Healthcare Provider Networks (HCPN) PDF

PFCM Dr. Derrick Martin Healthcare Provider Networks (HCPN) ○ [READ] RA11223 (universal health care law) What...

PFCM Dr. Derrick Martin Healthcare Provider Networks (HCPN) ○ [READ] RA11223 (universal health care law) What is HCPN? ○ Previously known as the health service delivery network in RA 11223 ○ Refers to a group of primary (grass root levels: barangay health stations and municipal health offices / MHO; first contact facilities of patients → usually manned by MHO and health staff) to tertiary (other higher levels of health care) care providers, whether public or private (or both), offering people-centered and comprehensive care in an integrated and coordinated manner with the primary care provider acting as the navigator and coordinator of health care within the network (municipal health and RHUs are the ones that will direct the patient into the network, where they need the health service) ○ It is the job of the MHO (primary care provider) to navigate the patient until such time that they receive the appropriate treatment within the service delivery network What is the objective of DOH AO No. 2020-2019: guidelines on the Service Delivery Design of Health Care Provider Networks? ○ “...to ensure that the continuum of care is delivered through people-centered (patiensts are the focus of services) and integrated (system wherein patients are navigated from one health care provider to another is inherent or already being practiced in the area) health system” Apex or End-referrral Hospital ○ The terms apex (at the top of the pyramid; highly specialized institutions, i.e. heart center, lung center) and end-referral hospital (tertiary or training hospital with several specialities; may not be considered apex if they do not comply with the criteria set by the DOH) are used interchangeably ○ Refers to a hospital, offering specialized services determined by DOH (determine which faiclitiies are considered apex hospitals), which is contracted as a stand-alone facility by PhilHealth Speciality centers → departmentalized specialities within a healthcare institution ○ Unit or department in a hospital that offers highly specialized care addressing particular conditions and/or providing specific procedures and management of cases requiring specialized training and/or equipment (which may not be available in primary care institutions such as MHO) Referral ○ Process in which a health facility officially and appropriately transfers the management of a patient to a better or differently resourced facility, and refers the patient back to the assigned primary care provider ○ Write a referral letter and send patient to higher institution (not lower); referral should go up the scale; once at the top and the management is done, it is required to return the patient back to the primary care provider for the continuity of care Health Care Provider - refers to any of the following ○ Health facilit: hospital ○ Health care professional: doctor, nurse, anyone that is a professional that delivers healthcare services ○ Community-based health care organization ○ Pharmacies or drug outlets: part of health delivery system ○ Labaoratories and diagnostics clinics Primary care Provider Network (PCPN) → component of HCPN ○ Refers to a coordinated group of public, private or mixed primary care providers, as the foundation of the HCPN (umbrella term that include its base or main foundation, aka PCPN)  PFCM Dr. Derrick Martin Primary Care Facility → give primary care, first line of care where patients go to ○ Private or public institution that primarily delivers primary care services which shall be licensed or registered bu the DOH with the prescribed service capability ○ Not all RHUs are condiserd primary care facility as they still need to undergo accreditation and assessment form the DOH Primary Health Care ○ Whole-of-society approach that aims to ensure the highest possible level of health and well-being through equitable delivery of quality health services ○ Another umbrella that encompass primary care Primary Care → component of primary health care ○ Initial-contact, accessible, continuous, comprehensive adn coordinated care that is accessible at the time of need including a range of services for all presenting conditions and the ability to coordinate referrals to other health care providers in the health care delivery system, when necessary Primary Care Provider ○ Not all health care providers are primary care providers ○ Health care worker, with defined competencies, which has received certification in primary care as determined by the DOH or any health institution that is licensed and certified by the DOH ○ Three components: Primary care practice - exercise of duties and responsibilities of multidisciplinary team of health workers which shall be eligible to be assigned to a catchment area or population in a primary care facility; action or application of primary care Primary care facility - institution that primarily delivers primary care services which shall be licensed or registered by the DOH; it is a health care facility, but not all can be a primary care facility; lowest on the pyramid Primary care worker - health care worker, who may be a health professional or community health worker/volunteer (nutrition scholars or barangay health workers), certified by DOH to provide primary care services; Population-based health services → health interventions that cannot be specificially traced back to a singular person or beneficiary; covers the entire population Criteria: ○ Intended to be relieved by population or identified froupd of people, of which outcomes contribute to the general public health, safety, and protection; ○ Rendered in response to a public health emergency or disaster or any circumstance of