Presentation on theme: "Chapter 7: Outpatient Services and Primary Care"— Presentation transcript:
1Chapter 7: Outpatient Services and Primary Care Lecturer: Monika M. Wahi, MPH, CPH
2Learning ObjectivesAt the end of this lecture, student should be able to:Give an example of a health outcome which is improved in a population with good access to primary careName and describe one of the domains of primary careDescribe one outpatient setting, and in that setting, one way primary care can be deliveredName one subpopulation in the U.S. which currently has reduced access to primary care, and say why
4Definitions What is “outpatient care”? What is “primary care”? “Ambulatory” used, but not interchangeable with “outpatient”“Outpatient” refers to any health care services that do not require an overnight stay in an institution of health care deliveryWhat is “primary care”?Not as easy to explain.
5Definitions of Primary Care WHO DefinitionIOM DefinitionPrimary health care, not primary care“Essential health care that is based on practical, scientifically sound, and socially acceptable methods and technology.”Accessible to community in acceptable wayCost is fair for individual and country“First level contact” between individuals and health care systemIOM Committee on the Future of Primary CarePreferred, but not only, route of entry into the health care system“The provision of integrated, accessible health care services by clinicians who are accountable for addressing a majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community.”
6Levels of Care Primary Care Secondary Care Tertiary Care Prevention, diagnostic, therapeutic svcs., health education, minor surgeryPrimary care is an “approach to providing health care”Primary CareShort-termSporadic consultation with specialist for advanced interventions not available in PCSecondary CareFor conditions that are relatively uncommonInstitution-based, highly-specialized (e.g. open-heart surgery)Tertiary Care
8WHO and IOM overlap in certain “domains” of primary care Point of EntryCoordination of CareEssential CareIntegrated CareAccountabilityFrom Exhibit 7.3 (page 172).
9Point-of-entry First contact allows gatekeeping IdealCurrent realityFirst contact allows gatekeepingProtects patients from unnecessary procedures/overtreatmentCommunity-based – widely available everywhere, routine, inexpensive, appropriate techCan refer on for “expensive” proceduresGatekeeping may not work because not enough PCPsLack of PCPs may cause system to malfunction, thus denying treatmentLack of PCPs may lead patients to get unnecessary tx anywayNot widely available, and may be very costly
10Coordination of Care PC clinicians are advisors and advocates Refers to specialized careAdvice on diagnoses and therapiesDiscuss treatment optionsContinuing care/chronic conditionsContinuity, comprehensiveness
11Coordination Role for Primary Care SpecialistsInpatient CareContinuityComprehensivenessPrimary CareIn what situations might this not work very well?SurgeryDx ServicesFrom Figure 7.1 (page 173)
13Primary Care Works!Countries with PC orientation have better health levels, higher satisfaction with health services, and lower expenditures overallWeak PC infrastructures associated with poorer health and higher costsIn U.S. states with higher PCP/patient ratio have better health, lower hospitalization for PC issuesAdults with PCPs as their main go-to for health care have lower death rates and incur lower costsClosely linked with specialty care – appropriateness of interventions and outcomes better with specialist when referred by PC vs. self-referral
14Essential CarePrimary care = essential care, meaning it leads to the optimization of not just individual health, but population health.Requires minimization of “disparities”Money talks – financing the key element to health care, and without national financing in U.S., difficultMixture of private and public financing in U.S. = fragmentation, so hard to “steer the ocean liner”Primary care model embraced by MCOs, but current role limited to low-cost general medicine and gatekeeping, thus controlling access to the rest of the health care system
15Integrated Care IOM: Accessibility Accountability Care provided over long-term by single provider/ teamProvision of health care svcs optimal to meet pt needsAddresses any health problem, any stage of pt’s life cycleIOM:AccessibilityAccountabilityComprehensiveCoordinatedContinuous
16Accountability Patient PCP IOM: Both pts and PCPs have accountability May not be equalWill change over timeMutual trust, respect, responsibilityPatientPCPInvolve others in dx/txManage all types of concernsKnowledge/ skillsResponsible for healthUse HC only when needed
18Primary Care and Outpatient Care Primary care – a philosophical approachOutpatient care – actual care that happens in various settings that are not inpatientCan be care by a specialist – which would not be primary careOften primary care happens here – but what about hospitalists?Primary care that is accessible in the community should take place in an outpatient care settingBut there are a lot of settings….
