A home based model to confront COVID-19 – the case of the Balearic Islands
A crucial question we face as we start thinking beyond the pandemic is what systemic factors have contributed to worsening its impacts, and which ones have mitigated them. I have expressed earlier RNAO’s concerns that an excessive hospital orientation within the health system in Ontario, and the neglect of community-based approaches, is most likely a factor that has aggravated the impacts in our province. Today I am profiling the way that the Balearic Islands, a province of Spain, has tackled COVID-19 with an innovative primary care and home-based approach. For the summary below, I thank my colleague and friend Consejera de Salud (Minister of Health for the past five years) of Islas Baleares, Patricia Gomez - an RN with primary care experience and the leader of the Balearic Islands province-wide RNAO BPSO, and the Deputy Director of the Health Service, Carlos Villafáfila.
The Balearic Islands, an archipelago in the western Mediterranean Sea, near the eastern coast of the Iberian Peninsula, is an autonomous community (a province) of Spain. COVID has hit hard on Spain, but there have been diverse experiences among different provinces within the country. The Balearic Islands has been successful, early on, in flattening its curve. It has brought down the curve to a relatively small number of new daily cases – around 20 new cases for a population of about 1.1 million during the last three days. The maximum number of daily cases hit 107 toward the end of March, and the curve went drastically down since then.
The Balearic Islands opted for a primary care (PC) approach to contain the COVID-19 pandemic. The restructuring of the entire PC in record time focused on the design of two differentiated work circuits within the province’s 45 community health centres – one specific for patients with respiratory symptoms, and the other for patients without those symptoms. In addition, a telephone triage system was put in place to distribute health care services through face-to-face, telephone and/or home visits, following the proper case definitions. Likewise, a virtual health consultation portal, #APMallorca, was launched in social media, with health professionals consulting online through Twitter, Facebook and Instagram. The community health centres played a central role – this is a network of primary care centres, each one serving, on average, about 20,000 people. They engaged proactively in telephone connection with advanced chronic patients or those with vulnerable pathologies to ensure their well-being, offer information and recommendations to family members and/or caregivers, and identify possible risk situations.
Parallel to the laser-speed reorganization of care through the community health centers, the government created mobile coronavirus care units (UVAC) served by an RN/family physician dyad and established a COVID-19 coordination centre led by primary care professionals. The UVAC did face-to-face home visits, obtained test samples at home, and followed-up with daily telephone monitoring of positive cases. The UVAC also refer these patients to hospitals in case of a worsening clinical situation. A team of nurses and doctors was placed in charge of the care and health education of family members and cohabitants of COVID+ patients, to minimize the spread.
A central role of the coordination center is the oversight on and control of nursing homes, where they carry out daily interventions, collect massive test samples of both vulnerable patients and healthcare workers in these homes, and also refer, when required, patients to hospitals.
For workplaces that continue active during the lockdown, five express (mobile) COVID units were launched to collect samples and carry out tests from essential workers, each unit carrying out about 200 tests each day.
This early primary care intervention has helped contain the outbreak in the home sector, thus protecting hospitals from collapse and allowing them to focus their efforts on the people severely affected by the disease. The organizing values for primary care as a gateway to the health system were defined as: accessibility, proximity, efficiency and resolution. This kind of primary care approach allowed hospitals to adopt the necessary structural and organizational measures to adequately care for patients affected with COVID-19, as well as maintain oncological and urgent activity not linked to COVID-19.
All this has been accompanied by an extraordinary increase in home and telephone care (in primary care and in hospitals), allowing the decongestion of the two healthcare areas.
From RNAO’s perspective, this is an insightful example of an approach that emphasizes keeping the health system whole for all. It limited the spread of COVID-19 by, early on, keeping people at home, including for purposes of getting tested. It promoted people’s active support by ongoing telephone connection and extensive homecare visits. The use of social media for virtual consultation with professionals is not something we have tried in Canada, nor is the intensive daily monitoring of COVID+ persons with extensive, quick, contact tracing and isolation. A coordination centre for COVID response led by primary care professionals is, again, a crucial element for us to consider in the go forward. The same holds for a reorganized health system of community care anchored in primary care and augmented robustly by home care, with responsibility for the totality of the population.
Many will remember these are concepts RNAO has advanced since the first release of Enhancing Community Care for Ontarians (ECCO) in 2012, revised and re-issued in 2014. This model has been discussed further, and a new revised version is forthcoming on May 12, 2020 – in celebration of Florence Nightingale’s 200th birthday. In RNAO’s view, these are important concepts to consider as we visualize Ontario’s future health system and the evolution of Ontario’s Health Teams (OHTs).