Comprehensive Community- and Home-based Health Care Model
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Community- and Home-based
Health Care Model
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SEARO Regional Publication No. 40
Comprehensive
Community- and Home-based
Health Care Model
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World Health Organization
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Regional Office for South-East Asia
New Delhi, India
SEARO Regional Publication No. 40
Comprehensive
Community- and
Home-based Health
Care Model
I
World Health Organization
LV Regional Office for South-East Asia
/ New Delhi
\
ISBN 92 9022 237 9
© World Health Organization 2004
Publications of the World Health Organization enjoy copyright protection in
accordance with the provision of Protocol 2 of the Universal Copyright Convention.
For rights of reproduction or translation, in part or in toto, of publications issued by
the WHO Regional Office for South-East Asia, application should be made to the
Regional Office for South-East Asia, World Health House, Indraprastha Estate,
New Delhi 110002, India.
The designations employed and the presentation of the material in this publication do
not imply the expression of any opinion whatsoever on the part of the Secretariat of
the World Health Organization concerning the legal status of any country, territory,
city or area of its authorities, or concerning the delimitation of its frontiers or
boundaries.
Printed in India Editorial, production and design coordination: Byword Design: Naveen Siromoni
CONTENTS
FOREWORD
v
ACKNOWLEDGEMENTS
vii
1. INTRODUCTION
1
2. BACKGROUND
1
3. DEFINITION
3
4. GOAL
4
5. OBJECTIVES
4
6. PRINCIPLES
5
7. STRATEGIES
6
8. CONCEPTUAL FRAMEWORK
8
9. CORE ELEMENTS
10
10. OPERATIONAL OVERVIEW
12
11. ACCESS TO CARE AT THE COMMUNITY LEVEL..........
12
12
12
14
14
14
15
15
16
12. IMPLEMENTATION GUIDELINES
12.1 Implementation Principles...........
12.2 Implementation Approaches.........
12.3 Actions.........................................
18
18
19
19
10.1 Nature of the Programme..........
10.2 Coverage and Eligibility Criteria
10.3 Provision of Care.......................
10.4 Programme Management.........
10.5 Human Resources.....................
10.6 Finance and Costing............................................................
10.7 Monitoring and Evaluation.................................................
10.8 Prerequisites for Successful Implementation of the CCHBHC
Phase 1: Preparing for the implementation...............
Phase 2: Implementing community- and home-based
health care.....................................
20
13. CONCLUSION
24
27
14. BIBLIOGRAPHY
30
ANNEX 1: LIST OF MEMBERS OF THE MULTIDISCIPLINARY
WORKING GROUP, PARTICIPANTS OF REGIONAL
CONSULTATIONS AND PRINCIPAL INVESTIGATOR
FOR THE FIELD TEST................................... 33
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ANNEX 2: EXAMPLES OF HEALTH WORKER SKILLS
37
ANNEX 3: HOME VISITS
40
ANNEX 4: AN EXAMPLE OF A WEEKLY SCHEDULE OF
SERVICES COORDINATED BY A
HEALTH CENTRE...............................................
43
ANNEX 5: EXAMPLES OF ACTIVITIES OF AYUTTHAYA
URBAN HEALTH CENTRE, THAILAND........
45
ANNEX 6: MONITORING AND EVALUATING THE
AYUTTHAYA APPROACH.........................50
ANNEX 7: SUGGESTED TERMS OF REFERENCE FOR THE
52
DISTRICT LEADING TEAM............................
: a
ANNEX 8: AN EXAMPLE OF A FAMILY FILE
53
ANNEX 9: CLINICAL SUPERVISION
65
J
FOREWORD
With the double burden of communicable and noncommunicable diseases,
and demographic changes, particularly an increase in population of the elderly,
the need for long-term and chronic care, and care to manage the activities of
daily living, in addition to strengthening the basic health care services, has
increased significantly. Moreover, given the escalating costs of health services,
vulnerable and underprivileged groups will be even more deprived. Therefore,
there is an urgent need for Member States to extend health services beyond
hospitals. This is particularly crucial for addressing the challenge posed by
HIV/AIDS and other priority public health problems.
Most countries of the South-East Asia Region have established various
community-based health care services that integrate into the primary
health care structure. However, many of these services lack horizontal
integration or proper coordination with other related key programmes
even though these services normally fall under the responsibility of the
same core health workers. Therefore, it is imperative to provide
comprehensive and properly coordinated essential health care services at
the community level.
The South-East Asia Regional Office has developed a generic model for
comprehensive community- and home-based health care to provide
information to Member States on how they can strengthen community
health services to meet the changing health needs and to provide holistic,
integrated and continuous care that is patient/client-centred, with the active
involvement of communities. I am pleased to note that during field-testing
this model has been found to be a useful tool in assisting countries to better
organize and manage their community health services.
WHO is deeply committed to help Member States adapt this model for
use, including developing national capacity and to strengthen their health
services to the community. I am confident that its application will
contribute substantially to increased accessibility to quality health services,
particularly for vulnerable and underprivileged groups. I firmly believe that
our joint efforts can, and will, make a major difference to the quality,
effectiveness and efficiency of health care in the Region.
Samlee Plianbangchang, M.D., Dr.P.H.
Regional Director
vii
ACKNOWLEDGEMENTS
This Comprehensive Community- and Home-based Health Care Model is
a collaborative work of Departments of Family and Community Health,
Health Systems Development, Non-communicable Diseases and Mental
Health and Communicable Diseases. This has been developed with the
assistance of a Multidisciplinary Working Group formed by the Joint WHO
Collaborating Centre for Nursing and Midwifery Development, Faculty of
Nursing (Siriraj) and Nursing Department, Faculty of Medicine at
Ramathibodi Hospital, Mahidol University, Thailand. Acknowledgement is
gratefully made to the Joint WHO Collaborating Centre and each member
of the Multidisciplinary Working Group who has helped in developing this
Model.
This Model was under critical review for its relevance and practicality
within the South-East Asia Region context by concerned national
authorities from the countries of the Region in a regional consultation held
in August 2001. It was then field-tested in Bhutan, Myanmar, Nepal and
Thailand in 2002-2003. A regional consultation was later convened in
December 2003 to review the lessons learned from the field test and
finalize the Model. WHO gratefully acknowledges the valuable contribution
of concerned authorities who participated in the consultations for the
development of this Model.
Deep appreciation is due to Dr Guru Prasad Dhakal of Bhutan, Dr Pe Win
of Myanmar, Ms Vijaya KC of Nepal and Dr Ronnachai
Tungmunanantakul of Thailand and their respective teams, who
painstakingly field-tested the Model and provided valuable inputs for its
development.
WHO gratefully acknowledges the valuable contribution of Dr Yongyuth
Pongsupap of the Ayuthaya Urban Health Centre Project, Thailand and his
team who provided training to the principal investigators and participating
personnel of countries involved in the field test on the concepts and
practices of the Model.
Sincere appreciation is also extended to many WHO Staff from the
Regional Office as well as from the Country Offices and Headquarters for
their valuable contributions throughout the process.
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Comprehensive Community- and Home-based Health Care Model
1. INTRODUCTION
The countries of the South-East Asia Region (SEAR) face a major challenge
from increasing health care costs. Thus, accessibility to health services
becomes an important issue that the SEAR countries need to address. There
is a continuing trend to shorten hospital stay. In addition, with the increase in
the incidence of noncommunicable diseases and an ageing population, there
is a great need for long-term and chronic care. For cost-effective care, several
health interventions can be effectively carried out within the community or at
home. Furthermore, for most people, home is the setting of choice for
receiving care. Therefore, it is imperative to extend the health services
beyond the hospital walls, particularly to those in the greatest need.
The model for comprehensive community- and home-based health care
(CCHBHC) has been developed to ensure better accessibility to health and
quality community health care.
This document contains background information related to the
development of the model, clarification of the goal and objectives, and
articulation of the principles underpinning the model. A range of strategies
to facilitate delivery of the model is highlighted. The document identifies
the core elements of the model and provides an overview of the issues that
need to be taken into consideration wherever the model is implemented.
The model is based on partnership and local context, linking formal and
nonformal caregivers, empowering individuals, the family and community
for self-care and self-reliance, and providing a bridge between the
individual, family and community, and the health care system. The
document concludes with guidelines for implementing the model.
2. BACKGROUND
Several decades ago, primary health care was successfully established in
many SEAR countries as an essential approach for the delivery of the
‘Health for all’ policy of the World Health Organization (WHO). The
primary health care infrastructure provides a foundation for the provision
of health care in most of the countries. This approach has increased the
accessibility to health care in most countries in the region. However, there
are still a considerable number of people for whom this is not yet a reality.
Early models of primary health care focused on the prevention and control of
communicable diseases. However, the health needs of the population are
changing because of increased life expectancy, an ageing population and
changes in disease patterns. There is an increasing need to provide health care
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Comprehensive Community- and Home-based Health Care Model
within peoples’ homes and in local community settings. This includes acute,
curative and rehabilitative care in addition to the promotion of health and
prevention of illness. Existing models and approaches need to be adapted and
developed to meet these changing needs and provide more effective support to
individuals, families and communities, enabling them to make better use of
existing resources. Traditionally, for many people, health care has been mostly
provided by nonformal caregivers. These caregivers have had litde recognition
for their contribution and little support from the health care system.
The Regional Office developed the model for CCHBHC to provide
information to countries on how best they can strengthen their community
health services to meet the changing health needs and for better utilization
of resources. This model places patients/clients at the centre of care and
acknowledges the contributions that individuals, groups and communities
make in achieving and maintaining their health, and managing illness
throughout the lifespan. It provides an overall framework, and includes
systems and processes that can be adapted to meet the needs and priorities
of local communities. It, however, builds on the existing health system that
is available in the community, and aims to make essential care for priority
health problems more accessible to the needy, such as Directly Observed
Treatment, Short-course (DOTS) for the treatment of tuberculosis (TB)
and home-based AIDS care in support of the 3 by 5 Strategy.1
This model is developed with the active involvement of Member States.2
It is based on good practices in countries within and outside SEAR. It was
field-tested in Bhutan, Myanmar, Nepal and Thailand in 2002-2003. The
field test revealed that this model is a useful managerial tool to assist
countries in strengthening their existing community health services and
enable them to effectively work with individuals, families and communities
for the provision of quality health care.3
This model has been further refined by taking into account the outcomes of
die field test exercises. It is intended to be a generic model that can be
adapted and implemented by each SEAR country according to the country’s
needs and context.
■
1
2
3
WHO AIDS Strategy to treat 3 million AIDS patients by 2005.
The Model was developed with assistance of the Multidisciplinary Working Group formed by
the Joint WHO Collaborating Centre for Nursing and Midwifery Development, Mahidol
University, Thailand. It was under critical review before field-testing in a regional consultation
in August 2001. It was then field-tested in Bhutan, Myanmar, Nepal and Thailand in 20022003. A regional consultation in December 2003 reviewed the field-testing experiences and
finalized this model. The list of Working Group members, participants of the two
consultations and principal investigators of the field test are given in Annex 1.
Detailed information of the outcomes of the field test is provided in WHO (2004) Modelfor
comprehensive community- and home-based health care: Report ofa regional consultation, 2-4
December 2003. New Delhi: World Health Organization, Regional Office for South-East Asia.
Comprehensive Community- and Home-based Health Care Model
3. DEFINITION
In this model, CCHBHC is defined as an integrated system of care designed
to meet the health needs of individuals, families and communities in their
local settings. It includes primary prevention, i.e. prevention of health
problems and/or diseases before they occur (health promotion and disease
prevention); secondary prevention, i.e. early detection of problems or
diseases and intervention (curative care and support); and tertiary prevention,
i.e. correction and prevention of deterioration, rehabilitation and terminal
care (rehabilitative care). It is underpinned by the partnership between
health workers, clients/patients and members of the local community.
CCHBHC can be provided in numerous settings in the community, by
various people including health professionals, care assistants, and
nonformal caregivers such as volunteers and family members. Examples of
the types of activities involved are provided in Table 1.
Table 1. Examples of community- and home-based health care activities
Setting
Primary
prevention
Secondary
prevention
Tertiary
prevention
Home
• Health education©
• Health promotions
• Disease prevention
• Antenatal care
• Immunization
• HIV counselling
• Condom promotion
• Simple treatments, e.g.
wound care
• Referral
• Drug administration
• Safe delivery
• Newborn care
• Rehabilitation
• Palliative care
• Management of chronic
diseases, e.g. diabetes,
HIV/AIDS*+** ♦
Community, e.g.
