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Chapter 2 PRIMARY HEALTH CARE DEFINED The idea of primary care in health is well-known and widely supported, but there is considerable disagreement about the precise mean- ing of the term. In formulating a definition of primary care useful to practitioners and patients, and to educators and policy-makers, the committee examined dozens of definitions put forward by organizations and individuals. Several views on the meaning of primary care were presented at an open meeting held by the committee in January 1976 at the National Academy of Sciences in Washington, D.C. Thirty-eight definitions used by various individuals and groups were analyzed and compared. 1/ The committee found these views helpful to its own efforts to construct a definition of primary care and to develop criteria for determining whether primary care is being delivered. One conclusion drawn from the definitional analysis and discussion was that primary care is distinguished from other levels of personal health services by the scope, character, and integration of the services provided. Personal health services exclude public, environmental, and occupational health programs. Primary care cannot sufficiently be defined by the location of care, by the provider's disciplinary training, or by the provision of a particular set of services. The scope, character, and integration of services therefore are the basis of the definition of primary care presented in this chapter. Because services define primary care, good practitioners can be trained in any of a variety of disciplines. Many more primary care practitioners graduate from family medicine programs than from surgery programs. Nonetheless, it is possible for a graduate from either program to practice exemplary primary care. It is also possible for a family physician to provide care other than primary care. Primary care may be furnished by a solo practitioner, a group practice clinic, or a health maintenance organization. Excellent primary care services can be delivered by a nonphysician, such as a family nurse practitioner with suitable backup. In most cases, the complete array of services cannot be offered by a single individual and should be provided by a team that might include physicians, nurses, physician assistants, social workers, technicians, administrators, secretaries, and others. In addition, important health services are provided by dentists, podi- atrists, optometrists, pharmacists, and other health professionals. 2/ -15-

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Primary care responsibility is exercised by physicians, nurse practitioners, and physician assistants. This report uses the term 'primary care practitioner' to refer to physicians, nurse practitioners, and physician assistants providing primary care as defined in this chapter. Similarly, the term 'primary care physician' refers in this report to a licensed doctor of medicine or osteopathy who provides primary care as defined, irrespective of the physician's specialty designation or training. The attributes discussed below describe primary care as it should and could be practiced in the United States today. Primary care units that meet all criteria specified in this paper are not often found, but all primary care providers should attempt to achieve these standards. Professionals who train men and women for primary care should accustom their students to a practice environment that meets or exceeds these standards. THE DEFINITION The five attributes essential to the practice of good primary care are accessibility, comprehensiveness, co- ordination, continuity, and accountability. ACCESSIBILITY OF SERVICES Accessibility is especially important at the primary care level because primary care practitioners are the initial and most constant providers of health services. Patients must be able to reach the practitioner or a member of the team at all times. In addition, the physical location and the internal facilities of the primary care unit should be such that the patient can reach and use the provided services. The provider should be concerned that the cost of services and the way in which they are provided are acceptable to patients so that those who need care are not deterred from seeking it. Accessibility refers to the responsibility of the provider team to assist the patient or the potential patient to overcome temporal, spatial, economic, and psychologic barriers to health care. Secondary to accessibility are availability, attainability, and acceptability. Availability refers to the temporal aspects of access--for example, the maintenance of around-the-clock coverage and reasonably fast response to requests for service. Attainability covers physical and economic aspects of access. Acceptability refers to psychologic and social aspects of access. -16-

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Services should be available 24 hours a day, seven day a week, although it is recognized that isolated practitioners, who may practice excellent primary care, cannot keep such a schedule. These practi- tioners usually have a coverage arrangement with a doctor in a neighboring town or a nearby emergency room. The arrangement is known to the patients and to the covering provider who routinely transmits patient information back to the practitioners. How- ever, a practitioner who leaves town without ensuring that patients are informed of coverage arrangements, or even without arranging for coverage, is not practicing adequate primary care. Similarly, a hospital that closes the doors to its general clinic at 5:00 p.m. and routes all later patients to the emergency room without additional instructions or arrangements is not practicing acceptable primary care. Such a clinic should have an off-hours call schedule so that a patient can contact his or her own practitioner or one who has immediate access to the patient's records. Less acceptable would be a system in which a member of the primary care practice unit is "on call" to the emergency room, responding when one of his or her patients arrives, and incorporating a report of all such visits into the office record. Some feel that primary care practitioners should care for their patients regardless of their ability to pay* Others feel that a primary care practitioner should always accept assignment under Medicare, and should always accept Medicaid patients. Under the current system of payment, the provider unit must maintain some control over the payment structure or face economic disaster. For this reason, these qualifications are not considered essential to this definition; however, the primary care provider should be concerned about the economic status of the patients, and should assist them whenever and however possible to over- come financial barriers. COMPREHENSIVENESS OF SERVICES Comprehensiveness refers to the willingness and ability of the primary care team to handle the great majority of the health problems arising in the population it serves. A primary care practitioner may limit practice to an age group (pediatrics, internal medicine) or to one sex (obstetrics and gynecology). However, he or she -17-

