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--> Index A Academic health centers, 188, 206, 207 interdisciplinary team training, 11 mission of, in primary care, 9, 24, 144, 257 role in primary care delivery, 111-112, 143-144, 173 Accessibility of services, 44, 47, 65-66, 240, 329 in primary care definition, 2, 31, 32, 33, 45-46 and workforce supply, 9, 20, 168, 169 Accountability in clinician-patient partnership, 57-58 for efficient use of resources, 33, 49 for ethical behavior, 33, 49 for patient satisfaction, 33, 48-49 of patients, 49-50 in primary care definition, 2, 31, 33, 46-50 for quality of care, 33, 46-48, 242-243 research, 242-243 Accreditation organizations, 141, 193 and primary care curriculum, 10, 186, 194 Acute care, 40-41 Advanced care planning, 85 Advocacy skills, 192 African Americans, 157, 195 Agency for Health Care Policy and Research (AHCPR), 218, 220, 221, 223-224 All-payer system for graduate medical education, 11, 202, 259 for primary care training, 6, 10, 201-202, 258-259 for research funding, 233 Alternative medicine, 126 American Academy of Family Physicians (AAFP), 190, 199 American Academy of Pediatrics, 199 American Board of Family Practice (ABFP), 208 American College of Obstetricians and Gynecologists (ACOG), 123, 190 American Society of Internal Medicine (ASIM), 122, 183 Asian Americans, 157, 195 Association of American Medical Colleges (AAMC), 182, 184 Availability of services, 8, 112-113, 253

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--> B Behavioral sciences, 81-82 Biomedical sciences, 3, 81, 191 Bureau of Health Professions (BHP), 198, 199, 220 C CALPERS (California Public Employees Retirement System), 139 Capital markets, 22, 108 Capitation payments, 114-116 and mental health services, 115, 300-302 and withholding of services, 327 and workforce composition, 315 Caregivers, 35, 60 Catastrophic health insurance, 117 Centers for Disease Control and Prevention (CDC), 221 Certification and licensure, 10, 47 after physician retraining, 11, 210-211 examinations, 185 of nurse practitioners, 159-160, 316 Chronic care, 2, 18, 41, 67 Classification, see Diagnostic classification and coding Clerkships, 182-184 Clinical decisionmaking, 3, 39, 83-84, 355 importance of continuity of care, 57 and mental disorders, 86-87, 288, 293-298, 299 by nonphysician clinicians, 320 patient participation, 85-86 theoretical bases, 81-83 Clinical nurse specialist (CNS) programs, 161-162 Clinical trials, 236-237 for mental health treatment, 287 Clinicians, 5, 148-149 communication skills, 47, 82 core competencies, 9, 188-194, 258, 314 in primary care definition, 29, 33, 36, 44-45, 148 salaried, 115, 116 see also Education and training; Nurse practitioners; Partnership with patients; Physician assistants; Physicians; Specialists and specialty care; Workforce Coding, see Diagnostic classification and coding Collaborative care, 71-72 in mental health, 9, 136-137, 304-305, 307 see also Primary care teams Communication and interpersonal relations, 47, 82 training in, 10, 191, 194-195, 258, 307 Communities coordination of services within, 36, 43, 71-72, 127 in primary care definition, 3, 31, 32, 33, 35-36 research on, 243 Community-Based Public Health Initiative, 196 Community health information networks (CHINs), 365 Community-oriented primary care (COPC), 28, 30, 71, 133, 351-352, 357, 369 Comorbidity, 80, 237, 289 with mental disorders, 292-293, 295 Competencies, see Core competencies Comprehensive care, 28, 68-69 and care outcomes, 68-69 integrated services, 32, 38-41 Computer-based patient records, 44, 57, 69-70, 88, 125, 126, 142 Computer networks, 38 Consolidated Omnibus Budget Reconciliation Act, 197 Consortia, see Primary care consortium Consultation/liaison (C/L) psychiatry, 305 Continuing medical education (CME), 142, 192, 207 Continuity of care, 28, 29, 44, 69, 117-118 and clinician-patient partnership, 56-57 and mental health care, 302 research, 241 and service integration, 32, 43-44

