Primary Care Is an Essential Ingredient to a Successful Population Health Improvement Strategy

Social Determinants of Health

In 2010, the World Health Organization created a framework to outline the SDH, which includes 9 interdependent factors impacting health: education, employment, health systems and services, housing, income and wealth, physical environment, transportation, public safety, and social environment.⁷ By highlighting the diverse and interconnected factors across several domains that impact health, this SDH framework helps to foster an understanding that a complex sociocultural environment shapes health and suggests that interventions to address adverse SDH can improve a person's health as well as the health of a population. Theoretically, PCPs and primary care teams are well poised to identify a patient's adverse SDH and intervene to bridge health care and social services to improve patient and population health.³ But, how exactly does this happen in the real world? During the past 20 years, patients and families have taught me important empirical lessons to demonstrate how this theory applies to real-world settings.

Spencer

I met Spencer during residency while working nights in the emergency department (ED). After seeing him a couple of weeks in a row for preventable complications from his diabetes and congestive heart failure, he asked me when I was scheduled to work my next ED shift because he found it helpful to have continuity with the same emergency physician. I told him that my ED rotation was ending and I would be transitioning to my obstetrics rotation. I recommended that he schedule visits with his PCP more regularly. With a quizzical look on his face, he told me he had never had a PCP and was unsure how to find one. I offered to be his PCP (not realizing he needed to ride 3 different buses to visit my clinic).

Over the next several years, our primary care team had the privilege of helping Spencer manage his complex chronic diseases, coordinate his specialty referrals, and improve his mental health. Once his trust in us deepened, he started bringing his wife and other family members to our clinic, too. He eventually shared his fears about their unsafe housing situation and their need for healthier food and reliable transportation. Our team helped him find safer housing and connected him with mental health care and other social services that his family needed. Several years later, he remarked to our team that he never needed to go back to the ED after meeting me there and that my small gesture offering to be his PCP changed his life. Our team's work enabled him to receive care that was patient- and family-centered, comprehensive in addressing his social care needs, and coordinated across the medical neighborhood.^8,9 Eliminating his need to return to the ED also saved the system a significant amount of money.

The lifesaving work that happens in primary care is often less visible than the work done by trauma surgeons and oncologists who bring people back from the brink of death. Primary care lifesavers have the power to heal, which happens over years—through building trusting relationships during a lifetime, creating patient-centered medical homes, connecting patients to social services, and advocating for healthy policies in communities.^3,10,11 The stories of Spencer and José (below) are representative of the countless stories held dear by every primary care team about patients and families we have been privileged to serve. When each of us is reminded about our individual stories and experiences, it is easy to understand the way in which PCPs and teams impact health beyond the health care services we provide and how, taken to scale for a population, having PCPs in a community can make a difference to a community's health.^4,12

José

José was one of the first babies I had the privilege of delivering (more accurately: his mom delivered him, I was honored to attend the delivery). As a single parent living in poverty, his mom continuously struggles to make ends meet, and they have been forced to move multiple times to find safe, affordable housing. Amid the turmoil in their lives, I feel fortunate to have been their family's PCP for more than 15 years. Recently, I offered José the option to change to a new PCP. Now in his teens, I thought he might be more comfortable with a male PCP. He emphatically told me “no” because I had cared for him since birth, and he trusts and respects me as his doctor. He told me that he has only a few adults in his life whom he trusts.

Before entering the examination room at his most recent well child visit, our medical assistant remarked that he had lost weight and looked sad. He usually does not like to complete the standard forms we give patients at check-in with questions about their health behaviors, depression symptoms, and other concerns. I glanced at his forms while opening the door to say “hello”; not surprisingly, they were blank that day. I started a casual conversation about how he was liking school and if he was still enjoying video games. I wove in questions about his mental health, substance use, school performance, sexual activity, and also asked about food insecurity. He dodged most of my questions about alcohol, drugs, and sex. However, he did confide in me that he and his mom often do not have enough food to last through the month, that he is flunking several classes, that his mom lost her driver's license because they could not afford car insurance, and that he is having trouble controlling his anger. I was able to connect him with our social worker to get additional assistance. She also arranged for him to start seeing a psychologist regularly, adding another trusted adult into his life. Knowing that they had limited transportation options to get to the clinic, our team started checking in with José and his mom regularly via telephone and patient portal messages. Several months later, his mother shared with me that she believed our team's interventions saved his life at a time when he was seriously contemplating suicide.

An automated review of Jose's medical chart during this period of time would have shown that he was in perfect health. He attended his yearly well-child visits, and he was up-to-date on his immunizations. He had a normal vision and hearing screening test; he was getting regular dental care. He had a normal blood pressure and body mass index. His medical list contained only multivitamins, and he had no chronic medical conditions. Contrary to what the system would have seen with an automated review, our long-term relationship with José and his mom helped to uncover that he was at significant risk. Our primary care team's comprehensive approach and the continuity of care we provided enabled us to learn that he had social and behavioral needs that were negatively influencing his health. By building trust and addressing adverse SDH, we may have prevented a suicide attempt.

Primary Care's Role in Addressing Adverse Social Determinants of Health

Spencer, José, and many others through the years have taught me about the important role primary care teams play in identifying and addressing adverse SDH for patients.^3,13 Sometimes, this role entails administering a survey to ask patients about social factors impacting their ability to be healthy,^13⇓–15 but often it goes far beyond this type of screening activity. The number of screenings completed in a practice is easy to measure. More difficult to capture or describe is how the dedication and compassion of primary care teams enables many patients to share painful stories about trauma and adversities they are experiencing. Primary care teams create safe spaces for patients and their family members to share some of their most intimate thoughts and fears.¹⁰

Bolstering Support for Primary Care That Improves Population Health

Given primary care's lifesaving impact on populations and the critical ways in which primary care bridges health care and health, it is not surprising that many population health improvement strategies include strengthening primary care. Bolstering primary care does not simply mean hiring more primary care providers and adding more patients to their panels. It means supporting primary care teams to strengthen relationships, to ensure continuity, and to better integrate and coordinate care. Focused efforts on improving delivery, payment, and measurement systems for primary care are great places to start.

Summary

PCPs and primary care teams facilitate effective connections between health care and health. Investing in delivery models that preserve and enhance longitudinal, trusting relationships between patients and primary care teams is foundational to the success of any population health improvement program. Payment systems must break out of fee-for-service models to align compensation with a comprehensive approach and continuity of care to better support the important work that happens continuously, not just during a clinic visit or inside the clinic walls.^16⇓–18 Shifting away from assessing easy-to-measure indicators and working on developing measures that matter to primary care will help primary care teams to more effectively focus on health.¹⁹ In brief, primary care is an essential ingredient to any population health improvement strategy and will have maximum impact on improving a population's health if health care systems and payers stop flocking toward episodic, convenience models of care. Instead, they need to pay for longitudinal, comprehensive primary care provided by multidisciplinary teams and shift toward measuring more of what matters to patient, community, and population health.