Is it possible to bring primary care back to the center of modern-day health care?
We should rethink that question, says Sara Singer, and put patients at the center. The primary care clinician is critical to ensuring that patients receive the care they need. But patients need someone knowledgeable about all the care they receive, over time, both in the doctor’s office and at home — and that someone should not just be the primary care doctor. Everyone who interacts with and on behalf of that patient should be involved, explains Singer. “I wouldn’t think of it as putting primary care, clinician, or specialist clinician at the forefront,” she says. “It’s really the patient we need to have there. We need to think about teams that function around those patients.”
“I would love the primary care role to really be in that coordinator’s role so that our patients and their families don’t have to be,” adds Care Redesign Lead Advisor Amy Compton-Phillips, noting that primary care is ideally suited to orchestrating all the pieces, particularly comorbidities.
Singer agrees — but with a note of caution. A primary care doctor or specific care coordinator in their office could play that role, she says, particularly for translational help with the more technical aspects of care. But patients or family members of those patients may also want to be the coordinator. We also need more experimentation to determine how this role will work before we create a final model.
From a specialist standpoint, the primary care clinician is crucial to overseeing comorbidity and polypharmacy, adds Bastiaan Bloem. His Dutch ParkinsonNet has staff trained in over 12 disciplines. Primary care is not one of them, but it still plays an important role. Bloem stresses that patients should never receive care from a specialist alone. “A specialist on an island is a threat to health care,” he says.
“I foresee a future where we have funnels of knowledge where there are networks dedicated around specific diseases, where networks function dedicated to that particular condition, but there is an overlaying layer of primary care physicians — and the ultimate generalist is the patient,” says Bloem. “He or she works together with the primary care physician. They oversee comorbidity, polypharmacy, and exploit these expert networks when needed.”
From the NEJM Catalyst event Care Redesign: Creating the Future of Care Delivery at Kaiser Permanente Center for Total Health, September 30, 2015.