Community Health Centres

In 1978 world leaders gathered in Astana to renew their commitment to health for all, which resulted in signing Alma Ata Declaration3. The Declaration called for global commitments to achieving Health for All by the year 2000. It was based on the principles of equity and community participation in health planning and policymaking, through an intersectoral approach.

Alma-Ata Conference brought up the issue of the right of every human being and every nation to health care and health promotion, to a new, global level. It has also recognized the importance and role of the primary health care philosophy in addressing the above issue. This recognition implies de facto that the health of the population is linked to the social and economic development of society.
The conference also brought forward the capacity of the developing countries to be agents of change and not passive recipients from external help. The poor countries showcased how they progressed on the health front.

In October 2018, government, civil society, the private sector and other stakeholders met again to emphasise a global commitment to primary health care. They have reaffirmed that primary health care is about caring for people, rather than simply treating specific diseases or conditions. They also endorsed a new declaration emphasizing the critical role of primary health care around the world. The new Astana declaration aims to refocus efforts on primary health care to ensure that everyone everywhere is able to enjoy the highest possible attainable standard of health. The new declaration has renewed political commitment to primary health care from Governments, non-governmental organizations, professional organizations, academia and global health and development organizations. The new declaration was also a chance to commemorate the 1978 Declaration of Alma-Ata, and reflect on how far we have come and the work that still lies ahead.

The concept of community health care and community health care centres can be traced back to 1901; when milk stations for infants in New York City were established as the entry points for the general health of the population6. In 1965 the first American community health centres were launched as a small  demonstration program as part of the US President Johnson’s Office of Economic
Opportunity. With roots in both the civil rights movement and the War on Poverty, the earliest health centres had a mission to use the health care system to change the health and lives of their communities’ residents.

In Europe, Jan De Maeseneer and a group of medical students, proposed a definition of the Community Health Centre as: “A community health centre is a co-operation of different health care providers (nurses, family physicians, social workers, physiotherapists…) working together on an equitable basis as far as function, impact on policy and financial reward are concerned. The aim is to realize a comprehensive (psycho-socio somatic) care of people living in a neighbourhood focusing on health literacy and empowerment, to contribute to a health care system, involving the population of the neighbourhood in the governance. We defined a neighbourhood as a group of people with similar interests and needs living in the same geographical area”.

The concept of Community Health Centres was inspired by experiments such as the “Local Centre for Community Health: Pointe-Saint-Charles” in Montreal (Canada), by primary health care centres in the United Kingdom and the Netherlands. As a follow to of the report, professionals from social and health sectors started to reflect with students in nursing, medicine, physiotherapy, and social work on how a Community Health Centre could offer an innovative perspective for professionals in health care.

A “Community Health Centre (CHC)” is a model of primary health care that can take a variety of names depending on the region of the world in which it is located. The International Federation of Community Health Centres defines and identifies a “Community Health Centre” according to the minimum criteria listed below. In certain jurisdictions, additional criteria may be in place.

— Community Health Centres deliver comprehensive primary health care through an interprofessional team that integrates primary care services, psycho-social care services, health promotion programs, and population/community health programs.
— Community Health Centres integrate, into their daily activities, attention to the broader causes of illness like poverty, inadequate housing, food insecurity and others (the social determinants of health), addressing them through intersectoral services and cooperation.
— Community Health Centres place a strong emphasis on community engagement and civic participation in health and health care, which often includes the participation of local community members in the governance of the local health centre.
— Community Health Centres take responsibility for a defined population that can be geographically- determined or defined through empanelment of citizens in a CHC.

— Community Health Centres commit to equity and social inclusion and emphasize access to health care (with special attention given to the most vulnerable).
— Community Health Centres contribute to universal health services coverage and are strongly committed to being accessible for individuals and families, irrespective of race, religion, social status, and other factors, including the ability to pay for care.

