The health care system, health policy, and health professional curricula in the United States are undergoing a period of rapid change. These shifts, particularly those that involve integrated delivery systems (Shortell et al., 1994), could not have been reflected in the Millis Commission report, Alpert and Charney's 1973 monograph, or the earlier IOM reports. The development of integrated delivery systems means that primary care cannot be defined or assessed in isolation from the overall system of which it is a part. Such systems involve physicians and other clinicians and the facilities they use to deliver a full array of services, for a given price, to a defined population, in settings that are most appropriate to patients' needs. The committee's first task in considering the future of primary care was to reexamine the 1978 IOM definition and other definitions in light of the current and anticipated health care environment. In doing so, the committee supported the essential features of the earlier definition but also believed that a new definition was needed to reflect the dramatic health system changes that have occurred in the past 18 years and to anticipate and to guide future change. After release of its recent interim report (IOM, 1994b), the committee invited public comment on its definition at conferences, in a published article (Vanselow et al., 1995), and in a public hearing that specifically requested comment on its definition. After considering all comments and letters that the committee received, it concluded that the new definition was well accepted, and it was adopted for this report. The definition is described below.

The definition of primary care adopted by the IOM Committee on the Future of Primary Care follows:

Each term in the definition is summarized in Box 2-1 and is explained in the text following the box.

Although the new definition is based on the 1978 IOM definition, it recognizes three additional important perspectives for primary care: (1) the patient and family, (2) the community, and (3) the integrated delivery system. 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. The new definition thus stresses the importance of the patient-clinician relationship (a) as understood

Front Matter (R1-R16)

Summary (1-12)

Introduction (13-26)

Defining Primary Care (27-51)

The Value of Primary Care (52-75)

The Nature of Primary Care (76-103)

The Delivery of Primary Care (104-147)

The Primary Care Workforce (148-178)

Education and Training for Primary Care (179-215)

Research and Evaluation in Primary Care (216-246)

Implementation Strategy (247-262)

Appendixes (263-264)

A Site Visits (265-267)

B Public Hearing (268-273)

C Workshops (274-284)

D Mental Health Care in the Primary Care Setting (285-311)

E Life in the Kaleidodscope: The Impact of Managed Care on the U.S. Health Care Workforce and a New Model for the Delivery of Primary Care (312-340)

F Integrating Our Primary Care and Public Health Systems: A Formula for Improving Community and Population Health (341-373)

G Committee Biographies (374-384)

Index (385-395)