From fragmentation to people-centered integration

New provider competencies for people-centered, integrated care

Beyond clinical knowledge and skills, provision of community-oriented, people-centered integrated care requires a range of competencies for effective collaboration among the PHC team, the community, and other care providers. Access to care goes beyond physical or geographic and financial accessibility to include approachability, as well as acceptability for patients and communities to feel comfortable in seeking and obtaining health care (Levesque, Harris, and Russell 2013). Multidisciplinary teams will need to evaluate local health needs and acquire knowledge on communities’ state of health and related influencing factors (Muldoon et al. 2010). They will also require strategic communications capacity to clearly communicate their vision of PHC and new ways of working, along with interpersonal skills and political savvy to build or strengthen their relationships with other stakeholders that are important for the health of their empaneled population (AAFP n.d.a; Fellows and Edwards 2016; Kumpunen et al. 2017). The team’s population will likely have varying levels of health status, including healthy groups, patients who need specialist intervention, complex patients at risk of hospital admissions, and frail patients discharged from hospitals. Such a diverse spectrum of needs calls for professional management skills to stratify the patient population into risk groups and design targeted management interventions for each cohort (AAFP n.d.b; Hall 2011; Kumpunen et al. 2017).

At the intervention level, the PHC workforce must acquire new competencies to effectively work within a team-based model and ultimately help patients achieve their health goals. Ability to work and coordinate across boundaries is critical when providing care to an aging population with multimorbidities who must interact with multiple providers on a long-term basis. Case management is indispensable for improving quality and efficiency, considering that a small percentage of patients often accounts for the majority of total health spending (Conwell and Cohen 2005; Williams 2004; Wodchis, Austin, and Henry 2016). For conditions that involve self-management, the PHC workforce needs to engage and empower patients for joint planning and management around the patients’ health goals (Global Health Workforce Alliance 1983; Raleigh et al. 2014).

The competencies discussed, in turn, highlight the importance of capacity to use and interpret data. The interactions between providers and patients

111

112

generate an enormous amount of data that is then stored in various forms, including files in providers’ cabinets, electronic health records, and registry systems. (Ideally, the PHC platform should benefit from a single interoperable digital platform with unique patient identifiers; see Priority Reform 1).Data about the empaneled population (demographic and socio-economic profiles, health service utilization, costs and outcomes, and other information) that are available to the PHC workforce, if properly applied, will be extremely useful for them as they evaluate community health needs, stratify risk groups, and provide integrated people-centered care. In Turkey, an enrollment database allows family physicians to identify individuals in a screening target group and enables community health centers to organize public campaigns and arrange transport for patients on the day of appointments. Close collaboration between family practices and the centers resulted in a significant increase in coverage rates for breast, cervical, and colorectal cancers between 2007 and 2014 (Jakab et al. 2018).

Finally, “soft skills” are needed to develop a trusting relationship between providers and patients, improving patient satisfaction and supporting positive health outcomes (Farmer 2015; Fellows and Edwards 2016; Heckman and Kautz 2012; Sills 2015). Such skills can be wide ranging, including responsiveness, empathy, adaptability, flexibility, time management, communication and teamwork, cultural sensitivity, collaboration, and brokering partnerships (AAPC Knowledge Center 2019; Feffer 2016). More importantly, in reimagined PHC settings, health workers need to develop the skills to act as partners and facilitators, rather than authorities, to empower patients and engage them in a shared decision-making process (Imison and Bohmer 2013).

Reorienting medical education and on-the-job training to better prepare the health workforce

Appropriate education is essential for ensuring that the PHC workforce has and can demonstrate the competencies necessary for delivering integrated people-centered care in the community and across the health system (Global Health Workforce Alliance 1983; WHO 2013b). Experts have called for a “third generation” of medical education reform to improve the performance of health systems by adapting core professional competencies to specific local contexts, while drawing on global knowledge. The proposed program emphasizes transformative learning that involves three fundamental shifts: from fact memorization to searching, analysis, and synthesis of information for decision-making; from seeking professional credentials to achieving core competencies for effective teamwork in health systems; and from noncritical