Healthcare providers in a community health centre put the person at the center. They pay attention not only to the disease itself but also to the patient’s context, experience, and life goals. By emphasizing wellbeing and capacities instead of health problems, space is created for shared decision-making in which healthcare provider and care recipient have a dialogue as equal partners.

In a community health centre, both the patients’ care needs and public interest are taken into account. Striving for high-quality care is in the interest of patients, healthcare providers, funders, and authorities in charge. Each of these parties looks at quality from their perspective, but all strive to fulfill 7 objectives:

1. Effectiveness: care must meet the predetermined goal, be based on scientific knowledge (evidence-based medicine) and be limited to patients who benefit from the intervention.

2. Patient orientation: the care provided is respectful and responds to the goals, needs, and values of the individual patient.

3. Efficiency: efficient care avoids wasting available resources (money, staff, supplies, ideas, energy, …). The cost of care cannot be considered without considering the quality of care that brings about better health.

4. Equity of care: the care does not vary in quality according to personal characteristics of the patient, such as gender, ethnic-cultural background, location, socio-economic status,…

5. Timely care: avoiding waiting times and harmful delays.

6. Safety: care must be safe, i.e. avoidable injuries should be averted as much as possible. The care that is meant to help the patient may not cause them unnecessary harm.

7. Sustainability of care: care should integrate a long term perspective with special attention for the ecological impact.

CHC Botermarkt

It was the second CHC opened in Flanders (Belgium) founded in 1978. It provides primary care for the people living in the southern part of Ghent. It employs 10 FTE GPs (General practitioners), 10 nurses, nurses, 2 social workers, one heath promoter, dentists and psychologists, circa 50 people altogether. The Botermarkt Community Health Centre currently serves circa 6000 patients and that is the capacity limit (both from the location and number of staff perspectives). The CHC is financed by an integrated needs-adjusted interprofessional capitation, without co-payment for the patient.

CHC Botermarkt provides high-quality, accessible primary health care for all residents of Ghent South, Ledeberg, part of Melle and Merelbeke. It contributes to an open, solidarity-based, just, and sustainable society with attention to diversity in all its aspects.

Employees follow the principle of proportional universalism: an equal commitment for everyone (universalism), but where necessary it can be adapted to the needs of the individuals (proportional).

Therefore, the objective is to try to work in a tailor-made way for everyone who registers in the practice. Proportionally, the effort will be greatest for people who are most vulnerable.

The central building block of CHC Botermarkt is that delivering comprehensive primary care services that are person-centred, integral, integrated, continuous and high quality. As the health of an individual and of the community go hand in hand, CHC Botermarkt contributes to a healthy living environment in the neighbourhood as a precondition for healthy behaviour.

With 43 years of the presence in the community, CHC Botermarkt offers an interprofessional team to listen and learn from the community and to strengthen resilience. Importantly, there is a team focusing on health promotion with a ‘health promotion officer’. The centre pays special attention to people with multimorbidity, starting from the patient’s life goals. This is used as the basis for designing a range of subsequent services and interventions by the broader care team that will meet patients’ specific needs.

CHC Nieuw Gent

CHC Nieuw Gent was founded in 2000 under the impetus of the Department of Family Medicine and Primary Health Care of Ghent University. It has 31 full-time equivalents (42 employees) and serves circa 4400 patients, with the potential to add 500 patients within the current capacity.

The specificity of the area for Nieuw Gent is that more than 50% of the housing is social housing. Due to the poor condition of the housing blocks from the 1960s, buildings are taken down en rebuilt, which results in the negative migration saldo.
Apart from the staff and specialists listed in the definition of the CHC (nurses, family physicians, social workers, physiotherapists), there is also a psychologist and pedologist and a dietician that were hired in response to the need in the Nieuw Gent community.

Part of the team is a care coordinator — a person who is responsible for cooperation between all professionals and disciplines. That person is organizing meetings, creating agendas, make sure that cases are being discussed, including complex patient cases, to develop a common vision and common strategy and to facilitate goal-oriented care. Currently, also the prevention and so-called lifestyle medicine is being discussed during those meeting as well — the need of people improving their habits — sleeping, moving, healthy eating, and having a healthy mind.

