Form follows function. No one expects a three-story 1890’s-style brick house to work for a family living in Albuquerque, New Mexico. Neither would a flat clay adobe dwelling be efficient in Harrisburg, Pennsylvania. Housing choices are determined by the materials that are available locally, the environment in which the house is being built, and the needs of the people who will live in the house. And yet the majority of houses in the United States have the same standard features, such as indoor plumbing and electricity.
Our care systems should be built or remodeled with the same principles in mind. What works will draw not only on the standardized approaches that we know work everywhere (ie, relationships, data, and teamwork) but also will be built around the needs, strengths, assets, the resources of the patient, and the requirements of his or her community.
Although this “form follows function” approach will result in models that are seemingly very different, the overall affect would still be felt: more timely access to quality services when care is needed, more coordinated care across providers and settings, more prevention of disease, better management of chronic disease and comorbid disorders, and, ultimately, lowered overall healthcare costs and better health outcomes. When healthcare providers are freed up by design to focus on the core of their training—caring for patients—job satisfaction will increase and the number and quality of professionals choosing the specialties most in need—pediatrics, family physicians, OB/GYNs—will rise.
All of these ideas may sound common sense and obvious, but too often perceived barriers stand in the way of change. Moreover, funding and information technology are not yet structured in a way that will allow these changes to happen.
But we can take steps now to remodel or rebuild the healthcare system. As we discuss in this paper, many models are already up and running. For those wishing to take the lead in redesigning local or regional systems, the first step is to design a planning process in which stakeholders share data, jointly discuss options and alternatives, jointly implement change, and jointly evaluate outcomes:
• Assess local needs, resources, and strengths—listen to the health department, community agencies, and groups as well as academic medical centers and provider practices.
• Gather as much information from as many entities as possible to paint an accurate picture of care and need now (eg, days lost from school or workplace, public health department community assessments, local health coalition priorities, inventory
• Identify the gaps in the system; hold meetings with communities, providers, and other stakeholders to identify the options for filling these gaps.
• Begin to educate all clinicians, patients, and their families about the role and responsibilities of a healthcare team.
• Incorporate design and improvement knowledge into training, including team training models that are suitable for different practice settings.
CONCLUSION
We purposely avoided—as much as possible—using the phrase “primary care” in this paper to demonstrate the artificial distinctions people make in thinking about system design in terms of fragmented service sectors. To truly achieve success, we need to think in terms of a seamless circle where input from all stakeholders is included in planning, analyzed, actualized, and evaluated. It is important to offer an array of levels and types of healthcare based on population needs.
A slow shift is already taking place from physician-based delivery systems to a wider array of interventions based on local needs, resources, and strengths. This process needs to speed up and be diffused, disseminated, adopted, adapted, implemented, and institutionalized more widely. This is not a one-size-fits all process! High-quality care can be developed in many ways and in many different settings and environments. The key to success is the use of evidence-based healthcare and evidence-based community and public health interventions. NIH’s Clinical Translational Science Awards program is working to assist the nation in this process. Ongoing evaluation will also be central to building better care models that are responsive to the needs of diverse populations. Health reform at every level is never a one-time effort; it is an ongoing process. Any attempt to improve quality will require multiple cycles of development to find best practices and to adapt to the evolution of community needs of an increasingly diverse nation.
ACKNOWLEDGMENTS
The authors would like to thank Kevin Grumbach, M.D. for his assistance in conceptualizing this paper.
1. Gawande A. The cost conundrum: What a Texas town can teach us about healthcare. The New Yorker. June 9, 2009:34-44.
2. Anderson GF, Hussey PS, Frogner BK, Waters HR. Health spending in the United States and the rest of the industrialized world.
Health Aff (Milwood). 2005; 24:903–914.
3. Nolte E, McKee CM. Measuring the health of nations: updating an earlier analysis. Health Aff (Milwood). 2008;27:58.
4. Schoen C, Osborn R, Doty MM, et al. Toward higher-performance health systems: adults’ healthcare experiences in seven countries.
Health Aff (Milwood). 2007;26:w717.
5. The Dartmouth Atlas of Healthcare. Accessible at http://www. dartmouthatlas.org/ (Access date: November 20, 2009). 6. Sutherland JM, Fisher ES, Skinner JS. Getting past denial—
the high cost of healthcare in the United States. N Engl J Med. 2009;361:1227-1230.
7. Fisher E, Goodman D, Skinner J, Bronner K. Healthcare Spending,
Quality, and Outcomes: More Isn’t Always Better. 2009. Accessible
at http://www.dartmouthatlas.org/atlases/Policy_Implications_ Brief_022709.pdf (Access date: March 17, 2010).
8. Fisher ES, Bynum J, Skinner J. The Policy Implications of Variations in
Medicare Spending Growth. Accessible at http://dartmouthatlas.org/
atlases/Spending_Brief_022709.pdf (Access date: March 17, 2010). 9. Billings J, Anderson GM, Newman LS. Recent findings on
10. Schoen C, Osborn R, Doty MM, et al. A survey of primary care physicians in eleven countries, 2009: perspectives on care, costs, and experiences. Health Aff (Millwood). 2009;28:w1171-w1183.