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should handle most of the problems arising in the served population For example, an obstetrician and gynecologist who refers patients elsewhere for general physical examinations, headaches, febrile illnesses, and other similar needs and problems is not practicing primary care. Primary care includes provision of such preventive services as blood pressure and weight measurement, in addition to pap smears and breast examinations. Most obstetricians and gynecologists neither practice nor desire to practice primary care as defined in this paper, although they could do so if they wished. Similarly, the internist or pedia- trician who has a subspecialty interest should provide total care for the majority of patients' complaints and be willing to care for patients in the appropriate setting--whether the hospital, chronic care unit, or the home. Comprehensiveness of services is an attribute that distinguishes the primary care practitioner from the secondary care practitioner or referral specialist. The latter chooses not to provide common medical services in order to concentrate on more specialized services. The primary care practitioner may have an area of special medical interest, such as heart disease or diabetes mellitus, but does not limit services to concentrate on this interest. Many professional groups provide services that are an important part of the spectrum of primary care services. Pharmacists provide valuable advice and services to patients. Optometrists, podiatrists, dentists, and many other health professionals provide services that are a part of good health and medical care. However, these professionals generally do not provide the range of services characteristic of primary care. Nurse practitioners, physician assistants, and other nonphysicians working as part of a primary care unit can provide most, but not all, primary care services. In most states, they would be violating medical practice acts if they practiced independently. They are valuable members of the primary care team, not only because of their ability to increase the number of patients seen but also because they can add to the physician's usual range of services. Social workers also expand the scope of services. -18-

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COORDINATION OF SERVICES The primary care practitioner coordinates the patient's care, including that care provided by other specialists. The practitioner is the ombudsman for patient contacts with other providers, referring patients to appropriate specialists, providing pertinent information to and seeking opinions from these specialists, and explain- ing diagnosis and treatment to patients. In addition, the primary care practitioner coordinates the patient's plan of care with his or her financial capabilities and personal desires. This implies an understanding of the patient's family and occupational environment, financial circumstances, preferences, and way of life. CONTINUITY OF SERVICES Continuity is the fourth essential attribute of primary care, and it cannot exist without the first three. Inaccessibility of a practitioner encourages patients to use emergency rooms or other providers of services, destroying continuity. Referral of patients to others for services that should be within the scope of the primary care unit promotes discontinuous and fragmented care. Failure of the primary care practitioner to seek results from referral sources and to incorporate this information into the patient's record or failure to accommodate and adapt to the patient's preferences also destroy continuity. The primary care provider should be more aggressive in seeking continuity than is commonly the case today. An instruction to return in one year for an examination should be followed by a reminder card or telephone call before the scheduled visit, and a missed ap- pointment should evoke some effort to determine the reason and to reschedule for a later time. In today's practice environment, the patient's record is of increasing importance in achieving continuity of services. The solo practitioner of the past may have been able to recall the most relevant facts about his or her patients. However, in a modern practice, quantitative data from tests and coverage shared among partners place more importance on a readily accessible record in which significant problems are highlighted and the treatment plan is outlined clearly. 19

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ACCOUNTABILITY Accountability is an attribute not unique to primary care, but essential to it. The primary care unit should review regularly both the process and the out- comes of its care. Reviews should lead to education activities to correct deficiencies and expand skills and services. All members of the staff should be included. In addition, the professional staff of the primary care unit should establish a policy of providing appropriate information to the patient about risks and possible undesirable effects of treatment, and about unexpected or undesirable outcomes, so that the patient can make informed decisions about proposed care. Also, the physician has an obligation to maintain appropriate financial accountability, including adequate professional liability coverage. A PRIMARY CARE CHECKLIST To introduce as much specificity as possible into this definition of primary care, a list of activities or indicators has been prepared. They would be useful evidence of the achievement or presence of these attributes in a given practice unit. These indicators are not of equal importance or value. They have been placed in order by separating those considered "essential" from those considered "important." An essential indicator must be present for the unit to be considered as having achieved the attribute under which the indicator is listed. This checklist could have many uses. Among the most important is its use as a self-evaluative instrument for a clinic or practice unit. The checklist could also be used by an outside agency as one measure In determining whether or not a teaching clinic provides a true primary care experience for its trainees. There are other indicators that might have equal or greater value, and others may wish to validate these indicators with more precision or to use another format. In the list below, those items considered essential are designated by the enclosed box in the right hand column, while those that are important, but not essential, are designated by a dash. -20-

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A. ARE SERVICES ACCESSIBLE ? 1. Are Services Available to Patients? Is access to primary care services provided 24 hours a day, seven days a week? b. Is there an opportunity for a patient to schedule an appointment? c. Are scheduled office hours compatible with the work and way of life of most of the patients? d. Can most (90 percent) medically urgent cases be seen within one hour? Can most patients (90 percent) with acute but not urgent problems be seen within one day? Can most (90 percent) appropriate requests for routine appointments, such as preventive exams, be met within one week? 2. Are Services Convenient to Patients? a. Is the practice unit conveniently located, so that most patients can reach it by public or private transportation? b. Is the practice unit so designed that handicapped or elderly patients are not inconvenienced? Does the practice unit accept patients who have 21

