The PEN-Plus model
PEN-Plus is a package of clinical services that enables front-line providers in low-income health systems to provide care for people living with severe NCDs. These people often require complex and precise ongoing management, historically only provided at national referral hospitals. The PEN-Plus model aims to address the burden of severe NCDs among rural and unreached populations through decentralized, integrated outpatient services in first-level referral health facilities (see Box 1). It strengthens the implementation of WHO PEN by bridging the gap in access to care for severe NCDs. The guiding principles include a whole-of-government approach, multisectoral collaboration, universal health coverage and partnerships.
PEN-Plus trains and equips nurses and clinical officers to deliver essential medical services – including diagnosis, symptom management and psychosocial support – across a range of severe NCDs. For now, the model focuses primarily on four sentinel PEN-Plus conditions; type 1 diabetes, sickle-cell disease, and rheumatic and congenital heart disease. The long-term goal, however, is to strengthen health care systems to provide quality care for all severe NCDs.
The model bridges major gaps in training, mentorship and referral pathways for NCD services. PEN-Plus nurses and clinical officers with advanced NCD training provide training, supervision and mentorship to staff who deliver WHO PEN services at health centres. WHO PEN training and mentorship enable health centre staff both to improve the quality of care for more common, less severe NCDs and to recognize and refer patients with severe NCDs to a first-level referral facility. In turn, PEN-Plus providers receive training and mentorship from specialists at referral hospitals, refer patients for specialized services when necessary, and provide essential chronic care services following acute specialized interventions, including surgery.
Box 1. How PEN-Plus works
The first level of care
The primary or community health centre (or clinic) is where WHO PEN is active. It provides outpatient primary care for common noncommunicable diseases that front-line clinicians can manage, often in tandem with other conditions, such as HIV and tuberculosis.
The second level
The first referral or district hospital, offers more advanced care and provides administrative oversight to primary health centres. Strengthening capacity for management of severe NCDs at this level of health service delivery is important for reducing premature mortality from NCDs. It is at this level that the PEN-Plus model is focused. As part of PEN-Plus, nurses and doctors provide care for patients with severe, chronic NCDs that cannot be managed at the primary care level. Each of these hospitals is also responsible for the training and supervision of multiple health centres in their district in a satellite, hub-and-spoke fashion.
The third level
Generally the national referral hospital, provides PEN-Plus clinicians with training and mentorship. In turn, PEN-Plus clinicians send patients to the national referral hospital for surgery when needed and provide essential chronic care services following acute specialized interventions, such as surgery.
