Presentation on theme: "1 Public Health – Primary Care Linkages Kurt C. Stange, MD, PhD Professor of Family Medicine & Community Health, Epidemiology & Biostatistics, Oncology."— Presentation transcript:
1 Public Health – Primary Care Linkages Kurt C. Stange, MD, PhD Professor of Family Medicine & Community Health, Epidemiology & Biostatistics, Oncology & Sociology Gertrude Donnelly Hess, MD Professor of Oncology Research Director, Residency in Preventive Medicine & Public Health Case Western Reserve University American Cancer Society Clinical Research Professor Editor, Annals of Family Medicine Promoting Health Across Boundaries DCCPS through the Intergovernmental Personal Act
2 Primary Care & Public Health - Very Different Primary Care Underfunded Misaligned mission & incentives Misunderstood Broad scope, fragmented approach Increasingly about chronic illness Mission more about promoting health than delivering commodities About partnerships Public Health Underfunded Misaligned mission & incentives Misunderstood Broad scope, fragmented approach Increasingly about chronic illness Mission more about promoting health than delivering commodities About partnerships
3 Efforts to Reform Primary Care & Public Health - Very Similar Primary Care More funding Different funding More information support Greater integration within Greater integration across sectors More targeting and incentives Greater focus on population health Public Health More funding Different funding More information support Greater integration within Greater integration across sectors More targeting and incentives Greater focus on population health AAFP, AAP, ACP, AOA. Joint principles of the PCMH. 2007; IOM.For the Public’s Health: Investing in a Healthier Future. Washington: National Academies Press, 2012.
persons 800 report symptoms 327 consider seeking medical care 217 visit a physician’s office (113 visit a primary care physician’s office) 65 visit a complementary or alternative medical care provider 21 visit a hospital outpatient clinic 14 receive home health care 13 visit an emergency dept 8 are hospitalized <1 is hospitalized in an academic medical center Fig. Results of a reanalysis of the monthly prevalence of illness in the community and the roles of various sources of health care. (Green LA et al., N Engl J Med 2001, 344: )
5 Primary Care Large majority of needs (comprehensive) Sustained partnership (personalized) Context of family & community Integrated (considers parts and the whole) Accessible Donaldson MS, Yordy KD, Lohr KN, Vanselow NA, eds. Primary Care: America's Health in a New Era. Washington D.C.: National Academy Press; 1996.
6 Primary Care Countries with strong primary care –Have lower overall costs –Generally have healthier populations Within countries –Areas with higher primary care physician availability (but not specialist availability) have healthier populations –Greater primary care physician availability reduces the adverse effects of social inequality Starfield B. New paradigms for quality in primary care. Br J Gen Pract 51: , Macinko J, Starfield B, Shi L. Quantifying the health benefits of primary care physician supply in the United States. Int J Health Serv. 2007;37: Starfield B, Shi LY, Macinko J. Contribution of primary care to health systems and health. Milbank Q. 2005;83(3):
7 Community-Oriented Primary Care Takes responsibility for the health of a defined population Steps –Define the population.Define –Assess the defined population's health needs.Assess –Organize an effective intervention strategy.Organize –Evaluate the success of the intervention.Evaluate Mullan F, Epstein L. Community-oriented primary care: new relevance in a changing world. Am. J. Public Health. 2002;92(11): Tollman S. Community oriented primary care: origins, evolution, applications. Soc. Sci. Med. 1991;32(6): Nutting PA. Community-Oriented Primary Care: From Principle to Practice. Washington, DC: U.S. Government Printing Office;1987. DHHS Publication No. HRS-A-PE 86-1 (Now available from the University of New Mexico Press).
8 Public Health – Primary Care Integration is “IN”
9 Institute of Medicine of the National Academy of Sciences “The interactions between the two sectors are so varied that it is not possible to prescribe a specific model or template for how integration should look.” General principles IOM. Integrating Primary Care and Public Health.
10 Principles of Integration Shared goal of population health improvement Community engagement in defining and addressing population health needs Aligned leadership –Bridges disciplines, programs, and jurisdictions –Clarifies roles and ensures accountability, –Develops and supports appropriate incentives –Has the capacity to manage change Shared infrastructure Collaborative use of data & analysis IOM Committee on Integrating Primary Care and Public Health. Exploring Integration to Improve Population Health. Washington: National Academies Press, 2012.
