'El Carmel' community-orientation experience

Introduction : “El Carmel” health center is located in a social deprived area in Barcelona city with around 20000 inhabitants. Since the Spanish reform of the primary health care in 1984, Primary Healthcare Centers (PHC) have to provide healthcare services for individuals, families and the community assigned. However the reality is that the majority of PHC focus their practice into individuals, and community care is frequently left in oblivion. Here we present the strategy to progressively orient our practice to the community. Description of practice change implemented : Our project aim is to improve the health of the community as a whole, empowering citizens to face their own problems, beating against health inequities and creating a healthier neighborhood. Goals are : to achieve a community health diagnosis and to implement community health programs based on priorities agreed We identified three eligible situations: 1. In the medical/nurse consultation, using the patient-centered clinical method, contextualizing the health demands and looking for a salutogenic approach when possible. 2. At the PHC level we conducted a health diagnosis, and established priorities of action. 3. In the PHC outreach activity, we collaborate with the Neighborhood-Community-Project (NCP) in which are represented the main local citizen associations, the local government and other public and private services included social services. Key findings : In 1994 the PHC team began a community orientation in a very slow pace, facing internal and external constraints. a) In 2000 we finished a community health diagnosis (quantitative and qualitative). The document was updated in 2004 with a list of priorities b) In 2000 the NCP invited us to participate to developing a strong social network and promoting the community engagement. From 2004 until 2014 the NCP has developed a wide range of activities in which the PHC has participated, especially when related to health promotion. This process follows the "community plans" methodology. c) From 2005 to 2012 a child-obesity community program has been implemented to improve healthy food habits and an active life style. This program follows the Community-Oriented-Primary-care methodology. Health outcomes: significant improvement in life-style (from 40% to 61%) and quality of diet (from 52% to 64%) d) Since 2004 a walking group project for people over 65 has been developed, especially for those at risk of social isolation. At this moment we have 6 walking groups with around 150 participants. The project follows the Participatiory-Action-Research methodology. Health outcomes: significant decrease in blood pressure (from 136,7 to 131,3 for systolic blood pressure and from 75,6 to 73,2 for dyastolic) and even more in patients over 70 yo. e) In 2014 the NCP decides to engage issues on health inequities. In March 2015 we presented a short illustrated book explaining the role of social factors in the neighborhood health. We look forward using them in future events (schools, local associations). f) In September 2014 a choral group was formed with patients affected by chronic conditions with the aim to improve quality of life. A 6 months clinical trial has showed an improvement in the quality of life and the participants expressed great interest to continue with the activity. Nowadays there are around 25 participants and the group has started to sing in community events. g) In 2015 the PHC joined the ‘COMsalut' project. The aim of this project is to facilitate and recognize the community work of the PHC in Catalonia. h) At this time we are working in a data base of community assets and preparing a basic set of socioeconomic data to include in the individual electronic health record. Highlights : The main constraints for the community orientation has been the lack of knowledge in community engagement; the overload of work in consultation; the few recognition of the community work and the pressure of the employer to achieve goals in clinical area. We have been developing a close relationship with different partners of the NCP and we’ve been progressively improving our competences in community and groups work. We have realized along these years that the presence of the PHC in community events or activities is a tool to gain citizens interest. We have developed the ability to accompany various groups and slowly let them gain autonomy. Joining the ‘COMsalut’ project has been a good resource to face eventual problems in future. Conclusion : The community orientation of the PHC team is an important contribution to face social and health iniquities of a defined community. With the support of our employer and the recognition of these activities as a part of the assigned work task, the community orientation of the primary care services could be sustainable. We think our experience is not unique and in any case is transferable to other practices with a similar context.