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Presentation Transcript
Objectives To understand the following: -Primary health care -Definition -Functions -ROLE OF PRIMARY CARE IN A WELL- FUNCTIONING HEALTH CARE SYSTEM -Principles of good primary care
Primary care is health care that is accessible, comprehensive, coordinated, and continuing. It is provided by physicians specifically trained for and skilled in comprehensive first-contact and continuing care for ill persons or those with an undiagnosed sign, symptom, or health concern (i.e., the undifferentiated patient) and is not limited by problem origin (i.e.,biologic, behavioral, or social), organ system, or gender.
In addition to diagnosis and treatment of acute and chronic illnesses, primary care includes health promotion, disease prevention, health maintenance, counseling, and patient education in a variety of health care settings (e.g.,office, inpatient, critical care, long-term care, home care). Primary care is performed and managed by a personal physician, using other health professionals for consultation or referral as appropriate.
Primary care is the backbone of the health care system and encompasses the following functions: 1. It is first-contact care, serving as a point of entry for the patient into the health care system. 2. It includes continuity by virtue of caring for patients in sickness and in health over some period.
3. It is comprehensive care, drawing from all the traditional major disciplines for its functional content. 4. It serves a coordinative function for all the health care needs of the patient. 5. It assumes continuing responsibility for individual patient follow-up and community health problems. 6. It is a highly personalized type of care.
In a 2008 report, Primary Health CareNow More than Ever, the World Health Organization (WHO) emphasizes that primary care is the best way of coping with the illnesses of the 21st century, and that better use of existing preventive measures could reduce the global burden of disease by as much as 70%. Rather than drifting from one short-term priority to another, countries should make prevention equally important as cure and focus on the rise in chronic diseases that require long- term care and strong community support. Furthermore, at the 62nd World Health Assembly in 2009, WHO strongly reaffirmed the values and principles of primary health care as the basis for strengthening health care systems worldwide.
To find out what primary care physicians actually do, a comprehensive study of the activities of family physicians directly observed 4,454 patient visits to 138 family physicians in 84 practices. Among the findings of that study follows: An extensive variety of common, rare, and undifferentiated problems are managed in primary care. Often, management includes a process in which the patient presents with new symptoms and leaves with a new or provisional diagnosis.
Prevention is practiced broadly in primary care visits, and not just during physicals. During 32% of illness visits, the family physician delivers at least one service recom- mended by the US Preventive Services Task Force. Health habit messages are tailored toward high-risk patients and teachable moments; for example, smoking counseling is more often given in the context of smoking-related illness visits. Mental health problems present frequently and are often managed without referral. For example, in 18% of visits, family physicians either diagnose or provide counseling related to depression or anxiety.
Patient education is a major part of primary care practice. Fully 90% of office visits, and 19% of visit time overall, involve patient education or health habit advice. Care is often provided in the context of family. 70% of patients have another family member seeing the same physician. In 18% of visits, care is provided to another family member in addition to the identified patient.
Coordination of care is common. During 10% of office visits, a referral is made to a medical specialist, mental health provider, physical therapist, social worker, or other health professional. The study also showed that family physicians have to prioritize among a broad agenda of competing opportunities, taking a patient-centered approach. By developing relationships over time, problems are addressed gradually, over many visits.
In summary, primary care practice involves a broad series of activities that include early diagnosis, chronic disease management, acute care, mental health care, prevention, family care, and attention to community. These activities occur because of ongoing relationships between the patient and a personal physician who knows and is trusted by the patient. It is not surprising, then, that costs are lower and health outcomes better when primary care is the cornerstone of a health care system.
-Primary care physicians play a key role in the worlds most cost-effective health care systems. -The higher the ratio of primary care physicians to subspecialists, the better the outcomes and the lower the cost. How does a greater emphasis on primary care lead to better, more cost-effective overall health care? care is integrated, personalized, and prioritized; preventive services are more consistently delivered; chronic diseases, such as asthma, cardiovascular disease, and diabetes, are better managed;
acute problems are diagnosed and treated earlier; people with low incomes tend to have greater access to care and, concomitantly, fewer disparities in health outcomes; primary care physicians tend to be active at a community level to improve health care resources and attitudes for both healthy patients and those with chronic diseases.
When patients go to subspecialists for their care without having a primary care provider, their care tends to be fragmented and discontinuous . Furthermore, treatment focused on one body system can have unintended adverse impacts in other areas; more and more care is not necessarily best for patients. On the other hand, when access to subspecialists is severely restricted, patients often suffer symptoms for months or years without getting available treatments. Therefore, a well-functioning health care system needs both primary care providers and subspecialists. As a result, a 2008 analysis in the Annals of Internal Medicine concluded that investment in primary and preventive care can result in better health outcomes.
