WELLNESS APPROACH IN PRIMARY HEALTH CARE

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WELLNESS APPROACH IN PRIMARY HEALTH CARE

• Dr Noridah Mohd Saleh
• Ketua Penolong Pengarah
• Bahagian Pembangunan Kesihatan Keluarga
• KKM

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Background

• Changing Paradigm Illness to Wellness (expanded
  scope in 7MP)
  
• One of the 8 Future Health Goals
• One of the main focus in 9MP
• - TWG paper Achieving lifelong Wellness

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DEFINITION

• Health is a state of complete physical,
  mental, and social well-being and not merely the
  absence of disease" (WHO, 1947, p. 1)
  
• Illness the response a person has to a disease
  it is an abnormal process in which the persons
  level of functioning is changed compared with a
  previous level
• Wellness an active process by which an
  individual progresses towards maximum potential
  possible, regardless of current state of health.
  Five dimensions of wellness (physical,
  socialcultural, emotional, intellectual
  environmental)

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PRIMARY HEALTH CARE
Primary Care
Family Health
FHD / BPKK
Illness wellness
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Future Health Goals

• Wellness Focus
• Person Focus
• Informed Person
• Self Care
• Care provided at/near home
• Seamless Continuous Care
• Service Tailored As Much As Possible
  (Empowerment) (to individuals and groups)
  
• Affordable and Equitable

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The 8 HS Goals

• Wellness
• Not to be merely a theory

To be translated Into Action
well at risk
ill
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Why Wellness Approach?
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Challenges

• Disease Pattern
• - 1 in every 10 has Diabetes
• - 1 in every 5 deaths is due to
• Cardiovascular problems
• - 1 in every 8 has Asthma
• - Breast ,Cervix, Prostate Cancer
• Demographic
• - 1 in 20 is an elderly
• ( 1 in every 10 by Year 2020)
• Higher Demands and Expectations , Resource
  constraints,

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Top 10 DALYs
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I - Prevent and Reduce Disease Burden

• 70 of total Health Budget
• 2m inpatients
• 40m outpatients

ILL
WITH RISKS
POTENTIAL RISKS
HEALTHY No identified Risks
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LIFE Expectancy
LIFE EXPECTANCY
AGE
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Health Expectancy
HEALTH EXPECTANCY
AGE
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Experience

• What have we learn from
• MCH services?

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Prevent and Reduce Disease Burden

• Experience from MCH WELLNESS Services
• 30 years of investment
• Maternal Mortality 282(P) 30 / 100,000
  LB
  
• Infant Mortality 41(1970) 5 /100,000 LB
• Burden of Dis (2003) Leading cause of DALY
• Measles 126
• Polio 102
• Hypertension in Preg 1,268
• Maternal Sepsis - 171
• Obstructed Labour 14

IHD - 113,887 CVD/Stroke - 86,372 Major Depresn
- 67,211
Diabetes- 56,390
OBESITY from 5 to 10-13 in 10years??
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Prevent and Reduce Disease Burden

• Experience from the MCH wellness Services
• Screening
• Examination Immunisation
• Health Education
• Follow-Up Home Visits
• Treatment

IS
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MCH Services Investments

• Dedicated Clinics
• Dedicated Staff
• Trained Midwives and PHN
• Trained Doctors and Obstetrician
• Effective MCH FP Protocols
• Effective Referral System

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Current Promotive and Preventive Limitations

• Mass-address
• Not-specific to clients problems
• Behavior modification unassisted
• Big Bang effect much desired
• individualised
• and personalised

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Wellness approach

• How to do it?

