Cuban Medical Research

Integrated Work Between Hospitals And Community-Level Primary Care Facilities: A Practical Approach

Isidoro A. Páez Prats, M.D. 1
José Rodríguez Abrines, M.D. 2

ABSTRACT: This study describes the experiences of healthcare providers at the Miguel Enriquez Clinical and Surgical Hospital, in the 10 de Octubre municipality of Havana, in terms of the integration of their work with the community-level primary care facilities in the municipality.  Emphasis is placed on the importance of continuity in patient care through the primary and secondary levels to achieve efficient healthcare delivery and on the positive feedback this offers to primary care providers through participation in the analysis and discussion of the causes of death of hospitalized patients.  This new working strategy is considered the cornerstone for the fulfillment of the Cuban Ministry of Public Health's main objective for the year 2000: to improve the health status of the Cuban population.  Collaborative work between primary and secondary care facilities includes not only medical attention to patients referred to a hospital from a community-based primary care facility but also pedagogical activities in hospitals for primary care providers.  Moreover, this type of work facilitates the proper follow-up by family doctor and nurse teams  of patients who have been hospitalized for  noncommunicable chronic disorders or for suicide attempt.

Healthcare facilities in Cuba have been integrated into a system that provides socialized comprehensive medical care for the whole population, ensuring universal access to medical and scientific resources available in the country with the purpose of meeting the particular needs of each patient.  Primary care is the first and fundamental unit in this system.1

With the introduction of neighborhood-based family doctor-and-nurse teams in 1984, significant changes were implemented at the primary care level in Cuba.  Family doctors and nurses live in the communities they serve, providing primary attention for the neighborhood’s population. These changes have positively influenced secondary and tertiary care, as hospitals and specialized institutes have adjusted their structural and functional framework to meet the demands posed by this new multilevel, comprehensive and integrated healthcare delivery approach.2

From independent specialized healthcare facilities, hospitals have become integral parts of a system in which their main function is to support the work of primary care facilities.  Although their role as specialized centers continues to be crucial, hospitals are no longer considered the mainstays of medical attention in the Cuban healthcare system; rather, one of their principal duties is to contribute to solving local needs, when a solution requires more specialized services.3

In Cuba, this “hospital-polyclinic-family doctor and nurse team” complex is charged with the delivery of medical care to the entire population (which includes ambulatory medical care, emergency services and hospitalization), including diagnostic services,  health promotion and disease prevention.  Furthermore, this system carries out social work, training, research and health monitoring.2

With the purpose of interconnecting the work of the three levels of medical care, a system of referral and counter-referral has been created and implemented.  However, despite these efforts, some expectations and demands of the public and of health providers remain unmet.4                

Red tape bogged down this system of referral and counter-referral and tended to transform it into a bureaucratic routine.  What's more, the flow of information from hospitals to primary care facilities has, in some cases, been almost nonexistent.2

The reports provided by hospital doctors to family doctors paid insufficient attention to treatment and follow-up of discharged patients--the main tool for the work of family doctors with these patients.5  Continuous care for these patients in the community goes beyond the capabilities and possibilities of hospitals.  Effective attention depends primarily on the continuity of care and a comprehensive understanding of patients in their context, which in turn depends on achieving a close working relationship between hospital staff and family doctors.6

The purpose of our paper is to trace the evolution of relations between the Miguel Enriquez Clinical and Surgical Hospital and the community-based primary care facilities in the 10 de Octubre municipality where the hospital is located, beginnin in 1994, when some of the above-mentioned deficiencies were noted. This hospital serves approximately 500,000 people in five municipalities in Havana: 10 de Octubre, Cotorro, San Miguel del Padrón, Guanabacoa and Regla.

Initially, the work of this hospital with municipal primary care facilities was limited to a monthly meeting held in the hospital with the directors of municipal polyclinics and the community-based health care administrators.  Attendance at these meetings was poor, and the agenda was limited to discussing administrative matters.  This quickly prompted an analysis by the hospital's management, which proposed changing the focus.

The first change was to decentralize the meetings:  instead of one at the hospital, a number of meetings were held, one at each municipal polyclinic.  The purpose of the meetings was to promote dialogue between hospital staff and the primary care providers.  Participants included the hospital’s deputy director in charge of outpatient facilities, the chair of the hospital's quality control board, an internist and a pathologist; and for the primary care staff, included polyclinic and health area directors, professors, specialists and comprehensive general medicine  and administrative workers, professors, and both residents and specialists in comprehensive general medicine.                             