The principles of good primary care are embodied in the principles of family medicine: -Access to care - Continuity of care -Team-based, comprehensive, personalized care - Coordination of care - Community orientation - Prevention focus - Patient self-empowerment and self-management - Evidence-based practice - Family orientation - Biopsychosocial, life-cycle perspective
Primary care should be readily available. Open access is one way of helping assure this. It is a system of organizing a medical practice that keeps slots open for same-day appointments, uses telephone protocols to triage patients by urgency of need, and organizes schedules to correspond with consumer demand.
A 24-hour call service for patients and secure email correspondence can save time and facilitate closer monitoring. One example is providing day-to-day insulin adjustments in a newly diagnosed diabetic.
The average family medicine patient visits the same practice 20 times in 5 years. Seeing the same provider over time is called continuity of care. Several evidence-based reviews have identified numerous favorable outcomes from continuity of care. In addition, it is associated with fuller, more satisfying relationships for both the doctor and the patient. However, because no physician can be available all the time, continuity of care can be enhanced by using a comprehensive, shared medical record (continuity of information) and by organizing a large practice into small teams.
A family physician manages without referral between 85% and 90% of patient problems. In doing so, a wide range of services are provided, including acute care, chronic disease care, preventive care, and care for biomedical and psychosocial problems, and they are tailored to the personal needs and priorities of the patient.
This provision of a wide variety of services, covering the majority of patient needs, is termed comprehensiveness of care. However, as health care has become more complex, primary care offices are increasingly using multidisciplinary teams and electronic health records to enhance their ability to provide comprehensive care.
Team-based services can include onsite behavioral counseling on such issues as smoking and diet, a pharmacy, dental services, physical therapy, and a variety of complementary/alternative health providers.
Electronic health records enhance comprehensiveness (and quality) of care by providing ready access to clinically useful information, such as practice guidelines, standardized order sets, evidence summaries, disease tracking, prevention reminders, and drug interaction data.
Primary care providers help their patients negotiate the complex health care system by serving as coordinators of care. This process of coordination includes being aware of the variety of services available, making appropriate requests for consultation or referral, collecting and interpreting results of studies and specialist visits, and advising when additional care is and is not warranted.
. Although most of the physicians work is at the patient level, good primary care physicians also seek to improve the broader health of the community. In working with patients, they are aware of the many community resources, both formal and informal, that are available to help patients manage their medical and psychosocial needs, often relying on other health care team members (such as nurses or social workers) to help link patients to community resources.
As part of this community orientation, primary care physicians are often active in a variety of volunteer activities. Examples include serving on a local school board, acting as advisor to the local health department, lobbying for improved pollution controls in a local factory, advocating for better snacks in school vending machines, providing medical oversight for a free clinic or homeless shelter, organizing pre- participation screening for children, and standing at the sidelines as team physician during high school football games.
Preventive care is the most common reason patients visit a family physician s office. Examples of preventive visits include prenatal care, adult physicals, well-baby checkups, well child examinations, pre-employment physicals, visits in preparation for international travel, and checkups before participation in sports or summer camp.
Among the facets of preventive care are measures to reduce disease risk, such as assistance with smoking cessation; immunizations; measures to prevent morbidity in people who have established disease, such as prescription of aspirin for people with coronary artery disease; and minimization of disability through such services as therapeutic exercises for people with arthritis or rehabilitation for someone who has suffered a stroke.
Effective chronic illness care requires a partnership in which medical providers help the patient acquire the knowledge, skills, and self-empowerment to manage risk factors, monitor the illness, and make adjustments in their care. For example, literature has shown that asthmatics who are able to independently adjust their medications when symptoms change have better symptom relief and fewer acute attacks; similarly, diabetics who have been educated in self-management achieve better hemoglobin A1c levels.
Exemplary primary care is evidence-based. By this we mean that the primary care physician has access to and uses effectively what is available in the literature to guide practice. Unfortunately, the majority of clinical questions that arise in family medicine practice do not have adequate empirical data to be answered in a wholly evidence-based manner. As a result, primary care physicians must integrate different kinds of evidence, depending on logic, clinical intuition, and knowledge of the patient, family, and community to arrive at the best decisions
Quality primary care must take into account the family context, that can comprise a patient s close social network. Being oriented to the family context is important in medical care because most health behaviors and illness episodes involve some connection with the patient s social support network.
Many tools are available to assess and treat families, though most family physicians do the majority of their history-taking and therapeutic work with families informally. A genogram (formal family tree) can at times be helpful in understanding family relationships in complex systems. Another simple tool is the family circle.
Effective primary care physicians view patients from a broad perspective, taking into account physiology, physical illness, emotional health, and the social, occupational, and environmental context, Such a bio-psychosocial approach is important because health and illness behavior are strongly colored by the personality and environment within which the person lives.
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