Primary Care Advocacy Tool Kit |
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CONSUMER GUIDEAnn Cary, Nick Burnett, Marie -Eileen Onieal Introduction How to use this guide to obtain Primary Care Services Primary health care has been on the minds of Americans for decades. Many experience barriers to their ability to receive care and services from the health care system. Today's health care environment offers multiple settings, from the office with a single provider to a comprehensive setting with every possible service and provider under one roof. Regardless of the number of providers or size of the practice, the healthcare system can be a real challenge to those needing access and care. This guide was developed to aid consumers in obtaining appropriate primary healthcare. The goal is to provide consumers with ideas to consider when choosing a heath care plan, provider, or practice. The toolkit prompts the consumer to think about what they want and what they need when they enter the health care system. It is also important to remember that other people and organizations have a voice in how health care is provided in your community, as discussed in the final part of the guide. There are five key elements of primary care; each has its own impact on the ability or inability to get care and each influence the consumer's judgment of adequate access to primary care. These five elements are access, accountability, comprehensive care, continuity and coordination. Each of the elements is discussed separately. Descriptions of the element and key points for the consumer to consider are included in each section. Because each element may vary in importance to the individual, it is helpful to weigh the element accordingly. The authors present this guide with the expectation that it helps develop what is important and a priority for you. In addition, they present it as an aid to making informed choices about which system or provider better meets your healthcare needs.
Five Features of Primary Care that can Determine the Quality Outcomes of your Health Care Experiences ACCESS to a Primary Care Provider All of us eventually enter the health care system. However, the ease with which we can see providers and communicate with them as they diagnose and treat our health problems may differ. When we are unable to access our providers the result can be a delay in finding the problem, starting treatment, obtaining the correct treatments or obtaining referral to a specialist. These delays often contribute to unwanted signs and symptoms, reduced quality of life and functioning, absenteeism, ineffective treatments, economic loss, and general stress. In order to obtain the best possible primary care, we should understand the factors that will assist us to obtain the right care at the right time with the right outcomes. Health care consumers have expressed a number of concerns in access to primary care. Some are concerned with travel times and routes, inconvenient office hours, no weekend or evening care, long waiting room times, and lengthy intervals for available appointments. Others note limited financial coverage, restrictions by insurers, and providers who control their access to other referrals. Finally, consumers have experienced language and cultural difficulties with providers, feeling rushed and not listened to during their visits, communicating by impersonal voice mail and telephone triage. Selecting a primary care provider who can match your expectations for performance in the areas discussed will improve your experiences with the health care system and ultimately the outcomes of your care. The following list of questions are organized to reflect general concerns expressed by consumers and can guide you in selecting a primary care provider for a quality health care experience. Answers to these questions can help guide you in assessing a provider's ability to respond to your decision to seek care. Is your provider geographically accessible:
Is the provider accessible with your schedule:
When you seek care from a provider:
Communication with providers
Answers to these questions will guide you in selecting a provider who has the greatest likelihood of meeting your needs for care over a period of time. Access to a provider who meets your needs is the first step in obtaining quality care. While access is essential it is not sufficient for quality primary care outcomes. Four other areas can guide you to a successful experience in health care and can be found in the following sections.
ACCOUNTABILITY Accountability is the responsibility clinicians take for care they provide and the degree to which they are legally and morally liable for the organization, management and outcomes of that care. There are four elements of accountability: providing quality care, patient satisfaction, efficient use of resources, and ethical behavior. Primary care providers must have professional knowledge and competence. They are able to educate their patients on what to expect from the care provided. Credentialing requirements (licensure, certification) are in place to protect the public from unsafe and incompetent providers. Certification distinguishes providers as experts in their specialty area. Maintaining credentials requires the provider to participate in activities which increase their knowledge of changes in the field of practice and which provide for continued technical competence. Being able choose a provider whose expertise matches your health care needs greatly improves your satisfaction and ultimately the outcomes of your care. In addition to meeting your health care needs, it is important that you have confidence in the providers' abilities. The following questions can help guide your assessment of the providers' ability to respond to your needs. Questions on Accountability:
How important to you is accountability when compared to accessibility, coordination of care, comprehensive care and continuity of care?
COMPREHENSIVE CARE Comprehensive care refers to care that addresses the majority of an individual's physical, mental, emotional and social needs. It includes both first contact as well as long term care. Coordination must also be considered as part of the comprehensive care, since no single provider can deliver comprehensive care to every patient, therefore, provision of many services must be arranged for and coordinated. Comprehensive care can be considered in two very different ways, that of the office visit and that of health care in general. Having all needs met during a single visit would be an example of comprehensive care. Such an encounter would encompass the communication and relationship between the patient and the provider, and receiving desired services during a visit. For general health care, the ability to receive multiple services at one site may be important. Examples of multiple services may include generalist, specialist, preventative or rehabilitative health care and teaching. These services are not limited to physical health but include mental and social health services as well. Stated simply, comprehensive care is "One stop shopping". The following are examples of what might be available in a comprehensive clinic. This list is more idealistic than reality and is designed to stimulate your considerations for what services you would like to have at your main site of primary care service Testing procedures such as;
Therapeutic modalities such as;
Supplies such as;
If comprehensive care is not available, health care can become cumbersome and difficult to manage. Certainly comprehensive care is an advantage to a mother with a child who requires x-rays, casts or splints for a broken bone and medications. Imagine taking a small child to three different facilities to meet these simple but urgent needs. Care that requires visits to multiple offices may affect the payment of the insurance claim. Perhaps an unauthorized source or service was used, or a product specific brand was not covered. Perhaps the request required pre-authorization in order to be covered. Once access to care with an authorized provider is established, coordinated and comprehensive care should facilitate insurance coverage. Having an understanding of how important comprehensive care is to you may help you to select a provider or system that best fits your needs. It would be unusual to find one clinic with all of the items listed in the example above. Consider which needs you may have when reviewing the following comprehensive care questions.
