alc intra2 cp peru - who · iii. methodology: intra ii-peru study the used investigation method was...

FOCUS GROUP STUDY INFORM

INTRA II

INTEGRATED RESPONSE OF HEALTH CARE

SYSTEMS TO RAPID POPULATION AGEING

PERU 2004

INTEGRATED RESPONSE OF HEALTH CARE SYSTEMS TO RAPID POPULATION

AGEING INTRA II – Perú

General Coordinator

Dr. Luis Varela Pinedo

Coordinator Team

Dr. Helver Chávez Jimeno Dr. Antonio Herrera Morales Dr. Francisco Méndez Silva

Dr. Miguel Gálvez Cano

Ejecutive team

Pro-Vida Peru Association

Dr. Blanca Flor Deacon Castillo Dr. Ana María Vilchez Vargas-Machuca

Dr. Felipe Germán Aguirre Salinas Lic. Gladis Ballivian Rosado

Lic. Rosa Luz Vieira Mrs. Milagros Gonzales Castillo

Mr. Juan Gonzales Castillo

Multidisciplinary team

Dr. Luis Varela Pinedo – General coordinator Dr. Helver Chávez Jimeno

Dr. Antonio Herrera Morales Dr. Fernando Portocarrero Salazar

Dr. Carlos Sandoval Cáceres Dr. Elizabeth Sánchez Yturrizaga Dr. José Francisco Parodi Garcia

Dr. Pedro Vera Vilchez Dr. Juan Del Canto y Dorador

Dr. Carmen del Pilar Estela Benavides Dr. Francisco Méndez Silva

Dr. Miguel Gálvez Cano Dr. Luis Alvarez Cóndor

Dr. River R., Cersso Bendezú Dr. Diana Rodríguez Hurtado Dr. María del Pilar Gamarra

Dr. Isabel Benate Gálvez Dr. Blanca Deacon Castillo Dr. Felipe Aguirre Salinas

Secretary

Elizabeth Aguilar Figueroa

INDEX

PÁG.

I.- INTRODUCTION ....................................................................................... 5

II.- THE INTRA PROJECT .............................................................................. 6

III.- METODOLOGY: INTRA II – PERU STUDY ..................................... 7

IV.- RESULTS . ............................................................................................... 11

- PROFESSIONALS RESULTS CHARTS …………………………………... 11

- USERS RESULTS CHARTS…………………………………………………37

- USERS RESULTS SUMMARY CHART. ………………………………….. 74 - PROFESSIONALS RESULTS SUMMARY CHART......................................78 V.- ANALYSIS OF RESULTS BETWEEN PROFESSIONALS AND USERS ………………………………………………………………... 87

VI.- CONCLUSIONS …………………………………………………………. 91

VII.- RECOMENDATIONS …………………………………………………... 92 VIII.- SUMMARY …………………………………………………………… 94

INTEGRATED RESPONSE OF HEALTH CARE SYSTEMS TO RAPID POPULATION AGEING

INTRA II

INFORM OF THE FOCUS GROUP STUDY I. - INTRODUCTION During the last 50 years a decrease of the world natality and mortality had been leading progressively to the populational aging. In the Latin American countries, among them the Peru, the population's aging is also a demographic characteristic that is acquiring great importance; due to the economic and social consequences that this implies, as well as changes in the work areas, housing, recreation, education and mainly in the health necessities that will take place. This aging process is even more important in the developing countries as ours due the increased speed of this process; contrary to the one gived in the developed countries in which it took a relatively long period of time. While the elderly adult population increases, an increase exists in the population's proportion that suffers of chronic non communicable diseases and disability, therefore a higher use of services and more expense. The health systems of our country are not prepared for this epidemiologic change, since their structures are inadequate. There is a poor coordination of services and a lack of development of appropriate programs for this age group. The developed countries have demonstrated that the prevalence of chronic non communicable diseases and the disability levels in the elderly adults can be reduced with appropriate health preventive interventions.

II.- THE INTRA PROJECT WHO’s Ageing and life course unit, convinced of the necessity to investigate the population's conditions in the developing countries, design the called study: “Integrated Response of Health Care Systems to Rapid Population Ageing” (INTRA). The project will investigate the problems associated with the fragmentation and lack of preparation of the health systems, giving special attention to the primary health care system, for the promotion and protection of the elderly adult’s health. Of the obteined data the necessary components will be extrapolated for an integrated model of primary health care for elderly adults, accordingly to the specific situation and characteristics of each country that are facing the problem of the rapid population aging. Their main objectives are:

1. foster South-South cross-fertilization through exchange of views, experiences and models of practice;

2. create interdisciplinary/ intersectoral national teams able to undertake the

practical application of the findings;

3. produce country profiles on populations ageing to include an overview of the health care systems in each of the participating countries;

4. produce knowledge-base to assist participating countries in guiding future

actions and policies towards more integrated health and social systems;

5. include recommendations for reorienting health and social services in order to better serve ageing populations

6. identify potential factors that facilitate and impeding for the integration of

health and social/community services;

7. Develop key indicators that will monitor the implementation of recommended policies and interventions.

The project INTRA has been developed in two phases. The first phase or INTRA I adopts the use of a quantitative investigation in six countries. The second phase or INTRA II search to complement the INTRA I; with the use of a qualitative investigation methods in the 6 countries of the INTRA I and in 6 more additional countries. The qualitative investigation will be driven among three main pillars of the systems of care of health: 1. Users 2. Health and social professionals 3. People in charge of taking the decisions and politicsl of multiple sectors.

The following table shows the countries that will be paired with INTRA I countries. The selection of INTRA II countries has been made in order to reflect, to a degree, the realities of INTRA I countries' (within the same WHO regional office) current health care system, political, socio-economic similarities and regional proximity (thus facilitating exchanges).

Regional Office INTRA I INTRA II EMRO Lebanon Syria AFRO Botswana Ghana AMRO Chile Peru WPRO Korea China – Shanghai municipality AMRO Jamaica Suriname SEARO Thailand Sri Lanka

The results of the project will facilitate the formulation of action plans to be developed at local and national levels, for the health of the people elder than 50 years. III. METHODOLOGY: INTRA II-Peru study The used investigation method was the FOCUS GROUP, a qualitative and observational procedure. The interdisciplinary team of the Association Pro-Vida Peru (NGO) conformed by physician, psychologists, social worker and social communicators assumed the development of the Focus Group (execution, transcription, analysis and report of results). The focus groups were carried out from April 24th to May 04th in the city of Lima (the county of Callao was also included); this city was chosen by WHO’s recommendation because it was the capital of the Country. It is located in the central coast of the Peru and for the year 2004 had 8049619 inhabitants (Lima and Callao) The Health Ministry has divided the city in five health directions (DISAs), the city has 206 PHC centers with at least one physician (called health centers) distributed in the following way:

Health directions Number PHC centers East Lima DISA 35 North Lima DISA 58 South Lima DISA 37 Lima city DISA 26 Callao DISA 50 Total 206

In this study only 16 PHC centers were included, from them were chosen the health personnel. Of these 16 PHC centers 2 were chosen (one in a district of high economic level and one in a district of low economic level) to select the users that would participate in the study. The selection criteria of the PHC centers were: - That the centers had the professionals required by the study (physician, nurse and a social assistant or physicologist) - Each DISA suggested a group of PHC centers under its jurisdiction that completed the requirements before described - The definitive selection of the participant PHC center was made at random based on the centers suggested by the DISAs The PHC centers selected for the present study representing the high economic level were: Of DISA Callao - La Punta - Bellavista Peru - Korea Of DISA Lima City - San Isidro - Miraflores - San Miguel Of DISA East Lima - La Molina - Salamanca Of DISA South Lima - Gaudencio Bernasconi (Barranco) The selected PHC centers representing the low economic level were: Of DISA Callao - Gambeta Alta Of DISA Lima City - San Cosme Of DISA East Lima - Huaycan - Moron Of DISA South Lima - San Martin of Porres - Cesar López Silva Of DISA North Lima - Piedra Liza - Canto Grande The selection of the health personnel was carried out by the chief physician of the selected PHC center in most of the cases, in a few ones by the Health Direction (DISA) to which this center belonged. The selection crieria for the health personnel were:

- Work time in this PHC center for more than 1 year. - To be a regular personnel of the PHC center. - In the case of the physicians, they had to be a general physician, or of the specialties of internal or family medicine. The focus groups of professionals took place in the auditory of the DISA South Lima in the district of Barranco; participating 39 professionals. The distribution was the following one: Chart Nº 1: PARTICIPANT HEALTH PROFESSIONALS

FOCUS GROUPS

PROFESSIONAL DISTRICT SOCIO-ECONOMICAL

LEVEL

MEN WOMEN

1 Physicians “A” 05 03 2 Nurses “A” - 08 3 Social workers “A” - 06 4 Physicians “B” 1 04 5 Nurses “B” 1 06 6 Social workers “B” - 06

Totales 07 32 The users were selected of the PHC centers "Gaudencio Bernasconi" (for users of high economic level district) and "Piedra Liza" (for users of low economic partner level district) by the nurse of each establishment; the election of these PHC centers was due to logistical reasons. The users' selection criteria were the following ones: - At least 1 year of attendance to the center of health - Patient with at least a chronic disease The exclusion criteria were the following ones: - Cognitive impairment (moderated and severe levels according to the test of Pfeifer) - Very ill and cannot be mobilized for his/herself - Difficulties to speak or to listen 40 users participated and were divided in groups in the following way:

Chart Nº 2: PARTICIPANT USERS

FOCUS GROUPS

USERS DISTRICT SOCIO-ECONOMICAL LEVEL

AGE TOTAL

1 Women “A” 50-64 years 09 2 Women “B” 50-64 years 09 3 Women “A” 65 or more 08 4 Women “B” 65 or more 10 5 Men “A” 50-64 years 08 6 Men “B” 50-64 years 08 7 Men “A” 65 or more 08 8 Men “B” 65 or more 08

Totals 68

The focus groups for users of high economic level were carried out in the auditory of the south DISA in Barranco and PHC center Gaudencio Bernasconi; the focus groups for users of low economic level were carried out in the auditory of the Piedra Liza PHC center. 68 users participated.

V. RESULTS CHARTS 5.1.- Professional’s results charts

FOCUS GROUP Number 1

NEEDS AND CARE SOURCES CHART PROFESIONALS: PHYSICIANS – LEVEL A

Date: 24.03.2004

Moderator: Dr. Blanca F. Deacon C. Assistant: Dr. Felipe Aguirre S.

Transcription: Mr. Juan Gonzales C.

Group characteristics: Gender: 05 men y 03 women - Group actitude: Proactive, expectant, induced participation, feel poor recognition to their work. - Group Problems: A high degree of dissatisfaction and frustration related to:

a) The conditions, difficulties and requirements of the daily work. b) The great demand of patients that limit the quality of the medical attention c) The necessity of an integral and well differentiated attention

They emphasize the necessity of more preventive work for chronic non communicable diseases The group wants more capacitation in Geriatric and Gerontological topics. 1. Health Needs Correspondance Source of care 1.1Fast diagnosis of chronic non communicable diseases: Ischemic Cardiopathy, Diabetes Mellitus, Osteoporosis, Hypertension..

1.1 Primary health care center Hospitals

1.2 Mental diseases attention, depression and anxiety.

1.2 Primary health care center, users / Family

1.3 Nutrition education 1.3 Primary health care center, Users

1.4 Health education: Health promotion and prevention

1.4 Health Ministry Primary health care

center 2. Non covered needs (why) 2.1 Economical and human resources for the application of preventive-promotional programs (not priority for the Peruvian state)

2.1 Health Ministry

2.2. Free or low cost outpatient attention, medicines and diagnostic test for the users in a poverty situation

2.2 Primary health care center Users

2.3 Administrative personnel must be educated to treat the elderly adult in a proper way (with respect)

2.3 Primary health care center

3. Eldelyy adults services and care: General medicine, dental care. nutrition By initiative of the health personnel: recreational programs.

3. Primary health care center

4.Satisfaction with the services quality Personnel and users dissatisfaction The Ministry wants only productivity (in terms of quantity), and the quality and warmness is lost The physician must see one patient in 15 minutes A WHO- PAHO study adopted by Peru (Health Ministry) says 24 patients must be attended in 6 work hours No respect for the public establishments

4. Primary health care center

Health Ministry


COORDINATION RESULTS CHART PROFESIONALS: PHYSICIANS – LEVEL A

Date: 24.03.2004



Group characteristics: Gender: 05 men y 03 women - Group actitude: Motivated, higher level of participation, reflexive. - Group Problem: The primary health care (PHC) center chief must have more liberty when making decisions for the administration improvement inside and outside the PHC.