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--> Coordination of services, 32, 41-43, 55-56, 69-70, 88, 126 research, 240-241 specialty referrals and other services, 41, 55, 109-110, 124-126, 130-139, 131-132, 356 Core competencies, 9, 188-194, 258, 314 for nurse practitioners, 192-193 training, 5, 10, 183-184, 186-187, 188-194, 258 Costs and cost control, 14, 21, 64, 347-348 patient resistance, 23, 39 specialty care, 13, 63-65 and technological innovation, 24 Council on Graduate Medical Education (COGME), 14, 170-171 202, 367 Cultural sensitivity, 36, 85-86 training in, 10, 191, 194-196, 258 Culture and social norms, 35, 85-86, 329 Curricula, see Core competencies; Education and training D Data sources, 222-229 development of national data set, 11, 224-225, 228-229, 260 episodes of care, 79-80, 101 patient interviews and surveys, 48-49 patient records as, 48, 57-58, 227 population-based surveys, 218, 223-224, 229n on workforce issues, 10, 170-171, 172, 257 see also Medical Outcomes Study; Medicare Current Beneficiary Survey; National Ambulatory Medical Care Survey; National Health and Nutrition Examination Survey; National Health Interview Survey; National Medical Expenditures Survey; Netherlands Transition Project Data standards, 12, 233-234, 261, 355-356 Definitions, see Primary care definition Delivery of primary care academic health centers' role in, 9, 24, 111-112, 143-144, 173, 257 coordination with other services, 109-110, 124-126, 130-139, 356 diversity within, 109, 296 organizational arrangements, 4, 108, 118-119 professional roles in, 110, 119-126 specialists' role in, 12, 41, 44, 110, 122-124, 238-239, 261 to underserved populations, 4, 8, 111, 126-130, 255 see also Financing of primary care; Infrastructure development; Integrated delivery systems; Managed care Demand for clinicials, 156, 165-166, 167-168 monitoring of, 5, 10, 170-171, 257 see also Geographic distribution; Underserved population; Workforce Dentists and dentistry, 44, 109, 125, 165 Department of Defense (DOD), 196, 221 Department of Health and Human Services (DHHS), 11, 12, 218, 219, 220, 223 Department of Veterans Affairs (VA), 109, 196, 221 Depression, 295, 297, 298, 302 Diagnosis, see Clinical decisionmaking; Early detection Diagnostic and Statistical Manual for Mental Disorders (DSM), 79, 294, 295-296 Diagnostic classification and coding, 12, 228, 233, 234, 235, 261 international systems, 79, 90, 218, 294, 296 Diagnostic tests, 84 Disease prevention, see Preventive care E Early detection, 41, 58-59; see also Preventive care Educational levels, 71

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--> Education and training, 5-6, 19, 167-170, 179-180, 307-308 in ambulatory care settings, 10, 202-203, 258 community contexts, 191-192 continuing medical education (CME), 142, 207 in core competencies, 5, 10, 186-187, 188-194, 258 funding of, 5-6, 157-158, 166, 179, 181, 196-203, 257 interdisciplinary approaches, 6, 11, 203-206, 259-260 minority participation, 157, 169-170 of nurse practitioners, 20, 159, 160-162, 200, 206, 316 of physician assistants, 157, 196-200 of physicians, 150, 156-158, 180-187 see also Graduate medical education; Retraining of physicians; Undergraduate medical education Efficiency and productivity, 15, 61-62, 115 accountability for, 33, 49 of nonphysician clinicians, 317-319, 321, 332 Elderly persons, 2, 18, 20, 60, 137, 138 Emergency care, 45, 65-66, 67, 111 Epidemiological studies, 82-83 Episodes of care, 56, 225-226 comparison of U.S. and Dutch data sets, 89-101 as unit of assessment, 48, 79-80, 226-228 Ethics and ethical behavior, 82, 192 accountability for, 33, 49 Evidence-based medicine, 82-83 F Faculty reimbursement, 197-198 Family members and relationships, 81, 191 care givers, 35, 60 in primary care definition, 3, 31, 32, 33, 35 research on, 243 Family practice, 19, 63, 64, 77, 192 residencies, 186-187, 199 Federated Council of Internal Medicine Curriculum Task Force (FCIMCTF), 189-190 Fee-for-service (FFS), 8, 114, 115, 116, 254, 314 HMO payments to clinicians, 315n and mental health services, 300 Financing of primary care, 113-118 impact on quality of care, 327-332, 355 payment