practice

adoption of educational models to creative adaptation of global resources to address local priorities (Frenck et al. 2010).

In alignment with this transformative vision for medical education, several shifts must take place in the orientation and culture of medical education and on-the-job training. Training for PHC should not be considered a “specialization,” as this can reinforce health system silos. Interprofessional education (Interprofessional Educational Collaborative 2016) (box 4.3)—a pedagogical approach that engages two or more health care professions in an integrated learning environment (Gilbert, Yan, and Hoffman 2010)— has proved useful to ensure that professionals value one another’s disciplines, increase providers’ collaborative knowledge and skills, and improve their ability to manage people

BOX 4.3 CORE COMPETENCIES FOR INTERPROFESSIONAL COLLABORATIVE PRACTICE

The core competencies developed through interprofessional education feature the following desired principles: patient and family centered; community and population oriented; relationship focused; process oriented; linked to learning activities, educational strategies, and behavioral assessments that are developmentally appropriate for the learner; able to be integrated across the learning continuum; sensitive to the systems context and applicable across practice settings; applicable across professions; stated in language common and meaningful across the professions; and outcome driven. + Competency 1: Work with individuals of other professions to maintain a climate of mutual respect and shared values. (Values/Ethics for Interprofessional

Practice)

+ Competency 2: Use the knowledge of one’s own role and those of other professions to appropriately assess and address the health care needs of patients and to promote and advance the health of populations. (Roles/Responsibilities) + Competency 3: Communicate with patients, families, communities, and professionals in health and other fields in a responsive and responsible manner that supports a team approach to the promotion and maintenance of health and the prevention and treatment of disease. (Interprofessional Communication) + Competency 4: Apply relationship-building values and the principles of team dynamics to perform effectively in different team roles to plan, deliver, and evaluate patient/population-centered care and population health programs and policies that are safe, timely, efficient, effective, and equitable. (Teams and

Teamwork)

Source: Interprofessional Education Collaborative 2016.

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with chronic conditions (Cubic et al. 2012; Darlow et al. 2015; Hammick et al. 2007; Reeves et al. 2016). Creating shared values and common goals between primary care providers and other care providers helps trainees internalize integrated care precepts. The asymmetry of information between providers and patients has a long-standing presence in the health sector (Arrow 2001), but these patterns are changing rapidly, as technology enables patients to acquire knowledge more easily (Hardey 1999; Pandey et al 2013; Powell, Darvell, and Gray 2003). In this context, health workers at the PHC level may need to assume the role of advisers, guiding patients to reliable sources of information, rather than experts who consider themselves the sole authoritative sources of health information. Future PHC workers should be encouraged to take a participatory approach to promoting health and well-being in the communities they serve. Further, medical education and training need to prepare the PHC workforce to understand and apply evidence-based medicine principles to a rapidly expanding research and evidence base, for example, by learning how to follow new algorithms and protocols.

Health professionals will need education, training, and awareness of content not traditionally covered in the medical curriculum, such as community health needs assessment, risk stratification, coordination and case management, and personalized medicine, as well as their impact on practice. In Belgium, for example, one university’s medical, nursing, and social work students undertake a “community diagnosis” exercise as part of the curriculum. The exercise involves analyzing relevant epidemiological, sociodemographic, and other population-based data on local communities, together with findings from visits to households and care providers, to arrive at a “community diagnosis” and draft an advocacy letter to local authorities recommending actions for improvement. Some countries (for example, Hungary and Kazakhstan) have also adjusted medical curricula for nurses to receive specific training in chronic diseases focused on patient education, prevention of complications, and chronic disease management (Jakab et al. 2018). In addition, coaching for frontline health care workers can also be provided to improve their soft skills, for example, via in-person and online training, role playing, case studies, guest speakers, and personality assessment tests (Conkey et al. 2013; Jünger and Köllner 2003; KICSS 2018).

Educational and accreditation standards should be adjusted and integrated into overall quality assurance mechanisms to support these pedagogical shifts, ensure adequate training in these competencies, and ensure consistency in quality standards from education through to practice (Bitton et al. 2019). Accreditation should also cover the competencies of educators and

trainers and the adequacy of infrastructure, equipment, and clinical learning sites (Jakab et al. 2018).

PHC workforce policies for integrated, peoplecentered care

Collaborative practice and integrated care across the care continuum require a shared vision on the role of PHC. Mutually accepted interdisciplinary care protocols need to be established between PHC teams and providers or organizations from other settings and levels of care. Based on such protocols, consensus can be achieved on the content of care at each level of provision and on criteria for two-way referrals. Coordination, a key function that connects multiple providers under an integrated people-centered care model, should be included as part of the PHC work routine.

While providing integrated care in the community and across the health system, primary care teams need well-aligned quality measurement that promotes accountable performance by rewarding team members for managing complexity, solving problems, and thinking creatively when addressing the unique circumstances of patients with complex needs. Priorities for outcome and performance management include people-centered reporting and metrics that capture avoidance of inappropriate testing or treatment, while documenting attributes associated with better outcomes, lower costs, and improved patient experiences (Bitton et al. 2019; Bodenheimer et al. 2014).

PHC workforce performance can be improved through the increased use of tools for communication and management. People-centered care can be enhanced through communication tools such as integrated and individualized care plans, structured patient education, decision aids, outreach activities, lifestyle counseling, multidisciplinary assessments, and multidisciplinary treatment protocols. Similarly, care integration and population health management can be facilitated by patient registries, health registries, and risk stratification tools, building on health data generated via the empanelment process (Jakab et al. 2018).

Workforce planning and deployment should align with the reimagined PHC vision and performance management framework. Existing workforce skills and competencies should be carefully reviewed to identify any gaps and mismatches, as well as mitigation strategies. As previously discussed, repurposing the current workforce through task shifting is a commonly used strategy to engage existing health workers for new roles (Hoeft et al. 2018; Some et al. 2016; WHO 2008).When there is little scope to expand the roles of the

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