Primary Health Care and Primary Care
Primary Care
Primary care is prevention-oriented general wellness and illness care of individuals and families. Primary care is characterized as being accessible, affordable, continuing, comprehensive, and coordinated. This form of personal health care delivery evolved to its contemporary state in the 1960s from earlier public health nursing and general medicine practices.
Later, primary care became the foundation and entryway to secondary and tertiary care, especially in managed care systems.
The Institute of Medicine (IOM) defined 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 within the context of family and community” (Donaldson, Yordy, Lohr, & Vaneslow, 1996, p. 33).
Primary care can be defined according to the type
of provider, actual service, level of acuity of the illness, delivery setting,
and client-provider relationship (Marion, 1996; Starfield, 1998).
Primary Care and Challenges
Primary care is facing major challenges to its value in the United States. Primary care delivery is unequal in access and quality according to race, income, type of employment, and other factors (IOM, 2003).
Also, primary care medicine is reported to be in crisis (Moore, G., & Showstack, 2003) due to consumer preference for specialists and emergency departments, less use of primary care physicians as managed care gatekeepers, slipping salaries and unfilled residencies, and increased access to alternative health care providers.
Cooper, Getzen, McKee, and Laud (2002) predicted a shortage of primary care physicians in the near future.
In the face of change and challenges inherent in the US health care system without coverage for many of its residents, advanced practice nurses (APNs) have entered the field of primary care delivery in increasing numbers. Teams of APNs have influenced traditional primary care and created innovative models through basic health and health care knowledge transfer.
Nurse researchers, with funding from the National Institutes of Health (NIH) and other funding sources, have investigated health phenomena and have conducted “translational” research by evaluating utilization of basic science and applied science.
In addition to the traditional nursing research doctorate (PhD) for
generating new knowledge, there has been a resurgence of the practice doctorate
to support evidence-based practice and new delivery model development (Marion
et al., 2003).
Primary Care and Nursing Aspects
The nursing perspective is largely congruent with that of the 1996 Institute of Medicine, except that the family as well as the individual is considered to be a primary care client. Also, nurses place primary care in the context of primary health care, a set of beliefs and principles concerning rights and responsibilities of individuals, communities, and providers as partners (World Health Organization, 1978).
Finally, nurses emphasize their
teaching/coaching, case management, and caring competencies in providing primary
care (National Organization of Nurse Practitioner Faculties [NONPF], 2002).
Primary Care Versatility
The ideal primary care team is multidisciplinary, with nursing, medical, and other types of professionals collaborating in a mutually respectful way to capitalize on each member's individual strengths.
Outcomes of this arrangement have shown potential for reducing utilization while maintaining health status (Sommers, Marton, Barbaccia, & Randolph, 2000). Nurses who deliver primary care include advanced practice nurses (APNs), such as nurse practitioners, certified nurse midwives, nurse specialists, and generalist nurses with basic nursing preparation.
Primary care physicians are
prepared in family and internal medicine, obstetrics and gynecology, and
pediatrics. Health care specialists often provide primary care services to
their clientele, and these specialists may or may not ensure that a full range
of primary care services are delivered within the specialty system.
Primary Care as Health Services
Primary care research can generally be categorized into health services delivery, effectiveness of diagnostic methods and care regimens for specific health needs, and client provider interaction research.
Primary care as a method of health service delivery includes health services access and utilization: cost; process and outcomes according to type of provider, health care system, setting, geographic region, and payment mechanism; client satisfaction; barriers to care; and continuity-of-care models.
Defining primary care, determining essential (diagnosis and treatment) and cutting edge (technology and genomics) primary care competencies, and identifying preferred providers for specific activities are topics for further research.
Distance care, such as telehealth to support self-care, is a health services delivery modality that is receiving much attention from researchers. Targeting care to groups of individuals with common needs and tailoring care to the actual individual are foci of health promotion and chronic disease management.
To understand commonalities appropriate for group interventions, researchers are analyzing large data sets to identify what individuals fit into groups, such as for cost effective disease management (Bodenheimer, 2003). To tailor interventions to the individual, qualitative and mixed methods help to plan intervention protocols for testing.
Related to health services delivery is health care policy research. The effects of policy on primary care and the effects of primary care trends in policy are explored and described in this field of research.
Primary Care Evaluation
Effectiveness among diagnostic methods and care regimens for client specific health needs has been a main focus of primary care research. Primary care client needs span most of the health continuum from health promotion to palliative care. Various forms of effectiveness research encompass the development and evaluation of
(a) screening protocols: based on the epidemiology of the problem and the community
(b) diagnostic procedures
(c) pharmacotherapeutics
(d) exercise, nutrition, and other health promotion prescriptions
(e) alternative therapies
(f) comfort measures
(g) others.
Effectiveness measures include benefits such as health/illness and functional status, quality of life, costs, and client (individual and family) satisfaction. Translating new knowledge to care delivery through evidence-based guidelines is a priority for the NIH Roadmap (NIH, 2003).
Primary Care Researchers
Client-provider interaction is of great interest to primary care researchers. Interaction is a vehicle to gain and deliver information, demonstrate caring and support, and plan health care on a mutual basis.
Besides the development of a trusting relationship, interaction is largely directed at improving client health behaviors and supporting adherence to recommended regimens for specific health problems. Because the client is ultimately responsible for these activities, client-provider interaction is crucial to the health outcome.
Increasingly, providers are using methods such as
computerized-based tailored interventions to extend their reach to more people
and to get better outcomes. Reaching the right balance of face-to-face and
other methods of behavior change and support is a focus in primary care
research today.
Nursing and Primary Care
Research on nursing within a primary care context has mostly centered on APN processes and outcomes in comparison of those of physicians and physician assistants using medical care models (Marion, 1996). Also, primary care APN data are often buried and unidentifiable within physician and insurance data sets.
The numerous small studies with limitations provided a convincing picture of competence and cost effectiveness. More recently, Mundinger and others (2000) conducted a randomized trial comparing primary care patient outcomes between physicians and nurse practitioners with the same authority, responsibilities, productivity, and administrative requirements, and the same patient populations.
The investigators concluded that the patient
outcomes of health status, health service utilization, and satisfaction were comparable.
In 1996, The American Academy of Nursing, with initial funding from the Agency for Health Care Policy and Research (now Agency for Healthcare Research and Quality JAHRQ), Department of Health and Human Services, began to explore the possibility of a practice-based research network (PBRN) to study primary care among primary care APNs to describe their clientele, practices, and health delivery systems.
Since that time, two APN primary care PBRNS have been established with funding by AHRQ: one in the Northeast and another in the Midwest.
The Michigan Academic Consortium of nurse managed academic centers has undergone comparative financial analyzes among the four centers (Vonderheid, Pohl, Barkauskas, Gift, & Hughes-Cromwick, 2003).
Nursing Future in Primary Care
The potential for future APN primary care PBRNs exists in evolving networks in national organizations. In 2004, the National Organization of Nurse Practitioner Faculties had approximately 1,200 faculty members, with over three quarters in clinical practice.
These members represented over 100 graduate nursing programs with academic nursing centers, and many of these programs had several primary care delivery sites. These sites include school and college-based clinics, occupational health settings, mental health facilities, churches, homeless shelters, public housing, and other community agencies.
Are the same time, the National Nursing Center Consortium is increasing numbers of nursing centers throughout the nation and has adopted a minimum data set for data collection. In summary, primary care research has a broad base, covering health phenomena of individuals, families, and communities and the delivery of health services, with the goal of improving the health of the nation.
Give your opinion if have any.