Evolution in Care

Primary Care Takes a Team Approach

Feature 1 - Evolution in Care
By Sandy Graham
Photography by Dan Sidor

Teamwork can take a disparate collection of individuals and shape them into something powerful.

Consider the San Francisco Giants. 2010's World Series champs reached baseball's pinnacle without a superstar, instead assembling a motley collection of players who turned out to have perfectly complementary talents.

Teamwork also is becoming a winning force in American health care. Just as the most successful baseball teams call on the blended talents of pitchers, hitters and fielders, primary care is employing a continually expanding cadre of health professionals including physicians, nurses, dentists, social workers, pharmacists, mental health therapists, health educators, dietitians and care managers.

The goal: to deliver primary care in a more efficient, effective, economical and prevention-focused manner.

"The main thing driving this change is we've got a nonsustainable system," says Frank Verloin deGruy III, MD, chair of the Department of Family Medicine at the University of Colorado Denver School of Medicine. "It's really expensive and provides low-quality, fragmented care."

Mark Earnest, MD, PhD, director of Interprofessional Education and associate professor of General Medicine at the University of Colorado Anschutz Medical Campus in Aurora, agrees: "It's the recognition that we're paying a lot and we're not getting much for our money. We really don't measure up very well for all this tremendous investment we make in health care."

The country spent nearly $2.5 trillion for health care in 2009, up a record 17.3 percent from the year before, according to independent actuaries at the federal Centers for Medicare and Medicaid Services. Yet the country ranks below many other developed nations in various health outcomes.

Demand for primary care is growing. The post-World War II baby boomers began turning 65 years old in 2011, and older people typically need more health care. And the Affordable Care Act (ACA), the federal health care reform law signed in 2010, will bring millions of now-uninsured people into the system.

"There's going to be a significant bulge in demand for primary care services from the ACA," says Steve Holloway, director of the Primary Care Office of the Colorado Department of Public Health and Environment. "People who have been uninsured for a period of time are going to have health issues that are unmet." He estimates that the state's primary care workforce will have to expand by 25 percent in the next decade to address those needs.

The Association of American Medical Colleges estimated last year that the country will need an additional 45,000 primary care doctors by 2020. A shortage of primary care providers already exists in some parts of the country, especially in low-income and rural areas. All but two Colorado counties (Broomfield and Douglas) contain areas that are federally designated as "health professional shortage areas," meaning they could use more primary care, dental or mental health providers. But health students incurring heavy debts during their education (see box below) find higher-paying specialty practices more attractive than primary care.

While programs to encourage students to enter primary care are valuable, many experts see a greater need to look beyond practitioner numbers and change the way health care is delivered. That transformation, which includes integrating physical, mental and dental health and tapping the talents of a wide range of primary care professionals in addition to physicians, has begun.

"If you look at primary care practices over the past decade, they don't look much different than they were. But that is starting to change," says Earnest. "There's a growing recognition that we need to be much more team-oriented, collaborative and integrated than we have been."

There is strong interest in a model of care called the patient-centered medical home or health care home, which delivers accessible, continuous, comprehensive, coordinated and culturally sensitive care from a physician-led team of health professionals. In some cases, health care homes are led by other health professionals.

"Interest in the [patient-centered] medical home has really grown over the past five years," Holloway says. While some people may not know the term, surveys have found that most people are positive about the attributes of medical homes, he says. "They like the idea of a relationship with a provider who knows them and knows their health care needs."

DeGruy points to a 1996 Institute of Medicine report, "Primary Care: America's Health in a New Era," as the catalyst in primary care's evolution. The report gave a new definition to primary care: 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 people, and practicing in the context of the family and the community. It defined clinicians to include physicians, nurse practitioners and physician assistants, but deGruy sees the cast growing even larger.

"There's a whole new workforce now that didn't used to exist," deGruy says. For example, he explains, the use of health educators sprang out of people's need to prevent illness and manage their chronic diseases. Health care navigators, also called patient advocates, have evolved to guide individuals through the complexities of the health care system. (For more about the expanding roles in primary care, see story, Who's Who in Primary Care.)