A Description of the

actual situation

B Ideal situation

concept

Factors that facilitate the change

A→B

Barriers for the change A→B

Coordination between professionals inside the primary health care center

-Poor coordination in the administrative personnel schedule and the beginning of the outpatient office consult

-The personnel must be identificated with their work and the primary health care center

- Friendship - Respect and recognition -Health personnel identification with the institution

-Some health centers chiefs don’t support the workers initiatives -lack of sensibility and will for work in some workers.

Coordination between professionals outside the primary health care center

-Some health centers have an administrative committee integrated by: only by health personnel and others with administrative and health personnel -PHC center health programs financed by private laboratories and philanthropic institutions

-Support for auto-administrative initiatives: more autonomy for the health center chief -Inter-sectorial work group: Municipality, army, church, schools, etc. -Strategic alliances

-Internal agreements and administrative initiatives

-Burocratic proceedings that interfere with the development of initiatives of the PHC centers


CONTINUITY OF CARE RESULTS CHART PROFESIONALS: PHYSICIANS – LEVEL A

Date: 24.03.2004



Group characteristics: Gender: 05 men y 03 women - Group actitude: Motivated, Participative. - Group Problem: Dissatisfaction for the daily work exigencies that need more time, personnel and resources Insufficient development of preventive promotional health programs Group definitions about “Continuity of care”

-Is given through health clubs: Selfcare. -Health education. -Sensibilization of the health personnel (compromise). -Diffusion of the attention and treatment offered by the primary health care center. -Elderly Adults Club formation. -Preventive attention.

A Description of

the actual situation

B Ideal situation

concept

Factors that facilitate the

change A→B


Continuity of care inside the primary health care center

-Outpatient office consult -Inter-consults

- Improvement of the outpattient office attentions and development of preventive promotional health programs

-Perseverance -Will for work

-Lack of geriatric training -Patients higher demand in some PHC centers

Continuity of care outside the primary health care center

-Health campaings

-Elderly adults club formation

- Initiative - support of some PHC chiefs

-Lack of personnel and logistics

Professionals or responsible team to give continuity care inside the primary health care center

- There is not at the moment. Generally is coordinated by the nurse

Team: from the physician to the janitor

-Delegate responsibilities in some punctual cases

-Lack of time and human resources to assume a continuity of care.

Professionals or responsible team to give continuity care outside the primary health care center

- There is not at the moment.

-Health promoters (domiciliary visits). -Family with continual capacitation

- Personnel identification with the primary health center.

-Lack of budget for a permanent gerontological training

Perceived necessecity for training to improve the continuity of care.

Geriatric and Gerontological training for the health and administrative personnel Continual capacitation for the health promoters. (community agents).


NEEDS AND CARE SOURCES CHART

PROFESIONALS: NURSES – LEVEL A

Date: 26.03.2004


Transcription: Mr. Juan Gonzales C. Group characteristics: Gender: 08 women - Group actitude: Proactive, motivated, solidary, spontaneus, moderate participation level and low recognition feeling. - Group problem: Great concern about:

a) Lack of resources for the elderly adult health needs satisfaction b) Lack of specialized personnel. c) Incipient team work and, d) Need of capacitation in Geriatrics topics.

1. Health needs Correspondance Sources of care

1.1 Early Cancer, Hypertension and Diabetes Mellitus detection. Treatment of Menopause, Falls and complications, dental and nutritional problems


1.2 Mental problems attention: Depression / Psychological maltreatment.

1.2 Primary health care center Family

1.3 Healthy life styles (Health education). 1.3 Primary health care center

2. Non covered needs (why) 2.1 Low cost Medicines, diagnostic test and dental treatment (user’s lack of the economical resources).

2.1 Central Government Health Ministry

2.2 Social Work personnel for the study of some cases

2.2 Health Ministry Primary health care center

2.3 Vaccines


2.4 More nurse personnel


2.5 Adequate work arquitectonic infraestrucutre

2.5 Health Ministry

2.6 Elderly adults attention protocols 2.6 Primary health care center Health directions (DISAs)

2.7 Trained personnel in geriatric topics. 2.7 Health Ministry Primary health care center

2.8 Nutritional services for the elderly adults with tuberculosis


3. 3. Eldelry adults services and care: -General medicine.

-Selfsteem classes.

-Social-recreative activities.

3. Primary health care

center

4. Satisfaction with the services quality -No. Because of the lack of insfraestructure for the attention of geriatric patients; also the health and administrative personnel is not well trained to give the proper attention to the elderly patient.

4. Health Ministry Primary health care center


COORDINATION RESULTS CHART PROFESIONALS: NURSES – LEVEL A

Date: 26.03.2004


Transcription: Mr. Juan Gonzales C. Group characteristics Gender: 08 women - Group actitude: Higher degree of participation and motivation, solidary - Group problem: Frustration feelings for the logistics and collaboration difficulties to accomplish their labour.


actual situation

B Ideal situation

concept


change A→B



-Minimal. The information is not socialized, the directive level don’t involve the field teams in the planification process -The coordination is always assumed by the chief physician and is not socialized.

-The coordination management could be rotated every 6 months between the team professionals. - Not only the physicians can be in charge of the coordination

-The nurse is not in charge of the coordination but realize direct administrative and assistance coordination work.

-The coordination is realized at directive level (chief physician ) and is not shared -Great part of the health and administrative personnel is not sensibilized with the elderly adult population problems


-Institutions: Municipalities, Churches, Social Clubs, etc. Nurse realizes direct coordinations.

- The coordination management should be rotated every 6 months - Shares information and encourage the team work. - Health and Administrative Personnel sensibilizated with the elderly adult population

- Non official efforts shared by the health personnel

- The coordination programs are assumed generally only by the physician - The capacitation is given only to the current chief physician that is changed and removed (in some cases)to other institution every 6 months or even less.


CONTINUITY OF CARE RESULTS CHART

PROFESIONALS: NURSES – LEVEL A

Date: 26.03.2004


Transcription: Mr. Juan Gonzales C. Group characteristics Gender: 08 women - Group attitude: Colaboration, feeling of lack of recognition and facility to accomplish their labour - Group problem: Concern for the lack of budget and personnel to realize proper continuity services.Group definitions about “Continuity of care”

-Is the patient follow-up -Team domiciliary visits -Look for the elderly adult at their own routine, leading them to a healthy life cycle before, meanwhile and after he/she gets sick


actual situation

B Ideal situation concept


A→B



-Outpatient office attention -Inter-consults.

- Promote a healthy life style cycle before, meanwhile, and after the illness

- Initiative and personal motivation

-Lack of economical and human resources


-Incipient communitarian work: elderly adult clubs development

Promotional preventive health programs. Census and monitoring of the elderly adults necessities

- Personal motivation - Elderly adults wishes to participate in the health care prevention programs

- Lack of economical and human resources.


-Personnel more capacitated in the elderly adult needs

-Personnel more capacitated in the elderly adult needs

- Personal motivation -Social emotion.

- Excesive work burden


-Social services -Capacitated Health promoters in some centers

-Health promoters (domiciliary visits). -Health Committee (representative institutions)

-Valorized image of the elderly adult ( it’s not given, it’s not contributing to the change)

Lack of economical and human resources for the communitarian work.

Perceived training needs for improve the continuity of care

-Training in geriatrics (of the most prevalent diseases). -Teach the community what means to be an elderly adult.


NEEDS AND CARE SOURCES CHART PROFESIONALS: SOCIAL WORKERS – LEVEL A

Date: 29.03.2004


Transcription: Mr. Juan Gonzales C. Group charactersitics: Gender: 06 women - Group actitude: moderate participation level and feeling of low recognition and comprehension for their labour. - Group problem: Great concern about:

a) High degree of frustration for the users non covered needs b) Lack of budget c) Social workers scarce possibilities to give effective help to the geriatric patients

Need of capacitation in Gerontological topics. 1. Health necessities Correspondance Sources of care 1.1 Hypertension, Diabetes Mellitus and Cholesterol levels control


1.2 Osteoporosis treatment (fractures). 1.2 Primary health care center General Hospital

1.3 Vision problems

1.3 General Hospital

2. Non covered needs (why) 2.1 Health services accessibility

(principally by economical factor).

2.1 Health Ministry (Health politics)

2.2 Preventive care 2.2 Primary health care center

Health Ministry 2.3 Complete basic attention personnel in the health center.

2.3 2 Primary health care center Health Ministry

2.4 Specialized services

2.4 Primary health care center Health Ministry

2.5 Trained sensibilizated personnel tha work as a team


Health Ministry 2.6 Adecuate arquitectonic infraestructure (some health centers function in old and not practical buildings)

2.6 Health Ministry

2.7 Family support 2.7 Family Primary health care center

2.8 Adequate lodgings for the elderly adults

2.8 Family

3. 3. Elderly adults services and care: 3.1 Diagnosis of some diseases campaigns 3.1 Primary health care

center Community institutions

3.2 Dental prophylaxis program. 3.2 Primary health care center

3.3 Domiciliary visits. 3.3 Primary health care center

4. Satisfaction with the services quality No, because they don’t have: 4.1 Personnel properly trained in an adequate elderly adult attention


4.2 Elderly adult community census health campaings.

4.2 Health Ministry /health directions (DISAs)

4.3 Enough time and education for the attention of the population elderly than 75 years.

4.3 Primary health care center Health Ministry


COORDINATION RESULTS CHART PROFESIONALS: SOCIAL WORKERS – LEVEL A

Date: 29.03.2004



Group characteristics Gender: 06 women - Group actitude: Higher degree of participation, attention and reflexion about the talked issues - Group problem: Frustration feelings for the logistics and collaboration difficulties to accomplish their labour.


actual situation

B Ideal situation

concept


A→B



-Interdisciplinary work, community meetings. -Users Census Proyect

-Prevention work plan -The program chief must coordinate with the other team members at least once time a week.

-All the health center professionals participate in the center meetings -Work with responsability

-The continual changes of the chief physician creates difficulties to make a work plan for the elderly adult -Communication problems -Difficulties between the profesionals for the team work (schedules problems) - Some professionals don’t give importante to the elderly adult issue. -Administrative personnel maltreatment to the elderly adult.


-Strategic alliances for diagnosis campaigns and recreactive activities: Social clubs, laboratories, municipalities, Peruvian sport Institute, Museums, Military institutions.

-More diffusion of social recreational activities with the elderly adult family.

Professionals participation in the communitary talks - Work with responsability.

The continual chief physician changes interrupt the coordinations.


CONTINUITY OF CARE RESULTS CHART PROFESIONALS: SOCIAL WORKERS – LEVEL A

Date: 29.03.2004


Transcription: Mr. Juan Gonzales C. Group characteristics: Gender: 06 women - Group attitude: Participative, solidary. - Group problems: lack of personnel and facilities difficulties to work in the continuity of care of the elderly adult Group definitions about “Continuity of care”

-Prevention and its aplication (changes toward better life styles). -Incentive the participation of “health agents” to guide the elderly adult in the use of the health center services -Health promoters support to the elderly adults that live alone -Participation of a geriatric specialist that could guide the process

A Description of


B Ideal situation

concept


change A→B



- Cases attention in different services

-Capacity to give solution to most of the users problems -Activities to make them a group -Prevention practice

-Innovation of some activities to make them and keep them as a group.

-Economical factor-Doesn’t count with specialized services, not the proper personnel


- Health talks to community

-Monitoring: domiciliary visits- Prevention

-Social workers and users motivation

-Hospitals don’t give attention facilities (impotence feeling) -Economical factor


- Health team and social services

-Health team -Social Services

- Monitoring.

- Economical factor. - Non specialized personnel.


- Not given -Health promoters -Community health watch units

-Users cooperation

- Lack of economical, human resources and logistic suppport. - Excesive work burden


-Selfcare -Work with quality in the integral attention of the elderly adult - Training


NEEDS AND CARE SOURCES CHART PROFESIONALS: PHYSICIANS – LEVEL B

Date: 31.03.2004


Transcription: Mrs. Rosa Luz Vieira.

Group characteristics: Gender: 01 man y 04 women - Group Attitude: Participative, high professional aspirations, feel poor recognition for their labour. - Group Problems: Lack of economical, human and architectonical resources to give a proper attention, these needs are partially covered with creative actions to improve the elderly adult attention. The group wants more capacitation in Geriatric topics.

