Person-Focused Care
Studies that focus on the prevention and management of patients’ problems over time provide a different and complementary approach to a visit-oriented approach. The literature on primary care-oriented health systems postulates that one of the mechanisms for benefit results from a greater focus on patients as they transition from one health problem to another.8 Primary care is person-focused, not disease-focused, care over time. To be person-focused, it must be accessible, comprehensive (dealing with all problems except those too uncommon to maintain competence), continuous over time, and coordinating when patients have to receive care elsewhere. The essence of person focus implies a time focus rather than a visit focus. It extends beyond communication because much of it relies on knowledge of the patient (and of the patient population) that accrues over time and is not specific to disease-oriented episodes. Physicians and patients working together to reach mutual decisions often require a long-standing relationship.9 Patients are more likely to follow medication regimens if they share their physicians’ belief about causes of health outcomes.10 This is unlikely to be the case when visits are with practitioners not well known to patients (and vice versa).
Family physicians’ views concerning genetic conditions support the notion that care over time is critical to understanding patients’ needs and problems.11 In contrast to judging possible genetic predispositions to rare genetic problems, genetic influences on common illnesses cannot be determined in individual encounters with patients.11
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A major failure of primary care, particularly in countries such as the US (where specialty care, including major teaching hospitals, is so dominant), is the great underestimation of the importance of long-term relationships with patients independent of care for specific disease episodes. A specialty dominance dictates that interest is mainly in individual diseases, chosen because they are costly or because they are thought to cause considerable premature mortality. Contrary to conventional wisdom, the main determinant of high costs of care is not the presence of chronic illnesses. Rather, it is the combination of various types of illnesses—that is, multimorbidity—over a period of time (Efrat Shadmi, PhD; Ran Balicer, MD, MPH, PhD; Karen Kinder, MBA, PhD; Chad Abrams, MA; Barbara Starfield, MD, MPH; Jonathan Weiner, DrPH, personal communication 2010).a,12
The importance of a person focus (a nondisease focus) in primary care is highlighted by primary care clinicians’ views of their roles. They appreciate the importance of costs and severity of condition (which is difficult to judge in clinical settings, except in the case of acute conditions), but they identify three additional issues: patients’ viewpoint of the problem’s relative importance, the duration of time over which priorities are set (short or long term), and the level of evidence of benefit in primary care practice.13 Inherent in a person focus is the notion that attention to patients’ problems in the context of their multimorbidity (multiple coexisting diseases) is at least as important as appropriate care for their individual diagnoses. Good primary care is not the sum of care for individual diseases.
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