8 Core Tenets of Primary Health Care Improvement in Middle and High-Income Countries
Around the globe, spurred by the WHO’s call to action, a new paradigm for improved health care delivery is gaining momentum. It is called integrated people-centered health services or IPCHS and the goal is to provide the right service to the right patient at the right time. The foundation of IPCHS is a successful, high-functioning primary health care system.
The Primary Health Care research team at Ariadne Labs developed an 8-tenet model that characterizes effective primary health care systems in middle and high-income countries. The 8 tenets grew from our work with the World Bank on the China Health Study, which lays out a pathway for health care reform across China. As part of the study, 19 case studies were commissioned to analyze 22 performance improvement initiatives to strengthen person-centered, integrated primary health care in 10 counties in China and in 12 other countries.
The case studies were designed to provide a comprehensive understanding of successful strategies that can be used for improving primary health care delivery across a range of settings and through a range of approaches. The eight tenets were derived from the case studies and offer a framework for understanding and putting into action the characteristics of a successful primary health care system and are described below:
The first foundational characteristic of a strong primary health care system is solidifying the role of primary health care as the point of first contact for the majority of the patient’s needs. Making primary health care the “entryway” into the health care system requires patients to know where to seek care (or have care seek them), and to be able to access competent, caring providers in a timely manner. It also requires providers to know the population for which they are responsible and to have processes by which they can guide patients to the appropriate level of care. Designating particular segments of the population as the responsibility of each primary health care facility encourages a continuous, trustful, knowledgeable relationship to grow between that community and that facility. In turn, the community will receive care that is better coordinated across the continuum of health care (primary, secondary, tertiary), benefiting both the patient and the system. There are several sub-strategies for ensuring that PHC is the first point of contact for patients for a majority of their health care needs, which include:
- Empanelment of the target population Empanelment–the process by which all patients in a given facility and/or geographic area are assigned to a primary care provider or care team–is a fundamental component of population health management. Empanelment forms the foundation basis for managing the health of a population. It facilitates the receipt of continuous, optimized care, whether or not patients regularly seek care (Qualis Health 2015). Empanelment can contribute to building patient-provider relationships and trust, ensuring responsibility at the PHC level for the health of a population, and shifting health-seeking behavior away from hospitals.
- Employ risk stratification as a way to better target outreach and care management efforts Risk stratification uses risk prediction tools to proactively identify individuals within an empaneled reference population who are at a higher risk for developing poor outcomes or who have or are at risk for having high rates of service utilization, particularly hospitalizations. Individuals identified through this process can be proactively targeted for interventions designed to provide needed higher intensity and coordinated care in the PHC setting and high utilizers can be engaged to understand and address their needs and reduce preventable use of higher cost and intensity services. Risk stratification can range from simple more complicated efforts. It can be based on prioritized target conditions, clinical guidelines, inequitable disparities in care, a recent history of high utilization, a summative process of clinician’s clinical intuition, or by identifying specific diseases that are associated with high costs, require complicated management, or are associated with high risk for poor outcomes.
- Build robust and reliable referral mechanisms Referral systems have two functions: to reliably and appropriately triage patients to specialty care, and to ensure communication and coordination between levels of care. Gatekeeping–in which patients are either required or encouraged to see their primary care provider before obtaining speciality care–is an important mechanism for ensuring that patients receive the right care at the right place at the right time. However gatekeeping must include a strong referral system so that patients, when appropriate, have reliable and timely access to higher levels of care. The referral system must include functionality to ensure coordination of care through effective communication between the referring PCP and the sources of specialty care.
- Ensure accessibility for patients Accessibility is a critical component of effective service coverage. Providing options for patients to see or speak to their providers when they perceive the need is a critical function of primary health care. After-hours care options and same-day visit opportunities strengthen the ability of primary health care to reduce avoidable harm as well as unnecessary upstream utilization of more expensive care options. Financial incentives can be used to improve access, and access standards can be legislated. Additionally, strategies such as home-based care and mobile clinics can improve access, particularly for elderly patients, or patients with limited mobility.
Multidisciplinary teams are non-hierarchical groups of clinical and non-clinical staff who provide comprehensive and integrated care to patients. Teams generally coalesce around a core primary health care provider or experienced clinician; however, team members should ideally have a variety of backgrounds in order to provide a fuller range of services. Non-clinical roles might include community health workers, social workers, doulas, or coaches. Regardless of her background, a team member’s role should be clearly defined.
In an appropriately collaborative environment, high-functioning multidisciplinary teams provide better care to their patients by offering more comprehensive and more integrated services, by creating and implementing more effective individual patient care plans, and by coordinating care both inside and outside the facility. Such a team can successfully treat a wide range of complaints, from acute infections to long-term management of chronic diseases, from childbirth to palliative care, without needing to invoke a referral to a higher level of care. Critical early steps to establishing effective teams include the presence adequately trained health personnel, defined roles and responsibilities for each team member, and the establishment of collaborative cultures of patient-centered care.
Vertical integration refers to the coordination of primary, secondary, and tertiary health care services within a tiered service delivery system. Vertical integration is often achieved through a system of communication between facilities to facilitate patient referrals and collaborations between provider. Successful vertical integration relies upon active cooperation from all facilities at all levels of the health care system. To that end, each facility must understand its clearly defined role and range of services offered and proactively participate in the communication system. While higher-tier facilities can offer support in the form of technical assistance, mentorship, partnership, staff skills-building, and/or supervision to lower-tier facilities, they should not be the sole (or even primary) drivers of the integration. Ensuring effective, affordable transportation between facilities for urgent referrals is also important, especially in rural regions.