1. Health necessities Correspondance Sources of care 1.1 Hypertension, diabetes mellitus and cholesterol control (specially if there is an previous or family antecedent)


1.2 Most common diseases control: diabetes, osteoporosis, Hypertension

1.2 Primary health care center General Hospital

1.3 Mental health care 1.3 Primary health care center, specialized center

1.4 Sensibilization of the family about the elderly adult care


1.5 Health attention by tradicional means 1.5 Primary health care center Family

2. Non covered needs (why) 2.1 Low cost medical attention (economical problems and cultural factors)

2.1 Health Ministry

2.2 Programs development (lack of budget)

2.2 Health Direction (DISA) Health Ministry

2.3 Trained health personnel in gerontological topics


2.4 Geriatric outpatient office in the PHC center


3. Elderly adults services and care: 3.1 General Medicine 3.1 Primary health care center

Free health campaings : cholesterol, vision, etc.

3.2 Laboratories support

Social-recreative activities 3.3 Users / Family

3.4 Psychology, rehabilitation and nutrition services (in most of the health centers)


4. Satisfaction with the services quality: No, because: 4.1 Geriatric topics are not included in the General Medicine education in most of the universities, making difficult the diagnosis of the elderly adult diseases


4.2 The efforts in the attention of the elderly adult are limited by the treatment continuity for users with scarce economical resources.


4.3 Diagnostic campaigns stay only at the diagnosis phase because the lack of resources.



COORDINATION RESULTS CHART PROFESIONALS: PHYSICIANS – LEVEL B

Date: 31.03.2004


Transcription: Mrs. Rosa Luz Vieira. Group characteristics: Gender: 01 man y 04 women - Group Attitude: Proactive, solidary, suggest ideas to improve the elderly adult situation. - Group Problems: Frustration feelings in relationship with the coordination, the lack of budget, sensibilization and will at directive levels for resolve the needs of the users.


actual situation

B Ideal situation

concept


change A→B



-The physician sends the patient to the team professional required. -Excessive work burden for the temporary employed personnel (generally employed yearly, the contract is renewable, also this personnel lacks of certain benefits)

-Capacitated health team that gives a quality and warm attention.

- Motivated health personnel to offer a better attention to the user with scarce resources.

- Not temporary personnel wants always to assume the programs control but don’t want to work more, if they are not payed better. - Excessive work burden for the temporary employed personnel.


- The health personnel get help for the users (medicines, some free services) by means of the community support. -Patients with more problems visit’s are coordinated with health agents promoters -Creation of a volunteer system. .

- Sensibilization of family, community, universities, local and political authorities for the elderly adult attention. - Strategic alliances with other institutions for the inclusion of the health center in their activities program.

-Adequate communitarian support -Participation of university’s medical interns.

- Treatment following limitations due to economical problems.


CONTINUITY OF CARE RESULTS CHART PROFESIONALS: PHYSICIANS – NIVEL B

Date: 31.03.2004


Trascription: Sra. Rosa Luz Vieira. Group characteristics: Gender: 01 men y 04 women - Group attitude: More participation, solidary with the user’s problems. - Group problem: Great insatisfaction with the lack of support and also because in spite the efforts and creativity used, the elderly adults health problems are not improved enough. Group definitions about “Continuity of care”

- User follow-up: prevent them to get lost (periodical visits, domiciliary visits). - Prevent the automedication - Don’t see them only when they are sick, but also when they are healthy.

A Description of


B Ideal situation

concept


change A→B



-Create conscience in the user about the importance of health prevention

- Elderly adult population performing preventive measures. -Forming groups by pathologies for special training and self care. -Group activities integration

- User’s interest in become part of preventive programs. -A warm attention

-Excesive number of patients. -Lack of professionals -Lack of time to the program dedication - Excessive work burden for the temporary employed personnel.


- Users referred to general hospitals. -Leaders formation.

-Development of community health prevention programs. - Health personnel continual capacitation -Leaders formation

-Health personnel initiative, creativity, and perseverance.

-Lack of capacitated professionals that can assume the control of the programs.


-Actually not given

-Nurses -Any member of the team in a rotative way

- Health professionals will for work.

-Lack of time - Lack of economical resources


- Actually not given social services (domiciliary visits)

-Health promoters -community leadres capacitated in gerontology issues.

- Health professionals and communitary leaders capacitated in gerontology issues will for work.

- Lack of time - Lack of economical resources


-Elderly adult pathologies and risk factor for NCD’s -Control of functionality and cognitive level by means of Katz index, Minimental test and others. -System and instruments to measure program impact



PROFESIONALS: NURSES – LEVEL B

Date: 02.04.2004



Group characteristics: Gender: 01 man y 05 women - Group attitude: Expectant, induced answers, solidary and reflexive. Feel poor recognition for their labour. - Group problem: Concern for the lack of interest in the differentiated elderly adult attention, also concern about the lack of elderly adult programs in some primary health centers. 1. Health necessities Correspondance Sources of care 1.1 Visual and hearing care 1.1 General Hospital 1.2 Hypertension, diabetes, colesterol, osteoporosis diagnosis programs


1.3 Diseases prevention (nutrition and hygiene talks)


1.4 Elderly adult tuberculosis special program


2. 2. Non covered needs (why) 2.1 Psychological support for the elderly adult an his/her family


2.2 2.3 Administrative personnel don’t treat the elderly adult in a proper way (with respect)


2.3 Integral Social Service (SIS) (A type of government insurance given mainly to pregnant women and children)

2.3 Health Ministry

2.4 Low cost attentions 2.4 Primary health care center / Health Direction (DISA)

3. Elderly adults services and care: 3.1 Medical attention 3.1 Primary health care

center

3.2 Some health centers have an arterial pressure control program and free medical consult once day a week


3.3 Some health centers have health professional meetings every two weeks


3.4 Some health centers offer a day for the elderly adult once a month, that includes free medical consult, weight control (by the nurse), nutrition and psicology.


4.Satisfaction with the services quality 4.1 No, because they think the personnel have a lack of training in gerontological and geriatric issues.

4.1 Health Ministry / Health Direction (DISA)

4.2 There is not enough time to give an efficient attention


4.2 Users dissatisfaction in some health centers due discrimination (ageism)

4.2 Primary health care center personnel


COORDINATION RESULTS CHART PROFESIONALS: NURSES – LEVEL B

Date: 02.04.2004



Group characteristics: gender: 01 man y 05 women - Group attitude: Proactive, motivated. - Group problems: More commitment for the improvement of the health situation of the users by means of coordination with community institutions as a strategy due the lack of resources of the primary health care center.


actual situation

B Ideal situation

concept


change A→B



-Team work in the making of the eldelry adult atention chart. -With Social Services: Regulating the payment exonerations

Interdisciplinary work by trained personnel in the elderly adult attention

Health personnel motivation for an eficient attention in spite the limited resources

-Lack of economical resources for drugs, diagnostic test, etc. -Health personnel lack of time for coordination meetings. - Health and administrative personnel lack of sensibilization.


-With the Health Direction (DISA) for more personnel (odontologist, nutritionist) and health campaigns

With the municipality and other institutions for a most integral management

-DISA’s support for campaigns and inter-institutional alliances

-Lack of budget and opportune management


CONTINUITY OF CARE RESULTS CHART PROFESIONALS: NURSES – NIVEL B

Date: 02.04.2004


Trascription: Mrs. Rosa Luz Vieira. Group characteristic: Gender: 01 man y 05 women - Group activity: Proactive, solidary, high level of professional aspirations. - Group problem: Concern and frustration due to the lack of budget, logistics, and operative expenses to accomplish the community health demands. Group definitions about “Continuity of care”

-Continuty of the health care, health needs satisfaction -Medical specialists coordination to elaborate attention protocols - Prevention with the family -Domiciliary visits -Vaccination campaigns

A Description of


B Ideal situation

concept


change A→B



-The follow-up and a proper care are the supports for the accomplish of the users necessities

-Organization of diagnosis, vaccination campaigns. - Selfcare application

-Health personnel commitment and mystic.

-Lack of personnel


-Minimal participation of community institutions.

Strategic alliances with representative institutions.

-Actually not given

-Continuity is not considered as a part of the health chain.


-Chief physician

- Interdisciplinary team member in a rotative way.

- Actually not given

-Work verticality maintenance. (too hierarchical)


- Voluntary system

Health promotors - Active participation of some community agents.

- Lack of training in gerontological topics. - Lack of logistic suppport and incentive.


- Capacitation in geriatric and gerontogical issues and team work


NEEDS AND CARE SOURCES CHART PROFESIONALS: SOCIAL WORKERS – LEVEL B

Date: 05.04.2004



Group characteristics: Gender: 06 women - Group attitude: Moderate collaborative, expectant, reflexive, feel poor recognition for their labour. - Group problem: Concern about the improvement of the health services for the users, about the lack of support and comprehension at the hierarchical superior levels due their lack of interest or ignorance about the elderly adult problems and the lack of adequated logistics to attend their necessities. The preventive health work must be emphasized. 1. Health necessities Correspondance Sources of care 1.1 Emotional problems attention: depression (Suicide attempt) familiar violence.

1.1 Primary health care center Specialized hospital

1.2 Visual, hearing and functionality problems attention.

1.2 Specialized hospital

1.3 Cholesterol, triglycerides control for the menopause women


1.4 Drugs and alcoholism attention 1.4 Specialized hospital 1.5 Improvement in the elderly adults with tuberculosis attention


2. Non covered needs (why) 2.1 Low cost medical attention and auxiliary diagnosis test

2.1 Health Ministry Family

2.2 Family support ( discrimination and abandon)


2.3 Specialized services 2.3 Primary health care center General Hospital

2.4 Adequate infrastructure attention 2.4 Health Ministry

2.5 Capacitated health personnel 2.5 Health Ministry

3. Elderly adults services and care: 3.1 Medical consult 3.1 Primary health care

center

3.2 Domiciliary visits


3.3 Health campaigns(for all the population)


4.Satisfaction with the services quality 4.1 No, because the health center don’t have a personnel trained in the elderly adult attention.

4.1 Primary health care center Health direction (DISA) Health Ministry

4.2 Sensibilizated personnel for the elderly adult attention

4.2 Health direction (DISA) Health Ministry

4.3 Preventive programs for the elderly adult population

4.3 Primary health care center Health direction (DISA)

4.4 Support by other institutions 4.4 Primary health care center DISA / Health ministry

4.5 The chief physician don’t support enough his/her personnel



COORDINATION RESULTS CHART PROFESIONALS: SOCIAL WORKERS – LEVEL B

Date: 05.04.2004


Transcription: Mrs. Rosa Luz Vieira. Group characteristics: Gender: 06 women - Group attitude: Collaboration and solidarity with users, suggest possible solutions. - Group problem: The group feels a lack os sensibility and collaboration of the administrative and health personnel. Also consider a priority the coordination to sensibilizise the users to improve their quality of life.


actual situation

B Ideal situation

concept


A→B



- Lack of places and time for teamwork coordination

-Effective teamwork meetings with the support of the chiefship and respect for the professional criteria. -Development of recreational activities to improve the communication and the labour setting.

- Group commitment, will and the teamwork professional challenge.

-The health centers are only executive entities, the coordination and decisions are carried out at central level. -Lack of commitment of some part of the health and administrative personnel. -Indifference of some chiefships. -Multiplicity of functions and schedules that interfere with the coordination


-The chiefship coordinates with the Health Direction (DISA): Popular dining rooms, churches and universities.

-Establish a concertation table with support of the health team -Chiefship support to the personnel labour.

-Coordination support for the development of programs.

- Lack of recognition, incentives and motivation for their labour. -Lack of economical resources


CONTINUITY OF CARE RESULTS CHART PROFESIONALS: SOCIAL WORKERS – NIVEL B

Date: 05.04.2004


Trascription: Mrs. Rosa Luz Vieira.

Group characteristics: Gender: 06 women - Group attitude: High participation level, colaborative, solidary. - Group problem: Dissatisfaction with the work done and the support received. Propose to assure the labour condition of the personnel, impulse the preventive promotional health work, establishment of concertation meetings with community representatives and sensibilization of the community. Group definitions about “Continuity of care”

-Generate attitude changes in relation of the life styles. -Community education (preventive and self care)


actual situation

B Ideal situation

concept


change A→B



- Incipient preventive health programs development -Domiciliary visits

- Permanent health personnel capacitation - Health prevention and promotion. -Health preventive programs development. - Personnel initiative, creativity and perseverance

- Creativity in the preventive team work. -Formation of voluntary system as health agents who can support the domiciliary visits.

-Lack of personnel if these programs are activated - Personnel with limited academy formation in geriatrics topics -Family group gives only a small support.


- Mostly not given. Some experiences of health prevention and conservation campaigns.

-Sensibilize the elderly adult population and their families about the benefits of some life styles changes. -Development of community preventive health programs - Voluntary system as health agents who can support the domiciliary visits

- Personnel initiative, creativity and perseverance.

- Lack of professionals that can assume the control of the programs.


-Actually not given -Multidisciplinary team promoting an integral work

- Professionals will for work.

