Navigating the New Primary Care

Primary Care Service covers a range of prevention, wellness, and treatment for common illnesses. 
Primary Care includes doctors, nurses, nurse practitioners, and physician assistants. 
These clinicians often maintain long-term relationships with you and advise as well as treat you for a range of health-related issues.

A new patient came to my practice, establishing me as her primary care physician. Her unique job took her to different locations and she was now to be in Los Angeles for 6 months. She knew her current medications and was able to share with me her medical history. The appointment was scheduled for 20 minutes but her intake took quite a bit longer, as did addressing her current concerns. Thereafter came her labs and studies that didn't quite reconcile with her medical history. Off hours, I was able to reconcile some of her medical records to give my patient a better plan of care. All our interactions after the visit were virtual. She will probably do this with a new primary care physician (PCP) in about 6 months. I'm trying to be a good steward by addressing all outstanding concerns, clarifying problems, and working with my patient about future goals, all to help my patient and her next PCP. This is the new paradigm.

As a practicing Family Medicine physician for the past three decades, working in multi-specialty partnership within a managed care organization, I would like to share my thoughts on a Paradigm of Primary Care and potential pathways to saving Primary Care in America: A Primary Care Playbook.

Primary Care typically encompasses Family Medicine, Internal Medicine, and Pediatrics. Urgent Care and OB-GYN, among other specialties, also incorporate aspects of primary care services. There are dire warnings though that the days of primary care are numbered either due to a shortage of clinicians, perceived low value additive care, low enumeration for services, and impending disruption and replacement by Artificial Intelligence (AI) services.

Primary Care Areas of Focus
Preventive Care, Acute Care, Chronic Disease, Partnership, a Fallow Day

Central to Primary Care are Preventive Care Services, such as immunizations, cancer/disease screenings, counseling on health risks and facilitating health improvements. Preventive care helps identify patients at risk and seeks to educate, prevent disease, and facilitate improvements in life and longevity.

How well does your organization attend to preventive care services in all patient interactions?

A segment of primary care that has also been part of the foundation of services is Acute Care Services, defined as care that is typically needed today for common illnesses.

• "Self Care" is the most common form of acute care, whereby we decide on our own, either by our self-knowledge, by tradition, by advice from family or friends, or increasingly through the internet or social media of how best to take care of ourselves. Self care is proportionally the largest "tool" utilized in acute care services, yet one with the most variable results given inconsistent advice from, at times, contradicting sources.
• This area is ripe for disruption by Artificial Intelligence (AI) Services as AI may allow for personalized engagement and advice based on established guidelines, facts, and studies. It will help the patient by sharing the "weight of evidence" for any recommendation, enabling patients to make the best informed choices for themselves. This also helps physicians and providers as they will know that patients have already utilized standardized treatments before seeking care.

How are you and your organization empowering your patients to be self-sufficient in self care?
Is your organization collating such "search data" to better prepare for when your patients do seek care from your physicians and providers?

• Virtual Care, be it telephonic or video-based, saw its renaissance during the 2020 COVID pandemic and associated lockdown. While the gains have lessened with the loosening of pandemic restrictions, there continues to be a role for virtual care services, be it telephonic, video, or now text/chat based interactions. This has particularly been helpful in triaging care, helping decide on the best venue for the next level of care, and for follow-up after either an acute illness, procedure, or hospitalization or, more commonly, for chronic disease management, especially in behavioral health services.
• With the aide of Remote Patient Monitoring Tools and devices, allowing for consistent tracking of biometric functions, virtual care has helped patients avoid having to take much time out of their day to come to an office or having to rely on transportation to get service.
• Virtual care has additionally allowed flexibility for Primary Care physicians and providers as they are able to integrate other aspects of daily or professional life around virtual visits, unlike an office-based environment.

How well are you and your organization ultizing virtual care services to meet the needs of your patients?  
Are you meeting your access and service goals through virtual care, or have you not considered these metrics?

