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Part 3: The New Definition and an Explanation of Terms
Pages 15-33

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From page 15...
... The 1978 IOM report addressed the first perspective,and the 1984 COPC report addressed the second. In recognizing the increasing importance to primary care of the integrated delivery system, this report addresses all three.
From page 16...
... Continuity is a characteristic that refers to care over time by a single individual or team of health care professionals ("clinician continuity") and to effective and timely communication of health information (events, risks, advice, and patient preferences)
From page 17...
... 30~. Majority of personal health care needs refers to the essential characteristic of primary care clinicians: that they receive all problems that patients bring unrestricted by problem or organ system end have the appropriate training to manage a large majority of those problems, involving other practitioners for further evaluation or treatment when appropriate (see p.
From page 18...
... Other primary care clinicians, for example, pediatric nurse practitioners, care for patients of a particular age. Use of the term families in this report also acknowledges their caregiving roles, Me concerns of family members, and the impact of family dynamics on health and illness.
From page 19...
... In its broadest sense, primary care must also be linked to the larger community and environment in which people work and live. This requires that primary care clinicians be aware of what may be happening in the community such as occupational dangers, patterns of childhood injuries, patterns of lead poisoning or other environmental hazards, homicides, issues of domestic violence, and epidemics.
From page 20...
... In medical centers, a clinician refers to someone with direct patient care responsibilities; in using the term clinician, then, this report underscores the importance of a relationship between a patient and an individual who uses judgment, science, and legal authority to evaluate and diagnose patient problems and to manage them. Partnership The term sustained partnership refers to the relationship established between the patient and clinician with the mutual expectation of continuation over time.
From page 21...
... Clinicians are accountable as described below; patients are responsible for helping to sustain the relationship, for conveying complete and timely information to the primary care clinician, for aspects of their health that are effected by obtaining preventive care, for lifestyle choices, and for seeking care as appropriate, for following instructions, and observing treatment effects and side effects. Health Care Needs and EIealth Care Services The term personal health care needs includes reference to physical, mental, emotional, and social concerns that involve the functioning of an individual.
From page 22...
... The committee's use of the term integrated when describing personal health care services should not be confused with the widely used term as applied to horizontal and vertical integration in integrated delivery systems. To integrate primary care Filly, however, primary care clinicians are likely to practice in teams and in such integrated delivery systems.
From page 23...
... In many circles, the term gatekeeper has been used to describe the function of using the experience and judgment of the pnmary care clinician to determine whether diagnostic tests are necessary, whether a patient's problem can be handled by the primary care practice, or whether a person needs to be evaluated or treated by another specialist or subspecialist. Patients view gatekeeping with suspicion because they fear that efforts to control use of services and to manage costs may ultimately work to the detriment of their health.
From page 24...
... That phrase refers to the essential characteristic of primary care clinicians: that they receive all problems that people bring unrestricted by problem or organ system and have the appropriate training to manage a large majority of those problems, involving other health professionals for further evaluation or treatment when appropriate, and continuing to act as advocates for their patients. Primary care addresses a mixture of health problems along the spectrum of disease as they occur singly or in combination within a single individual.
From page 25...
... The goal is to focus on interactions with patient and family and their health concerns, clarify clinical care decisions, advise hospitalized patients and their families, and help patients and their families cope with the social and emotional implications of disease or illness. The primary care clinician will often be the principal clinician of inpatient care for certain conditions that require hospitalization (e.g., pneumonia)
From page 26...
... The composition of primary care teams depends on the needs of the patients and the population served: The team involved in providing primary care services to a relatively healthy, employed group of people would be different from that needed to manage a group of elderly retired persons or patients with chronic illnesses. Both of those teams would be quite different from ones that are organized to care for patients with complex social and environmentalproblems such as domestic violence.
From page 27...
... Continuity encompassespatient and clinician knowledge of one another, and the effective and timely communication of health information that should occur among patients, their families, other specialists, and primary care clinicians. Some means of ensuring continuity are found in integrated delivery systems.
From page 28...
... Meeting the need for continuity of care is a significant element of computer-based patient records. Continuity can apply to an integrated delivery system, apnmary care practice or team, and a single primary care clinician.
From page 29...
... For example, integrated delivery systems may establish policies regarding maximum waiting times for an urgent appointment, periodic health examinations, coverage when a clinician is out of the office, and getting patients into substance abuse treatment programs on a weekend. Primary care is a key to accessibilitybecause it can provide an entry point to appropriate care.
From page 30...
... Quality of Care Primary care practices are accountable for the quality of care they provide. A 1990 IOM report, Medicare: A Strategyfor Quality Assurance, defined quality of care in the following way: Quality of care is the degree to which health services for individuals and populations increase the likelihood of desired health outcomes arid are consistent with current professional knowledge [IOM, 1990, p.
From page 31...
... As policymakers shift attention toward systems of care, integration, and team approaches to health care delivery, it will be especially important to understand the relative risks and benefits to health outcomes and patient satisfaction of promoting or disrupting personal relationships. Patient Satisfaction An emphasis on satisfaction and information highlights the importance of patients' and society's preferences and values and implies that they should be elicited (or acknowledged)
From page 32...
... Although the issues are not unique to primary care, clinicians need to be competent in managing events with significant ethical overtones, such as informed consent and advance directives, avoidance of conflicts of interest in financial arrangements, care of family members when goals are in conflict, reproductive decisionmaking and genetic counseling, privacy and confidentiality, and equitable distribution of resources. Primary care clinicians are accountable for their advice to and care of patients when they have financial or other incentives to use or not use certain resources.
From page 33...
... AN INTERIM REPORT Acco a] stability of Patients 33 The committee acknowledges another aspect of accountability: that of the patient.


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