Preventive Health Programs in Social Health Insurance english final (3)
Preventive Health Programs in
Social Health Insurance
Dr Lily Sriwahyuni Sulistyowati, MM
1. Current situation
Epidemiological Transition
Causal of Death, 1990-2015
1990
2000
Cedera; 7%
Penyakit Tidak Menular; 37%
Penyakit Menular; 56%
2010
Cedera; 8%
Cedera; 9%
Penyakit Menular; 33%
Penyakit Menular; 43%
2015
Cedera; 13%
Penyakit Menular; 30%
Penyakit Tidak Menular; 49%
Penyakit Tidak Menular; 58%
Penyakit Tidak Menular; 57%
Source : Double Burden of Diseases & WHO NCD Country Profiles (2014)
No
Causal of Death
1 Stroke (I60 - I69)
2 Coronary Heart Disease (I20 – I25)
3 Diabetes mellitus with complication (E10 –
E14)
4 Tuberkulosis (A15 – A16)
5 Hipertension with complication (I11 – I13)
6 CPOD (J40-J47)
7 Hepatitis/liver Diseases (K70 – K76)
8 Injury (V01– V99)
9 Pneumonia (J12 – J18)
10 Diarrhea and GIT infections (A09)
National Health Survey (Riskesdas) 2013
Source Sample Registration Survey (SRS)2014
%
21.1
12.9
6.7
5.7
5.3
4.9
2.7
2.6
2.1
1.9
HiGH COST/expenditure on the treatment of diseases
Total number of impatient CVD is ranked 4th, however the expenditure is the highhest (3.5
Trillion IDR) pembiayaannya menyerap biaya tertinggi (3,5 T)
Top 10 Diseases
Claimed of Impatient Year 2014: NHI , total
GASTRAOINTESTINAL INFECTION
774,276
DELIVERIES/LABOR
644,207
PARACIYE AND INFECTION
448,816
CARDIOVASCULAR DISEASES
448,342
RESPIRATORY DISEASES
401,059
STROKE
WOMEN REPRODUCTIVE
Top 10 Diseases Claimed as Outpatient
Biaya Klaim Penyakit Rawat Inap
Tahun 2014: Rp Milyar
327,132
CARDIOVASCULAIR
DISEASES
GASTRAOINTESTINAL
INFECTION
3,503.4
3,318.8
2,396.7
2,341.5
1,919.4
1,535.5
1,509.2
1,440.9
1,214.7
RESP IRATORY DISEASES
934.7
DELIVERIES/LABOR
RENAL DISORDERS
MUSCULOSCELETAL
THMT
320,777
274,469
265,645
173,936
Source: BPJS Kesehatan, 2014
MUSCULOSCELETAL
STROKE
RENAL DISORDERS
PARACYTE
AND INFECTION
WOMEN REP RODUCTIVE
SKIN DISEASES
4
2. Policy Support
National Health Strategic Plan
2015-2019
Health
Paradigm
Program
All recources are
pooled to
tackled the
priority program
• Health in all Policies
• Promotive-Preventive
as main Pillar of
Health
• Community
empowerment
Strengthening
Health Delivery
System
Program
• Increase access at
Primary care
• Optimalization of
Referral system
• Quality
Improvement
continuum of care
Health risk
assessment
intervention
NHI
Program
• Benefit package
• Insurance Financing
System Gotong
royong
• Quality Assurance
and quality control
• Target: fully
Subsidized & Non
Subsidized
Membership card
Indonesian Health card
Strategic opportunity INCREASE HEALTH BUDGET from 2,5 TO 5%
DIRECTED TO BREAKTHROUGH PRIORITY PROGRAM TO BOOST THE ACHIEVEMENT OF NATIONAL
DEVELOPMENT INDICATORs
INCREASING NATIONAL
HEALTH STATUS
CONDUCIVE
ENVIRONMENT
•
•
•
HEALTH REGULATION
LAW 36/2009
DECENTRALIZATION
LAW 23/2014
GOVERNMENT
REGULATION
109/
HEALTH
MINISTER
REGULATION
DECREASE MMR
AND IMR
DECREASE
DECREASE MORBIDITY
MORBIDITY
AND MORTALITY
AND
MORTALITY FROM
FROM
ATM
ATM (AIDS,
(AIDS, TB,
TB, MALARIA)
MALARIA)
DECREASE
Stunting
DECREASE
DECREASE MORBIDITY
MORBIDITY
AND EARLY
AND
EARLY MORTALITY
MORTALITY
DUE
DUE TO
TO NCDS
NCDS (CVD,
(CVD,
SUPPORTING
EFFORTS
DIABETES,
DIABETES, CPOD,
CPOD, CANCER,
CANCER,
OBESITY)
OBESITY)
INCREASE ACCESS TO QUALIFIED HEALTH
SERVICE DELIVERY (Continuum of Care)
