Promoting Access and Care through Innovative Strategies in Chittoor (PROACTIVE CT), An Implementation Research

This project aims to strengthen the delivery of primary health care and improve access to timely, quality health care for residents of Gudipala Mandal in Chittoor district (population of 50000 persons). Primary health care is the backbone of health service delivery and is envisaged to be the hub of integrated, coordinated care across levels of health care. Primary health care caters to 75% of basic health needs and focuses on prevention and health promotion. Improved primary health care access would result in improved health status, well controlled chronic conditions like diabetes and hypertension as well as improved responsiveness of the health system to people’s needs.

The expected outcomes of this intervention can be measured before and after the interventions through a baseline and endline survey. There would be mixed methods approach to quantitatively assess health status as well as qualitatively assess the responsiveness of the health system to peoples needs.

The project would seek to implement coordinated, continuous quality primary care for the people of Gudipala Mandal in Chittoor district. The main intervention of this project is the development and deployment of a care coordination hub and schedule appointments. The care coordination hub would include a team of care coordinators centrally located that are able to provide information and serve as a triage to direct people to appropriate level of care.  Depending on the persons need, the hub will be able to register patients for care at the most appropriate health facility ensuring prompt access to a health facility. The medical record of the visit would be saved in the same system for further follow up action by the care coordinators. The center will facilitate follow up and reminders for those that do not seek care or follow up care received or those with poorly controlled health conditions.

While the community stands to benefit from this program, they are also a potential risk/challenge to the success of the project. The community acceptance of this care coordination program would be crucial to its success, and mitigation will be done through our engagement with the community. A series of meetings will be conducted with the community to involve them in the design and deployment process efforts will be made to inform the entire community about how this would function and the benefit they can expect.

Another potential challenge is coordination between all the various facilities and ensuring completion of records by all stakeholders. Since the success of the project rests on the sufficiency of data and the availability of information, it would be important to ensure that all stakeholders, including doctors enter information onto the system. Capacity building workshops will be conducted with doctors as well as involve all stakeholders throughout the design and deployment phases.

The portal and the services of the digital hub will be extended to the government run primary care facilities like the health and wellness center and the primary health center. This would be important to demonstrate the applicability of the technological solution across all primary health care facilities. The government will have to be involved and engaged early in the project even though extension would only happen later in the project. Efforts will be made to involve and inform the government throughout the design and implementation stages of this program.

In order that CMC Chittoor campus implement this project we will need to employ new staff- the care coordinators and community staff. Arrangements will be made for the space for the digital hub. We propose to locate this in the secondary hospital area to facilitate coordination of care for persons coming to the hospital or alternatively we could house this hub in a location close by to the hospital. We will need to introduce a digital health record at the primary care facilities and link it to the secondary level of care, this is currently done on paper manually.

The project is sustainable and will contribute to enhancing the work currently undertaken through CMC Chittoor’s, community health department. The need for a digital solution that links primary to secondary care is a longstanding need and has application across all the primary outreach health care services of CMC. The findings on the deployment of this project will also be integrated with the Andhra Pradesh government to cater health care needs to its maximum potential to the people of the rural areas.

Abstract

In this study we aim to implement and evaluate an intervention package that includes deployment of care coordinators and a digital application that facilitates appointments and care coordination across health facilities to improve the access to reliable information, timely care and an appropriate level of care, Responsiveness of the health system, Clinical outcomes of care for chronic conditions (hypertension, diabetes, COPD and asthma control) and patient satisfaction.

Methods: We propose to use an implementation research approach and a before and after design to study the effectiveness of the intervention package to improve timely and appropriate care for persons living in Gudipala mandal. The interventions proposed are-

1. Care coordinators at a call enter to triage patients to an appropriate level of care, schedule appointments and enable follow-up and reminders that integrates with private and public health facilities in a mandal of Chittoor district.

2. A digital solution that enables appointment scheduling, follow up reminders and alerts to the facility at appropriate level of care

3. Follow up of persons in the community through community volunteers.

These interventions will be developed and implemented using participatory methods that include stakeholder mapping, co design and regular stakeholder engagement.

The effectiveness of the intervention will be measured quantitatively through a cross sectional survey at baseline and after 18 months of implementation.

1. Timeliness of care, 2. Appropriate level of care, 3. Out of pocket expenditure, 4. Responsiveness of the health system 5. Clinical outcomes of care for chronic conditions (hypertension, diabetes, COPD and asthma control) and Patient satisfaction

2. implementation outcomes of reach/ penetration, feasibility and acceptability

The study will be conducted in three phases

Phase 1 Baseline assessment and enrollment of the residents in Gudipala Mandal

Phase 2 Deployment of the call center and digital app for care coordination in Gudipala Mnadal

Phase 3 Outcome assessment at 18 months