Patient-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 interactions 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 I: MS. DAREN IS READY TO DIE

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

Evidence of Patient-Centered Care

The primary care provider in this situation has a challenge to make sure that Ms. Daren is competent to make decisions about her care. The primary care provider should assess Ms. Daren for confusion, depression, or a neurological deficit that could impair judgment, review medication combinations that could affect pain relief or ease of respirations, and verify Ms. 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 Ms. 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 (Association of State and Territorial Health Officials, 2013; Holzemer & Belcher, 2014; Thomas, 2004). A community may need more health-related teaching about issues important to the community. Resources might be needed, for example, to screen for or treat an emerging communicable disease.

SITUATION 2: MR. WHITE CHOOSES TO KEEP INJECTING DRUGS

Mr. White is under the care of a primary care provider to monitor his diabetes and methadone maintenance. He is thought to be an active injection-drug user and is not following diabetic dietary guidelines even though he has access to government food coupons.

Evidence of Patient-Centered Care

The primary care provider facilitates getting Mr. White placed in drug rehabilitation. After many meetings with the interprofessional team, the primary care provider is unsuccessful in helping him participate more fully in his health care; Mr. White rejects drug rehabilitation. The primary care providers make every effort to invite Mr. White back into a more full therapeutic relationship, when he continues to come to the primary care clinic for episodic, sporadic care. The primary care staff members assisted the patient’s closest friends and relatives in coping with Mr. White’s decision to not enter a recovery program. They are referred to social services and psychological counseling to assist them in coping with the patient’s decision.

The relationships of primary care providers and patients on the whole can be examined through community assessment. The results of the community assessment, a picture of the community’s health, can be used to allocate resources to improve the health of the community. The Alliance for Health Model provides one blueprint to help students and primary care providers understand components of community health assessment and care delivery. This model offers a view of health and illness that incorporates the health care needs of the community as well as the process of obtaining sufficient resources to support systems of care delivery.

The Alliance for Health Model identifies the relationship between the provider and the care recipient as critical to successful care delivery. Over time, providers and patients develop relationships that allow for sound, cost-effective decision making when these relationships foster cooperation. Primary care providers may not actually conduct a community assessment, but need to be aware of the data that are collected, and may be of critical importance to them as they plan and develop care strategies. Providers depend on community assessment data provided by state, territorial health departments, the census, and regional assessment projects (National Center for Health Statistics, 2011–2013).

Components of the Alliance for Health Model

The five components of the model represent core areas for assessment:

CARE-MANAGEMENT TECHNIQUES

EXPERTISE OF THE INTERPROFESSIONAL TEAM

The expertise of the interprofessional team depends on the involvement of all disciplines giving care. Although each team member will be somewhere on the continuum between expert and novice, the team as a whole needs to be competent to care for the public’s health. With varied expertise, the team will have the resources to make referrals within and outside the group. Team members need to work together successfully to make a positive difference in the care people receive.

VALIDATION OF SERVICES BY THE PATIENT

Health care services must be available, accessible, affordable, appropriate, adequate, and acceptable (Krout, 1994). Only patients can validate health-related services as being those that they want or need. Certain vulnerable populations, such as prisoners, children, and people with severe disabilities, need to have others act for them to validate services. If it is impossible to validate services with the patient or his or her health care proxy, the provider should offer services that reflect a general standard of care. Standards are generated by professionals who are charged with defining safe and prudent care. The standard of care must reflect regional or national research-based best practices.

THE RELATIONSHIP BETWEEN THE ALLIANCE FOR HEALTH MODEL AND EVIDENCE-BASED CARE

The Alliance for Health Model is closely related to the essential components of evidence-based care in three ways. First, the core of community-based needs—systems of care management—influences resource allocation decisions and should be grounded in the appropriate qualitative or quantitative research findings. For example, research information on the spread of methicillin-resistant Staphylococcus aureus (MRSA), or the prevalence of multiple chronic conditions directly informs the core of safe and effective care (Agency for Healthcare Research and Quality, 2013; Ward & Schiller, 2013).

In addition to research, to inform the core of safe and effective care, the Alliance for Health Model requires that the expertise of the interprofessional team and validation of services by the client are the two variables that place the health care event in proper context (Holzemer, 2014). It takes time for the elements of problem assessment, expertise of the provider, and needs of the client to come together. The movement of the “relationship” in patient-centered care to a mature exchange allows the provider and the patient to improve their efforts to move toward, and maintain, the highest level of health. The gold standard of research is complemented by the delivery of patient-centered care.

COMPARISON OF TWO COMMUNITIES