STRENGTHENING PRIMARY, SECONDARY AND
TERTIARY PREVENTION
LIFE CYCLE APPROACH
1.INTEGRATED AND COMPREHENSIVE
HEALTH DELIVERY SYSTEM
2.INTEGRATED DRUG
SYSTEM
MANAGEMENT
3.REACHING OUT THE UNREACH
FAMILY FOLDER APPROACH
4.INTEGRATED PLANNING AND
PROMOTION AND CONTROL OF RISK FACTOR
EVALUATION
5.INCREASE EVIDENCE BASE
INTERVENTION
NCD, CD, MCH Global Targets included as
National Development Targets
in the Medium-term National Development Plan 2015-2019
Strategic policy approach
strategic to embrace other sectors to share their
contributions in achieving the targets
1.
2.
Reduction of Raised Blood Pressure from 25,8% (2013) to 23,4% (2019)
Halt the rise of prevalence of Obesity from age 18+ years (at 15,4%)
3. Relative reduction of current tobacco consumption at age < 18, from 7,2 (2013) to 5,4 (2019)
4.
Prevalence of TB, from 280/100,000 in 2015 to 245/100,000 in 2015
5.
Prevalence of HIV maintain below 0.5%
6.
Decreasing MMR (maternal Mortality Rate)
7.
Decreasing IMR (Infant Mortality Rate)
Policy for promotive preventive measures in ncd
control
• Health Minister Regulation no
71/2015 on NCD Control
• MOH Strategic Plan indicator
•
Percentage of villages that have POSBINDU PTM/ NCD CBI
• Draft of Government Regulation (RPP) on Minimum
Standard of Services at Districts/Cities (SPM) Standar
Pelayanan Minimal Bidang Kesehatan Di Kabupaten
Kota
•
•
•
•
Standard Health Screening at age 15-59 years (once/year)
Standard Health Screening at age 60 years above (once/year)
Access to Standardize case management for Hypertension
Access to Standardize case management for Diabetes Mellitus
Family Health Approach
Primary care
Community NCD CBIs, Health Posts,
School Health, etc
family
family
family
family
family
3. First promotive preventive Approach
Keeping Healthy people healthy
Strengthening Early Detection of Risk Factor
Through NCD CBI (Posbindu PTM)
POSBINDU PTM
NCD CBI- Noncommunicable Disease Community Based Intervention
BACKGROUND
• Prevalence of Common Risk Factors (Smoking, AlcoHol Consumption,
physical inactivity, unhealthy diet) for NCDs are increasing and alarming
without any intervention people with common risk factors will turn to either
DM, Hypertension, Cardiovascular Disease, COPD and Cancer
• 2/3 cases of NCD (in particular DM and Hypertension) are still undiagnosed
increase comorbidity and complications at point of services
• The increasing trend of major NCDs (DM, CVD, COPD, Cancer) if not tackled
immediate will have the implication on the quality of human resource,
increasing health cost/expenditure and creating economic burden to the
nation
• NCD cases are chronical diseases and creating lots of comorbidity and
complication, disablity, and premature mortality promotive preventive
efforts should become primary pilars in the fight against NCD
Goal Of NCD CBI
1.To reach the healthy people at the community age 15-59 years and 60 above
to do routine standard health screening at least once a year and increase
access to promotive preventive intervention at community level (Posbindu
PTM) with the ultimate goal to keep healthy people healthy.
2.To reach the people who identify themselves as healthy but already having
NCD high risk factors to be earliest detected and admit in intevention package
for behavior risk modification at individual, group or community movement.
