Primary Care -- Copyright -- Preface -- Acknowledgments -- Contents -- Summary -- DEFINITION OF PRIMARY CARE -- VALUE OF PRIMARY CARE -- THE NATURE OF PRIMARY CARE -- THE DELIVERY OF PRIMARY CARE -- THE PRIMARY CARE WORKFORCE -- EDUCATION AND TRAINING FOR PRIMARY CARE -- RESEARCH AND EVALUATION IN PRIMARY CARE -- A STRATEGY FOR IMPLEMENTATION -- 1 Introduction -- THE INSTITUTE OF MEDICINE STUDY -- Funding -- The Study Committee and Its Charge -- Study Activities -- Commissioned Papers -- Interim Report -- Site Visits -- Public Hearing -- Workshops -- UNDERLYING ASSUMPTIONS -- HISTORIC ROOTS AND THE CONTEMPORARY CONTEXT FOR PRIMARY CARE -- Historic Roots -- Before World War II -- The 1960s -- The 1970s -- Current Forces -- Health Care Reform -- Other Forces -- ORGANIZATION OF THE REPORT -- REFERENCES -- 2 Defining Primary Care -- EARLY DEFINITIONS -- THE FIRST IOM DEFINITION -- DISTINGUISHING PUBLIC AND PERSONAL HEALTH SERVICES -- THE 1984 REPORT ON COMMUNITY-ORIENTED PRIMARY CARE -- CHANGES IN HEALTH CARE DELIVERY TODAY -- THE NEW DEFINITION AND AN EXPLANATION OF TERMS -- Recommendation 2.1 To Adopt the Committee's Definition -- Patient -- Family -- Community -- Clinician -- Partnership -- Health Care Needs and Health Care Services -- Integrated -- Comprehensive -- Coordinated -- Interaction with Communities -- Continuous -- Comment: Who Is a Primary Care Clinician? -- Accessible -- Accountable -- Quality of Care -- Quality Measurement -- Patient Satisfaction -- Efficiency -- Ethical Behavior -- Accountability of Patients -- ACHIEVING THE GOALS OF PRIMARY CARE AS DEFINED -- REFERENCES -- 3 The Value of Primary Care -- THE VALUE OF PRIMARY CARE FOR INDIVIDUALS -- Addressing Most Problems That Patients Bring -- Guiding Patients in Using the Health Care System -- Providing an Ongoing Relationship Between Patient and Clinician -- Continuity.

Accountability -- Preventing Illness and Detecting Diseases Early -- Bridging Personal Health Care, Family, and Community -- Primary Care and the School -- Primary Care and the Elderly -- Primary Care and Public Health -- Comment -- PRIMARY CARE AND COSTS, ACCESS, AND QUALITY -- Costs of Care -- Access to Care -- Quality of Care -- General Observations -- Outcomes -- Attributes of Primary Care -- Management of Referrals -- Preventive Care -- THE LIMITS OF PRIMARY CARE IN IMPROVING POPULATION HEALTH -- SUMMARY -- REFERENCES -- 4 The Nature of Primary Care -- CONTENT OF PRIMARY CARE -- The Large Majority of Health Care Needs -- Episodes of Primary Care -- CHARACTERISTICS OF PRIMARY CARE -- Biomedical and Social Sciences -- Biomedical Sciences -- Social Sciences and the Humanities in Primary Care -- Evidence-Based Medicine -- Clinical Decisionmaking -- General Observations -- Influence of Different Clinical Roles -- Personal Aspects of Primary Care -- Mental Health and Physical Health -- Health Promotion And Disease Prevention -- The Power of Information -- SUMMARY -- APPENDIX: DATA ON THE MAJORITY OF PERSONAL HEALTH CARE NEEDS -- Description of Data -- The Netherlands Transition Project -- The U.S. Data -- Results -- The Netherlands Transition Project -- The U.S. Data -- Comment -- REFERENCES -- 5 The Delivery of Primary Care -- CURRENT PATHWAYS FOR PRIMARY CARE -- Spread of Managed Care -- Development of Integrated Health Care Delivery Systems -- Consolidation of Health Plans and Systems -- Growth in For-Profit Health Plans and Delivery Systems -- Diversity Among and Within Markets -- Coordination of Primary Care with Other Services -- Current and Evolving Professional Roles -- Primary Care in Rural Settings -- Care of the Urban Poor -- Role of Academic Health Centers -- MOVING TOWARD DELIVERY OF PRIMARY CARE AS DEFINED.