methods and mechanisms, 8, 115-118, 254 universal coverage, 113-114, 253-254 see also All-payer system; Capitation payments; Fee-for-service First-contact care, 27, 28, 29, 38-39 by non-medical professionals, 124-126, 165 For-profit ownership, 22, 108 G Gatekeepers, 20, 39, 125 in mental health services, 302 General practitioners, 19, 41n, 63, 64, 68, 190 Geographic distribution of managed care programs, 106-107 of physicians, 64, 67, 158 of primary care workforce, 10, 171-173, 257 Global capitation, 114-116 Graduate medical education (GME), 157, 185-187 financing, 196-203 Medicare support, 196, 197-198, 202-203, 259 as a public good, 200-201 H Health Care Financing Administration (HCFA), 128, 197, 221, 223, 224, 254

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--> Health care reform, 7, 21, 113 Health care services, in primary care definition, 2, 31, 32-33, 37 -38 Health Maintenance Organization Act, 20 Health maintenance organizations (HMOs), 20, 22, 63, 106, 107, 351 payments to clinicians, 115 staffing patterns, 322-327 Health promotion, 2, 3, 18, 58, 87-88, 132, 134 Health services research, 236 HEDIS (Health Plan Employer Data and Information Set), 139 Hispanic Americans, 157 Hospital-based care, 13 excess capacity, 21 preventable, 66, 67 Households, see Family members and relationships Humanities, 81 I ICD, see International Classification of Diseases Inappropriate care, 47 Income levels, 71 Information management, 3, 88, 142, 192 and accessibility of services, 46 in community contexts, 36, 44, 355-356, 361 networks, 38, 365 patient records, 43-44, 57-58, 69-70 Informed consent, 85 Infrastructure development, 141-143 for research, 11, 218-219, 235 Insurance, 116 mental health care coverage, 87, 297, 299 primary care disincentives, 116, 117, 136, 137 see also Universal coverage Integrated delivery systems, 2, 18, 32-33, 35, 38, 143 accessibility, 45-46 and clinician training, 206-207 organization of, 22, 31, 107-108 Integrated services in community context, 352-372 comprehensiveness, 32, 38-41 continuity in, 32, 43-44 coordination in, 32, 41-43, 126 for mental health care, 303, 304-305, 357-358 in primary care definition, 2, 29, 31, 32, 33, 38-44, 314 research, 240-241 Interdisciplinary teams, see Primary care teams Internal medicine and internists, 19, 20, 77, 122, 156 training, 186-187, 192, 194, 199-200, 209 International Classification of Primary Care (ICPC), 80, 90, 218 International Classification of Diseases (ICD), 79, 90 and mental disorders, 294, 296 International medical graduates (IMGs), 149 J Judgment, see Clinical decisionmaking K Kaiser Permanente, 107, 320-321 Kellogg, W. K., Foundation, 134, 179, 196, 222, 352 Korean Americans, 86 L Latino populations, 195 Life-cycle curriculum, 191 Long-term care, 9, 60, 109, 114, 137-139, 256 M Managed care, 2, 18, 21-22, 64, 105-107, 312, 356 consolidation in, 22, 108

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--> geographic distribution, 106-107 and information management, 355 and mental health services, 300-301, 302 and public health, 132-133, 134-135, 355 and underserved populations, 111, 118, 119, 127-128, 172-173, 327-328 workforce impacts, 106, 313-327 Market shares, 107, 108 Medicaid, 20, 22, 130, 167-168, 196 cost-of-care studies, 64 managed care arrangements, 22, 106, 127-128, 132 Medical Outcomes Study (MOS), 63, 68 Medical savings accounts (MSAs), 117 Medicare, 20, 22, 64, 116 graduate medical education support, 196, 197-198, 202-203, 259 managed care arrangements, 22, 106, 128 nursing education support, 200 Medicare Current Beneficiary Survey (MCBS), 224 Mental health comorbidity, 292-293, 295 and insurance reimbursement, 87, 297, 299 prevalence of disorders, 289 relation to physical health, 3, 86-87, 237, 286-288, 299 research, 237, 306 Mental health ''carve-outs," 109, 135, 136, 302-303 Mental health services, 9, 109, 135-137, 255-256, 285-308 collaborative care models, 9, 136-137, 304-305, 307 financing of, 87, 135-136, 300-304 parallel systems, 135, 304 research, 306-307 Mexican Americans, 86, 157 Minority groups, 85-86 