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ProposingPlan Preventive Maintenance Approach
Wellness..
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Primary Health Care

• Primary Health Care is The Thrust of Health
  Services
  
• Kontek di peringkat temu-pertama di antara
  pesakit dengan sistem penjagaan kesihatan
  (personel kesihatan )
  
• Menekankan equity, accessibility, affordability
  and appropriate technology
  

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Ninth MP - Consolidation

• Primary Goals
• Prevent and Reduce Disease Burden
• Enhance Health Care Delivery
• Supporting Goals
• Optimisation of Resources
• Enhance Research
• Manage Crisis and Disasters
• Strengthen Health Information MS

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Prevent and Reduce Disease Burden
Health Promotion, Screening, Early diagnosis,
Prompt Treatment, Rehabilitation

Integrated services
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Existing Framework
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Services Provided KK (2)(3)

• Kesihatan Ibu
• Ibu Mengandung
• Pemeriksaan kesihatan, kandungan dan darah
• Lawatan ke rumah
• Ibu Bersalin
• Menyambut Kelahiran
• Ibu Lepas Bersalin
• Pemeriksaan kesihatan
• Pemeriksaan bayi
• Lawatan susulan di rumah
• Khidmat perancang keluarga
• Promosi susu ibu
• Kesihatan Anak
• Pemeriksaan kesihatan
• Imunisasi
• Early intervention Program
• Lawatan ke rumah
• Kesihatan Sekolah
• Pemeriksaan kesihatan murid-murid Tahun 1, 6 dan
  Ting 3
  

• Kesihatan Warga dewasa
• Promosi Kesihatan
• b) Perkhidmatan penyaringan dan penilaian
  risiko
  
• Perkhidmatan pengurusan risiko
• Pemeriksaan kesihatan
• Perkhidmatan kesihatan reproduktif
• Kaunseling
• Rawatan dan rujukan
• Kesihatan Wargatua
• Promosi Kesihatan
• Pemeriksaan kesihatan
• Pemeriksaan pergigian
• Rawatan dan rujukan
• Kaunseling dan Rehabilitasi
• Kesihatan Mental
• Promosi Minda Sihat
• Penyaringan faktor risiko, DASS, gaya tindak
• Intervensi awal / susulan teknik relaxasi,
  urutan leher dan bahu
  
• Pengurusan pesakit psikososial, farmakologikal

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Services Provided - KK

• Pemakanan dan Dietetik
• Promosi makan secara sihat
• Pengurusan berat badan
• Pengurusan pemakanan pesakit kronik
• Rehabillitasi pemakanan
• Dapur sihat / kafeteria sihat
• Kesihatan Pergigian
• Promosi kesihatan pergigian
• Saringan dan Pemeriksaan kesihatan pergigian
• Rawatan
• Rujukan pakar
• Kesihatan Pekerja
• Pemeriksaan kesihatan pre employment, routine
  medical examination
  
• Penilaian risiko pekerjaan / hazard
• Rawatan dan rujukan
• Siasatan penyakit/wabak
• Rehabilitasi
• Pemulihan anggota
• Pemulihan cara kerja

• Surveilan kesihatan
• Pengesanan kes secara aktif dan pasif
• Pengesanan kontak
• Pengesanan kes tercicir
• Promosi kesihatan
• Perkhidmatan sokongan
• Perkhidmatan patologi
• - Pengendalian spesimen
• - Ujian makmal
• Perkhidmatan pengimejan diagnostik
• - X Ray dan Ultrasound
• Perkhidmatan farmasi
• - Pendispensan ubat-ubatan
• - Kaunseling

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Current challenges - PHC

• High load of patients to doctor
• (30m 13m) 40 -50 m (total encounters)
• (Medical assistants / Nurses)
• 1000 drs (130 FMS)
• 6300 nurses (3700 SN)
• 2000 MAs
• Increasing scope of services
• Lack of building space and equipment
• Poor maintenance
• Increasing demands by clients

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Review the deliverables

• Process
• Integrated wellness screening adult
  elderly
  
• Risk Management
• Reorg clinic illness
• Physical
• Outcome
• Percentage of the population / community
  assessed, without risk, with risk,

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Process of healthcare delivery Need to enhance
Fast Access, Safe and high quality ,Hassle-free
and greater comfort

• Optimisation of Resources
• Multi-skilling, Sharing, Remote management
• Enhance Research
• Participate towards evidence based planning and
  intervention
  
• Manage Crisis and Disasters
• Increase HR capacity and capability
• Adequate and appropriate facilities
• Current protocols for management
• Strengthen Health Information MS
• Enhance sharing of data and info facilitate
  continuity of care
  