- Lack of time and economical resources


-Actually not given -Social services (domiciliary visits)

-Promoters -Community leaders trained in some gerontological issues.

Capacitation and labour coordinated esocial services and the community leaders.

-Lack of time and economical resources

Perceived training needs for improve the continuity of care.

- Gerontology training - Human relationships and teamwork training

5.2.- USERS CHARTS


NEEDS AND CARE SOURCES CHART USERS: WOMEN LEVEL A (50 to 64 years)

Date: 07.04.2004


Trascription: Mrs. Milagros Gonzales C. Group characterstics: 50 – 64 years Gender: 09 women - Group Attitude: Proactive, participative, and motivated. - Group Problem: They feel discrimination and maltreatment by the health and administrative personnel. They feel impotent due this sitution. They feel also the lack of economical resources for their attention. They can not aquire laboratory patented drugs. All these generate insecurity for their health status and conservation. 1. Health needs Correspondance Sources of care 1.1 Breast and uterus cancer prevention

prevention 1.1 Primary health care

center Specialized hospital

1.2 Memory problems 1.2 Primary health care center Psichlogycal support

1.3 Specialized elderly adults attention 1.3 Primary health care center

2. No covered needs (why) 2.1 Low cost drugs (prescribed in the PHC center)


2.2 Specialized services 2.2 Primary health care center

2.3 Economical factor accessibility 2.3 Primary health care center

2.4 Personnel trained in elderly adult issues.


2.5 Some free health services 2.5 Primary health care center /Health Direction(DISA)/Health Ministry

3. Elderly adults services and care: 3.1 Geriatrics 3.1 Primary health care

center

3.2 Otorrinelaryngology 3.2 Primary health care center

3.3 Ophalmology 3.3 Primary health care center

3.4 Reumathology 3.4 Primary health care center

3.5 Social-recreative activities:

walks, gimnasium, movies, etc.

3.5 Primary health care center Municipality, churches

3.6 Psychology meetings

(“they can teach us to live in a different way”)


4.Satisfaction with the services quality 4.1 No, because: There are diagnosis contradictions that mislead the patient


4.2 Only a few professionals are really efficient


4.3 There is a lack of human relationship with the patient (prepotency, administrative and health personnel maltreatment)


4.4 The physician’s acquaintances are attended first


5. Health Attention ¿How to improve it? 5.1 Meetings with the chief physician to improve the PHC center situation


5.2 Medical personnel rotation 5.2 Primary health care center

5.3 Improve the administrative personnel treatment.


5.4 Preferential attention (elderly adults must not wait too much for the medical consult and for other services)



COORDINATION RESULTS CHART USERS: WOMEN LEVEL A (50 to 64 years)

Date: 07.04.2004


Trascription: Mrs. Milagros Gonzales C. Group characteristics: 50 – 64 years Gender: 09 women - Group attitude: Higher participation and motivation. They thank the concern showed to known about their problems. And they expect corrective measures. - Group problem: They feel the lack of unity in the physician’s diagnosis criteria, situation that gets worse when there are problems between them.


actual situation

B Ideal situation

concept


change A→B



-They don’t know about the inside PHC center coordinations, but they observe lack of union between professionals. -The support of some nurses.

-A staff (all the staff) meeting every month to evaluate the work done.

- Some nurses support.

- The lack of union between professionals. - Different diagnosis criteria mislead the patient.


-The physicians don’t know other physician patients.

- Someone who function as leader and show the general population the elderly adult problems.

- The user’s suggerences to improve the medical attention. - The participation of the community.

- The elderly adult needs are not taken in consideration when making health programs.


CONTINUITY OF CARE RESULTS CHART USERS: WOMEN LEVEL A (50 to 64 years)

Date: 07.04.2004


Trascription: Mrs. Milagros Gonzales C. Group charactersitics: 50 to 64 years Gender: 09 women - Group attitude: Very participative, motivated, solidary, reflexive, suggest solutions. - Group problem: Lack of specific programs for their health attention, this situation generates insecurity about their future health status. They wish to participate in health prevention and conservation educational programs. They propose the solidary support between themselves by means of the formation of health promoters and voluntary system. Group definitions about “Continuity of care”

- The follow up of each user disease

A Description of


B Ideal situation

concept


change A→B



-Different physicians, very patients attention. - Each physician changes (ask for new) laboratory tests.

- That the nurses and/or administrative personnel place us always with same physician

- The follow-up of the disease with the same health professional

- Schedule or institution professionals changes stop or make difficult the follow up


- They don’t know

-Support between users (health promoters, voluntary system)

- Some health professionals and users disposition.

- The lack of evaluation of the few activities that the health personnel do.


- They don’t know

- Geriatrics physician

-Support given by some professionals of the field team.

- There is not a clear division of each professional function.


- They don’t know

- Domiciliary physician -The users -The family

- Support given by some professionals of the field team.

- Lack of community education.


- Health and administrative personnel training. - Preventive health programs for users


NEEDS AND CARE SOURCES CHART USERS: WOMEN LEVEL B (50 to 64 years)

Date: 19.04.2004


Trascription: Mrs. Rosa Luz Vieira Group characteristics Gender: 09 women • Group attitude: moderate, reactive, tense. • Participation level: moderate, induction needed, they think about their general needs (not

only health needs), some ideas and opinions are repeated. • Personal aspirations: That government programs take in consideration the elderly adult

population • Suggestion: The elderly adults must organize them as a group. Group problem: lack of economical resource to attend their health problems. 1. Health needs Correspondance Sources of care 1. More importante needs 1.1. Diagnosis test services, radiography.

Primary health care center

1.2. Specialist attention (geriatrics, nutritionist, traumatology, cardiology, etc.)

Hospital

Private physician 1.3. Emergency services Hospital 1.4. Medical checking (tomography, densitometry, etc.)

Hospital

1.5. Feeding for the most needy. Church Community dining rooms Glass of milk program

1.6. Non communicable chronic diseases care

Hospital

1.7. Social support (Medicines) Users Family Church

1.8. Moral support Family 1.9. Family care Family 1.10. Domiciliary care, and practical help

Usuers

1.11. Help with mobility Family 1.12. General consult


2. Non covered needs 2.1 Social services: help the

needy, medicines, etc.

2.2 Special prices for the elderly adults (medicines, diagnosis test, etc.) 2.3 Elderly adult Identification Document. 2.4 Elderly Adult Insurance 2.5 Good treatment / preferntial attention 2.6 Health education 2.7 Free Medical campaings (diagnosis test) 2.8 Vitamins 2.9 Trained proffesionals

Non covered because: - The government doesn’t look out for the most needy. - Ther is not communication with the high ranking government functionary. - Lack of economical resources.- Lack of coordination between the health ministry and the president. - The municipality does nothing for the elderly adult..

3. Elderly adults services and care:

Services the elderly adult users want in the primary health care center.

3.1. Incide the primary health

care center

-Complete diagnosis services/ tomography, etc - Emergency - Respect to the attention order - Trained proffesionals - Nutricionist, psicologis, geriatrics physician. - Health education

3.2. Outside the health center

- Free medical diagnosis campaigns

Organized by local directive board

4 Satisfaction with the services quality

Yes, but the previously mentioned must be implemented

5. Satisfaction with the primary health care attention

Physicians: Yes Nurses: No. Administrative personnel: no


COORDINATION RESULTS CHART USERS: WOMEN LEVEL B (50 to 64 years)

Date: 19.04.2004

Moderator: Dra. Ana María Vilchez V-M. Assistant: Lic. Gladis Ballivián Rosado. Trascription: Mrs. Rosa Luz Vieira .

Group characteristics Gender: 09 women • Tranquility attitude, less tension. • Low participation level, strong induction necessity, difficulty to process some questions. • Professional aspirations, Better treatment to the elderly adult population in the primary health

care center • Group problem: acknowledge of the internal relationships insider the primary health care center

A Description of


B Ideal situation

concept


A→B



- The physicians don’t coordinate when taking decisions for the elderly adult situation improvement. - Nurses don’t give the adequate attention - Administrative personnel *Not responsible (talk between themselves too much)

-The physicians: Like now but with more coordination and collaboration between themselves. - Dialog between professional would be better for the patient treatment. - All personnel must give the elderly adult a good treatment - Personnel must fulfil their functions with responsibility.

- Physicians could initiate/facilitate this cahnges

- Part of the personnel don’t fulfil their funtions.


- Coordination with some entities that do something for the population. Example:

- -

Mothers Club Directive, Glass of Milk Coordinator.


CONTINUITY OF CARE RESULTS CHART USERS: WOMEN LEVEL B (50 to 64 years)

Date: 19.04.2004

Moderator: Dra. Ana María Vilchez V-M. Assistant: Lic. Gladis Ballivián Rosado.

Trascription: Mrs. Rosa Luz Vieira Group charactersitics: Gender: 09 women • Group attitude of doubt, not interested in the issue Participation level: low, strong induction needed, The interventions did not answers the questions, they only refer to the regular presence of the primary health care personnel in the PHC center. • Personal aspirations: Need of an elderly adult insurance. • Group problem: Use of primary helath care services only when thay have time and economical

resources. Group definitions about “Continuity of care”

Presence of the same personnel in the PHC center, appropiate physician training. Good treatment.


actual situation

B Ideal situation

concept


change A→B



-Nurses *Schedule rotation *Maltratment. -Physicians *General * They know about the situation and pacient treatment - Lost of time and sometimes consult left for other day.

-Good attention and treatment to the elderly adult - Attention at low cost - Medicines at low cost

- Nurses with lack of patience - Lack of respect to the attention order - Part of the personnel work without responsibility - Labour strikes.

Continuity of care outside the primary

- Non existant - -

health care center Professionals or responsible team to give continuity care inside the primary health care center

- - PHC center chief pshysician - Geriatrics physician

- -


- - PHC center chief pshysician - Geriatrics physician

- -


Properly training for the nurses, technicians and especially for the administrative personnel in the appropriate elderly adult treatment.


NEEDS AND CARE SOURCES CHART USERS: WOMEN LEVEL A (65 years or more)

Date: 12.04.2004 Moderator: Dr. Ana María Vilchez V-M. Assistant: Lic. Gladis Ballivián Rosado Trascription: Mrs. Rosa Luz Vieira

Group characteristics: Gender: 08 women • Group attitude: harmonic, motivated. • Participation level: moderate, most of the interventions were spontaneous; opinions were

centered in the issue. • Personal aspirations: Community geriatrics services needed, preventive health education • Group problem: Most of the elderly adults live alone, the have family support from distance

(other countries), frequent use of the primary health care center. 1. Health needs Correspondance Sources of care

1. Most important needs

1.1. Specialized health attention Hospital Church Private physician /Private clinic attention Social Security (insured)

1.2. Chronic diseases care Hospital

Social Security

1.2. Moral support /care. Family

1.3. Emergency Hospital

1.4. Family care /support Family (only a few)

1.5. ADL, practical help User

1.5. General consult Primary health care center

2. Non covered needs (why)

Not covered because: -There is not government concern - Lack of budget, for that reason specialists are only in hospitals and not in the primary health care centers

2.1. Social assistance (drugs at minimal cost) 2.2. Health education 2.3. Elderly adult medical center, to access to laboratory diagnosis tests, wheelchair, special beds, cardiology and traumatology attentions at minimal cost 2.4. Specialized physcian 2.5. Diagnosis campaings, for the ones who are not insured.


3.1. Inside the PHC center - Social services - Emergency services - Geriatrics physician /special outpatient office for the elderly adult. - Attention at minimal cost. - Attention with specialists (cardiology, dermatology, ophthalmology, etc.)

They wish they had these services

3.2. Outside the PHC center - Specialized center for the elderly adult. -Health campaings. - Help with some medicines.

They think it should be given but they can’t define who must give it.

4. Satisfaction with the services quality

Some are satisfied, but all suggest that the PHC center must have more specialties and personnel

5. Satisfaction with the PHC attention

Yes. There is a good treatment, moral support, and care.


COORDINATION RESULTS CHART USERS: WOMEN LEVEL A (65 years or more)

Date: 12.04.2004

Moderator: Dra. Ana María Vilchez V-M. Assistant: Lic. Gladis Ballivián Rosado. Trascription: Mrs. Rosa Luz Vieira .

Group characteristics: Gender: 08 women • Group attitude: confused, poor understanding of the issues, tense. • Participation level: low. • Professional aspirations: none. • Group problem: Lack of knowledge of the internal relations of the PHC center personnel.


actual situation

B Ideal situation

concept


change A→B

Barriers for the change

A→B


-Coordination when is needed. -Communications. - Leave some functions for the auxiliary personnel

- The errors must be communicated to the chief physician. -More personnel for the attention. -Better elderly adult treatment

Personnel receptivity to improve.