11 Affordable Care Act Opportunities Community Transformation Grants Community Health Needs Assessments Medicaid Preventive Services Community Health Centers National Prevention, Health Promotion & Public Health Council & the National Prevention Strategy CMS Innovation Center Accountable Care Organizations Patient-Centered Medical Homes Primary Care Extension Program National Health Service Corps Teaching Health Centers IOM Committee on Integrating Primary Care and Public Health. Exploring Integration to Improve Population Health. Washington: National Academies Press, 2012.
12 Communities of Solution Emerging young family medicine leaders Updated 1967 Folsom Report 13 grand challenges Organizing community & personal health services The Folsom Group. Communities of Solution: The Folsom Report Revisited. Ann Fam Med. 2012; 10(3):
CDC National Cancer Conference Tom Frieden Public health & clinical medicine can work synergistically –Public education, outreach –Care coordination –Service provision –Quality assurance, surveillance & monitoring –Organized systems
CDC National Cancer Conference Rich Wender Barriers to PC – PH collaboration –Incentives not aligned –Under-funded –Operate at edge of viability Few resources for innovative partnerships –Different cultures –It is hard work To make it work –High functioning PC & PH –Central staffing for population work –Local staffing for personal work –Get in the same room with stakeholders focused on a community problem
AHRQ Expert Panel on Clinical- Community Relationships Measures Creating measures atlas Evaluation roadmap
16 Re-emerging Political Space for Linking Person and Community Through Primary Health Care 4 themes from national policy key informants: Affirmation of primary care as the foundation of a more effective healthcare system Patient-centered medical home is a transitional step to foster practice innovation & payment reform Urgent need for an increased focus on community and population health in primary care Ongoing need for advocacy and research efforts to keep primary care & public health on policy agenda Sweeney SA, Bazemore A, Phillips Jr. RL, Etz RS, Stange KC. A re-emerging political space for linking person and community through primary health care. Am J Prev Med, 2012; 42(6S2): S184-S190.
17 Public Health – Primary Care Collaboration/Integration is “IN” Its about how to get it done. Your examples and mine
18 Two Current Cleveland Initiatives
19 Activating Resources for Community Health Promotion (ARCH) Intervention –Database of community programs –Health behavior prescription pad Results –In- –Significant increase in community program use and healthy behaviors Flocke SA, Gordon LE, Pomiecko GL. Evaluation of a community health promotion resource for primary care practices. Am. J. Prev. Med. 2006;30(3):
20 Participatory Implementation Process (e.g., stakeholder engagement; CBPR; team-based science; patient centered) Practical Progress Measures (e.g., actionable & longitudinal measures) Intervention Program/Policy (Prevention or Treatment) (e.g., key components; principles; guidebook; internal & external validity) Multi-Level Context Intrapersonal/Biological Policy Interpersonal/Family Community/Economic Organizational Social/Environment/History Feedback Evidence Stakeholders Evidence Integration Triangle (EIT) Glasgow RE, Green LW, Taylor MV, Stange KC. Am J Prev Med 2012, 42:
21 Public Health – Primary Care Partnership Great potential Great challenges Synergy in each doing what we’re good at Questions –What are you good at? –Who do you have access to, and when? –What data do you have / need? –What work is value-congruent? –How can we come to the table around mutual need? –How can we partner for complementary effect?
23 Extra (Optional) Slides
24 Participatory Implementation Process Iterative, wiki activities to engage stakeholder community, measurement experts and diverse perspectives Practical Progress Measures Brief, standard patient reported data items on health behaviors & psychosocial issues -- actionable and administered longitudinally to assess progress Intervention Program/Policy Evidence-based decision aids to provide feedback to both patients and health care teams for action planning and health behavior counseling Multi-Level Context Dramatic increase in use of EHR CMS funding for annual wellness exams Primary Care Medical Home Meaningful use of EHR requirements Feedback Evidence: US Preventive Services Task Force recs. for health behavior change counseling; evidence on goal setting & shared decision making Stakeholders: Primary care (PC) staff, patients and consumer groups; PC associations; groups involved in meaningful use of EHRs, EHR vendors Evidence Integration Triangle (EIT) - A Patient-Centered Care Example
25 IOM Case Studies of Integration San Francisco, CA –Healthy SF focused on access –Health Improvement Partnerships New York, NY –EHR support –Community organization partnerships Durham, NC –CCNC, a statewide network to coordinate & improve care –Diverse participants –Collaborative financing structure IOM Committee on Integrating Primary Care and Public Health. Exploring Integration to Improve Population Health. Washington: National Academies Press, 2012.