11. Schoen C, Osborn R, How SK, et al. In chronic condition: experiences of patients with complex healthcare needs, in eight countries. Health Aff (Millwood). 2009;28:w1-16.
12. Starfield B, Shi L, Macinko J. Contribution of primary care to health systems and health. Milbank Q. 2005;83:457-502.
13. Baum FE, Bégin M, Houweling TA, Taylor S. Changes not for the fainthearted: reorienting healthcare systems toward health equity through action on the social determinants of health:
Am J Public Health. 2009;99:1967-1974.
14. Brook RH. Disruption and innovation in healthcare. JAMA. 2009;302:1465-1466.
15. Christensen CM, Grossman JH, Clayton C, Hwang J. The
Innovator’s Prescription: a Disruptive Solution for Healthcare: New
York: McGraw Hill Professional; 2009.
16. Christensen CM, Baumann H, Ruggles R, Sadtler TM. Disruptive innovation for social change. Harv Bus Rev. 2006;84:94.
17. NCQA Patient-Centered Medical Home Resources and Tools. Accessible at http://www.ncqa.org/tabid/631/Default.aspx (Access date: March 22, 2010).
18. Joint Principles of the Patient-Centered Home. Accessible at http:// www.ncqa.org/tabid/631/Default.aspx (Access date: March 22, 2010). 19. The Patient-Centered Primary Care Collaborative. Accessible at
http://www.ncqa.org/tabid/631/Default.aspx (Access date: March 22, 2010).
20. Medical Home Concept Gains Momentum. Accessible at AAMC Reporter: http://www.aamc.org/newsroom/reporter/march08/ medicalhome.htm (Access date: February 19, 2009).
21. Backer LA. The medical home: an idea whose time has come... again.
Fam Pract Manag. 2007;14:38-41.
22. Foubister V. Quality matters: Patient-centered medical homes. Accessible at http://www.commonwealthfund.org/Content/ Newsletters/Quality-Matters/2008/January-February.aspx (Access date: March 4, 2010)
23. Shortell SM, Casalino LP. Healthcare reform requires accountable care systems. JAMA. 2008;300:95-97.
24. Fisher ES, Staiger DO, Bynum JP, Gottlieb DJ. Creating accountable care organizations: the extended hospital medical staff. Health Aff
(Millwood). 2007; 26:w44-57.
25. Fisher ES. Building a medical neighborhood for the medical home.
N Engl J Med. 2008;359:1202-1205.
26. Mercier CE, Barry SE, Paul K, et al. Improving newborn preventive services at the birth hospitalization: a collaborative, hospital-based quality-improvement project. Pediatrics. 2007;120:481-488.
27. Berenson RA, Hammons T, Gans DN, et al. A house is not a home: keeping patients at the center of practice redesign. Health Aff
(Millwood). 2008;27:1219-1230.
28. Grumbach K. Redesign of the healthcare delivery system: a Bauhaus “form follows function” approach. JAMA. 2009;302:2363-2364. 29. Margolis P, Halfon N. Innovation networks: a strategy to transform
primary healthcare. JAMA. 2009;302:1461-1462.
30. Michener JL, Yaggy SS, Lyn MM, et al. Improving the health of the community: Duke’s experience with community engagement.
Acad Med. 2008;83:408-413.
31. Michener JL. New models of care: building medical homes in empowered communities. N C Med J. 2007;68:172-175.
32. Liburd LC. Diabetes and Health Disparities: Community-Based
Approaches for Racial and Ethnic Populations. New York:
Springer; 2009.
33. Bodenheimer T. North Carolina Medicaid: a fruitful payer-practice collaboration. Ann Fam Med. 2008;6:292-294.
34. Milstein A, Gilbertson E. American medical home runs. Health Aff
(Millwood). 2009;8:1317-1326.
35. Yaggy SD, Michener JL, Yaggy D, et al. Just for us: an academic medical center-community partnership to maintain the health of a frail low-income senior population. Gerontologist. 2006;46:271-276. 36. Sisson E, Kuhn C. Pharmacist roles in the management of patients
with type 2 diabetes. J Am Pharm Assoc (2003). 2009;49 (Suppl 1):S41-S45.
37. Pottie K, Farrell B, Haydt S, et al. Integrating pharmacists into family practice teams: Physicians’ perspectives on collaborative care.
Can Fam Physician. 2008;54:1714-1717
38. Bentz CJ, Bayley KB, Bonin KE, et al. The feasibility of connecting physician offices to a state-level tobacco quit line. Am J Prev Med. 2006;30:31-37.
39. Rudavsky R, Pollack CE, Mehrotra A. The geographic distribution, ownership, prices, and scope of practice at retail clinics.
Ann Intern Med. 2009;151:315-320.
