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Delivering Healthcare (Part 2) Lecture A
- 1. Introduction to Health Care and Public Health in the U.S. Delivering Health Care, Part 2 Lecture a This material (Comp 1 Unit 3) was developed by Oregon Health & Science University, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number 90WT0001. This work is licensed under the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. To view a copy of this license, visit http://creativecommons.org/licenses/by-nc-sa/4.0/.
- 2. Delivering Health Care, Part 2 Learning Objectives • Describe the organization of clinical health care delivery in the outpatient setting, and the organization of outpatient health care (Lectures a-c) • Describe the organization of ancillary health care delivery in the outpatient setting (Lecture d) • Discuss the role of different health care providers, with an emphasis on the delivery of care in an interdisciplinary setting (Lecture e) 2
- 3. Outpatient Care • Outpatient = not hospitalized • Visits an "outpatient facility" for care • Outpatient facilities – Primary care offices – Specialty care offices – Single specialty or multi-specialty offices • Specialty Offices – Single – All providers have same specialty – Multi-specialty – Providers have different specialties 3
- 4. Other Outpatient Facilities • Dental offices • Medical and diagnostic laboratories • Urgent Care Centers • Mental Health Clinics • Alcohol and Substance Abuse Treatment Center • Outpatient Surgical Centers • Physical and Occupational Therapy Centers • Home Health • Hospice Care 4
- 5. What Is Primary Care? • Primary care medical specialties are – Family medicine – General internal medicine – General pediatrics – Obstetrics and gynecology • Do only physicians provide primary care? – Nurse practitioners – Physician assistants – Other mid-level providers 5
- 6. Care Level and Care Setting • Primary care is an entry point to the health care system • Levels of care – Primary care o Outpatient ambulatory care – Secondary care o Inpatient hospital care – Tertiary care o Inpatient hospital care 6
- 7. Primary Care as a Strategy • A strategy for organizing the health care system as a whole • Greater emphasis on community-based health care – Less costly – Patients are healthier 7
- 8. The Patient-Clinician Relationship 3.1 Image: Primary Care: America's Health in a New Era-1996. 8
- 9. Narrow vs. Broad View of Primary Care • Narrow view – If primary = “first” in time or order – Then primary care = “ground floor” of health care delivery • Broad view: – If primary = “chief” or “main” – Then primary care = “central” to health care 9
- 10. Attributes of Primary Care • 1978 Institute of Medicine (IOM) definition: – Care that is accessible, comprehensive, coordinated and continuous – From perspective of patient and family • Comprehensive definition – Broaden perspectives to include: o Community o Integrated delivery systems o Ecosystem 10
- 11. IOM Definition of Primary Care • In 1994 - updated definition: – Primary care is the provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community. 11
- 12. Primary Care Characteristics - 1 • Integrated - provision of services that are: – Comprehensive – Coordinated – Continuous – A seamless process of care combining events and information that occur in different settings 12
- 13. Primary Care Characteristics - 2 • Accessible – Easy for patients to initiate interaction for a health problem with a clinician? – Efforts to eliminate barriers to patient care • Primary care– array of services that are performed by health care professionals for the purpose of promoting, maintaining or restoring health 13
- 14. Primary Care Characteristics - 3 • Clinician – Individual who uses a recognized scientific knowledge base and has the authority to direct the delivery of personal health services to patients. • Patient – Individual who interacts with a clinician either because of illness or for health promotion and disease prevention. 14
- 15. Primary Care Characteristics - 4 • Sustained partnership: – First visit – relationship established – Expectation of continuation – Develop trust, responsibility and respect 15
- 16. Primary Care Characteristics - 5 • Accountable care – primary care clinicians and the systems in which they operate are responsible to their patients and communities for – Quality of care – Patient satisfaction – Efficient use of resources – Ethical behavior 16
- 17. Primary Care Characteristics - 6 • Primary Care Clinicians – Diagnose and manage most needs – Have limitations within practice • Due to limitation – May call other practitioners – May include specialists for further evaluation/treatment 17
- 18. Delivering Health Care, Part 2 Summary – Lecture a • Outpatient facilities • Primary care • IOM definition of primary care • Services and barriers involved in primary care • Goals and parties involved in primary care 18