• Health centres
• Schools
• Village halls
• Places of
worship
• Workplaces
• Exercise programmes**
• Elderly/health clubs*
• Environmental health
campaign***
• Mosquito control
campaign***
• School health*
• Development of personal
skills **♦
• Parenting classes
• Women/community
empowerment groups
• Safe sex campaign***
• Information, education
and communication, e.g.
family planning
• Screening*
• Referral
• Needs assessment
• Care
• Mass/group treatment
(e.g. deworming of
schoolchildren)
• Self-help groups such as
mental health support
groups* and HIV/AIDS
self-help groups*
• Emergency care
• Community-based
rehabilitation
• Community-based
AIDS care
Activities could be led by:
‘Health worker including doctors, nurses and midwives
©Traditional healers and traditional birth attendants
+Community member
♦Volunteer
♦ Family member
♦Client/patient/consumer
Comprehensive Community- and Home-based Health Care Model
4. GOAL
The goal of CCHBHC is to ensure better accessibility to effective and
efficient health care in community and home-settings to improve health and
well-being, and contribute to morbidity and mortality reduction.
5. OBJECTIVES
To achieve the goal of providing accessible, effective, efficient and
comprehensive health care addressing the country/community’s priority
health problems, the objectives of CCHBHC are broadly divided into five
categories as follows:
5.1 Promoting a healthy lifestyle and preventing illness by motivating and
supporting members of the community to proactively maintain and resist
threats to their health. Self-care reliance of the individual, family and
community, and proper health-seeking behaviours are die expected outcomes.
5.2 Managing the consequences of illness by meeting the needs of those
requiring care as a result of changing physical, psychological, social and/or
cognitive functional capacities across the lifespan.
5.3 Serving the needs of the vulnerable and underprivileged by reaching out to
them and meeting their health needs as identified in the community
assessment. This would include people with disability mothers and
children, the elderly, and the poor and minority groups.
5.4 Supporting informal caregivers by acknowledging the contribution of
family members, neighbours and volunteers and providing them with the
Comprehensive Community- and Home-based Health Care Model
knowledge, skills, resources and emotional support to enable them to
continue to provide hands-on care at home.
5.5 Strengthening the community by establishing, and/or strengthening
partnership and networking between the community, health care providers
and other sectors within the government and nongovernmental organiza
tions (NGOs) to facilitate community actions for health and well-being.
6. PRINCIPLES
The model is designed to reflect the following principles that are used to
guide decision-making and strategy development:
• Quality - structures and processes of care are organized to ensure that
the care delivered is holistic,4 integrated5 and continuous,6 and in
accordance with the agreed standards;
• Partnership - appropriate opportunities and methods are made available
to enable and empower all stakeholders, including intersectoral partners
to participate in decision-making and work in an honest and open
partnership;
• Equity - equitable access is ensured to all services and resources with a
focus on the vulnerable and underprivileed groups;
• Effectiveness7 - special efforts are made to ensure that an intervention or
service provided for the patient/client yields the intended result(s); and
• Efficiency8 - optimal use is made of the range and mix of available
resources (e.g. financial, human, physical and technical resources) in
support of the delivery of evidence-based practice.
Holistic cure focuses on the interaction among physical, psychological, social and spiritual
well-being. Interconnectedness between the individual, family and community is
recognized.
5 Integrated care is characterized by integrating different care dimensions to derive the best
benefit including primary, secondary and tertiary prevention (i.c. health promotion and
disease prevention, curative care and support, and rehabilitation).
6 Continuous care refers to the smooth continuation of care between home/community and
health facilities, including the referral system.
7 Effectiveness is a measure of the extent to which a specific intervention, procedure, regime or
service when deployed in the field in routine circumstances achieves what it is intended to
do for a specified population (WHO Health Systems Performance: http:/www.who.int/
hcalth-systcms-pcrformancc/doc/glossary.htm#effectiveness accessed 3/30/04).
8 Efficiency is the capacity to produce the maximum output for a given input (WHO Health
Systems Performance: http :/www.who.int/health-systems-performance/doc/
glossary. htm#effectiveness accessed 3/30/04)
4
5
6
Comprehensive Community- and Home-based Health Care Model
7. STRATEGIES
To attain the objectives and ultimately achieve the goals, a variety of
strategies need to be employed. It needs to be ensured that all parts of the
health care system function in a coherent and integrated way. The strategies
reflect the principles underpinning the model and include the following:
• Strategies for involving all stakeholders ensuring political commitment
and support;
• Strategies for mobilizing and managing resources building on the
existing system; and
• Strategies for developing and implementing appropriate health
information systems.
Some of the components of these strategies are given in Tables 2-4.
Table 2. Strategies for involving all stakeholders
Input
Process
Empowerment
Major stakeholders such as:
• Individuals
• Families
• Caregivers
• Volunteers
• Communities
• Organizations
• Education and training
• Mechanisms for communi
cation and decision-making
Major stakeholders who
are:
• Committed
• Supportive
• Involved
• Motivated
• Influential
• Confident
• Self-reliant
Partnership and
participation
• Individuals
• Families
• Community groups
• Village committees
• Existing local structures
• Self-help groups
• Key contacts in other
sectors
• Agencies in other sectors
• Religious groups
• Nongovernmental
organizations (NGOs)
• Referral organizations
• Hospitals
• Academic institutions
• Partnership building
• Networking
• Coordinating
• Advocacy
• Organizing community
meetings
• Developing mechanisms
for communication and
decision-making
• Involvement of relevant
major stakeholders in
primary, secondary and
tertiary prevention (i.e.
health promotion,
disease prevention,
curative care and
support, and
rehabilitation)
• Ownership
• Commitment
• Agreed priorities
• Joint action
• Solidarity
• Sustainability
Output
Comprehensive Community- and Home-based Health Care Model
Table 3. Strategies for mobilizing and managing resources
Input
Process
Output
Human
resources
• Nonformal caregivers
• Volunteers
• Family members
• Community members
• Health workers
- assistants
- nurses
- midwives
- doctors
- others
• Identification of key people • Right people right place,
• Identification of skills
right skills and right
required*
attitudes
• Education, training and
• Training programmes
development of health
workers and nonformal
caregivers
• Supportive supervision
Financial
resources
• Resource mobilization
• Funding mechanisms
• System of financial
management
• Identification of key
stakeholders and
potential backers
• Integration with existing
systems
• Agreement on costing and
control mechanisms
• Self-financing
• Third-party payers
Material
resources
• Equipment
• Drugs
• Technical materials
• Establishment of systems • Right equipment, drug
and processes to ensure
and technical materials
a continuous and timely
in the right place at the
supply of essential materials
right time
in the right quantity
• Maintenance of equipment
• Efficiency
• Accountability
• Transparency
*An example of the required skills is provided in Annex 2
Table 4. Strategies for developing and implementing appropriate information systems
Input
Process
Health and
management
information
• Systems for collecting,
using, storing and
retrieving information
Information for
Practice
• Information resources
• Development and use of
including books and
knowledge and skills to
journals
identify and manage
• Teaching aids
appropriate information
• Quality improvement tools,
e.g. care standards, home
visit protocols or guidelines
Output
• History-taking of individual • Information to plan,
and family health
implement, monitor and
• Assessing community
evaluate needs and
needs
care provided when
• Ongoing dialogue
and where needed
• Information to improve
and monitor the system
of care
• Appropriate levels of
access and ability to
use relevant information
including evidence to
change and develop
practice
• Use of evidence-based
guidelines and protocols
Comprehensive Community- and Home-based Health Care Model
8. CONCEPTUAL FRAMEWORK
A conceptual framework of the model is provided in Figure 1. It
highlights the dynamic nature of the model, which includes multiple
feedback loops, and ongoing monitoring and evaluation indicating that
changes and deviations can be addressed at any point in the ongoing
implementation of the model. The principles are shown to underpin every
aspect of the model.
This model is based on the assumption that, at present, comprehensive
health care provided at home and in community settings is not well
established or in place in the existing health system.
Figure 1. A conceptual framework of the model
......... ........... . . . . .... . .. ..... .................
QUALITY: HOLISTIC, INTEGRATED AND CONTINUOUS CARE
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OUTCOME
OUTPUT
• Healthy ifestyle
• Systems
Systems
and prevention
• People
• Reorienting
of
illness
• Money
----- ► • Restructuring ----- >•
Management
of
• Materials
• Redesigning
consequences
• Management
People
of illness
• Involving
•
Support
for
• Empowering
nonformal
• Managing
caregivers
• Educating
• Serving needs
• Supporting
of vulnerable
Money
and under
• Managing
privileged groups
• Mobilizing
• Strengthening
the community
Materials
• Managing
• Developing or
rebuilding
Management
• Using
information
Monitoring and evaluation -
EFFECTIVENESS AND EFFICIENCY
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Accessible,
effective and
efficient health
care in
community and
home-settings
to improve
health and
well-being, and
to contribute
to morbidity
and mortality
reduction
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Comprehensive Community- and Home-based Health Care Model
To implement this model, the existing health care system has to be
reoriented towards the provision of holistic, integrated and continuous
health care that needs to be extended beyond health care facilities. In
addition, there needs to be a restructuring of health services to shift the
emphasis on curative care (or to restore health) towards increased
attention to health promotion and protection (or to build good health).
Health care services must be redesigned to meet local health needs as
agreed with the community.
The community must be actively involved in planning, implementing,
monitoring and evaluating care. The active participation of individuals,
families and communities in protecting and promoting their own health has
been shown to improve effectiveness. In addition, empowering individuals,
families and communities will increase the awareness and demand for
quality health services.
There should be sufficient health care providers to give care at home and in
communities. In addition, these health personnel must be educated
systematically and continuously to improve their understanding of the
concepts and practices in CCHBHC, and build their skills for providing
quality care. In addition, community and nonformal caregivers must be
supported and empowered. Moreover, partnership will also need to be
established or strengthened with other key actors in the community (e.g.
NGOs, social welfare workers, etc.) to provide quality health care.
For the sustainability of CCHBHC, special efforts have to be made for
effective financial management and resource mobilization. Costing, when
9
10
Comprehensive Community- and Home-based Health Care Model
appropriate, and financial control mechanisms will need to be decided with
the involvement of community to ensure equity, effectiveness and efficiency
of care.
Moreover, tools to provide holistic, integrated and continuous care will
need to be developed or redesigned for use in target populations, such as
home visit standards, family folder or personnel book for home visit. The
use of information in the management of CCHBHC needs to be
strengthened to provide as well as monitor and evaluate the quality of
CCHBHC. These will facilitate the attainment of the objectives of
CCHBHC, which will ultimately lead to achieving the goal of better
accessibility to effective and efficient health care in community and home
settings. This will improve the health and well-being of the community, and
contribute to morbidity and mortality reduction.
9. CORE ELEMENTS
CCHBHC builds on the three levels of prevention common to primary
health care. It places an increased emphasis on health promotion, long
term and palliative care, and rehabilitation in addition to curative care.
(i) Primary prevention consists of activities for health promotion and
prevention of illness at the individual, family and community level.
(ii) Secondary prevention focuses on screening, early detection, provision of
treatment and care for common illnesses and ailments, and appropriate
referral.
(iii) Tertiary prevention comprises the provision of rehabilitative and
palliative care for patients with chronic illness and disabihty.
The minimum service package for CCHBHC needs to be determined in
each country based on health needs at the community and home level, and
available resources. Examples of care delivery of each core element are
provided in Figure 2.
Comprehensive Community- and Home-based Health Care Model
Figure 2. Examples of care delivery of the core elements of comprehensive community- and home
based health care
PRIMARY PREVENTION
Health promotion
Disease prevention
• Distribution of health
information
• Health promotion activities
for all age groups, e.g.
elderly clubs and school health
• HIV counselling
• Management of the
environment in the family
and community to prevent
accident/injuries and
promote health
• Immunization
• Health surveillance
• Condom promotion
campaigns
• Surveillance of specific
health problems, e.g. drug
misuse, adolescent health
and behavioural problems
/Comprehensive
community- and
< home-based
SECONDARY PREVENTION
TERTIARY PREVENTION
Health screening and treatment of
common illnesses and ailments
Rehabilitative, palliative
and long-term care
• Health assessment
• Treatment of illnesses and ailments
such as diarrhoea, fever, sore
throat, wounds and abrasions, and
acute respiratory infections
• Health care at home
• Referral
• Self-help groups
• Health care at home/
palliative and hospice care
• Community care for AIDS
• Care for people with
disabilities and
impairments, e.g. following
cardiovascular accidents
Comprehensive Community- and Home-based Health Care Model
10. OPERATIONAL OVERVIEW
To develop and implement die CCHBHC model, the following issues need
to be taken into consideration.
