Organization of rural population medicare and prospect of its development
1. The conception about medicare
Medicare according to the village population appears on general bases, however complicated realization of medical and prophylactic measures in an optimal volume and at sufficient level is by the row of circumstances, which are needed to take into account during its organization
It is possible to select among them;
• social-economic terms;
• medically-demographic features;
• state of morbidity and disability;
• natural terms;
• development of infrastructure on the whole and networks of medical establishments in particular.
Availability of prophylactic treatment aid in complicated by the features of settling apart of village population, which stimulate the low levels of morbidity from data of appeals. The number of visits of doctor and level of general morbidity diminished at the increase of distance from a village to the village district hospital (out-patient’s clinics). At the same time the indices of the “exhausted” morbidity, set as a result of the deep special selective researches, are considerable enough.
The network of prophylactic treatment and establishments was folded during great while. As above all things the specific of the system of settling apart of village population was taken into account with its geographical, economic and social features.
Gradually to the extent of alteratioetworks and growth of material well-being by a medical personal in its forming went into effect principle of staging:
I-st stage is a village hospital provides the primary medical sanitary aid.
ІІ stage are district medical establishments which give secondary (specialized) medical aid mainly (the primary aid on this stage appears only to the habitants of district center and villages adjoining to him – registered in hospital).
ІІІ stage are regional hospitals and dispensaries provide the highly-specialized aid.
The IV stage, which is represented by the inter-regional and state specialized centers which formed in modern terms. In addition, in the grant of medicare to the village population take considerable part and city hospital.
Consequently, on every next stage the population gets medicare higher after the degree of complication.
Bringing in to the medical providing of village population in cities and regional hospital allows to a certain extent to decrease disagreements in the levels of material well-being of villagers (especially it is up to the stationary aid).
It is considerably more difficult to provide the village population by the ambulatory-policlinic aid, as in her acted noticeable part and continue to play medical workers.
From the commoumber of visits by the villagers of medical establishments on the II-nd stages (7,4 on one habitant) on the first are only 2,3, that is not sufficient.
It testifies to the urgent necessity of the PMSA (primary medically-sanitary aid) strengthening, is necessary of more active introduction of bases of domestic medicine.
A village medical hospital plays important role in the grant of population medicare, conducting of prophylactic and health measures.
For the organization of village hospitals are taken into account:
• quantity of population;
• features of settling apart;
• hospital of district;
• distance between the settlements;
• state of ways.
On the end of 1999 year the 3300 village medical hospitals were counted in
Above all establishment are the district hospitals or independent medical out-patient’s clinics.
Basic tasks of district hospital:
• providing of village population by the ambulatory and sanitary medical aid;
• realization of prophylactic treatment and general health measures for the health protection of mother and child;
• organization and conducting of prophylactic measures and to decrease of morbidity indices and cases of traumatism;
•to advance the modern methods of prophylactics, diagnostics and treatment;
•Organization of medical guidance and control by activity of health protection establishments.
A volume and types of stationary aid is determined, coming power of hospital from full strength by the proper specialists. Regardless of power of permanent establishment in some village hospitals the aid must appear to the therapeutic and
2. District hospitals
For providing of treatment and care of patients, except for doctors, foreseen positions of medical sisters.
In district hospitals to treat mainly the sick by therapeutic type. Considerable part of them are hospitalized not so much after medical, as after social testimonies (old people, that need examination and conducting of supporting treatment). During great while the particle of such sick hesitated within the limits of 40-60%.
The district hospitals are low-powered, their logistical support were skilled and insufficient. As a result of growth of requirements to quality of medicare the population gravitates to establishments, which give specialized and more high-quality aid.
In accordance with the volume of medicare quality for village population of stationary aid considerably diminished exactly at primary level that in district hospitals.
The ambulatory aid is the important section of work of village medical hospital.
