Primary Care’s Challenge

Tomorrow’s primary care practice should feature multiple team members, closer collaboration with other providers, and a greater awareness and usage of community resources. How will it get from here to there?

Visits to primary care clinicians are declining, the workforce pipeline is shrinking as clinicians opt for more lucrative fields, and many practices are struggling to remain open. Yet primary care is the only part of health care in which an increased supply is associated with better population health and more equitable outcomes.

“A strong foundation of primary care is critical to the health system,” conclude the authors of a new report from the National Academies of Sciences, Engineering and Medicine, “Implementing High-Quality Primary Care: Rebuilding the Foundation of Health Care.” It should be a common good, they say, made available to all individuals in the U.S., promoted by responsible public policy, and supported with the resources to achieve health equity.

The recommendations in the report echo those of a 1996 publication by the Institute of Medicine. But those recommendations “remain fallow,” the authors of the new report admit. “[Twenty-five] years since the Institute of Medicine report, ‘Primary Care: America’s Health in a New Era,’ this foundation remains weak and under-resourced, accounting for 35% of health care visits while receiving only about 5% of health care expenditures. The foundation is crumbling.”

Some of the report’s recommendations cover well-trodden ground, including:

  • Shifting away from fee-for-service payment toward value-based models.
  • Increasing physician payment for primary care services to more closely match that of specialty services.
  • Creating new health centers, particularly in underserved areas.
  • Developing digital health technology.

But two recommendations, if implemented, could signal a new direction for the primary physician practices whom The Journal of Healthcare Contacting readers call on:

  • The development of interprofessional care teams.
  • The creation of community-based training programs for primary care providers.

Interprofessional teams

Primary care teams should fit the needs of communities, work to the top of their skills, and coordinate care across multiple settings, say the report’s authors. To do so, they need to “consider how to meaningfully engage the full range of primary care professions, including physician assistants, nurse practitioners, medical assistants, community health workers, behavioral health specialists, and others.” Furthermore, they should make efforts to integrate primary care and public health, behavioral health, oral health and pharmacy.

Interprofessional teams typically include a core team, an extended health care team, and what the authors refer to as an “extended community care team.”

  • The core team comprises the patient, their family, and various informal caregivers; primary care clinicians, who may be physicians, PAs, NPs, or RNs; and clinical support staff, such as medical assistants and office staff.
  • The extended health care team can include community health workers, pharmacists, dentists, social workers, behavioral health specialists, lactation consultants, nutritionists, and physical and occupational therapists.
  • The extended community care team includes organizations and groups, such as early childhood educators, social support services, healthy aging services, caregiving services, home health aides, places of worship and other ministries, and disability support services.

“Team-based care improves health care quality, use, and costs among chronically ill patients, and it also leads to lower burnout in primary care,” according to the report. But such teams demand skilled leadership, decision-making tools and real-time information. In addition, interprofessional teams:

  • Are proactive and provide well-thought-out care, including pre-visit planning and laboratory testing.
  • Distribute and share the delivery of care among team members.
  • Share clerical tasks, such as documentation, non-physician order entry, and prescription management.
  • Enhance communication through a variety of strategies.
  • Optimize the function of the team through co-location, team meetings, huddles, and mapping workflow.

“Family members and other informal caregivers are an important part of overall quality and care of patients,” says Rachel Buckholtz, a Medical Group Management Association consultant, commenting on the report. “Oftentimes they can provide reliable data that may otherwise get missed, which can help the provider make better decisions for the patient. They are better able to express the true medical condition, especially in the elderly population.

“I see providers relying on resources in the community, but I do feel they need to become more aware and comfortable with all resources available to patients,” she adds. “That’s a hard ask, but one that is necessary, especially as functional medicine progresses. I have had many providers tell me they ‘don’t practice that kind of medicine,’ not understanding the resources available.

“In some areas it’s as simple as telling [patients] where they can participate in co-ops for healthy fruits and vegetables. Many still only focus on treating a patient when they are sick enough for medications, instead of using the community resources to help them make wiser decisions on health before it becomes a chronic issue requiring traditional medications.”

Community-based training

Training primary care clinicians individually in inpatient settings will not adequately prepare them to deliver high-quality primary care, says the report. The federal government should support training opportunities in community settings and in rural and underserved areas, and provide economic incentives such as loan forgiveness and salary supplements. Trainees should be given the opportunity to work alongside non-physician care providers and extended care team members.

“Core to the delivery of primary care are competencies underlying team-based care; how to function in an integrated, interprofessional manner; and how to integrate and coordinate care with community-based care team members.… The challenge of achieving those competencies lies in incorporating interprofessional didactic and experiential learning into the already crowded medical and health professional education. Challenges also exist in educating and training students alongside the current workforce, especially in settings where the workforce itself is not functioning as an interprofessional team.

“The ability of a primary care team to address the broad range of population needs, including identifying community expectations, engaging individuals in preventive health care and counseling, and managing simple and moderately complex medical problems, is essential to creating a system in which the requirements of the populations and individuals are addressed efficiently and cost-effectively.”

The study – undertaken by the Committee on Implementing High-Quality Primary Care – was sponsored by the Agency for Healthcare Research and Quality, American Academy of Family Physicians, American Academy of Pediatrics, American Board of Pediatrics, American College of Physicians, American Geriatrics Society, Academic Pediatric Association, Alliance for Academic Internal Medicine, Blue Shield of California, the Commonwealth Fund, U.S. Department of Veterans Affairs, Family Medicine for America’s Health, Health Resources and Services Administration, New York State Health Foundation, Patient-Centered Outcomes Research Institute, Samueli Foundation, and Society of General Internal Medicine.

The dream team

Teams in highly functioning primary care practices:

  • See themselves as the linchpin between communities, and link people and families to specialists, acute care hospitals, and chronic care facilities.
  • Have a deep grasp of physiology, therapeutics and technical medicine.
  • Appreciate the assets and challenges of the communities they serve.
  • Understand how the health system is constructed and works.
  • Exercise exceptional skills in team-building, communication and collaboration.
  • Demonstrate strong leadership and advocacy skills.

Source: “Implementing High-Quality Primary Care: Rebuilding the Foundation of Health Care,” National Academies of Sciences, Engineering and Medicine