10.1 Nature of the Programme
The CCHBHC model aims to increase the accessibility to quality health
care in the community and home, as well as in facilities (first-level of
contact, e.g. health centre). It also aims to increase the self-care abilities of
individuals, the family and community. It places
patients/clients at the centre of care. By expanding
the focus of existing systems of primary health care
with the inclusion of rehabilitative as well as
palliative and long-term care, curative and
emergency care, the model offers a holistic approach
to address the health and illness continuum
throughout the lifespan. The care providers could be
health personnel, family members, groups, the
community, etc. Health personnel will be responsible
for providing training and support to nonformal
caregivers and the community. Services can be delivered at home through
home visits (^see Annex 3), at the health centre or in any appropriate place
in community settings, e.g. clinic, school, village meeting hall and places of
worship, according to the community needs.
10.2 Coverage and Eligibility Criteria
The CCHBHC model aims to cover all age groups in various health states
in a geographical area. The priority health states will be based on
community diagnosis and priorities agreed upon with the local community.
It is not realistic to expect to meet all possible health needs and demands,
therefore, services will need to be rationalized accordingly. Thus, criteria
for identifying health priorities (e.g. whether to give priority to chronic
conditions, or acute illnesses, or health promotion, etc.) as well as the
target population and those requiring home visits will have to be clearly
defined and agreed to by the community so as to effectively utilize
resources.
10.3 Provision of Care
This model builds on die existing health system but because access to care
Comprehensive Community- and Home-based Health Care Model
is through multiple entry points it is essential that supportive mechanisms
are in place to ensure that care provision is coordinated and integrated.
This requires clear systems and processes designed to facilitate the smooth
movement of the patient through the health care system, including the
health centre and hospital, and back to the home and community. A key to
success is efficient and effective use of information by all those involved in
the provision of services to the patient.
The care provided will depend on local priorities. Activities and tasks should
ideally be the responsibility of the person or institution best suited to
perform them. Health personnel will refer patients for more specialized care
and treatment when necessary. All services should place patients/clients at the
centre of care and contribute to the development of a good relationship
between the service providers and clients, based on mutual trust.
The services at a health centre or primary care unit should include, but not
be limited to, the following:
• Health promotion and disease prevention programmes;
• Outpatient clinic;
• Care and active follow-up in emergency situations;
• Care and active follow-up of acute and chronic patients;
• Care and active follow-up of high-risk groups;
• Home visits; and
• Community meetings.
Community meetings provide a forum for health personnel to have
systematic interaction with the community. This is imperative as parmership
with the community is essential for the successful operation of CCHBHC.
Community meetings should be scheduled with a set agenda, which will
facilitate active involvement of the community in the management of
CCHBHC as well as strengthen the community as a whole.
Annex 4 contains an example of a weekly schedule of services coordinated
through a health centre at the subdistrict level. Some examples of the
activities carried out in the Ayutthaya Research Project,9 Thailand are
provided in Annex 5.
9
The Ayutthaya Research Project (1989-96) was a health system research project resulting
from a collaboration between the Ministry of Public Health, Thailand and the Institute of
Tropical Medicine, Antwerp, Belgium, with EU funding. The general objective of the
project was to establish health system research for continuous improvement of the health
services to attain an integrated health care system. Principles of the project had been
adopted and developed further from the Kasongo Project, Zaire.
14 .
Comprehensive Community- and Home-based Health Care Model
10.4 Programme Management
The CCHBHC model will have to be managed as part of the existing
health system for the sustainability of services. Successful management of
the model is dependent on its integration with health system priorities, the
relationships and sense of ownership between the community and relevant
agencies such as health centres, and on intersectoral collaboration.
However, NGOs, religious organizations and the private sector could be
involved in the development, implementation and management of the
programme at a certain level. Therefore, special efforts will need to be
given to ensure complementarity of services provided by these
organizations and those provided under the CCHBHC model, and to
minimize duplication of work.
10.5 Human Resources
It is suggested that the health centre or primary care unit should have at
least two health personnel who may be nurses, nurse midwives, or other
primary health care workers with the necessary
knowledge and skills. Health volunteers are also
essential and they need to be appropriately
trained and supervised by the health workers.
The staff and skills mix ratio will be dependent
on the local health needs and priorities, and the
level of human resources available in the
communities, including the services of volunteers
and national human resource for health policies.
The roles and functions of each health worker in
the provision of CCHBHC will need to be
clearly defined and suitable training provided to
them.
Where possible, it is also recommended that an appropriate person be
identified to manage the clerical and administrative functions, thus enabling
health personnel to focus on clinical activities. Leadership in this health
centre or primary care unit will also need to be strengthened.
10.6 Finance and Costing
Mobilization of financial resources for the programme will be largely
determined by the existing national policy with particular emphasis on
Comprehensive Community- and Home-based Health Care Model
affordability and sustainability Costing and financial control mechanisms will
be agreed within the context of the overall financial strategy in each country.
10.7 Monitoring and Evaluation
Monitoring mechanisms need to be in place to ensure that activities are
carried out according to the plan, and in case deviations occur, corrective
actions are taken immediately. Feedback loops need to be established so
that lessons can be learned and acted upon without delay and waiting for
the final evaluation.
The overall evaluation will include a number of facets including the extent
to which the objectives have been achieved and their contribution to public
health; and the process and outcomes of implementation. As the model
seeks to offer people a better quality service based on agreed principles, the
indicators used will be both qualitative as well as quantitative. Indicators
for monitoring the attainment of health-related Millennium Development
Goals at the community and national level may also be used. Some
examples for process and outcome indicators are suggested below. Detailed
information about the approach used in the Ayutthaya Research Project is
included in Annex 6.
• Levels of appropriate health-seeking behaviours
• Utilization rates and trends
• Coverage of the CCHBHC
• Referral patterns
• Immunization coverage, e.g. proportion of 1-year-old children
immunized against measles
• General awareness among the population
• Community involvement and sense of autonomy.
10.8 Prerequisites tor Successful Implementation of the CCHBHC
Successful implementation of the model will largely depend on:
• Political support at every level;
• Effective financial management;
• Leadership skills and motivation of health workers and die community;
• Clear understanding of the concepts and practices of CCHBHC at all
levels; and
• Level of autonomy of the family and community, and their ability to be
involved in and influence the decision-making process.
■15 ;
Comprehensive Community- and Home-based Health Care Model
11. ACCESS TO CARE AT THE COMMUNITY LEVEL
The CCHBHC model is based on strong linkages between the home,
community and health facility. Collaboration between all partners is
necessary for the delivery of holistic, integrated and continuous care. Thus,
the role of village health volunteers and health personnel at different levels
of the district health system needs to be maintained and expanded. Figure 3
shows the relationship between individuals and primary, secondary and
tertiary levels of care with the health volunteers at the interface.
Figure 3. Linkages at different levels of care in comprehensive communityand home-based health care services
Tertiary care
Secondary care
----------
Primary care
First referral unit
(e.g. district hospital)
First-level health service facility
(e.g. health centre, health post)
/
/
I
,
\
Village health volunteers X
Community groups
\
Nonformal caregivers
\
\
(
\
.
\
\
Individual \
I
\
family
and
/
\
home
J
\
/
/
/ .
<--------------------------------- ----------Community
Definitions of terms used in Figure 3 are as follows:
• Home or family is the essential unit that influences individual health
behaviours and health status. The family provides care for patients with
both acute and chronic conditions.
• Community health volunteers are selected by their own community and
trained by the health sector to carry out particular activities. They
Comprehensive Community- and Home-based Health Care Model
1,7
provide an interface between individuals and health facilities wherever
necessary. For example, they can work collaboratively with the health
personnel to promote health, distribute health information, conduct
group meetings, provide care at home, and identify and refer cases to
the health facilities.
• Health centre is a first-level health care facility which might have
different names in different countries. Care is provided in the health
centre as well as in the community and home. When necessary, cases are
referred to the first referral unit such as a district hospital. For more
severe cases requiring complex interventions, referral may take place to
a secondary care facility such as a provincial hospital. The most severe
cases are referred, as required, to tertiary care facilities such as a
regional hospital or medical centre.
• Primary-level care refers to care provided at home, in the community,
first-level health facilities and first referral unit.
• Secondary-level care refers to a higher level of more specialized care
requiring sophisticated technology.
• Tertiary-level care refers to superspecialized, high-technology care.
>4
Comprehensive community- and home-based health care can be accessed
through multiple entry points as illustrated in Figure 4.
Figure 4. Multiple entry points to comprehensive community- and home-based health care
Home visit
Case-finding
_______________________
Outreach clinic
Health promotion campaign
Drug store
Private clinic
Health
volunteer
Alternative care
Traditional healer
k
School
Factory/workplace
Church/temple/
mosque/gurdwara
<
First referral
unit
Comprehensive Community- and Home-based Health Care Model
Example: The mother of a 2-year-old boy who has had diarrhoea since the
previous evening might use a home-made rehydration remedy or buy an
oral rehydration treatment from the local drug store. Alternatively, she
may ask for help from the village health volunteer. If the diarrhoea
persists, the mother may take the child to the health centre. Following
assessment by a health worker at the first-level health facility, enteric fever
could be diagnosed. If treatment is not possible at this level, the child is
referred for admission to a district or provincial hospital. In recognition of
the possibility that this has been caused by the use of contaminated water
within the community, the health campaign for preventing communicable
diarrhoea is put into operation by the health personnel. Following the
child’s discharge from hospital, a home visit is made to ensure full recovery
and prevent contamination within the family.
12. IMPLEMENTATION GUIDELINES
The guidelines for the implementation of the CCHBHC model are based
on strategies that were used effectively in countries within and beyond
SEAR. Particular attention was focused on ±e lessons learned from the
Thailand experience of the Ayutthaya Research Project and Health Care
Reform Project10 as well as from the field test of the model in Bhutan,
Myanmar, Nepal and Thailand.
12.1 Implementation Principles
A framework for implementing the model is built on die following principles:
• The health centre11 is the main structural focus involved in providing and
facilitating community- and home-based health care. Therefore, the
infrastructure of the health centre should be strengthened to create
maximum opportunities for access in every aspect, i.e. geographical,
cultural and psychological, as well as financial aspects.
• Careful planning must precede the implementation of the model.
• Each country must decide its own implementation plan as well as the
best strategies and actions.
M
10 Health Care Reform Project (1996-2000) originated from a scries of reform initiatives
that started in the late eighties and early nineties, and owed a lot to the Ayutthaya Research
Project, which developed a new model of primary health care delivery, and led to the
‘Decade of Health Centre Development?
11 The health centre is defined as an element of the district health system whose specific
function in primary health care is to be a point of interaction between the service and a
defined community to which it supplies comprehensive health services.
Comprehensive Community- and Home-based Health Care Model
12.2 Implementation Approaches
A policy decision needs to be taken at the national level to implement the
model for strengthening community health services and to accept
responsibility for the overall management of the model.
Responsibility for planning, strengthening and implementing CCHBHC
lies at the district level. Local demonstration sites will be used to develop
and strengthen the concept; to learn lessons about the adaptations required
to fit the country and local community situations; to ensure effective
implementation; and to plan scaling up of CCHBHC within the country.
Close cooperation is necessary at the national, district and local levels at all
stages, right from the initial decision-making and planning stages to the
implementation and evaluation stages.
Implementation of the model in a country requires
• National policy and support
• Local action
• Involvement of all stakeholders throughout the process
• Initiation of small trials in selected areas to learn lessons
• Evaluation of experiences and lessons learned for sustainable strategies
• Coverage of and expansion to other areas
12.3 Actions
The model should be implemented as part of the existing community
health services in countries of the Region. However, some changes will be
necessary to enhance the quality and accessibility of the existing
community- and home-based health care.
Whenever new changes or innovations are introduced, they are likely to be
taken up by only a few leaders. When they are demonstrated to be
successful, others begin to adopt the changes. Eventually, these become
routine practices. To be successful, the implementation of the model needs
to be undertaken in a careful and phased manner. It should be carried out
over the following two well-defined phases:
• Phase 1: Preparing for the implementation
• Phase 2: Implementing community- and home-based health care.
However, it is not necessary to carry the following activities in a linear and
sequential manner. A number of activities take place at the same time,
19
Comprehensive Community- and Home-based Health Care Model
depending on the local situation. The activities require different time-scales.
Some are one-off activities, such as identifying the demonstration site,
while others are continuing activities such as involving communities and
engaging in dialogue with families, skills development, providing care and
supervision. Throughout Phases 1 and 2, monitoring and evaluation will be
ongoing so that changes and deviations can be addressed at any point
during the activities.
