The Coastal Research Group

[At the Twentieth National Conference, a new feature, "The Thought Provocateur" session, was instituted to focus on particular ideas of relevance to the general issues of primary health care access. This year Warwick Troy, Ph.D., a National Consortium fellow, proposes a revisiting of the subjects of geriatric medicine and long term care.]

Dr Troy’s presentation will introduce and analyze two recent  proposals for improving health workforce competencies: (1) for geriatrics and (2) for accountable services development in long term care. These approaches use community-based imperatives to plan and deliver accountable professional competencies and services critical to the spirit and substance of primary care.

Warwick Troy, Ph.D.

These proposals address the needs of a diverse, vulnerable and resource-poor community whose needs have been shamefully neglected for decades; and in so doing they are uniquely responsive to the core theme of this 21st National Conference – “Consequences” – in this case, the consequences of neglect.  Specific legislation is proposed: at very least a possible harbinger of  “services on the ground.”

A caveat: although this presentation is made in the context of health “reform,” it must be noted that one of its foci – long term care – has not been taken up, operationally at least, by health reform submissions.  This is hardly unexpected and, as the presentation will suggest, will someday reap its own dire “Consequences.”

Again, unlike long term care, its bedfellow and our other focus – expanded training in geriatrics – which derives from a medical and not a social services context, would seem to have some realistic hope of implementation within medical schools in the nearer future.

The presentation will invoke a number of seminal issues that have figured prominently previous National Conferences, including community-based medicine, the “Future of Family Medicine” reports, and integrated care (multi/interdisciplinary service delivery).

Without the workforce and practice changes that could be realized, there will be perils indeed for the needy and vulnerable and for the utility and future viability of community based primary care itself as a lever to lift communities.

In taking the conference theme, Consequences, seriously, this presentation assumes that health reform at the nexus of service delivery must spring from primary care as its core and the community as its sustaining base, if it is to meet the health needs of patients and other consumers in a timely, effective, efficient and enduring way.

It’s not that way now and, hence, the professional role options listed above.  Things – service planning and delivery and professional education and training – must change and must do so demonstrably.

The presentation intends to invoke the concept of  “regional infrastructures” as a lever for service (and for professional training) improvement by identifying workforce models that place the multiform roles of the health services provider in the context of existing resources, material and human (individual and collective).

The dual themes of the presentation are critical aspects of informed and accountable primary care, although having very different social and professional profiles.  However, the proposals seem to indicate that, for once, it looks as if the right mix of supporters are present: a rare development that must be handled opportunistically to be made to serve America’s diverse and neglected communities using an enhanced armamentarium for the foci within primary care.

To achieve this we identify two recent developments in health services policy that are not generally seen as critical aspects of the primary care armamentarium: long term care and geriatrics  – areas that are loosely allied.  For up to three decades both areas have had to contend with lip service as to their value and their legitimacy, grievous shortfalls in workforce service and training. Now there has been a vociferous call for protagonists to take up their separate and shared causes.  And this time it looks as if the right supporters are lined up to make changes that will transform their respective fields and likely the entire face of primary care.

It’s a perfect storm, but a healing one.  It’s a phenomenon: probably a one-time confluence that actually can be made to serve America’s diverse and neglected communities using a richly enhanced armamentarium for primary care.  Absent the workforce and practice changes that will result, there will be perils indeed for America’s most needy and for primary care itself as a lever to lift communities.