outpatient services and primary care

outpatient and primary care services

• Hospitals as major players

• Services provided outside of traditional acute care hospitals

• Better-equipped labs and diagnostic services

• Consolidation of solo practices

• Government-sponsored outpatient services

• Hospitals used to be the only place you could get health care services 

  • It is no longer like that = more options 

    • Dr’s office, ER, clinic 

• We now have technology that is able to do stuff in outpatient settings 

• Solo practice provider becoming group practices = have more say, a voice your opinion

outpatient care

• No overnight/hospital stay 

  • Ex: nursing home 

• Can receive outpatient services at:

  • Urgent care 

  • Primary care physician 

  • Chiropractor

  • Acupuncture 

ambulatory care

patient can walk in and get care 

• can leave on their own

growth in outpatient services

• don't have to stay in the hospital → most ppl don't like to stay there

  • With advanced tech we are able to provide minimally invasive procedures that decrease recovery time and hospital stay

• decrease in inpatient

  • Inpatient services will never completely go away

essential services lines 

• Outpatient is now becoming an essential part of the hospital system 

  • Esp in big hospitals (St. Jo, Baylor Scott, Memorial Herman)

home health agencies

• Home health agencies provide services in the home

• Can do surgeries in the outpatient setting 

  • Patients don’t have to stay as longer 

changes in reimbursement

• Reimbursement - money that the insurance company pays the healthcare provider 

  • Inpatient services bc outpatient services are cheaper 

    • Inpatient is more expensive because there are a lot of extra charges: pay for bed, technology, nurses, drs

reasons for growth 

• changes in reimbursement 

• New technology 

• Utilization controls 

  • Many ways the insurance company will reimburse providers 

  • Want you to use more of the preventive/primary care services so that you won't have bigger issues in the future (flu shots, annual check-up)

• Social factors 

  • Come up with more ways that allow patients to stay home 

private practice

• office-based physicians 

• Take care of your primary care needs

• Limited examination and testing

• Wait time is longer than the actually time with the physician 

  • Spend more time with nurse than dr 

• Can make a referral if they feel that you need more intense care 

• Solo practices merged into groups 

Hospital outpatient services

• Functions particularly in inner-city areas

• Key source of profits 

• Large hospitals have made clinics an essential part of their system 

• Many different types of hospital based outpatient care

Free-standing facilities (on their own) 

• Walk-in clinics

• Urgent care centers

• Surgical centers

• Walmart & CVS in-store medical clinics

• Ex: dialysis had to be done in the hospital before, but with clinics, it has become outpatient 

Mobile facilities for medical, diagnostic, and screening services

• Bring the services to the ppl instead of ppl to the services 

• Go to rural areas 

  • Patients have difficulties getting to the clinic 

• Mobile health units

• Mobile diagnostic care units 

• Flu shot clinic 

• Blood donation trailers 

• Dental clinics 

Telephone triage 

• Services delivered via phone

  • Parents call after hours and the nurses can go through the options and see whether the baby needs to go to the ER

• Expert opinion on how to take care of themselves

• Usually done after hours 

• Nurses have: 

  • Access to patient records

  • Guidance using protocols 

  • Consults with physicians 

Home care 

• Service brought into the home 

  • Wound changing 

  • Medication help

• Alternative to being institutionalized

  • Staying in hospitals or nursing homes 

• Goal is to keep people in the least restrictive environment possible

Hospice 

• For terminally ill patients with a life expectancy of six months of less

  • They are not going to get better, so they not getting active care 

    • Healthcare professionals are addressing special needs (pain management) 

  • Services that address the special needs of dying persons/families

  • Medical, psychological, and social services 

  • Two areas of emphasis: 

    • Palliative care - pain management

    • Psychological and spiritual support 

Outpatient long-term care services

• Care provided for long term 

  • Services people will receive for a longer period of time

    • Ex: Someone with long-term care taking medication 

      • Patient that have diabetes 

      • Cancer treatment 

• Nursing home → Old people 

• Two types of ambulatory LTC:

  • Case manager - expert that have a lot experience helping patients navigate their healthcare needs

  • Studies have shown that any older adults live with at least 3 chronic conditions 

  • Adult day care - family will send older adults to community centers where there are professionals that can take care of them 

    • Social gathering 

    • Meals 

    • At the end of the day, their family will come pick them up 

Public health services 

• Focuses on the community's wellbeing 

  • Focuses on local health department 

• Wide array of services 

  • Vaccination

Public and voluntary clinics 

• Community health centers - healthcare centers authorized by law (in the 1960s) to serve the medically underserved 

  • Funded by the government 

  • Required to be located medically underserved areas 

  • Provide services to anyone seeking care, regardless of insurance status or ability to pay

  • Provide family-oriented preventive care, primary care, and dental care

Free clinics

• Supported by donations/charities 

• Health4All in bryan 

• Services are usually delivered by volunteers (faculty from A&M → health for all)

• Three characteristics:

  • Services provided at no or a nominal charge

  • Not directly supported or operated by the government or the health department

  • Services delivered by trained volunteers

Alternative medicine 

• Complementary and alternative medicine (CAM)