Phase 1: Preparing for the implementation
First and foremost, it must be ensured that the government supports
implementation of the model as an integral part of the district health
system. Once the decision has been taken to implement the model, a
number of preparatory activities need to be carried out to ensure smooth
and efficient implementation.
Activities to prepare for implementation of the model
1.
Advocate widely for the need to implement the model.
2.
Mobilize support from the local administration.
3.
Form a leading team at the district level.
4.
Select a health centre as demonstration site.
5.
Define/redefine the catchment area for the provision of CCHBHC.
6.
Forge strong partnerships and linkages.
7.
Interact and negotiate with the defined population to be served.
8.
Identify health care activities to be provided at the health centre,
community and home.
9.
Strengthen support systems at the health centre.
10. Orient health personnel.
11. Formulate a plan of action.
It is important for countries to:
1. Advocate widely for the need to implement the model.
Commitment and motivation from organizations and individuals, who will
be involved in implementing the model, at both national and local levels,
are critical for successful implementation. Champions need to be identified
to share the vision and drive forward the initiative. Advocacy is also needed
to motivate the community to be actively involved throughout the
implementation process.
Comprehensive Community- and Home-based Health Care Model
Special attention will need to be given to motivate health personnel to
accept the model, as they will be required to change their practices. As
appropriate, the CCHBHC documents should be translated into the local
language to facilitate better understanding of the model.
2. Mobilize support from the local administration for innovative
approaches in the implementation.
Support from the district authority is needed to facilitate effective
implementation of the model and ensure sustainable development. This is
particularly important because of the need to challenge existing practices
and routines, and work in a more flexible manner.
3. Form a leading team at the district level, which will be responsible
for the coordination, management and completion of all activities.
The District Leading Team should comprise health officers at the district
level and health personnel at the health centre, as well as major
stakeholders including community leaders. It should be integrated within
the existing system to the extent possible. For example, these
responsibilities may be incorporated into the remit of an existing group or
committee. Optimally, there should be no less than 5 persons or no more
than 10 persons in the team. The suggested terms of reference for the
District Leading Team are provided in Annex 7.
4. Select a health centre as demonstration site to try out the model.
It is desirable to start on a small scale with a limited number of demonstra
tion sites before the model is implemented in the whole country. The
lessons learned from the demonstration sites can be utilized to improve the
model during its subsequent implementation in other areas. It is best for
each country to decide on the number and locality of health centres to be
used as demonstration sites.
Suggested criteria for selecting a health centre as a demonstration site
• The health centre is well established with adequate infrastructure,
operational budget, and supplies and equipment.
• There are stable full-time staff.
• Staff are motivated and committed to quality improvement.
• The designated referral hospital of that particular health centre and
higher-level administrative support system are likely to support the
transformation.
21
Comprehensive Community- and Home-based Health Care Model
5. Define/redefine the catchment area for the provision of CCHBHC.
The target population to be served should be area and need-based. The
number of target population and geographical areas should be manageable
to ensure adequate coverage.
6. Forge strong partnerships and linkages to ensure coordination and
collaboration among various partners for successful implementation.
Strong partnerships and linkages should be developed between the whole
range of stakeholders within and outside the health sector who will be
directly involved in the implementation of the model.
7. Interact and negotiate with the defined population to be served to
reach a consensus on the health services to be provided based on the
priority and requisite community support.
An early outline of the likely operational plan
should be shared with the population.
Systematic home visits and negotiations should
be carried out in the defined catchment area to
obtain information about families, and their
I ‘ I ISJ“'
health needs and demands. Family files/folders
should be prepared at this stage (an example of
a family file is provided in Annex 8). It is also
essential to involve health volunteers and
community members in the assessment process
from the beginning to build local ownership.
This assessment provides health personnel with
an opportunity to familiarize themselves with
and
establish relationships. Based on the
the community they serve
outcomes of the community assessment, health personnel will need to
negotiate with the community to agree upon the health services that will be
provided at the community and home level, and criteria for home visits and
support required from the community. This may be done through
community meetings.
iK'
As resources for health in most countries are limited, it is essential to
rationalize the health services to ensure optimal utilization of resources,
including the use of volunteers, to address identified priority community
health problems. In addition, ongoing interaction between health personnel
and communities needs to be maintained to ensure active involvement of
communities in the provision of care.
Comprehensive Community- and Home-based Health Care Model
8. Identify health care activities to be provided at the health centre,
community and home levels.
Services should be provided to meet identified needs as negotiated with the
community. They should include health promotion and disease prevention
programmes; an outpatient clinic for curative services; home visits; care,
active follow-up and referral in emergency situations for patients with acute
and chronic conditions, those needing long-term care as well as those in
high-risk groups; and community meetings.
Criteria for home visits and home care will need to be defined for optimal
utilization of available resources.
9. Strengthen support systems at the health centre to ensure provision
of holistic, integrated and continuous care, and improve the overall
service.
Existing support systems (e.g. health information system; supervision,
monitoring, recording and reporting system; staff continuing/in-service
education system; referral system; system for interacting with the
community) need to be assessed in terms of their contribution to the
quality of care (holistic, integrated and continuous care) at community and
home levels. Where necessary, the systems should be strengthened, adapted
or redesigned.
Appropriate records should be modified or developed to facilitate and
foster continuity of care between home and health facilities.
10. Orient health personnel to foster positive attitudes about the model.
All personnel need to be enabled to understand and internalize the
philosophy of the model: to acknowledge the changing relationships with
all stakeholders including patients and to develop a proactive and creative
approach to the provision of service.
11. Formulate a plan of action for effective implementation of the
model.
The foregoing activities should lead to the formulation of a clear, simple
and practical plan of action that can be linked with plans and activities
already in existence for the district health system.
24:
Comprehensive Community- and Home-based Health Care Model
It is necessary to ensure that there is ownership of the plan by policy
makers, planners, managers, health personnel and other stakeholders,
particularly the community. Everyone involved in the implementation of the
model should be aware of the total picture, and what action will be taken by
whom and when. Where practical, they should be involved in the
formulation of the plan, otherwise they should be given an opportunity to
comment on the plan.
Phase 2: Implementing community- and home-based
health care
The second phase in die implementation of the model is the provision of
community- and home-based health care by the health personnel of the
health centre selected as the demonstration site. Actions should also be
taken to carry out the plan of action for effective implementation of the
model formulated during Phase 1.
Activities to implement community- and
home-based health care
1.
Determine and mobilize human resources to ensure an adequate
number of care providers for the services.
2.
Skills development of health personnel and volunteers.
3.
Identify and mobilize financial and material resources.
4.
Provide holistic, integrated and continuous care.
5.
Supervise the provision of care to ensure continuing quality
improvement of service provision.
6.
Monitor the implementation of the model.
7.
Evaluate the implementation of the model.
8.
Review lessons learned from demonstration sites.
9.
Consider further expansion of the use of the model.
10. Disseminate the results of the evaluation and future action plans to
advocate for the wider implementation of the model.
It is important for countries to:
1. Determine and mobilize human resources to ensure an adequate
number of care providers for the services.
Based on the agreed services, an analysis of human resource requirements
needs to be made. This should take into account the available human
resources for care within die community such as health volunteers,
community groups and NGOs.
Comprehensive Community- and Home-based Health Care Model
The team at the health centre may need to be strengthened to cover a large
population or provide supplementary activity if they are to be introduced at
the health centre. Health volunteers should be identified early in close
collaboration with the community. In addition, roles of health volunteers
and other nonformal caregivers for providing CCHBHC, particularly in
home care and health promotion, will need to be clearly defined and
supported.
2. Skills development of health personnel and volunteers to effectively
provide quality community- and home-based health care.
Following a training needs assesment, appropriate skills should be developed
in health personnel as well as health volunteers and nonformal caregivers.
The staff need to be equipped with the requisite knowledge, skills and
attitudes to work with the community and other sectors as well as to train
and support volunteers and other nonformal caregivers in addition to their
clinical skills. As a considerable part of care will be home-based special
efforts should be made to develop home visit skills in the staff. Hands-on
experience and training is required for skills developemnt. Training should
be provided systematically and continously according to needs, to ensure
competency.
3. Identify and mobilize financial and material resources to ensure the
provision of quality care.
The level and type of financial and material resources required depends on
the services to be provided. The costing methods used and funding would
be based on the existing financial systems in the country. Every effort
should be made to maximize the use of available resources. Special efforts
should also be made to mobilize additional resources from other sources
such as community groups, NGOs or donor agencies.
4. Provide holistic, integrated and continuous care to improve the
health of the population.
Health personnel provide care in the community and home in accordance
with the criteria agreed upon with the community. They must ensure the
use of a systematic approach to maintain close and continuous interaction
with the community, and continuing support to nonformal caregivers.
25
-,26
Comprehensive Community- and Home-based Health Care Model
5. Supervise the provision of care to ensure continuing quality
improvement of service provision.
Supervision should be carried out in a systematic
way to support and develop health centre
personnel in providing care, and identify and
meet training needs. The supervision process also
provides a formal opportunity to acknowledge
achievements and developments as well as to
identify and address obstacles encountered in the
delivery of community- and home-based health
care (for further information, see Annex 9).
6. Monitor the implementation of the model to ensure continuous
feedback on progress.
A monitoring system needs to be established to provide feedback on
progress in line with the implementation plan developed in Phase 1. This
will enable prompt action to be taken in response to deviations from the
plan and further refine the plan to reflect changes in the situation.
7. Evaluate the implementation of the model to learn lessons from the
demonstration sites.
The evaluation strategy should address issues related to the acceptability,
applicability and usefulness of the model. It will identify achievements,
problems and solutions, use of resources and other lessons learned in each
demonstration site, and lead to more effective implementation at this and
other sites.
8. Review lessons learned from demonstration sites to further improve
the effectiveness of the model and services provided.
Evaluation reports from each demonstration site should be critically
reviewed and key issues identified. The model should be amended and
refined as necessary to improve the quality, effectiveness and efficiency of
the services provided.
Comprehensive Community- and Home-based Health Care Model
9. Consider further expansion of the use of the model to improve
accessibility, effectiveness and efficiency of care in community and
home settings.
A plan of action should be developed to guide the implementation of die
model in other sites and support the continuing development of the model
in the original sites. Special attention should be given to collaborate with
other home-based care initiatives in the area to optimally utilize the
available resources.
10. Disseminate the results of the evaluation and future action plans to
advocate for the wider implementation of the model.
Information should be shared using a variety of channels including a
programme of visits to die demonstration sites. All those participating in
the implementation of CCHBHC model in the demonstration sites may be
used as resource persons to assist in the implementation in other sites.
Overall activities for the implementation of the CCHBHC model for both
the phases are summarized in Figure 5.
J
This model provides one response to improve the equity of, and
accessibility to, quality healdi services within a local community. It includes
a particular emphasis on involving all members of the community in
identifying their needs and agreeing on priorities. It acknowledges the
contribution made by diose outside the formal health system to health and
health care, and provides additional support.
The model is likely to be subjected to ongoing change and development as
a result of lessons learned during the implementation or due to changes
within the community, or improved knowledge and skills of health
personnel. The lessons learned should contribute to the development of
national guidelines. Experiences in the implementation of the model
continue to be shared widely with die ultimate aim of contributing to a
reduction in morbidity and mortality across communities.
27
rigure b. overall activities ror implementation or tne moaei tor community- ana nome-oasea neaitn care
National policy and support for provision of CCHBHC as integral part of the district health system (DHS)
1
District Health Manager understands the concepts and practices of the CCHBHC model
§
1. Advocate
widely for
the need to
implement
the model
2. Mobilize
support
from the
local
administration
3. Form a
leading
team at the
district level
4. Select a
health
centre as
the
demonstration
site
5. Define
the
catchment
area
6. Forge
stronger
partnerships
and
linkages
7. Interact
and
negotiate
with the
defined
population
I
H
P
R
w
A
R
I
>
□
8. Define health care activities at
the health centre, community
and home
9. Strengthen the support
system at the health centre
c
• Health promotion and disease
prevention programmes
• Health information system
=
• Care and active follow-up in
emergency situations
•System for interaction with the
community
• Care and active follow-up of
acute and chronic patients
• Intersectoral collaboration
I
i
• Care and active follow-up of
high-risk groups
• Community meetings
• Referral system
• Staff training and supervision
• Monitoring and evaluation
10. Orient
health
personnel
11. Formulate
a plan of
action
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i
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O
R
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I
i
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• Other support systems
• Home visits
•:
i
o
f ■.N-’i
■■I
Implement a plan of action formulated during the preparation phase for effective implementation of the model
2. Skills development of health
personnel and volunteers
3. Identify and mobilize
financial and material
resources
• Health care providers
• Skills for interacting with the community
• Community resources
• Supportive/clerical staff
• Team work and interpersonal skills
• Government resources
• Health volunteers
• Empowerment skills
• Resources from NGO
• Community groups
• Financial management skills
• Resources from donors
• Care providers from nongovernment
organizations (NGO)
• Resource mobilization skills
• Other resource
1. Determine and mobilize human
resources to ensure an adequate
number of care providers for services
I
I
• Other nonformal caregivers
I
M
P
L
E
• Supportive supervision skills
• Technical skills
• Home visit skills
• Other skills
s
1
4. Provide holistic, integrated and continuous care
5. Supervise the provision of care to ensure continuing quality improvement of service provision
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6. Monitor implementaion of the model
Q.
