Deliverable 1

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Project acronym: Equity-LA II

Grant Agreement Number: 305197

Project title: The impact of alternative care integration strategies on health care networks’ performance in different Latin American health systems
Deliverable: 3.1 Design of the intervention

Lead beneficiary: ITM

Nature: Report Dissemination level: Public

Contractual date: 31.05-2016 Actual delivery date: 30-06-2016 first version

15-09-2016 second version


Summary…………………… 3
Argentina…………………….pg. 8
Brazil…………………………pg. 23
Colombia…………………… 60
Mexico……………………… 83
Chile………………………… 98
Uruguay…………………… 141

After finishing the qualitative and quantitative baseline research of the Equity-LA II project, in each of the six partner countries in Latin America a list of detected problems of care coordination and continuity was elaborated, preparing the intervention phase in this Participatory Action-Research. With the Local Steering Committee and the Platform of Professionals, and in some cases with users of health services, the processes of prioritisation of the problem(s) and the selection of the intervention(s) were then completed. The next step was what we inform in this deliverable 3.2, the design of the intervention(s) and the detailed plan of its implementation.
Since the process is part of a participatory action-research, the intervention and its implementation are different in each country. Nevertheless, we can find some common features, in the detected problems as well as in the proposed solutions. Referral systems are not functioning adequately, and contacts between health teams of the different care levels are far too few to create mutual trust and to guarantee a fluid coordination of care, essential for chronic patients to perceive continuity of care. Clearly defined and feasible patient pathways for chronic patients are lacking in some of the countries of the project. Each country team will now test context- and system-specific solutions to these common problems.
We present a summary of the much larger reports in Spanish of the six partners. Readers will observe that progress in the six countries is unequal, some partners have already defined a detailed implementation plan for the intervention strategy, with indicators for evaluation of the process and its results, others are still discussing which strategy they will apply.
An extensive process of feedback of the results of the baseline research was enacted, to members of the Local Steering Committee, the Platform of Professionals and municipal health managers. This was a crucial moment, it meant the collective construction of the strategic direction to be followed, taking into account the political viability of this direction.

Coordination problems were identified, with the help of Matus´s theory of strategic planning: long waiting times for visits and some tests at second care level and deficits of information exchange between professionals of both care levels. One of the possible causes of the latter was the persisting conflict between hospital-centred and primary health care paradigms.

The selected intervention has two objectives: to develop integral care processes for patients with hypertension and diabetes to ensure access to care and interaction between professionals, and to formulate a Guideline/Agreement for the care of these patients, with resources and care pathways in the whole network. Involved professionals would be primary care teams and cardiologists, nephrologists, endocrinologists, ophthalmologists, neurologists and nutritionists.

The team in Rosario, Argentina then planned an intervention in three phases: first, characterisation of the care pathway of patients with chronic diseases. To this purpose, a sample of patients with hypertension and diabetes who presented complications will be constructed and their care pathway investigated. Second, identification of the obstacles in the care processes (in their clinical, informational and administrative dimension) and third implementation of a tool or device for Integral Management of Care Processes. Permanent monitoring of the intervention is foreseen.

The final result would be to establish a consensus of care pathways for patients with hypertension and diabetes, to be materialised in Local Guidelines. Primary care centres would be increasingly ascribed to specialists, and each specialist would be responsible for his group of chronic patients. Mixed teams of first and second level care would periodically analyse these care processes.

A list of concrete goals for the intervention is proposed: goals for access to care, for information exchange and for quality of care. A SWOT analysis is presented as well as a first draft of the operative instructions for the implementation of the intervention

A chronogram of the intervention for the duration of one year is presented, and specific tasks for each group of actors described. Pertinent biographic references are presented.

Brazil is in the middle of a severe political crisis, with the recent destitution of president Rousseff for 180 days. This crisis is reflected in Pernambuco, where elections will take place in October. This situation was a serious obstacle in the participatory process of planning the intervention.

The process of prioritisation of the problems of coordination detected during the first phase of Equity-LA II is described in detail, with the criteria that were used: relevance of the problem, political feasibility, technical vulnerability. Seven problems were selected, and causes and effects projected.

