Glocal Lessons Learned
One obvious answer to the posited questions has to do with the operational definition of community as a “glocal,” or global to local, construct that transcends geography across the developed and developing world. Whether country or county, the common thread is the substantial challenge of managing hypertension in the setting of limited resources and limited income. The United States has a 76 million hypertensive target population, and may spend $76 billion in part on downstream complications (related to heart failure, dialysis, stroke, vascular dementia, and peripheral vascular disease) with procedures that are not available to the developing world. It matters not whether it be poor outcomes in urban areas of Port au Prince or Norfolk, Virginia. The basic principles are the same.
Evidence- and Reality-Based Medicine
As we enter the “glocal” circle, we need to not only educate and teach but also to learn. After a decade in Haiti, including the day of the 2010 earthquake (LMH), the cofounders of Colleagues In Care (a volunteer organization of medical professionals) have attempted to balance science, standards, and service in the development of sustainable systems in order to best leverage clinical problems with a double product of high population frequency and substantial negative prognostic impact. By virtue of the marriage of evidence-based medicine with reality-based medicine, tempered by the pragmatic limitations imposed by low resources, “Best Possible Practice” (BPP) models of care have been developed. Our approach has utilized IBM Smart Cloud technology-assisted communication tools to support the primary need for effective communication. In recognition that collaborative education leading to true collaboration, cooperation, and community is a human endeavor requiring adherence to principles of human and organizational learning systems, effective communication is the sine qua non. Technology is a tool.
The Primacy of Knowledge
Although always evolving and never perfect, knowledge is power, and it is unequivocally most powerful when shared. The key is to leverage knowledge and experience as we build effective transcultural bridges among individual colleagues in the helping and healing profession of medicine. It is a functional requirement that all must be fluently speaking the common language of BPP. Education, training, and BPP clinical care standards can allow expansion of the delivery system to include more nontraditional healthcare workers and volunteers, where the constant is performance and the variable is job title. In this regard, lessons to be learned include contributions of the “Accompagnateur,” who is essentially a task-oriented trained community health worker responsible for accompanying the patient through the system. This has been a successful model of care for infectious disease in Haiti, Boston, and beyond, with obvious implications for chronic noncommunicable disease management, especially hypertension and heart failure.
Values and Value
Clearly, the BPP glue is demonstration of values and value, classically defined as cost for specific outcomes, as modified for appropriateness. De facto, if we are able to maintain quality outcomes at low resource cost, we have attained high value. Using an approach of “value-based collaboration” rather than “value-based competition based on results,”[77, 78] cost will be determined on an interactive basis from the database, determined on a per patient-year of therapy basis driven primarily by pharmacologic decisions. Outcomes can range from standard awareness, treatment, and control comparators of achieved BP targets to the most important measurable impact on stroke events. The continued goal is to minimize unexpected and unexplained clinical variation; with the caveat that protocol noncompliance solely due to resource unavailability is neither unexpected nor unexplained.
Building an effective integrated system requires that the journey must begin by utilizing simple first steps of classic and basic structure and process-quality metrics, documenting the ability to do the right things right.
Haiti Hypertension Program
The Haiti Hypertension Program is a BPP program blueprint that has involved in-country partnerships with Dr Jean Claude Cadet, Dean of the Faculte de Medecine et de Pharmacie de l'Universite d'Etat d'Haiti (FMP UEH), and the leadership of Dr Roger Jean-Charles, Director of Centre Haitien d'Hypertension (CHH). Multi-level certification programs will establish acquisition of a solid fund of knowledge related to both diagnostic and therapeutic levels of hypertension management in the community (Table 3).
Table 3. Haiti Hypertension Program Best Possible Practice Education Model
|IA||Blood pressure measurement||Students, community health worker leaders, nurses, physicians, pharmacists|
|IB||Public health education providers||Students, community health worker leaders, public health educators, nurses, physicians, pharmacists|
|IIA||Basic science of hypertension||Medical students and physicians|
|IIB||Hypertension management in community guideline curriculum||Medical students and physicians, potentially advanced training nurses and pharmacists|
|III||Level II, plus clinical case studies, for postgraduates||Family practice/internal medicine residents, and physicians in the field|
|IV||Hypertension specialist fellowship training||Hypertension leaders|
Consistent with the Ministry of Public Health and Population (MSPP) health care delivery continuum from Teaching and Specialty Hospitals to Department Hospitals, Community Hospitals, and Village to Community Health Centers, the integrated hypertension system will go beyond the State University Medical School and urban Port au Prince central hypertension clinic into rural area clinics. Beginning with the Baptiste Clinic on the mountainous Dominican Republic frontier border, BPP models applicable to mobile clinics and community health centers will use standard hypertension protocol management and a defined interactive database. They will be supported by physical and virtual consultation for treatment-resistant hypertension patients who have bubbled up through standard protocol management. The goal is colleague-to-colleague support on the low complexity end of the telemedicine spectrum, potentially using mobile phone technology. From there, strategic nodal hypertension network centers will be added.
