Primary Care in the Community: Assessment and Use of Resources

Stephen Paul Holzemer PhD, RN

Joanne K. Singleton PhD, RN, FNP-C

Carol Green-Hernandez PhD, RN, FNP/ANP-C

One key aspect of integrated systems in primary care is the use of community assessment to guide the strategic use of resources. Participation in proactive primary care requires that providers know the actual and potential health-related problems in the community and know how to secure the resources to ameliorate them. Chapter 1 provided a context for examining the uncertainty of how systems of care will adapt to changes in the contemporary health care marketplace. This chapter promotes the importance of studying the community and its resources to meet the needs of people in changing care delivery systems.

Primary care providers from all disciplines are challenged to work together with their patients to create comprehensive primary care networks. Accurate and complete community assessment ensures that the picture of available health care resources is clear to both patients and providers. Evidence of a caring relationship between providers and patients can promote the public’s confidence that resource allocation decisions have the potential to promote the primary care needs of patients, families, and communities (Donaldson et al, 1996).

The meaning of relationship-centered care for the community as a whole will be reviewed, and examples of aggregate-level interventions will be identified and discussed. The Alliance for Health model (Holzemer & Arnold, 1997) will be introduced as one model that could be helpful for providers to use when participating in community assessment, a critical process in obtaining appropriate resources for relationship-centered primary care delivery.

RELATIONSHIP-CENTERED CARE IN THE COMMUNITY

Primary care providers and patients are responsible for creating acceptable plans of primary care. These plans are a reflection of professional caring, which frames relationship-centered care. Relationship-centered care respects and promotes the work of both the patient and the provider to improve health (Green-Hernandez, 1997). These relationships are displayed at the community level in the form of aggregate data, or health indicators on a population level.

Aggregate health indicators include variables such as morbidity, mortality, clean air standards, statistics on civil disobedience and unrest, family and community violence rates, and patterns of providing primary care to groups of people who cannot pay for care. Each community will have similar and different health indicators that reflect an aggregate level of wellness. Healthy communities are those where people, families, groups, and larger aggregates can work in harmony to create the primary care systems (with providers) that meet the needs of the public (Krout, 1994; National Association of County Health Officials, 1994; Pender, 1996; Tresolini & the Pew-Fetzer Task Force, 1994).

Primary care occurs within the relationship that develops between a health care provider or health care team and a patient, family, group, or community (the care recipient). The outcomes of these relationships are intended to heal or move the patient (and the community as a whole) toward improved health. The definition of healing or health differs according to patients’ cultural or ethnic and spiritual beliefs as well as their experience in getting their health care needs met. The overall success that people, families, and groups have in meeting their health needs as a whole provides a picture of the health of a community.

Relationship-centered care respects the needs of patients and is within the legal and ethical mores of society. Providers use standards of care if the patient cannot make his or her ethical and legal wishes for care known. The following two situations examine the relationships between patients and providers. The relationships are examples of interaction on a one-to-one level. To reiterate, the overall sum of relationships between providers and patients is one way to illustrate a community’s health. Community assessment, discussed later in this chapter, is a strategy to monitor the health of the relationships between the aggregate of patients and care providers.

In situation 1, the primary care provider is working with a patient who does not want to continue conventional treatment for her illness. The interaction between this provider and the patient can have an impact on the community. Allowing patients as a group to control decision making about care could be the first step in, for instance, negotiating hospice services for a growing elderly population, creating legislation to expand home care benefits for patients at the end of life, and changing the curricula in primary care programs to emphasize patient self-determination.

In situation 2, the patient continues to inject drugs and does not follow the health care goals set by him and the provider. The patient participates only sporadically in health care services, failing to establish a sound relationship with the provider because of his addictive behavior. Primary care providers are responsible for maintaining some level of a relationship even when the patient is not participating in his or her care. A population-focused intervention that could develop from a situation
where provider–patient relationships are not working could include implementing a street-based mobile health care service, increasing the cadre of drug addiction counselors to provide more support to the drug-addicted population, and developing a system of recreation activities to discourage drug use in neighborhoods where prevalence is high.

SITUATION 1: MRS. DAREN IS READY TO DIE

Mae Daren is a 65-year-old widow who is ready to die. Her primary care provider is optimistic that Mrs. Daren will want to enjoy life more once her chronic obstructive pulmonary disease is better controlled by medication. Mrs. Daren refuses to enter the hospital and wishes to be maintained at home on low-dose oxygen therapy alone. Mrs. Daren has a living will that reflects her wishes.

Evidence of Relationship-Centered Care

The primary care provider in this situation has a challenge to make sure that Mrs. Daren is competent to make decisions about her care. The primary care provider should assess Mrs. Daren for confusion, depression, or a neurologic deficit that could impair judgment, review medication combinations that could affect pain relief or ease of respirations, and verify Mrs. Daren’s decision with family members to elicit their support. The primary care provider then sets up home care services that will support the decision of Mrs. Daren to stay at home and makes a referral for hospice services as needed.

These situations reflect the dynamic relationships between patients and their care providers. Patient–provider relationships extend to the community as a whole as primary care providers implement population-focused activities to improve the health of the public. Primary care providers should participate in creating a plan, in partnership with the public, that outlines how to allocate resources that will maintain the health of the community (Centers for Disease Control and Prevention & National Association of County Health Officials, 1994; Committee for the Study of the Future of Public Health, Institute of Medicine, 1988). A community may need more health-related teaching about issues important to the community. Resources might be needed to screen for or treat an emerging communicable disease.