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7. Evaluate the implementation of the model
8. Review the lessons learned from the demonstration sites
9. Consider further expansion of the use of the model
10. Disseminate the results of the evaluation and future action plans to advocate the wider implementation of
the model in community and home settings
Note: These activities are not necessarily carried out in a linear sequential manner. A number of activities will be taking place at the same time
depending on the local situation. The activities require different time-scales. Some are one-off activities while others are continuing activities.
1
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Comprehensive Community- and Home-based Health Care Model
14. BIBLIOGRAPHY
Mercenier P. The role of the health centre in the context of district health
system based on PHC. Ayutthaya Project, Ayutthaya, Thailand, 1986.
Pongsupap Y, and Ayutthaya Urban Health Center. The first demonstration
family practice first line health service. Ayutthaya Research Project:
1989-1996 and Health Care Reform Project: 1996-2001. Ayutthaya,
Thailand, 2001.
Pongsupap Y, Van Lerberghe W. The demonstration diffusion strategy and
experience of its implementation for developing ‘first line health service’
(family practice) in Thailand. Bangkok, 2001.
Tarimo E, Webster EG. Primary health care concepts and challenges in a
changing world: Almar-Alta revisited. Geneva: World Health
Organization, 1997. Current concerns, ARA paper no. 7 (Document No.
WHO/ARA/CC/97.1). < http://whqlibdoc.who. int/hq/1997/
WHO_ARA_CC_97.1 .pdf>
World Health Organization. The role of health centres in the development of
urban health systems: a report of a WHO study group on primary health
care in urban areas (Geneva, 2-9 December, 1991}. Geneva: WHO, 1992
(WHO Technical Report Series 827).
World Health Organization. Evaluation of recent changes in the financing of
health services: report of a WHO study group (Geneva, 10-17 December,
1991). Geneva: WHO, 1993 (WHO Technical Report Series 829).
World Health Organization. Handbook on AIDS home care. New Delhi:
World Health Organization, Regional Office for South-East Asia, 2004.
World Health Organization. Integration of health care delivery: report of a WHO
study group. Geneva: WHO, 1996 (WHO Technical Report Series 861).
< http ://whqlibdoc. who.int/trs/WHO-TRS_861 .pdf>
World Health Organization. Improving the performance of health centres in
district health systems: report of a WHO study group. WHO: Geneva, 1997
(WHO Technical Report Series 869).
World Health Organization. Community health workers: The way
forward. In: Haile Mariam Kahssay, Taylor ME, Berman PA. WHO
public health in action, Series 4. Geneva: WHO, 1998. <http://
whqlibdoc.who.int/pha/WHO_PHA_4.pdf>
Comprehensive Community- and Home-based Health Care Model
World Health Organization. Home-bused long-term cure: u report of u WHO
study group. Geneva: WHO, 1999 (WHO Technical Report Series 898).
< http: //whqlibdoc. who. int/trs/WHO_TRS_898. pdf>
World Health Organization. Community home-bused cure: family curefaving:
curing for family members with HIV/AIDS und other chronic illness: the
impuct on older women und girls: u Botswunu cuse study (Murch-April
2000). Geneva: WHO, 2000 (Document No. WHO/NMH/CCL/OO.l).
< http ://whqlibdoc. who.int/hq/2000/WHO_NMH_CCL_00. 1 .pdf>
World Health Organization. The world heulth report 2000. Heulth systems:
improving performunce. Geneva: WHO, 2000.
<.http://whqlibdoc.who.int/whr/2000/WHR_2000.pdf >.
World Health Organization, UNAIDS, Myanmar Nurses Association and
National AIDS Programme, Myanmar. Implementution guide for
estublishment of community home-bused cure in pilot ureus in Myunmur.
Yangon: WHO Country Office for Myanmar, 2001.
World Health Organization. Model for comprehensive community- und homebused heulth cure: report of u regionul consultution. Bangkok, Thailand, 2-A
December 2003. New Delhi: World Health Organization, Regional
Office for South-East Asia, 2004 (Document no. SEA/NURS/451).
-'CPHE - SOCHPhA
Koranr-niu-.lH
Sull (CL
pHC
/
U
31
Comprehensive Community- and Home-based Health Care Model
ANNEX 1: List of members of the Multidisciplinary Working Group, participants of the
Regional Consultations and Principal Investigator for the field test
Multidisciplinary Working Group Members
(ThaUand)
From Joint WHO Collaborating Centre for
Nursing and Midwifery Development,
Faculty of Nursing (Siriraj) and
Nursing Department, Faculty of Medicine at
Ramathibodi Hospital,
Mahidol University
Dr Kobkul Phancharoenworakul
Ms SuPANEE SENADISAI
Dr Rutja Phuphaibul
Dr Fongcum Tilokskulchai
Ms Vajira Kasikosol
Dr Kanaungnit Pongthavornkamol
Dr Yajai Sitthimongkol
Ms SuPAVADEE LlMPANATHORN
Dr Wantana Maneesriwongkul
From other organizations
Dr Yongyuth Pongsupap
General Practitioner
Urban Health Center and Research of Health
Care Reformed Project
Ministry of Public Health
Nontaburi
Mr Katha Bunditanukul
Pharmacist
President of the Community Pharmacy Association
Bangkok
Mrs Nuankanit Likhitluecha
Nursing Bureau
Ministry of Public Health
Nontaburi
Ms Rujinart Autthasit
Public Health Expert, Primary Care Center
Ministry of Public Health
Nontaburi
Mr Charat Junprasert
Public Health Expert
Pathumthanee Provincial Health Office
Pathumthanee
Ms Jintan a Jantharam
Social Worker
Public Health Care Center No. 31
Bangkok
Principal Investigators for the field test
Dr Guru Prasad Dhakal
District Medical Officer
Punaka, Bhutan
Dr Pe Win
Deputy Director (Public Health)
Department of Health
Ministry of Health, Myanmar
Ms Vijaya KC
Special Secretary
Ministry of Health, Nepal
Dr Ronnachai Tungmunanantakul
Director, Wang Noi Hospital
Ayutthaya, Thailand
First Regional Consultation (August 2001)
Mr Sheikh Shafi Ahmad
Joint Secretary (Hospital and Gender Issues)
Ministry of Health, Bangladesh
33
Comprehensive Community- and Home-based Health Care Model
Dr Guru Prasad Dhakal
Principal Investigator, Punaka, Bhutan
Ms Mridula Das
Assistant Director-General (Nursing)
Ministry of Health and Family Welfare, India
Dr Rachmi Untoro
Director
Directorate of Selected Community Health
Ministry of Health, Jakarta, Indonesia
Ms Husna Ibrahim
Nursing Supervisor
Indira Gandhi Memorial Hospital, Male’,
Maldives
Dr Kobkul Phancharoenworakul
Associate Professor Supanee Senadisai
Dr Yongyuth Pongsupap
Mr Katha Bunditanukul
Dr Rutja Phuphaibul
Observers (Thailand)
Dr Tassana Boontong
President, Thailand Nursing Council
Dr Surakiat Achananuparp
Faculty of Medicine
Ramathibodi Hospital
Mahidol University
Dr Pe Win
Principal Investigator
Yangon, Myanmar
Ms PlYADA PRASERTSOM
Ms Vijaya KC
Principal Investigator
Kathmandu, Nepal
WHO Secretariat
Ms Daya Kumarage
Director of Nursing (Public Health Servcies)
Ministry of Health
Colombo, Sri Lanka
Dr Ronnachai Tungmunanantakul
Principal Investigator
Ayutthaya, Thailand
Dr Kanitta Nuntaboot
Faculty of Nursing, Khon Kaen University
Khon Kaen, Thailand
Ms WlLAWAN SENARATANA
Faculty of Nursing, Chiang Mai University
Chiang Mai, Thailand
.•
Working Group Members
Dental Health, Department of Health
Ministry of Public Health
Dr Kumara Rai
Regional Adviser, Health Systems Development
WHO/SEARO
Dr Duangvadee Sungkhobol
Regional Adviser, Nursing and Midwifery
WHO/SEARO
Dr Madan Upadhay
Regional Adviser, Disability and Injury Prevention
WHO/SEARO
Dr Miriam Hirschfeld
Director, Home-based Long-term Care
WHO Head-Quarters
Comprehensive Community- and Home-based Health Care Model
Second Regional Consultation
(December 2003)
Ms JOYESSRI DATTA
District Public Health Nurse
Chittagong, Bangladesh
Dr Lalrintluangi
Deputy Commissioner
(Research, Studies and Standards)
Department of Family Welfare
Ministry of Health and Family Welfare
New Delhi, India
Ms Rusmiyati
Directorate of Community Healdi
Ministry of Health
Jakarta, Indonesia
Ms SUHARTATI
Directorate of Nursing and Medical Technician
Ministry of Health
Jakarta, Indonesia
Ms Indira Thapa
Central Regional Health Directorate
Ministry of Health
Nepal
Ms Husna Ibrahim
Nursing Supervisor
Indira Gandhi Memorial Hospital
Male’, Maldives
Daw Mu Mu Win
Township Nurse Officer
Shwekyin Township
Kachin State, Myanmar
Ms Kalyani Shrestha
Staff Nurse, District Health Office
Saptari, Nepal
Ms VlJAYA KC
Principal Investigator
Kathmandu, Nepal
Dr PAD Tissera
Director (Primary Health Care)
Ministry of Health
Colombo, Sri Lanka
Mrs NN Marikkar
Public Health Nursing Officer
Deputy Provincial Director of
Health Services Office
Kegalle, Sri Lanka
Dr Phattarapol Jungsomjatepaisal
Bureau of Health System Development
Ministry of Public Health
Nontaburi, Thailand
Dr Ronachai Tungmunanantakul
Principal Investigator
Ayutthaya, Thailand
Dr Myint Myint Than
Medical Officer, Bago Divisional Healdi Office
Bago Division, Myanmar
Mrs Sommai Hirunnuj
Director of Bureau of Nursing
Ministry of Public Health
Nontaburi, Thailand
Dr Tin Tin Win
Medical Officer, Bago Divisional Healdi Office
Bago Division, Myanmar
Mr Agapito da Silva Soares
Head, District Health Services
Dili, Timor Leste
.36
Comprehensive Community- and Home-based Health Care Model
Special Invitee
Ms Lene Svendsen
UNAIDS Nursing Consultants
Strengthening Nursing and Midwifery
Personnel for HIV/AIDS in Myanmar
Yangon, Myanmar
Observers (from Thailand)
Mrs Nuankanit Likhitkluecha
Bureau of Nursing, Ministry of Public Health
Nontaburi
Mrs Nuttaya Pattanavanichnun
Wangnoi Hospital
Ayutthaya
Mrs Sirjpun Bootsri
Wangnoi Hospital
Ayutthaya
Dr Yongyuth Pongsupap
Urban Health Center and Research of Health Care
Reformed Project, Ministry of Public Health
Nontaburi
Assistant Professor Supawadee Limpanathorn
Faculty of Nursing, Mahidol University
Bangkok
Pattriya Jarutut
Director
Sirindhorn National Medical Rehabilitation Centre
Nontaburi
Sriluck Hangsasuta
Chief, Community-based Rehabilitation Unit
Sirindhorn National Medical Rehabilitation Centre
Nontaburi
Assistant Professor Varunee Kansook
Faculty of Nursing, Chiang Mai University
Chiang Mai
MrSuTAT Kongkhuntod
Bureau of Health System Development
Ministry of Public Health
Nontaburi
Mrs Wilawan Nangern
Bureau of Health System Development
Ministry of Public Health
Nontaburi
WHO Secretariat
Dr Duangvadee Sungkhobol
Regional Adviser, Nursing and Midwifery
WHO/SEARO
Dr T Walia
Regional Adviser, Health Systems Development
WHO/SEARO
Ms Rose Johnsen
Nurse Administrator
WHO, Dhaka, Bangladesh
Dr Deborah Hennessy
Short-term professional (Nursing)
WHO, Jakarta, Indonesia
Ms Sarah Sullivan
Short-term professional (Nursing)
WHO, Dili, Timor Leste
Dr Kobkul Phancharoenworakul
Joint WHOCC for Nursing and Midwifery
Development
Mahidol University
Bangkok, Thailand (local organizer)
Associate Professor Supanee Senadisai
Joint WHOCC for Nursing and Midwifery
Development
Mahidol University
Bangkok, Thailand (local organizer)
Comprehensive Community- and Home-based Health Care Model
,37
ANNEX 2: Examples of health worker skills
Examples of tasks and skills12 required to deliver comprehensive community- and home-based health
care (CCHBHC) and for working with the community are provided below.