3.To reach out undiagnosed NCD cases in the community and detecting at the
earliest stage of NCD (pre-Diabetes or Hypertension)
4.To enforce the people who are detected as having earliest form of NCD to be
referred at Primary Health care to receive standardize treatment
5.To motivate community to get enrolled under JKN
Posbindu PTM at multiple Setting
15
NCD CBI KIT
TENSIMETER
BODY FAT ANALYZER
HEIGHT MEASUREMENT
WAIST CIRCUMFERENCE
GLUCOMETER
Activities At NCD CBI
Activities
5
Intervention,
counseling,
education
,
nutrition /
physical
activity
therapy
Activities
Activities
4
3
Secondary
Measurement
screening:
of BMI
Blood pressure
Examination,
Blood glucose
measurement
evaluation of
eye and ear
dysfunction
Activities
2
Primary
screening:
interview
Activities
1
Registration
REFERRAL SYSTEM
POSBINDU PTM Primary Health Center
Early Detection of
common risk factors
Criteria for Blood Glucose screening :
IMT>23,age >40, family history on DM,/ other
NCD BB lahir lebih 4kg, Lingkar perut >80(P),
>90(L), having symptom of TB or known as TB
patients
Intervention
behavior/ lifestyle
modification
At individual, group
and community
Refer to PHC
Observe the changes
in 3-6 months
If no change
Source of Funding
•
•
•
•
•
•
Self reliance (from the community)
CSR (Corporate Society Responsibility )
Central and Local government scheme (Dekon dan DAK)
Allocated funding for SPM at District
Village Funding
Other sources
Second promotive preventive Approach
Strengthening Integrated Approach of NCD
(PEN: Package essential for NCD) at PHC
INTEGRATED APPROACH TO NCD (PEN)
PEN WHO
CARTA WHO/ISH
Goal: to increase NCD case detection
and management of major risk factors
(Stop Smoking Counseling, decrease
consumption of alcohol , decrease
Hypertension, Hyperglicaemia,
Obesity, Dislipidemia) at Primary
Health Care Setting (Puskesmas and
other facilities)
Target: 100 % of people >15 are
reached by Posbindu PTM to receive
standardize health screening at least
once a year (SPM Health)
Integrated Case Management od
Hipertension and Diabetes conducted 21
through Risk Factors approach and Risk
prediction of CVD and Stroke using Charta
PROMOTIVE PREVENTIVE EFFORTS UNDER NATIONAL HEALTH INSURANCE
Primary Preventive
screening
Health/ Lower risk
Healthy Life style
(education, nutrition
intervention, physical
activity/excercise))
High Risk but
Un-diagnosed as Chronic
PRIMARY PREVENTION
•
•
HEALTHY LIFE STYLE MOVEMENT
COUNSELLING
Risk factors classication
Risiko Tinggi
Secondariy preventive
screening
Medical grouping
diagnosis classification
Chronical Disease
Diagnosis
SECONDARY AND TERTIARY CASE
MANAGEMENT
(Chronical Disease Management Program
PROLANIS PPDM - PPHT
JKN Card Holder: increaseing benefit 0f Promotive & Preventive packages, Increasing access to quality health services
BPJS : Grouping and prevention of Disease risks & expenditure control strategy
www.ptaskes.com
Paparan Resmi PT Askes (Persero)
Chronical Disease Management
Back
Referral
program
PRB
Participant join and actively engaged in Prolanis health Club
Supported by Professional Organization and Mobile Apps data recording System
PROLANIS Activity
Specialists’ Mentoring
Specialist Doctor have a role as “Supervisor” for several
primary care services (FKTP) at their coverage areas:
1. Case Studies of Chronical Disease
2. Workshop to improve the capacities in reading EKG,
Rontgen resolts etc
3. Evaluation of Patients condition at Primary Care setting
(FKTP)
4. Networking of Back Referral Program
Supported by related professional organizations: PERKENI, PAPDI, PERNEFRI, PERKI, etc
Standardized and Increase competencies of Primary Care Physician
24
Back Referral Program
Permenkes No 59 Tahun 2014
Program Rujuk Balik (PRB) for:
1. Diabetes mellitus
2. Hypertension
3. CVD
4. Ashma
5. Chronic Obstructive Pulmonary Disease (COPD)
6. Epilepsy
7. Mental Health
8. Stroke, and
9. Systemic Lupus Eritematosus (SLE)
10. Other Chronical disease determine by MoH
and Professional organization
