Paediatric Subspecialty Interfacing with Primary Health Care

Paediatric Endocrinology & Primary Care Paediatrics

Dr. Huen Kwai – fun President The Hong Kong Society of Paediatric Endocrinology & Metabolism

Referral Pattern to a Paediatric Specialist Clinic

Respiratory problems 17% Growth & Endocrine problems 16% Neurological problems 16% Heart problems 12% Renal problems 6% NNJ 6% Abdominal pain 3% Others 24% HKMJ Vol 6 No 1 March 2000,24-28

Growth & Endocrine Referrals

>55% referrals from Student Health Service >9% referrals from private practitioners >5% referrals from MCHC >2% referrals from A&E ?% referrals from GOPC HKMJ Vol 6 No1 March 2000,24-28

Relationship between General Pediatricians and Subspecialists

No clear consensus to what types and severity of problems, or what aspect of any given chronic problem, should be managed by primary care pediatricians and what should be the domain of the specialist.

Children’s subspecialist services are relatively new compared with equivalent adult services

Research in internal medicine on the outcomes and quality of care provided by generalists and subspecialists is limited and conflicting.

Data for pediatric patients is lacking.

Demand for Subspecialist Service Several studies suggested parents are not confident with

generalists level of skill in managing complex illnesses.

Rapid advances in specialist care in past decade

Increased survival of children with previously fatal conditions cause a steady increase in volume of work and demand for specialist services

Access to tertiary services recommended as minimal standards of care ( rising patients’ rights and access to medical information)

Benefits of a Tertiary Centre in Paediatric Endocrinology

Provide comprehensive training program in PE Improve the quality of care through provision of service

standards, development of management guidelines and audit of clinical service

Provide specialized laboratory services e.g. molecular biology, steroid chemistry, tissue culture, etc.

Provide consultation service to other service providers Co-ordinate and promote collaborative research Pool resources and expertise in PE Promote the practice of PE

Primary , Secondary & Tertiary Care in Paediatric Endocrinology

General Paediatricians

General Paediatricians with special interest in Paediatric Endocrinology

Specialists in Paediatric Endocrinology

Relationship between primary, secondary and tertiary care for children and their families (BPA, 1995)

Service Integration

With a specialist to coordinate an expert multidisciplinary team and liaise with consultant paediatricians, primary care providers and community services, children with chronic diseases can lead normal or near normal lives

Success Interface Between Primary Care Paediatricians and Subspecialists

1. Common goals

2. Common criteria for good practice

3. Information, Clinical and Financial bridges to overcome barriers

4. Structured Training Program

Common Goals

Strengthen service providers collaboration with sharing of standards, quality practices, training and development opportunities and patient information among different providers

The ultimate objective is to improve the outcome and quality of care to maximize the benefit to the child with the best utilization of our resources

Criteria for good practice

The Child and Family are central to the process. Total patient care which is patient-centered and addressing needs at home & in the community.

Active participation in training and continuous professional education/development

Participation in shared care according to agreed clinical protocols, including health promotion, prevention and screening activities where appropriate

Criteria for good practice

Participation in clinical management meetings and clinical audit

Participation in community care, out of hours consultation, where appropriate

Contribution to clinical data, research, teaching, and disease surveillance

Installation of good quality infrastructure and participation in quality improvement projects

Bridging the barriers

To avoid fragmentation and imbalance of service between Primary care paediatricians and Subspecialists

1. Information bridge

2. Clinical bridge

3. Finance bridge

(1) Information Bridge

Continuity of care achieved through unimpeded flow of clinical information across different providers and across time

Develop suitable IT infrastructure and applications aimed at cross providers usage

All concerned parties must be involved at the very start

Information Bridge

Willing to share medical records with patient’s consent, and standardize data definition and data entry

Ensure system security and maintenance

Government could provide subsidy as incentive for private participation, especially for solo practitioners

(2) Clinical Bridge

We need to build up the knowledge and research infrastructure that makes use of the data available, and work hand in hand with the quality side to set agenda for improvement initiatives

We need an over-arching planning framework to coordinate interests of various providers/sectors