It took some time for the care coordinators to facilitate learning from each other, build trust and mutual understanding and appreciation of roles and responsibilities.

All team members are implementing goal-oriented care15 by being engaged in developing so called a “chronic care plan”. This label is used to describe a process involving the patient, which consists of a conversation and the co-creation of a care plan, as well as a consultation within the health care team. The patients for whom care plans were created were initially those in a chronic and/or complex (medical or social) situation, with a limited or absent social network, involving multiple care providers and/or in which the care providers involved have a sense of being “stuck”. Patients with these characteristics generally perceive structuring the care provided by the team and sharing of information as a very meaningful exercise.

An in-depth conversation takes place with the patient with the aim of creating an ICF (International Classification of Functioning) “photo” and finding out the patient’s (and the informal carer’s) health care goals. The health care provider can be from any discipline, and a trusting relationship is more important than a medical or paramedical background. This is because goal-oriented care uses a universal language that is spoken by all health disciplines and used with patients and their informal carers. The care team consultation is used to finalise the care plan and set out a number of specific interventions for the members of the health care team. The care plan is included in the Electronic Medical Record (EMR) and used as a reference resource. The care team plans the follow-up.

The health and social issues in the community based on 2-year research (including a sample of the population, data from EMRs (in a GDPR proof way), employees, people well connected in the community, such as shopkeeper, pharmacist, social welfare worker, plus data from health insurance companies, in collaboration with the University of Louvain, so broad qualitative and quantitative research) by the team of CHC Nieuw Gent are:

— Acute infectious diseases
— Problems of the musculoskeletal system
— Chronic diseases: hypertension, obesity, sleep disorders
— Social problems
— HIV, schizophrenia, and psychosis
— More chronic cardiovascular risk factors at a younger age
— Dental problems
— Higher incidence of allergenic rhinitis and asthma
— Limited capacities (mental & physical)
— Poverty
— Limited social network
— Cultural diversity
— Housing problems
— Lack of safety

Based on the issues several initiatives were launched, such as:

— Low threshold physical exercise lessons
— Cycling Lessons
— Advocacy meetings re. a mold problem in social housing
— Dental awareness campaign
— Info sessions to stop smoking
— Informing people and signalling/advocacy meetings on urban development and projects in the neighbourhood
— Social artistic project on wellbeing and life goals
— Symposium on the health needs assessment
— Mediation between the social housing companies and tenants regarding bed bugs problem

The main challenges to tackle nowadays are:

— How to have an impact on broader health determinants, such as low income, poor housing conditions?
— How to successfully address policymakers through advocacy and information on problems?
— How to increase networking and collective actions?
— How to better inform and empower the population?
— Setting up boundaries for the CHC role and level on engagement and resources spent in solving a particular issue (especially regarding issues that are not perceived as health-related by the stakeholders — housing, poverty, urban planning, etc.)

The governance of CHCs in different countries varies a lot, and in particular, funding mechanisms depend on the design of the healthcare system. In terms of the healthcare professionals hired, there are also local differences, depending on the needs of local communities. In general, the governance principles can be focused on shared values and distinct approaches, as depicted in the graphs below.

CHC Botermarkt

The biggest advantage of a Community Health Centre is a broad view on the definition of healthcare, and a comprehensive approach on integrating the context of the patient in the care process. Healthcare professionals are aware they do not see a patient, they see a parent, child, employee, member of the community etc., and all those contexts are being taken into account. It does not happen within one appointment with one GP but is being built over time with different providers. Many professionals have a strong vision of appropriate care, but it is not shared and aligned with the other team members. When working in CHCs it becomes necessary to agree upon the care strategies and its implementation with a certain patient, and to harmonize the communication.

