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Primary Care for the 21st Century: The Future of Care
The interests of patients are best served when their care is provided by a physician or through an integrated practice supervised directly by a physician.40 We must not compromise quality for any American, and we don’t have to.
The AAFP encourages health professionals to work together as clinically integrated teams in the best interest of patients. Integrated practice arrangements should include a licensed physician supervising one or more nonphysician health care providers (physician assistants, advanced registered nurse practitioners, certified nurse midwives, various levels of nursing personnel, and other nonphysician providers), and possibly other physicians working as an interdependent team. The central goal of an integrated health care practice is to provide the most effective, accessible, and efficient care to the patient, based upon clinical and patient-focused outcome measures or assessments. The team member assuming lead responsibility for various aspects of patient care will ultimately be determined by matching team members’ clinical competencies and skills with patient needs.41 A nurse practitioner, for example, may take the lead to manage care for a patient with stable diabetes.
The PCMH represents an example of an integrated practice arrangement in which a licensed physician (MD/DO) works jointly with other health care personnel to manage the care of an individual patient and a population of patients using an integrated approach to health care. The arrangement should support an interdependent, team-based approach to care. It should address patient needs for high-quality, accessible health care and reflect the skills, training, and abilities of each health care team member to the full extent of his or her license. The characteristics of the highest-quality PCMH include:
- Personal physician—Each patient has an ongoing relationship with a personal physician trained to provide first contact, continuous, and comprehensive care.
- Physician-directed medical practice—The personal physician leads a team of individuals at the practice level who all take responsibility for the ongoing care of patients.
- Whole-person orientation—The personal physician provides for all the patient’s health care needs or takes responsibility for appropriately arranging care with other qualified professionals. This includes care for all stages of life, acute care, chronic care, preventive services, and end-of-life care.
- Care is coordinated and/or integrated across all elements of the complex health care system (e.g., subspecialty care, hospitals, home health agencies, nursing homes) and the patient’s community (e.g., family, public, and private community-based services). Care is facilitated by registries, information technology, health information exchange, and other means to ensure that patients get the indicated care when and where they need/want it, in a culturally and linguistically appropriate manner.
- Quality and safety are hallmarks of the medical home:
- Medical practices advocate for their patients to help them attain optimal, patient-centered outcomes defined by a care-planning process that is driven by a compassionate, robust partnership between physicians, patients, and patients’ families.
- Evidence-based medicine and clinical decision-support tools guide decision making.
- Physicians in the practice accept accountability for continuous quality improvement through voluntary engagement in performance measurement and improvement.
- Patients actively participate in decision making, and feedback is sought to ensure patients’ expectations are met.
- Information technology is utilized appropriately to support optimal patient care, performance measurement, patient education, and enhanced communication.
- Practices go through a voluntary recognition process by an appropriate nongovernmental entity to demonstrate that they have the capabilities to provide patient-centered services consistent with the medical home model. Patients and families participate in quality-improvement activities at the practice level.
- Enhanced access to care is available through systems such as open scheduling, expanded hours, and new options for communication between patients, their personal physicians, and practice staff.