Realizing the Dream: The Future of Primary Care Research

Person and Family Centeredness

To implement person- and family-centered care,^3,6 primary care needs to build continuous, trusting relationships in which clinicians, patients, and families are partners in care planning. The organization, financing, and delivery of care to promote wellness, prevent disease, and manage illness needs to support models of care that enable primary care practices to deliver comprehensive and continuous whole person care rather than primarily focus on specific diseases and services, and engage patients in coproduction of health and in shared decision making. It is essential that patients are involved in research as partners and play an integral role in identifying research priorities, meaningful outcomes to measure, and ways to redesign care. Meaningfully engaging patients will foster the implementation of person centeredness in primary care.

Community Centeredness

Primary care practices should play an integral role in improving and promoting the health of the communities they serve. Community centeredness can be fostered by creating linkages with community-based organizations and services, public health, and other sectors that influence health, such as education, housing, and transportation. Community members as practice partners can inform the design and operation of the practice, bringing their intimate knowledge of community needs and local resources.¹⁴ Innovative research to design, implement, and evaluate clinical-community–partnered interventions that align the clinical management role of primary care practices with evidence-based community approaches to address population health can advance this aim. Investment in outreach and relationship building will be required. Community-oriented primary care can be further enabled by practices’ access to available data on the health of the community served and available community resources. To make the best use of these data, practices will require easy-to-use tools. Research on how to best create bidirectional information flow between practices and public health will be as essential to addressing the next pandemic or natural disaster as to addressing chronic disease prevention and management.

Primary Care Centeredness

In a primary care–centered health system, all individuals would receive comprehensive, longitudinal, and coordinated care anchored in primary care. Ideally, primary care clinicians with a holistic perspective of the people for whom they provide care will coordinate and integrate that care with specialty care, behavioral health, home care, acute care, and post-acute care. Primary care practices would serve as the medical home, integrated with the broader “medical neighborhood,” where patients seek their care, trust their clinicians, and value continuity. Together, patients and primary care clinicians can determine when expertise of specialist clinicians is needed. Such bidirectional communication with specialty care would include shared and stepped-care approaches to management, with patient goals and preferences informing decision making. Transitions across providers and settings of care would be designed to optimize outcomes and avoid errors of omission and/or duplication due to poor information sharing and communications. Research is needed on the models of care necessary to actualize primary care–centeredness. Such models would ensure that patients receive the best care that aligns with their goals, values, and expectations.

Advancing Health Equity

Primary care should seek to eliminate pervasive and long-standing inequities in access, quality, and outcomes of care. Increasing access to effective health care for racial/ethnic minorities, low-income and rural communities, and other populations experiencing disparities is necessary, as are targeted improvement interventions. Quality improvement interventions can narrow, maintain, or widen health inequities depending on their relative effectiveness in different populations. Populations and communities that currently experience suboptimal health outcomes, unequal treatment, bias, or discrimination must be active partners in codesigning effective interventions and coproducing the evidence needed to eliminate health inequities. Success will require researchers to not only intentionally recruit participants in primary care studies who represent populations served, but also engage members of the community as stakeholders and leaders in those studies. This participatory and partnership research along with the mainstreaming of health equity goals in study design can assure that society’s investments in primary care transformation and research benefit all.¹⁵

Digital Health Solutions

Ongoing advancements in health information technology and the development of digital health solutions tailored to primary care practice can enable the desired renaissance in primary care delivery. User-centered digital health applications designed to facilitate patient care, self-management support, care transitions and coordination, and population health, all have the potential to improve care delivery while reducing the burden on clinicians, primary care teams, patients, and caregivers. User-centered design, agile implementation, and rigorous testing and evaluation can be used to develop interoperable, user-friendly electronic health records designed to support patient care, quality improvement, and population health management.

Advances in clinician and patient-facing clinical decision support (CDS), together with implementation research on how to effectively integrate CDS tools into workflows, will increase access to the best evidence at the point of care to inform decision making and improve quality. Research can also provide advances in our understanding of how to structure patient-clinician encounters that bring together patient-generated health data, remote monitoring, synchronous and asynchronous virtual care, and data from other non–visit-based encounters. Interoperable shared e-care plans can facilitate management of individuals with complex physical, mental health, and social needs, especially those who are older, frail, and/or have multiple chronic conditions. Research is also needed on the role of digital health solutions within multicomponent improvement interventions.

Aligning Payment

Fundamental transformation of primary care is not possible without equally fundamental changes in the allocation of resources to primary care. Supporting the core attributes of primary care will require payment policies that align incentives with desired outcomes. Evidence is needed for payment models that support team-based care and allow practices to engage fully in community-centered care, advancing health equity, and incorporating digital health solutions. Studying diverse states’ experiences with implementing payment reform to support primary care can lead to the adoption of effective approaches to increase the proportion of health care spending allocated to primary care.¹⁶ Researchers in partnership with primary care practices and the communities they serve need to learn what types of technical assistance are necessary to finally transition away from the fee-for-service paradigm to payment mechanisms that support whole-person health. We need measures to assess the effectiveness of these alternative payment models in supporting the delivery of high-quality primary care.

Workforce Development

Transformation of primary care requires transformation of the primary care workforce. Addressing health disparities requires diversifying the primary care workforce to fully represent the communities served, including racial, ethnic, and linguistic minorities, individuals from low-income and working-class backgrounds, and those from rural communities. A commitment to understanding and addressing clinician burnout and its underlying causes is fundamental. Research is needed on how to effectively use teams of professionals—both clinicians and non-clinician staff—to improve access, efficiency, and coordination of care. We need evidence identifying the optimal use of community health workers or promotores, patient navigators, and other community-based professionals. We need tested models of care that integrate behavioral and mental health professionals into primary care practices either as a shared community resource or embedded in practices. Front-line clinicians need to be included as partners in research and be engaged in codesigning real world solutions.

Innovation in Primary Care Research

Achieving the universal implementation of the core attributes of primary care will require innovative approaches to primary care research. We need to understand what works for which populations and in which contexts as well as how to successfully implement new models of care. By integrating implementation science with quality improvement, we can generate practice-based evidence while implementing new models and approaches to care delivery. Agile implementation methods and rapid-cycle evaluation can increase the probability that proposed interventions will lead to measurable improvements. Methods drawn from complexity science can inform interventions that address the complex needs of individuals receiving care in the context of their lives and communities from a health care system that is also complex. Multilevel interventions align the work of health systems, practices, patients, caregivers, communities, and public health. The long timeframes for conducting research are at odds with practices’ needs for timely evidence for decision making, but continuous learning and prespecified interim results of studies could help. The goal is to discover interventions that result in sustainable changes.

Data for Evidence Generation

The next generation of primary care research can be nurtured by the development of data to assess primary care nationally and locally. Data development is also needed to better manage both individuals and populations. Practice-based research networks (PBRNs), to which AHRQ provided infrastructure and capacity-building funding over many decades, can play a critical role in assuring that practice-based evidence from real world primary care data is available to guide evidence-based practice. Data on clinical processes and health outcomes can be harnessed through optimizing the use of electronic health records, patient registries, health information exchanges, and patient-generated health data. Predictive analytics have the potential to support risk stratification, and to identify and target those most likely to benefit from specific services and supports. Tools are needed that allow clinicians and researchers easy access to and use of patient-level, aggregated, and contextual data for quality improvement, population health, and health services research.