- 19. Delivering Health Care, Part 2 References – 1 – Lecture a References Fry, 1980; Institute of Medicine: Primary Care: America's Health in a New Era, The National Academies Press, 1996. Institute of Medicine. Defining Primary Care: An interim report (1994). National Academy of Press, Washington DC. Retrieved from http://www.nap.edu/openbook.php?record_id=9153&page=R1. Accessed January 20, 2017. Institute of Medicine : Primary Care: America's Health in a New Era, The National Academies Press, 1996. Retrieved from http://www.nap.edu/catalog/5152/primary- care-americas-health-in-a-new-era. Accessed January 20, 2017. Institute of Medicine. Primary Care in Medicine: A Definition. In A Manpower Policy for Primary Health Care : Report of a Study. Washington, D.C. : National Academy Press, 1978. Office of Technology Assessment. Nurse Practitioners, Physician Assistants, and Certified Nurse-Midwives: A Policy Analysis. Washington, D.C.: U.S. Government Printing Office, 1986. 19
- 20. Delivering Health Care, Part 2 References – 2 – Lecture a References Pew Health Professions Commission, Nurse Practitioners: Doubling the Graduates by the Year 2000. San Francisco: Pew Health Professions Commission,1994. Images Slide 8: Image from Institute of Medicine: Primary Care: America's Health in a New Era, The National Academies Press, 1996. Retrieved from http://www.nap.edu/catalog/5152/primary-care-americas-health-in-a-new-era. Accessed May 12, 2016. 20
- 21. Introduction to Health Care and Public Health in the U.S. Delivering Health Care, Part 2 Lecture a This material was developed by Oregon Health & Science University, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number 90WT0001. 21
Editor's Notes
- Welcome to Introduction to Health Care and Public Health in the U.S.: Delivering Health Care, Part 2. This is lecture a. The component, Introduction to Health Care and Public Health in the U.S., is a survey of how health care and public health are organized and how services are delivered in the U.S. It covers public policy, relevant organizations and their interrelationships, professional roles, legal and regulatory issues, and payment systems. It also addresses health reform initiatives in the U.S.
- The learning objectives for Delivering Health care, Part 2 are to: Describe the organization of clinical health care delivery in the outpatient setting and the organization of outpatient health care Describe the organization of ancillary health care delivery in the outpatient setting And, discuss the role of different health care providers, with an emphasis on the delivery of care in an interdisciplinary setting
- This lecture will discuss the types of outpatient health care facilities and the role of primary care, including its definitions, goals, and the parties involved. The term “outpatient” refers to the delivery of health care services in a setting where the patient is not hospitalized. The patient typically visits an outpatient facility for medical care. Outpatient facilities include physicians’ offices. These offices may provide primary care or specialty care, and they may also be single-specialty offices or multi-specialty offices. A specialty is a branch of medicine that focuses on a particular area of expertise. In a single-specialty group practice, all the providers are in the same specialty, for example internal medicine. In a multi-specialty practice, the providers have different specialties. For example, a multi-specialty practice may house specialists in internal medicine, gastroenterology, general surgery, and orthopedic surgery within the same group. They all share office space and they may also share office personnel.
- Outpatient facilities also include dental practices, and these may be the offices of general dentists or dentists who are specialists. Other outpatient facilities are medical or diagnostic laboratories, urgent care centers, mental health clinics, alcohol and substance abuse treatment centers, outpatient surgical centers, physical or occupational therapy centers, home health services, and hospice care services.
- The basis of outpatient care is primary care. Some medical specialties are designated as primary care specialties, including family medicine, general internal medicine, general pediatrics, and obstetrics and gynecology. However, physicians are not the only providers of primary care. Primary care is also provided by nurse practitioners, physician assistants, and other mid-level providers.
- Primary care may also be distinguished by the fact that it is an ambulatory model of care, as opposed to an inpatient model of care. Primary care may also be described in terms of level of care. Primary care is considered the entry point to the health care system. Primary care is provided outside the hospital and is typically referred to as outpatient car or ambulatory care. Other care levels include secondary care and tertiary care. Secondary care is inpatient care provided by community hospitals. Tertiary care is inpatient care provided by medical centers and teaching hospitals.