27 The Generalist Approach Recognizing systems connectedness (belonging & participation in community & Kosmos) Being - open, humble, connected Knowing – iterates between whole & particulars Perceiving – scanning & prioritizing Thinking/doing – most important parts in context, lower level tasks enable higher Stange KC. The generalist approach. Ann Fam Med. 2009;7(3):
28 Principles of Primary Care Accesibility as 1 st contact with health care Accountability for large majority of healthcare needs (comprehensiveness) Coordination & integration of care across settings, acute & chronic illnesses, mental health & prevention Sustained partnership – relationships over time in a family & community context Starfield B. Primary Care. Balancing Health Needs, Services and Technology. New York: Oxford University Press, Donaldson MS, Yordy KD, Lohr KN, Vanselow NA, eds. Primary Care: America's Health in a New Era. Washington D.C.: National Academy Press; Stange KC, Nutting PA, Miller WL, et al. Defining and measuring the Patient-Centered Medical Home. J Gen Intern Med. 2010; 25(6):
29 Paradox of Primary Care Poor quality of care by disease-specific process of care measures Better quality at population level Similar whole-person functional health Better population health Lower resource use and cost Stange KC, Ferrer RL. The paradox of primary care. Ann. Fam. Med. 2009;7(4):
30 Global Typology of Primary Care Organisational Developments OrganisationalStructure andValue BaseService FocusLocationEndpoint TypeProcess(examples) ExtendedSimpleNormativeRegisteredHealthPatient general practicepartnershippatient listcentre Managed careComplex,CalculativeTarget groupsPhysiciansUser enterprisestakeholdergroup Reformed Coalition,CommercialMedicalMulti-Client polyclinicdivisionalconditionsspecialist clinic District healthHierarchic,ExecutivePublic healthGeneralPopulations systemadministrativeimprovementhospital CommunityAssociation,AffiliativeLocalHealthCitizen developmentnetworkpopulationsstations agency FranchisedQuasi-RemunerativePayersPrivate,Customer outreachinstitutional,hospital virtualpremises Meads G (2006) Primary Care in the Twenty-First Century: An international perspective. Oxford: Radcliffe Publishing.
31 Crossing the Quality Chasm Recommended health care focus –Reduce illness burden, injury, disability –Improve health and function of people Health care should be –Safe –Effective –Patient-centered –Timely –Efficient –Equitable Institute of Medicine. Crossing the quality chasm: A new health system for the 21st century. Washington, DC: National Academy Press; 2001.
32 Crossing the Quality Chasm Old RulesNew Rules Care is based on visits.Care based on continuous healing relationships Professional autonomy drives variability. Customized to patient needs & values Professionals control care.Patient as source of control Information is a record.Shared knowledge, free information flow Decisions are based upon training and experience. Evidence-based decision making Do no harm is an individual responsibility. Safety as a system property Secrecy is necessary.Transparency The system reacts to needs.Anticipation of needs Cost reduction is sought.Continuous decrease in waste Preference for professional roles over the system. Cooperation among clinicians
34 Expanded Chronic Care Model Barr VJ, Robinson S, Marin-Link B, Underhill L, Dotts A, Ravensdale D, Salivaras S. The expanded Chronic Care Model: an integration of concepts and strategies from population health promotion and the Chronic Care Model. Hosp. Q. 2003;7:73-82.
35 Safety Net Providers’ Strategic Alliance Practice-Based Research Network Cleveland Safety Net Practices Mission to generate new knowledge to –Improve patient care –Advocate to close holes in the safety net AHRQ PBRNs: Cleveland CTSC: Madden MH, Tomsik P, Terchek J, Navracruz L, Reichsman A, Clark TC, Cella P, Weirich SA, Munson MR, Werner JJ. Keys to successful diabetes self-management for uninsured patients: social support, observational learning, and turning points: a safety net providers' strategic alliance study. J Natl Med Assoc. 2011;103(3): Reichsman A, Werner J, Cella P, Bobiak S, Stange KC; SNPSA Diabetes Study Working Group. Opportunities for improved diabetes care among patients of safety net practices: a safety net providers' strategic alliance study. J Natl Med Assoc Jan;101(1):4-11.
