Analysis and perspectives Analysis and perspectives of GPs gathering models in Italy of GPs gathering models in Italy

according to the latest according to the latest Italian National GPs Joint Italian National GPs Joint

AgreementsAgreements

Mazzeo M.C.*, Ceccarelli A.* °, Cicchetti A.* °, Le Rose C.*, Milillo G.*

* GISAP – Independent Group for the Study of Primary Health Care° Catholic University of Sacred Heart - Rome

Pisa, 30-31 August 2010

Gruppo Indipendente per lo Studio dell’Assistenza Primaria

Independent Group for the Study of Primary Health CareEstablished in 2009, currently its members are:• Maria Concetta Mazzeo: President• Elio Guzzanti: President of the Scientific Committee• Americo Cicchetti: Founding member• Giacomo Milillo: Founding member

Goals:Goals:Promotion and fulfillment of research and study activities on

the organization, economics and healthcare policy, particularly with regard to an in-depth examination of problems related to the promotion and development of

Primary Health Care, also through the organization of educational activities.

For more information, visit our website For more information, visit our website www.gisapitalia.itwww.gisapitalia.it

GISAP

Purpose of the Purpose of the studystudy

This study analyzes the collaboration between GPs and

other Primary Health Care (PHC) professionals compared to what

Italian National GPs Joint Agreements plan and according to

some Regions’ experiences.

BackgroundBackground New trends:• in demographyin demography→ significant increase of

population aged >65 years

• in healthcare needsin healthcare needs

Need to rethink the Primary Need to rethink the Primary Health Care providing Health Care providing

mechanismsmechanisms

Evolution of the context:

• Institutional→ Constitutional Law 3/2001

and Law 42/2009

• Organizational • Financial→ severe constraints on

the Italian budget

Source: Eurostat (2006-2007)

BackgroundBackgroundGeneral Practice has been working for several years to define health care providing models:

• based on the gathering of different professionals and skills;

• in which the GP is responsible of the achievement of a “professional integration”;

• which are aimed at proposing to citizens a more complete and qualified service.

Effectiveness – Efficiency - Effectiveness – Efficiency - AccountabilityAccountability

““Functions” to be realized by Functions” to be realized by GPsGPs

• Clinical: activities of prevention, diagnosis, care and rehabilitation (h24; 7 days out 7; 365 days per year);

• Organizational: creation of adequate information flows and contribution to services planning;

• Educational: promotion of healthy life styles and assignment of responsabilities to patients and citizens.

BackgroundBackground

MethodsMethods

A perspective analysis of gathering models was performed and

compared to those experienced in some Italian Regions through

Regional GPs Joint Agreements.

FindingsFindings

Italian National Joint Agreements considered voluntary forms of collaboration between

GPs linked to financial incentives diversified according to the organizational

complexity of gathering.

2000-20082000-2008

FindingsFindings

•Simple Association (Associazione Semplice):Simple Association (Associazione Semplice): 3 to 10 GPs in their own studies Regular peer-review meetings

•Network Association (Medicina in rete):Network Association (Medicina in rete):

3 to 10 GPs in their own studies Network computer connection to allow each GP to

access patients’ medical files

• GPs Group (Medicina in gruppo):GPs Group (Medicina in gruppo): 3 to 8 GPs in a single building Possibility to share assistants, nurses, medical and

computer technologies

National GPs Joint Agreements 2000-National GPs Joint Agreements 2000-20082008

Complex models Complex models of GPs gathering of GPs gathering

The “The “Equipe”Equipe” proposal (2000) proposal (2000)

Several regional modelsSeveral regional models

“Local structure characterized by a

multidisciplinary and interprofessional integration, able to provide complete answers

to population health needs.”(National GPs Joint Agreement, 2000)

Gathering of GPs, Paediatricians, and other professionals aimed at ensuring

the integration of social and health interventions in a determined area.

EquipeEquipe

Local Primary Care Units (UTAP): Local Primary Care Units (UTAP): 20052005Experimental gathering models Experimental gathering models defined as:

“Integrated structures for the supply of Primary Health Care, formed by the gathering of several

doctors (GPs, Paediatricians, Specialists) who work in a single building, ensuring a high level of integration between general practice and

secondary care.”(National GPs Joint Agreement, 2005)

Complex models Complex models of GPs gathering of GPs gathering

Local Primary Care UnitsLocal Primary Care Units

•Structured in a single building •Have a basic organizational structure •Have a basic technological equipment

Purpose: Purpose: To ensure a full continuity of care; an

appropriate management of clinical pathways; To provide home and institutional care; some

secondary care.

Primary Health Center (Casa della Primary Health Center (Casa della Salute)Salute)New experimental model provided by the Ministry of

Health Programme “A new Deal for Health”, presented to the Parliament in June 2006.

Main Goal:Main Goal:To promote, through the contiguity of facilities and of

professionals, the integration between essential levels of health and social care.

Complex models Complex models of GPs gathering of GPs gathering

Primary Health CenterPrimary Health CenterPolyvalent structure able to supply the and to ensure Continuity of Care and activites of prevention to a catchment

area of 5-10.000 inhabitants.

multidisciplinary approach to multidisciplinary approach to population care needspopulation care needs

FindingsFindings

• Although these models developped among GPs the attitude towards teamwork, time highlighted their limits.

• In few cases these models succeeded in minimizing negative effects of GPs competition, which is still the main obstacle to a full GPs collaboration.

Limits of the voluntary models Limits of the voluntary models of GPs gatheringof GPs gathering

FindingsFindings

Introduction of the Multidisciplinary Primary Multidisciplinary Primary Care Units - PCUsCare Units - PCUs (Unità Complesse di Cure Primarie - UCCP): •mandatory;•described as an “extended team” of professionals;•each professional performs different and each professional performs different and integrated functionsintegrated functions.

2009-FUTURE2009-FUTURE

• Gathering of GPs, Paediatricians, and Specialists;

• Can be defined as an “extended team” of professionals having their own tasks but the same mission;

• Don’t have a predetermined configuration: can be a single building or a network structure with headquarters in which some activities, technologies and services are concentrated.

Multidisciplinary Primary Care Units

FindingsFindings

Discussion Discussion

Multidisciplinary Primary Care Units should provide a more complete and more complete and

qualified answer to population needsqualified answer to population needs through the provide of a 7/7d and 24/24h care by professionals who, thanks to the

support of nurses and other support of nurses and other professionalsprofessionals, could be appropriately

concentrated on their clinical functionsclinical functions.

ConclusionsConclusions

The new Multidisciplinary Primary Care Unit model provided by the 2009 Italian National GPs Joint Agreement must be:

• tested in some Regions in order to be validated;

• implemented at the national level taking into account the singularities of each territory.

How to make the “dream come How to make the “dream come true”?true”?

• How to share out work? How to define tasks and roles?

• Who has the power (or the duty) to take decisions? What kind of (and how much) hierarchy?

• How to manage new and specific situations?

ConclusionsConclusions