Individual and family level
Duty
Task
1. Health
screening and
simple
treatment
1.1 Health assessment
1.2 Prescribe medication from the
Essential Drugs List
1.3 Refer patients as needed
Skills
1.1 Interview skills
1.2 Observational skills
1.3 Physical and basic mental health
assessment
1.4 Simple tests and interpretation
of the results
1.5 Simple treatment as given in
the Essential Drugs List
1.6 Decision-making for referral as
needed
1.7 Emergency management
2. Health
promotion for
individual and
family
3. Disease
prevention
2.1 Child health services
2.1 Physical assessment skills for
- Assess and record child's growth and
development
- Child health counselling
2.2 Elderly health services
- Health assessment
- Promotion of health counselling and
self-care
- Empowering the community for the
elderly
2.3 Health campaigning
- Distribute health information
- Conduct and promote healthy lifestyles
- Collaborate with family and
community for environmental and
specific health issues
2.4 Advocate for health
the growth and development of
children, and health
assessment for the elderly
2.2 Counselling skills for parenting
and elderly
3.1 Immunization
3.1 Skills in maintaining the cold
chain
3.2 Skills for giving injection
3.3 Assessment skills for health
problems, e.g. drugs used,
family violence and mental
health
3.2 Case-finding
3.3 Health problem alert, e.g. prevalence
of drug use and violence in the family
and community
3.4 Environmental and sanitation
management
■
12 Adapted from Rujkornkan D. Community health nursing model in Sri Lanka: an assignment report. New Delhi: World
Health Organization, Regional Office for South-East Asia, 2001 (unpublished).
Comprehensive Community- and Home-based Health Care Model
Individual and family level
Duty
4. Long-term care
Task
4.1 Make home-visit and provide
rehabilitative care for clients with:
- diabetes
- hypertension
- cardiovascular accidents
- heart disease
- HIV/AIDS
- tuberculosis
- mental health problems
- impairment and disability
Skills
4.1 Home visit skills
4.2 Skills in providing direct care to
4.3
4.4
4.5
4.6
5. Health care at
home
6. Referral for
appropriate
care
5.
Home visit
5.1 Provide health education to the
client and his/her family
5.2 Provide counselling and support to
the client and family
5.3 Liaise with medical personnel and
clients
5.4 Collaborate with the appropriate
sectors for assistance if required
5.5 Provide physical care according to
the individual's self-care deficits
6.1 Coordinate with the individual and
agencies
6.2 Collect data for referral
6.3 Give information to the patient and family
6.4 Conduct first-aid or appropriate care
before referring (if needed)
7. Counselling and
guidance
7.1 Establish appropriate counselling
facilities
7.2 Provide marriage counselling
7.3 Provide counselling on substance
abuse, STDs, voluntary counselling
and testing for HIV/AIDS
7.4 Promote family functions and
relationships
7.5 Assist the family in problem-solving
7.6 Refer to a specialist if required
patients with diabetes,
hypertension, cardiovascular
accidents, heart disease,
HIV/AIDS, tuberculosis, mental
health problems and specific
disabilities
Interpersonal skills
Counselling skills
Training skills for caregivers
within the family
Skills in mobilizing community
resources
5.1 Build relationships and trust
5.2 Assess self-care ability
5.3 Skills for wound dressing,
insulin injection and positioning
5.4 Teaching and guiding skills
5.5 Counselling and emotional
support skills
5.6 Communication skills
5.7 Skills for promoting self-care
6.1 Communication skills
6.2 Interpersonal skills
6.3 Decision-making skills
6.4 Skills in cardiopulmonary
resuscitation
6.5 Skills in caring for burns,
surgical wounds, injuries, etc.
6.6 First-aid techniques
7.1 Family assessment skills
7.2 Family intervention skills
7.3 Trust-building skills
7.4 Being reliable and trustworthy
7.5 Being flexible
7.6 Counselling skills
7.7 Maintaining emotional stability
Comprehensive Community- and Home-based Health Care Model
Individual and family level
Duty
8. Building
strengths and
coping skills of
the family
Task
Skills
8.1 Provide information regarding social
8.2
8.3
8.4
8.5
support systems, employment or
occupation
Liaise with GOs and NGOs for health
and social support
Find information about health and social
services needed for the family
Mobilize community resources
Provide psychosocial support
8.1 Collaborating skills
8.2 Interpersonal skills
8.3 Management skills
8.4 Psychosocial support skills
GO: governmental organization; NGO: nongovernmental organization; STDs: sexually transmitted diseases
Community level
Task
Skills
1. Community
assessment
and diagnosis
1.1 Collect data about health and related
1.1 In-depth interviewing skills
1.2 Skills to conduct focus group
discussions
1.3 Community survey skills
1.4 Observation skills
1.5 Constructing interview guidelines
2. Working with
the community
to implement
activities
2.1 Set priorities for problems and needs
2.2 Set objectives
2.3 Write a project proposal
2.4 Mobilize funds as needed
2.5 Implement projects
2.6 Manage projects
2.7 Evaluate projects
2.1 Decision-making skills
2.2 Interpersonal skills
2.3 Leadership skills
2.4 Management skills
2.5 Group process skills
2.6 Planning skills
2.7 Project planning and writing skills
3. Mobilizing
community
participation
and resources
3.1 Promote self-reliance
3.2 Promote interdependence in the
3.1 Management skills
3.2 Group process skills
3.3 Stress management skills
3.4 Counselling skills
3.5 Teaching skills
3.6 Training skills
Duty
factors
1.2 Identify needs and problems
1.3 Identify resources and constraints
community
3.3 Organize regular meetings with
community representatives
3.4 Establish self-help groups and
awareness programmes
3.5 Design appropriate activities for
aggregates and high-risk groups
Comprehensive Community- and Home-based Health Care Model
ANNEX 3: Home visits
Home visits provide an opportunity for health personnel to see a complete
picture of clients’ living experiences, in which illness is only one aspect of
their lives. This will enable them to better provide holistic care that meets
the physical, psychological, social and spiritual needs of their clients. In the
home, health personnel see environmental factors that affect health, and
social and psychological influences; relationships between and among
family members; and interaction of clients with families and social
networks. In addition, health workers can see first-hand how well the
clients can perform self-care at home and make a more accurate evaluation
of the health care interventions required.
A home visit is effective when clients are able to exercise more control over
their care and are part of the health care team, rather than dependent,
passive recipients of care. Health personnel should promote a sense of
empowerment in the clients and families for self-care and healthy living as
well as proper health-seeking behaviours.
PURPOSES
Home visits are carried out for several purposes such as:
• case-finding for public health and protection in cases such as abuse,
neglect communicable diseases and school-related health conditions;
• promoting health and preventing illnesses by providing services such as
antenatal, newborn and well-baby care; child development and care of
the elderly; and
• providing care for the sick and terminally ill such as home health, and
palliative and hospice care.
CRITERIA
FOR HOME VISITS
_____________________________________
It is not cost-effective to provide care at home for every client. For optimal
utilization of resources for the health of the community, eligibility criteria
for home visits and home care will need to be decided and agreed upon
with the community. This will vary from place to place, depending on the
health needs identified during community assessment.
Comprehensive Community- and Home-based Health Care Model
In general, priority should be given to make health care more accessible to
vulnerable, disadvantaged and high-risk groups. These include the following:
• Handicapped people;
• Elderly people;
• Those who are confined to their homes and are unable to seek care at
health facilities, such as mothers who have delivered recently and
newborns, and post cardiovascular accident cases;
• Pregnant women and children under 5 years of age who miss appointments;
• Chronic patients whose condition is not under control and those who
miss their appointments;
• Clients requiring long-term, home-based care such as those with HIV/
AIDS; and
• Clients requiring follow-up care at home post-hospital/operation.
CONDUCTING A SUCCESSFUL HOME VISIT
Actions that health personnel should carry out for a successful home visit
from die beginning to the end are provided below.13
Pre-visit/planning stage
• Determine which clients need to be seen according to die agreed criteria.
• Prioritize the scheduled visits based on clients’ health needs and in
coordination with other health team members.
• Review family folders, clients’ records, goals of care and reasons for the
home visit.
• Validate the scheduled visit with clients and/or family members, and assess
the specific needs of clients and nonformal caregivers (such as supplies).
• Conduct inventories of the home visit bag, equipment needed, and
supplies and educational materials for clients.
• Review safety considerations, such as the timing of die visit and
assessment of the environment.
Implementing the visit
• Initiate the visit by the introduction and identification of health
personnel to the client, and a brief social dialogue to establish rapport.
13 Lundy, KC. The home visit. In: Lundy KC, Janes S (eds). Essentials ofcommunity-based
nursing. Ontario: Jones and Bartlett Publishers, 2003:301.
41
Comprehensive Community- and Home-based Health Care Model
• Practice appropriate hygienic practices before assessing the client such as
hand-washing.
• Review plans for the visit with the client.
• Determine the expectation of the client regarding home visits.
• Conduct an assessment of the environment, client, medication, nutrition,
functional abilities and limitations, psychosocial-spiritual issues, and
evaluate the effectiveness of previous visit interventions.
• Modify the plan of care based on clients’ needs and situation.
• Carry out health interventions.
• Deal with distractions—environmental and behavioural.
Evaluating the visit
• Evaluate the effectiveness of the interventions based on established
short-term (response during the visit) as well as long-term outcome
criteria (effects of the intervention at subsequent visits).
• Evaluate the conduct of the visit: availability of appropriate supplies and
preparation of health personnel for a visit.
*•
Documentation
• Document in the family folder and other record(s) according to standard
procedures.
• Validate diagnoses and additional health needs based on visit.
• Record actions taken, response of client and outcomes of intervention
(short-term and long-term).
• Record both objective data (health worker-based) as well as subjective
data (client-based).
Termination
• Termination begins with the first visit as the health worker prepares the
client for the time-limited nature of home visits.
• Review goal attainment widi the client/family, and make recommenda
tions and referrals as appropriate for continued health care issues.
• Develop strategies for appropriate closure with clients who die, refuse
visits, or are terminated as care is no longer required due to various
reasons such as complete recovery or moving out from the area.
Comprehensive Community- and Home-based Health Care Model
43
ANNEX 4: An example of a weekly schedule of services coordinated by a health centre
Time
Monday
Tuesday
Wednesday
Thursday
8:00-12:00
(at the
outpatient
clinic)
• ANC,
counselling
and FP
• Outpatient
clinic
• ANC,
counselling
and FP
• Outpatient
clinic
• ANC,
counselling
and FP
• Outpatient
clinic
• ANC,
counselling
and FP
• Outpatient
clinic
13:00-16:00
(at home and
in the
community)*
• Home visit
• Home visit
• Community
• Community
health
health
surveillance
surveillance
• Campaign for a • Campaign for
healthy lifestyle
a healthy
lifestyle
• School health
• Home visit
• Home visit
• Community
• Community
health
health
surveillance
surveillance
• Campaign for
• Campaign for a
a healthy
healthy lifestyle
lifestyle
• Environmental
summary
health
ANC: antenatal care; FP: family planning
Note: A community meeting is organized once a month.
*There should be one health worker on standby at the clinic in the afternoon
tOhce a month supervision
A brief description of each of the key activities is provided below.
1. The outpatient clinic
The clinic should be organized to provide health screening and simple
treatment as active and rational health activities and not as a passive
response to an irrational demand while considering the following:
• The use of decision trees (strategies of diagnosis and treatment) drawn up
with the objective of detecting and dealing adequately with priority problems.
• The use of essential drugs to reduce costs, improve use and promote
the use of effective drugs.
• The systematic referral to hospital and an institution of a higher
technical level when needed.
2. Care and active follow-up in emergency situations
Health workers should be enabled to develop the necessary knowledge and
skills to provide relevant and appropriate advice, care, treatment and
referral in emergency situations.