Next, criteria for the selection of the intervention(s) were adopted: technical feasibility, short-term effect, long-term sustainability and political visibility. Originally, the main intervention would be to improve communication between professionals of different care levels, and the second one comprises training of doctors of first and specialist level. Also, better use of the referral system, improved regulation of patient flow through care levels and more interaction between health services and academia.

After a new reflection round, the final intervention was narrowed to the main objective of joint meetings of health teams of different care levels, with two components: discussion of clinical cases including inter-consultations (by e-mail or group Whatsapp) and design and implementation of care pathway for diabetes, with permanent training as transversal element.

A detailed chronogram of the planned activities is presented, until May 2017, with a first cycle of the action-research ending 6 months followed by an operative and analytical evaluation. Operative instructions are described for each component of the intervention, with their respective responsible actors; these will need to be more detailed in the near future.

Finally, operative indicators are described for the process evaluation of the two main components of the intervention, and a long list of analytical indicators to evaluate its results.

The Colombian partner implemented an extremely participatory process of devolution of results of the qualitative and quantitative investigations, with visits to all the concerned health services. All health staff of the different care levels was then involved in the prioritisation of problems and a preliminary selection of the future intervention.

Due to conjuncture difficulties, essentially a change of government in the city of Bogotá, with change of previously contacted health authorities and an extremely high turn-over of health staff, combined with a financial crisis in the third level hospital in the area of intervention, the process of prioritisation of the problems and selection of intervention strategies was slower than originally planned.

Criteria for the prioritisation were reached in consensus; at the end seven problems remained, and for each of them causes and effects were described, by professionals in the health centres, hospitals and the Local Steering Committee. The seven problems were then considered according to the prioritisation criteria, the main two problems were then “inadequate communication between professionals of care levels” and “lack of agreement on clinical management between generalists and specialists”. Again, very detailed trees of causes and effects were construed.

The next step was the process of selection of possible interventions. First, internal documents of the Equity project and relevant literature were reviewed. Brainstorming mechanisms were used and staff of both care levels were asked to look for solutions to the seven previously selected problems, with 4 selection criteria. A long list of solutions for each problem was the result. The scheme of coordination mechanisms proposed by Terraza-Nuñez was then applied to regroup the strategies. In another round of participatory decision-making by the Local Steering Committee and the Platform of Professionals, two intervention strategies were selected: improving communication and collaborative work between generalists and specialists in the network, and fostering agreement between generalists and specialists in relation to the clinical management of the patient with diabetes mellitus type II and arterial hypertension.

A detailed plan for the implementation of the two interventions is proposed, with a chronogram till May 2017, the final evaluation. Operational instructions for the selection of clinical cases and the joint sessions of clinical training between generalists and specialists and indicators have now been defined. The analytical evaluation will be implemented through focal groups and a series of analytical indicators, still under discussion.

After the process of prioritisation of problems and the participatory selection of interventions, the Mexican partner decided on a double intervention. The main intervention is about online tutoring, the complementary intervention is education for health.

With respect to online tutoring, the aim is to improve managerial coordination and coordination of information flow between general and specialist physicians. An existing system (osTicket) will be adapted to implement the online consultations. Participating physicians will be trained. The queries will help to identify the existing need for extra training in certain pathologies.

The second intervention, complementary to the first one, is an education for health activity, which comprises reorienting the access to medical care together with improving the functioning of the referral system. Educational material will be elaborated and dissemination implemented by health staff, with information about the optimal use of health services and transitions between care levels. Visual material will be installed in the health centres and health staff will distribute brochures for patients.
65 general physicians in 7 Health Centres, 16 specialist will participate, under the coordination of the Local Steering Committee and the research team.
SWOT analysis shows strength in support by current authorities, opportunity because of existing interest in networks in national health policy, weakness because of high turnover of health staff and a clear threat because of elections and change of authorities.
A chronogram of activities is presented ending in May 2017. Detail about operational and analytical evaluation of the Participatory Action-Research process is still to be elaborated as well operative instructions for all actors involved. The starting date of the actual intervention depends on the sanction to be given by local health authorities, the Mexican public health services being a very hierarchical system. Fortunately, recently the two selected interventions were approved by current local health authorities. Local elections are due at the beginning of June 2016.

