Abstract
Background COVID-19 rapidly spread in the middle of 2021 lead to health system crisis in Bangkok, high occupancy of hospital beds; hence, Home Isolation (HI) policy was announced by the department of health, July 1st, 2021, although home isolation services provisions were limited to hospital facility. COVID-19 infection rate rapidly progresses with Delta strain and leading to health system crisis in Bangkok. The Royal College of Family Physicians of Thailand together with the GP/FP Association of Thailand agreed upon stepping in appointing a committee on July 7th, 2021, to help resolving the situation, building capacity for primary health care via three key strategies. The first strategy is to provide academic support, adjusting home isolation guideline to be more holistic, following family medicine principle, comprehensively covered all dimension of services need for the patient, family and community. Apart from this, continuous learning environment was developed via case study learning and sharing platform as well as providing relevant learning materials to build capacity of providers in primary care setting. The second strategy is to mobilize resources, recruiting health professionals for volunteering services, providing care for COVID-19 patients in Bangkok who need to get access to medical services under home isolation services package via telemedicine. To leverage maximal resource utilization, home isolation services provision via private primary care providers are essential. Hence, co-ordination was used as the third key strategy to enable services provision in primary care. In enabling primary care providers to provide services, co-ordination was used as the third key strategy. Coordinate with stake holders at various levels to enable service provision in primary care practice, including National Health Security Office, Institute of HIV Research and Innovation and Community Based Organizations, working in the community with increased number of case, and National Science and Technology Development Agency, the developer of AMED-Telehealth program, in order to establish COVID-19 Primary Care hub as one of key mechanism to solve health system crisis. This implementation research as objects to 1) analyze the key factors for success and barriers for the implementation 2) evaluate the result from the implementation and services outcome and 3) to synthesis policy recommendation in order to response to New Emerging diseases in the future. Methods This mixed-method study was conducted between February 2022 to March 2023. Consolidated Framework for Implementation Research was used to evaluate the implementation process and used Conceptual Model of Implementation Research was used to assess the implementation output and outcome. Both quantitative and qualitative information were collected from various sources of information including document used in the implementation process, focus group interview and in-depth interview, data from patient’s experience survey conducted by Health Accreditation Institute between 7-9 September 2021. Data recorded in AMED-telehealth was also used for the analysis of the implementation outcome and services outcome. Results The implementation of COVID-19 Primary Care Hub to strengthen the capacity of primary health care in Bangkok achieved to improve access to services. Two-thousand three hundred and forty health professionals recruited to Fammed-CoCare Volunteering network and work with Pribta-Tangerine clinic, by IHRI, of these 1,544 were physicians. From July 1st to December 31st. 2021, 90,816 patients with COVID-19 received home isolation in the record of AMED-Telehealth, of these, 18,592 received treatment from Fammed-CoCare-Tangerine Clinic. There were 26 private primary care clinics, under the brand wam community clinic, agreed upon working in collaboration with COVID-19 Primary Care Hub, to receive academic support, consultation with specialist and coordination to receive needed medical supply as well as referral coordination, and 5, 285 patients received home isolation care from these 26 clinics. Overall, there were 24,237 patients with COVID-19, received services under the support of COVID-19 Primary care hub. There were 190 warm community clinics joining the program to provide home isolation, and 21,966 patients received home isolation services from these clinics. There were 68 health centers by Bangkok Metropolitan Area (BMA), considered as pubic primary care services, providing home isolation services and 35,218 patients received from these public primary care facilities. Home isolation services were eventually provided by primary care providers since the coordination of the committee to work on Strengthening Primary health Care System in Bangkok. This committee achieved to communicate with NHSO, Department of Health and the Department of Services Support, enabling home isolation services being provided at primary care service facility, through the correction of regulations that were set as barrier. Home isolation services provided by primary care provider achieved to reduce the gap of inequity, with resource mobilization, strengthening the capacity of service provision in primary care, enable critical care services, and care for patients with severe illness who need hospitalization but could not get access to. Key factors for success include the characteristic of COVID-19 primary care hub that is relevant to the established primary care infrastructure in Bangkok, in which warm community clinics play important roles, although there was challenges in the beginning as the clinic staff needs preparation and there was shortage of medical supplies during that period. Academic Support and capacity building for staff in primary care settings as well as consultations and making needed medical supply available help in building confidence the capacity for service provision. Coordination with community-based organization, community leaders and volunteers in the community has key role in providing support and coordination for the vulnerable. Most importantly, financing and re-imbursement mechanism is the most important factors for the success in the implementation of home isolation services. Health System crisis has drive private sectors and people in the society to step in and provide support inorder to overcome the challenging situation, having insufficient human resources for home isolation in Bangkok. The working culture and value that prioritize integration, patient centered approach, putting patients, family and community at the central role of services enable harmonize collaboration, working towards a common goal to reduce inequity, of people working in the field of primary health care, achieved to have demonstrated model for integrated services delivery. Horizontal integration is the key function in the process of this implementation activity which allows public-private and people partnership. Conclusion Investment and resource management in order to have sufficient primary health care staff providing services at primary care level is essential. In addition to this, Continuous learning mechanisms to enable capacity building through routine workflow is important to strengthen primary care capacity, considered as leverage point to enable integrated high quality primary care services. Telehealth has a crucial role in primary health care strengthening, especially in the situation of an epidemic or pandemic, preventing the spreading of infection. Community leaders and community-based organizations are sensitive to changes or unusual situation that occurs in community and have crucial role in coordinating needed support to the vulnerable.
