So What is Primary Care Anyway?

To understand the Primary Care Behavioral Health (PCBH) model and really be successful at implementing it, it’s important to understand the setting in which it operates—the primary care setting—and the goals, values, and mission of primary care setting. Without this understanding, integration into primary care will be difficult, and we will struggle to demonstrate the value of having integrating behavioral health services into primary care.

So what is primary care? I often ask my new interns this question on the first day of orientation, and the answers span the range but are often influenced by their own experience with primary care. They will often discuss that primary care is your “family doctor,” the “first place you go when you get sick,” or “the provider who refers you to where you actually need to go.” As the training year goes on, I tend to see these descriptors refined as they learn more about the primary care setting.

Ultimately though, we need a good operational definition to guide the work of understanding the primary care setting, and how best to integrated services into that setting. The definition I find most useful comes from the National Academy of Sciences:

The provision of whole-person, integrated, accessible, and equitable health care by interprofessional teams who are accountable for addressing the majority of an individual’s health and wellness needs across settings and through sustained relationships with patients, families, and communities .

This definition provides a foundational understanding of what primary care encompasses: whole-person care, integration, accessibility, and sustained relationships. However, to fully appreciate the context in which behavioral health services must integrate, we need to examine the broader values that drive the primary care system. These values are formalized in what healthcare experts call the “Quintuple Aim,” which represents the overarching goals shared across healthcare settings, including primary care.

The Quintuple Aim states that quality healthcare improves the patient experience, improves the health of the entire patient population, reduces the cost of healthcare , reduces provider burnout, and increases equity in the provision of healthcare services . These aims are described in the literature as a “North Star” which should guide attempts to improve the healthcare system.

While there is overlap with other specialties and primary care in the Quintuple Aim, primary care also has values that are unique to this setting. Most commonly, these values or goals are described as the “4 Cs”: first Contact, Comprehensive, Coordination, and Continuity .

The 4 Cs describe that primary care is the first contact for patients, providing access when the patient needs it without long wait lists. When patients have a health concern, the first place they call is their “doctor”—meaning their primary care provider (PCP). Primary care is comprehensive, providing a wide range of generalist services including those that are preventative, and treating the full range of patients represented in the community. Primary care coordinates and integrates all of the care the patient receives anywhere in the healthcare system—the patient may be referred out for consultation or treatment by a specialist (or many specialists), the PCP remains responsible for the patient’s whole health, and for integrating the treatment and findings of the specialist. Finally, primary care provides continuity in the form of longitudinal relationships that can span an individual’s whole life, resulting in strong trust between provider and patient .

The bottom line is that primary care is the place that most people go to get most of their healthcare needs met. Understanding the Quintuple Aim and the 4 Cs will allow us to better integrate ourselves into the primary care setting. Future articles will explore how specific issues that arise during integration can be resolved by returning to this foundation—by centering primary care in primary care settings, a host of issues can be avoided.

References