• Acute Care is also being given at Non-Traditional Sites of Care, commonly your local pharmacy, typically attached to your grocery store. Care rendered includes immunizations, risk screenings and health advice. But how about at your barber or hair dresser, sites we visit more often that a medical clinic or center, and where we may feel comfortable given established trust? Is it a stretch to consider having access to healthcare at a place where you service your car? These partnerships may be critical to the delivery of Primary Care services and engages the community at large.

How aware are you and your organization of how your patients get care in non-traditional settings?  
How well have you partnered with these sites of care?

• A well functioning Urgent Care also attends to acute care services with a team approach. The evolving story of urgent care services vacillates between meeting the needs of convenience to requiring full-service care short of an emergency room visit. A full-service urgent care, able to treat patients of all ages with most conditions, while offering procedural medicine, has truly become the pinnacle of acute care beyond the primary care continuum of care, and patients appear to be accepting of and possibly driving this paradigm shift.

Is your organization providing full-service urgent care for your patients?  
Does your urgent care attend to preventive care services and how well does it partner with primary care?

Primary care also provides for Chronic Disease Management, such as diabetes, hypertension, asthma, among other conditions, typically in partnership with specialty services.

How interdependent are your specialists and primary care teams?

• Patients are exceedingly mobile with seeking care services and their full health histories should follow them seamlessly to their new physicians/providers and healthcare teams. A Comprehensive On-Boarding process is desirable to minimize disruption and/or duplication of care services, especially for a patient with chronic diseases or complex needs. This may be achieved by having an integrated Electronic Medical Records (EMR), having a patient fill out relevant information beforehand, possibly with assistance by AI services to either direct or expedite care, and/or having a care navigator assist patients in this process.

What is your on-boarding process for your new patients?
Do you rely on your patients to engage your system instead?

• A Care Navigator can also be a prudent partner providing assistance and avoidance of unnecessary visits to the emergency room or hospitalizations, especially for the most complex and vulnerable patients. They may also be helpful in managing and maintaining good health in patients with chronic disease such as diabetes, congestive heart failure, and weight management, among other conditions. The full team may include Social Workers, Pharmacists, Occupational & Physical Therapists, Dietitians, and Health Educators, all communicating with one another, assisted by remote monitoring of patients.

How often do you use ancillary services to assist your physicians/providers in helping deliver care to patients with chronic diseases?

• Remote Patient Monitoring similarly achieved a renaissance during the COVID-19 pandemic. The ability to reliably and quickly collect data on patients at a distance has revolutionized medicine in addition to engaging patients in their healthcare. Additionally these tools may improve access for in-person visits by freeing up visits now resolved by using remote tools. These tools may also improve quality of care due to clinicians making recommendations based on reliable and timely data from a patient, and it may allow a clinician to spend more time with patients who have the highest need for in-person visits.

Remote monitoring makes healthcare more accessible, efficient, and effective.
How is your organization utilizing remote monitoring in Primary Care?
How is remote monitoring helping your physicians/providers/teams deliver care?

The success of Primary Care is based on Partnership with Specialty Services, Non-Medical Entities, and Organizational Goals.

Partnership refers to a collaborative and coordinated relationship in which all parties work together with common goals and work to improve patient care.

• Partnership between Primary Care and Specialty Services involves Sharing Information about patient care. It involves engaging in Shared & Joint Decisions regarding patients' needs and treatments. It involves working together to create a Seamless Patient Experience in the continuum of care. It involves collaborating on Quality Improvement Projects including developing clinical guidelines and aligned resource stewardship.
• Non-Medical Entities such as community organizations, businesses, and government agencies can be strong partners in improving health and promoting wellness. Beyond promoting preventive care and healthy lifestyles, such entities may be able to provide resources and services to patients in need, in addition to fostering connections between physicians/providers and patients, especially those with chronic diseases.
• Health Care Organizations set annual goals/metrics, either developed by themselves, or established by industry or regulatory bodies. These typically involve Access, Service, Quality, and Finance and they may, at times, impose immediate challenges to Primary Care. For example, Access and Service metrics may impose certain restrictions that may compromise the Quality of Care delivered in Primary Care. Financial goals may inadvertently have Primary Care reactively restrict care services without consideration of long-term outcomes either for patients or partners in healthcare. Having an Organization freely discuss and develop goals and metrics together with Primary Care Services may ensure successful implementation, acceptance, and desirable outcomes.