equal magnitude, such as diseases for elimination, that has affectedm or can potentially affect, a population Examples: ○ Surveillance and monitoring ○ Prevention and control of epidemic diseases ○ Health communication and dissemination (information campaigns; health promotions) ○ Public health policy development ○ Disaster preparation and response Individual-based health services → are services that: ○ Can be definitively traced back to one (1) recipient ○ Has limited effect at a population level; ○ Does not alter the underlying cause of illness General Guidelines ○ Public, private, or mixed HCPNs shall be established to provide all population groups with continuous health care from primary to tertiary, which shall be delivered in a safe, efficient, and coordinated mechanism  PFCM Dr. Derrick Martin ○ All HCPNs shall have functional care coordination with the PCPN (foundation) serving as the patient’s initial-contact and navigator ○ HCPNs shall establish a patient navigation and coordination system, patient records management system, harmonized information and communication technology, medical transport system, standardized network mechanisms for operations, and financial and performance management ○ Public HCPNs may complete their service capability through contractual arrangements with the private sector or vice versa; not all public facilities can provide all that is needed for the patient, for those that they can't provide, that can arrange contractual arrangements (i.e., MOA) to secure what their patients need ○ All HCPNS shall have primary to tertiary care providers with linkages to an apexhospital and other facilities providing specialized services needed by its catchment population; HCPN must have a linkage to at least one apex hospital ○ All DOH hospitals shall endeavor to become apex hospitals ○ The DOH shall determine eligible apex or end-referral hospitals ○ All hospitals shall have a Public Health unit to facilitate the implementation of population-based health services and seamless patient navigation within the HCPN; population-based services is the responsibility of only the public facilities (governemnt), as private may not provide population-based services Types of HCPN: Public, mixed, private PUBLIC - Primary care: RHUs, component barangay health stations, or organized localities and health offices - Secondary: level 2 hospitals - Tertiary: highly specialized institution - APEX: is a stand-alon and not a part of the triangle - It is determined by demographic and political boundaries, since it is public → responsibility to take care their assigned pubic stations PRIVATE - Mirrors the same triangle, however, the classification is based on market forces [private hospitals are built for profit] MIXED - There can be a combination of public and private care via contractual arrangements depedneing on the case  PFCM Dr. Derrick Martin What are the components of the HCPN? - Patients go to barangay health stations (component of RHU); if all the patients’ need are met in the primary care, he or shee could stay there, however, if they need higher level facility or services, they are navogated through the network (level 1 → level 3 hospitals) - Again, apex is stand-alone hospital, a separate entity form the network The HCPN shall be composed of PCPN providing primary care service, and hospitals delivering secondary and tertiaty general health care 1. The PCPN shall be composed of the following health faiclitites that provide population and or individual-based primary care services: a. Primary care facilities (RHUs, health centers, medical outpatient clinincs) which shall ensure proper coordination and service delivery across PCPN; and, b. Other health facilities necessary for the delivery of primary care, such as but not limited to, health stations, stand-alone borthing homes, stand-alone laboratories, pharmaceutical outlets, and dental clinics 2. Following health faiclities, whether public or private, shall prvide general in-patient care services for the HCPN: a. Infirmaries, if present in the existing geographic or political boundary b. Hospitals, as classfified by the DOH, which shall include: i. At least one level 1 providing secondary care; and, ii. At least one level 2 or 3 hospital providing tertiary care Linkage of HCPNs to Apex Hospitals ○ Apex hospitals shall be linked to HCPNs and shall deliver specialty health care services not expected to be provided in HCPNs ○ DOH shall determine eligible apex hospitals based on the following servoce capabilty i. Single-specialty hospital (e.g. heart or lung center) that is designated by law or licensed by DOH, or ii. General hospital with the following: - Accredited teaching and training in at least the following four major departments: medicine, pedicatirc, surgery, obstetrics, and gynecology - At least 2 speciality centers according to DOH standards  PFCM Dr. Derrick Martin Management Structure of the P/-CWHS ○ The provincial or city health boards (P/CHB) shall be stweard of the integrated local health system and responsible for setting the policy and strategic directions of the P/CWHS. ○ ICC - independent component cities ○ HUC - highly ubranized cities ○ In provincial health board, there is always a part of the indigenous cultural communities Composition of the P/CHB Postiion Province HUC/ICC Chairperson Provincial governor City mayor Vice-chairperson Provincial health officier City health officer Members Cheir of commitee on Chair committee on health-sangguniang panlalawigan health-sangguniang panlungsod DOH representative DOH representative PO, NGO or Private Sector PO, NGO or Private Sector Representative Representative ICC/IP representative, as applicable CC/IP representative, as applicable Representative/s of municipalities and component cities included in PWHS