  • Not endorsed by western medicine 

• Non traditional forms of care 

  • Acupuncture 

  • Homeopathy 

  • Massage 

Primary care WHO definition

• Needed by people in all stages of life

• Should be the first level of contact when people need medical care 

  • Don’t want people to immediately go to specialists 

• Affordable cost to maintain health at every developmental stage 

• Doesn’t matter 

IOM definition

• The usual and preferred route of entry, but it is not the only route of entry into the system

• The provision of integrated, accessible health care services 

  • Primary care providers have a closer relationship with patients than specialists (develop a partnership) 

• Less intense levels of services 

Levels of care (Primary)

• Studies have shown that primary care differs from the other services due to its duration, frequency, and level of intensity 

  • Common illness, so time you are using it is shorter 

  • We want people to use more primary care services = higher frequency

Levels of care (secondary)

 

• Usually short term

• Consultation from specialist 

• Routine surgery 

  • Hernia surgery (can be done in a few hours)

  • Minimally invasive surgery 

• Rehab 

Levels of care (tertiary)

• Most complex level of care for conditions that are uncommon 

• Usually institution-based 

  • Institution = hospital or area where you stay 

• Lot of technology 

• See it in large teaching hospitals 

  • Hospitals that work with universities 

  • Train future healthcare providers 

• May be long-term care 

  • Trauma, burn treatment, NICU, transplants, open heart surgery

Domains of Primary Care

• Point of entry - 

  • We hope that when most people need to use healthcare services, they start with primary care 

    • PCP is point of entry 

  • Gatekeeper 

    • PCP, NP, PA

    • Patients do not see a specialist without physician referral 

    • Protect patients from unnecessary procedures and overtreatment 

    • We want to save patients time/money 

Goal

• Bring health care as close to the population as possible 

• Community based 

  • Find it in the community where we live 

• Convenience 

• Accessibility 

Coordination of care 

• Sometimes patients have multiple needs, but they don’t know how to put everything together 

  • PCPs can coordinate the delivery of health services 

  • Refer patients to sources of specialized care

  • Provide advices

  • To ensure continuity and comprehensiveness

  • Discuss treatment options

  • Provide continuing care of chronic conditions

    • If you have multiple healthcare needs, it's likely you’re going to see multiple providers and multiples treatment plans 

Countries and primary care

• Countries with health systems oriented toward primary care:

  • Achieve better health levels

  • Higher satisfaction with health services

  • Lower expenditures in the delivery of health

• Countries with weak primary care infrastructures incur: (USA)

  • Poorer health outcomes

  • Higher health care costs

Essential care

• Goal is to optimize pop health 

  • For disparities to be minimized to ensure = access

• In US - 

  • Public and private financing have created a fragmented system.

  • Primary care does not form the organizing hub for continuous and coordinated health services

  • Our healthcare system is fragmented 

    • We don’t really have a way to provide primary care from childhood → adulthood

Integrated care

• Comprehensive

  • Dr’s appointments

  • Preventive care 

  • Screening services 

  • About the whole person 

• Coordinated 

  • Help patient navigate all the complicated services they need

• Continuous services 

  • Primary care services are needed at all stages of life

    • Primary care services should always be used 

Accountability (= responsibility)

• Not only drs have to accountable, patients do too 

  • Dr: 

    • Providing best quality care

    • Produce higher satisfaction 

    • Using resources efficiently 

    • Behaving in an ethical manner 

Patients and their responsibility

• Patients: 

  • Their own health to the extent of influencing it 

    • Following the drs instructions of finishing your antibiotics 

  • Be judicious in the use of resources 

    • Don’t overuse services 

    • Avoid moral hazard 

• Build a partnership between a patient and a clinician 

  • Mutual trust, respect, and responsibility are the hallmarks of the partnership 

prevention/partnership

• Preventive interventions should be carried out in primary care (delay onset of disease)

  • Flu shot

  • Screening service (cancer)

• If a patient goes to one pcp continuously they r gonna have a good outcome 

  • Stronger partnership 

  • Improve overall wellbeing 

Community-oriented primary care

• Primary care must be central in delivery 

• Must focus on social and behavioral sciences (anxiety/depression)

• Primary and secondary care should be linked

• Public health must have clinical interventions in conjunction with: 

  • School, churches, employers, agencies etc.

Disease management

• Evidence exists that:

  • Hospitalizations for ambulatory sensitive conditions are less frequent when primary care is strong

Costs of care

• Overall health care expenditure as a country goes up every year

• If we can increase primary care physician-to-population ratio we can lower the overall healthcare costs

Morbidity & mortality

• Higher PCP supply has been associated with: 

  • Higher birth weights

  • Lower infant mortality 

  • A lot higher compared to other countries

  • Early detection 

  • Better controlled hypertension

• The supply of PCP has been shown to have a direct influence on:

  • Life expectancy

  • Stroke

  • Post-neonatal health

  • Total morality

• Countries that have better primary care systems have overall better population health 

The Medical-home Strategy

• Model that focuses on the coordination of primary care services 

• Chronic care model with a multidisciplinary team

• PCP is accountable for the patient’s care 

Community Health Centers

• Community health centers are mostly focused on primary care 

• Usually received funding from government to be located in medically underserved areas 

• Clinics that receive funding to operate in underserved areas

  • Basic primary care 

• Because they receive funding from the government, oftentimes they don’t get enough funding 

• Even people in those areas can get primary care services to maintain their wellbeing 

• Not a lot of physicians work on these so clinicians have high volume of people they need to take care of