“Mandatory” if the condition of patients
already stabile, certified with “Letter for
Back Referral signed by Specialist or
subspecialist
THANK YOU
Social Health Insurance
Dr Lily Sriwahyuni Sulistyowati, MM
1. Current situation
Epidemiological Transition
Causal of Death, 1990-2015
1990
2000
Cedera; 7%
Penyakit Tidak Menular; 37%
Penyakit Menular; 56%
2010
Cedera; 8%
Cedera; 9%
Penyakit Menular; 33%
Penyakit Menular; 43%
2015
Cedera; 13%
Penyakit Menular; 30%
Penyakit Tidak Menular; 49%
Penyakit Tidak Menular; 58%
Penyakit Tidak Menular; 57%
Source : Double Burden of Diseases & WHO NCD Country Profiles (2014)
No
Causal of Death
1 Stroke (I60 - I69)
2 Coronary Heart Disease (I20 – I25)
3 Diabetes mellitus with complication (E10 –
E14)
4 Tuberkulosis (A15 – A16)
5 Hipertension with complication (I11 – I13)
6 CPOD (J40-J47)
7 Hepatitis/liver Diseases (K70 – K76)
8 Injury (V01– V99)
9 Pneumonia (J12 – J18)
10 Diarrhea and GIT infections (A09)
National Health Survey (Riskesdas) 2013
Source Sample Registration Survey (SRS)2014
%
21.1
12.9
6.7
5.7
5.3
4.9
2.7
2.6
2.1
1.9
HiGH COST/expenditure on the treatment of diseases
Total number of impatient CVD is ranked 4th, however the expenditure is the highhest (3.5
Trillion IDR) pembiayaannya menyerap biaya tertinggi (3,5 T)
Top 10 Diseases
Claimed of Impatient Year 2014: NHI , total
GASTRAOINTESTINAL INFECTION
774,276
DELIVERIES/LABOR
644,207
PARACIYE AND INFECTION
448,816
CARDIOVASCULAR DISEASES
448,342
RESPIRATORY DISEASES
401,059
STROKE
WOMEN REPRODUCTIVE
Top 10 Diseases Claimed as Outpatient
Biaya Klaim Penyakit Rawat Inap
Tahun 2014: Rp Milyar
327,132
CARDIOVASCULAIR
DISEASES
GASTRAOINTESTINAL
INFECTION
3,503.4
3,318.8
2,396.7
2,341.5
1,919.4
1,535.5
1,509.2
1,440.9
1,214.7
RESP IRATORY DISEASES
934.7
DELIVERIES/LABOR
RENAL DISORDERS
MUSCULOSCELETAL
THMT
320,777
274,469
265,645
173,936
Source: BPJS Kesehatan, 2014
MUSCULOSCELETAL
STROKE
RENAL DISORDERS
PARACYTE
AND INFECTION
WOMEN REP RODUCTIVE
SKIN DISEASES
4
2. Policy Support
National Health Strategic Plan
2015-2019
Health
Paradigm
Program
All recources are
pooled to
tackled the
priority program
• Health in all Policies
• Promotive-Preventive
as main Pillar of
Health
• Community
empowerment
Strengthening
Health Delivery
System
Program
• Increase access at
Primary care
• Optimalization of
Referral system
• Quality
Improvement
continuum of care
Health risk
assessment
intervention
NHI
Program
• Benefit package
• Insurance Financing
System Gotong
royong
• Quality Assurance
and quality control
• Target: fully
Subsidized & Non
Subsidized
Membership card
Indonesian Health card
Strategic opportunity INCREASE HEALTH BUDGET from 2,5 TO 5%
DIRECTED TO BREAKTHROUGH PRIORITY PROGRAM TO BOOST THE ACHIEVEMENT OF NATIONAL
DEVELOPMENT INDICATORs
INCREASING NATIONAL
HEALTH STATUS
CONDUCIVE
ENVIRONMENT
•
•
•
HEALTH REGULATION
LAW 36/2009
DECENTRALIZATION
LAW 23/2014
GOVERNMENT
REGULATION
109/
HEALTH
MINISTER
REGULATION
DECREASE MMR
AND IMR
DECREASE
DECREASE MORBIDITY
MORBIDITY
AND MORTALITY
AND
MORTALITY FROM
FROM
ATM
ATM (AIDS,
(AIDS, TB,
TB, MALARIA)
MALARIA)
DECREASE
Stunting
DECREASE
DECREASE MORBIDITY
MORBIDITY
AND EARLY
AND
EARLY MORTALITY
MORTALITY
DUE
DUE TO
TO NCDS
NCDS (CVD,
(CVD,
SUPPORTING
EFFORTS
DIABETES,
DIABETES, CPOD,
CPOD, CANCER,
CANCER,
OBESITY)
OBESITY)
INCREASE ACCESS TO QUALIFIED HEALTH
SERVICE DELIVERY (Continuum of Care)
STRENGTHENING PRIMARY, SECONDARY AND
TERTIARY PREVENTION
LIFE CYCLE APPROACH
1.INTEGRATED AND COMPREHENSIVE
HEALTH DELIVERY SYSTEM
2.INTEGRATED DRUG
SYSTEM
MANAGEMENT
3.REACHING OUT THE UNREACH
FAMILY FOLDER APPROACH
4.INTEGRATED PLANNING AND
PROMOTION AND CONTROL OF RISK FACTOR
EVALUATION
5.INCREASE EVIDENCE BASE
INTERVENTION
NCD, CD, MCH Global Targets included as
National Development Targets
in the Medium-term National Development Plan 2015-2019
Strategic policy approach
strategic to embrace other sectors to share their
contributions in achieving the targets
1.
