Primary Care Advocacy Tool Kit

An Ideal Vision of Primary Care

Anthony L. Schlaff, MD, MPH
Director - Futures Project
Director, MPH Programs
Department of Family Medicine and Community Health
Tufts University School of Medicine
136 Harrison Avenue
Boston, MA 02111
anthony.schlaff@tufts.edu
(617) 636-6584

What should primary care look like?

There is no one perfect model for primary care, as the context of family and community require that providers and provider systems adapt to reflect the needs and values of communities across the country that vary widely in terms of age, ethnic identity, cultural values, and health problems. Nevertheless, some features should be shared by all primary care practices.

Primary care should be integrated. This does not mean that all care should be provided by a single person or at a single site. Rather, it suggests that for each patient there be a provider in the health care system that can access and understand the full range of issues and problems facing a patient, and that simultaneously has expertise in understanding the full range of services potentially available in the health care system, and can work in partnership with the patient to arrange the best possible array of services, including specialty care. That provider can simultaneously educate the patient about the health care system and advocate for the patient’s needs within that system.

Primary care should be accessible. Access is a multi-dimensional construct, but in brief it has financial, perceptual, and objective dimensions. Patients should always feel that they can get the care they need in a way that is reasonably convenient and affordable. Community and individual barriers to getting such care must be continually accessed and removed by the primary care practice. The system must be structured in a way that patients get effective care based on sound clinical and public health science. Preventive interventions that affect population health must be available to all patients, and where research has demonstrated improved quality by specialty providers, primary care providers must provide timely referrals.

The care must be accountable. Primary care providers have a responsibility to do the best they can for patients, to educate patients fully, to share decision making with patients, and to respond to issues and concerns raised by patients. They have an obligation to make the processes of care and the coordination of services within the health care system as understandable and comfortable as possible. They must have and demonstrate to the patients an unqualified allegiance to the patient in giving recommendations and in providing services. Patients must have absolute confidence that providers have no incentives to either provide too much or too little service. Providers must protect patients from over-treatment and advocate for needed care.

Primary care must offer a sustained partnership. For people who are ill, this reflects a willingness to participate in the integration of care even when other providers provide the bulk of services, and to make sure that their relationship and knowledge of the patient is used to insure that the patient’s values and preferences are incorporated in treatment decisions. It implies an effort by providers to know and remember their patients and to assist other care-givers in avoiding needless duplication and repetition of services. For healthy patients, a sustained partnership may not be a priority for the patient, but primary care providers should seek to provide on-going and comprehensive preventive care to people in the community who will accept such services, and they should offer the opportunity for patients to enter such a partnership in a way that is comfortable to them at any stage of life or of a disease process.

Finally, primary care practice must occur in the context of family and community. Providers should understand as much as they can about the social, psychological, and cultural background and needs of their patients, and attend to these as well as to biologically mediated illness. They must educate patients using language and terms that patients understand. While offering the best that biomedical science has to offer, they must accept patient values and beliefs as valid inputs into joint decisions. They must understand the range of services and supports available to the patient in their family and community, and work with the patient to use these supports as constructive assets in managing the patient’s health care.