Village out-patient’s clinic carries out:
• to early exposure of diseases and risk factors;
• timely treatment of patients in out-patient’s clinic and at home;
• selection of persons which need clinical observation, timely their inspection, treatment and to make here healthy;
• organization of urgent medical aid;
• direction of consultations and preparation to the review by the doctors, specialists of district establishments in their planned departure on village medical hospitals;
• timely hospitalization of patients;
• examination of patients with temporary disability;
• direction on the medically-social expert commission (МSЕC) of the patients with the signs of proof disability;
• dynamic observation by the state of women and children’s health;
• planning of the graphs and conducting of consultative receptions of patients on territory of the activity;
• conducting of health and anti-epidemic measures.
The structure of out-patient’s clinic, as component part of hospital, enter register office, cabinets of doctors, manipulation, bandaging cabinets.
3. The norms and notes.
There are the following norms and notes:
1. Regulary norms are used at the calculation of the states of the ambulatory points located in the distance anymore as a
Their application to the ambulatory points, which are created in the settlements located in the distance to a
Main tasks of the ambulatory manager:
• conducting of ambulatory reception and maintenance of calls;
• implementation of setting of doctors, conducting of certain physical therapy procedures and laboratory researches;
• participation in organization of prophylactic medical reviews, by the selection of persons for the clinical observation;
• organization of transportation of patients to the general medical establishments, accompaniment the sick children who lived more than 1 year;
• early exposure of infectious patients; providing of isolation, and if necessary – hospitalization of these patients;
• realization of patronage of patients with tuberculosis, psychical disorders; there is participation in their ambulatory treatment;
• conducting of inoculations;
• conducting of anti-epidemic measures in the cases of infectious diseases;
• conducting of current sanitary observation from the proper objects and territory of settlement;
• conducting of prophylactic measures of agricultural traumatism;
• medically-hygienic learning of population; drafting of plans of the ambulatory work;
• filling of registration documents and drafting of report of ambulatory point (f.024);
• to delivery of sheets of disability (pursuant to the proper order of regional department (management) of health protection.
The main functions of the ambulatory midwife:
• annual census of children more than 15 years;
• conducting of ambulatory reception of children, pregnant, gynecological patients and quality of medicare at home;
• organization of consultations at the diseases of children (especially early age) of district doctor (pediatrician), timely hospitalization to the general hospital;
• conducting of prophylactic reviews of all women;
• patronage of pregnant women and children;
• if necessary the direction of women to the gynecologist;
• implementation the children of settings to the doctors, pregnant and gynecological patients;
• conducting of certain physical therapy procedures and laboratory researches;
• quality of medicare at the acute diseases and accidents;
• conducting of inoculations;
• medically-hygienic education of women and children.
A medical assistant and midwife have a rights:
• to conduct the inspection within the limits of the jurisdiction , combination of diagnosis, appoint treatment;
• to execute necessary manipulations;
• to write recipes (except for strong and poisonous remedies);
• to give the certificates.
The important role in the ambulatory activity is taken to the prophylactic of traumatism and providing of sanitary-epidemic prosperity. For that the medical workers carry out the current sanitary observation after educational establishments, farms and processing productions, sources of water-supply and others like that, the inoculation is conducted in accordance with an operating calendar and after epidemiology testimonies.
CDH provides the quality of the specialized aid for the population of district and is the center of organizationally-methodical work, as carries out guidance by all prophylactic treatment establishments on territory of district, to carry responsibility for organization and quality of medicare.
Positions of doctors in hospitals establishment to depend with the amount of beds and type of separations. In accordance with it the states of middle medical workers are formed.
Basic tasks of CRH (central regional hospital).
• direct grant of primary ambulatory-policlinic aid for the population of village and district;
• quality of the specialized ambulatory-policlinic and stationary aid to all population of district;
• providing by quickly and exigent medicare of district population ;
• introduction into practice the modern methods of work in district hospital and facilities of prophylactic, diagnostics and treatment;
• organization of consultative work;
• organizationally-methodical guidance by work of all district hospital, and also control after its activity;
• development and introduction of measures directed by medical providing;
• development, organization and realization of measures on the in-plant and rational uses of medical personnel’s and material and technical resources training of medical personnel’s;
• planning, financing and organization of logistical support of establishments of health protection district.
