Implementing High-Quality Primary Care Rebuilding the Foundation of Health Care (2021) / Chapter Skim
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4 Person-Centered, Family-Centered, and Community-Oriented Primary Care
4 Person-Centered, Family-Centered, and Community-Oriented Primary Care
Pages 93-140
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From page 93... ...
Many primary care settings today are structured in a way that prevents the team from understanding and addressing the context in which a patient lives. An approach to care limited in this way perpetuates disadvantage and health inequity.
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From page 94... ...
. There is no one formula for a successful PCMH, but the characteristics they share include management of patient populations, interprofessional care teams to improve care coordination, and care safety, efficiency, and quality.
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From page 95... ...
. Another study found that misalignment between current payment systems and PCMH goals was common, largely because primary care clinicians were unable to spend the extra time and effort needed to establish an engaging and well-integrated medical home with spe cialized and coordinated care for every patient (Alexander et al., 2013)
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From page 96... ...
. While primary care teams have known this for a long time, primary care has encountered significant barriers -- most notably incompatible payment models -- that prevent it from moving away from a biomedical, disease-focused model to one that addresses people's expressed needs and preferences, includes individuals and families more in their care, and responds to the multitude of factors that impact health, including the context of the community (Puffer et al., 2015)
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From page 97... ...
. Continuity of Relationships A defining aspect of the committee's vision of primary care is the trusting relationship between the interprofessional care team and the person seeking care.
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From page 98... ...
With this knowledge, the care team should design care that can help the person and their family achieve the goal that was most important to them. Integrating these two processes would dramatically change how health is viewed and help us get the outcomes that matter for the person and family.
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From page 99... ...
One theme was that the primary care team took a wait-and-see approach, instead of really listening to the parents. The fragile relationship was illustrated by families reporting fear that if they raised concerns or disagreed with their clinician, it would impact the care their child received.
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From page 100... ...
Parents expect primary care clinicians to provide education and information about their child's challenging conditions and referrals to specialists and connect the family to community resources and supports. She described the role of primary care clinicians as comprehensive and conducted in partnership with the family, understanding the problems families face and helping them to learn and support their child's well-being.
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From page 101... ...
Whereas patient-centered care is commonly understood as focusing on the individual seeking care -- the patient -- people-centered care encom passes these clinical encounters and also includes attention to the health of people in their communities and their crucial role in shaping health policy and health services.
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From page 102... ...
Furthermore, this knowledge, and the time spent attaining it, strengthens the relationships between the primary care team and the people seeking care. Compared to patient-centered care, person-centered care has been shown to lead to agreement on care plans, better health outcomes, and higher patient satisfaction (Ekman et al., 2011)
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From page 103... ...
. In addition, a family member or other informal caregiver can be a valuable source of health information and insights about the home and community environments that clinicians may not get from the person seeking care.
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From page 104... ...
. In the early years of this emerging new medical and academic discipline, family medicine adapted care based on the biopsychosocial model of care and incorporated unique training elements to strengthen the expertise of primary care teams to think of individuals within the context of their families and their communities (Borrell-Carrió et al., 2004; Engel, 2012; Martin et al., 2004)
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From page 105... ...
Geriatrics care tends to focus on assessing function and cognition and emphasizes the goals of care. Involving the family in assessing and caring for older adults is both important and challenging, particularly for the many who have multiple chronic disorders (American Geriatrics Society Expert Panel on the Care of Older Adults with Multimorbidity, 2012; Boyd et al., 2005; Tinetti et al., 2012)
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From page 106... ...
For example, some clinicians have difficulty recognizing the power dynamics between them and other care team members or people seeking care: specifically, the power that inherently comes with the position of health care clinician (Nimmon and StenforsHayes, 2016; Singer, 1989)
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From page 107... ...
In addition, primary care is increasingly using technology-enabled care delivery modalities, including telehealth and smartphone apps. As a result, the personal relationship between the person seeking care and the care team providing that care as a foundation for consistency is more important than ever.
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From page 108... ...
While some suggest simply reprioritizing and freeing up time to work on relationships, other more novel options have been conceived including changes to the electronic medical record system, building communication skills, reconfiguring the primary care team, and overhauling payment models so they are compatible with the time and effort needed to build and sustain relationships with people seeking care (AHRQ, 2018; Montague and Asan, 2014; Pollack, 2019)
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From page 109... ...
The Alaska Native–owned, nonprofit health care organization also focuses on responding to the wide range of opportunities for feedback from patients, whom SCF refers to as "customer-owners." SCF succeeds in part as a result of the bespoke tailoring of its system for the people, families, and communities it serves. From the beginning, the entire health system was based on Alaska Native values and needs.
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From page 110... ...
Ensuring equitable access to high-quality health care for all is not a guaranteed way to reduce health disparities and ensure health equity, given the many factors that have a much greater impact on health than health care does. BOX 4-2 Definition of Health Disparities "Health disparities are health differences that adversely affect socially dis advantaged groups.
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From page 111... ...