Part of the personnel doesn’t fulfil their functions.


- The PHC center must have a special physical space dedicated for the elderly adult.

- -


CONTINUITY OF CARE RESULTS CHART USERS: WOMEN LEVEL A (65 years or more)

Date: 12.04.2004


Trascription: Mrs. Rosa Luz Vieira Group characteristics: Gender: 08 women • Group attitude: doubtful, tense. • Participation level: low, strong induction. • Personal aspirations: None. • Group problem: Relate continuity of care to presence of the same PHC center personnel, not

much about their medical treatment. Group definitions about “Continuity of care”

Continuity of care is accomplish when the patient know his/her physician and trust him/her; the physician know his medical record. There are enough drugs for treatment

A Description of the actual

situation

B Ideal situation

concept


change A→B



- Only in general medicine, not in specialities. -Rotation of professionals and chief physicians but without harm the medical attention. -Good physicians performance. Still on strike the physicians work by turns. -There are some medicines. - Fast attention. Only fail the male admittance personnel “lack of patience”.

- Adequate performance of the physicians and the rest of the PHC center personnel. -Good treatment for the elderly adult -Cheaper medicines. - Well paid personnel.

-The personnel want to be properly trained in geriatric issues. -Physicians with vocation of service.


- Municipality Medical Center, directed by inadequate personnel. - Some churches offer some health services (cardiology, traumatology, ophtalmology, laboratory diagnosis test).

Creation of a Geriatric Institute


None answer Geriatric physician



Administrative personnel training about the proper elderly adult treatment.


NEEDS AND CARE SOURCES CHART USERS: WOMEN LEVEL B (65 years or more)

Date: 21.04.2004 Moderator: Dr. Ana María Vilchez V-M. Assistant: Lic. Gladis Ballivián Rosado Trascription: Mrs. Milagros Gonzales

Group characteristics: Gender: 10 women • Group attitude: tense, reactive, frustrated, dissatisfaction. • Participation level moderate, report personal situations, others opinions are repeated, poor

knowledge of the primary health care center services. • Personal aspirations: Search for solutions of personal health problems, they wish education

about the aging process. They want differentiated attention. . • Suggestions: Organize group of elderly adults Group problem: First oportunity to talk about health problems, all the situations are related to the poverty situation, eventually their interventions go back to this issue. Most of them live with their family. 1. Health needs Correspondance Sources of care 1. Most important needs

1.1. Medical attention Private physician


1.2. Elderly Adult especialists Hospital

1.3. Domiciliary care Family

1.4. ADL – practical help User Family

1.5. Moral support /care

Family

1.6. Family care Family

1.7. Help with mobility

Social Security (insured)

1.8. General consult Hospital

1.9 Alimentary support for the most needy

Popular dining rooms

2. Non covered needs

Not covered because: - Non government support - The Health Ministry receives a poor budget from the central government. - The poor people is not important for the government. - There is not health education for the elderly adult.

- Social assistance (medicines) - Orientation /advises - Health education - Preventive care (vaccines) - Integral Social Insurance for elderly adults - Vitamins - Chronic diseases attention - Good treatment to the elderly adult - Elderly adult specialzed center


3.1. Inside the PHC center:

- Geriatric medical attention. - Low cost attention - Medicines - Social assistance - Personnel that could guide the elderly adult - Emergency services - Help with mobility (wheelchair) - Hygiene, ventilation - Separated attention from the other age groups

Services that the users want inside the PHC center.

3.2. Fuera del Centro de Salud There is not The municipality offers nothing to the elderly adult

4. Satisfaction with the services quality

No, lack of resources and infrastructure

5. Satisfaction with the PHC center attention.

Physicians: Yes Nurse technicians: Elderly adult maltreatment


COORDINATION RESULTS CHART USERS: WOMEN LEVEL A (65 years or more)

Date: 21.04.2004


Trascription: Milagros Gonzales Group charactersitics: Gender: 10 women • Group attitude: insecure, poor knowledge of the issue. Tension. • Very low participation level, difficulty to understand the questions, opinions about other issues. • Personal aspirations: None • Suggestions: That the PHC personnel treat the elderly adults with more respect and affect Group problem: Most of the PHC users know the concept of “coordination”, but not its action


actual situation



change A→B



They think there must be some kind of coordination and collaboration between them. But there must be a deficiency because: - The attention is slow and the attention order is not respected.

Chief physician put some order to improve the attention and treatment of the elderly adult. Personnel: Organized, Receive economical help.Trained in a properly elderly adult treatment.

Personnel feel the necessity to improve.

Personnel not well paid: “They have poor Hill for work because they are not well paid and have to go fast to go to another job”


- That the coordination with other institutions helps the elderly adult, developing health campaigns. -That the municipalities help the PHC center with some medicines. -The local Church should continue its labour (medical and assistant) but in coordination with the PHC center.

Existant resources: Church (physician, etc.)

- Municipality


CONTINUITY OF CARE RESULTS CHART USERS: WOMEN LEVEL B (65 years or more)

Date: 21.04.2004 Moderator: Dr. Ana María Vilchez V-M. Assistant: Lic. Gladis Ballivián Rosado Trascription: Mrs. Milagros Gonzales

Group characteristics: Gender: 10 women • Group attitude: Indiferent, tense • Particiaption level: low • Personal aspirations: That the PHC center improve the public attention. • Suggestions: geraitrics porfessionals demand. • Group problem: Elderly adults use health services only when they have obvious and strong

symptoms, due the insufficient economical capacity to acquire the medicines and do the laboratory diagnoses test.

Group definitions about “Continuity of care”

- Attention by the same physician


actual situation



change A→B


A→B


Users economical situation make difficult the follow-up Personnel rotation

Professionals must have always the same schedule. Attention and medicines at low prices

Users lack of economical resources


- -Community attention, to the pueblos jóvenes

- -Probably there would not a economical recognition for the domiciliary attention personnel


- Chief physician Social assistant, Nurses.

- -


- Church minister Municipality, mayor

- -


Health personnel need training in the elderly adult treatment.


NEEDS AND CARE SOURCES CHART USERS: MEN LEVEL A (50 to 64 years)

Date: 04.05.2004 Moderator: Dr. Ana María Vilchez V-M. Assistant: Lic. Gladis Ballivián Rosado Trascription: Mr. Juan Gonzales.

Group characteristics: Gender: 08 men • Group attitude: motivated, proactive. • Participation level: high, opinions start with personal necesitéis but they are also about the

elderly adult population as a group. Answers focused on the issue. • Group aspirations: Preventive health education, differentiated attention, need of geriatrics

physician.

1. Health needs Correspondance Sources of care 1. More important needs

1.1. Specialist physicians/ attention of diseases (prostatitis, artrosis, vision and hearing impariment)

Hospital

1.2. Chronic non communicable diseases care

Social Security

1.3. Health campaings Health ministry


1.5. Moral support Family

1.6. ADL, practical help User

1.7 Emergency services Hospital

1.8. General consults Hospitales Social security

1.9. fast and good attention. Primary health care center

2. Non covered needs 2.1. Professionals with sensibility “humanity”. 2.2. Health education 2.3. Help with mobilization 2.4. Geriatric attention 2.5. Rural hospitals and PHC centers 2.6. Vitamins / good and low cost medicines. 2.7. Modernization of diagnosis and treatment equipments “they are obsolete”. 2.8. Social assistance 2.9 Good elderly adult treatment. 2.10 Adequate medical evaluation

Non covered because: - Lack of budget. - Lack of personnel. - Lack of specific laws for the elderly adult helath care - Corruption, bad investment


It should be given by:

3.1. Inside the PHC center. - Preferential attention. - Elderly adult orientation. - Health census of the elderly adult population (by locality) - Specific outpatient office for elderly adults. - Domiciliary visits - Emergency services - Social services

Primary Health Care Center

3.2. Outside the PHC center It should be given by: -Elderly adult special attention center.

Municipality

-Domiciliary visit (spiritual part) Church - Feeding programs for the most needy.

Church

“Glass of milk program” - Municipality

4. Satisfaction with the PHC center services

Yes, they see an improvement

5. Satisfaction with the PHC center attention

Yes, but they think it could be better if there is more personnel and if this is better paid.


COORDINATION RESULTS CHART USERS: MEN LEVEL A (50 to 64 years)


Group characteristics: Gender: 08 Men • Group attitude: motivated. • Moderate participation level, deductive opinions due the lack of knowledge of the coordination

inside the center. • Group aspirations: Personnel must improve their treatment to the eldelry adult


actual situation

B Ideal situation

concept


change A→B



- Seen as: * Physician meetings * “to make other business”. - Not a very good clinical records filing system and manual search are the reasons for the delay. -Personnel maltreats the user. - Poor dedication to their work, many cases of leave for absence.

Team work, that manifest in a good and fast attention, a good treatment (thagt must be efficient for the user). - Trained personnel in the elderly adult atention

Some dedicated and good profesionnals.

- Users demands. - Personnel personal problems. - Lack of communication with patient.


Coordinacion with other institutions (Lions Club, Church, Municipality and others), for the production of informative publication or radio program about elderly adult health care and also that informs about health campaings.


CONTINUITY OF CARE RESULTS CHART USERS: MEN LEVEL A (50 to 64 years)


Group characteristics: Gender: 08 men • Group attitude, motivated • Parcipation level, moderated • Group aspirations: more professional ethics between the physicians. Group definitions about “Continuity of care”

- The continuity of care is given when the profesional (the same or other) knows the patient disease and treatment, there is trust in the health professional and treated well.

A

Description of the actual situation

B Ideal situation

concept


change A→B


A→B


On spite the chabge of physicians, the elderly adult feels they know their treatment.

- 24 hours attention /emergency services. - Special outpatient office for the elderly adult -Better attention / Elderly adult preference - More difusion of the PHC center services. - Personnel should live in the same local area. (as the PHC center)

Some dedicated and good profesionnals.

- Patients own discomfort or lack of cooperation. - Physician insecurity when giving the diagnostic.-User’s distrust for the personnel. - User’s lack of economical resources to follow a treatment.



Geriatric physician /Family physician Psychologist Nurse Social assistant


Chief physician Geriatrics physician


Training the personnel in attention and good treatment to the elderly adult.


NEEDS AND CARE SOURCES CHART USERS: MEN LEVEL B (50 to 64 years)

Date: 23.04.2004 Moderator: Dr. Ana María Vilchez V-M. Assistant: Lic. Gladis Ballivián Rosado Trascription: Mr. Rosa Luz Vieira .

Group Characteristics: Gender: 08 Men • Group attitude, motivated, reactive. • Participation level, spontaneous, their health needs depend on economic issues, Direct

responses about the issue. • Personal aspiration: Differentiated treatment, geriatric physician need. • Group problem: Most of them are pensioners (Social Security users), eventual use of the PHC

center facilities.

1. Health needs Correspondance Sources of care 1. More important needs 1.1. Specialties medical attention, routine consult and tests.

Social security Hospital

1.2. Routine test and consults Social security Hospital

1.3. Prevention campaigns Social security

1.4. Non chronic communicable diseases care

Social security


1.6 Domiciliary help Family

1.7. ADL – practical help User

1.8. Moral support /care Family

1.9. Help with mobility Family Friends

1.10. General Consults Primary health care center

1.11. Walks, Church 1.12. Feeding for the most needy. “Glass of milk” program

Municipality. 2. Non covered needs 2.1. Routine tests 2.2. Vaccinnes 2.3. Diagnostic diseases campaings 2.4. Health education 2.5. Integral Health Insurance for the elderly adult 2.6. Ophtalmology, physical therapy, cardiology, traumatology services. 2.7 “Recreational system” for the elderly adult at minimum cost. 2.8. Trained personnel 2.9. Geriatric establishment (therapy, Psychology) 2.10 Social help /social services.

Non covered because: - User’s lack of knowledge about the attention needs and services. - Government – Health Ministry does not consider an appropriate budget for the elderly adult attention.


The user want this services to be given in the PHC center

3.1. Inside the PHC center - Perodical routine controls/permanents. - Moral support - Social assistant - More efficient X-ray services - Ambulance services. - Wheelchairs. - Geriatric physician - Domicialiary visit. - Fast attention /preferential admission, special schedules - Hygienic services clean and differentiated (men/women) - Ophtalmology, physical therapy, cardiology and traumatology services. - Specialized pharmacy, well stocked.

3.2. Outside the PHC center. - Recreational locals

It should be given by:


Yes. Although most of them think that it would be better with more infrastructure and more personnel and other considerations already mentioned.


Most of the users are satisfied, but not with the administrative personnel. They think it should be more personnel medical and administrative and they should have more training in elderly adult issues.


