PASAPORTES DE SALUD Low-tech approach for sustainability for short-term international medical projects AAFP Family Medicine Global Health Workshop October 15, 2011

PARTNERSHIPS AND COLLABORATIONS VCU Department of Family Medicine College of William and Mary Podemos Dominican Aid Society of Virginia

OBJECTIVES  1. Identify the issues of sustainability in short-term international medical projects, and describe ways in which project planning can address them.  2. Describe the role and design of a health passport and explain how a health passport can help enhance sustainability of short-term international medical projects.  3. Analyze challenges to using health passports efficiently, and determine approaches to overcome these challenges.

OUTLINE  Context  Our community  Early efforts in the DR  Pasaportes de Salud in Honduras  Pasaportes de Salud in the DR  Future directions

CONTEXT  Chronic diseases (non-communicable diseases, or NCDs) increasingly the focus of WHO and UN.  April 2011: WHO Global Forum: Addressing the Challenge of Noncommunicable Diseases  “The rise of chronic noncommunicable diseases presents public health with an enormous challenge. For some countries, it is no exaggeration to describe the situation as an impending disaster. I mean a disaster for health, for society, and most of all for national economies.  We must not forget that the same so-called “modernization” that contributes to the rise of these diseases is being accompanied by a growing need for chronic care of mental illness. The burdens are numerous.”  (Dr. Margaret Chan, WHO Director-General)

CONTEXT  September 2011 United Nations high-level meeting on noncommunicable disease prevention and control  “We, Heads of State and Government and representatives of States and Governments, assembled at the United Nations from 19 to 20 September 2011, to address the prevention and control of non-communicable diseases worldwide, with a particular focus on developmental and other challenges and social and economic impacts, particularly for developing countries,  1. Acknowledge that the global burden and threat of non-communicable diseases constitutes one of the major challenges for development in the twenty-first century, which undermines social and economic development throughout the world, and threatens the achievement of internationally agreed development goals;”  (Political Declaration of the High-level Meeting of the General Assembly on the Prevention and Control of Non-communicable Diseases )

CONTEXT  Per the United Nations:  Noncommunicable diseases - or NCDs – including heart attacks and strokes, cancers, diabetes and chronic respiratory disease account for over 63% of deaths in the world today.  Every year, NCDs kill 9 million people under 60.  As Dr. Spann noted in his presentations during this meeting:  Cardiovascular disease, cancer, chronic respiratory diseases, diabetes all contribute to NCD mortality.  In developing nations, mortality from NCD is premature related to developed nations.

OUR COMMUNITY  The College of William and Mary (W&M)’s Student Organization for Medical Outreach and Sustainability (SOMOS) and the Dominican Aid Society of Virginia (DASV) have been working in the community since  We focus in Paraíaso, a sub barrio of Villa Mella, just northwest of Santo Domingo.  Two major neighborhoods: Altos (on a hill, more permanent) and Esfuerzo (in the flood plain, little infrastructure).  Inconsistent electrical power in both communities.

OUR COMMUNITY  Patients access medical care through our outreach efforts (two trips yearly) and with local physicians.  Hypertension is our most-recognized NCD. Adherence to treatment is inconsistent.  Medications for treating NCDs mostly purchased in the DR.  Patients will have intermittent contact with Dominican physicians, but our clinics have become increasingly recognized as sources of regular medical care.

OUR COMMUNITY

EARLY EFFORTS  Over the first few years, we recognized the importance of documenting treatments to enhance follow-up care and continuity of care.  Desire to promote greater awareness of health issues/practices.  DASV developed a patient visit sheet.  Intent to update each visit.  This sheet was not very successful, partly because it was too fragile.

PASAPORTES DE SALUD IN HONDURAS  Matt Imm (W&M alum, now a Med/Peds resident at University of Miami) helped start PODEMOS (Parntership for Ongoing Developmental, Educational, and Medical Outreach Solutions) while a medical student at Ohio State College of Medicine.  As part of their ongoing project in Honduras, PODEMOS designed pasaportes de salud.  Pasaportes de salud are small booklets that serve as personal health records (PHRs). Patients keep these booklets, and can have them updated any time they receive medical care, either from PODEMOS teams or from local physicians.

PASAPORTES DE SALUD IN HONDURAS  First passport distribution: passports.  Only 8 or 10 were returned at follow-up.  Few patients had any outside documentation  Challenges included itinerant patient populations, larger cachement area with less consistent patient follow-up.  Over time, working with community health workers and reinforcing passport use has led to 50-75% patients presenting to visits with passports.

PASAPORTES DE SALUD IN THE DR  In January 2011, DASV and SOMOS distributed 269 passports modeled after the PODEMOS passports.  In June 2011 we assessed how many patients returned for follow-up with passports:  34 patients (12.6%) recalled receiving passports in January.  15 patients actually returned with their passports (44% of those who recalled receiving passports; only 5.6% of all passports given out).  Of the 15 patients who brought back their passports, 11 had been previously diagnosed with hypertension.  No passports had any documentation from Dominican physicians.

PASAPORTES DE SALUD IN THE DR  Unclear why the rate of passports available for use in follow-up care was so low, considering there was great enthusiasm during the passport distribution in January.  Some possibilities:  Some patients could not find their passports.  There appears to have been little overlap between January and June’s patient populations, even though we work in the same communities each time.  Passports were distributed to all patients, not just those patients with NCDs.  Slow adoption of a new process  This is a good idea…but evidently there is more work needed to make it effective in our community.  We have not yet determined our best use for the passports.

FUTURE DIRECTIONS:  Continue to determine the best use of the passports, and how they will fit into our project.  Continue to distribute the passports, and emphasize their use and importance.  Consider using the passports in conjunction with community health workers (also under consideration) to facilitate care in the community, or to access a pharmacy dispensing site.  Adapt the passport design to tailor them to our clinic.  Discuss the purpose of the passports with local individual physicians— not just with the public hospital leadership.

FUTURE DIRECTIONS:  Emphasize passport distribution to patients with NCDs. Perhaps use the passports to prioritize care in clinic?  Use EMR in parallel to passports to prevent loss of information.  Personalize the passports: photos, etc.  Empower the community to document health problems or illnesses that occur between our visits to help focus attention on community development needs (increase patients’ agency).

THANK YOU  or