1. Introduction to Health Care and Public Health in the U.S.
Delivering Health Care, Part 2
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.
Lecture a
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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)
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

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
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.

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
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.

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
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.

6. Care Level and Care Setting
Primary care is an entry point to the health care system
Levels of care
Primary care
Outpatient ambulatory care
Secondary care
Inpatient hospital care
Tertiary care
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.

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
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.

8. The Patient-Clinician Relationship
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.
3.1 Image: Primary Care: America's Health in a New Era-1996.

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
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.

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:
Community
Integrated delivery systems
Ecosystem
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.

11. IOM Definition of Primary Care
In 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.
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.

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
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.

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
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.

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.
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.

15. Primary Care Characteristics - 4
Sustained partnership:
First visit – relationship established
Expectation of continuation
Develop trust, responsibility and respect
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.

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
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.

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
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.

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
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.

19. Delivering Health Care, Part 2 References – 1 – Lecture a
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 Accessed January 20, 2017.
Institute of Medicine : Primary Care: America's Health in a New Era, The National Academies Press, Retrieved from 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.
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20. Delivering Health Care, Part 2 References – 2 – Lecture a
Pew Health Professions Commission, Nurse Practitioners: Doubling the Graduates by the Year 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, Retrieved from Accessed May 12, 2016.
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Health IT Workforce Curriculum Version 4.0

21. Introduction to Health Care and Public Health in the U. S
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.
No audio
Health IT Workforce Curriculum Version 4.0