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The five building blocks of a value based primary care organization

Professor Barbara Starfield was the first to show irrefutable evidence that well-organized primary care contributes to better health outcomes, higher life expectancy and lower costs. Her research forms the foundation of many government policies on sustainable healthcare systems, with a prominent role for primary care. When primary care is well-organized, general practitioners, pharmacists, district nurses and paramedics work together closely. From this collaboration, the care is coordinated to municipalities, community health services and hospitals. This might sound easy, but primary care is characterized by insufficient organizational strength in many countries. Primary care providers operate on their own little islands and mutual cooperation within, and especially beyond the walls of their practice can sometimes be hard to find. The major question is: how do you change this? Fortunately, science offers a solution with five building blocks that, if applied correctly, are important pillars for a future-proof primary care organization.

Building Block 1: Leadership and management

In countries such as the US and Australia, practice shows that primary care organizations are particularly successful when clinical and managerial leadership are combined. What we often see in these organizations is that a general practitioner, physiotherapist or nurse has become proficient in management. This works well, because they understand how things work in the daily healthcare operation. Clinicians with managerial skills are generally better able to lead improvement projects and to set concrete and measurable goals. They are also able to earn the trust of colleagues faster. However, an open and safe organizational culture is essential for achieving success. A culture in which learning is stimulated and mistakes are not swept under the carpet. Clinical and managerial leadership do not necessarily have to be represented by one person. These skills can also be represented by a duo in a duo position. We see this in many successful hospitals and larger care groups.

Building block 2: Data-driven performance management

To realize change and improvements, the focus needs to be (more) on data. This is increasingly the case in hospitals, but primary care is lagging behind. General practitioners do not realize that the clinical data in their electronic health records and data management systems is a pot of gold. By connecting various data management systems a large amount of clinical data becomes accessible. This allows practice variations to be detected, trends to be observed and, with the correct algorithms, even predictions to be made about people’s expected healthcare needs. This, in turn, makes it possible to use and manage clinical and business processes efficiently, and to organize consultation hours more efficiently.

Building block 3: Cooperation and shared responsibility

The third basic condition for a well-functioning primary care organization is multidisciplinary collaboration. A number of scientific studies have shown that the better the teamwork and the greater the safety within the team, the lower the mortality, the number of unwanted readmissions and costs. Multidisciplinary cooperation can be achieved by making good mutual agreements, drawing up codes of conduct, using communication tools effectively and by jointly bearing responsibility. This involves the four D’s: Determining the strategy, Deciding and managing, Discussing interests and Developing significance. Research shows this is easier said than done.

Building block 4: Coordination of healthcare

A similar significant relationship has been demonstrated with the coordination and continuity of primary care. Proper coordination is characterized by active case management, drawing up healthcare plans that are accessible to everyone and structural multidisciplinary consultation. The better this is arranged, the lower the mortality rates, unwanted hospital admissions and healthcare costs, and the higher the patient satisfaction. Continuity and coordination of healthcare are particularly important for complex patients, such as those suffering from multimorbidity and frail elderly people; groups we increasingly see in our society. Because primary care is at the crossroad of our healthcare system, it is especially suited for coordinating care for these patient groups and for fulfilling a gatekeeper function. General practitioners can be leading in this regard, but we’re also seeing nurses fulfilling this role in other countries.

Building block 5: Accessibility

This last building block is certainly not the least important. Currently direct offline and online access to a primary care practice is extremely important for patients, but also for the practices themselves, so they can better manage their capacity. As a healthcare organization, this means having to make smart use of e-Health applications, such as making online appointments, digital access to medical records and e-consults. However, it is important to connect a steering mechanism to this to prevent a proliferation of digital applications. This is difficult to organize for individual practices, but by collaborating you can increase your options.

Building on the legacy of Starfield

Applying the five building blocks requires a different perspective and patience, and sometimes a major cultural change. However, best practices show that it is in fact possible. Starfield has studied and proved the positive effects (see the figures below for concrete results of her research). Added value primary care Health outcomes

Until her passing away in 2011, she continued to fight tirelessly for a generalist and people-oriented approach of patients and advocated for strong primary care that guides people through the jungle of facilities and brings them to the right place. Her research, publications and lectures have significantly contributed to the role of primary care.Added value primary care_Health outcomes

But since her death, research into the added value of primary care is almost non-existent. This has to change because we cannot continue to build on multi country studies from before 2011, or continue the wrong way by focusing exclusively on disease specific programs. The world is changing rapidly. E-Health applications and other applications are emerging quickly, new insights are gained and even the demand for care is changing.Added value primary care_premature mortality

The marketing mechanism eagerly reacts to this. New management philosophies appear continuously (e.g. Value-based Healthcare), all of which lack a scientific foundation, hardly comprehend the concepts of health and healthcare and often do not excel in the implementation phase. We must not allow ourselves to be distracted by this, and instead organize and continue to test primary care according to the five building blocks. We should furthermore dare to take further steps by increasingly letting go of the traditional silos of social, primary and secondary care and by looking at the characteristics of the system as a whole.

Want to know more about the follow-up steps? Download the whitepaper Value Based Healthcare: a call for integrated action.

Pim Valentijn

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