36 Visits by Diabetic Patients in a CHC Mean of 25 problems (range 13 to 32) Multiple acute & chronic illnesses, prevention Variety of issues –Biomedical –Behavioral –Social –System –Environmental health Bolen SD, Sage P, Perzynski AT, Stange KC. No Moment Wasted: The Primary Care Visit for Adults with Diabetes (under review), 2012.
37 The PHAB Initiative in Promoting Health Across Boundaries Supported by: Case Western Reserve University Forward Thinking Interdisciplinary Alliance Innovation Pilot Investment Grant Research Professorship from the American Cancer Society Grant from the Patient-Centered Outcomes Research Institute (PCORI) Intergovernmental Personnel Act (IPA) from the National Cancer Institute
38 PHAB Promoting Health Across Boundaries Problem A view of health too narrowly focused on disease and health care has resulted in unhealthy people, families, communities, environments, and fragmented, unsustainable health care systems.
39 PHAB Promoting Health Across Boundaries Mission The mission of the PHAB initiative is to advance the knowledge and practice of boundary-spanning activities that enable health.
40 Health Person & Family Primary Health Care Health Care System Public Health & Community Personalized Health Care Healing Environments Responsible, Evolvable Organizations Healthy Environments
41 Promoting Health Across Boundaries
42 Cohen D, McDaniel RR, Crabtree BF, et al. A practice change model for quality improvement in primary care practice. J Healthc Manag, 2004; 49:
44 What is Health? Among these definitions, a concept is emerging of health as a resource to support meaningful work and connection.
46 “Paper or plastic?”
47 Problem of Fragmentation
48 US Health Care “Fundamentally flawed” * Most expensive in the world** 37 th in the health of our people** More integrated systems provide greater value*** *Institute of Medicine. Crossing the quality chasm: A new health system for the 21st century. Washington, DC: National Academy Press; **WHO. Press Release WHO/44: World Health Organization assesses the world's health systems. World Health Organization, Geneva Switzerland. ***Starfield B, Shi LY, Macinko J. Contribution of primary care to health systems and health. Milbank Quarterly. 2005;83(3):
49 Fragmentation Focusing on the parts without appreciating their relation to the whole Limited understanding of how the components of health and disease processes and health care work together Leads to –Uncontextualized investigation –Fragmentation of care –Devaluing of health care’s higher order functions and possibilities. Engel, GL. The need for a new medical model. Science 1977;196:129–136. Stange KC. The paradox of the parts and the whole in understanding and improving general practice. Int J Qual Health Care, 2002; 14(4): Stange KC. The problem of fragmentation and the need for integrative solutions. Ann. Fam. Med. 2009;7(3):
50 Robert May, President of the Royal Society “Application of the physical and biological sciences has made today arguably the best of times… But the unintended consequences of these well-intentioned actions…could well make tomorrow the worst of times. The significant breakthrough we really need is better understanding of human institutions, particularly of the impediments to collective, cooperative activity in which all individuals pay small costs to reap large group benefits. Darwin recognised the evolution of cooperative behaviour as one of the most important unsolved problems of his day. We have made relatively little progress since then. Perhaps the social scientists of 2056 will have succeeded in combining the rigour of the "hard" (that is, easy) sciences with the thoughtful introspection of the humanities to solve this problem. I certainly hope so.” 18 November 2006, NewScientist.com news service.
51 Consequences of Fragmented Approach to Healthcare Inefficiency & ineffectiveness Inequality Commoditization Commercialization Deprofessionalization Depersonalization Despair & discord Stange KC. The problem of fragmentation and the need for integrative solutions. Ann. Fam. Med. 2009;7(3):
52 International Comparisons Primary care orientation –Health care system characteristics –Practice characteristics Health status and cost –Rank on a composite of 14 health indicators –Rank on per capita health care spending Starfield B. Primary Care. Balancing Health Needs, Services and Technology. New York: Oxford University Press, 1998.
53 Source: Starfield B. Primary Care. Balancing health needs, services, and technology. New York: Oxford University Press, Primary Care and Health Outcomes
54 Source: Starfield B. Primary Care. Balancing health needs, services, and technology. Oxford, New York, Primary Care and Health Care Expenditures
55 US Primary Care Physician Supply Review of 10 studies of primary care & health Improved all-cause, cancer, heart disease, stroke & infant mortality; low birth weight; life expectancy; and self-rated health All-cause mortality –↑ of 1 primary care physician /10,000 population –→ 5.3% or 49 per 100,000 / yr ↓ mortality Macinko J, Starfield B, Shi L. Quantifying the health benefits of primary care physician supply in the United States. Int J Health Serv. 2007;37:
56 Inter-State Comparisons Adjusted Medicare spending –State-specific cost of living adjustment –Age, sex, race of Medicare population Quality measures –24 Medicare Quality Improvement Organization measures –6 common medical conditions MI Breast Cancer Diabetes Heart Failure Pneumonia Stroke Baicker K, Chandra A. Medicare spending, the physician workforce, and beneficiaries’ quality of care. Health Affairs W W4-197, 2004.