The research team in Chile implemented a very participatory process towards the definition of the intervention strategy. While investigating previous or pre-existing “best practices” regarding care coordination, in one of the hospitals of the intervention area previous and ongoing experiments with the referral system were identified, and a corresponding keen interest expressed by health authorities to continue enhancing the functioning of the sometimes failing referral system.
In several meetings with the Local Steering Committee and the Platform of professionals, 5 critical points were identified: lack of a shared vision on the existence of a health network, low exchange of information and use of the patient to transmit it, limited communication, trust and communication between health personnel of different care levels, limited shared objectives for clinical treatment, interruptions in continuity of care and information not accompanying the patient during his trajectory through the system. These were then reconsidered and condensed into two problems: lack of vision or shared perception on the existence of the network of health services, and limited communication, lack of trust and collaboration between teams of professionals at the distinct levels of care.

For each of these two problems a series of possible interventions was considered, and actions at two different levels were prioritised, first by the Platform of Professionals and then by the Local Steering Committee:

  • At the level of the health services (the network):

    • A single information system, a shared medical file

    • Strengthening of the role of articulation of the network management, with a vision of public health and humanization

    • Time reservation for networking

  • Specific activities to support the articulation of care levels:

    • Installing a model of communication between physicians and professionals of different care levels for the clinical management, based on best practice and its improvement

    • A program of introduction to working in the network

After more deliberation in the Local Steering >Committee and the Platform of Professionals, two interventions remained: introduction to work in a network of health services (the intervention area), and inter-level communication between professionals of the different care levels in that network. A third intervention is not specific to the project: the introduction of a single information system for the different care levels. The project will enhance this endeavour, and the availability of shared information will improve coordination of care.
A separate chronogram is presented for both interventions, with concrete activities in the framework of Equity-LA II till May 2017. A lengthy sector is dedicated to the description of factors that facilitate or impede the implementation of both interventions.
Operative indicators to evaluate the process have been developed. For each intervention, a detailed description of its components, the operative indicators and their source is presented. A scheme for the analytical evaluation of both interventions is proposed, with indicators and their source of information.

The partner in Uruguay, as informed before, had enormous difficulties and major delays to get the project endorsed by health sector authorities in Montevideo, and later on had to expand the rather small and rural intervention and control areas to get the necessary number of physicians for the quantitative survey. As a result, an important delay occurred in the research process, particularly in the quantitative phase.

The report describes the problems detected regarding coordination of care in the intervention area. Results of the interviews with professionals and of the quantitative survey are presented, particularly the suggestions to improve coordination, classified accruing to priority. As in the other countries of Equity-LA, there is a demand for meetings between personnel of the different care levels, to enhance communication, to improve the use of the referral form among others. Health authorities are looked upon as not facilitating care coordination.

A table is presented with a list of problems of coordination, as the result of a participatory exercise with 12 small groups of personnel of the intervention area. Causes and effects of these problems were analysed and the corresponding possible strategies to solve them proposed. Finally, the Local Steering Committee reflected on theoretical mechanisms to improve coordination (standardisation of skills, processes and results) mutual adjustment, supervision and information systems. The Committee then considered how these theoretical mechanisms could work in practice in the concrete context of the intervention area.
Three possible interventions were identified: a) improving the referral system, by way of supervising its functioning and by computerizing the system, b) organizing meetings between professionals of different care levels to discuss clinical cases and c) creating the figure of a link structure to coordinate care levels, with a pathway description for users and with the power to impose it. In the framework of Equity-LA, the first intervention will be applied.
Four operative objectives are proposed for the intervention regarding the referral system, and four expected products. A detailed chronogram for the 8 months of the intervention is presented, with a proposal for the implementation of the cycles or spirals of the Action Research Process, according to the theory of Fals Borda.
Finally, internal and external strengths and weaknesses are identified for the intervention strategy.

Impacto de las estrategias de integración de la atención en el desempeño de las redes de servicios de salud en diferentes sistemas de salud de América Latina (Equity-LA II) en Rosario, Argentina

Diseño de la intervención y plan de implementación

Rosario, 25 de Junio de 2016

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