Implementations of these difficult tasks are fixed on the proper structural subdivisions in a hospital.
In the cases when power of some CRH does not allow creating the specialized separations (ophthalmology, urology, traumatology), the inter-district separations are created.
In permanent establishments of central district hospitals the norms of establishment of positions of medical sisters (chamber) practically do not differ from the norms foreseen for permanent establishments of city hospitals.
Organizationally-methodical work to assignment.
• analysis of indices of population health;
• analysis of indices of work of the district hospital;
• study and distribution of experience;
• planning and organization of departures of the specialists hospitals on village hospitals for the consultative aid between the population and doctors;
• planning and providing of conducting of prophylactic medical reviews;
• planning and organization of the in-plant training of medical workers of district;
• development of measures on the improvement of the medical providing of population of district.
The important role in organization of medicare for the children in village society belongs to the district pediatrician.
The main functions of pediatrician:
• consultative aid of the district center hospital, village medical hospitals from the questions of organization of medicare for children;
• the ambulatories visit and village hospitals (out-patient’s clinics), review of healthy and consultation of sick children, verification of timeliness of conducting of prophylactic inoculations and sanitary-anti-epidemic measures;
• control after conducting of clinical observation by children, above all things in the first year of life; after conducting of prophylactic inoculations to the children;
• drafting jointly with the sanitary-epidemiology station (SES) of the plan of the anti-epidemics measures directed on the fight against children’s infectious diseases;
• providing of the in-plant training from pediatrics for the doctors of village hospitals, medical workers of child’s preschool establishments and schools, health-visitors, medical personnel ambulatories;
• visit of children’s preschool establishments, control after their activity;
• analysis of reports of children’s prophylactic-treatment establishments, study and estimation of the state of children’s health of village, district and the hospital activity, generalization of findings and development of concrete measures of medicare;
• bringing in of representatives of local organs of power, public organizations, assistance of Society of Red Cross to conducting of the measures directed on the improvement of medical care to the children.
Regional hospitals are leading establishments of the third stage of the medical providing of region population. The amount of them makes
Next to direct participation in providing of stationary and consultative polyclinics aid, a regional hospital coordinates prophylactics-treatment and organizationally-methodical work which is carried out by hospitals and dispensaries in towns and district centers, regions. This establishment is a base for the in-plant training of doctors and middle medical personnel.
4. Basic tasks of regional hospital
They are the following ones:
• providing of population of region by the high specialized stationary and polyclinic aid;
• organization and grant of urgent and consultative medicare on region;
• introduction into practice the modern methods of hospital work and facilities of diagnostics, treatment, experience;
•training of doctors in-plant and middle medical personal of region establishments;
• organization, guidance and control by a statistical account and accounting, drafting of the taken reports, analysis of performance indicators of prophylactic-treatment establishments of region;
• development of measures, directed on medical providing and on the improvement of population’s health.
A consultative polyclinic is important structural subdivision of regional hospital, which functions are belong:
• grant of highly specialized consultative aid for the patients by directions of region establishments;
• decision of questions about subsequent treatment of the consultative patients with determination of medical technology and place;
• bringing into consultation of highly skilled doctors– specialists of hospital and other, and also workers of research institutes and medical institutes;
• direction for hospital, which sent on consultation of patients, conclusions with pointing of the diagnosis, set in a polyclinic, conducted and recommended treatment;
• development for the hospital region of suggestions (sights) about an order and testimony for direction of patients to the polyclinic;
• organization and conducting (together with the separation of urgent and medically-sanitary aid) of departure consultations of specialists of districts, and also extra-mural consultations of the doctors;
• systematic analysis for the districts of region (the cases of diagnoses disagreements between hospitals), in which the patients sent consultation in polyclinic;
• error assumed by hospital doctors at the inspection and treatment of patients before direction of them to the polyclinic analysis;
• drafting looked over informative sheets about the state and level of medically-diagnostic work in districts.