- Primary care can also be defined as a strategy for organizing the health care system as a whole. For example, primary care places a greater emphasis on community-based health care. Health care that is provided in the community is generally less costly than care provided in secondary and tertiary hospitals. Current care improvement goals include a focus in providing high-quality care in the outpatient setting so patients are healthier and are less likely to need intensive acute care medicine.
- This figure shows the patient-clinician relationship and the interdependence of the constituents in primary care. At the center of the figure are intersecting circles representing the clinician and the patient and demonstrating the centrality of the patient-clinician relationship. The clinician is part of a team that delivers health care and the team functions within an integrated delivery system, as shown by the circles to the left of the figure. The patient is nurtured by family and exists within a community, as shown by the circles to the right of the figure. This figure demonstrates a model of community-oriented health care.
- Another way to look at primary care is to take a narrow view or a broad view. If primary refers to being first in time or order, then primary care represents the first contact or the ground floor of health care delivery. In the broad view, primary suggests chief or main. In this context, primary care is a fundamental and central aspect of health care and the primary emphasis of health care in the community.
- Primary care can also be defined as a set of attributes. In 1978, the Institute of Medicine defined primary care as care that is accessible, comprehensive, coordinated, and continuous. This definition looks at the concept of primary care from the perspective of the patient and the family. A more comprehensive definition of primary care would broaden these perspectives to include the community and integrated delivery systems, as well as the ecosystem.
- In 1994, the Institute of Medicine Committee on the Future of Primary Care updated the definition of primary care as “the provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community.” This definition is explored further in the next few slides.
- Primary care is the provision of integrated care. Integrated care refers to services that are comprehensive, coordinated, and continuous. Comprehensive care means that health care services address any health issues that the patient may experience throughout his or her life, from birth to death. Coordinated care ensures that combinations of health care services and information are processed in a fashion that meets the needs of the patient. It also suggests that there is a connection or ordering among these services, including the resources that are available within the community. Continuity or continuous care means that a single member of the health care team must have a long-term, continuous relationship with the patient. Clinical continuity allows effective and timely communication of health information, including events, advice, and patient preferences. This information is recorded over time for future reference, with the goal of improving care for the patient. Integrated care is a seamless process that combines information and events that occurred in different settings, at different levels of care, and at different times, into a single entity -- the primary care environment.
- The question of accessible primary care means how easy it is for patients to initiate an interaction with a clinician for any health issues that they may have. What do they do to initiate this interaction? By telephone or telehealth services? Or do they need to go to a specific geographic location such as a primary care clinic? Many groups in the U.S. experience barriers to health care. These barriers may include geography, culture, language, financial issues, and even administrative hurdles. Accessibility is a measure used to delineate the efforts that have been made to eliminate these barriers. In short, primary care is a broad array of health care services performed by health care professionals for the purpose of promoting, maintaining, or restoring health.
- As illustrated in a previous slide, the clinician-patient relationship is at the center of the primary care universe. But what is a clinician and what is a patient? A clinician is an individual who has a recognized scientific knowledge base and has the authority to direct the delivery of health services for patients. A patient is an individual who interacts with the clinician because he or she is ill or is simply interested in health promotion and disease prevention.
- The primary care model entails a sustained partnership between the patient and the clinician. When the patient comes in to see the clinician, a relationship is established. There is a mutual expectation that the relationship will not only continue over time, but will also develop aspects of trust, responsibility, and respect.
- As the relationship between the patient and the clinician develops over time, the primary care model mandates accountable care. Clinicians and the systems in which they operate are responsible to their patients and communities for the quality of care they provide and for ensuring patient satisfaction. They need to use resources efficiently, and they need to practice the art of clinical medicine in an ethical fashion.
- Primary care clinicians are trained to diagnose and manage most of the health care needs of their patients. However, primary care does have limitations on the scope of its practice. When appropriate, primary care clinicians call upon other health care practitioners or specialists for further evaluation or treatment of patients.
- This completes lecture a of Delivering Health Care, Part 2. In summary, this lecture described the types of outpatient facilities and the role of primary care, including its definitions, goals, and the parties involved.
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