3. Care and active follow-up of chronic patients
The follow-up process involves self-evaluation by analysis of data for case
finding as well as monitoring attendance of chronic patients at clinics. A
Friday
• Well child
counselling
(immunization)
• ANC, counsel
ling and FP
• Outpatient
clinic
• Home visit
• Supervision
for village
health
volunteerst
• Health
report
44J
Comprehensive Community- and Home-based Health Care Model
systematic strategy was developed to retrieve cases, and give a simple and
obvious objective to purposeful home visits. It involves identifying, in a
small and well-defined group, the cultural and environmental determinants
of human behaviours and the means of influencing them positively.
4. Care and active follow-up of high-risk groups
In any community, it is necessary to identify high-risk groups. These may
include groups of people exposed to occupational health risks, e.g.
industrial workers or agricultural workers exposed to pesticides, or age
groups such as the elderly or schoolchildren. The identification of these
high-risk groups calls for a certain amount of previous epidemiological
knowledge. Epidemiological data would be necessary to formulate
appropriate follow-up strategies for these groups.
However, young children and women of reproductive age are considered
risk groups found in every community. Family health care services for
family planning, and antenatal and postnatal care should be offered. Well
child care with periodic weighing, immunization and education for parents
should be included.
5. Health promotion programmes
Promotion of healthy lifestyles in the home and community settings could
include a school health programme, an environmental health and
occupational health programmes established by health workers. Healthy
nutrition, exercising for health, accident prevention, drug abuse prevention,
HIV prevention, TB control, anti-smoking campaigns are some examples
of healthy lifestyle-promoting activities.
The above services are very basic, and necessary to start and expand
primary health care concepts. Other functions such as environmental
sanitation, community health education, etc. require a long-term
relationship between the health service and community.
6. Community meetings
Community meetings are a part of the formal health centre activities. These
should be convened on a regular basis with a set agenda to facilitate and
foster active involvement of the community in the provision of health care as
well as for addressing priority health issues confronting the community.
Health personnel should facilitate the community meeting. However, it
should be chaired or led by a community leader or other prominent figure
in the community Overall development of the community could also be
achieved through these meetings.
JH
Comprehensive Community- and Home-based Health Care Model
ANNEX 5: Examples of activities of the Ayutthaya Urban Health
Centre. Thailand
Concrete examples of activities carried out by the Ayutthaya Urban Health
Centre are provided below.
1. CURATIVE CARE
1.1 Curative care at health centre
Provision of curative services is in great demand. Treatments implemented
at the health centre include injections, simple surgery, Thai traditional
massage, etc. Time is also invested in explaining how to take the medicine
or recommending lifestyle changes based on knowledge about the patient
and his/her home circumstances.
The most common diseases seen in the community by personnel at the
Health Centre can be summarized as follows:
• Minor conditions, e.g. acute throat infections, vertigo-dizziness,
gastroenteritis, etc. are the most common;
• Acute major diseases, e.g. pneumonia, severe depression, acute
myocardial infarction, etc.; and
• Chronic diseases, e.g. hypertension, diabetes mellitus, chronic psychiatric
problems, heart disease, TB, etc.
The latter two are often detected in the demonstration health centres but
are seldom dealt within the existing Thai health centres.
1.2 Home care for curative service
Staff of the Health Centre make home visits to registered patients14 who
need close observation with such conditions as acute febrile illness and
vomiting in children or acute asthmatic attacks.
1.3 Organized interaction with the provincial hospital
The Health Centre can use the services of the hospital for laboratory
investigations, specialist consultation, drug supply and admission on
■
14 Registered patients refer to individuals residing in the catchment areas who arc registered at
the health centre to be recipients of care.
,45.
Comprehensive Community- and Home-based Health Care Model
payment of a fee-for-services basis. In cases of hospital admission, some
patients are referred by the Health Centre staff while others go directly to
the hospital when the Health Centre is closed. The staff of the Health
Centre visits them at the hospital, and uses the opportunity for discussion
with the specialist and dialogue with the patient.
2. CARE AND ACTIVE FOLLOW-UP OF PATIENTS WHO NEED
LONG-TERM CARE
These services need much more effort to ensure continuity of care
compared with purely curative activities. However, because the patients are
known to the staff there is more opportunity to address the issues of health
promotion and illness prevention.
2.1 Detection: recruitment for chronic disease programmes
The systematic home visits, including the census and negotiation meetings,
with the defined population provide opportunities for the staff and family
members to get to know each other. Many families ask about chronic
diseases, because some members have suffered from them and others are
concerned about their future risk. This provides an opportunity to
encourage them to go to the Health Centre to confirm their status. Very
often the presence of chronic disease is detected at the curative clinic. The
overall process of detection is a balance between active (discussion at home)
and passive (curative clinical approach) detection.
2.2 Care for the chronically ill: an important part of the workload
As patients make the greatest demands at the start of care, continuity of
care requires less treatment. The nature of chronic diseases means that cure
is difficult, therefore, a dialogue is needed to enable patients to understand
the logic of the treatment. Once chronic diseases or other long-term care
problems are detected, it is obvious that the workload of the health centre
is increased. Such patients need home visits and home care. However, this
aspect of care is included in the minimum package necessary for health
centre activities.
2.3 Home visits and home care for chronic and long-term care
patients
Home visits are made to patients with chronic conditions who have missed
appointments for more than seven days and those with poorly controlled
Comprehensive Community- and Home-based Health Care Model
47
conditions, such as diabetes mellitus and hypertension. Home-based, long
term care usually involves nonformal caregivers, including family, friends
and neighbours. The two main categories of patients who require home
care are the elderly suffering from stroke, dementia or degenerative
neurological diseases, and people who needing palliative care and wish to
die at home. The frequency of visits depends on the patient’s condition and
the level of nonformal support available to them.
Health Centre personnel cany out a range of activities at home including
wound care for patients with bedsores; changing Foley catheters or
nasogastric tubes; and teaching and supporting nonformal caregivers in the
delivery of care. Home visits also provide an opportunity for health
personnel to act as a bridge between the family’s traditional belief system
and the scientific medicine belief system. This is particularly important in
the terminal stages of illness where health personnel need to understand
and accommodate the religious and personal belief systems (meeting
spiritual and psychological needs) of the patients and their family
members.
3. CARE AND ACTIVE FOLLOW-UP FOR HIGH-RISK GROUPS
In the Ayutthaya Urban Health Centre, high-risk groups were identified
during die systematic home visits and negotiations with the community.
The groups included young children (under 5 years of age), women of
reproductive age and pregnant women. The following activities were
provided for these groups:
• For young children under 5 years of age, periodic immunization was
given at the same time as growth monitoring and education of mothers
in nutrition, breastfeeding, etc.
• For pregnant women, antenatal care was organized with periodic
surveillance of pregnancies, tetanus immunization, care of associated
illness, identification of high-risk deliveries for early referral and training
of mothers in breastfeeding. The deliveries took place at the provincial
hospital with the Health Centre again taking responsibility for
postpartum care.
• For postpartum women, periodic routine home visits for talcing care of
the mothers and infants at home were carried out.
• Family planning was organized by providing opportunities to discuss
health education and select appropriate contraceptive methods.
IB
48
Comprehensive Community- and Home-based Health Care Model
3.1 Home visits for high-risk groups
To ensure the continuity of care and have better coverage, the Health
Centre staff carry out home visits for children less than 5 years of age if
they miss an appointment and do not present within 7 days, and for
pregnant women who miss antenatal appointments.
4. PRIORITIES FOR HOME VISITS AND HOME CARE
Home visits and home care are integrated into the various activities of the
health centre as mentioned above. In practice, they are routinely organized
in the afternoon of every weekday with normally not more than 5 cases per
day. Priorities are determined as follows:
• Acutely ill patients who require observadon or nursing care;
• Patients who are discharged from die hospital and at risk for developing
complications;
• Postpartum mothers and their newborn to give health education; family
planning for the mother; and immunization for the child;
• Chronic patients whose condition is not under good control;
• Chronic patients who miss an appointment for more than seven days;
• High-risk groups such as pregnant women and children under 5 year of
age who miss appointments for more than seven days;
• Handicapped and elderly people for both physical and mental
rehabilitation; and
• Collection of samples (e.g. blood, urine, sputum) when necessary.
There was no formal community organization in this catchments area
earlier. Thus, die Health Centre has organized a regular community
meeting.
The first community meeting was led by health personnel to discuss the
issue of financial management of die centre. The second meeting was also
organized by the health personnel by informally inviting people who came
to the Health Centre for services to continue the discussion on financial
managenient and care provided by the Centre.
After seeing the usefulness of the community meeting, die members
agreed to set a regular meeting once a month to discuss any topic of
concern related to the Health Centre and community. Later on, objectives
Comprehensive Community- and Home-based Health Care Model
of the routine monthly community meeting were developed to maintain
mutual understanding, evaluate mutual decisions, and find concrete
solutions to address new problems.
The number of participants in die community meetings varied from about
10 to over 100 with an average of 20-50 participants at a meeting. With
too many people participating in die meeting, community members felt
that there was a need to have a community organization to link in a more
systematic way with the Health Centre. Consequendy, an informal
committee was formed to organize the meeting and a chairperson was
selected by the community. Healdi personnel were also members of this
informal committee and played a supportive role in these meetings.
Community meetings have been organized regularly. The place of the
meeting varied among the temples in a village (5 in all) so that people
from various areas could participate. The functions of die committee were
to maintain and promote mutual understanding and trust between the
Health Centre and community, and control and administer the community
funds that were set up before this committee was formed.
49
Comprehensive Community- and Home-based Health Care Model
ANNEX 6: Monitoring and evaluating the Ayutthaya approach
The strategy for monitoring and evaluating the Ayutthaya Project was
based on the belief that comprehensive community- and home-based health
care (CCHBHC) seeks to offer people a better overall service, and the
objective of monitoring and evaluating is not merely to measure the specific
impact of health service activities on particular health problems.
Evaluation of the direct impact has often been advanced as a justification
for vertical or specific programmes. However, when such programmes are
integrated in CCHBHC, the objectives of die programme necessarily
change. Therefore, in CCHBHC, the evaluation of direct impact is better
replaced by the indirect method of ‘process evaluation’. This aims at
providing healdi professionals and the population with methods of self
evaluation so as to produce an internal feedback and improvement in the
service. For example:
• A simple measure of the number of contacts per inhabitant per year: In
itself this figure is not significant, except in giving information on the
acceptability of the Health Centre by means of comparing and
observating trends.
• Internal functioning of the district health system: This can be gauged by
the rate and impact of referral of patients to die referral unit, and the
quality of the transmission of information, e.g. percentage of patients
attending the hospital with appropriate, relevant and timely information.
• Continuity of care: This includes the quality of follow-up of chronic
patients such as the number of patients with tuberculosis who are regular
in their treatment in relation to all patients with tuberculosis who are
treated or risk episodes (months of pregnancy at first antenatal visit and
number of consultations during antenatal surveillance).
• Coverage for immunization and antenatal care: This can be estimated by
a comparison between health centres and evaluation of trends in each
centre rather than using targets arbitrarily set by central officials.
• Financial equilibrium of the Health Centre.
• Community involvement: This is evaluated by simple indicators such as
regularity and attendance of health committee meetings. More elaborate
measurements have been developed such as the type of problems raised,
involvement of members in decision-malting, identification of problems
and putting forward of appropriate solutions.
• General awareness of the population: This can be evaluated by selecting
certain major educational objectives and following the gradual
development of understanding.
Comprehensive Community- and Home-based Health Care Model
• Intersectoral activities: This could be evaluated in the same way as
community involvement.
Comprehensive community- and home-based healdi care puts stress on
community participation and, therefore, on decision-making from bottomup. One of the challenges is to find an appropriate interface between dais
form of decision-making and die more traditional top-down system of
decision-making. Widi its role as a point of interaction between the service
and community, the Health Centre is evidendy in a central position here.
Basically, top-down decision-making is necessary, but there is a place for
bottom-up decision-malting so that people can express their priority
demands and use their own resources, including, when applicable, their
own financial contribution to die system.
Process evaluation is more complex than traditional forms of evaluation,
since it cannot use particular targets (because in the case of a system these
are arbitrary) or specific impacts. Instead, it uses local comparisons and
trends. In relation to the various aspects of development, this could yield
semi-quantitative information. Frequently, die information collected has no
single explanation; a number of different hypotheses might be put forward
to explain it. It is only by collecting information of different kinds that the
uncertainty can be reduced and one of the hypotheses suggested becomes
the most probable.
