Part 5

Issues to Be Addressed in the Full Report

The definition of primary care and of the terms in this report will guide the committee's further work. That work will result in a comprehensive strategy, both short and long term, for achieving improvements in primary care. Because the committee believes that primary care is a complex activity and that many factors will affect its improvement, the strategy will be multifaceted, relevant to a broad range of practice settings and populations, and performance oriented. It will aim to benefit the health status and satisfaction of individuals, to make more efficient use of resources that are devoted to health care, and to promote a fulfilling experience for health care clinicians.

Any strategy needs to be guided by goals, and this report has described the goals of primary care. Although the particulars of the strategy required to achieve these goals are yet to be developed, the following is a list of some of the key questions that the committee will be addressing. In outlining these questions, the committee recognizes that other groups have carried out extensive analyses of some of the questions, in particular, reimbursement of primary care clinicians, adequacy of supply of primary care clinicians, and curriculum content for primary care education. The committee will review this work. The committee will concentrate its efforts, however, on those questions that have received less attention than they deserve and on the development of a comprehensive and integrated strategy for improvement of primary care. The questions the committee will address in the full report include:



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OCR for page 35
Defining Primary Care:: An Interim Report Part 5 Issues to Be Addressed in the Full Report The definition of primary care and of the terms in this report will guide the committee's further work. That work will result in a comprehensive strategy, both short and long term, for achieving improvements in primary care. Because the committee believes that primary care is a complex activity and that many factors will affect its improvement, the strategy will be multifaceted, relevant to a broad range of practice settings and populations, and performance oriented. It will aim to benefit the health status and satisfaction of individuals, to make more efficient use of resources that are devoted to health care, and to promote a fulfilling experience for health care clinicians. Any strategy needs to be guided by goals, and this report has described the goals of primary care. Although the particulars of the strategy required to achieve these goals are yet to be developed, the following is a list of some of the key questions that the committee will be addressing. In outlining these questions, the committee recognizes that other groups have carried out extensive analyses of some of the questions, in particular, reimbursement of primary care clinicians, adequacy of supply of primary care clinicians, and curriculum content for primary care education. The committee will review this work. The committee will concentrate its efforts, however, on those questions that have received less attention than they deserve and on the development of a comprehensive and integrated strategy for improvement of primary care. The questions the committee will address in the full report include:

OCR for page 35
Defining Primary Care:: An Interim Report What are the implications of the definition for the scope of primary care? What are the health problems and risks in a population that constitute the potential targets of primary care? What is the relationship of these primary care functions to specialty care, other first-contact health services, mental health and substance abuse services, community and population-based health services, social services, and people's responsibility for their own health? How do the functions of primary care have to be modified to meet the special needs of some population groups, such as those living in rural areas; the socially and economically disadvantaged; people with different cultural backgrounds; the elderly; women, children, and adolescents; and the chronically disabled? How does or how can primary care contribute to the objectives of the U.S. health care system, including quality of care, access, efficiency, patient satisfaction, and clinician satisfaction? Who should provide primary care? What is the role of primary care clinicians, i.e., those whose predominant practice is focused on the primary care function as defined? What are the roles in primary care of other specialists and subspecialists? What are the roles of nonphysician clinicians (i.e., nurse practitioners and physician assistants), whose predominant activity is the provision of primary care as defined? What are the roles of other health professionals, both in first-contact and referral roles (e.g., dentists, pharmacists, podiatrists, physical therapists, and optometrists)? What are the characteristics of the primary care team and how does a team affect the roles of the participating clinicians?

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Defining Primary Care:: An Interim Report How are roles affected by different aspects of the primary care function (e.g., health assessment, symptomatic acute illness, and chronic illness management)? How are roles affected by different care settings (e.g., rural, inner city) and the needs of special populations? How could primary care be organized? Is the movement to vertically integrated systems and managed care facilitating the provision of primary care? What can such systems teach us about organizing primary care services? How can coordination of primary care and public health, social, long-term care, mental health, and substance abuse services be facilitated? How should primary care services be organized to meet the special needs of vulnerable populations? What are the organizational requirements for effective teamwork among primary care clinicians? How can the consulting role of specialists be more effectively integrated with the primary care practice? How can the roles of academic health centers in the provision of primary care be more effectively organized to facilitate their roles in education, research, and service innovations? What steps can be taken to improve the content and availability of primary care? How can education and training for primary care be improved to carry out the function as defined? Are there enough primary care clinicians? If not, what can be done to increase or reconfigure the supply? What are the essential infrastructure needs for primary care and how can they be met, e.g., information and decision systems, patient education, links to community resources, practice management, and training, including the special infrastructure needs of such populations as the elderly, rural groups, and the economically disadvantaged? What are the needs for primary care research, both content and support? How can existing primary care models and programs at the state and community levels be evaluated effectively so other programs can learn from their experience? What outcomes measures can be used to assess the quality of office-based practices? How can measures of patient health and functional status and patient preferences and satisfaction be incorporated into primary care databases?

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Defining Primary Care:: An Interim Report How can the financing of primary care, both capital and services, better reflect the appropriate place of primary care in the U.S. health care system? How can the public be better informed about the functions of primary care so they can make better choices and be better participants in their own care? What should be the elements of a comprehensive and coordinated implementation strategy to meet primary care needs as defined in this study? What is the appropriate phasing for implementing such a strategy? In implementing the strategy, what are the roles of the federal government, state governments, health care plans, professional organizations, communities, and patients?