Translating the mission and building a true identity is a long process. It does not stop with writing things down. Step by step the mission needs to be turned into a policy plan, that is followed by framing strategic deliverables. It is like driving on a road when you have different cars but they all should move in one direction to achieve impact and reach the destination. So it is less about strict and rigid guidelines, but more about the alignment and practical implementation of the mission and vision.

Interprofessional integration requires governance and organisation has to be guided and organized. It rarely happens organically, especially in a bigger organization.

Clarifying expectations towards the staff is very important, especially when the CHC aspires at innovation of care processes. The first thing in CHC Botermarkt mission is that health care uses an eco-bio-psycho-social frame of reference, hence staff members are expected to endorse this broad vision. Everyone needs to understand that they engage with patients with the aim to achieve their life-goals, particularly in patients with chronic conditions and multi-morbidity. This approach in taking care of a patient requires professionals to become humble. It requires cooperation, understanding that the professional has the knowledge, and wants to help, but the final result is based on shared decision-making and not the professional’s orders. The professional is an expert in providing care, but is not deciding what is better for the patient. That’s why CHC Botermarkt also provides training in goal-oriented care for healthcare professionals.

What remains challenging is that the Botermarkt community health centre is perceived as a place for the most vulnerable people. While its objective is that the patients mirror the social stratification of the neighbourhood with more and less vulnerable people. The social equity focus strives at integrating all kinds of people. Currently, the tendency is that a lot of organizations are referring the most vulnerable patients to CHC Botermarkt, resulting in overrepresentation within that group, when less vulnerable people do not become part of the community centre, which means that the centre is not truly representing the community in its diversity.

Nieuw Gent

One of the things that require a continuous discussion is the role and responsibility of the CHC. Decision on which type of topics and areas need the attention and resources. It is particularly difficult when the financing does not cover tasks that for the CHC represent a high priority. It is sometimes difficult to decide on how far the centre is going to engage in several actions and interventions.

For example, low income and poor housing conditions in the area are huge problems, so the centre is aware that they cannot be approached and solved by one organization. But even if there is a coalition of different agencies, the challenge is to define the role of the CHC, which usually focuses on spreading information and empowering the population.

The biggest impact that the CHC made and can observe is on a policy level.

CHC Botermarkt

The broad understanding of patients’ needs resulted in a much better response during the pandemic. From the 6000 patients that CHC Botermarkt takes care of, in 3 hours a list of a couple of hundreds of patients that needed proactive outreach, was created. This proactivity and deep human interest, and working with the most vulnerable people, from different cultures and different ethnical contexts was a very good example of what Community Health Centre stands for.

Even though the principle has always been to work across different functions and professions, in reality, people were mostly focusing on their area of expertise plus there was an informal hierarchy, with doctors on top of everyone else. When the pandemic hit it became obvious for the physicians that they cannot cover every care and need of their patients. There were so many phone calls, different problems, patients with needs that required follow-up, that the only way forward was better cooperation.

Essentially doctors and nurses have realized that they complement each other, doctors could do less repetitive tasks and concentrate on their core-business. Nurses took over some of the tasks that GPs used to do: it was less hierarchical and more cooperative, helping and supporting one another. Especially when the difficult decision had to be taken, such as whether they have a ‘life’-consultation with a patient (considering all circumstances), the nurses and doctors divided responsibilities between themselves, talked to each other. They found out they can share the information easily and they have a mutual advantage of doing so.

In times with less pressure from the pandemic, doctors and nurses were looking and discussing in which areas the cooperation could be maintained and improved. This change has accelerated cooperation. It is an organic change required by the external, demanding circumstance.

A similar change was observed regarding communication and cooperation with people working at the front-desk, who were under continuous stress, constantly answering phones. Nowadays receptionists, nurses, and GPs are truly collaborating. They have also discussed how to handle the pressure in times when it is difficult for everybody. Overall, it pushed the collaboration to the next level.

It also helped to get to know the patients better, their vulnerabilities and struggles.