The phase IA foundational base of the hypertension program pyramid is focused on resolving well-documented, widespread difficulties in the ability to take an accurate and reproducible BP measurement using manual devices. Incorporating multiple international training and technical standards, the Haiti BP Measurement Specialist Certification Program is based on a successful program utilized by the Virginia Department of Health. The culturally modified course manual has been rewritten in French, Spanish, and Creole, with supportive video including a sights and sounds examination of Korotkoff sounds for testing, and pre-/post-course testing for certification. Documentation of competency for certification is consistent with published guidelines. The BP Measurement Specialist Certification program has begun with medical, nursing, and pharmacy students. They will then become the teachers and become engaged in database collection from BP screening kiosks (specific BP measurement specialist certification-related references available upon request).
A complementary phase IB certification program is being developed for those who wish to be involved in public education. This will focus on stroke and salt sodium/potassium education. The plan is to have a standardized video series to be filmed in Haiti, scripted collaboratively in French, Creole, and Spanish. In order to avoid the pitfalls of a purely folklore method of instruction, public educational material will be standardized, in concert with “teach back” or “show me” techniques utilized for health literacy education.[80, 81]
There is movement to build on phase I certification programs, addressing challenges in low resource areas, and potentially integrating a recommendation for the preferential use of semi-automatic manometric devices as an international standard. This is in recognition of the reality that in many countries such as Haiti with a UNICEF 2002 pre-earthquake reported 0.25 physician/1000 population, with similar nursing personnel challenges, there has to be an option for quality-based expansion of the hypertension outreach screening and diagnosis system with appropriate documented standards enlisting support of community health workers, public health educators, nursing assistants, and pharmacists.
There is an appropriate expanding leadership position for physicians and nurses integrating education, training, and an oversight management role in support of hypertension BPP suggested models of care with appropriate database and protocols. Upper-level clinical management of hypertension in the community will require managing systems as well as individual patients.
The Management of Hypertension in the Community guideline document will serve a dual purpose as both the basis for a hypertension curriculum offering certification in clinical hypertension, as well as suggestions for BPP consideration. For students in training, it begins with basic science review of cardiac, renal, and endocrine aspects of hypertension, collaboratively developed by a coalition of medical school physiologists.
The medical education system in Haiti is such that after medical school there is a compulsory national social service year. This requires working in outreach clinics and hospitals throughout the system, often as the sole primary care medical resource. The goal is to start with all medical students to confirm competence in hypertension management for this year of service. Building on clinical experience, documentation of hypertension management competency could expand to residents in family and internal medicine training. Post graduates out in the trenches in practice could eventually challenge the examination to allow hypertension management certification via a continuing medical education mechanism.
Once a multi-tiered integrated clinical hypertension management team is built from the bottom up, the management of hypertension in the community approach may be eventually adopted as a national standard, with consensus on a national formulary. That is the road map. The ultimate dream is for a hypertension specialist fellowship training program at Faculte de Medecine et de Pharmacie de l'Universite d'Etat d'Haiti (FMP UEH), under the direction of Dr Jean-Charles and colleagues, with aspirations to ultimately achieve the level of a comprehensive hypertension center for education and research at the University Hospital.
System theorists and learning organization leaders have observed that when faced with the challenge of immediately unattainable quality and value goals, there are two options. Successful programs will avoid the symptomatic solution to lower the bar so low that metrics are ignored or are easily attained, and keep the aspirations bar appropriately high with the realistic recognition that while we cannot get there now, it remains the focused goal. This is the philosophy of BPP, that is individual colleagues supporting colleagues, together working towards the “R-7” solution of the right provider doing the right thing, the right way, to the right patient, at the right time, in the right place, and at the right cost, perhaps with an asterisk for human rights access to appropriate levels of medical care, and the medical professional right to knowledge acquisition.