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• What do we offer ?
• Wellness services

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OBJEKTIF KLINIK WELLNESS

• Meningkatkan kesedaran pemeriksaan kesihatan di
  kalangan komuniti ( Bilangan kedatangan kes
  baru)
  
• Meningkatkan pengesanan awal kes-kes yang
  berisiko tinggi (Bilangan kes yang mempunyai
  risiko)
  
• Memperkasakan komuniti untuk melakukan
  pemeriksaan kesihatan sendiri (Bilangan pelanggan
  yang dapat melakukan pemeriksaan sendiri dengan
  betul)
• Mengurangkan morbiditi ( Bilangan intervensi yang
  berjaya)

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Wellness - Target groups

• Healthy population
• Aged from 10 to 70 years
• Follow up interval every 5 years
• Followed-up patients for counseling and health
  education
  
• Patients for Rehab follow-up

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(5) Outcome -

• Wellness Service
• Womb Tomb
• Maternal
• Child
• Adolescent
• Adult
• Geriatric

School Health Home Visits Home Nursing
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Prevent and Reduce Disease Burden

• Treat the ill
• Manage those with risk
• Prevent the onset of preventable risks
• IMPROVE HEALTH EXPECTANCY

WELLNESS SERVICES
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Approach

• Medical
• Nutrition
• Exercise
• Smoking
• Minda Sihat
• PT/OT
• HEd
• - Occ Health

• Maternal
• Childhood
• Remaja
• Dewasa Wanita
• Dewasa Lelaki
• Wargatua

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Health Services In Clinic
Adolescent Adult Geriatric Mental health
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Reviewed Approach - Physical
I - Wellness Clinic Ibu Anak Remaja Dewasa
Warga Tua
II - illness Clinic Kecemasan Akut Kronik Pe
nyakit Berjangkit

School Health Home Visits Home Nursing

• III - Emergency
• Support Pre-hospital
• Support Call centre
• Support Rapid Response

III - Support Services - Makmal - Farmasi - R
adiologi
- Sistem Informasi dan komunikasi
Wellness Illness Support Emergency
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Wellness -approach

• Appointment
• Integrated, Comprehensive Screening according to
  age group
  
• Clinical Pathway in management of risks (Evidence
  Based)
  
• Health education and Behavior modification /
  rehabilitation
  

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Risks reduction / prevention

• Maternal and Child Mortality and Morbidity
• Adolescent Geriatric Mortality and Morbidity
• - 10 top Disease Priorities
• IHD Cardiovascular
• Cerebrovascular
• Diabetes
• Depression, anxiety, stress, schizophrenia
• Injury
• Cancer
• Congenital
• Asthma

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Risk Assessment by Age Gp
For Female Adult Osteoporosis
For Older Adult Stroke
For Child and Adolescent
Child and Adolescent Health Risk Profile (Text
Version)

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screening tool

• Self
• Assisted

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Wellness (PPP) Activities / Services

• Resource Implications
• Space - BIG
• Equipments
• Training
• HR
• Dr
• Dietician
• Health Education Officer
• Medical Assistant
• Nurses
• Clerical

• Guided Self-Check
• Checklist for Risk Screening according to age
  group
  
• Triage
• Counseling and Health Education
• Risk Assessment
• Risk Management

• Process Implications
• Consolidation of islands of clinics

Adolescent, Paps smear, BSE, HRT, Mens, OKU,
CVD, PSR, Occ health, geriatric health, .
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Self Risk Assessment

• Butir peribadi (perubatan peribadi keluarga)
• Penilaian Fizikal (BMI, secondary sexual
  development/reproduktif, pemakanan, pergigian,
  
• Senaman
• Penilaian Minda Sihat (Risiko Murung /Resah/ )
• Penilaian Tingkahlaku Berisiko (dadah/rokok /
  sexual habits penderaan/ Kecederaan)
  
• Pengurusan Risiko
• - Klinikal /pemakanan/senaman/minda sihat
• sokongan moral (e.g kaunselor, psikologis

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- Achieving lifelong Wellness

