Implications for Primary Care Practice and Policy
| Implications for primary care practice teams |
| Identification of patients at high risk for hospitalization for ACSCs by complementing predictive modeling with assessment of patients’ social situation, medication adherence, and self-management capabilities |
| Regular medication review (what medication is taken and how?), easy-to-read medication schedules, and shared treatment plan among patients, caregivers, and physicians to improve adherence |
| Regular (telephone-) monitoring of symptoms and treatment adherence in high-risk patients |
| Self-management training of patients and caregivers (eg, should enable them to manage acute deterioration or to seek timely help of primary care resources) |
| Identification of existing social support systems (eg, family, friends, neighbors) and community resources |
| Health technology systems (eg, recall system for monitoring, updated links to community resources and ambulatory services, shared medical records between primary care practices and hospitals/after-hours care) |
| Enhanced communication between physicians across sectors (eg, treating physicians and external physicians in after-hours care, admission and discharge management, easy access to colleagues to ask for advice in case of diagnostic uncertainty) |
| Implication for policy and management |
| Accountability for hospitalization is shared across all sectors, including primary care, secondary care, hospitals, communities, and patients |
| Hospitalizations for ACSCs do not automatically reflect poor quality of care and should be measured either on a highly aggregated level (large geographic areas) or with sufficient adjustment for its complex causality |
| Selection of defined ACSCs that may in future be refined to primary care–sensitive conditions based on evidence rather than expert view |
| Communication skills including cultural-sensitive medicine may be emphasized in physician education and training |
ACSC=ambulatory care–sensitive condition.