One of tasks of regional hospital is organization and grant of urgent and planned-consultative aid. This work is planned and is executed by independent subsection-separation with a similar name. It will organize round-the-clock controller’s service (medical assistant) of reception and registration of calls from the hospitals of districts, bridge of region and provides the timely grant of urgent and planned-consultative aid for the population. Before the work the specialists of regional hospital are attracted, other hospital regions, employees of medical institutes of higher, research institutes on the concordance with the general establishments and establishments, pursuant to the order of the proper management of health protection.
After the grant of necessary medicare in place, in the case of necessity, the separation provides transporting of patients to the regional center, on occasion outside a region to the proper hospitals.
To that end it uses both sanitary aviation and ground vehicle, depending on the state of patient, distance, meteorological terms, season, time of days and others like that.
In the feature of different regions it is needed here and there at reduction of bed fund of district hospitals of replacement of the usual three-staging system of grant of stationary aid (district, regional hospitals) by two-staging (district, regional hospitals).
Reduction of beds in district hospitals can be compensated definitely due to the sanitary-replacing aid – daily permanent establishments. It is expedient also to have the certain amount of beds in village out-patient’s clinic (3-5 beds) for temporal hospitalization of patients which need stationary treatment oext stages.
Reduction of stationary aid on the first stage is to be compensated by the increase of volume of medical ambulatory aid and its approaching to the villagers, that is possible on condition of careful replacement of establishments medical assistants medical.
Needs urgent decision of realization of complex of measures on the improvement of conducting of the centre system health and making healthy of village population. With the purpose of upgrading prophylactic reviews and development of prophylactic-treatment measures clinical patients are foreseen to engage in this work not only the specialists CRH but also regional hospitals (pursuant to the order of Health Ministry of Ukraine № 261 from 29.10.99).
The improvement of quality of prophylactic-treatment aid requires subsequent development of quick and exigent aid, which is provided on the second stage by district hospitals.
The administrative decisions must be directed on saving of network of establishments of medical aid, as its availability depends from it.
Reorganization of the system of prophylactic-treatment aid to the village population must take place gradually. The beds of district hospitals can be used as medico-social and for the separations of sisterly examination that the question is not about mechanical reduction of stationary aid on the first stage, and about its pre-orientation oew organizational forms expedient from the point of view economic efficiency and socially-psychological positions. With it attitude of population is linked toward reorganization of the medical providing, perception by him changes in the system of health protection.
PRINCIPLES OF FAMILY MEDICINE
A harmonious relationship between family physicians and specialist/consultants is essential for high quality medical care. Patients are crucial partners in the relationship, and important ethical principles have to be considered. Efforts to improve the relationship must have as a primary goal the welfare of patients. To these ends, guidelines for the consultation, referral process and a set of specific recommendations are in two categories: patient-centred and profession-centred.
Patient-centred recommendations: Referring physicians should involve patients in the decision to refer, the choice of specialist/consultant, and the proposed management plan, including follow up and continuity of care. Referring physicians and specialist/consultants are responsible for making available to patients appropriate consultations within reasonable times.
Profession-centred recommendations: Recommendations are addressed to universities and hospitals, and to other interested parties. They deal with the roles, responsibilities, and functions of family physicians and specialist/consultants; with guidelines on the referral process; with the need for review and evaluation of consultation and referral; with education, training, and demonstration of consultation and referral to students and residents; and with ethical aspects of the referral process.
The family physician’s role is to provide comprehensive, continuing primary medical care; the specialist/consultant’s role is to address the problem that led to the referral, assess the patient, and promptly communicate findings and recommendations to the patient and the referring physician. Normally specialist/consultants should send patients back to their family physicians for continuing care, but sometimes it is appropriate for specialist/consultants to provide concurrent, ongoing care. If referral to another specialist is indicated, specialist/consultants should discuss the matter with both the patient and the referring physician. A patient who has no personal family physician should be encouraged to select one.
