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Importance of Understand the Population of Patients for Whom the Primary Care Team Is Responsible as a Strategy in Improving the Providing of Health Care and Its Accessbility

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Since its introduction in 1961, the term primary care has been defined in various ways, often using one or more of the following categories to describe what primary care is or who provides it. These categories include the care provided by certain clinicians—Some proposed legislation, for example, lists the medical specialties of primary care as family medicine, general internal medicine, general pediatrics, and obstetrics and gynecology. Some experts and groups have included nurse practitioners and physician assistants.

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At its core is maximizing value for patients: that is, achieving the best outcomes at the lowest cost. We must move away from a supply-driven health care system organized around what physicians do and toward a patient-centered system organized around what patients need. We must shift the focus from the volume and profitability of services provided—physician visits, hospitalizations, procedures, and tests—to the patient outcomes achieved. And we must replace today’s fragmented system, in which every local provider offers a full range of services, with a system in which services for particular medical conditions are concentrated in health-delivery organizations and in the right locations to deliver high-value care. Making this transformation is not a single step but an overarching strategy. We call it the “value agenda.” It will require restructuring how health care delivery is organized, measured, and reimbursed. In 2006, Michael Porter and Elizabeth Teisberg introduced the value agenda in their book Redefining Health Care. Since then, through our research and the work of thousands of health care leaders and academic researchers around the world, the tools to implement the agenda have been developed, and their deployment by providers and other organizations is rapidly spreading. The transformation to value-based health care is well under way. Some organizations are still at the stage of pilots and initiatives in individual practice areas. Other organizations, such as the Cleveland Clinic and Germany’s Schön Klinik, have undertaken large-scale changes involving multiple components of the value agenda. The result has been striking improvements in outcomes and efficiency, and growth in market share. There is no longer any doubt about how to increase the value of care. The question is, which organizations will lead the way and how quickly can others follow? The challenge of becoming a value-based organization should not be underestimated, given the entrenched interests and practices of many decades. This transformation must come from within. Only physicians and provider organizations can put in place the set of interdependent steps needed to improve value, because ultimately value is determined by how medicine is practiced. Yet every other stakeholder in the health care system has a role to play

Patients, health plans, employers, and suppliers can hasten the transformation—and all will benefit greatly from doing so. The first step in solving any problem is to define the proper goal. Efforts to reform health care have been hobbled by lack of clarity about the goal, or even by the pursuit of the wrong goal. Narrow goals such as improving access to care, containing costs, and boosting profits have been a distraction. Access to poor care is not the objective, nor is reducing cost at the expense of quality. Increasing profits is today misaligned with the interests of patients, because profits depend on increasing the volume of services, not delivering good results.

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Of all of the changes envisioned as part of the transformation to improved and more patient-centered primary care, perhaps none is more promising and more challenging than the transition to team-based delivery of care. Team-based care is defined by the National Academy of Medicine (formerly known as the Institute of Medicine) as "...the provision of health services to individuals, families, and/or their communities by at least two health providers who work collaboratively with patients and their caregivers—to the extent preferred by each patient - to accomplish shared goals within and across settings to achieve coordinated, high-quality care." (Naylor MD, 2010) Well-implemented team-based care has the potential to improve the comprehensiveness, coordination, efficiency, effectiveness, and value of care, as well as the satisfaction of patients and providers

To achieve this potential, the transition to team-based primary care requires, for most practices, profound changes in the culture and organization of care, in the nature of interactions among colleagues and with patients, in education and training, and in the ways in which primary care personnel and patients understand their roles and responsibilities. In addition, although team-based care may implicitly be considered patient-centered from the perspective of the health care system—because it is designed to make primary care more comprehensive and accessible, thereby meeting important needs of patients and families—this perception may not be universal. From the perspective of some clinicians and patients, team-based care may feel like a departure from patient-centered care because of its perceived potential to (1) disrupt relationships that are highly valued and seen as the foundation of good care, and (2) splinter care delivery across multiple team members. (Coleman K, Reid R., 2013)

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In sum, the areas reviewed included primary care definitions, primary care measurement, primary care practice, primary care and health, primary care and quality, primary care and cost, primary care and equity, primary care and health centers, and primary care and healthcare reform. In both developed and developing countries, primary care has been demonstrated to be associated with enhanced access to healthcare services, better health outcomes, and a decrease in hospitalization and use of emergency department visits. Primary care can also help counteract the negative impact of poor economic conditions on health.

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Naylor MD, Coburn KD, Kurtzman ET, et al. Inter-professional team-based primary care for chronically ill adults: state of the science. Unpublished white paper presented at the ABIM Foundation meeting to Advance Team-Based Care for the Chronically Ill in Ambulatory Settings. 2010 March 24-25; Philadelphia, PA.

Mitchell P, Wynia R, Golden B, et al. Core principles and values of effective team-based health care. Discussion Paper. Washington, DC: Institute of Medicine; 2012.

Okun, S, Schoenbaum S, Andrews D, et al. Patients and health care teams forging effective partnerships. Discussion Paper. Washington, DC: Institute of Medicine; 2014.

Coleman K, Reid R. Continuous and team-based healing relationships: improving patient care through teams. In: Phillips KE, Weir V, eds. Safety Net Medical Home Initiative Implementation Guide Series. 2nd ed. Seattle, WA: Qualis Health and The MacColl Center for Health Care Innovation at the Group Health Research Institute; 2013.

Shojania KG, Ranji SR, McDonald KM, et al. Effects of quality improvement strategies for type 2 diabetes on glycemic control: a meta-regression analysis. JAMA 2006;296(4):427-440.

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