How to Move Healthcare Forward by Looking Back

With our recent blogs on August 3 and August 17 focused on innovative care models, it seems appropriate to pause and review the historical context that served as the foundation for many current innovative efforts. While the focus of today’s article is primary care, many of the learnings have broad applicability.  

A Definition of Primary Care

Interestingly, much of the groundwork for current innovations to improve care was provided in  1978. At that time the Institute of Medicine (IOM) proposed a definition of primary care as “…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 patients, and practicing in the context of family and community.”

Dr. Starfield’s Legacy

In her seminal book published in 1992, Dr. Barbara Starfield made the case for primary care driving improved quality and lower costs across the globe.¹  She was able to show that primary care availability positively correlates with improved health outcomes and lower cost trends. Perhaps less well known from that same book is her delineation of the four pillars of primary care. 

Building on the definition created by the IOM, she described four essential elements of primary care as: 

1. First contact 
2. Continuity of care 
3. Comprehensive care 
4. Care coordination 

It wasn’t until 15 years later, in 2007, that the American Academies of Pediatrics (AAP) and Family Practice (AAFP) together with the American College of Physicians (ACP) and American Osteopathic Association(AOA) published their “Joint Principles” document that embedded Dr. Starfield’s four pillars into their definition of a patient-centered medical home.

The Power of Teams

Building on this work, Dr. Tom Bodenheimer studied the attributes of health care providers that were particularly successful in establishing and maintaining those four capabilities. In the March, 2014 Annals of Family Medicine he published, “The 10 Building Blocks of High Performing Primary Care”, which can be roughly sorted into three categories:  leadership,  structure, and function.

Bodenheimer delineates key leadership attributes including knowledge and experience in change management, driving a culture of “leading from where you are” and data driven decision making.  At the structural level, he focuses heavily on the important role of teams in efficiently and effectively supporting their patients’ needs. At the core of the team is a clinician with a dedicated panel of patients. That clinician is then paired with one or more support staff that serve as a “teamlet” that owns the relationship with every patient in their panel. In most practices, several “teamlets” come together to form a team that shares administrative and clinical support needed to ensure that all operational requirements of the practice are met. At the functional level, Bodenheimer starts with Dr. Starfield’s four pillars and adds to them the importance of population health capabilities. His final building block was a “template of the future” that foresaw virtual visits, group visits and visits with non-clinicians when appropriate.  

Many current attempts to adopt innovative clinical models are built on the foundation described here. As practices look forward to a post-COVID world that will have even greater emphasis on value-based contracting, they would do well to study the work of Drs. Starfield and Bodenheimer for guidance in building efficient and sustainable accountable care capabilities.  

¹ Starfield, B, (1992). Primary care: concept, evaluation, and policy: Oxford University Press