UNIT I: THE CONTEXT OF
INTERPROFESSIONAL PRIMARY CARE

CHAPTER 1 The Structure of Primary Care

Joanne K. Singleton, PhD, RN, FNP-BC, FNAP, FNYAM • Robert V. DiGregorio, PharmD, BCACP • Carol Green-Hernandez, PhD, ARNP, FNP-BC, FNS • Stephen Paul Holzemer, PhD, RN • Eve S. Faber, MD • Lucille R. Ferrara, EdD, RN, MBA, FNP-BC, FNAP • Jason T. Slyer, DNP, RN, FNP-BC, CHFN, FNAP

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 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 biological 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 the later part of the 20th century, when it was acknowledged that the health care needs of the United States, access to services, and the ability to pay for them in a 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 overuse of services, resulting in trillion-dollar health care costs in the United States. Despite this enormous expenditure, more than 40 million Americans were without health insurance. Access to health care, in the absence of universal health care coverage, remained an issue of national concern. The cost of health care, access to health care, types of services, and delivery of those services were common topics of conversation both inside and outside the health care arena.

HEALTH CARE REDESIGN

The Institute of Medicine (IOM) report, in 2001, Crossing the Quality Chasm, acknowledged the difficulty in translating knowledge into practice, as well as safely and appropriately applying technology to support care. At that time, the IOM specifically identified the lack of multidisciplinary infrastructures to support the complex needs of the aging population and the concomitant increase of chronic illnesses. Furthermore, they concluded that the important work of health care was conducted in silos.

Crossing the Quality Chasm called for health care redesign and identified the following 10 rules or principles necessary for that redesign:

Care is based on continuous, healing relationships

Care is customized according to patient needs and values

The patient is the source of control

Knowledge is shared and information flows freely

Decision making is evidence based

Safety is a system priority

Transparency is necessary

Needs are anticipated

Waste is continuously decreased

Cooperation among clinicians is a process

Health care constituents were asked to commit “to continually reduce the burden of illness, injury and disability and to improve the health of the people of the United States” (IOM, 2001, p. 3). Six aims for health care improvement were identified by the IOM; they called for care to be safe, effective, patient centered, timely, efficient, and equitable.

HEALTH PROFESSIONS EDUCATION: A BRIDGE TO QUALITY

In 2003, the IOM published another critical report that identified core competencies of all health professionals as a bridge across the quality chasm. Health Professions Education: A Bridge to Quality identified five competencies central to the education of all health care professionals: provide patient-centered care, apply quality improvement, employ evidence-based practice, utilize informatics, and work in interprofessional teams. The IOM called for accountability of educators in achieving these competencies.

Each proposed solution to the growing issue of delivering safe, quality health care to all Americans posed different challenges, and led in 2010 to the United States’ major move toward health reform, the Patient Protection and Affordable Care Act (ACA). In March 2010, the passage of the ACA became a major historical event in U.S. history.

The ACA seeks to improve the current health care delivery system, increase the number of Americans covered, and control costs. The ACA is, and will continue throughout its implementation, to be an ambitious, complex plan, to change health care in the United States.

Highlights of the ACA are many. Notably, the ACA establishes and encourages new models of care, which are an important strategy to address care fragmentation and the current fee-for-service model that drives up the cost of care without accountability of outcomes. These new models of care also recognize that no single practitioner is responsible for a patient’s care; therefore, care must be patient centered, coordinated, and team based.

New models of care include:

Accountable Care Organizations (ACOs)—ACOs consist of groups of primary care clinicians, hospitals, specialists, and other health professionals, and will be responsible for the primary care and coordination of care for their patients. The goal is to reduce duplication, increase safety, and reduce costs. ACOs enable the sharing in cost savings that they achieve for their included patients. These practice organizations must demonstrate the ability to promote practices based on evidence. Quality outcomes and cost will also be reviewed.

Medical Homes/Patient-Centered Medical Home (PCMH)—The PCMH has goals similar to those of ACOs, namely, cost reduction with improved quality and increased care coordination. Multiple PCMHs may join together to form an ACO. The PCMH is a primary care model that aims to improve access to care, and increase communication (via e-mail, or other technologies through the use of electronic health records or other health information technology) among patients and care providers. Care is organized around a patient’s needs, preferences, and values. Access to care will be increased with extended appointment hours, and predetermined quality outcomes will be tied to payment.