40. Devdutta S, Michelle L, Michener L. Defining high-performance teams and physician leadership. Physician Exec. 2008;34:44-51. 41. Christensen CM, Bohmer R, Kenagy J. Will disruptive innovations
cure healthcare? Harv Bus Rev. 2000;78:102-112.
42. DesRoches CM, Campbell EG, Rao SR, et al. Electronic health records in ambulatory care—a national survey of physicians.
43. Kawamoto K, Houlihan CA, Balas EA, Lobach DF. Improving clinical practice using clinical decision support systems: a systematic review of trials to identify features critical to success. BMJ.
2005;330:765.
44. The HITECH Foundation for Information Exchange. Accessible at http://healthit.hhs.gov/portal/server.pt?open=512&objID=140 6&parentname=CommunityPage&parentid=5&mode=2&in_hi_ userid=11113&cached=true# (Access date: March 3, 2010).
45. Wegner SE, Humble CG, Feaganes J, Stiles AD. Estimated savings from paid telephone consultations between subspecialists and primary care physicians. Pediatrics. 2008;122:e1136-e1140.
46. Bodenheimer T. Coordinating care—a perilous journey through the healthcare system. N Engl J Med. 2008;358:1064-1071.
47. Naylor MD, Brooten DA, Campbell RL, et al. Transitional care of older adults hospitalized with heart failure: a randomized, controlled trial. J Am Geriatr Soc. 2004;52:675-684.
48. Jencks SF, Williams MV, Coleman EA. Rehospitalizations among patients in the Medicare fee-for-service program. N Engl J Med. 2009;360:1418-1428.
49. Avorn J. Debate about funding comparative-effectiveness research.
N Engl J Med. 2009;360:1927-1929.
50. Steinhauer J. New mammogram advice finds a skeptical audience.
New York Times. November 18, 2009.
51. Rashid JR, Spengler RF, Wagner RM, et al. Eliminating health disparities through transdisciplinary research, cross-agency collaboration, and public participation. Am J Public Health. 2009; 99:1955-1961.
52. HRSA Knowledge Gateway. Accessible at http://www. healthdisparities.net/hdc/html/home.aspx (Access date: March 4, 2010).
53. Wilson C, Gilliland S, Cullen T, et al. Diabetes outcomes in the Indian health system during the era of the Special Diabetes Program for Indians and the Government Performance and Results Act.
Am J Public Health. 2005;95:1518-1522.
54. Sequist TD, Cullen T, Hays H, et al. Implementation and use of an electronic health record within the Indian Health Service.
J Am Med Inform Assoc. 2007;14:191-197.
55. Sequist TD, Cullen T, Ayanian JZ. Information technology as a tool to improve the quality of American Indian healthcare.
Am J Public Health. 2005;95:2173-2179.
56. Fact Sheet: Medicare-Medicaid Advanced Primary Care
Demonstration Initiative. Accessible at http://healthreform.gov/ newsroom/factsheet/medicalhomes.html (Access date:
March 4, 2010).
57. Larson EB. Group Health Cooperative—one coverage-and-delivery model for accountable care. N Engl J Med. 2009;361:1620-1622. 58. Steiner BD, Denham AC, Ashkin E, et al. Community Care
of North Carolina: improving care through community health networks. Ann Fam Med. 2008;6:361-367.
59. Durham Health Innovations. Accessible at http://www.dtmi.duke. edu (Access date: March 4, 2010).
60. Annual State of the Physician Workforce Address: Healthcare Reform and the Physician Workforce. Accessible at http://www. aamc.org/workforce/2009annualmeeting.htm (Access date: March 4, 2010).
61. Olds DL, Kitzman H, Hanks C, et al. Effects of nurse home visiting on maternal and child functioning: age-9 follow-up of a randomized trial. Pediatrics. 2007; 120:e832-e845.
62. Gravelle H, Dusheiko M, Sheaff R, et al. Impact of case
management (Evercare) on frail elderly patients: controlled before and after analysis of quantitative outcome data. BMJ. 2007;334:31. 63. Columbia Basin Health Association Application for HIMSS
Nicholas E. Davies Award of Excellence Community Health Organizations. Accessible at http://www.himss.org/davies/docs/ CHO/CBHA_application.pdf (Access date: March 4, 2010).
64. A Success Story In American Healthcare: Using Health Information Technology to Improve Patient Care in a Community Health Center in Washington. Accessible at http://www.healthreform.gov/reports/ ruralsuccess/index.html (Access date: March 4, 2010).
65. Kessler RC, Aguilar-Gaxiola S, Alonso J, et al. The global burden of mental disorders: An update from the WHO World Mental Health (WMH) Surveys. Epidemiol Psichiatr Soc. 2009;18:23-33.
66. Journey P, Aguilar-Gaxiola S. The Context of Depression in Latinos in
the United States. New York: Springer; 2008.
67. Ginsburg IF, Eng C. On-site mental health services for PACE (Program of All-inclusive Care for the Elderly) Centers.