While federal health care reform is expected to put more pressure on the nation's primary care system, the law also is helping train new providers, notes Mary Wakefield, PhD, RN, administrator of the Health Resources and Services Administration (HRSA) in the U.S. Department of Health and Human Services. Her agency works to fill health care gaps for the uninsured, isolated or medically vulnerable. (See story, Building the Primary Care Team, for more about HRSA's work to improve primary care.)

HRSA supports the concept of team-based care. "The primary care workforce in the United States is absolutely evolving and becoming more team-oriented and prevention-focused," Wakefield asserts.

To strengthen the workforce, HRSA is distributing $250 million, authorized by the federal reform bill, for the training of 500 new medical residents in 82 programs, 600 new physician assistants in 28 programs, and 600 new nurse-midwives and primary care nurse practitioners in 26 nursing schools – all by 2015. It also is funding 15,000 additional health care providers through the National Health Service Corps, whose members agree to serve in underserved areas in return for scholarships and loan repayment.

"Ensuring that individuals have access to primary care services is clearly an important objective, and the federal government plays a key role," Wakefield says.

As with so many issues in American health care, payment remains the biggest hurdle team-based primary care faces. Now, practitioners are paid according to the number of examinations, treatments, tests or X-rays they perform. Team care, such as that practiced in patient-centered medical homes and other models, emphasizes counseling or educating people receiving care to become more involved in their care and take steps to head off illness, complications or hospitalizations. Teams incorporate different types of practitioners who use their skills in defined ways – a health educator teaching diabetes self-care techniques, for example, or a physician taking the most complex medical issues.

"We have to stop paying for health care and start paying for health," says deGruy. Increasingly, larger health payers, including some insurance companies and major employers, are turning to payment models in which primary care providers receive a set amount to care for each person and must meet certain health goals. For example, providers might have to screen people in their care for mental health conditions, control their blood pressure or diabetes, and ensure they are immunized against influenza. Technology, such as electronic medical records, is making this easier to track and achieve.

Earnest notes there are already "bright spots" in the health care system where this evolution is well under way, such as Denver Health, one of the state's primary "safety net" hospital and clinic systems, which has successfully integrated primary, preventive and acute care services.

However, the total transformation of primary care is not an overnight process.

"Change is always a lot slower than we think or hope it will be," says Earnest. "But I think the team orientation of primary care is something that is going to happen more and quicker as time goes on."


Pressure on Primary Care
  • Approximately 40 percent of practicing physicians are more than 55 years old.
  • Approximately one-third of the nursing workforce is more than 50 years old.
  • Debt for students completing physician training at a public school averages $145,000 ($180,000 for a private school), so many pursue higher-paying specialties instead of primary care.
  • Federal health care reform, the Affordable Care Act, is expected to add 32 million previously uninsured people to the rolls by 2019.
  • Approximately 78 million baby boomers will turn 65 and become eligible for Medicare by 2030.

Source: Alliance for Health Reform, "Health Care Workforce: Future Supply vs. Demand, 2011."


State Office Fills Workforce Needs

Steve Holloway is like the little Dutch boy with his finger in the dike.

Holloway, as director of the Colorado Department of Public Health and Environment's Primary Care Office, assesses primary care workforce needs and directs significant incentives to providers if they practice in underserved Colorado communities or among populations that aren't getting the primary care services they need. He estimates the state will need 25 percent more primary care providers in the coming decade.

Through participation in the Colorado Health Service Corps and National Health Service Corps, practitioners can have their school loans repaid. The state corps also provides scholarships for some participants.

"These are both exciting and frightening times," Holloway says. "There's lots of interest in and general appreciation for the scope of the [primary care] problem. At the same time, some of the resources we'd hoped to count on from the Health Resources and Services Administration for this work are not available."

Despite the growing pressures on federal and state budgets, Holloway has had some success. A few years ago, there were fewer than 100 providers placed through a state or federal program for underserved areas working in Colorado's health professional shortage areas. As of July 1, there were 450. The federal stimulus bill plus several Colorado foundations, including the Colorado Health Foundation, have provided substantial funding.

Communities need physicians in family medicine, pediatrics, obstetrics, gynecology or psychiatry as well as advanced practice nurses (such as nurse practitioners), clinical social workers, licensed professional counselors, psychologists, dentists and dental hygienists.