57 Baicker K, Chandra A. Medicare spending, the physician workforce, and beneficiaries’ quality of care. Health Affairs W W4-197, 2004.
58 Baicker K, Chandra A. Medicare spending, the physician workforce, and beneficiaries’ quality of care. Health Affairs W W4-197, 2004.
59 Starfield’s Summary Countries with strong primary care –Have lower overall costs –Generally have healthier populations Within countries –Areas with higher primary care physician availability (but not specialist availability) have healthier populations –Greater primary care physician availability reduces the adverse effects of social inequality Starfield B. New paradigms for quality in primary care. Br J Gen Pract 51: , Macinko J, Starfield B, Shi L. Quantifying the health benefits of primary care physician supply in the United States. Int J Health Serv. 2007;37: Starfield B, Shi LY, Macinko J. Contribution of primary care to health systems and health. Milbank Q. 2005;83(3):
60 Paradox of Primary Care Poor quality of care by disease-specific process of care measures Better quality at population level Similar whole-person functional health Better population health Lower resource use and cost Stange KC, Ferrer RL. The paradox of primary care. Ann. Fam. Med. 2009;7(4):
61 Primary Care 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. Donaldson MS, Yordy KD, Lohr KN, Vanselow NA, eds. Primary Care: America's Health in a New Era. Washington D.C.: National Academy Press; 1996.
62 Visits to Family Physicians Variety of patients, problems and complexity Top 25 diagnostic clusters account for <50% of visits 10 minute average duration Reason for visit 58% acute illness 24% chronic illness 12% well care Average patient paid 4.3 visits in the past year Stange KC, Zyzanski SJ, Flocke SA, et al. Illuminating the ‘black box’: A description of 4454 patient visits to 138 family physicians. J Fam Pract, 1998; 46:
63 Multiple Problems Per Visit Average of 3 problems per visit –37% >3 problems –18% 4 problems –2 problems per visit on bill Special groups –Patients > problems per visit –Diabetics - 5 problems per visit Beasley JW, Hankey TH, Erickson R, Stange KC, Mundt M, Elliott M, Wiesen P, Bobula J. How many problems do family physicians manage at each encounter? Ann Fam Med, 2004; 2; Flocke SA, Frank SH, Wenger DA. Addressing multiple problems in the family practice office visit. J Fam Pract. 2001; 50:
64 Competing Demands Theory Many worthwhile services compete with each other for time on the agenda of primary care patient visits. When primary care clinicians are not doing one activity under scrutiny (e.g. preventive services), they may be doing something else that is more compelling. Jaén CR, Stange KC, Nutting PA. The competing demands of primary care: A model for the delivery of clinical preventive services. J Fam Pract. 1994; 38: Stange KC, Fedirko T, Zyzanski SJ, Jaén CR. How do family physicians prioritize delivery of multiple preventive services? J Fam Pract. 1994; 38:
65 Competing Demands and Tobacco Counseling Hierarchy of taken & missed opportunities –Good (5As) counseling:21% –Competing demands:24% –Failure in a non-smoking related visit27% –Failure in a smoking-related visit25% –Failure in a health maintenance visit2% Guidelines to counsel every visit unrealistic Systems & individual approaches are needed Jaén CR, McIlvain H, Pol L, Phillips RL, Flocke SA, Crabtree BF. Tailoring tobacco counseling to the competing demands in the clinical encounter. J Fam Pract, 2001; 50:
66 Continuity of Care Particularly valued by vulnerable patients –Very young and old –Less educated –Women –More illnesses and medications –Poorer health Lower reported quality of care when valued and not received Duration & shared key experiences valued Nutting PA, Goodwin MA, Flocke SA, Zyzanski SJ, Stange KC. Continuity of primary care: To whom does it matter and when? Ann Fam Med 2003; 1: Mainous AG III, Goodwin MA, Stange KC. Patient-physician shared experiences and value patients place on continuity of care. Ann Fam Med, 2004; 2:
67 Opportunistic Preventive Service Delivery 32% of outpatient visits for illness Health habit advice (28%) Immunization (5%) Screening (4%) No difference in patient satisfaction Visits longer by 2.1 minutes Stange KC, Flocke SA, Goodwin MA. Opportunistic preventive service delivery: Are time limitations and patient satisfaction barriers? J Fam Pract, 1998; 46:
68 Opportunistic Preventive Service Delivery More common during visits by: Patients who smoke, drink or are overweight Patients with high risk diseases New patients Patients with fewer visits in the past year Patients requesting preventive services Less common during visits involving: Another family member Acute illness Prescription of a drug Flocke SA, Goodwin MA, Stange KC. Predictors of opportunistic preventive service delivery J Fam Pract, 1998; 47: Podl TR, Goodwin MA, Kikano GE, Stange KC. Direct observation of exercise counseling in community family practice. Am J Prev Med. 1999; 17: Eaton CB, Goodwin MA, Stange KC. Direct observation of nutrition counseling in community family practice. Am J Prev Med, 2002; 23: Jaén CR, Crabtree BF, Zyzanski SJ, Stange KC. Making time for tobacco counseling. J Fam Pract, 1998; 46:
69 The “Secondary Patient” Family members other than the identified patient 18% of outpatient visits Care of secondary patient Advice, information, explanation Prescription Follow-up of a previous episode of care Visits longer by 1.3 minutes No difference in primary patient’s Preventive service delivery Satisfaction Billing Flocke SA, Goodwin MA, Stange KC. The effect of a secondary patient on the family practice visit. J Fam Pract, 1998; 46: Orzano AJ, Gregory PM, Nutting PA, Werner JJ Flocke SA, Stange KC. Care of the secondary patient in family practice: A report from the Ambulatory Sentinel Practice Network J Fam Pract, 2001; 50:
70 Two Styles of Family Focus Family history as context for care of individuals Higher preventive service delivery rates Family as the unit of care Greater knowledge of the patient and family Medalie JH, Zyzanski SJ, Goodwin MA, Stange KC. Patient outcomes from two different styles of family focus. J Fam Pract, 2000; 46:
71 Recent Emotional Distress Reported by 19% of patients seeing a family physician 18% of these were diagnosed with anxiety or depression Visit duration 10 min - not distressed 11.5 min - distressed, not diagnosed 12.8 min - distressed and diagnosed Dramatic differences in time use Callahan EJ, Jaén CR, Goodwin MA, Crabtree BF, Stange KC. The impact of recent emotional distress and diagnosis of depression or anxiety on the physician-patient encounter in family practice. J Fam Pract, 1998; 46:
72 Recent Emotional Distress Lower rates of Screening tests Less time spent on Screening Tobacco counseling Callahan EJ, Jaén CR, Goodwin MA, Crabtree BF, Stange KC. The impact of recent emotional distress and diagnosis of depression or anxiety on the physician- patient encounter in family practice. J Fam Pract, 1998; 46:
73 Preventive Service Delivery to African Americans & Whites Similar rates of screening & immunization Higher rates of health habit counseling Williams RL, Flocke SA, Stange KC. Race and preventive service delivery among African-Americans and Whites seen in primary care. Med Care, 2001;11:
74 Forced Discontinuity of Care 24% of patients with managed care insurance forced to change their family physician in the past 2 years because of an insurance change Had lower quality of primary care than those not forced to change No difference in the quality of primary care for patients with mc and ffs insurance Differentially affects vulnerable patients Flocke SA, Stange KC, Zyzanski SJ. The impact of insurance type and forced discontinuity on the delivery of primary care. J Fam Pract, 1997; 45: Kahana E, Stange KC, Meehan R, Raff L. Forced disruption in continuity of primary care: the patient’s perspective. Sociological Focus. 1997; 30:
75 Competing Demands Theory Many worthwhile services compete with each other for time on the agenda of primary care patient visits. Jaén CR, Stange KC, Nutting PA. The competing demands of primary care: A model for the delivery of clinical preventive services. J Fam Pract. 1994; 38:
76 Theory of Competing Opportunities Integrated, prioritized care within an ongoing personal relationship Breadth of care Depth of knowledge of the patient, family and community over time Bridging of the boundaries between health and illness Guiding access to more narrowly focused care Stange KC, Jaén CR, Flocke SA, Miller WL, Crabtree BF. The value of a family physician. J Fam Pract, 1998; 46: