Primary, Secondary, and Tertiary Care
One concept is essential in understanding the topography of any health care system: the organization of care into primary, secondary, and tertiary levels. In the Lord Dawson Report, an influential British study written in 1920, the author (1975) proposed that each of the three levels of care should correspond with certain unique patient needs.
Primary care involves common health problems (e.g., sore throats, diabetes, arthritis, depression, or hypertension) and preventive measures (e.g., vaccinations or mammograms) that account for 80% to 90% of visits to a physician or other caregiver.
Secondary care involves problems that require more specialized clinical expertise such as hospital care for a patient with acute renal failure.
Tertiary care, which lies at the apex of the organizational pyramid, involves the management of rare disorders such as pituitary tumors and congenital malformations.
Two contrasting approaches can be used to organize a health care system around these levels of care: (1) the carefully structured Dawson model of regionalized health care and (2) a more free-flowing model.
One approach uses the Dawson model as a scaffold for a highly structured system. This model is based on the concept of regionalization: the organization and coordination of all health resources and services within a defined area (Bodenheimer, 1969). In a regionalized system, different types of personnel and facilities are assigned to distinct tiers in the primary, secondary, and tertiary levels, and the flow of patients across levels occurs in an orderly, regulated fashion. This model emphasizes the primary care base and a population-oriented framework for health planning.
An alternative model allows for more fluid roles for caregivers, and more free-flowing movement of patients, across all levels of care. This model tends to place a higher value on services at the tertiary care apex than at the primary care base.
Although most health care systems embody elements of both models, some gravitate closer to one polarity or the other. The traditional British National Health Service (NHS) and some large integrated delivery systems in the United States resemble the regionalized approach, while US health care as a whole traditionally followed the more dispersed format.
The Regionalized Model: The Traditional British National Health Service
Basil, a 60-year-old man living in a London suburb, is registered with Dr. Prime, a general practitioner in his neighborhood. Basil goes to Dr. Prime for most of his health problems, including hay fever, back spasms, and hypertension. One day, he experiences numbness and weakness in his face and arm. By the time Dr. Prime examines him later that day, the symptoms have resolved. Suspecting that Basil has had a transient ischemic attack, Dr. Prime prescribes aspirin and refers him to the neurologist at the local hospital, where a carotid artery sonogram reveals high-grade carotid stenosis. Dr. Prime and the neurologist agree that Basil should make an appointment at a London teaching hospital with a vascular surgeon specializing in head and neck surgery. The surgeon recommends that Basil undergo carotid endarterectomy on an elective basis to prevent a major stroke. Basil returns to Dr. Prime to discuss this recommendation and inquires whether the operation could be performed at a local hospital closer to home. Dr. Prime informs him that only a handful of London hospitals are equipped to perform this type of specialized operation. Basil schedules his operation in London and several months later has an uncomplicated carotid endarterectomy. Following the operation, he returns to Dr. Prime for his ongoing care.
The British NHS has traditionally typified a relatively regimented primary—secondary—tertiary care structure (Fig. 5-1).
Organization of services under the traditional National Health Service model in the United Kingdom. Care is organized into distinct levels corresponding to specific functions, roles, administrative units, and population bases.
For physician services, the primary care level is virtually the exclusive domain of general practitioners (commonly referred to as GPs), who practice in small- to medium-sized groups and whose main responsibility is ambulatory care. About half of all physicians in the United Kingdom are GPs.
The secondary tier of care is occupied by physicians in such specialties as internal medicine, pediatrics, neurology, psychiatry, obstetrics and gynecology, and general surgery. These physicians are located at hospital-based clinics and serve as consultants for outpatient referrals from GPs, in turn routing most patients back to GPs for ongoing care needs. Secondary-level physicians also provide care to hospitalized patients.
Tertiary care subspecialists such as cardiac surgeons, immunologists, and pediatric hematologists are located at a few tertiary care medical centers.