Recommendation 5.1 Availability of Primary Care for All Americans -- Financing of Primary Care Services -- Recommendation 5.2 Health Care Coverage for All Americans -- Recommendation 5.3 Payment Methods Favorable to Primary Care -- Recommendation 5.4 Payment for Primary Care Services -- Organizing Primary Care Services -- Understanding Professional Roles in Primary Care -- Background -- The Primary Care Team -- Recommendation 5.5 Practice by Interdisciplinary Teams -- Role of Specialists in Primary Care -- Roles of Other First-Contact Health Professionals -- Ensuring Primary Care for Underserved Populations -- Background -- Managed Care and Underserved Populations -- Recommendation 5.6 The Underserved and Those with Special Needs -- Other Approaches for Underserved Populations -- Coordinating Primary Care with Other Services -- Public Health and Primary Care -- Recommendation 5.7 Primary Care and Public Health -- Mental Health and Primary Care -- Recommendation 5.8 Primary Care and Mental Health Services -- Long-Term Care and Primary Care -- Recommendation 5.9 Primary Care and Long-Term Care -- Performance Monitoring for Primary Care -- Recommendation 5.10 Quality of Primary Care -- Infrastructure Development for Primary Care -- Role of Academic Health Centers in Delivery Of Care -- Recommendation 5.11 Primary Care in Academic Health Centers -- SUMMARY -- REFERENCES -- 6 The Primary Care Workforce -- WORKFORCE TRENDS AND SUPPLY PROJECTIONS: PHYSICIANS -- Overall Levels of Supply -- Primary Care Physicians -- Who Is Included -- Trends in Supply -- Education, Training, and Licensure -- Geographic Distribution of Primary Care Physicians -- WORKFORCE TRENDS AND SUPPLY PROJECTIONS: NURSE PRACTITIONERS -- Primary Care Nurse Practitioners -- Trends in Supply -- Current Work Environments and Responsibilities.

WORKFORCE TRENDS AND SUPPLY PROJECTIONS: PHYSICIAN ASSISTANTS -- Primary Care Physician Assistants -- Current Work Environments and Settings -- OTHER FIRST-CONTACT PROVIDERS -- COMMENT ON WORKFORCE ESTIMATION -- CONCLUSIONS AND RECOMMENDATIONS ABOUT THE SUPPLY OF PRIMARY CARE CLINICIANS -- Training Programs for Primary Care Clinicians -- Basic Goals -- Recommendation 6.1 Programs Regarding the Primary Care Workforce -- General Issues of Access and Quality of Care -- Minority Participation in Primary Care Training and Practice -- Monitoring Supply And Requirements -- Recommendation 6.2 Monitoring the Primary Care Workforce -- Geographic Maldistribution of the Primary Care Workforce -- Recommendation 6.3 Addressing Issues of Geographic Maldistribution -- Impediments to the Use of Nurse Practitioners and Physician Assistants -- Recommendation 6.4 State Practice Acts for Nurse Practitioners and Physician Assistants -- SUMMARY -- REFERENCES -- 7 Education and Training for Primary Care -- APPROPRIATE TRAINING IN PRIMARY CARE -- THE EDUCATION OF PHYSICIANS -- Undergraduate Medical Education -- Experience in Primary Care Settings -- Recommendation 7.1 Training in Primary Care Sites -- Curricular and Other Structural Reforms -- Graduate Medical Education -- Residency Programs in Family Practice, Internal Medicine and Pediatrics -- Primary Care Tracks -- OTHER CONTENT ISSUES IN TRAINING FOR PRIMARY CARE -- Future Steps for Academic Health Centers -- Common Core Competencies -- Defining Core Competencies in Medicine -- Defining Core Competencies in Nursing -- Defining Core Competencies Across Primary Care Clinical Fields -- Recommendation 7.2 Common Core Competencies -- Implementing Common Core Competencies -- Recommendation 7.3 Emphasis on Common Core Competencies by Accrediting and Certifying Bodies -- Special Areas of Curricular Emphasis.

Recommendation 7.4 Special Areas of Emphasis in Primary Care Training -- FINANCIAL SUPPORT FOR GRADUATE TRAINING IN PRIMARY CARE -- Current Sources of Graduate Medical Education Funding -- Medicare Funding -- Title VII Funds for Primary Care Training -- Funding of Nurse Practitioner Education -- Graduate Medical Education as a Public Good -- Recommendation 7.5 All-Payer Support for Primary Care Training -- Support for Advanced Training in Primary Care Sites -- Recommendation 7.6 Support for Graduate Medical Education in Primary Care Sites -- INTERDISCIPLINARY EDUCATION OF PRIMARY CARE CLINICIANS -- Recommendation 7.7 Interdisciplinary Training -- Recommendation 7.8 Experimentation and Evaluation -- INTEGRATED DELIVERY SYSTEMS AND PRIMARY CARE TRAINING -- CONTINUING MEDICAL EDUCATION -- PHYSICIAN RETRAINING -- Reasons for Retraining -- Kinds of Retraining -- Certification After Retraining -- Recommendation 7.9 Retraining -- SUMMARY -- REFERENCES -- 8 Research and Evaluation in Primary Care -- SUPPORT FOR THE INFRASTRUCTURE FOR PRIMARY CARE RESEARCH -- Federal Leadership and Support for Primary Care Research -- Recommendation 8.1 Federal Support for Primary Care Research -- Placement and Role of a Lead Agency -- Collaborative Responsibilities of a Lead Agency -- Data Sources and Needs -- Need for a Primary Care Database -- Existing Data Sources Relevant to Primary Care Research -- Recommendation 8.2 National Database and Primary Care Data Set -- Episodes of Care -- Structure of a Primary-Care-Oriented Survey -- Primary Care Research in Practice-Based Research Networks -- Recommendation 8.3 Research in Practice-Based Primary Care Research Networks -- Using Practice-Based Research Networks -- Funding for Research Through Practice-Based Networks -- Standards for Data Collection -- Recommendation 8.4 Data Standards.

PRIORITY AREAS FOR PRIMARY CARE RESEARCH.