COORDINATION RESULTS CHART USERS: MEN LEVEL B (50 to 64 years)


Group characteristics: Gender: 08 men • Group attitude moderate, reactive, hesitant • Low participation level, induction necessities. • Personal aspirations: health education, geriatric physician presence in the PHC center • Group problems: Poor knowledge of the internal relations inside the PHC center.


actual situation

B Ideal situation

concept


change A→B



- Physicians: they coordinate to give a more accurate diagnosis and treatment. - Administrative personnel: Bad functioning (delay of attention) *In delivering the medical records. *Only one cash box to pay *In pharmacy for the delivery of medicines

- Better treatment for the elderly adult - Fast attention. - Efficient administrative system - More work dialog between the personnel (meetings).- Trained personnel.

- Administrative personnel


Not given Health personnel must coordinate with: - Administration of human settles, clubs, community associations; visits, health education, specialist physicians consult; organize recreational and educational courses.

Sport culture association could give some place for the meetings.

-


CONTINUITY OF CARE RESULTS CHART USERS: MEN LEVEL B (50 to 64 years)


Group charactersitics: Gender: 08 men • Group attitude: tense • Low participation level: difficulty to focus in the answers of the issue • Personal aspirations: none • Group problem: Lack of confidence in the medical personnel, use of different community

services. Group definitions about “Continuity of care”

- Trust in the personnel that knows about his/her case and cares about the user, and makes the user follow the treatment. - That the PHC center has medicines.

A Description of


B Ideal situation

concept


change A→B


A→B


- Professional changes of schedules and institutions - Sometimes the PHC center pharmacy don’t have medicines - The users have confidence in some physicians.

- Professional interested in the user as a person, and propitiates and open dialog with the user. - That the PHC center personnel visit the user that did not went to their appointed consult. -Medicines in the PHC center pharmacy. - Atention and adequated treatment

Deficient attention


- - Health education (Alzheimer disease) - Health programs (Vision loss) - Health campaigns: dental, hypertension, diabetes at low cost. - Brochures or magazines about the Elderly Adult health


- The one that is more capacitated. Team coordinated by the general physician, and/or specialist physician; the team must also have a nurse, social assistant and psychologist.

- -


- Social assistant, psychologist and trained personnel for the domiciliary visits, Health promoters

- -


Personnel training


NEEDS AND CARE SOURCES CHART USERS: MEN LEVEL A (65 years or more)

Date: 21.04.2004 Moderator: Dr. Blanca F. Deacon C.

Assistant: Dr. Felipe Aguirre S. Trascription: Mrs. Milagros Gonzales

Group characteristics: Gender: 08 male - Group Attitude: Adequated participation, reflexive. - Group Problem: They recognize there is some degree of fear that makes them not take care of their health. They feel dissatisfaction due the quality of the received service and they think that the economical factor is the cause.

1. Health needs Correspondance Sources of care 1. More important needs 1.1. Emergency medical attention

Hospital 1.2. Chronical non communicable diseases care

Hospital

1.3. Family care Family 1.4. Moral support Family

1.5. Adequated life styles (exercises nutrition)

User

1.6. Health attention with herbs (folkloric medicine)

User

1.7. Health campaings Municipality Club

1.8. Practical help and ADL User 1.9. General consult Primary health care

center 1.10. Basic dental service Primary health care

center 2. Non covered needs - Preventive care - Health education (by radio, TV, newspapers, schools) - Specialized services at low cost - Periodical checking consults. - Free medical attention and medicines. - Vitamins -Attention with good treatment. -Ambulance services (for the not insured) -An specific health center for the elderly adult.


It should be given

3.1. Inside the PHC center. - Specialized services (ophthalmology, cardiology, pneumology) - Ambulance services - Social services: facilities for the elderly adult -Preferential attention for the eldelry adult “not too much waiting” / exclusive attention schedules (evenings) - Geriatric physician. - Brochure or magazine about the elderly adult health - Free medical consult and medicines from time to time for small periods of time. - Domiciliary visits

3.2. Outside the PHC center


Maybe a more limited service, but a good service. The implementation in the point 3.1 is needed


-Physicians: Yes, they give a kind attention. - There is not complaints about the rest of the personnel.


COORDINATION RESULTS CHART

USERS: MEN LEVEL A (65 years or more)



Group characteristics: Gender: 08 men - Group attitude: Participative, motivated y solidary. - Group problem: They feel that the health personnel fulfil their mission without the proper coordination between them.


situation

B Ideal situation

concept


change A→B


A→B


There is not coordination Three “degrees-concept” of coordination given: Level 1 – Physician consult between themselves about the user’s diagnostic and treatment. There is no consensus ones think it happen this way others not. Level 2: Coordinate to give a better attention. Lack of time and personal motivation. Level 3: Coordination depends on the Health Ministry. The PHC center is not autonomous.

Level 1: Physician consult between themselves to find a better user’s diagnostic and treatment. Level 2: Motivated personnel that have meeting every 15 days. Level 3: Fluid coordination between the PHC center and the Health Ministry

Nice and good treatment from the personnel, Personnel receptivity for improvement.

Non motivated professionals


- - - -


CONTINUITY OF CARE RESULTS CHART USERS: MEN LEVEL A (65 years or more)



Group characteristics: Gender: 08 men - Group attitude: Very participative, motivated. - Group problem: They manifest that only exists continuity at the level of health campaigns. Also, the elderly adult is not included in the Integral Health Insurance. Group definitions about “Continuity of care”

Ser atendidos por el mismo médico pues conoce el caso. Asequibilidad a medicinas


actual situation



change A→B


A→B


-No consensus about if there was or not a change in the medical personnel. -Medical general attention only. -They facilitate medical drugs samples.

- Users must always be seen by the same physician. - User must have access to speciality physicians, medicines and domiciliary visits.

-Professionals wishes to be trained in elderly adult issues. -Physicians and other professionals with service vocation.

-Changes of physicians and of schedules -User’s lack of economical resources.


Health campaigns every 3 moths in the municipality club

That other community institutions do health campaigns


- Professionals specialist in elderly adults Cardiologist Ophthalmologist Psychologists


Group people (could be elderly adults) trained as health promoters for domiciliary visits Medicine university students in the last years of study of the career


Training of the health personnel and other people (not necessarily health professional related) to become health promoters.



USERS: MEN LEVEL B (65 years or more)

Date: 26.04.2004 Moderator: Dr. Ana María Vilchez V-M.

Assistant: Lic. Gladis Ballivián Rosado. Trascription: Mrs. Rosa Luz Vieira

Group characteristics: Gender: 08 men • Group attitude: moderate, reactive • Low participation level, necessity of induction, opinions start from their health personal and

economical problems. • Aspirations: Differentiated attention, necessity of a geriatric physician. • Group problems: Difficulty for order their ideas and express them, they make refer their

health problems as health necessities. 1. Health needs Correspondance Sources of care 1. More important needs 1.1. Healthy life styles User 1.2. Specialized care and attention Hospital 1.3. Routine controls Private insurance (insured

by his son) Social security

1.4. Social support with food for the most needy

Glass of milk problem

1.5.Family care Family


1.7. Practical help – ADL Usuer

1.8. General consult

Social security (those who have access) Primary health care center

2. Non covered needs 2.1 Specialist physician in elderly adults 2.2. Chronic non communicable diseases care. 2.3. Prevention (vaccines) 2.4. Health education 2.5. Low cost medicines 2.6. Social assistance /social help / Some medicine must be with lower prices for the elderly adult / 2.7. Rehabilitation therapy 2.8. Vitamins 2.9. Specialists (Ophthalmology, traumatology, cardiology) 2.10. Help with mobilization 2.11. Recreational activities

They think they are not covered because: - Change of physicians - Deficient government administration (Health Ministry) - There is not interest in attend the elderly adult population.


3.1 Inside the PHC center - Better and master attention / respect for the attention order. - Pharmacy of the health ministry / Medicines with a special discount. - Specialist physician

Services that the users want in their PHC center

3.2. Outside the PHC center - Popular dining rooms and glass of milk program for the elderly adults with less resources.

Municipality

- Spiritual help Local church 4. Satisfaction with the PHC center services

Yes, but there must be a control how many medicines are received and how many are missing.


Yes, but sometimes the nurses and administrative personnel don’t treat the users well.


COORDINATION RESULTS CHART USERS: MEN LEVEL B (65 years or more)



Group charactersitics: Gender: 08 men • Group attitude: tense, reactive. • Moderate participation level, necessity of induction, vague opinions, repeats the opinions. • Aspirations: Better treatment for the elderly adult in the PHC center • Group problem: Lack of knowledge about the coordination actions of the health personnel,

opinions based on the way the personnel treat them.


actual situation

B Ideal situation

concept


change A→B



-They don’t know if they do it.

Coordination to improve the conduct of the personnel, the attention and medical treatment

(they have no idea)

Bad treatment of the nurses and administrative personnel.


The physician must coordinate with all the community, health personnel must help in this task.

- -


CONTINUITY OF CARE RESULTS CHART USERS: MEN LEVEL B (65 years or more)



Group charactersitics: Gender: 08 men • Group attitude: tense, reactive, show exhaustion. • Low participation level, necessity of induction. • Group aspirations: Domicliary attention for the eldelry adults. • Group problem: They use the PHC center services when there is an emergency and when they

need medicines, they recognize that they don’t follow the treatment save the one of tuberculosis


Continuity of treatment by having the same physisicna, that the PHC center treats them well and with respect, appropriate access to the PHC center and help in the treatment of the users with less economical resources.

A

Description of the actual situation

B Ideal situation

concept


change A→B


A→B


- Change of physicians - Lack of medicines. - Users lack of economical resources to follow the treatment.

- More direct relationship, better attention. - PHC center well stocked with medicines. - Domiciliary visit and/or facilitate the transportation of the user to PHC center

Lack of medicines or at to high cost


- Relationship of the PHC center with the municipality, local police and local church.


Physicians Nurses Social assistant


Local church Physicians


Users wish an improvement in the treatment toward them.

5.3.- USERS SUMMARY CHART

NEED AND CARE SOURCES SUMMARY CHART- USERS All of them Most of them Only a few

Health needs

Correspondance

Source of care

1. More important needs 1.1. Medical attention Recognized as important but only a few as real access due the user’s lack of economical resources. Routine control, diagnosis analysis

Primary Health Care Center

Hospital (diagnosis analysis)

Social security



1.4. General consults Primary Health Care Center

Hospital 1.5. help with the AVD – practical help (only one person reported that she need some help from her daughter)

User

1.6. Specialist attention (nutritionist, traumatology, cardiology) Important by consen but accecible for only a few.

Hospital Social security (some are insured)

1.7. Nutriotional support for the most needy (most of them did not know that in some cases the elerly adults are included in these programs)

Church Glass of milk program

2. Non covered needs - Social assistant service. - Health education - Preventive care (vaccine) - Integral health insurance - Vitamins - Attention for chronical non communicable diseases - Medical center specially for the elderly adult - Ophtalmology, cardilogy services and others at low cost. - Recreational system for the elderly adult at low cost - Free medical campaings - Help with mobility

Not very well precised sources but they think the necessities are not covered because: - Poor budget for the health minsitry, and poor budget ofthe health minstry for the eldelry adult attention. - Not support by the government


3.1. Inside the PHC center - Geriatric medical attention. - Medical specilist attention (cardiologist, psicology, nutriotionist, and others) -Social assistance (help with medicines) - Low cost attention. - Fast and preferential attention, special schedule - Domicliary visit - Ambulante services. 3.2. Outside the PHC center (No consensus) - Free medical campaings - recreative activities or locals

Necesitéis required inside the PHC center.

There is lack of knowledge of the concept of primary attention by the users.


Not all are satisfied, but all agree that the PHC center must be improved


Most of them are satisfied with the physician attention. Some with nurses, almost noe with the administrative personnel.

COORDINATION RESULTS CHART – USERS


situation

B Ideal situation

concept


change A→B



Most of them think there must be some kind of coordination but don’t know how it could work. Their opinions are centered in the good or bad funtioning of the admission, the bad administrative work and others, that they consider are factors of the bad attention.

Most of them: Comunication and work meetings could achieve a faster attention and better treatment to the elderly adult.

Not consensus, lack of answers. Some: Reciptivity of the physicians and health personnel to initiate the change.

Lack of answers.Some: personnel not well paid, and parto f them don’t fulfil their actions.


Users lack of knoledge about this issue.

Most: PHC center coordinate with community institutions: glass of milk, local church, municipality, for health education, recreational activities, health campaings, and others.

Poor knowledge of the users A few: mentioned other community that are doing or could do something, as facilitate infraestructure for recreational activities and health education for the eldelry adults.

Users lacko f knowledge. A few considered the municipality as a barrier.

