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Primary Care Arthur Carson, fr You may wonder why a sub-subspecialized person is talking about primary care. It raises the important point to all of us that this was a group effort. Not only was it a group effort, but this is something that the spe- cialists will buy into. This is something the primary care doctors will also buy into. This is an absolutely marvelous program, and it is my honor to go over it with you. To make sure that we are all on the same page of what a community health center is, I remind you that they are 501(c)~3)s. They are places where people go that can be established networks of practices and should not be considered just a single place. They are both urban and rural. Two- thirds of the people who utilize their services are poor, and an interesting piece is that the majority of active clients actually serve as board mem- bers. If you look at their boards, you'll find that the majority of the board members are active clients of the community health center. The administration has focused on community health centers as a way to get services to the uninsured and other vulnerable populations. What we are after is using a series of preexisting, fairly successful initiatives and building on them in primary care. I would point out you can do the same thing in specialty care as well, despite the fact that this is a primary . . . . care shave. The overall goal was to come up with 40 exemplary primary care prac- tices over the next three years. My own personal subgoal is broader than that. These practices are geared toward primary care, but any practice in the United States can use these very same principles and we probably 9

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10 FOSTERING RAPID ADVANCES IN HEALTH CARE should pay attention to that. One way in which community health centers have already done well is by managing chronic conditions. I thought I would focus on some interesting things that many of us who do health services research understand. But for those of us who don't, just look at the question of asthma. There is a marvelous community health center in New Haven that has come up with a real reduction in symptom-free days, school days missed, and emergency room visits be- ing decreased. Those are the types of very practical outcomes we are discussing be- ing measured and coming out of these particular situations. Team-based care is something that has already been featured in the community health centers. Team-based care runs the gamut from nursing to social work to primary care physicians and even specialists. This is not a new term but has recently been made very important at learning collaboratives, which are simply a large number of people. There are 500 of these community health centers that have already gotten together and talked about ways of improving health care, which is improving the way that they study health care and ultimately improving delivery. The second piece of what they have already done is the implementa- tion of electronic patient registries with evidence-based guidelines. I think the important piece here is that not as many of us are worrying about electronic records. It's not simply about getting the record at home and not having to go to the hospital. It is about guidelines with reminders. The way that the electronic medical records really help us are as reminders related back to guidelines and visit notes that ultimately generate statis- tics so that we can begin to develop large databases and understand even better how to take better and better care of the patients. Now, the goals for everyone are high quality, patient-centered care and redesigning preventive acute and chronic care. It is very interesting: the community health centers' endless initiative focuses in particular on chronic care. Anywhere from 60 to 100 million people in the United States have chronic disease right now. This is a very, very appropriate focus. The use of effective teams or participatory care means not only just that patients take care of them- selves, which is self-care, but participate in decision making as well. The concept of same-day open access is an interesting point made in the re- port. Many of us had a real problem with "no-show" patients. If you have access, which is something that I learned in reviewing the report, no- shows which can account for a tremendous amount of inefficiency and actually lost care are markedly reduced with same day access, evidence- based, safe care. The learning collaboratives allow people to share best practices of delivery and process and show how to improve outcomes to provide effi-

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PRIMARY CARE 11 cient, effective care. The report talks quite a bit about inpatients. I would point out one very simple thing about outpatient care that many of us don't think about. That is the return visit of "come back in a year." Think about how many times you say "Well, you should come back in a year or you should come back in two years." These are the sort of data that can be generated by these kinds of learning collaboratives. Finally, the equitable part is so important: meeting diverse needs and reducing disparities. Ultimately, in order for this to work, however, we have to evaluate demand. We have to evaluate the demonstrations, com- municate the results, not only among the cells in the learning collabora- tive, but also to the larger community.