Partnership helps to promote continuity of care, increase patient satisfaction, and improve overall health outcomes.
What does partnership look like in your organization?

12 Key Takeaways So Far per #ChatGPT OpenAI

1. Primary care services encompass a range of prevention, wellness, and treatment for common illnesses and are provided by doctors, nurses, nurse practitioners, and physician assistants.
2. The three primary specialties of primary care are Family Medicine, Internal Medicine, and Pediatrics, but other specialties such as Urgent Care and OB-GYN also offer primary care services.
3. Preventive care services are central to primary care and include immunizations, screenings, and health risk counseling.
4. The use of self-care is a significant aspect of acute care services, but is prone to inconsistent results. Artificial Intelligence (AI) services have the potential to improve this area.
5. Virtual care, including telephonic, video, and text/chat interactions, has become more prevalent due to the COVID-19 pandemic and has improved access to care, triage, and chronic disease management.
6. Acute care services are also being offered at non-traditional sites such as pharmacies and barbershops, with the potential for further partnerships to engage the community.
7. Urgent care services have evolved to provide full-service acute care short of an emergency room visit.
8. Primary care also provides chronic disease management in partnership with specialty services.
9. Patients' health histories should follow them seamlessly as they seek care from different providers, through comprehensive onboarding processes.
10. A care navigator can provide assistance in avoiding unnecessary hospital visits, manage complex patients, and work as part of a full health care team including social workers, pharmacists, therapists, and educators.
11. Remote patient monitoring became more prevalent during the COVID-19 pandemic and has improved access to care.
12. The future of primary care may include increased use of AI services, more partnerships with non-traditional care sites, and improved care navigation and patient monitoring.

Another Consideration for Primary Care Wellbeing - A Fallow Day

What does a Fallow Day have to do with Primary Care? A fallow field is land that a farmer plows but does not cultivate for one or more seasons to allow the field to become more fertile again.  How does this concept relate to medicine, Primary Care in particular?

Consideration should be given to Primary Care physicians/providers for such time devoted to Education, Teaching, Charity, Service, or HealthCare Advocacy. Weekends and personal time-off may be for personal healing through Physical Activity, Creativity, Spiritual Growth/Prayer, and Exploration of their immediate neighborhoods that they care for on a daily basis.

A physician/provider needs to be able to see beyond the transactional for the larger connections that will help guide a patient's overall care. An organized "Fallow Day" will allow physicians/providers to step back so as to be able to replenish their knowledge base, regain their strength, and ultimately feed into their passion for caring for their patients. Such moments should also be an integral part of the workweek and incorporated into the educational journey for all Primary Care residents and students. This important time away may too easily be usurped by the overload of low-value tasks that need to be done but fall generally upon the Primary Care physician/provider to fulfill repeatedly. We need to protect Primary Care from such a system due to the risk of burnout for the clinician and, ultimately, disengagement from the patient.

The Fallow Day is an organized endeavor that is done for the enrichment of the physician/provider for the benefit of the patient.

Summary

Primary Care has a focus on healthy patients and healthy communities. A healthy patient touches the lives of so many, enriching the families, their communities, and the nation. Thus the breadth of care provided by Primary Care, where all care comes to rest, is immense. For a physician/provider to stay successfully engaged in the continuum of a patient's care, they need a properly functioning team to help take care of a patient. The team needs to rely on multiple tools in all aspects of care, including preventive care, acute care, chronic disease, and partnerships with specialty and non-medical entities. AI foremost will be part of this engagement. To prevent burnout, a Primary Care physician/provider should occasionally step back from the numerous tasks that need to be completed during the work week--tasks that do not directly enrich the patient experience--for the sake of replenishing their knowledge base, regaining their strength, and ultimately feeding their passion for caring for their patients.

We need to bring joy back to the practice of Primary Care.

This Paradigm of Primary Care aims to achieve this goal.