Another observation was how the approach and CHC principles are helping when it comes to vaccination against COVID. It quickly became clear that dismissing or not taking seriously patients’ doubts does not help to change patients’ minds. It was decided to ask the patient about their doubts and fears, explain the consequences. CHC Botermarkt helped patients to take responsibility and to cope with the doubts. Healthcare professionals used their knowledge and skills, taking into account the difficult conditions the patient had to deal with.

CHC Nieuw Gent

One of the biggest achievements, in the pandemic time was the acceleration of the implementation of telemedicine, that will stay in some form after the pandemic. Another silver lining was the recognition of the role and importance of front desk workers. It was the realization that they could do more on the triage process, asking the right questions, making sure the patient is being directed to the right healthcare provider. It was also a revelation to the receptionists, that they can do more than they thought.

At the beginning of the COVID-19 pandemic, there was a lot of goodwill to help people and organize something but very little coordination. It resulted in different people offering the same help, or food, and some people received way too much, while others couldn’t find any support. It showed the importance of having an emergency plan and an acute need of cooperation within it. Slowly things have changed and currently, many tools and platforms had been put in place to facilitate collaboration and to match the people with the support they need.

Another discovery made during the difficult time was that purely administrative tasks can be done from home. This allowed increasing the efficiency and quality of work.

Pandemic has also accelerated the introduction of Community Health Workers (CHWs), a project that was planned 2 years before. CHWs are employed by the municipality and coordinated by the local welfare organization, and guide people on how to find their way in the health system, both primary and secondary, especially for migrants, who are not familiar with the Belgian health system. Community Health Workers are also supporting people with poor health literacy. Even though this project was organized from the perspective of the professionals, it does help. It did not influence the system though, but it became helpful for both patients and healthcare workers.

Community Health Centres are an exemplification of ICC in practice — with a multidisciplinary approach, goal-oriented care, and focus on communities. It is an example of operationalizing the ICC principles in practice and implementing them in a well-organized model of Community Health Centres.

The community-oriented primary care strategynwithin the Community Health Centres aims to adapt services to needs in the community, identified via a stepwise process:

1. Identification of care needs and underlying social determinants in individual care provider-patient contacts (e.g., through info in the electronic patient records);
2. Interdisciplinary patient meetings in the centre to identify relevant topics for a larger part of the population;
3. Prioritisation and validation in the population using data and experiences of relevant stakeholders at regional and city level. The centre actively participates in ‘community diagnosis’ meetings with local actors (local schools, welfare organisations, etc.) These meetings — initiated and organised by the local government — help to give a voice to the community residents’ needs and aspirations.

That is why this is an example of how Integrated Community Care (ICC) is  resilience-oriented approach that seeks to strengthen communities by tackling the determinants of health. It assumes accountability towards a territorially defined population, creating new cross-sectoral and interdisciplinary partnerships and taking a population health approach with a focus on prevention. In ICC, a new power dynamic and relationship is forged: people and communities co-design and co-produce health and care; the role of government is that of an equaliser (ensuring resources are allocated to those most in need) and investor in public services; and the traditional boundaries between informal and formal care are blurred.

www.educationforhealth.net/

www.ifchc.org/what-are-chcs/

Integrated Community Care — A Community-Driven, Integrated Approach to Care,
Handbook Integrated Care pp 105-118

link.springer.com/chapter/10.1007/978-3-030-69262-9_7

transform-integratedcommunitycare.com/wp-content/uploads/2019/05/transform_turin_synthesisreport.pdf

Goal-oriented care a shared language and co-creative practice for health and social care, A publication of the King Baudouin Foundation and the Dr. Daniël De Coninck Fund.
https://www.kbs-frb.be/en/goal-oriented-care-shared-language-and-co-creative-practice-health-and-social-care

An Van De Walle — Coordinator of the Community Health Centre Nieuw Gent
An.vandewalle@wgcnieuwgent

Jan Van Speybroeck — Coordinator of the Community Health Centre Botermarkt
jan.vanspeybroeck@wgcbotermarkt.be