Improving our underachieving healthcare system is more than an economic, medical, technological, or academic puzzle. It’s personal. For people across the U.S., it has a profound impact on their quality of life; even more so for individuals with complex care needs, mental illness, and those facing broader health-affecting challenges like poverty or homelessness. One of the most powerful solutions we have to support individuals who need the most complex support and care coordination is one that considers whole-person health: team-based primary care.
Primary care that is focused on whole-person health is the foundation of a well-functioning healthcare system. Without it, prevention, early diagnosis and treatment, and care of chronic conditions are delayed, missed, or ignored. Social needs are unidentified and unmet, and healthcare dollars are spent on care that is fragmented, less effective, and more expensive.
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Primary care is in increasingly short supply, even though it should play an outsized role in our healthcare system. Hospital emergency departments and other options—from urgent care to on-demand telehealth—may offer convenience but fail to offer a comprehensive approach or facilitate trusting relationships with patients. This leads to further fragmented and potentially inadequate care that falls short on prevention and chronic disease management.
This is a significant contributor to the cost and time burden of our underachieving healthcare system. Yet, there is a solution. Team-based primary care provides a uniquely holistic approach to healthcare that can boost our system’s performance and lead to better health. While the individual components may vary, all teams have commonalities: 1) they develop powerful relationships with patients; 2) they incorporate new skills and care delivery opportunities that more comprehensively address patient needs; and 3) they leverage payment models that reward collaboration to promote better health.
Consider this real-world story of a middle-aged woman from a rural town in Colorado. She had a history of substance use, severe mental and physical illnesses, inadequate housing, and complex social relationships. She frequently visited her local hospital’s emergency room to escape the winter cold. The woman’s personal hygiene and untreated mental illness affected other patients so much that staff began offering her a shower and clean clothing, which led to even more frequent visits and no lasting change.
Alerted by the hospital administration, the local primary care clinic identified this woman as high-need and intervened through an outpatient care coordinator (OPCC) to make an appointment. In collaboration with her new primary care physician, the OPCC began to respond to the women’s needs, from getting incontinence supplies mailed to her home to advocating for psychiatric medication and engaging her family. The PCP and OPCC also worked to close significant care gaps, including diagnosis and treatment of hepatitis C, as well as getting an overdue pap smear and mammogram.
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Through the ongoing support and care coordination provided by the primary care team, the woman made significant progress in her health and well-being and was even able to apply for social security disability benefits to support her needs long-term. She began consistently taking her psychiatric medication, experiencing less pain, and was scheduled for a diagnostic psychiatric appointment. Her emergency room utilization also decreased significantly.
This story illustrates how primary care, working as a team and partnering with hospitals, specialists, community and patient support systems, can address both complex health needs and social factors that powerfully impact patients’ lives. The integration of care coordination and community partnerships is essential to provide comprehensive, patient-centered care that promotes optimal health outcomes.
Without an engaged primary care team connected to community resources, it’s likely that this woman would have continued to rely on the local emergency room. And it’s likely that the emergency room would have continued to discharge her with only her acute care needs being met, but not her other complex care needs.
Team-based primary care is needed now more than ever as our “on-demand” and mobile lives, complicated by a primary care shortage crisis, have led to a more transactional and fragmented healthcare experience. There are patients like the woman from Colorado living across the United States, and not enough primary care teams to help them. It is past time to invest in primary care models that reward multidisciplinary teams that leverage the considerable education, skills, and experience of doctors, nurses, pharmacists, social workers, and community health workers in the service of patients. They deserve better health and longer lives, and robust team-based primary care is the key that can unlock that future.
Photo: alphaspirit, Getty Images
Dr. Sara Pastoor is a family medicine doctor practicing in innovative primary care models for the last twenty years, with a focus on patient-centered medical home and health system transformation. Dr. Pastoor spent the first 15 years of her career in the Army Medical Department serving in various leadership roles supporting Army medicine’s transformation to a patient-centered system for health. Currently the Director of Primary Care Advancement for Elation Health, Dr. Pastoor spends time advocating for the powerful role of independent primary care physicians and the value of using a clinical-first electronic health record (EHR) platform. She is also Co-Director for Presence Health, a direct primary care practice in Austin, Texas.
Ann Greiner serves as President and Chief Executive Officer of the Primary Care Collaborative (PCC), where she is focused on defining and implementing an advocacy, research and education agenda that furthers comprehensive, team-based and patient-centered primary care. Greiner is a well-recognized leader in the quality field and has worked at a number of prestigious national organizations. Prior to joining the PCC in 2017, she served as Vice President of Public Affairs for the National Quality Forum (NQF), where she increased the visibility and influence of NQF on Capitol Hill. She also served as Deputy Director at the National Academies of Medicine, contributing to the Quality Chasm series of reports and related conferences. Ms. Greiner has also held leadership positions at NCQA and the American Board of Internal Medicine. She has a master’s degree in Urban Planning from the Massachusetts Institute of Technology and a Bachelor of Arts degree in English Literature from Hobart and William Smith Colleges.