Nurse Managed Health Clinics (NMHC)—The NMHC is a health delivery model led by advanced practice nurses with the goal of improving access to primary health care and wellness service for vulnerable populations living in underserved health care areas. NMHCs are often associated with colleges, universities, departments of nursing, federally qualified health centers, or other interprofessional providers. NMHCs use health information technology systems to collect data for use in quality improvement activities. Workforce capacity of primary health care providers will be improved through NMHCs, as these sites will be training centers for nurse practitioners and other health care professionals.

Integrated Care Models—Models of integrated and collaborative care are intended to be interprofessional. These models draw upon the specialized knowledge of all professionals in the patient’s health care team. Notably, by recognizing the importance and universality of medication use in the management of acute and chronic disease states, the ACA recognizes the importance of medication management and medication reconciliation across care models and the inclusion of pharmacists as part of the integrated team.

Transitional Care Model—The ACA includes suggested initiatives to improve the quality of patient care, decrease hospital-acquired conditions, reduce hospital readmissions due to preventable complications during transitions in care, and to make overall improvements in the transition of care process to reduce hospital readmissions. These models are also intended to be interprofessional in design.

Medication Therapy Management (MTM)—Those enrolled in Medicare Part D must be offered MTM services. Services and strategies include an annual comprehensive medication review furnished by a licensed pharmacist or other qualified provider and follow-up interventions, as warranted by the findings of such a review. In addition, at least on a quarterly basis, the medication use of an individual who is deemed to be at risk, but not enrolled in an MTM program, must be assessed.

HEALTH: A DYNAMIC STATE OF BEING

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 biological, psychological, social, and spiritual needs of the person. The integrated needs of the individual places the person within the context of his or her family and community. It also recognizes that health is not simply the presence or absence of disease, but rather 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 thus individuals must engage in the process of health if they are to actualize their health potential. This necessitates a change in perspective from the individual as a passive recipient of care to the individual as an active participant in his or her own health.

To meet these needs, health care delivery in the United States continues to strengthen primary care, in which providers address a wide range of health care needs and facilitate health care delivery. The ACA encourages new models of care delivery recognizing the value of team-based care, with the patient as the center of care, and calls for quality, safety, and accountability in outcomes of care.

EDUCATING FOR PATIENT-CENTERED CARE

In February 2011, a meeting was held to advance interprofessional education to support patient-centered care. The meeting was convened by the Health Resources and Services Administration, the Josiah Macy Jr. Foundation, the Robert Wood Johnson Foundation, and the ABIM Foundation in collaboration with the Interprofessional Education Collaborative. The Interprofessional Education Collaborative consists of the following:

American Association of Colleges of Nursing

American Association of Colleges of Osteopathic Medicine

American Association of Colleges of Pharmacy

American Dental Education Association

Association of American Medical Colleges

Association of Schools of Public Health

GLOBAL INITIATIVES

The World Health Organization defines interprofessional collaborative practice as “[w]hen multiple health workers from different professional backgrounds work together with patients, families, carers, and communities to deliver the highest quality of care” (2010).

Interprofessional education, according to the World Health Organization, is “[w]hen students from two or more professions learn about, from and with each other to enable effective collaboration and improve health outcomes” (2010). The importance and value of teamwork to quality, safety, and outcomes in patient-centered care are known and have been documented over several decades; the ACA, however, is a tipping point for putting into practice the evidence that supports patient-centered, interprofessional team-based care. Educating health professionals for practice in new models of care is imperative to improving the nation’s health. The Interprofessional Core Competencies provide this guidance. Four core competencies for interprofessional education were identified by the Interprofessional Education Collaborative Council expert panel, and include:

Values and ethics

Roles and responsibilities for collaborative practice

Interprofessional communication

Teamwork and team-based care (2011)

Within these four core competency domains are 38 specific competencies that describe the behaviors we should be able to see when the competencies are being practiced. 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 (Taylor, Machta, Meyers, Genevro, & Peikes, 2013). 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. Primary care, defined in this way, is provided within a primary health care context, and acknowledges “community” in its broadest sense, thereby recognizing the value of team-based care.

In today’s health care environment, economic considerations loom. Professional standards may be challenged through any 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 patient-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). Patient-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, interprofessional, and patient-centered primary health care networks that improve outcomes and satisfaction for both patients and providers.

This chapter identifies concepts essential for achieving patient-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.

THE FOUNDATION OF PATIENT-CENTERED CARE IN PRIMARY CARE: CARING AND TRUST