POTKU-project,
Putting the Patient in the Driver’s Seat
Patient centred model for health gain in Public Health Centers in Finland
Raimo Rintala, MD, Kauhava Primary Health Care District | Kauppatie 127A, 62200 Kauhava, Finland, raimo.rintala@kaksineuvoinen.fi
Keywords: self-management, patient centred care, health care plan
Purpose
THE CHRONIC CARE MODEL
• To develop prevention and care of chronic illnesses more
patient centred to achieve more health gain and more
cost-effective expenditure.
• To make health care professionals’ work more meaningful
and manageable.
Community
Health Systems
Resources and Policies
Organization of Health Care
SelfManagement
Support
Context
Delivery
System
Design
Decision
Support
Clinical
Information
System
Framework: Terveyshyötymalli-Health Gain Model, based
on the Chronic Care Model.
Informed,
Activated
Patient
Its six essential interrelated elements are:
• Self-Management Support
• Decision Support
• Delivery System Design
• Clinical Information Systems
• The Health System
• The Community
State of the art
Over 250 health care professionals in 61 municipalities
covering ca. 1 million people were involved in the development
activities.
Self-Management Support included development of:
• Patient-centred Health and Care Plan as a tool,
which was nationally accepted and digitalized
• Health and Care Plan’s Auditing tool
• The Self-Management Assessment form
• Training of life-style change trainers
• Life-style change coaching in small groups
Developed by The Mac Call
Institute®ACP-ASIM Journals
and Books
Improved Outcomes
IN DISEASE SELF-MANAGEMENT, YOU ARE THE MOST
QUALIFIED EXPERT –HEALTH CARE PROFESSIONALS
PROVIDE YOU WITH THE SUPPORT YOU NEED.
Care plan
5
4
1
Self-management
Your, your nurse
and your physician
together define your
care plan´s goals as
well as the methods for
attaining them.
Your own role in your health care
becomes clear, you know where to
get help, and you know when your
situation needs to be reassessed.
3
Mapping appointment
at the nurse´s office
Contact your
health care
center
A health care
professional will
schedule an appointment
of sufficient duration.
2
Preparation
The self-management
assessment form.
You and your nurse will together
assess your present health status
and self-management support needs
on the basis of the self-management
assessment form.
er?
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Statement
Patient centred Health and Care Plan reduces significantly
patients’ visits and related costs in the Health Centers.
Prepared,
Proactive
Practice Team
Productive
Interactions
Change in visits (%) to the Doctors and the Nurses
one year before and after the Health and Care Plan
was done in 2012 and 2014
2012 HCPlan n=239, Visits 5329
2014 HCPlan n=242, Visits 3592
2012
2014
%
50
39
40
30
Acknowledgements:
POTKU
www.potkuhanke.fi
Erja Oksman MHSc, Mari Sisso MA, Risto Kuronen MD,
name.name@phsotey.fi
Primary Health Care Unit of Päijät-Häme, Finland
20
10
0
Dr/acute
Dr/office
Dr/all
Dr/phone
-12
-30
-40
-50
-26
-17
-14
-20
-29
-42
Nrs/visits
Nrs/
phone
-10
-20
0
-30
-3
-8