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SCIENCE TIME
OPPORTUNITIES FOR THE DEVELOPMENT OF INTEGRATED CARE IN BULGARIA
Petrova Galina Rumenova, Medical University Prof. Dr. Paraskev Stoyanov, Varna
E-mail: gal_rumenova@abv.bg
Kostadinova Todorka Ignatova,
Medical University Prof. Dr. Paraskev Stoyanov, Varna
E-mail: kostadinovad@gmail.com
Teneva Nelly Nikolaeva, Medical University Prof. Dr. Paraskev Stoyanov, Varna
Georgieva Petrova Emilia, Medical College of Varna, Varna
E-mail: emi_georgieva33@abv. bg
Abstract. The fragmented communications and coordination between the primary health centers and the specialized outpatient health centers lead to difficulties in the diagnostic activities and deprivation of medical aid. The above mentioned creates a variety of mistakes and duplication of some of the medical services throughout the patients' treatment. Integrated care is a possible approach aimed at the optimization of the processes, effective use of the resources, utilization and efficiency enhancement as well as quality improvement of the provided care and customers' satisfaction (especially chronically ill patients with complex needs). In order to assess the level of knowledge about integrated care in Bulgaria and the attitude of medical professionals to its implementation, an anonymous survey among a group of respondents was carried out: medical doctors and other professionals.
Key words: Integrated care; priority; efficiency; development; health care reform.
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Introduction
Healthcare systems worldwide are undergoing a process of significant change, various ways to limit the growing costs are sought, as well as ways to achieve universal coverage and equality in access, quality and effectiveness of resources unitization for the achievement of health objectives. Many countries are looking for ways of providing universal care with increased control over costs and effectiveness improvement [1, 2,
4].
Integrated care is a reasonable way health care provision. European countries have come to the idea of integrated care in different ways. In a number of cases these are adaptations of the American idea of managed care [5].
Despite the differences regarding the details, the idea of integrated care is accepted everywhere as a model aiming at the integration of various healthcare activities and various institutions in the name of the patient, of the service quality and the economic effectiveness [6].
Health systems are in constant development. The incentives for reforms in a health system may originate from the need to limit the costs, universal coverage or effectiveness of utilization of the resources or the efforts to improve the satisfaction of the users or the providers [9].
In Bulgaria the new health policy was implemented at a time of consecutive economic crises, lowering the percentage of the healthcare coverage compared to the gross national product and increasing of the portion of direct payments made by the patients. That shortage of funds led to a gradual change in the medical services, which in turn led to ever greater disturbances and fragmentation. Therefore a new method of providing coherent and complex care is demanded. Integrated care services are a possible solution. [10, 11].
Therefore, integrated care is gaining importance. A number of countries have already gained experience in the application of that approach. That comes to show the ever growing importance, which is achieved by that approach [7].
Integrated care a coherent set of methods and models for financing, administration, organization, service delivery and clinical levels, designed to create connectivity, equalization and collaboration within and between the treatment and care sectors ... to improve quality of care, quality of life, user satisfaction and system efficiency for patients with complex problems passing through numerous services, providers and conditions (Kodner and Spreeuwenberg, 2002) [6].
"A complete and coordinated complex of services planned, managed and administered to individual patients or service users by different organizations and different professionals." Integrated care covers the entire spectrum of health and social care, i.e. medical treatment in the tertiary or secondary sector (hospitals) to primary care (general practitioners' offices) to the informal support (friends and relatives) and social assistance in the patients' homes (WHO, 2002) [7].
Integrated care as a conceptual method and model of organization, which can be applied in order to limit the fragmentation and doubling of services, raise the quality and the satisfaction of the patients, lower the costs, raise the economic effectiveness, and secure a full medical treatment [9].
The health care system in Bulgaria started to be reformed because of the population's health status, the shortcomings of the health care system as well as the need for the adoption of the universal health model as a prerequisite for equal participation in the family of European Nations.
Bulgarian health system involves all key directions of the system of healthcare: organization, execution, funding, and training of human resources. It is dominated by hospital establishments and regardless of the demographic and economic pressure their reformation proved to be exceptionally difficult, which naturally lead to aggravating of the status of the infrastructure and reducing of the medical treatment quality [13, 14, 16].
The elimination of the financial barriers is necessary but not sufficient for an optimal healthcare. Equality, and minimal inter-regional and social-demographic differences in the access to good-quality healthcare, is vitally important for the good social standards.
Health responsibility is not only an obligation of medical and other health professionals but also of the society and its executive institutions, governmental and volunteer organizations, and also of the individuals, the families and the non-formal groups of people with identical interests [3].
These changes, as well as the new requirements to healthcare, impose the application of new ways of organizing of the healthcare activities. Integrated care is one of these approaches, and it is aimed at the optimization of the processes, improvement of the utilization of the resources and increasing of the effectiveness, as well as raising of the quality of the provided healthcare.
The foreign experience can serve our country towards the solution of a number of issues, which have become important with the implementation of the health insurance system: like the poor interaction between the pre-hospital and hospital aid [8].
