CHAPTER 7
Outpatient and Primary Care Services
PRIMARY CARE
WHO vs. IOM definitions
Key components: Point of Entry, Coordination of Care, Essential Care
Patient-Centered Medical Home
OUTPATIENT SERVICES
Reasons for growth
1. Changes in reimbursement constraining inpatient services and favoring outpatient services.
• Few payment restrictions in outpatient services: surgeries, chemotherapy, dialysis—
2. Development of new technology.
3. Utilization controls—managed care.
• Restrictions on utilization
4. Social factors.
• Preference for obtaining services at home or in community-based settings—especially
HOSPITAL OUTPATIENT DEPARTMENTS
Hospitals have been in a competitive position to develop outpatient services.
2. Physical ability to provide appropriate facilities
3. Best equipped to provide emergency care
4. Excess (unutilized) capacity
Advantages:
• Significant contribution to profits
OUTPATIENT CARE SETTINGS
• Private practice—shift from independent solo practice to group practice, institutional
employment
Advantages to physicians:
• Lower operating costs (startup, sharing of overhead, equipment, diagnostics)
Five main types of hospital outpatient services:
2. Surgical services
3. Emergency services for acute conditions
• Emergent—require immediate attention
5. Women’s health centers
• Women are the major users of health care
• Greater proportion of women in the population
• Unique healthcare needs that were previously ignored
• Freestanding facilities—walk-in clinics, urgi-centers, surgi-centers
• Diagnostic vans—X-ray, MRI Service vans, eye and dental care
Non-hospital Based Settings: Freestanding Facilities, Mobile Medical, Diagnostic, and
Screening Services, Home Health Care, Hospice Services, Ambulatory Long-Term Care
ACA TAKEAWAY
The ACA includes several provisions in the hope of bolstering the nation’s primary care capacity.
Primary care, specialty care, and hospital emergency departments are expected to be overburdened
with a large influx of newly-insured patients.
TERMINOLOGY
• Accountability – Refers to the respective responsibility by clinicians and patients for the
provision and receipt of efficient and quality health care services.
• Adult day care—Complements informal care provided at home by family members with
professional services available in adult day care centers during the day.
• Community-oriented primary care (COPC)—Incorporates the elements of good primary care
delivery and adds to this a population-based approach to identifying and addressing community
health problems.
• Durable medical equipment (DME)—Includes certain medical supplies and equipment, such as
ostomy supplies, hospital beds, oxygen tanks, walkers, and wheelchairs.
own homes. Such patients are generally unable to leave their homes safely to get the care they
need.
• Hospice—Refers to a cluster of comprehensive services that address the special needs of dying
persons and their families. It blends medical, spiritual, legal, financial, and family-support
services. Services are taken to patients and their families wherever they happen to be located.
• Palliation —pain and symptom management associated with hospice care.
• Primary health care—Essential health care that constitutes the first level of contact by a patient
with the health delivery system and the first element of a continuing healthcare process.
• Secondary care—Includes routine hospitalization, routine surgery, and specialized outpatient
care, such as consultation with specialists. Compared to primary care, these services are usually
an ED or a physician’s office.
• Tertiary care—Constitutes the most complex level of care. Typically, tertiary care is
institution-based, highly specialized, and highly technological. Examples include burn treatment,
transplantation, and coronary artery bypass surgery.
• Urgent care center—Community-based freestanding clinics open 24 hours a day, 7 days a
week. These emergency centers, however, generally are not equipped to serve truly emergent
patients or to receive ambulance cases.
REVIEW QUESTIONS
1. Describe how some of the changes in the health services delivery system have led to a
decline in hospital inpatient days and a growth in ambulatory services.
Medicare reimbursement and cost-saving efforts of managed care are the two main factors that
have led to a decline in hospital inpatient days and a growth in ambulatory services. Medicare
2. What implications has the decline in hospital occupancy rates had for hospital
management?
Due to declining occupancy rates, hospital executives have been forced to view ambulatory care
as an essential portion of their overall healthcare business rather than a supplemental product line
3. All primary care is ambulatory, but not all ambulatory services represent primary care.
Discuss.
Accessibility is an essential feature of primary care. One of the goals of primary care is to bring
4. What are the main characteristics of primary care?
Primary care is the point of entry into the health services system where healthcare delivery is
organized around primary care. Primary care is the first contact a patient makes with the health
delivery system. Referrals for specialized services are made by primary care physicians.
5. Discuss the gatekeeping role of primary care.
In a gatekeeping system, patients do not visit specialists without a referral from their primary
6. Discuss how patient-centered medical home advances primary care.
A medical home consists of an interdisciplinary team of physicians and allied health
professionals who partner with patients and their families, taking responsibility for ongoing
patient care using a team approach, technology, and evidence-based protocols to deliver and
coordinate care.
Patient-centered medical home (PCMH) advances primary care by elevating the status,
importance, and value of primary care, by reinforcing the cardinal attributes of primary
7. What is community-oriented primary care? Explain.
1. Primary care will have to take the central role in the delivery of health services.
3. COPC cannot be achieved without appropriately linking primary and secondary
4. COPC foresees a strengthening of public health functions as an adjunct to clinical
8. Discuss the two main factors that determine what should be an adequate mix between
generalists and specialists.
The first factor is how rigidly a health delivery system employs the concept of gatekeeping. The