medical education and training, 157, 169-170 see also Cultural sensitivity; Culture and social norms Misuse of health services, 47 Mixed practices, 122 N National Ambulatory Medical Care Survey (NAMCS), 77, 91-92, 97-101, 223 National Board of Medical Examiners (NBME), 185 National Center for Health Statistics (NCHS), 218, 223, 228-229 National Committee for Quality Assurance (NCQA), 139 National Health and Nutrition Examination Survey (NHANES), 223 National Health Interview Survey (NHIS), 91-92, 97-101, 223 National Health Service Corps, 171-172 National Hospital Ambulatory Medical Care (NHAMC) survey, 223 National Institute for Mental Health, 305-306 National Institutes of Health, 126, 221 National Medical Expenditures Survey (NMES), 223-224, 226-227, 228 National Organization of Nurse Practitioner Faculties (NONPF), 192 Native Americans, 157 Navajo, 85 Netherlands Transition Project, 80, 89, 90-91, 93-97 Nonphysician clinicians, see Nurse practitioners; Physician assistants Nurse practitioners (NPs) certification, 159-160, 316 core competencies, 192-193 education and training, 20, 159, 160-162, 200, 206, 316 in managed care settings, 320-321, 322-323 as physician substitutes, 315, 317-319, 322-323, 332 quality of care, 319-320, 333-334 responsibilities, 110, 162, 316 scope of practice, 10, 173-175, 258, 314-315, 332-333 supply, 160-162, 171, 316 work settings, 162, 316

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--> O Obstetrics and gynecology, 77, 110, 122, 123, 154, 209 Omnibus Budget Reconciliation Act, 197 Optometry and vision services, 109, 125 Orthopedists, 77 Outcomes of care, 67-70 P Partnership with patients, 2, 3, 18, 44, 49-50, 53, 56-58, 61-62, 84-86, 329 in primary care definition, 3, 31-32, 33, 36-37 research, 241-242 theoretical bases for, 81-82 Patient education materials, 142 Patient records in accountability systems, 48, 57-58 as research data sources, 48, 57-58, 227 Patient satisfaction, 33, 44, 48-49 with nonphysician clinicians, 319 Patients, in primary care definition, 31, 33, 34 Pediatrics and pediatricians, 19, 20, 77, 156, 192 training, 186-187, 199-200 Performance monitoring, 114, 139-141, 256 measurement, 9, 24, 47-48, 140, 141 Personal health care needs, 18, 53-54 diagnostic clusters, 53-54, 77-78 in primary care definition, 3, 31, 33, 37, 40 research, 239-240 Pew Charitable Trusts, 134, 179, 221 Pew Health Professions Commission, 202, 204, 209 Pharmacy services, 109, 125-126 Physician assistants (PAs), 110, 162-163 education and training, 20, 163-164, 198, 206, 316 in managed care settings, 320-321, 322-323 as physician substitutes, 315, 317-319, 322-323, 332 quality of care, 319-320, 333-334 scope of practice, 10, 173-175, 258, 314-315, 332-333 supply, 163-165, 171, 316 work settings, 164, 316 Physicians demand and supply issues, 110, 149-153, 313, 315, 322-323 education and training, 150, 156-158, 180-187 geographic distribution, 64, 67, 158 primary care supply and shortages, 19, 20, 154-158 principal providers, 28, 41, 42, 123-124 and public health professionals, 353-354 retraining, 6, 11, 208-211, 260 substitution with nonphysicians, 241, 315, 317-319, 322-323, 332, 334 see also Specialists and specialty care Pike Street Clinic Project, 303 Practice-based research networks, 12, 230-233, 260 Preferred provider organizations (PPOs), 106 Preventive care, 2, 3, 18, 41, 58-59, 70, 87-88, 132, 134, 192, 345 actual practice of, 298 in community context, 35-36, 71, 348-352 Primary care consortium, 7, 12, 141, 250-252, 261 Primary care definition, 1, 2-3, 8, 31-34, 104, 119-120, 252-253, 313 development of, 29-31 early definitions, 19, 27-29 Primary care teams, 2, 8, 42, 110, 120-121, 254-255, 313n as care coordinators, 55-56, 138 in managed care, 327-332, 334-335 training, 11, 203-206, 259-260 Principal physicians, 28, 41n, 42, 123-124 specialists as, 41, 123-124 Productivity, see Efficiency and productivity Professional societies, 193. See also under names of individual societies

