J Am Board Fam Med
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New Zealand (NZ) has a central government-driven, tax-funded health system with the state as dominant payer. The NZ experience precedes and endorses the US concept of patient-centered medical homes providing population-based, nonepisodic care supported by network organizations. ⋯ Key elements include enrolled populations; an interdisciplinary team approach; health information technology interoperability and access between all providers as well as patients; devolution of hospital-based services into the community; intersectorial integration; blended payments (a combination of universal capitated funding, patient copayments, and targeted fee-for-service for specific items); and a balance of clinical, corporate, and community governance. In this article, we discuss reforms to NZ's primary care arrangements over the past 2 decades and reflect on the lessons learned, their relevance to the United States, and issues that remain to be resolved.
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Many primary care practices are currently attempting to transform into patient-centered medical homes (PCMHs), but little is known about how patients view aspects of the PCMH or how they define patient-centeredness. ⋯ Our patients want a provider to know them personally and to take time to listen to their issues. They feel that they cannot access their providers in a timely fashion, find our automated phone systems frustrating, and want more time with their provider. Although the technological and structural implementation of the PCMH requires considerable effort and resources, we cannot neglect the relationships we have with our patients. Patients should be involved in this process of change to ensure we address their concerns and preserve the primary care relationships they value.
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Since 1948 health care in the United Kingdom (UK) has been centrally funded through the National Health Service (NHS). The NHS provides both primary and specialist health care which is largely free at the point of delivery. Family practitioners are responsible for registered populations of patients and typically work in groups of 4-6 self-employed physicians. ⋯ These reforms have been associated with some major improvements in quality, including improved chronic disease management and reduced waiting times for specialist care. The four countries of the UK differ in some important aspects of health care organization: proposed reforms in England would move towards a more market-driven system, with family practitioners acting as payers for specialist care and controlling 70% of the NHS budget. The other countries (Scotland, Wales and Northern Ireland) focus more on trying to create area-based integrated systems of care.
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Patients with complex behavioral health and medical problems can have a disproportionate impact on emergency departments. ⋯ Team-based drop-in group medical appointments coupled with case management seem to be a cost-effective model to reduce emergency department visits by some patients with complex behavioral health and medical needs.
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Primary health care in Australia has undergone 2 decades of change. Starting with a vision for a national health strategy with general practice at its core, Australia established local meso-level primary health care organizations--Divisions of General Practice--moving from focus on individual practitioners to a professional collective local voice. The article identifies how these meso-level organizations have helped the Australian primary health care system evolve by supporting the roll-out of initiatives including national practice accreditation, a focus on quality improvement, expansion of multidisciplinary teams into general practice, regional integration, information technology adoption, and improved access to care. Nevertheless, there are still challenges to ensuring equitable access and the supply and distribution of a primary care workforce, addressing the increasing rates of chronic disease and obesity, and overcoming the fragmentation of funding and accountability in the Australian system.