• 5 Areas to be strengthened
• Healthy Eating
• Regular exercise
• Healthy Mind
• Stop Smoking
• Healthy and Safe Environment
• EMPOWERMENT

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Pelanggan
Komuniti, OPD, MCH, Sekolah
Kaunter informasi
Pegawai perhubungan pelanggan
Kecemasan
Pesakit Luar
Isi borang saringan asas(mengikut kumpulan
umur dan jantina) dan dapatkan temujanji
Kaunter Pendaftaran Klinik Wellness
Pembantu Tadbir
Lengkapkan Saringan Asas Ukuran Biometri
Pemeriksaan Fizikal Asas
Jururawat Masyarakat / Pembantu Perubatan
Penentuan Risiko
Pakar Perubatan Kesihatan Awam
Ada penyakit
Ada risiko
Tiada risiko
Pakar Perubatan Kesihatan Awam, Pembantu
Perubatan, Jururawat Terlatih, Kaunselor,
Jurupulih carakerja/ Anggota, Pegawai Zat Makanan
/ Dietician, Pegawai Pendidikan Kesihatan
Rujuk FMS
Pakej
Promosi Kesihatan Temujanji Discaj

• Minda sihat
• Berhenti merokok /Substance abuse
• Pemakanan sihat
• Senaman (termasuk PT, OT)

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• PERANAN PEMBANTU PERUBATAN
• menjalankan saringan asas ukuran biometri
• membantu menyelaras dan memantau perjalanan
  klinik
  
• melakukan pemeriksaan kesihatan
• membuat penilaian kesihatan dan penentuan
  risiko
  
• membantu menjalankan pakej intervensi yang
  berkaitan
  
• membantu membuat penilaian keberkesanan pakej
  intervensi yang ditawarkan kepada pelanggan
  
• membantu menilai pencapaian objektif klinik
  wellness.
  
• Membantu menyelaras penyelengaraan peralatan

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Keperluan Latihan

• Post- Basic Primary Health Care
• Post-Basic in risk identification and management
• Post-Basic in wellness management
• Post-Basic in Emergency Management,( Basic Life
  Support Advance Life Support)
  
• Post-Basic in Chronic Disease Management

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Latihan Perkembangan Kerjaya

• bidang pengkhususan (kepakaran)
• On Job Training
• In ServiceTraining
• Aktiviti CPD CME points
• Practice Standards
• Credentialing/Priviliging (coming soon!)
• Latihan tambahan diperlukan
• - jenis-jenis latihan dikenal pasti
• - melibatkan penukaran skima kerja
• baru
• - Penilaian Tahap Kecekapan (SSM)

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On going now

• merangka pelaksanaan Pendekatan Baru(Wellness)
• di klinik-klinik kesihatan dan menyediakan
  pakej komprehensif perkhidmatan Wellness secara
  integrasi
  

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On going now

• Menguji-cuba tool yang disediakan bagi tujuan
  saringan dan pengurusan risiko kesihatan kumpulan
  umur remaja , dewasa lelaki dan wanita serta
  wargatua dengan menggunakan Clinical Pathway
• Mengenalpasti kriteria kriteria untuk tahap
  risiko dan pakej pengurusan risiko berkaitan
  (mengikut prioriti) bagi setiap kumpulan umur
  
• Menyediakan pelan pelaksanaan projek

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On going now

• - Mengemaskini tool content saringan
  dan pakej pengurusan risiko kes-kes di
  perkhidmatan wellness secara integrasi
  

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PELAN PERANCANGAN PELAKSANAAN PROJEK PERINTIS
KLINIK WELLNESS

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Expected Standard Of Care

• High level Primary clinical Care
• - Specialist care
• - Comprehensive care
• - Continuity of care
• - Seamless from womb to tomb
• - Promote wellness
• - Care close to home
• - Cost-effective care
• - Evidence based practice
• Performance through several indicators and QA
  Programme
  

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Targets What of population ??
ILL
WITH RISKS
POTENTIAL RISKS
HEALTHY No identified Risks

• What gradient of change?
• How much can we invest?
• Can this new strategies make a difference?

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