, each comprising at least 15 primary care clinicians or ambulatory practices that are linked closely with their communities, have been conducting research on how to improve primary care delivery, often with an explicit focus on health equity (Westfall et al., 2019)
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From page 112... ...
Empanelment usually has delivery systems or care teams making the assignments, whereas attribution, covered further in Chapter 9, typically involves payers doing so (AIR, 2013)
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From page 113... ...
More sophisticated processes may also acknowledge population health profiles to more evenly distribute health needs among primary care teams and help team members better understand the needs of their panels (PHCPI, 2019)
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Chapter 6 explores the factors influencing the composition of the primary care workforce and strategies to increase its number and diversity. One critical strategy for aligning the primary care workforce with its community is to expand opportunities to integrate CHWs and promotores de salud into primary care teams.
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From page 115... ...
Innovative models of community-oriented primary care further integrate care delivery in non-clinical settings, including the workplace, college campuses and schools, recreation centers, places of worship, retail shops (e.g., barbershops) , homeless shelters, housing for older adults, and institutions (e.g., prisons and jails)
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From page 116... ...
Partnerships Among Primary Care, Public Health, and Community-Based Organizations Having primary care teams embedded within communities and partnering with public health and community-based organizations is not a new idea in the United States. In the late nineteenth century, dispensaries were established to provide medical care to the poor in neighborhood settings (Rosenberg, 1974)
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From page 117... ...
A community of solution comprises people who come together to address an important problem or seize an opportunity to improve health, and it envisions primary care teams collaborating with many diverse partners, depending on the nature of the problems and the community. In addition to community members and public health professionals, each unique community of solution would include many other public and private partners and community-based organizations (Gotler et al., 2020; Griswold et al., 2013; The Folsom Group, 2012; Westfall, 2013)
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From page 118... ...
. Delivery sites include tribal or urban American Indian and Alaska Native areas, remote sites connected to a community health center, and sites deemed "lookalikes" that meet the requirements of FQHCs but do not receive federal grant funding (Rural Health Information Hub, 2019)
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From page 119... ...
Health centers are also required to complete a community needs assessment every 3 years, which includes a review of barriers (including transportation) and unmet health needs of the medically underserved (including the ratio of primary care physicians relative to the population, health indexes for the population served, the poverty level, and other demographic factors in demand for services, such as the percent of the population over age 65)
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From page 120... ...
. One strategy health centers have employed to counter this is the Teaching Health Center Graduate Medical Education program, which places physician and dental trainees in health centers, mostly in primary care settings and rural or underserved areas (HRSA, 2021)
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From page 121... ...
. Despite many Tribal and Urban Indian Health Programs serving as "the glue that holds their communities together," the IHS is chronically underfunded and provides health care services to less than half the eligible population (UCLA American Indian Studies Center, 2016; Urban Indian Health Commission, 2007, p.
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From page 122... ...
Though NMHCs resemble community health centers in the populations and areas they serve, they are generally ineligible for FQHC status and federal funding due to a governance structure that includes the boards of their founding institutions, rather than the center's patients (HansenTurton et al., 2010)
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From page 123... ...
Care of the nursing home resident includes assessment and management of both acute and chronic physical and psychosocial health care needs, coordination of needed health care services, the management of transitions between different health care settings, and advance care planning, among other services (Unwin et al., 2010)
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From page 124... ...
Instead of responding to whole-health needs using a community-oriented approach, clinicians and health care organizations are rewarded for preventing, diagnosing, and treating diseases and performing procedures, prescribing medications, and providing care based on traditional biomedical models. Multiple levers can help shift primary care toward communityoriented models, including data systems, interprofessional care teams, care
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From page 125... ...
2013. The policy context of pa tient centered medical homes: Perspectives of primary care providers.
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From page 126... ...
2015. The war on poverty's experiment in public medicine: Community health centers and the mortality of older Americans.
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2011. Health disparities and health equity: The issue is justice.
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2020. Community health centers: Chronicling their history and broader mean ing.
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2012. Increasing knowledge of cardiovascular risk factors among African Americans by use of community health workers: The ABCD community intervention pilot project.
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2013. Reducing preventable emergency department utili zation and costs by using community health workers as patient navigators.
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2019. Integrating community health workers into health care teams without coopting them.
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From page 132... ...
2021. Teaching Health Center Graduate Medical Education (THCGME)
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2013. Access to oral health care: The role of federally qualified health centers in addressing disparities and expanding access.
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2019. Changes at community health centers, and how patients are benefiting: Results from the Commonwealth Fund national survey of federally qualified health centers, 2013–2018.
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Bethesda, MD: National Association of Community Health Centers.
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2014. Patients and health care teams forging effective partnerships.
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2005. Ability of community health centers to obtain mental health services for uninsured patients.
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2020. How community health workers put patients in charge of their health.
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Seattle, WA: Urban Indian Health Commission.
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2013. Pre paring community health workers for their role as agents of social change: Experience of the community capacitation center.
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