuals’ responsibility and did not involve medical staff in it. The pilot project provides prevention and management education to prevent high blood pressure and diabetes from transitioning to cardiovascular disease through doctors. The provision of one-on-one education based on doctor’s expertise not only enhances trust between the patient and doctor but also increases patients’ acceptance of it, achieving effects in stimulating their motivations to practice what they learned by, for instance, taking preventive steps.
As primary care doctors at clinics play the role of navigator, this model has won praises for controlling demand for secondary or tertiary institutions and restoring the latter’s original functions of in-patient management, education, and research. Ultimately, the project seems positioned to define the domain and roles of primary care to contribute to the reestablishment of different medical institutions’ specific functions within the healthcare system.
Q: What is the fundamental problem in Korea’s primary healthcare?
A: The reality is that primary care itself is not functioning properly. First of all, there are neither human resource development plans for neither primary care nor entry barriers to opening local clinics. This means anyone, ranging from physicians with all kinds of specialties to general physicians without training as a medical resident, can open a clinic. Moreover, institutions are not properly divided by function, resulting in indiscreet competition at the primary care level.
Also, the increase of patients receiving full insurance benefits is accelerating the influx of patients to large hospitals. Furthermore, the fiscal incentives are mostly determined by the relative value of the action service, making medical acts focus on various examinations. All this works as disadvantages for primary care, which is responsible for treating patients through persuading them and easing their anxiety.
Q: What policies are needed to solve these issues and reinvigorate primary healthcare?
A: Some are suggesting a family doctor system, but its implementation will not be easy. The concept of a family physician is crucial, but both patients and physicians are highly likely to resist it if we force all people to register with their family doctors and choose the medical institution their physician selects for them in Korea, unlike the cases of other countries with advanced primary care system.
In a situation like this, a shift toward a system where patients voluntarily choose their doctor as their navigator is a more realistic solution. For this, we need a policy to adequately compensate doctors for their consultation time and provide benefits for patients who choose a regular doctor. Under the current system of making payment by the relative value, we should make efforts, at the same time, to raise the relative value of consultation with doctors who focus more on the doctor-patient relationship than on examination.
Another prerequisite is the division of functions among institutions and the strengthening of the proper commission system. Only, in Korea where the specialists of a wide variety and even untrained doctors are mixed with primary care professionals, the focus of division should be on the institutions’ real functions, not on their formal types.
Lastly, we need to examine the establishment of a system to develop high-quality primary care workforce as a mid- to long-term policy task. Amid accelerating population aging, patients’ diseases have become very complicated, leading to corresponding growth in medical demand. To make local primary care specialists go-to doctors for patients, communities need trusting primary care professionals. For the nation’s primary care system to have various related functions and meet patients’ demands for consistent management, personalized treatment, and smooth communication, Korea must have an institution exclusively responsible for training primary care specialists.
Q: Are there any last thoughts you want to share?
A: We call trusted relationship between doctors and patients “rapport,” which is crucial from the aspect of treatment. Establishing rapport is also vital for treating the disease called our country’s health care problem. Unfortunately, the implementing process of the existing medical policies has tended to hamper the establishment of such rapport. I’ve been pushing for the project with the thought that we should never follow this path. I firmly believe that this project will contribute to restoring rapport in every relationship – between patients and doctors, among doctors themselves, between medical and public institutions and between the medical community and the government. My hope is that all related areas will make efforts to establish primary care system.
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