Health care delivery in the United States reflects a history of change in response to science, technology, and the cost of health care. Helping people meet their health needs is the central mission of all health disciplines. How this is accomplished, however, continues to change with the times. Lacking a scientific basis, health care before the 20th century was able to offer little more than caring and attention to personal health in the home setting.

The scientific basis for health care became more formalized after 1900 with the inclusion of sciences in the medical and nursing curricula. Health was defined as the presence or absence of disease, and the development of technology was directed at treating and curing diseases. This necessitated the movement of the delivery of care into the hospital setting, where patients were seen as passive recipients of specialized, technologic care that focused on their physical and biologic needs.

In the early years of the 20th century, great advances were made in the control of infectious diseases. As a result, specialization and technology became more highly regarded than caring and personal care. Although it was recognized that with these changes something had been lost (Flexner, 1930), health care continued to proceed in that direction. Highly specialized care dominated, yet it lacked oversight of the appropriate use of services, the need for services, or the cost of those services.

This view persisted until it was acknowledged in the past decade that the health care needs of the United States, access to services, and the ability to pay for them in the current fee-for-service system of reimbursement had changed. Health care needs of Americans were changed by the profound advances made in the control of infectious diseases and the use of technology. This resulted in people living longer, and with this came the advent of chronic diseases.

In the fee-for-service system, economic incentive was based on the use of services. Ultimately, this led to inappropriate use and over-use of services, resulting in health care costs that are approaching one trillion dollars each year in the United States. Despite this enormous expenditure, almost 40 million Americans are without health insurance. Access to health care, in the absence of universal health care coverage, remains an issue of national concern. The cost of health care, access to health care, types of services, and delivery of those services have become common topics of conversation both inside and outside the health care arena. Each proposed solution poses different challenges.

Today’s view of health must acknowledge the juxtaposition of multiple factors that may influence and predispose a person to illness(es). These factors include the complex interdependent biologic, psychological, social, and spiritual needs of the person. The integrated needs of the individual places the person within the context of their family and community. It also recognizes that health is not simply the presence or absence of disease, it is an ongoing process that can be fostered through activities directed at health promotion and disease prevention. Health as a dynamic state of being is active, and as such, for individuals to actualize their health potential, they must engage in the process of health. This necessitates a change in perspective from the individual as a passive recipient of care to the individual as an active participant in their own health.

To meet these needs, health care delivery in the United States is shifting to primary care, in which providers address a wide range of health care needs and facilitate health care delivery.

Primary care in this book is recognized as the provision of integrated, accessible health care services by providers who are accountable for addressing a large majority of personal health care needs. These providers develop sustained partnerships with patients and practice within the context of family and community (Donaldson et al, 1996). This concept of primary care allows patients and providers to enter relationships where patients, families, and communities have the opportunity to become full participants in health care decision making.

In today’s health care environment, economic considerations loom. Capitation of services through managed care is one current response to cost containment. Capitated reimbursement means that there are fixed prepaid fees for each enrollee. That fee must cover the entire range of services the enrollee is entitled to through the plan. If enrollees use more services than covered by the plan, providers are at risk for absorbing those costs. The objective is for providers to have the incentive to keep their enrollees healthy. More than 50 million Americans are insured through managed care plans, and this number is expected to increase to 100 million by the year 2000 (Bodenheimer, 1996).

It is unclear how systems of care will adapt, and how providers will be able to deliver effective, comprehensive care in capitated managed care or other fiscally restructured environments. One key issue is whether financial incentives can safely guide clinical decision making.

Professional standards may be challenged through the managed care approach. Despite these changes, providers must rigorously adhere to practice standards and maintain the integrity of their clinical relationships. The patient must remain the focus of care, regardless of whatever changes are occurring in health care. Providers need to work together to develop creative strategies to sustain and nurture relationship-centered care.

Foundational to the therapeutic nature of patient–provider interactions is the relationship that develops between patient
and provider. This relationship is believed to be central to improved patient outcomes and patient–provider satisfaction (Tresolini, 1994). Relationship-centered care redefines the therapeutic value of patient–provider interactions, recognizing the importance of the health care relationships formed by providers with families and communities. Primary care providers can use this time of change in the delivery of health care as an opportunity to work with each other and their patients to create comprehensive, interdisciplinary, relationship-centered primary care networks that improve outcomes and satisfaction for both patients and providers.

This chapter identifies concepts essential for achieving relationship-centered primary care. The idea of caring and trust as the foundation of primary care is explored. Building upon this, a framework for providers to facilitate comprehensive assessment and management is presented. This foundation and framework creates a structure for providers and patients to work together as architects in the redesign of health care.