In addition to evaluating administrative aspects and the referral and counter-referral system, new agenda items included themes related to teaching and medical attention.  In particular, selected cases of patients deceased due to noncommunicable chronic diseases were discussed.  This latter was a problem for the hospital, since the expected impact of the family doctor and nurse teams on their internal medicine service had not reached the predicted level.7

Other activities were incorporated into these discussions, such as clinical-pathological and clinical-radiological meetings, discussion of interesting cases and bibliographic reviews.

These meetings between the hospital and the five municipalities mentioned above were carried out from mid-1994 through late 1995.  The exchanges also included meetings with the presidents of the Municipal Assemblies of People's Power (local government), with the general secretaries of the Municipal Party Committees and with other organizations in each municipality, all aimed at discussing the health problems of the population in each municipality. 

In 1995, there were significant changes in the health indicators of these communities, especially in crude and net mortality rates.  These positive changes evidently resulted from the new form of integrated work that had been established between hospitals and community-based primary care facilities.  This first stage of the dialogue was named “approaching the community”, which was to be followed by a second stage of “integration with the community”--one of the new challenges and responsibilities of hospitals as their contribution to efforts by the Cuban healthcare system to further improve the public health situation for the 21st century.3

 “Integration with the community” is conceived on the basis of three aspects:

1. Hospitals should be cognizant of the results of the health situation assessment in the communities they serve.  This should include numerical findings as well as the factors affecting the health situation of each community.

2. Community members should be informed of the results of the health situation assessment in their community, as well as in the other communities served by each hospital.  This includes information on:

• Chief complaints of patients visiting hospital emergency services.

• Chief complaints of patients visiting hospital outpatient facilities.

• Causes of hospitalization.

• Causes of death.

• Origin of hospitalized or deceased patients.

3. Patients should receive integrated attention, with continuity between hospital and primary care services.  This includes:

Common access to and use of results of laboratory and other findings.

Access to the outpatient and inpatient clinical records.

Continuity of patient rehabilitation

Support for at-home “hospitalization”.

Rational use of hospital beds.

This two-stage process has now been extended to the San Miguel del Padrón Municipality in Havana.

References

1. Hadad Hadad J, Ramírez Márquez A, Ochoa González D.  Nuevos escenarios, tendencias y enfoques en la garantía de la calidad de la atención médica en Cuba.  Rev Cubana Salud Pub 1993;19(1):57-67.

2. Gómez Cabrera R, Klaindorf Shainblatt B.  Cuba.  La interrelación Hospital-Médico de la Familia dentro de las Estrategias de la Atención Primaria de Salud.  Educ Med Salud 1991;25V:233-240.25(3).

3. Tejada Pardo D.  El Hospital en los Sistemas Locales de Salud.  Salud Popular 1988;6(2):278-288.

4. Pritchard P.  Manual de Atención Primaria de Salud.  Madrid:  Editorial Díaz de Santos, 1981.

5. Manresa Presas JM.  El Informe de Alta Hospitalaria:  la cenicienta del clínico.  Med Clin (Barc) 1993;101(1):253-254.

6. Turabián JL.  Cuadernos de Medicina de Familia y Comunitaria.  Una introducción a los principios de Medicina de Familia.  Madrid: Editorial Díaz de Santos, 1995.

7. Pérez Peña J.  Impacto del médico de la familia en el funcionamiento de los servicios de Medicina Interna.  Rev Cubana Salud Pub 1989;15(4):309-315.

8. de Moraes Novaes H.  El Hospital Público: tendencias y perspectivas, eds. Humberto de Moraes Novaes, José María Paganini. (HSS/SILOS 39) Washington DC.  OPS, 1994.

This article originally appeared in Spanish in the Revista Cubana de Medicina General Integral, vol. 13, No. 2, 1997.

1 First Degree Specialist in Internal Medicine.  Instructor,  Hermanos Ameijeiras Clinical and Surgical Hospital, Havana.

2 Second Degree Specialist in Health Administration.  Assistant Professor, Miguel Enriquez Clinical and Surgical Hospital, Havana.