An Integrated Public Health, Health Care, and Social System Approach to Chronic Disease Prevention
With rates of chronic disease and multimorbidity on the rise, there has been an increased focus on prevention and a push for personalized care in the treatment and management of health conditions. There is no ‘one size fits all’ approach to addressing chronic diseases, and treatments need to be grounded in an understanding of the social determinants of health (SDOH) that predispose people to certain health conditions. Public health focuses on prevention, emphasizing interventions that promote upstream approaches targeting the SDOH. However, the health care system is not designed to support this, as it still responds reactively instead of proactively. In order to effectively address chronic disease, there must be a coordinated effort between the health care system and public health to focus on person-centred and upstream approaches.
How can we better enable and build the capacity of our health care system to provide this type of care to better support public health efforts? I believe it starts with primary care. By implementing a patient-centred approach into the primary care system, health care professionals can take a proactive approach to preventing chronic diseases. By recognizing a patient’s lived experience, practitioners may be able to better understand and address the root causes of their illness. This can influence care planning in a way that also encompasses the patient’s needs, values, and preferences. The Institute of Medicine defines person-centred care as, “Providing care that is respectful of, and responsive to, individual patient preferences, needs and values, and ensuring that patient values guide all clinical decisions.”¹ The design of the primary health care system does not promote patient-centeredness, due to a focus on treatment over prevention and patient preferences combined with a lack of coordinated care for multimorbidity between health care providers.²
Numerous studies have examined the benefits of patient-centred care in primary care, most often cited as improvements in physical health, psychological health, subjective health status, self-management capabilities, and secondary outcomes such as health-related behaviours, improved physician-patient relationships, and increased patient decision making.³ While patient-centred care is promoted by medical organizations in Canada, such as the College of Family Physicians of Canada, what does implementing a patient-centred approach actually look like in practice?⁴ One example is Health TAPESTRY, a primary care intervention by the McMaster Department of Family Medicine.⁵ The program utilizes patient goal setting as a patient-centred approach to meet the complex health needs of older adults 70 and older in the community. The program has shown promising results in shifting care from a reactive to a preventative approach, with participants having lower hospital admissions, higher physical activity, and more primary care visits than the control group.
When primary care is able to effectively provide a patient-centred approach for all patients, approaches such as social prescribing may also be more feasible to implement. Social prescribing enables health care practitioners to assess the SDOH that cumulatively influence a person’s health status and enables practitioners to connect the patient to health and social supports, such as art gallery visits, food banks, and community groups and programs. The Alliance for Healthier Communities recently published their final report of a social prescribing pilot project in 11 community health centres across Ontario.⁶ Their findings suggest that social prescribing integrated interprofessional teams, clinical care, and social supports in a way that improved participants’ mental health, decreased loneliness, and increased feelings of social connectedness to their community. In order to effectively promote health and prevent diseases, we must expand the capacity of the health care system to address the SDOH and to shift from a reactive to a proactive approach. This will require an integrated public health, health care system, and social system working collectively to prevent illness and deliver coordinated person-centred care.
- Oneview. (2015). The eight principles of patient-centred care. Retrieved from https://www.oneviewhealth care.com/the-eight-principles-of-patient-centered-care/
- Tinetti, M., Fried, T. R., & Boyd, C. M. (2012). Designing health care for the most common chronic condition—multimorbidity. Journal of American Medical Association, 307(23), 2493–2494. doi: 10.1001/jama.2012.5265
- Coulter, A., Entwistle, V. A., Eccles, A., Ryan, S., Shepperd, S., & Perera, R. (2015). Personalised care planning for adults with chronic or long-term health conditions. Cochrane Systematic Review- Intervention. https://doi.org/10.1002/14651858.CD010523.pub2
- The College of Family Physicians of Canada. (2020). The Patient-Centred Approach. Retrieved from https://www.cfpc.ca/en/evaluationobjectives/patientcentered
- Dolovich, L., Oliver, D., Lamarche, L., Thabane, L., Valaitis, R., Agarwal, G., ... Price, D. (2019). Combining volunteers and primary care teamwork to support health goals and needs of older adults: A pragmatic randomized controlled trial. Canadian Medical Association Journal, 191(18). doi:10.1503/cmaj.181173
- Alliance for Healthier Communities. (2020). Rx: Community - social prescribing in Ontario. Retrieved from https://www.allianceon.org/Rx-Community-Social-Prescribing-Ontario