CONTINUITY OF CARE RESULTS CHART – USERS


Most of them considered: be attended always by the same physician, that the physician knows the patient and give a better medical treatment. On behalf of the patient he/she must have confidence in the physician, enough economical resources to pay the medical consult and the medicines.


actual situation

B Ideal situation

concept


change A→B


A→B


Almost all: - Rotation and change of health professionals - Good performance of the physicians. - User lack of economical resources limit continuity of treatment (can not access to more consult or some medicines)

Most of them: medical attention and medicines at accesible prices to follow a complete treatment. Good attention by the health personnel, mainly a good treatment to the elderly adult

Poor answers Some: -Physicians with service vocation. - Health personnel are willing to be trained in elderly adutl issues.

Most of them: Users lack of economical resources


Some: Not existant.

Domiciliary visitSome: Health campaings and education.


Most of them: Geriatric physician Some: nurse, general physician, social assistant, psicologists.


Most of them: Chief physician. Some: Local priest, geriatric physician, health promotors.


Most of the user think the personnel must be trained in gerontologic issues, and above all in good treatment of the elderly adults

5.4.- HEALTH PROFESSIONALS SUMMARY CHART

NEED AND CARE SOURCES SUMMARY CHART- PROFESSIONALS All of them Most of them Only a few

Health needs

Correspondance

Source of care

1. More important needs 1.1 Fast diagnosis and attention of chronic non communicable diseases: Hypertension,diabetes mellitus,osteoporosis, and others

1.1 Primary Health Care Center

1.2 Sensibilization and training of the health and administrative personnel in the elderly adult population attention.

1.2 Health Ministry / health direction

1.3. Mental health problems attention: anxiety, depression, family violence, alcoholism, drugs.


Hospital

1.4. Falls, vision and/or hearing impairment, mobilization problems, dental and nutritional problems, Tuberculosis


Hospital

1.5. Health education, promotion and prevention.


1.6. Induction (of the user) to healthy life styles


2. Non covered needs The asignated budget is insufficent for developing the human resources and the infrastructure to satisfy the main needs of the elderlya dutl population.

Health Ministry

2.1 Continual preventive promotional work.

2.1 Primary Health Care Center/Health direction /Health Ministry

2.2 Low cost attention and medical treatment for the user (diagnostic test, medicines and more complex health services)

2.2 Primary Health Care Center/Health direction /Health Ministry

2.3 Personnel trained in geriatric issues.

2.3 Health Ministry/Health Direction

2.4 Quality and warm attention from the administrative personnel toward the elderly adult user.


2.5 Specific programs for the elderly adult population attention.

2.5 Primary Health Care Center /Health Direction

/Health Ministry/Hospitals 3. Elderly adults services and care:

3.1 General medicine 3.1 Primary Health Care Center

3.2 Social-recreative activities 3.2 Primary Health Care Center

3.3 Odontology (dental prevention)


3.4 Phsicology


3.5 Diagnosis campaings of: TBC , hypertension, obesity , cholesterol, vision impairment


3.6 Rehabilitation services


3.7 Domiciliary visits 3.7 Primary Health Care

Center

4.Satisfaction with the services quality

4.1 No, because the user’s demand denies more time for the elderly adult attention (a good elderly adult attention usually demands more time)


4.2 Lack of gerontolgy training of the health and administrative personnel.

4.2 Health Ministry

4.3 Incipient work of health prevention and promotion


4.4 Diagnostic campaings stay only in the diagnosis phase due the lack of economical resources.


COORDINATION RESULTS CHART – PROFESSIONALS

Por consenso Por mayoría Algunos

Actual situation

Correspondence

Source of care

-Coordination assumed by the Chief-physician. Most of them don’t socialize the information neither plan an apropiatte team work.


- Only a few coordination spaces created for the team work and evaluation of goals.


-Delay in the beggining of the schedule of medical consults due delay of the administrative personnel in the location of the medical records.


-Most of the consult labour or other activities are assigned to temporary personnel.


-Lack of budget or a minimun asigned to the accomplishment of health education, campaings. Sometimes the team coodinators are designed in the last moment.

Health Ministry/Health Direction

-Initial team-work efforts in the elaboration of an attention format for the elderly adults, also in the stablishment an exoneration system for the health attention payment.


b.-Ideal Situation

-PHC center chiefship delegates functions and coordinate weekly the elderly adult’s program advances


-Elaboration of the work plan for the prevention of chronical non communicable diseases.

Health Ministry/Health

Direction

- Half-yearly rotation of the chief coordinator of the elderly adult program between the team members


-Team meetings for the programmed activities, with the presence of the PHC center chiefship and respect for the professional criteria.


-Development of a recreational space to improve the comunication and labour enviroment. (walks, social meeting, among other):


c.- Factors that facilitate the change

- In practice the nurse assume the practice of the coordinations of the direct attention.


-The assistance personnel, in spite the lack of resources work with determination, responsability and identification of users necessities.


d.- Barriers for the change

-The administrative personnel is not sensibilizated with the PHC center or the elderly adult population necessities. These situations sometimes generate maltreatment to the users.


-The coordination are made at central level without the participation executive teams

Primary health care center / Health Direction

-Communication problems between the personnel


-The mainstay personnel don’t want to take control of the health programs (to much work, the pay is the same)


- Chief physicians also experience frustration due the lack of budget, logistics difficultiess and lack of colaboration to accomplish


their labour. -The health personnel has an excesive work burden, multiplicity of functions and schedules that interfere with coordinations.


-The medicines and laboratory tests are not accesible for most of the elderly adult population due the lack of economical resources


-The PHC center chiefship don’t support the initiatives of the personnel


- The continual changes of the chief physician make difficult the continuity and coordination of programs.


CONTINUITY OF CARE RESULTS CHART – PROFESSIONALS


-Control and follow-up: Periodical controls, domiciliary team visits, automedication supervision and satisfaction of needs. - Preventive attention: Vaccination and diagnosis of chronical non communicable diseases campaings, social recreative activities in health clubs and health education for the user and his/her familiy. -Participation of health promotors for suppport the eldelry adults that live alone or guide them in the use of PHC center services.


actual situation

B Ideal situation

concept


change A→B



-General medicine attention, nursing, psicology -Inter-consults - In some cases odontology, nutrition, rehabilitation centers -Incipient develeping of preventive health programs.

- Improve the direct attention and preventive promotional services.

-Initiative, perseverance, will, motivation, professional creativity.

-Increased demand and lack of personnel. - Lack of training in gerontologic issues. - Lack of economical resources. -Minimun family support.


-Minimun particiaption of community institutions. -Incipient communitary work (occanionally prevention campaings) -Patients are sent to general hospitals.

-Census and monitoring of eldelry adults health needs. -Developning of community preventive health programs. - Permanent personnel sensibilization and training in prevention and promotion. -Formation of voluntaries and leaders as health agents that support domiciliary visits. -Eldelry adult and family

-Health personnel initiative, creativity and perseverance. - Support of some chief physicians in professional initiatives. - Elderly adults will for be part of the health programs.

-Continuity is not considered as part of the health chain. - Lack of professionals to assume the coordination of programs. -Lack of personal, economic and logistic resources. - Hospitals don’t give attention facilities, or pay exonarations to elderly adults that come from the PHC center.

sensibilization toward gerontologic issues. -Strategic alliances with representative community institutions.


-In most of the cases there is not a formal responsable of the elderly adult program. -In the practice the responsable in most of the cases is the nurse, follow by the social worker and in a few cases the chief physician.

-The resposible can be a different member of the multidisciplinary that rotates half-yearly. -The personnel more capacitated in the elderly adult attention. -Nurse, social worker. -PHC center chief physician.

-Will, motivation and social emotion. -Delegation of responsabilities (in some cases)

-lack of human and economical resources. Lack of time -Excesive work burden. -Lack of personnel trained in geriatrics and gerontology -Mantienance of work verticality.


-In some PHC centers (incipient): Nurse, social services, chief physician, health promotors.

-Promoters and community leaders trained in gerontologic issues. -Family with continual training in gerontologic issues. -Health commite integrated by representative institutions. -Survillance health community units.

- Professionals will for work -Community agents will for work - Elderly adult family support.

-Lack of budget for continual gerontologic training and for community work.


- Health and administrative personnel trainig in geriatric and gerontologic issues. - Human relationships and team work workshops. - Trainig in health actions impact measure. -Training in evaluation instruments (Katz index, Minimental examination test, and others) - Continual training for the health promoters - Community training in geriatric issues (selfcare)

VI. - ANALYSIS OF RESULTS ANALYSIS OF RESULTS BETWEEN PROFESSIONALS AND USERS 6.1. - HEALTH CARE NECESSITIES BETWEEN PROFESSIONALS AND USERS - Almost all of the health professionals manifest that the detection and attention of chronic non communicable diseases is high-priority for a population elder than 50 years; while the users consider the family as the primory health care support due the lack of economic resources that prevent them to make use of the PHC center services. "Some people, when they reach the 50 years begin to worry about their arterial pressure, their cholesterol levels... A lot of them had not had a medical consult 10 or 15 years ago, they had not taken any type of prevention measure, they sometimes go (to the PHC center) for curiosity and realize that they are diabetic." "I have the help of my family till now, all my family especially my wife and my children" - The consults, diagnostic tests, medicines, more complex services of health and to the Integral Health System (SIS) access, is manifested as a necessity felt in the user population. The attention in general medicine, only reaches the diagnostic presumption what means an interruption in the chain of attention and health continuity, added to a time and budget invested by the state government without benefit to the user. "Another factor... it is the economic one... to tell.... the patients come, we requests him a battery of laboratory tests, they cannot took them because they don't have the economic resources... and if they has a chronic pathology and a treatment is given neither they can complete it because they cannot acquire the medication that are usually expensive and that we don't have in the pharmacy of the PHC center... then it is an impediment factor." - In consent both groups (professional-users) consider very important the development of specific preventive-promotional programs for the elderly adult population attention, as well as the domiciliary attention; that t would reflect the growing interest to improve the quality of the elderly adult population's life. It is important to point out that in some PHC centers are developing promotional preventive activities incipiently, this programs are carried out mainly by the effort of professionals interested in campaigns of detection of diseases, even when these are limited and little perceived by the population due to the lack of resources for the promotion and publicity. "We are health recuperative physicians more than health promoters physicians, I am completely sure the new generations of doctors are already trained for this and I believe that the changes will be seen in the mediate future. We have to continue fighting, already treating the declared illness more than making a true prevention, but also we don’t have enough time for this... ".

".... personally I try to make a prevention work, but the patient.... most of the population is not accustomed to prevention." - The users demand geriatric attention and other specialized services in the PHC centers, however, the general phys ician requieres training in Gerontological and Geriatrics issues. Also most diffusion about to the PHC center services to user population. “I have osteoporosis, I have varicose veins but I continue,…. the doctor tells me to do nothing, that I should not run.... ". ".... For elderly adults is necessary to have a geriatric physician that we don’t have here." - With regard to the satisfaction of the quality of the services, Almost all of the professionals and users manifested their dissatisfaction for the lacks of the PHC center concerning the eldelry adult attention, the excessive number of patients, the slowness of the services, the inadequate infrastructure, the health and administrative personnel not qualified that gives a bad treatment to the patient, the accessibility to the SIS, among others. "Regrettably we work for the (Health) Ministry and they tell us to give quality but they give us more quantity.... ". "The social assistans are also another thing, it is another of the reefs.... look, my economic situation is bad. I am sick, my son doesn't give me neither for medicines... the social assistant tells you… “Mrs. go to visit his house!”,... if for some reason she founds that you have a television, or some device that you could have bought some time ago, because the situation was better, then she don’t give you a exoneration, they close you the doors, there is not a dialogue, she ask you “you have this: when you bought it?, why do you have it?, …the economic situation is terrible, and sometimes one don’t have enough to buy a pill for a thoot pain.... " - The atmosphere of constant tension that is perceived generates frustration in both parts (professional-users) depreciating the image of the PHC center and the services thatit lends. "... but the indifference... and those that have a position believe that they are powerful and the rest of the people are below... the human being.... I am not worth anything... ". 6.2. COORDINATION AND COLLABORATION RESULTS BETWEEN PROFESSIONALS AND USERS - The coordination is one of the biggest difficulties found in the PHC center, the lack of coordination is perceived inside and outside the establishment. - Almost all of the professionals point out that the coordination is always assumed by the chief physician, who doesn't socialize the information neither the plans the teamwork. The frequently changes of the chief physician interrupts the application of programs and activities.