Successful vertical integration improves continuity of care for each patient across the various tiers of health care delivery. For example, care necessary after a hospital stay should be provided by a primary care facility; in a successfully vertically integrated system, a patient’s primary care provider would be in communication with the hospital team caring for her patient and receive necessary documentation of the hospital or post-acute facility stay and discharge plans.
Horizontal integration spans the boundary between public health and curative care systems and encompasses the presence and coordination of multiple types of health care services within frontline primary health care facilities, including promotive, preventive, curative, rehabilitative, and palliative care. Though not a requirement, horizontal integration often is best accomplished through physical co-location of services; for example, a primary health care facility may house not only curative primary health care capacities but also public health services such as vaccinations and family planning materials and basic emergency care. Primary care may also be integrated with specific (often chronic) disease programs, like tuberculosis, HIV or diabetes care. Regardless of the model, policymakers should purposefully design horizontal integration into their primary health care systems with the patient experience firmly in mind.
Horizontal integration (especially physical co-location) frequently increases the efficient use of limited resources. More importantly, such service integration allows for more effective management of health care delivery and better-coordinated care based on the needs of the patient rather than the convenience of the delivery system or the vagaries of the environment or geography. Well-designed and well-executed horizontal integration enables the provision of holistic, comprehensive care that treats patients as people rather than as cases of diseases, including taking into account psychosocial and contextual factors that affect health states.
Advanced information and communication technology (eHealth) includes tools such as electronic scheduling, text messaging, intra-facility virtual consultations, and electronic health records that give patients and providers the opportunity to more fully engage with care processes, to improve care management, and to make more effective decisions. For example, electronic scheduling improves patients’ ability to visit their physicians, while text messaging allows patients the flexibility of asking questions and seeking health information without requiring a full visit. Similarly, text messaging and intra-facility virtual consultations provide physicians with access to their colleagues for the purposes of patient care or professional development.
The electronic health record (EHR) is the centerpiece of an effective eHealth system. A well-designed and high-functioning EHR will create a more coordinated care pathway for both providers and patients by improving clinical decision support, care transitions, record keeping, and other factors. Affordable or even open-source EHRs are increasingly available worldwide. The full potential of an EHR, however, can only be achieved when all the relevant providers and the patient herself has access to it. Therefore, an EHR should be the centerpiece, but not the entirety of a successful eHealth system. Patient portals with links to mobile technology offer the opportunity for asynchronous communication and remote monitoring between a patient and her health team.
Clinical pathways are standard therapeutic methodologies that providers use to treat particular conditions. Because the backbone of the pathways is comprised of international best practices and because the pathways are continuously evaluated and revised with local clinical rigor, physicians can place a greater degree of trust in the system. At the same time, the pathways are also tailored to the needs and interests of the local population. Such pathways offer a highly valuable decision-making support tool for providers in all tiers of health care provision.
A crucial aspect of clinical pathways is a strong dual referral system, which refers to a well-delineated standard for referring patients “up” or “down” the tiers of the health care system. Within the context of a system that is integrated both horizontally and vertically, a strong dual referral system makes explicit the circumstances under which patients will be referred from primary to secondary care, from tertiary to primary care, or any other care transition necessary. The system thus improves care coordination for each patient, reduces unnecessary and duplicate referrals, strengthens relationships and collaboration between facilities within the health care system, and can be fiscally beneficial at all tiers of the health care system.
A successful primary health care system requires constant awareness and learning about its own processes and outcomes in order to continuously improve care delivery. The first step in such awareness and learning is instituting a system of measurement that reflects national standards and the core functions of an effective care delivery system (coordination, comprehensiveness, integration, and technical and experiential quality). Indicators should measure quality at the patient, provider, and system level; this information must then be shared with relevant individuals through a well-designed and agile feedback loop, so those individuals may coach providers, facilities, and systems in addressing quality gaps and strengthening and redesigning systems.
Sharing quality data with the community encourages patients to engage more fully with the health care system by building trust and by empowering the community (and providers) to lobby for improvement and redesign to meet their own needs. Additionally, measurement and feedback loops serve as a basis for guiding the technical assistance, supervision, and mentorship that a secondary tier facility and providers can offer to primary health care facilities and providers. Improvement can result from facilities and providers making incremental changes in processes in immediate response to feedback, from identifying early positive outliers who then teach others their processes, from better understanding a disease burden and the context in which it occurs and improving treatment pathways to fit it, or from other specific methods.
An often under-recognized function of primary health care is its potential to serve as a locus of accountability for population health outcomes. The other core action areas of improvement mentioned above, when done in concert, allow increasing degrees of accountability for ensuring critical population health targets to be met in high-performing systems. Ensuring that facilities and providers meet these targets requires higher order management and leadership capacities within frontline systems. High-performing systems expend considerable resources training managers and fostering strong leadership styles in system managers.
However, many PHC systems lack strong management and leadership capacities. A first step for improvement for some areas is the implementation of national or regional certification standards. Certification is the process of requiring facilities to meet certain predefined structural and/or performance targets within a specified time period. Certification systems make sense on a theoretical level but are often challenging to implement in an agile, effective way. The successful creation of a system of certification requires setting aspirational but attainable functional standards, defining specific metrics against which facilities will be measured, and establishing a transparent and reliable process for conferring certification. Implementing a certification program is one method of catalyzing facility transformation according to system-wide priorities: by defining the necessary model(s) of care delivery through certification, a health care system can set standards for a facility’s or system’s infrastructure (resources, eHealth, human resources), organization (integration, facility roles), form of care delivery (people-centeredness, comprehensiveness, continuousness, coordination), and outcomes.