2.
Reduction of Raised Blood Pressure from 25,8% (2013) to 23,4% (2019)
Halt the rise of prevalence of Obesity from age 18+ years (at 15,4%)
3. Relative reduction of current tobacco consumption at age < 18, from 7,2 (2013) to 5,4 (2019)
4.
Prevalence of TB, from 280/100,000 in 2015 to 245/100,000 in 2015
5.
Prevalence of HIV maintain below 0.5%
6.
Decreasing MMR (maternal Mortality Rate)
7.
Decreasing IMR (Infant Mortality Rate)
Policy for promotive preventive measures in ncd
control
• Health Minister Regulation no
71/2015 on NCD Control
• MOH Strategic Plan indicator
•
Percentage of villages that have POSBINDU PTM/ NCD CBI
• Draft of Government Regulation (RPP) on Minimum
Standard of Services at Districts/Cities (SPM) Standar
Pelayanan Minimal Bidang Kesehatan Di Kabupaten
Kota
•
•
•
•
Standard Health Screening at age 15-59 years (once/year)
Standard Health Screening at age 60 years above (once/year)
Access to Standardize case management for Hypertension
Access to Standardize case management for Diabetes Mellitus
Family Health Approach
Primary care
Community NCD CBIs, Health Posts,
School Health, etc
family
family
family
family
family
3. First promotive preventive Approach
Keeping Healthy people healthy
Strengthening Early Detection of Risk Factor
Through NCD CBI (Posbindu PTM)
POSBINDU PTM
NCD CBI- Noncommunicable Disease Community Based Intervention
BACKGROUND
• Prevalence of Common Risk Factors (Smoking, AlcoHol Consumption,
physical inactivity, unhealthy diet) for NCDs are increasing and alarming
without any intervention people with common risk factors will turn to either
DM, Hypertension, Cardiovascular Disease, COPD and Cancer
• 2/3 cases of NCD (in particular DM and Hypertension) are still undiagnosed
increase comorbidity and complications at point of services
• The increasing trend of major NCDs (DM, CVD, COPD, Cancer) if not tackled
immediate will have the implication on the quality of human resource,
increasing health cost/expenditure and creating economic burden to the
nation
• NCD cases are chronical diseases and creating lots of comorbidity and
complication, disablity, and premature mortality promotive preventive
efforts should become primary pilars in the fight against NCD
Goal Of NCD CBI
1.To reach the healthy people at the community age 15-59 years and 60 above
to do routine standard health screening at least once a year and increase
access to promotive preventive intervention at community level (Posbindu
PTM) with the ultimate goal to keep healthy people healthy.
2.To reach the people who identify themselves as healthy but already having
NCD high risk factors to be earliest detected and admit in intevention package
for behavior risk modification at individual, group or community movement.