"In coordination that are in the operative part are sleeping, in what is coordinations and lines of authority there are chief physicians that receive training, and till now they don't work anything, because day by day they don't live this situation, they only live the administrative part and that doesn't help the progress or the study, the information is not shared." - The coordination and evaluation achievements spaces are scarce, due the lack personnel. The minimum basic personnel has a multiplicity of functions and an increased demand of patients that added to the lack of budget, logistical difficulties and lack of collaboration make the coordination efforts minimum, deferred and without effective results. - The coordinations of the PHC center with community representative institutions in most of the cases are personal efforts of the health team of the PHC center that don't end up enlarging their covering due budget lack, the lack of autonomy of the PHC center chief physician, the slowness of bureaucratic steps of the Health Direction (DISA). "In our establishment the workers collaboration and health direction (DISA) is minimum. For example today, the World Day of the tuberculosis, they send a directive with a chronogram to make activities but no money, each establishment have then to be organized to make their own activities, to give something to the patients. What have we made? I have sent a letter to the Rotary club, othre to the Club of Lions. The Rotary supports me with a ¼ of chicken for each patient, the Club of Lions with the local area to make activities... " - The users perceive that a tense labor enviroment generates miscoordinations in the attention (inadequate operation in the admission office and critics among the medical personnel, of infirmary, technician and of social work). "... there is a lot of enmity, there is not union... ". "... am I with a doubt,... if a person is professional and the other person is also a professional. Why can’t they coincide? One tells me a thing and other tells me another thing the same day, my doubt is then there... ". - The analysis of this situation points out that the coordination inside and outside the PHC centers are one of the problems that needs urgent solution, there is miscoordination that settles down from the superior hierarchical levels toward the PHC center and the community. The professionals of the Center are forced to carry out the coordinations of last moment directly. When designating the Chief physcian of each PHC center, generally, it is not contemplated the formation and administrative qualities, neither the technical, social and teamwork capacity. Also, the continuous changes of the PHC center chief-ship and the lack of autonomy prevent that the activities finish in the opportune time. The frustration levels in the users keep a direct relationship with the miscoordinations perceived in the PHC center. "... There is will, what it lacks is support, all the programs we want to make just stay there (in the wish to do them) for these reason."

"... The medications that the doctors prescribe are medications that are sold by laboratories and that are very expensive. they don't send basic (generic) medications because one goes (pharmacy) and they say there is not and one goes to the street… the basic (generic) medication is more comfortable (economically) and it is the same medicine that they have prescribed but with the changed name." 6.3 CONTINUITY OF CARE BETWEEN PROFESSIONALS AND USERS - The Continuity of Care is a concept that has not been defined with clarity in the professional’s focal groups and less still in the user’s focus groups. There are diverse opinions in this respect that go from the domiciliary visits, health campaigns, the attention by the same health professional, follow-up and control, even the PHC center diffusion of the activities. - Regarding the continuity of care inside the PHC center, most consider that this is only given in general medicine. The ideal situation for most of the users is the direct attention by the same professional and that the PHC center have preventive-promotional and pharmacy services within all’s reach. "The continuity also can be achieved through the formation of clubs in which participates the community, mainly the people elder than 50 years... the hypertension club, the lipids control club, the diabetic club, of the patients with osteoporosis organizing them to make manual and cultural activities. The patient can be educated so that he/she takes conscience that their selfcare should continue through the time... periodically going to consult, being controlled, participating in the activities of the establishment." - With relationship to the continuity of care outside of the PHC center most of participants of the focal groups point out that incipient and sporadic activities of continuity of health services in the community that require more diffusion; being the health promoters and particularly the family group as fundamental nexus between the users and the PHC center. “The health promoter is important but I think that more important is the family, because if the family doesn't take conscience that that is necessary to take the eldelry adult (to the PHC center) who more?... they have to make diffusion at community level... " - The existent confusion around the concept of continuity of care services determines that there are not appropriate programs and activities and a clear delegation of functions and responsibilities in the health professionals. The users hardly perceive the continuity of services, especially outside of the PHC center. The cut of the heañth chain in relation to this topic influences negatively in the user population well-being.

VI. CONCLUSIONS 1. Focus Group study has allowed us to confirm the current situation of the PHC centers attention, where the different participants: physicians, nurses, social workers, pshycologist and users show minimum levels of satisfaction and maximum of frustration due the daily found limitations, demands, miscoordinations, labor enviroment and others in the health services giving and to receiving respectively. Nevertheless that perceived reality, the participants show their restlessness and desire to find alternatives solutions that have been captured in proactive attitudes that commit to effective change answers to short and medium term. 2. The health professionals consider that training in primary attention and gerontologic topics are necessary for them and for the administrative personnel to confront the care necessities, the differentiation in the attention and the application of specific health programs for the eldelry adult population. 3. The elderly adult users profile is characterized for: use of the services when the pathology presents complications or becomes critical; lack of economic resources to carry out medical consults, laboratory tests or to acquire medicines; finally victims of abuse especially by the PHC center administrative personnel's, but also sometimes by the Infirmary and Infirmary Technician personnel. Nevertheless, the PHC center constitutes for the great majority of the users the only option for its basic health attention. 4. There is a distance between the necessities of care of the population's health and the necessities that cover the PHC center. The users and the personnel identify the PHC center as an establishment that only offers direct attention and they require of more participation of the Health Ministry to assist this necessities. 5. The miscoordination interferes with the processes of production of health services inside and outside of the PHC center. It is a constant found in most of the personnel, originating delay administrations, faulty results, conflicting labor enciroment, among others; this dimish the quality and warmth of the services offered. 6. The perception of most of the professionals and users of the PHC centers is negative because of the deficiencies that are presented in the attention gived and received, specially, on behalf the professionals due the demands in the daily work. The PHC center personnel and resources are not enough or nearly cover the actual demand; when there is an incipient work the lack of recognition to the developed work and the little support of some chief physicians in relation to the initiatives to improve the attention finish or don’t let the growth of these programs.

7. There are some efforts of some members of the health team in offering a better attention to the elderly adult population based on their vocation of service and identity, also standing out their sincerity in recognizing their lack of formation in geriatric topics to give a more integral service. 8. A critical posture of the health professionals is perceived in front of the continuous chief physician changes, the lack of autonomy and the extensive bureaucratic steps that impede the development of the activities of the PHC center and its relationship with the community. 9. A misinformation is appreciated in most of the health professionals and users about the concept and application of the continuity of care; however the necessity is recognized of considering it in the chain of health services. 10. The users of more age and the personnel of the PHC center request a specialized attention with quality, warmth and team work. A Board of intersector works with institutions of the community to carry out work group and activities, the formation of health promoters for domiciliary visits and effective connection with the professionals of the PHC center. 11. In spite of taking the most of the burden in the elderly adults primary, the family is not prepared neither is supervised by the formal health systems. VIII. RECOMMENDATIONS 1. Revalue the human potential with which the PHC centers count, since it constitutes a fundamental pillar for the direct and effective application of preventive-promotional programs of health attention. 2. To establish the administrative, administration and coordination mechanisms able to provide the personnel of the PHC center the necessary infrastructure, equipment, logistics and other conditions, for the application of an effective work with the eldelry adult population. 3. The positions of trust should be assigned to professionals that possess the technical sufficiency and administrative capacity, it is also suggested that the duration of this position should not be short and allow to evaluate the traced goals. 4. Special emphasis should be given to the establishment of a more effective coordination system that embraces the hierarchical superior levels to the operative levels, to improve the productivity of the health services.

5. To develop human relationships and team-work workshops and courses to improve the communication and the efficience in the different involved actors. 6. To carry out a Census of the eldelry adult population's necessities for the implementation of programs that could respond to their demand. 7. Train the field personnel of the PHC centers prioritarily in primary attention and Gerontologic issues. 8. To emphasize the development of continuity of health services programs to improve the offer and the satisfaction of the necessities of the elderly adult users' health. 9. To strength the mechanisms of diffusion of elderly adult health programs that will allow to enlarge the covering and convocation power. 10. To formalize strategic alliances with institutions of the civil society to improve the health attention of the user population. 11. To improve the access to the health services by placing them within reach of their users, although the self-management of the services is a current tendency, this should not be constituted since in the practice limits more the access of the poorest sectors denaturalizing their reason for being and the mission of the Health Ministry. 12. The formal health systems should involve and educate the family of the elderly adults, so that they are the axis on which the other systems must rotate.

SUMMARY

The INTRA II-Peru is a qualitative study made under the Focus Groups methodology and took place between the months of March and April 2004 in Lima City. Of the 206 health centers existing, 16 health centers were selected from which user (06) and professional (08) groups were formed. All the methodology provided by World Health Organization (WHO) for such study was followed. A total of 107 people were included from which (39) corresponded to the professional group and (68) to the user group. NEEDS AND CARE SOURCES - The elderly adult population receives general medical attention although they need geriatric

attention and of specialties for degenerative diseases as well as educational promotional-preventive attention.

- The majority of elderly adult users do not have financial capacity for affording diagnostic

tests, medicines and specialized procedures. - Family has an important role in satisfying the basic needs and health attention of the elderly

adult individual, but such action is limited due the lack of economical resources. - A differentiated, integral and specialized attention for elderly adult persons is necessary - The users feel unsatisfied with the health care because:

Shunning and bad treatment principally from the administrative personnel, and in some cases from technical personnel and nurses. Health and administrative staff are not well trained in geronto-geriatric attention. Difficult access to the Integral Health System (Sistema Integral de Salud) (SIS)

- The group of professionals and users consider the Health Center as their primary source of care for the health needs.

- The health personnel manifest a high degree of dissatisfaction and frustration because of the

inadequate infrastructure and the lack of resources, personnel, logistics and support from the hierarchically superior staff in the Health Center.

COORDINATION - There is a miscoordination of activities inside and outside the health center. - The coordination is undertaken by the Chief physician of the health center. Many of them

do not share the information nor plan the tasks and work with the health and administration teams. The nurse generally assumes, within practice, the coordination of services.

- The professionals consider that:

A) There is little time for coordination of team work and the evaluation of goals B) Delay in the beginning of outpatient attention schedules related to the delay of

administrative personnel C) The heavier labor load is given to temporarily hired personnel.

The users do not understand all that implies to coordinate such services, but they still perceive the malfunctioning of the services rendered within and outside the health center. - The professionals would wish:

A) A Coordinated health care could be given, with clear rules, kindness and quality B) A rotation of coordination every six months providing for an efficient administrative

system. C) That a plan for preventing diseases exists. D) Strategic alliances with other institutions may be formalized

A consensus exists that the majority of hindrances are found in:

A) A lack of budget and personnel. B) A lack of autonomy health center chief redounding has. C) Bureaucracy in state establishments. D) Limited coordination with hospitals because of economical reasons related to patients.

CONTINUITY

- The concept of continuity is unknown to the majority of professionals and users. The users perceive continuity of services as:

A) Only in general medicine B) To be attended by the same professional when establishing a humane and positive

relationship with the user C) Financial capacity for medicine and consultation.

- In the professional group continuity is not perceived as part of a health chain, but the concept is not precise, and is considered as:

A) The follow up and control of the patient (periodic visits, home visits, supervision of

auto medication and needs satisfaction). B) Preventive actions ( disease detection, user and family health education and social

recreational activities)

- The continuity of services and care is not made possible because of the lack of financial resources of the elderly adult

- The ideal situation proposed considers:

A) Professionals: Direct health care attentions and preventive promotional services. B) Users: Care always received from the same doctor, the same schedules and

specialists, good attention and interest from the professional with the elderly adult, and medicines available to all patients.

- The hindrances perceived :

A) Lack of human resources, economy and of time. B) Lack of budget for gerontological training and community work.

- The professionals in charge of continuity are sometimes the physician in chief and in other cases the nurse and/or the social worker.

- Ideally the one perceived in such role must be the geriatric physician and in lesser

proportion, the nurse, the social worker, psychologist and general physician. - They also perceive that the work outside the center must be done by the health center

director, geriatric physician or to the most capable health care professional. CONCLUSION - The Health Ministry lacks sufficient budget for the direct attention of elderly adults, and for

promotional preventive programs. - The health system is inefficient for the demands of the elderly adult users in primary level

attention. - The users have little economical resources for their periodic health care and their repeated

demand has been that consultation, auxiliary exams and medicines should be of low cost and if possible exonerated from payment.

- The professionals and users recognize the need for training in geriatric care for health care

personnel, to give better care of the elderly adult population. - Respect and courtesy the elderly adult from the administrative and technical personnel of

the health centers is non frequent. - Miscoordination is a constant among the professionals within the health center and the

health center with the family, community institutions, hospitals, Health Directive (DISA) and the Health Ministry (MINSA).

- There is no integral concept of continuity, which is reflected in partial care from health

services that are provided.

alc intra2 cp peru - who · iii. methodology: intra ii-peru study the used investigation method was...

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