Clinical Bridge The common “currency” in this system should be

evidence based clinical protocols that cut across organizational boundaries

Such protocols should be developed through professional leadership and expert input, focusing on important diseases, but also with participation of involved parties to ensure practicability and enhance buy-in

It takes a proper structure and a bit of incentives for this work to be carried forward

Clinical Bridge Experience within HA – obstacles to progress –

either political or financial, or both, arising from hospital and departmental boundaries, particularly impact on budget and spending

Population-based funding and cluster management aiming to move patients from inpatient to ambulatory and primary care setting and to private sector, can lead to more efficient use of available resources

Clinical Bridge Clinical protocols will provide guidance on the

use of the most appropriate setting of treatment for different stages of diseases, and criteria for cross referral

The parallel development of information systems across sectors, system-wide clinical audit and operational research will answer questions of clinical outcome, cost, and policy appropriateness

(3) Finance Bridge

Develop products and incentives that attract patients to go back to their private doctors

Continued linkage with hospital and specialist backup important

Stable patients managed in primary care setting according to clinical protocols.

Finance Bridge Choice of doctors if they go back to their private

GP, while guaranteed of hospital backup if they need them

Incentive system designed to encourage practice of good medicine

e.g ‘preferred provider partners’ ‘green lanes’ for referral to specialist care subsidy either in kind or cash

Training Program

Principles

Training should lead somewhere – manpower situation and career structure need consideration

Structure and organization of training – integral part of CME / CPD

Proposed Training Profile

All Paediatricians – Basic Training General Paediatrics (2 years)

Neonatology (6 months) Rotation through 2-3 hospitals

Primary care paediatrics and child health (1 year) Ambulatory paediatrics (6 months) Child Assessment Centre (3 months – optional) Clinical genetics (3 months – optional) Rehabilitation (3 months – optional)

Intermediate examination

Proposed Training ProfileGeneral Paediatricians with special interest in PE Paediatric endocrinology (2 years)

District diabetic population

Children with primary hypothyroidism

Individuals with delayed puberty

Growth hormone deficiency

Short and tall stature children

Rotation through 2-3 hospitals

Child health and primary care paediatrics (1 year)

Exit examination

Proposed Training ProfileSubspecialist in Paediatric Endocrinology Paediatric Endocrinology (2 – 3 years)

Disorders of the adrenal gland Ambiguous genitalia Disorders of pituitary glands Hyperthyroidism Complications of diabetes Early puberty Hypoglycaemia Disorders of calcium metabolism Inborn errors of metabolism Liaise with adult and paediatric colleagues complex cases. Research essential 1-3 years, a higher degree MD or PhD

desirable

Suggested Flow Chart in Paediatric Training2 years

Core training1. General Paediatrics2. Neonatology

1 year Child health and primary care paediatrics- ambulatory paediatrics, assessment center, genetics, rehabilitation etc

Intermediate Assessment

3 years 3 yearsGeneral Paediatrics with special General Paediatrics with specialinterest(s) on primary paediatrics interest(s) on subspecialties

Exit Examination

2 years – Sub-specialties – general advance / sub-specialties

Success Integration of Service Common vision and mission common objectives and good practice criteria Clear Role Delineation clear service structure and financial incentives Appropriate training organized training program Good communication information and clinical bridges

Priority Areas for Interface in Paediatric Endocrinology

1. Common disorders - Management & referral guidelines

*Growth Disorders *Pubertal Disorders

2. New Morbidities – Screening & Management protocols

*Obesity *Type 2 Diabetes

Priority Areas for Interface in Paediatric Endocrinology

3. Health Promotion Programs * Encourage exercise * Balanced nutrition and healthy eating style

4. Public Health Screening Programs * PKU *Maternal iodine deficiency

“ The Artist is nothing without the Gift,

but the Gift is nothing without Work”

Emile Zola

Work is Love made Visible.

The Artist is nothing without the Gift; but the Gift is nothing without Work.

Emile Zola

Emile Zola

HAPPY BIRTHDAY

HAPPY BIRTHDAY