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l a means of payment, regardless of source (Medicare, Medicaid)? 3. Are Services Acceptable to Patients? a. Is the waiting time for most (90 percent) of the scheduled appointments less than one half hour? b If a substantial minority (25 percent) of patients have a special language or other communication bar- rier, does the office staff include people who can deal with this problem? c. Are waiting accommodations comfortable and uncrowded? d. Does the practice staff consistently demonstrate an interest in and appreciation of the culture, background, socioeconomic status. work environment, and living circumstances of patients? Is simple, understandable information provided to patients about fees, billing procedures, scheduling of appointments, contacting the unit after hours, and grievance procedures? Are patients encouraged to ask questions about their illness and their care, to discuss their health problems freely, and to review their records, if desired? Does the practice unit accept patients without regard to race, religion, or ethnic origin? -22- _/ _/ / /

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B. ARE SERVICES COMPREHENSIVE? Within the patient population served, and realizing that this might be restricted to a certain age (pediatrics) or sex (obstetrics and gynecology), unit willing to is the practice -v handle, without referral, the great majority (over 90 percent) of the problems arising in this population (for example, general complaints such as fever or fatigue, minor trauma, sore throat, cough, and chest pain)? - 2- Are appropriate primary and secondary preventive measures used for those people at risk (for example: for tetanus, polio; early detection of hypertension; control of risk factors for coronary disease)? . . . Immunizations Are the practiti Inure ' . . . In the Unit W1 lung, if appropriate, to admit and care for patients in hospitals? 4. Are the practitioners in the unit willing to admit and care for patients in nursing homes or convalescent homes? Are the practitioners in the unit willing, if appropriate, to visit the patient at home? 6. Are patients encouraged and assisted in providing for their own care and participating allies in their own health plan (for example, through instruction in a_ :_ _ , ~ , exercise, accident prevention, family planning, and adolescent problems)? as care mltr, ti on rli at -23- / / / / / / / /

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7. Do the practitioners in the unit provide support to those agencies and organizations promoting com- munity health (for example: health education programs for the public; disease detection programs; school health and sports medicine pro- grams; emergency care training)? C. ARE SERVICES COORDINATED? 1. Do the practitioners in the unit furnish pertinent information to other providers serving the patient, actively seek relevant feedback from consultants and other providers, and serve as the patient's ombudsmen in contacts with other providers? Is a summary or abstract of the patient's record provided to other physicians when needed? 3. Do the practitioners in the unit develop a treatment plan with the patient that reflects consideration of the patient's understanding? Do the practitioners use a variety of tactics to ensure that the patient will cooperate in the treatment? Does the plan of treat- ment reflect the patient's physical, emotional, and financial ability to carry it out? 4. Is another source of care recom- mended when a patient moves to another geographic area? D. ARE SERVICES CONTINUOUS? 1. Can a patient who desires to do so make subsequent appointments with the same provider? 2. Are complete records maintained in a form that is easily retriev- able and accessible? -24-

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3. Are relevant items or problems in the patient's record high- lighted, regularly reviewed, and used in planning care? 4. Is each patient reminded of his or her next appointment? E. IS THE UNIT ACCOUNTABLE? 1. Do the practitioners in the unit assume responsibility for alert- ing proper authorities if a patient's problem reveals a health hazard that may affect others in the community (for example: discovery of exposure to toxic chemicals in an industrial plant; discovery of a communicable disease)? 2. Is there a patient-disease and age-sex registry maintained that can provide the basis of : practice audit? Is there a system for regular review of the quality of the process of medical care (for example, reviews for complete- ness of therapeutic programs and follow-up of acute illnesses)? Is there a system for regular assessment of the outcomes of the care offered (for example: review of outcome of treatment of specific illnesses; review of level of satisfaction of patients with the services provided; review of compliance with recommendations)? 5. Is there evidence that the unit regularly assesses the capability of the staff and provides oppor- tunity for continuing education? 6. Are patients appropriately informed about the nature of their condition, the benefits and risks of available treatments, and the expected outcome? -25-

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Are they provided the opportunity to ask questions and discuss their medical record? 7. If unexpected or undesired outcomes occur, are they made known and adequately explained to patients, and is a method established for responding to any expressed dis- satisfaction (such as conferences, counseling, arbitration, adjustment of billing, or referral)? 8. Does the provider maintain financial accountability by keeping accurate records and having adequate profes- sional liability coverage? -26- . 1

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REFERENCE S Chapter 2 1. See staff paper, "Definitions of Primary Care. " 2. See staff paper, "Roles of Other Professions in Primary Care. " 27

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