3.To reach out undiagnosed NCD cases in the community and detecting at the
earliest stage of NCD (pre-Diabetes or Hypertension)
4.To enforce the people who are detected as having earliest form of NCD to be
referred at Primary Health care to receive standardize treatment
5.To motivate community to get enrolled under JKN
Posbindu PTM at multiple Setting
15
NCD CBI KIT
TENSIMETER
BODY FAT ANALYZER
HEIGHT MEASUREMENT
WAIST CIRCUMFERENCE
GLUCOMETER
Activities At NCD CBI
Activities
5
Intervention,
counseling,
education
,
nutrition /
physical
activity
therapy
Activities
Activities
4
3
Secondary
Measurement
screening:
of BMI
Blood pressure
Examination,
Blood glucose
measurement
evaluation of
eye and ear
dysfunction
Activities
2
Primary
screening:
interview
Activities
1
Registration
REFERRAL SYSTEM
POSBINDU PTM Primary Health Center
Early Detection of
common risk factors
Criteria for Blood Glucose screening :
IMT>23,age >40, family history on DM,/ other
NCD BB lahir lebih 4kg, Lingkar perut >80(P),
>90(L), having symptom of TB or known as TB
patients
Intervention
behavior/ lifestyle
modification
At individual, group
and community
Refer to PHC
Observe the changes
in 3-6 months
If no change
Source of Funding
•
•
•
•
•
•
Self reliance (from the community)
CSR (Corporate Society Responsibility )
Central and Local government scheme (Dekon dan DAK)
Allocated funding for SPM at District
Village Funding
Other sources
Second promotive preventive Approach
Strengthening Integrated Approach of NCD
(PEN: Package essential for NCD) at PHC
INTEGRATED APPROACH TO NCD (PEN)
PEN WHO
CARTA WHO/ISH
Goal: to increase NCD case detection
and management of major risk factors
(Stop Smoking Counseling, decrease
consumption of alcohol , decrease
Hypertension, Hyperglicaemia,
Obesity, Dislipidemia) at Primary
Health Care Setting (Puskesmas and
other facilities)
Target: 100 % of people >15 are
reached by Posbindu PTM to receive
standardize health screening at least
once a year (SPM Health)
Integrated Case Management od
Hipertension and Diabetes conducted 21
through Risk Factors approach and Risk
prediction of CVD and Stroke using Charta
PROMOTIVE PREVENTIVE EFFORTS UNDER NATIONAL HEALTH INSURANCE
Primary Preventive
screening
Health/ Lower risk
Healthy Life style
(education, nutrition
intervention, physical
activity/excercise))
High Risk but
Un-diagnosed as Chronic
PRIMARY PREVENTION
•
•
HEALTHY LIFE STYLE MOVEMENT
COUNSELLING
Risk factors classication
Risiko Tinggi
Secondariy preventive
screening
Medical grouping
diagnosis classification
Chronical Disease
Diagnosis
SECONDARY AND TERTIARY CASE
MANAGEMENT
(Chronical Disease Management Program
PROLANIS PPDM - PPHT
JKN Card Holder: increaseing benefit 0f Promotive & Preventive packages, Increasing access to quality health services
BPJS : Grouping and prevention of Disease risks & expenditure control strategy
www.ptaskes.com
Paparan Resmi PT Askes (Persero)
Chronical Disease Management
Back
Referral
program
PRB
Participant join and actively engaged in Prolanis health Club
Supported by Professional Organization and Mobile Apps data recording System
PROLANIS Activity
Specialists’ Mentoring
Specialist Doctor have a role as “Supervisor” for several
primary care services (FKTP) at their coverage areas:
1. Case Studies of Chronical Disease
2. Workshop to improve the capacities in reading EKG,
Rontgen resolts etc
3. Evaluation of Patients condition at Primary Care setting
(FKTP)
4. Networking of Back Referral Program
Supported by related professional organizations: PERKENI, PAPDI, PERNEFRI, PERKI, etc
Standardized and Increase competencies of Primary Care Physician
24
Back Referral Program
Permenkes No 59 Tahun 2014
Program Rujuk Balik (PRB) for:
1. Diabetes mellitus
2. Hypertension
3. CVD
4. Ashma
5. Chronic Obstructive Pulmonary Disease (COPD)
6. Epilepsy
7. Mental Health
8. Stroke, and
9. Systemic Lupus Eritematosus (SLE)
10. Other Chronical disease determine by MoH
and Professional organization
“Mandatory” if the condition of patients
already stabile, certified with “Letter for
Back Referral signed by Specialist or
subspecialist
THANK YOU