Hospital planning followed the same regionalized logic as physician services. District hospitals were local facilities equipped for basic inpatient services. Regional tertiary care medical centers handled highly specialized inpatient care needs.
Planning of physician and hospital resources within the traditional NHS occurred with a population focus. GP groups provided care to a base population of 5,000 to 50,000 persons, depending on the number of GPs in the practice. District hospitals had a catchment area population of 50,000 to 500,000, while tertiary care hospitals served as referral centers for a population of 500,000 to 5 million (Fry, 1980).
While this regionalized structure has recently become more fluid (Chapter 14), patient flow still moves in a stepwise fashion across the different tiers. Except in emergency situations, all patients are first seen by a GP, who may then steer patients toward more specialized levels of care through a formal process of referral. Patients may not directly refer themselves to a specialist.
While nonphysician health professionals, such as nurses, play an integral role in staffing hospitals at the secondary and tertiary care levels, especially noteworthy is the NHS’ multidisciplinary approach to primary care. GPs work in close collaboration with practice nurses (similar to nurse practitioners in the United States), home health visitors, public health nurses, and midwives (who attend most deliveries in the United Kingdom). Such teamwork, along with accountability for a defined population of enrolled patients and universal health care coverage, helps to avert such problems as missed childhood vaccinations. Public health nurses visit all homes in the first weeks after a birth to provide education and assist with scheduling of initial GP appointments. A national vaccination tracking system notifies parents about each scheduled vaccination and alerts GPs and public health nurses if a child has not appeared at the appointed time. As a result, more than 85% of British preschool children receive a full series of immunizations.
A number of other nations, ranging from industrialized countries in Scandinavia to developing nations in Latin America, have adopted a similar approach to organizing health services. In low-income nations, the primary care tier relies more on community health educators and other types of public health personnel than on physicians.
The Dispersed Model: Traditional United States Health Care Organization
Polly Seymour, a 55-year-old woman with private health insurance who lives in the United States, sees several different physicians for a variety of problems: a dermatologist for eczema, a gastroenterologist for recurrent heartburn, and an orthopedist for tendinitis in her shoulder. She may ask her gastroenterologist to treat a few general medical problems, such as borderline diabetes. On occasion, she has gone to the nearby hospital emergency department for treatment of urinary tract infections. One day, Polly feels a lump in her breast and consults a gynecologist. She is referred to a surgeon for biopsy, which indicates cancer. After discussing treatment options with Polly, the surgeon performs a lumpectomy and refers her to an oncologist and radiation therapy specialist for further therapy. She receives all these treatments at a local hospital, a short distance from her home.
The US health care system has had a far less structured approach to levels of care than the British NHS. In contrast to the stepwise flow of patient referrals in the United Kingdom, insured patients in the United States, such as Polly Seymour, have traditionally been able to refer themselves and enter the system directly at any level. While many patients in the United Kingdom have a primary care physician (PCP) to initially evaluate all their problems, many people in the United States have become accustomed to taking their symptoms directly to the specialist of their choice.
One unique aspect of the US approach to primary care has been to broaden the role of internists and pediatricians. While general internists and general pediatricians in the United Kingdom and most European nations serve principally as referral physicians in the secondary tier, their US counterparts share in providing primary care. Moreover, the overlapping roles among “generalists” in the United States (family physicians, general internists, and general pediatricians) are not limited to the outpatient sector. PCPs in the United States have assumed a number of secondary care functions by providing substantial amounts of inpatient care. Only recently has the United States moved toward the European model that removes inpatient care from the domain of PCPs and assigns this work to “hospitalists”—physicians who exclusively practice within the hospital (Wachter & Goldman, 1996; Goroll & Hunt, 2015).
Including general internists and general pediatricians, the total supply of generalists amounts to approximately one-third of all physicians in the United States, a number well below the 50% or more found in the UK (Agency for Healthcare Research and Quality, 2014). To fill in the primary care gap, some physicians at the secondary and tertiary care levels in the United States have also acted as PCPs for some of their patients. In contrast to physicians, nurse practitioners, and physician assistants are more likely to work in primary care settings and are a key component of the nation’s clinical workforce.
US hospitals are not constrained by rigid secondary and tertiary care boundaries. Instead of a pyramidal system featuring a large number of general community hospitals at the base and a limited number of tertiary care referral centers at the apex, hospitals in the United States each aspire to offer the latest in specialized care. In most urban areas, for example, several hospitals compete with each other to perform open heart surgery, organ transplants, radiation therapy, and high-risk obstetric procedures. The resulting structure resembles a diamond more than a pyramid, with a small number of hospitals (mostly rural) that lack specialized units at the base, a small number of elite university medical centers providing highly super-specialized referral services at the apex, and the bulk of hospitals providing a wide range of secondary and tertiary services in the middle.
Critics of the US health care system find fault with its “top-heavy” specialist and tertiary care orientation and lack of organizational coherence. Analyses of health care in the United States over the past half century abound with such descriptions as “a nonsystem with millions of independent, uncoordinated, separately motivated moving parts,” “fragmentation, chaos, and disarray,” and “uncontrolled growth and pluralism verging on anarchy” (Somers, 1972; Halvorson & Isham, 2003). The high cost of health care has been attributed in part to this organizational disarray. Quality of care may also suffer. For example, when many hospitals each perform small numbers of surgical procedures such as coronary artery bypass grafts, mortality rates are higher than when such procedures are regionalized in a few higher-volume centers (Gonzalez et al., 2014).
Defenders of the dispersed model reply that pluralism is a virtue, promoting flexibility and convenience in the availability of facilities and personnel. In this view, the emphasis on specialization and technology is compatible with values and expectations in the United States, with patients placing a high premium on direct access to specialists and tertiary care services, and on autonomy in selecting caregivers of their choice for a particular health care need. Similarly, the desire for the latest in hospital technology available at a convenient distance from home competes with plans to regionalize tertiary care services at a limited number of hospitals.
Balancing the Different Levels of Care
Dr. Billie Ruben completed her residency training in internal medicine at a major university medical center. Like most of her fellow residents, she went on to pursue subspecialty training, in her case gastroenterology. Dr. Ruben chose this career after caring for a young woman who developed irreversible liver failure following toxic shock syndrome. After a nerve-racking, touch-and-go effort to secure a donor liver, transplantation was performed and the patient made a complete recovery.
Upon completion of her training, Dr. Ruben joined a growing subspecialty practice at Atlantic Heights Hospital, a successful private hospital in the city. Even though the metropolitan area of 2 million people already has two liver transplant units, Atlantic Heights has just opened a third such unit, feeling that its reputation for excellence depends on delivering tertiary care services at the cutting edge of biomedical innovation. In her first 6 months at the hospital, Dr. Ruben participates in the care of only two patients requiring liver transplantation. Most of her patients seek care for chronic, often ill-defined abdominal pain and digestive problems. As Dr. Ruben begins seeing these patients on a regular basis, she starts to give preventive care and treat nongastrointestinal problems such as hypertension and diabetes. At times she wishes she had experienced more general medicine during her training.
Advocates of a stronger role for primary care in the United States believe that it is too important to be considered an afterthought in health planning. In this view, overemphasis on the tertiary care apex of the pyramid creates a system in which health care resources are not well matched to the prevalence and incidence of health problems in a community. In an article entitled “The Ecology of Medical Care” published more than 4 decades ago, Kerr White recorded the monthly prevalence of illness for a general population of 1,000 adults (White et al., 1961). In this group, 750 experienced one or more illnesses or injuries during the month. Of these patients, 250 visited a physician at least once during the month, nine were admitted to a hospital, and only one was referred to a university medical center. Dr. White voiced concern that the training of health care professionals at tertiary care–oriented academic medical centers gave trainees like Dr. Billie Ruben an unrepresentative view of the health care needs of the community.
Serious questions can be raised about the nature of the average medical student’s experience, and perhaps that of some of this student’s clinical teachers, with the substantive problems of health and disease in the community. In general, this experience must be both limited and unusually biased if, in a month, only 0.0013 of the “sick” adults. . or 0.004 of the patients. . in a community are referred to university medical centers. . Medical, nursing, and other students of the health professions cannot fail to receive unrealistic impressions of medicine’s task in contemporary Western society. . (White et al., 1961)
Updating Kerr White’s findings, Larry Green found precisely the same patterns 4 decades later (Fig. 5-2) (Green et al., 2001).
Monthly prevalence of illness in the community and the roles of various sources of health care. Each box represents a subgroup of the largest box, which comprises 1,000 persons. Data are for persons of all ages. (Source: Green LA et al. The ecology of medical care revisited. N Engl J Med. 2001;344:2021.)
The ecological framework uses a population-based approach: For a defined population in the community, what is the incidence and prevalence of disease and health care needs and patterns of care seeking? This framework confirms the adage that “common disorders commonly occur and rare ones rarely happen (Fry, 1980).” The dominant pathology in an unselected population consists of minor ailments, chronic conditions such as hypertension and arthritis, and an array of behavioral conditions ranging from children with attention deficit and hyperactivity disorder to adults with depression and addictions to elders with cognitive decline. The incidence of new cancers is relatively rare, and only a handful of patients manifest complex syndromes such as multiple sclerosis. This is very different from the pattern of disease viewed from the reference point of an emergency department or intensive care unit, where distinct subsets of patients are encountered.
The ecological framework does not imply that most health care resources should be devoted to primary care. The minority of patients with severe conditions requiring secondary or tertiary care will command a much larger share of health care resources per capita than the majority of people with less dramatic health care needs. Treating a patient with liver failure costs a great deal more than treating a patient for hypertension. Even in the United Kingdom, where the 50% of physicians who are GPs provide the majority of ambulatory care, expenditures on their services account for about 10% of the overall NHS budget. In the United States, the percentage of the budget spent on primary care is even lower. Thus, the pyramidal shape shown in Figure 5-1 better represents the distribution of health care problems in a community than the apportionment of health care expenditures. While almost all industrialized nations devote a dominant share of health care resources to secondary and tertiary care, the ecologic view reminds us that most people have health care needs at the primary care level.
The Functions and Value of Primary Care
Dr. O. Titus Wells has cared for all six of Bruce and Wendy Smith’s children. As a family physician whose practice includes obstetrics, Dr. Wells attended the births of all but one of the children. The Smiths’ 18-month-old daughter Ginny has had many ear infections. Even though this is a common problem, Dr. Wells finds that it presents a real medical challenge. Sometimes examination of Ginny’s ears indicates a raging infection and at other times shows the presence of middle ear fluid, which may or may not represent a bona fide bacterial infection. He tries to reserve antibiotics for clear-cut cases of bacterial otitis. He feels it is important that he be the one to examine Ginny’s ears because her eardrums never look entirely normal and he knows what degree of change is suspicious for a genuinely new infection.
When Ginny is 2 years old, Dr. Wells recommends to the Smiths that she see an otolaryngologist and audiologist to check for hearing loss and language impairment. The audiograms show modest diminution of hearing in one ear. The otolaryngologist informs the Smiths that ear tubes are an option. At Ginny’s return visit with Dr. Wells, he discusses the pros and cons of tube placement with the Smiths. He also uses the visit as an opportunity to encourage Mrs. Smith to quit smoking, mentioning that research has shown that exposure to tobacco smoke may predispose children to ear infections.
Barbara Starfield, the foremost scholar in the field of primary care, conceptualized the key tasks of primary care as (1) first contact care, (2) longitudinality, (3) comprehensiveness, and (4) coordination. Dr. Wells’ care of the Smith family illustrates these essential features of primary care. He is the first-contact physician performing the initial evaluation when Ginny or other family members develop symptoms of illness. Longitudinality (or continuity) refers to sustaining a patient–caregiver relationship over time. Dr. Wells’ familiarity with Ginny’s condition helps him to better discern an acute infection. Comprehensiveness consists of the ability to manage a wide range of health care needs, in contrast with specialty care, which focuses on a particular organ system or procedural service. Dr. Wells’ comprehensive, family-oriented care makes him aware that Mrs. Smith’s smoking cessation program is an important part of his treatment plan for Ginny. Coordination builds upon longitudinality. Through referral and follow-up, the primary care provider integrates services delivered by other caregivers. These tasks performed by Dr. Wells meet the standard definition of primary care: “Primary care is the provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing sustained partnerships with patients, and practicing in the context of family and community” (Institute of Medicine, 1996).
A functional approach helps characterize which health care professionals truly fill the primary care niche. Among physicians in the United States, family physicians, general internists, and general pediatricians typically provide first contact, longitudinal, comprehensive, coordinated care. Emergency medicine physicians provide first contact care that may be relatively comprehensive for acute problems, but they do not provide continuity of care or coordinate care for patients on an ongoing basis. Some obstetrician-gynecologists provide first contact and longitudinal care, but usually only for reproductive health conditions; it is the rare obstetrician-gynecologist who is trained and inclined to comprehensively care for the majority of a woman’s health needs throughout the lifespan. Similarly, a patient with kidney failure or a patient with cancer may have a strong continuity of care relationship with a nephrologist or an oncologist, but these medical subspecialists rarely assume responsibility for comprehensive care of clinical problems outside of their specialty area or coordinate most ancillary and referral services.
In addition to physicians, many generalist nurse practitioners and physician assistants in the United States deliver the four key Starfield functions and serve as primary care providers for their patients. Research performed in a selected number of practices have demonstrated comparable quality of care for patients treated by primary care physicians and nurse practitioners (Cassidy, 2012; Horrocks et al., 2002).
Studies have found that the core elements of good primary care advance the “triple aim” of health system improvement: better patient experiences, better patient outcomes, and lower costs (Starfield, 1998; Bodenheimer & Grumbach, 2007). For example, continuity of care is associated with greater patient satisfaction, higher use of preventive services, reductions in hospitalizations, and lower costs (Saultz & Albedaiwi, 2004; Saultz & Lochner, 2005). Care that is comprehensive, provided by family physicians, is associated with a 10% to 15% reduction in Medicare expenditures per beneficiary (Grumbach, 2015). Persons whose care meets a primary care–oriented model have better perceived access to care, are more likely to receive recommended preventive services, are more likely to adhere to treatment, and are more satisfied with their care (Bindman et al., 1996; Stewart et al., 1997; Safran et al., 1998). International comparisons have indicated that nations with a greater primary care orientation tend to have more satisfied patients and better performance on health indicators such as infant mortality, life expectancy, and total health expenditures (Starfield et al., 2005). Similar observations have been made comparing regions in the United States (Starfield et al., 2005). In an analysis of quality and cost of care across states for Medicare beneficiaries, Baicker & Chandra (2004) found that states with more PCPs per capita had lower per capita Medicare costs and higher quality. States with more specialists per capita had lower quality and higher per capita Medicare expenditures.
Care Coordination and “Gatekeeping”
Polly Seymour, described earlier in the chapter, feels terrible. Every time she eats, she feels nauseated and vomits frequently. She has lost 8 lb, and her oncologist is worried that her breast cancer has spread. She undergoes blood tests, an abdominal CT scan, and a bone scan, all of which are normal. She returns to her gastroenterologist, who tells her to stop the ibuprofen she has been taking for tendinitis. Her problem persists, and the gastroenterologist performs an endoscopy, which shows mild gastric irritation. A month has passed, $3,000 has been spent, and Polly continues to vomit.
Polly’s friend Martha recommends a nurse practitioner who has been caring for Martha for many years and who, in Martha’s view, seems to spend more time talking with patients than do many physicians. Polly makes an appointment with the nurse practitioner, Sara Steward. Ms. Steward takes a complete history, which reveals that Polly is taking tamoxifen for her breast cancer and that she began to take aspirin after stopping the ibuprofen. Ms. Steward explains that either of these medications can cause vomiting and suggests that they be stopped for a week. Polly returns in a week, her nausea and vomiting resolved. Ms. Steward then consults with Polly’s oncologist, and together they decide to restart the tamoxifen but not the aspirin. Polly becomes nauseated again, but eventually begins to feel well and gains weight while taking a reduced dose of tamoxifen. In the future, Ms. Steward handles Polly’s medical problems, referring her to specialty physicians when needed, and making sure that the advice of one consultant does not interfere with the therapy of another specialist.
A concept that incorporates many of the elements of primary care is that of the primary care provider as gatekeeper. Gatekeeping took on pejorative connotations in the heyday of managed care, when, as described in Chapter 4, some types of financial arrangements with PCPs provided incentives for them to “shut the gate” in order to limit specialist referrals, diagnostic tests, and other services (Grumbach et al., 1998). A more accurate designation of the role of the PCP in helping patients navigate the complexities of the health care system is that of coordinator of care (Bodenheimer et al., 1999). Stories such as Polly’s demonstrate the importance of having a generalist care coordinator who can advocate on behalf of his or her patients and work in partnership with patients to integrate an array of services involving multiple providers to avoid duplication of services, enhance patient safety, and care for the whole person.
The Patient-Centered Medical Home
Dr. Retro is counting the days until he can retire from his solo practice of family medicine. He feels overwhelmed most days. The next available appointment in his office is in 10 weeks, and patients call every day frustrated about lack of access. A health plan just sent him a quality report card indicating that many diabetic patients in his practice have not achieved the targeted levels of control of their blood sugar, blood pressure, and lipids. He is also behind in keeping his patients up to date on their mammograms and colorectal cancer screening. Many days he has trouble finding information in the thick paper medical records about when his patients last received their preventive care services or diabetic tests. He was hoping to recruit a new family medicine residency graduate to take over his practice, but most young physicians in his region are pursuing more highly paid careers in nonprimary care specialties.
Dr. Avantgard has always embraced innovation. When she read a book about new primary care practice models (Bodenheimer & Grumbach, 2007), she proposed to her three physician and two nurse practitioner partners that their primary care practice become a Patient Centered Medical Home. Dr. Avantgard starts by revamping the scheduling system to a “same-day” appointment system, where 50% of appointment slots are left unbooked until the day prior so that patients can call and be guaranteed a same day or next day appointment. Despite her partners’ concerns about being overrun with patient appointments, the new scheduling system results in the same number of patients being seen each day, but with happier patients who are delighted to be able to get prompt access to care. The practice buys an electronic medical record system and uses the EMR to develop registries of all the patients in the practice due for preventive and chronic care services. Dr. Avantgard and her associates train their medical assistants to use the EMR, along with standing orders, to proactively order mammograms and blood lipid tests when due and to administer vaccinations and screen for depression during patient intake at medical visits. Now that many of the routine preventive and chronic care tasks are being capably handled by other staff, Dr. Avantgard and her clinician colleagues have more time during office visits to focus on the problems patients want to talk with them about. With the quality indicators and patient satisfaction scores for the practice rising to the top decile of scores for practitioners in the region, Dr. Avantgard plans to start negotiations with several health plans to add a monthly care coordination payment to the current fee-for-service payments, so that the practice can be compensated for the hours spent on care coordination outside of office visits.
By the turn of the 21st century, primary care in the United States had reached a critical juncture and alarms sounded about an “impending collapse of primary care medicine” (Bodenheimer, 2006; American College of Physicians, 2006). Primary care clinicians like Dr. Retro struggled to meet patient demands for accessible, comprehensive, well-coordinated care. Many gaps in quality existed, and care often fell short of being patient centered. PCPs were demoralized by outmoded practice models ill-equipped to meet the demands of modern-day primary care and an ever-widening gap between their take-home pay and the escalating earnings of specialists. In the face of these challenges, decreasing numbers of US medical school graduates selected careers in primary care and many policy analysts concluded that the nation faced a major shortage of PCPs (Bodenheimer & Pham, 2010; Petterson et al., 2015).
In response to this crisis, the four major professional organizations representing the nation’s primary care physicians—the American Academy of Family Physicians, American College of Physicians, American Academy of Pediatrics, and American Osteopathic Association—came together in 2007 and issued a report on a shared vision for reform of primary care. The Joint Principles of a Patient-Centered Medical Home has served as a rallying point for building a broad movement to revitalize primary care in the United States (Grundy et al., 2010).
The term “medical home” dates back to 1967, when it was first used by the American Academy of Pediatrics to describe the notion of a primary care practice that would coordinate care for children with complex needs. Rittenhouse and Shortell (2009) have provided a straightforward conceptualization of the patient-centered medical home as consisting of four basic cornerstones: primary care, patient-centered care, new-model practice, and payment reform. This framework begins by reaffirming Starfield’s fundamental functions of primary care and builds on those principles by calling for greater attention to patient-centeredness, such as the type of same-day scheduling methods adopted by Dr. Avantgard; implementation of innovative practice models, such as Dr. Avantgard’s development of team-care models that reengineer workflows and tasks; and changes in physician payment, such as blending fee-for-service with partial capitation and quality incentives. Another perspective on the patient-centered medical home is shown in Table 5-1.
Table 5-1“Old” and “new” model primary care: some elements of transforming a practice into a patient-centered medical home ||Download (.pdf) Table 5-1 “Old” and “new” model primary care: some elements of transforming a practice into a patient-centered medical home
|Traditional Model||Patient-Centered Medical Home|
|My patients are those who make appointments to see me ||Our patients are those who are registered in our medical home |
|Care is determined by today’s problem and time available today ||Care is determined by a proactive plan to meet health needs, with or without visits |
|Care varies by scheduled time and memory or skill of the doctor ||Care is standardized according to evidence-based guidelines |
|I know I deliver high-quality care because I’m well trained ||We measure our quality and make rapid changes to improve it |
|Patients are responsible for coordinating their own care ||A prepared team of professionals works with all patients to coordinate care |
|It’s up to the patients to tell us what happened to them ||We track tests and consultations, and follow-up after ED and hospital care |
|Clinic operations center on meeting the doctor’s needs ||An interdisciplinary team works at the top of our licenses to serve patients |
The primary care reform movement in the United States has gathered momentum, with many large employers and consumer groups joining the physician organizations authoring the Joint Principles and other health professional groups to form the Patient Centered Primary Care Collaborative (Grundy et al., 2010). The Affordable Care Act included several measures to support patient-centered medical home reforms. Organizations such as the National Committee on Quality Assurance (NCQA) established programs with a checklist of requirements for grading practices applying to be recognized as patient-centered medical homes. Groups facilitating comprehensive reengineering of primary care practices issued roadmaps to transformation, such as the Building Blocks of High-Performing Primary Care (Bodenheimer et al., 2014) and the Change Concepts of the Safety Net Medical Home Initiative (Wagner et al., 2012). Evaluation of the first wave of practices and systems implementing the types of practice innovations called for under patient-centered medical home reforms have demonstrated some improvements in patient satisfaction and quality of care and reductions in use of costly emergency department and hospital services (Nielsen et al., 2015).