19O/P Care Settings/Methods Office-based practitionersRise of MCOsPrivate PracticeHospital O/PFreestandingMobilePhone TriageHome CareInpatient reduced/discouragedClin, surg, home hth, women’s ERWalk-in, urg. care, surgicentersRehab, dental, retail healthMammo, MRI, at malls/fairgrndsSmall towns and rural cmntiesSpecially trained nursesGuidance/stand. protocolsAlternative to institutionaliz.Nurs. care, rehab, many svcs.From Exhibit 7.1 (page 161)
20O/P Care Settings/Methods Life expectancy <6 mos.Palliative, psych supportHospice CareO/P LTCPH SvcsCmty Hlth/FreeAlt. Med.Case managementAdult day careVery locally, limited in scopeSTD, fam. planning, MHFed grant-funds starting in 1960’sLow SES, migrant workersNon-traditional forms of care¼ adults with no pract. Visits had CAMFrom Exhibit 7.1 (page 161)
21Factors Affecting Outpatient Care Reimburse-mentTechnologic FactorsUtilization Control FactorsSocial FactorsLess-invasive surgical = ambulatory surgery centersShort-acting anestheticsLess traumatic, shorter recovery timeTechnology allows outpatient dx/tx never available beforePatients prefer care at home/ community-based settingSense of independence and controlQuality-of-lifeCosts less than inpatientQuicker inpatient discharge = more outpatientHospitals scrambled to set up hospital outpatient servicesAlso led to boom in home health carePayers discourage inpatient staysPrior authorization before admissionMonitoring inpatient stays to minimize length
22Americans and Current Primary Care Access and Services
23Access to Primary CareBonus question: Why is the red bar shorter than the others?Yellow = delayed or did not get medical care due to cost, red = did not get a prescription due to cost, and blue = did not get dental due to cost (2009).From Exhibit 7.2 (page 162)
24Outpatient Services in the U.S. 2008 National Ambulatory Medical Care SurveyAmericans made 960 mil visits, more than 3 per person, to office-based physiciansDO’s = 7.3% of visits91.5% took place in metropolitan areasVisits per person were higher in metropolitan areas (3.5) than rural areas (1.6)Visits per person highest in Northeast (3.6) and lowest in Midwest (2.9)
28Community-Oriented Primary Care 1978 International Conference on Primary Health Care (WHO)People through the world had little control over their own health carePersonal ownership= better health outcomesRequires partnership between clinicians/pts“Community-oriented primary care” is primary care plusConcern for population as well as individualBroader than strict medical, encounter-based activities (e.g., emotional and spiritual wellbeing)
29Secondary Prevention Preventing existing conditions from getting worse Not really a charge for primary careHowever, studies show secondary prevention can be positively affectedGood primary care = improved access to care, health outcomes
30Disease Management Common Conditions Ear InfectionsMigrainesOvarian CancerCommon ConditionsConditions seen in Primary Care and in Specialty ClinicsUncommon ConditionsGeneralists better than specialistsSpecialists better than generalists
31Hospitalizations/ER Care Poor primary care resources result in higher rates of hospitalization that could have been preventedKids with good primary care/involved PCPAdolescents with regular PC source has more preventive svcs, fewer ER
32How Primary Care Lowers Overall Cost of Health Care Care for common illnesses is more expensive if given by specialist vs. generalist, and health outcomes are the sameThis relationship has been demonstrated in other industrialized countries (higher PCP/person ratio, lower overall health care costs)This relationship has been demonstrated over the whole U.S. (higher PCP/person ratio, lower overall health care costs)More primary care doctors per person lowers overall cost of health care for elders in the U.S. in metro areas – both inpatient and outpatient
33Effect of PCP Supply on Health “..lower supply of specialists enhances the likelihood that PCPs will screen their patients for such cancers.”Effect of PCP Supply on Health PCPs PCPsRates of self-reported poor healthDiagnosis of colorectal cancer delayedGreater risk of uncontrolled hypertension (men)Higher rates of better healthFewer low-birthweight babiesBetter outcomes/access for children
34Morbidity and Mortality (M&M) Said another way: sickness and death“Ecologic studies” show association between higher PCP/individual ratio and lower M&MWhat is an ecologic study?Are you serious? Having more PCPs can lower the death rate??Affects life expectancy, stroke, postnatal and total mortality“Time series” studies show association, tooSame place studied over timeAs ratio changes, M&M changes in step
35Medical HomeIn 2006, American College of Physicians recommended a new model for primary careAdvanced Medical Home practices include:Providing patient-centered care based on Chronic Care ModelUsing evidence-based guidelinesApplying appropriate health information technologyDemonstrating “best practices”Consistently/reliably meeting needs of patientsBeing accountable for quality and value of care providedCan our current U.S. health care system do all of the above the way it is?
36“Medical Home” Approach One doctor deemed “personal physician” as primary, continual medical contactDoctor coordinates a directed team of caregivers across the health care system to wholly care for patientImplemented in small scale, and studies show it improves:Patient health and satisfactionImprovement in care quality (reduction in medical errors)Cost savings without causing worse health outcomesKey to why this works: Chronic disease care
37Conclusion Primary care is conceptually related to outpatient care Many outpatient settings where primary care can be deliveredUsing a primary care approach on a population (e.g., by way of Medical Home) can reduce cost while keeping quality steadyIncreasing access to primary care (by way of outpatient services) improves population health and decreases M&MToo many specialists and not enough PCPs reduces chances domains of primary care will play out, even with outpatient services available
38Learning ObjectivesAt the end of this lecture, student should be able to:Give an example of a health outcome which is improved in a population with good access to primary careName and describe one of the domains of primary careDescribe one outpatient setting, and in that setting, one way primary care can be deliveredName one subpopulation in the U.S. which currently has reduced access to primary care, and say why