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The Joint Principles enunciated by the four primary care societies include the
physician as the team leader. Given the absence of evidence that this is
associated with better achievement of the four key features of primary care,
the justification for such a proposal is unclear. Might it be the case that simply
having a team leader, regardless of the discipline of that professional, could do
as well as a physician? This remains to be explored.
Is disease orientation, wherein a practice or practitioner is evaluated by quality
of care for individual diseases, pursuant to good primary care, particularly
when comprehensiveness of care is a key feature of primary care? Evaluation
of the chronic care model has been directed at assessing benefit for a very
limited set of chronic conditions, mostly diabetes. In the absence of evidence
that quality of care for one disease is generalizable to other diseases, or is
pursuant to better person-focused outcomes (better functioning, less
comorbidity, less unnecessary use of services in general), it is questionable
that a disease-oriented model of care produces better health overall or equity
in receipt of services.
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Source: Chesluk BJ, Holmboe ES. How teams work--or don't--in primary care:
a field study on internal medicine practices. Health Aff 2010;29:874-9.
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Source: Leese B. Comprehensiveness v special interests: Family medicine
should encourage its clinicians to subspecialize. In Kennealy T, Buetow S.
Ideological Debates in Family Medicine. New York, NY: Nova Publishing,
2007.
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Source: Leese B. Comprehensiveness v special interests: Family medicine
should encourage its clinicians to subspecialize. In Kennealy T, Buetow S.
Ideological Debates in Family Medicine. New York, NY: Nova Publishing,
2007.
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Source: Starfield B, Gervas J. Comprehensiveness v special interests. Family
medicine should encourage its clinicians to specialize: Negative. In Kennealy
T, Buetow S. Ideological Debates in Family Medicine. New York, NY: Nova
Publishing, 2007.
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Source: Starfield B. The geographic accessibility of retail clinics for
underserved populations - invited commentary. Arch Intern Med
2009;169:950-1.
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Source: Grant C, Nicholas R, Moore L, Salisbury C. An observational
study comparing quality of care in walk-in centres with general practice
and NHS Direct using standardised patients. BMJ 2002; 324(7353):
1556.
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Source: Coleman K, Austin BT, Brach C, Wagner EH. Evidence on the Chronic
Care Model in the new millennium. Health Aff 2009;28:75-85
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Source: Gress S, Baan CA, Calnan M, et al. Co-ordination and management of chronic
conditions in Europe: the role of primary care--position paper of the European Forum for
Primary Care. Qual Prim Care 2009;17:75-86.
The Chronic Care Model (CCM) is, theoretically, an approach to managing health
problems that are chronic in nature in that they last indefinitely without possibility of cure.
It is based on a literature review of the demonstrated benefits of each of six components
of care: awareness of community resources and policy; health care organizations; self
management support; delivery system design; clinical information systems; and decision
support (information and guidelines). Every one of these components is a structural
feature of health systems and services; none are explicitly directed at changing the way in
which personal health care is delivered. As might be expected, improvement of health
depends on how these structures are put to use in improving services provided, but these
behaviors (processes) are not identified. Although proposed for implementation as a
package, the CCM has never been tested as a tool to change important processes of
care, nor has it been tested as an entity with all six components. Moreover, it has almost
always been tested with only ONE chronic disease, usually diabetes. This table shows
how unevenly it has been adopted as a model in eight European areas. Some areas
(Catalonia in Spain; England; Wales) are focusing on all six components but in the other
areas, only certain components are targeted. (As noted above, its intended application
has, so far, been only for selected chronic conditions.) In some countries (Belgium and
Austria), the CCM has received no attention. As with all health system interventions, it
cannot be assumed that the benefits shown in prior studies in selected people in selected
places are generalizable to other places, populations, and times, and there is little if any
knowledge about the benefits of the CCM when applied in unselected practices over a
wide range of chronic conditions.
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Source: CBG Health Research Limited. Review of the Implementation of
CARE PLUS (http://www.moh.govt.nz/moh.nsf/pagesmh/5567/$File/reviewimplementation-care-plus.pdf, accessed February 8, 2009). Wellington, New
Zealand : Ministry of Health, New Zealand, 2006.
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Source: Schillinger D, Handley M, Wang F, Hammer H. Effects of selfmanagement support on structure, process, and outcomes among vulnerable
patients with diabetes: a three-arm practical clinical trial. Diabetes Care
2009;32:559-66.