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--> Providers, see Clinicians Psychiatry, 305 Public health, 29-30 linkage to primary care, 9, 30, 60-61, 88, 109, 131-135, 243-244, 255, 342-372 research on, 243-244 Public health nurses, 19 Public Health Service Act Title VII funds, 157, 196, 198-200 Title VIII funds, 200 Puerto Ricans, 157 Q Quality assessment, 47-48, 242 Quality of care, 3, 66-70 improvement programs, 107-108, 256 and nonphysician clinicians, 319-320, 321-322 performance measurement, 9, 24, 47-48, 140, 141 R Randomized clinical trials (RCTs), 236-237 Referrals, 39, 70 coordination of, 41, 55, 131-132 incentives against, 115 to mental health professionals, 86, 135, 287, 302-303 Registered nurses (RNs), 158-159, 160 Relationships, see Collaborative care; Partnership with patients; Primary care teams Requirements for clinicians, see Demand for clinicians Research, 6, 216-217 and clinical trials, 236-237 on core concepts, 239-244 data sources, 222-229 data standards, 12, 233-234, 261, 355-356 lead agency for, 11, 219-222, 260 on mental health, 237 on specialty care, 238-239 see also Practice-based research networks Residency, 5, 11, 186-187, 197 Residency review committees, 186 Resource-Based Relative Value Scale (RBVRS), 116, 254 Retraining of physicians, 6, 11, 208-211, 260 Robert Wood Johnson Foundation, 20, 134, 179, 199, 221 Rural settings, 20, 111, 171-172 demands on practice in, 129, 298 managed care in, 106, 111, 127, 129-130, 172-173 S Satisfaction, see Patient satisfaction School outreach, 59-60 Scope of care, 40-41 Scope of practice, 5, 10, 23, 173-175, 258, 314-315, 332-333 Screening programs, 87, 125 Self-care, 76, 86 Self-declaration, 208, 209 Self-efficacy, 81 Self-referral, 39, 70 Social functioning, 37-38 Social sciences, 3, 81-82 Society, see Communities; Culture and social norms Society of Teachers of Family Medicine (STFM), 190 Socioeconomic conditions, 71 Southeast Asians, 195 Specialists and specialty care, 12, 13-14, 24, 68, 106, 123, 153 accessibility of, 13, 65-66 clinical decision-making, 83-84 cost issues, 13, 63-65 imbalance in supply, 19, 20, 23, 122, 155-156, 169 quality issues, 66-70 research on, 238-239 role in primary care, 12, 41, 44, 110, 122-124, 238-239, 261

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--> Special-needs populations, 128-129, 255 State scope of practice laws, 5, 10, 23, 174-175, 258 Stroke, 295 Substance abuse services, 109, 135 Substitution for physicians, 241, 315, 317-319, 322-323, 332, 334 Supply of professionals, see Workforce Surveys, see under Data sources T Team care, see Primary care teams Technical quality, 47 Technological innovations, 24 Telecommunication, 46, 88 Title VII funds, 157, 196, 198-200 Title VIII funds, 200 Traditional healers, 36, 126 Triage functions, 28, 118 U Undergraduate medical education, 180-185 competencies, 183-184 curricular reforms, 182-183 examinations, 185 faculty, 185 training in primary care settings, 5, 181-184 Underserved populations, 171-172n and managed care programs, 111, 118, 119, 127-128, 172-173, 327-328 primary care delivery, 4, 8, 111, 126-130, 255 Underuse of care, 47, 49 Undifferentiated problems, 40n Uninsured population, 22-23, 65, 66, 104, 113 in managed care markets, 107, 128 United States Medical Licensing Examination, 185 Universal coverage, 8, 21, 368 financing, 113-114, 253-254 Unnecessary care, 47 Urban poor, 20, 111, 130, 171-173 V Value of primary care, 2, 3, 14, 18, 52 accessibility of services, 65-66 for clinician-patient partnership, 53, 56-58 cost impacts, 63-65 as guide through health system, 53, 54-56 links with community and family, 53, 59-61 for preventive care and health promotion, 53, 58-59 quality issues, 3, 66-70 as route to appropriate care, 53-54 Vertical integration, 107 W Workforce, 4-5, 9-10 and care accessibility, 9, 20, 168, 169 estimation methods, 165-167 geographic maldistribution, 10, 171-173, 257 imbalances in supply, 5, 169 monitoring and data collection, 10, 170-171, 172, 257 nonphysician clinicians, 160-162, 171, 316 primary care physicians, 19, 20, 154-158 specialists, 19, 20, 23, 122, 155-156, 169 see also Education and training