The primary purpose of consultation or referral is to improve the quality of health care by making available to patients and referring physicians the knowledge and skills of specialist/consultants at appropriate times.
To achieve optimal benefit from consultation and referral, referring physicians, patients (and sometimes their families), and specialist/consultants have to accept certain responsibilities.
Responsibilities of referring physicians:
• to ensure patients understand the need for, and purpose of, referral and consultation;
• to demonstrate courtesy and respect for patients and specialist/consultants during consultation or referral;
• to communicate clearly to specialist/consultants the purpose and problems for which help is needed;
• to send specialist/consultants (where necessary and possible) the results of findings and investigations, including copies of radiological films, so that they will be available at the time of consultation; and
• to participate in peer and system review of the consultation and referral process.
Responsibilities of patients:
• to understand the need for, and purpose of, the consultation or referral;
• to demonstrate courtesy and respect for both physicians;
• to ensure they understand the time and place of the consultation and the records they are to bring, and to advise both physicians if they are unable to attend;
• to understand that the results of the consultation or referral will be communicated to them by the specialist/consultant;
• to understand that the results of tests carried out by laboratory-based specialist/consultants will be reported to them by the physician who ordered them so the results can be interpreted in the appropriate clinical context;
• to understand that, after the consultation or referral, they should return to the referring physician for continuing care and advice as a result of the consultation; and to participate in peer and system review of the consultation and referral process.
Responsibilities of specialist/consultants:
• to provide ease of access to their consultation services through courteous and collegial responses to referring physicians;
• to provide consultation at appropriate times or assist referring physicians to find other consultants;
• to demonstrate courtesy and respect for patients and referring physicians;
• to communicate clearly and promptly the results of consultation to referring physicians and patients;
• to promptly report the results of laboratory tests to referring physicians so the results can be reported to patients in the appropriate clinical context;
• to advise referring physicians promptly of their patients’ admission to hospital and provide prompt reports on discharge;
• to recognize referring physicians’ concerns about lateral or cross referrals for unrelated medical problems;
• to return patients to referring physicians for continuing care at the appropriate time (under some circumstances it is appropriate for specialist/consultants to provide concurrent, ongoing care for specific or complex problems. Where possible, this decision should be made with the consent of patients and referring physicians);
• to participate in peer and system review of the consultation and referral process.
FOUR PRINCIPLES OF FAMILY MEDICINE
1. The Patient-Doctor Relationship.
This principle incorporates the notions of continuity of care and comprehensiveness of care including caring for a patient in the context of the family and society, and also the role of patient advocate. The continuous relationship with a patient gives the physician access to insights not otherwise available and the opportunity to follow and study disease process over long periods of time.
2. Family Medicine is Community Based.
The context in which patients are seen may include office, hospital and home. In addition to acute and life-threatening disease, there is a high prevalence of chronic illness, emotional problems and transient disorders. Practice is significantly influenced by community factors. Problems are not pre-selected and are frequently encountered at an undifferentiated stage. The physician must be able to deal with any problem a patient presents.
3. The Family Physician as a Resource to a Practice.
The physician must be able to apply knowledge and skills efficiently including the ability to evaluate new knowledge and its relevance for practice in the community. An awareness of one’s own limitations, a knowledge of and a willingness to draw upon community resources, such as consultants, allied health professionals, and other agencies, is also important.
4. Clinical Skills.
The family physician must be a sound clinician. A wide range of clinical problems presents in the family practice setting. The family physician must possess the general knowledge and skills necessary to deal with these problems. These aspects of family medicine have major implications for the nature of the postgraduate family medicine residency programs. The experience in family medicine must form the basis for any residency program. The involvement of medical colleagues in other disciplines and other health professionals must always be guided by the goals and principles of family medicine.