Yet, the disappointing experience from the transition and reform in our health systems comes to show that there is a necessity to develop our own integrated care model, and not just copy an already existing one and that it should be critically assessed before it is borrowed [11].
There is a low awareness regarding the nature, content and parameters of integrated care, the lack of information about the end product or the result from that care, the lack of legislative and normative acts, the poor coordination between the health and social institutions, and the insufficient training of the medical professionals and social workers can create barriers to integrated care implementation and become the source of negative attitudes both among the various specialists, and among the
citizens [8].
Objectives
The main purpose of the research is to find out the level of knowledge and the opinions of 30 medical specialists and professionals from other spheres (social and health economy) towards the idea of implementation of a model of integrated care for chronically ill patients in Municipality Varna.
Methods and Materials
Sociological method and Individual interviews are used in the following survey. Three different types of questionnaires are used in the following survey. They are developed and changed during the research. The questionnaires are consisted mainly of close-ended questions and are structured in three blocks. The first block consists of questions connected to the level of knowledge of the respondents about the healthcare system, the way it functions and the meaning of integrated care. The second block of questions corresponds to the respondents' knowledge about the care of patients with chronic conditions and the need for integrated care. The third block of questions corresponds to the personal opinion of the respondents for the obstacles and possible barriers (education, reforms, and effective communication) for the implementation of integrated care model as well their opinion for the design and the financing of the model.
Results
1. In the research, the respondents are aware of the meaning of integrated care. This can be proven by the answers of the respondents. 66,60% of them understand integrated care as coordinated and holistic complex of services, provided by different healthcare and social-care specialists and agencies, while for 36,60%, it is a conception connected to the management, support, implementation, organization of services for diagnosis, treatment, care, rehabilitation of health.
2. 66,7 % of healthcare specialists think that there is not enough care provided to the chronically ill patients and the implementation of integrated care model will lead to successful treatment results. 33,3% of the respondents think that there is some kind of care for the chronically ill patients which is mainly the care connected to prescription of medications and regular check-ups. There is a need for introduction of a database of all chronically ill patients, according to 96,70% of the respondents. This database will improve the care of the patients and the communication between the different structures in the healthcare system.
3. There is a positive opinion for the implementation of integrated care model in Bulgaria. Besides the support of the idea for the introduction of the integrated care system, a large number of the respondents have interest in participation in a
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multidisciplinary integrated care team as consultants (83,3%) and 10 % of them working part-time.
4. The main barriers for the implementation of integrated care model in Bulgaria
are:
- A lack of integrated information system (89,7%);
- A lack of coordination between the different structures (75,9%);
- A lack of legal framework (71,4%);
- The funding of the integrated care model (60%);
- The ordinary working method in the healthcare system (58,6%).
5. The advantages of the implementation of the model for the users are: the formation of multidisciplinary team responding to the needs of the patients (79,8%); a holistic approach in the treatment of the patients (79,8%); more focused and effective services for the patients and reaching positive results for them (53,6%)
6. All the respondents agree that firstly, the general practitioner should be involved (93,3%), followed by psychologist (83,3%), social worker (70%), endocrinologist (70%), cardiologist (66,7%), ophthalmologist (56,7%) and nurse (50%).
7. The integrated care model should be financed by the National Health Insurance Fund (80%), through different programs (46,6%), health savings accounts (40%), voluntary health insurance (33,3%).
In spite of the obvious obstacles, there are opportunities for the implementation of integrated care model. There is a positive tendency in the opinions of the medical and social specialists, as well as a good deal of knowledge about integrated care for chronically ill patients. There is a need for further education of the different specialists when implementing such a model which will ensure its effective functioning.
Conditions and priorities for the development of integrated care should include:
a) At political level:
- The chronic diseases should be recognized as a priority in the health policy of Bulgaria;
- Supplementing and updating the regulatory framework in the field of chronic diseases;
- The state should take primary responsibility through multi-sectoral collaboration at all levels;
- The process of implementation of integrated care in Bulgaria should include the construction and implementation of an integrated information system and a register of patients with chronic diseases;
b) On organizational level:
- Construction of the required functionality - multidisciplinary teams, effective communication and partnerships. A working model of integrated care requires health professionals with the necessary skills and competencies;
- Training of participants about the essence of integrated care, the role of professionals, organization and scope;
- Providing modern continuous training of health professionals, especially GPs on the control, prevention and management of chronic diseases.
Conclusions
The implementation of integrated care is a complex approach which requires major additional funding at the beginning, and training of new knowledge and skills, as well as the development of a unified information system.
Policy makers can start with the solution of a number of issues by making a preliminary assessment of all financial consequences from the suggested model, and respectively adjust the expectations in accordance with the possible results.
Of a great importance is the designing and management of the process of execution. An inadequate planning and management may lead to negative consequences.
Other challenges are related to improvement of the resource management within the system, increasing of the engagement of all participants in the system, realizing the importance and need of timely actions for the optimization of the work and the interaction mechanisms within the healthcare system.
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