INTRODUCTION
WHY DO HEALTHCARE SYSTEMS NEED PRIMARY CARE?
Function | Outcome evidence |
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Access (first contact care for new health needs) | |
Continuity (long-term person-focused care) | |
Comprehensiveness (care for most health needs) | |
Coordination of care (when required outside the practice) |
WHY DO WE NEED A PRIMARY CARE REVOLUTION?
WHAT PRINCIPLES SHOULD GUIDE THE PRIMARY CARE REVOLUTION?
Patient history: Ms. W • 35-year-old single mother of two • Works nights as service professional • History of abusive relationships; current boss is emotionally abusive • Smokes 10 cigarettes daily; binge-drinks on weekends • Family history of colon cancer in two first-degree relatives including her father at age 42, lupus, diabetes, and depression • Intermittent mild–moderate depression and poorly controlled diabetes and hypertension • Frequently misses medical appointments | |||||
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Health state and example | Principle 1: Payment Reform towards Capitation | Principle 2: Team- and technology-supported relationships | Principle 3: Integration with specialists | Principle 4: Whole-person care | Outcome and impact |
Baseline health: • Ms. W’s daughter gets on her case about smoking, and she decides she would like to try and quit | • She shares her interest in quitting smoking during her twice-yearly email check-in by her health coach | • Her health coach forwards an evidence-based decision support and interactive tool on different pharmacotherapy options for smoking cessation • Her NP prescribes nicotine patches, which Ms. W has chosen • Her health coach also identifies mild depression based on Ms. W’s answers to PHQ-2 and PHQ-9 | • Her physician is focused on complex presentations by other patients, but based on a short conversation with the health coach, suggests a referral for CBT | • An LICSW reaches out to her, and they schedule time for an initial telephonic CBT session | • Ms. W fails to quit smoking this time • She does experience improvement in her depression, however, as indicated by follow-up PHQ-9s • Three years later, after one other unsuccessful quit attempt, she finally succeeds |
Acute, routine care: • Ms. W develops dysuria and suprapubic discomfort • “Feels like when she had a UTI” • No fevers, back pain, nausea or vomiting | • Ms. W emails the triage line for her practice • As there are no red flags, her care is managed virtually | • An interactive technology takes the basic history • Her NP calls Ms. W, confirms the history, prescribes antibiotic | • Her physician is focused on complex presentations by other patients | • Ms. W’s health coach calls her in 5 days to make sure she is feeling better • He reminds her that she is due for her colonoscopy and forwards a scheduling link | • Ms. W’s UTI symptoms completely resolve within 36 h • She does not have to use any of her sick time at work • After four more monthly automated email reminders, she does schedule and go for a colonoscopy, which is normal |
Chronic disease: • Ms. W develops her third yeast infection in a year • She has not had a hemoglobin A1C test in 9 months | • Ms. W’s health coach is notified that she is overdue for her hemoglobin A1C test and contacts Ms. W to urge her to get the test • Her hemoglobin A1C comes back at 8.8 | • Ms. W’s health coach checks in with Ms. W about her diet and schedules a virtual check-in with her NP • Her NP reviews her medications and learns that she is taking her sulfonylurea at maximum dose but has not been tolerating metformin, even in an extended-release formulation | • Ms. W’s NP checks in with her physician and they decide to e-consult an endocrinologist • The endocrinologist reviews the case and suggests a trial of sitagliptin | • Ms. W’s health coach calls her in 1 month; Ms. W is tolerating the sitagliptin but frequently missing doses; the health coach forwards an adherence support app for Ms. W’s smartphone • The health coach also reminds Ms. W that she is due for a retinal screening test and sends her the app for this | • Ms. W’s hemoglobin A1C in 6 months is down to 7.5, and she is no longer having recurrent yeast infections |
Acute, complex care: • Ms. W develops fever and shortness of breath | • Ms. W emails the triage line for her practice, flagging the message as urgent • The triage nurse forwards the email to her physician | • Her physician calls Ms. W 30 min later, takes a detailed history over the phone, and develops a differential that includes upper respiratory infection (including influenza), pneumonia, interstitial lung disease, and pulmonary embolus • She asks Ms. W to come in later that day for an exam | • On exam, Ms. W is mildly tachypneic, with a heart rate of 112 and an oxygen saturation of 92% • She has diffuse rales on her lung exam • Her physician e-consults with a rheumatologist and pulmonologist, and they agree that a chest CT is the next step | • Ms. W’s health coach and LICSW provide emotional and logistical support to help secure a work excuse and ensure that Ms. W gets help with her children | • With virtual support from specialists, Ms. W’s physician diagnoses her with lupus, starts her on prednisone, and arranges for an in-person visit with a rheumatologist • At that visit, the rheumatologist selects appropriate pharmacotherapy with a recommended monitoring schedule • Ms. W’s primary care team supports her on this medication with occasional e-consultation with a rheumatologist |