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Source: Damberg CL, Shortell SM, Raube K, et al. Relationship between
quality improvement processes and clinical performance. Am J Manag Care
2010;16:601-8.
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Source: Gilfillan RJ, Tomcavage J, Rosenthal MB, et al. Value and the medical
home: effects of transformed primary care. Am J Manag Care 2010;16:607-14.
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Source: Gilfillan RJ, Tomcavage J, Rosenthal MB, et al. Value and the medical
home: effects of transformed primary care. Am J Manag Care 2010;16:607-14.
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Source: Gilfillan RJ, Tomcavage J, Rosenthal MB, et al. Value and the medical
home: effects of transformed primary care. Am J Manag Care 2010;16:607-14.
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Source: Jaen CR, Ferrer RL, Miller WL, et al. Patient outcomes at 26 months
in the patient-centered medical home National Demonstration Project. Ann
Fam Med 2010;8 Suppl 1:S57-67.
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Source: Reid RJ, Coleman K, Johnson EA, et al. The Group Health medical
home at year two: cost savings, higher patient satisfaction, and less burnout
for providers. Health Aff 2010;29:835-43.
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Source: Reid RJ, Coleman K, Johnson EA, et al. The Group Health medical
home at year two: cost savings, higher patient satisfaction, and less burnout
for providers. Health Aff 2010;29:835-43.
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Source: Meyer H. Report from the field. Group Health's move to the medical
home: for doctors, it's often a hard journey. Health Aff 2010;29:844-51.
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Sources:
Coleman K, Austin BT, Brach C, Wagner EH. Evidence on the Chronic Care
Model in the new millennium. Health Aff 2009;28:75-85.
Dentzer S. Prologue: reorganizing chronic care delivery. Health Aff
2009;28:63.
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Source: based on Coye MJ, Haselkorn A, DeMello S. Remote patient
management: technology-enabled innovation and evolving business models
for chronic disease care. Health Aff 2009;28:126-35.
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The Joint Principles were developed and advanced jointly by the four major
primary care professional groups in the US: the American Academy of Family
Practice, the American College of Physicians, the American Academy of
Pediatrics, and the American Osteopathic Association. These principles
recognize the evidence that the characteristics of primary care are well
established and important to achieve in health systems. Enhanced access (to
facilitate first-contact care), ongoing relationships for continuous care that is
comprehensive and coordinated are the key facets of primary care and, when
combined with attention to clinical quality and safety (features of all levels of
care), are proposed as the underpinning of the patient-centered medical home
in the United States.
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At the same time the features of primary care were recognized as key to
achieving good primary care, the proposals for certifying US practices as
patient-centered medical homes focused heavily on structural features that
cannot improve health without improving the processes of care. These include
electronic health records, teams, and chronic care guidelines, none of which
are either central to the joint principles nor known to enhance the achievement
of the four principal features of primary care. Whether or not evaluations of
these structural “innovations” are eventually supplemented or replaced by
evaluation of the four key principles remains to be seen (at least as of 2009).
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Source: Steiner BD, Denham AC, Ashkin E, Newton WP, Wroth T, Dobson
LA,Jr. Community care of North Carolina: improving care through community
health networks. Ann Fam Med 2008;6:361-7.
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Sources:
Loxterkamp D, Kazal LA,Jr. Changing horses midstream: the promise and
prudence of practice redesign. Ann Fam Med 2008;6:167-70.
Eidus et al, letter to NCQA, February 2009.
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Source: Crampton P, personal communication, 2005.
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Source: Pan American Health Organization: Regional Declaration, 2005.
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Source: Schmittdiel JA, Shortell SM, Rundall TG, Bodenheimer T, Selby JV.
Effect of primary health care orientation on chronic care management. Ann
Fam Med 2006;4:117-23.
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Source: based on Coye MJ, Haselkorn A, DeMello S. Remote patient
management: technology-enabled innovation and evolving business models
for chronic disease care. Health Aff 2009;28:126-35.
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Source: Starfield B, Simpson L. Primary care as part of US health
services reform. JAMA 1993; 269(24):3136-3139.
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Source: Starfield B, Simpson L. Primary care as part of US health
services reform. JAMA 1993; 269(24):3136-3139.
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Source: Starfield B, Simpson L. Primary care as part of US health
services reform. JAMA 1993; 269(24):3136-3139.
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This list is the chapter headings of a book published in 2007. The authors of
this book (one from England and the other from Australia) believed these
issues to be the main topics for debate in primary care. As they are still
debated, they appear to be good research issues.
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