Carter Center Report Envisions Integrated Care at the Heart of a Reinvented Primary Care System

A new report from the Carter Center and the American College of Physicians argues that an overhaul of the primary care education system—including adoption of more rigorous training in mental illness diagnosis and treatment—is necessary to fully implement reform of the U.S. health care system. If the patient-centered medical home is to be the framework for 21st century care, as a panel of experts convened by the Carter Center agreed, then “With rare exception, the existing training model does not prepare students for the environment in which they can be expected to provide care …. Efforts to improve the delivery of health care, including models such as the patient-centered medical home and the accountable care organization, will require people with new skills and a team-oriented, interprofessional approach.”

The report emerged from discussions among 40 thought leaders from a variety of health professions, institutions, practice settings, and perspectives during the Health Education Summit held at the Carter Center in October 2010 and funded by grant support from the United Health Foundation. The participants were asked to develop a vision for a future health care system and list actions to drive development of an education model to support that vision. A ten-page report based on their responses, Five Prescriptions for Ensuring the Future of Primary Care, was released in late May.

As described in the report, a patient-centered system is one in which providers encourage informed decision making, self-care, and healthy lifestyles while demonstrating respect for individuals' needs, values, and preferences. The system's foundation is team-based primary care that is fully integrated with mental health care and focused on overall wellness and prevention. Teams operate within a carefully designed network of providers that is supported by a payment model aligning incentives, promoting collaboration, and creating value for each team member.

What skills and competencies are needed in this reinvented system? In a system based on integration of care, professionals must be knowledgeable about common mental health issues. Coursework in behavioral health can also teach students about the role of families and the importance of social support in treatment for chronic conditions. They must also understand public health approaches, and because they will serve as health educators, they will need training in health promotion and strategies for effective communication.

The report recommends that from the start, students should train and learn collaboratively with other health professionals to develop leadership and enhance communication skills. Core educational programs should support specialty differentiation according to students' performance, skills, and preferences and workforce needs. Experiential learning will be a hallmark of this educational system and should take place in high-need community and ambulatory health care settings that are patient centered. To develop a workforce that values integration of mental health care, the way in which students are exposed to behavioral health issues must change, according to the report. Currently, most students are not required to learn about integrated care, and there is no requirement for supervision and training in these topics. Medical students currently must complete a one-month psychiatry clerkship, but because most are conducted in the specialty sector students are exposed to the most severe cases, which may not be common in a primary care setting.

The panel identified several barriers to realizing this vision, including resistance in the health education system, where “teaching to the requirements” often leaves little room for training in areas that are important to an integrated system, such as mental health care. Other key barriers are the absence of credible projections of workforce needs in primary care, as well as what the panel described as a “demoralized primary care workforce” struggling with large workloads in understaffed environments—a scenario that does not attract new trainees. Funding is also a significant barrier, because reimbursement rates for primary care services are typically low and may not cover the interprofessional, team-based care needed in such a system.

After the Health Education Summit, a number of specific recommendations were compiled by the attendees and distilled into a set of specific conclusions and associated steps that constitute the five “prescriptions”: the importance of teaching context(that is, the multiple complex forces affecting 21st century care), the importance of teaching teamwork, the importance of teaching integration, the importance of providing resources (public and private funding), and the importance of measuring results. The report and recommendations are available for download on the Carter Center Web site at www.cartercenter.org.