If you were to prioritize your healthcare needs, how important would Comprehensive Care be compared to Accessibility, Accountability, Coordination and Continuity?
CONTINUITY Continuity of care is one of the hallmarks of primary care. Two kinds of continuity are possible: continuity with a single professional, and continuity with a place of service–a particular office or clinic. A long-term personal relationship between providers and patients is most important in promoting health, regardless of interruptions in continuity of care that can occur. There are many benefits to a continuous relationship between provider and patient. These include cost-savings such as fewer visits, faster problem identification, fewer diagnostic tests, improved communication, increased adherence to the treatment plan, shorter hospitalizations, and fewer emergency hospital admissions. Today there are major problems in maintaining continuity as a result of managed care and insurance coverage. Because of competition among plans, many people switch insurance or managed care companies every year. This often leads to a change in primary care providers and a decrease in continuity. When this occurs you may experience less efficient and effective care. The following questions can guide your evaluation of continuity by providers
How important to you is continuity of care when compared to accessibility, accountability, care coordination, and comprehensive care?
COORDINATION Coordination (or integration) of healthcare is an important part of wellness. It ties together all the components of care over time, distance and a variety of caregivers to meet the needs of an individual. Coordination enhances problem recognition, tracking and a holistic approach to care. Therefore, after an individual has accessed care, coordination provides a system of follow through. A simple example would be to coordinate care through specialty services. A person who sees a primary care provider because of low back pain might require interventions with radiology, orthopedics, neurology, neurosurgery, physical therapy and perhaps even anesthesiology in a pain clinic setting. Healthcare is costly at its best. When healthcare is not coordinated it can become even more expensive and perhaps life threatening. Repetitive or excessive testing, failure to follow up in a timely manner and inappropriate therapies can result from poor communications between healthcare team members. Questions may arise during the transition of care and coordination provides the smooth mechanism for answers. It is common to have testing or studies done at a routine office visit. How the test is tracked from the time it is ordered until action is taken on the results is a good example of coordination. If the test is not completed in a timely manner, does the person ordering it know why, or where the test is being held up? Will the client be notified? When the results are available will the client be notified about the results and any further testing or therapy required? How will it be done and does the client need to call or return to find out the results? All of this is coordination. Similarly coordination must take place in specialty referrals. Has the client been seen as requested, what was the outcome and does the client know? Does the client know what is next? Coordination can be done by individuals, by teams (case management), or by health plans. It can keep the patient in the know, prevent repetitive testing and reduce expenditures while providing timely healthcare to promote wellness. Review the questions below about coordination. Does your primary care provider:
How important is coordination of care to you when compared to Accessibility, Accountability, Comprehensive Care and Continuity of Care?
Over All Rating of the Five Factors Important to Primary Care Outcomes As you think about what is important to you, rank these five areas from the rank of 1 representing that which is of greatest importance to you and a rank of 5 as that which is of least importance to you. RANKING: 1-2-3-4-5 ACCESSIBILITY:_________________________ ACCOUNTABILITY:________________________ COMPREHENSIVE:________________________ CONTINUITY:______________________________ COORDINATION:___________________________
CONCLUSION The concept of primary healthcare is complex. The phrase is neither clearly defined nor is it a singular approach used by everyone in the healthcare system. Primary care represents different aspect of importance to each consumer. Certain elements are universally important to consumers, and this toolkit attempts to identify those elements that are important to evaluate when entering the healthcare system. The five elements that are universally important are: access, accountability, comprehensive care, continuity and coordination. The authors suggest that the consumer weigh the importance of each element when deciding on their health care provider. This toolkit is intended to help you find health care that best meets your needs by suggesting ways that you can assess the care given by a health care provider. Care from your provider is in part shaped by the demands by health insurance companies, employers that purchase health insurance, and government. They too should be accountable to you for how care is provided and whether it meets your needs. You may consider turning to your insurance company, your employer, or your state or local government, to better understand your options for health care, to lodge a complaint or make a suggestion for how care can be better delivered, or to learn more about your provider and what they can and cannot do in providing you with care. The specifics of how to do differ but you can use the following guidelines:
Whether the healthcare delivery system is an individual provider, a group practice or a multi-specialty system, the selection process is an important component in maintaining health. It is important that the chosen healthcare delivery system meet those five elements of primary care. This toolkit is presented as a means for a successful evaluation of the provider capability and to promote interaction between you and your chosen health care provider. Good health!
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of Primary Care Policy Fellows 1522 K Street, NW, Suite 702 Washington, DC, 20005 Tel: 202-289-7735 Fax: 202-289-8046 primarycaresociety@primarycaresociety.org |