■''' ^1;
pKCHOO
165-13
P°4'
I51
Comprehensive Community- and Home-based Health Care Model
ANNEX 7: Suggested Terms of Reference of the District Leading
Team
1. Plan and prepare for implementation of the comprehensive communityand home-based health care (CCHBHC) model in the demonstration
sites.
2. Mobilize support for the implementation of the CCHBHC, as required.
3. Coordinate and manage the overall implementation of CCHBHC in
health centres selected as demonstration sites.
4. Monitor and evaluate the implementation of CCHBHC.
5. Disseminate die outcomes of the implementation of CCHBHC.
6. Prepare a progress report of the implementation of the model to be
submitted to the health ministry.
7. Plan for further expansion of the model.
t
Comprehensive Community- and Home-based Health Care Model
ANNEX 8: An example of a family file
ADDRESS
House no.:
Village no.:
Subdistrict:
Household head:
Ayutthaya Urban Health Centre
in collaboration with
Ayutthaya Municipality and Ministry of Public Health
Family File
Map of house location/house characteristics/neighbourhood
or famous person in the area
ramiiy rue (.rr;
s
Inside the cover
Village number:
Address: House no.:
i
Subdistrict:
§
No
Regis
tration
date
Sex
Name
Date
of
birth
Occu
pation
Educa
tion
Marrital Family Health Note
status relation insurance (SCship coverage OC)
£
(D
Discharge
from FF
Date
Others/
WBC/
ANC/
FP/
dis
Reason abled
Code
i
I
Ia
1
2
3
I
4
O
Q
Q
5
O
Q
6
7
8
9
10
11
12
SC: synthesis card; OC: operational card; WBC: well-baby clinic; ANC: antenatal clinic; FP: family planning
Net family income:
Bahts/month
Status/role in the community:
Household condition:
Comprehensive Community- and Home-based Health Care Model
Personal Ticket for acute episodes
No.
No. of family File
Occupation
Date of Birth
Name
Address
Health Insurance Coverage
History of drug adverse effects
History of chronic conditions/diseases
Records of treatment
Date of
visit
Chief
complaint
Physical
examination
Diagnosis
Treatment
and advice
Follow-up
appointment
Yes
No
Examining
health
personnel
Page 1 of 2
Comprehensive Community- and Home-based Health Care Model
Personal Ticket for acute episodes
Records of treatment
Date of
visit
Chief
complaint
Physical
examination
Diagnosis
Treatment
and advice
Follow-up
appointment
Yes
No
Examining
health
personnel
Page 2 of 2
Comprehensive Community- and Home-based Health Care Model
Operational Card (OC) for chronic episodes
No.
No. of Family File .
Type..
No. 1
OC 2
3
Date
Date
Date
Household head
Chronic Episodes Operational Card
Name
Sex
Marital status
Occupation
Diagnosis
Date of birth
Chief complaint
Disease 1
Disease 2
Disease 3
Disease 1
Disease 2
Disease 3
on
on
on
Place provided diagnosis and treatment
Disease 1
*UC *General Hospital/regional hospital
♦Private *Hospital Centre/District Hospital
Disease 2
Disease 3
Records of important finding and plan of treatment (record only when findings or treatment were changed)
Date
Investigation results
Findings from investigation
Treatment
Remarks 1. For hypertension (HT)
2. For diabetic mellitus (DM)
3. Others (identify)
Page 1 of 2
>8
Comprehensive Community- and Home-based Health Care Model
Operational Card for chronic episodes
Records of appointment and treatment (record every visit)
Appointment Date of visit
date
Cause of delay in
visit/action
Physical examination and
investigation
BW
BP
FBS
Treatment and action
(including care and home
visit)
BW: boby weight; BP: blood presure; FBS: fasting blood sugar
Page 2 of 2
Comprehensive Community- and Home-based Health Care Model
59
Operational Card (OC) for children under 5 years of age
Type/no. OC
Child Health Operational Card
Address no
Household head
Date of birth
Sex
Name
No. ______ 1
Vaccine^. Appoint Inject
_______ 2
Appoint Inject
_______ Bl
3
Appoint
Inject
Appoint
Inject
_______ B2
Appoint Inject
BCG
HBV
DPT
OPV
Measles
Remarks
BCG: bacille Calmette-Guerin; HBV: hepatitis B vaccine; DPT: diphtheria, pertussis and tetanus;
OPV: oral polio vaccine; JEV: Japanese encephalitis vaccine; B: booster dose
Records of examination: treatment-appointment (in case of a child who needs continuous care: OC)
Appointment
date
Date of visit
Causes of delay in visit and
operation
Diagnosis and
finding
Treatment
Summary of significant illness or risk (Synthesis Card)
Starting date
Ending date
Hospital no.
Problem/diagnosis/treatment
Result of
treatment
Page 1 of 2
Operational Card for children under 5 years of age
oo
Back page
3
Tick / for things done or X for nothing done
3
3
12 34 567 891011^12 34567891011S
Breastfeeding
Supplementary
Mother is pregnant
1 2 3 4 5 6 7 8 9 1011
1 2 3 4 5 6 7 8 9 1011
I
13
1 1 2 3 4 5 6 7 8 9 1011 I
12
12
7-
11
10
9
9
/
8
/ /
5
7
7
14
14
13
13
<5
O
o
3
3c
Q
Q.
12
12
11
11
10
10
CD
CT
cn
CD
9
9
s
8
8
o
7
7
53
Q.
Q
§
6
Year 4
/
Years
5
7 7 7
/ 7
Important: history of child health
Labour
7 /
Year 3
/ /
7
2
15
o
/
3
15
2.
7 /
7
71 / /
6
4
v7
/
7 7
16
8
/
7
16
11
10
/
o
term
preterm
Weight
g
Abnormality/deformation
J.
Allergic to medicine.
Year 2
io
Nutritional status and child health
Blood group--------Others----------------
B
Q
Page 2 of 2
Comprehensive Community- and Home-based Health Care Model
61
Operational Card (OC) for pregnant woman
Type
No. of OC
Date
FF No.
Household head .
Pregnant Woman Operational Card
Name
Age
LMP
EDC by
Occupation
History of pregnancy and general health
Gravida.
Para.
Normal
Abortion
Abnormal
Last parity
Last abortion.
Stillbirth
Delivery place
History of latest pregnancy
History of previous pregnancy
History of general health/drug allergy
Plan of present pregnancy
Investigation/vaccination and other important findings
Height
centimeter
Decision (from laboratory results)
Blood group
Laboratory findings
Date
VDRL1
HIV
HBsAg
HCT
Date of vaccination of tetanus toxoid 1
Date of vaccination of tetanus toxoid 2
HIV: human immunodeficiency virus; HBsAg: hepatitis B surface antigen
Date
Body
weight
Urine
albumin
Blood
presure
Oedema
Uterine
fundus
Gestational
age
Other signs/
complaints
Decision
Follow
up
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
Remark: identify foetus position at 34 weeks of gestational age
Page 1 of 2
Comprehensive Community- and Home-based Health Care Model
Operational Card for pregnant woman
Labour history
Date.
Place
Type of delivery.
Child weight
Sex.
Complication
Live birth
Stillbirth
Complications.
Postpartum mother
Date
BT
BP
Lochia
Abdomen
perineal wound
Breast
feeding
Other signs,
complaints
Decision
Follow-up
BT: body temperature; BP: blood presure
Plan for contraception.
Opening date of Operational Card.
Baby
Date
BW
Umbilicus
Other signs, complaints
Decision
Follow-up
BW: birth weight
I
Opening date of Operational Card (Well-Baby Clinic)
i
Page 2 of 2
Comprehensive Community- and Home-based Health Care Model
,63:
Synthesis Card
Name
Sex
Date of birth
Address
History of health
Blood group
History of drug allergy, allergic
to
Abnormality/deformity
Vaccination (identify the date)
^\No.
Vaccine\
BCG
i
2
3
Bl
B2
HBV
DPT
OPV
Measles
JEV
Tetanus
BCG: bacille Calmette-Guerin; HBV: hepatitis B
vaccine; DPT: diphtheria, pertussis and tetanus;
OPV: oral polio vaccine; JEV: Japanese encephalitis
vaccine; B: booster dose
Other important history
1. Physical
2. Psychosocial
Page 1 of 2
Comprehensive Community- and Home-based Health Care Model
Synthesis Card
Synthesis of health problems and risks
Problem starting
date
Problem ending
date
Type/no. of
Operational Card or
Hospital no.
Problem/diagnosis/services
provided
Results of
services/treatment
Page 2 of 2
Comprehensive Community- and Home-based Health Care Model
ANNEX 9: Clinical supervision
A key factor in the successful implementation of comprehensive
community- and home-based health care is the provision of appropriate
clinical supervision for all health personnel. A number of models of clinical
supervision exist but, regardless of whether or not a particular model is
used, the key to success lies in the relationship established between the
supervisor and supervisee. In some situations, the concept of supervision
has tended to have negative connotations and is linked in many peoples’
minds to criticism and punitive action. However, effective clinical
supervision is a supportive developmental process.
PURPOSE
Clinical supervision serves a number of purposes as follows:
• It provides a formal system for health personnel to examine and explore
their practices in a safe and supportive environment;
• It enables individuals to develop dieir knowledge and understanding of
ways to enhance delivery of care and improve services; and
• It helps practitioners to accept responsibility and accountability for their
own practice.
■
■
.
CRITERIA FOR SELECTION OF SUPERVISORS
Supervisors need to:
• be seen as competent practitioners in the practice setting;
• have personal skills and knowledge to enable personnel to reflect on
their work and aim for continuous improvement; and
• create a supportive, positive, nonjudgemental and solution-seeking
approach to change.
CHARACTERISTICS OF A GOOD CLINICAL SUPERVISOR
A good clinical supervisor:
• acts as a role model and inspires others by his/her knowledge and
attitude or skills;
• has good listening skills, is able to develop supportive relationships and
perceptive to supervisees’ needs; and
• has a high level of self-awareness and acknowledges his/her own limitations.
65
Comprehensive Community- and Home-based Health Care Model
SUPERVISION PROCESS
A specific time needs to be identified for the supervisor and supervisee to
meet. Supervision is most likely to take place on a one-to-one basis but
group supervision may be appropriate in some situations.
As far as possible, die supervision time should be planned so as to meet
identified needs. This could include the provision of care to a specific
individual or group where the supervisee needs specific support in terms of
knowledge or skills to deal with a particular situation. Sometimes, the
supervisee may need time for a quiet and confidential discussion with the
supervisor away from patients and other personnel.
In implementing a new approach to practice, the supervisee may be
unaware of his/her deficits and learning needs. In such circumstances, the
supervisor may need to take a more proactive role in determining how to
use the time of supervision most effectively. This may include
demonstrating new and different ways of providing care and treatment;
establishing different systems or processes for managing the provision of
services; and using problem-solving skills to address particular difficulties.
It is important that records of the supervision experiences are maintained
so that health personnel can reflect on their practice and progress. The
supervisor should maintain an overall record of broad issues addressed
during die supervision sessions together with a summary of issues related
to changes required in the systems and processes of care within the health
centre. This is especially important during a period of change when the
lessons learned are likely to be generalizable to other people and locations.
However, every effort must be made to maintain appropriate confidentiality
for individual supervisees. This is essential if an appropriate supportive
relationship is to develop. Supervisees should keep their personal supervision
records, which should be confidential between them and their supervisor.
However, die supervisee should have the option to share them with other
colleagues, if so desired. The differences between the notes made and held by
die supervisor and diose by die supervisee are that the supervisor’s notes
reflect broad issues related to systems and processes of care delivery, and
identification and meeting of training needs. The supervisee’s notes reflect his/
her personal experiences and progress in developing practice.
The supervision records should include the date, time and location of the
supervision session together with a summary of the issues discussed,
lessons learned and action agreed. A sample proforma is attached (see p 69).
Comprehensive Community- and Home-based Health Care Model
Clinical Supervision Record
Supervisor
Supervisee
Location ....
Date
Time
Supervision activities
(These may include observation; demonstration; care delivery; skills teaching; problem-solving;
discussion; constructive feedback; identification of training needs; and action planning.)
Issues addressed
(These could include clinical issues related to specific patients; relationship issues within the health
system or with stakeholders; management of workload; health centre processes and procedures.)
Actions agreed upon
(Summary of actions to be taken by individuals, time-scale and review date)
9
1
Department of Family and Community Health
World Health Organization
Regional Office for South-East Asia
World Health House, Indraprastha Estate
Mahatma Gandhi Marg, New Delhi 11002, India
Email: fch@whosea.org, hsd@whosea.org
hllp://worldwideweb.whosea.org
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