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1 Introduction

The importance of family medicine and general practice as the backbones of primary care cannot be understated in the development of person and family centered health care. The role of family physicians and general practitioners is to integrate the complexity of health care and health needs. Health care is responsible for only about 10% of a person’s overall health [1]. Conversely, patients’ behaviors, their genetics, their environment, and their jobs are responsible for about 90% of their health. The important role of family physicians and general practice physicians is to be an integrator between individuals, families, the community, health care, and health. The process in which family physicians and general practice physicians achieve this integration of health and health care is through trusted relationships with people in a continuous and comprehensive manner over time. The skill of generalism and having a broad-based scope of practice that understands the complexities of the human body all age groups, both genders, and the context of family, community and peoples’ jobs is the important ingredient in providing person-centered care. It is this generalist knowledge that allows the big picture to be seen and acted on. It is in the subtle nuances of knowing not only what to do for a person or family that is having health care and health related issues but perhaps even more importantly knowing what not to do. All these things become important to efficient and effective resource utilization of health care to impact health as an outcome. This wise and thoughtful approach will not only maximize health care expenditures and improve the quality of health care outcomes, but at the same time manage sky rocketing cost that can be associated with redundant, ineffective, and wasteful health care dollars. Family medicine and general practice physicians are at the heart of primary care. Health care must be built around this type of generalism as being foundational to any functioning and effective health care system.

2 Health Systems Must Become More Responsive to Person-Centered Needs

Five common shortcomings of existing health care delivery across the world include inverse care, impoverishing care, fragmented and fragmenting care, unsafe care, and misdirected care. Inverse care plays out in most nations as the richest people getting the most care while the poor get the least care and have the greatest burden of suffering [2]. Impoverishing care is when the cost of care is causing a financial hardship or even bankrupting individuals, communities, nations, and the world. It is estimated that 100 million people worldwide go bankrupt around health care cost every year [3]. In the United States this represents 1.5 million people per year and averages one every 30 s [4]. Health care systems around the world are becoming more sub-specialized and reductionistic in approach. This leads to fragmented and fragmenting care versus the generalized holistic approach of primary care. Unsafe care is a result of poor system design, leading to medication errors, hospital acquired infections, and leads to increased morbidity and mortality. Misdirected care may occur with intensive or futile services - such as treatment of cancer, stroke, heart attack, or kidney failure—that offer only modest gains in longevity and quality of life but come at great cost.

Conversely, effective person-centered primary care promote health and wellness, can prevent 70% of chronic disease burden, and can add 25–30 years to people’s lives [3]. Universal and timely access to primary care is not available throughout much of the world. This results in considerable fragmentation in healthcare and magnifies disparities in care, with some receiving high quality care close to home while many more lack access to basic primary care services. These wide disparities in primary care access create significant disparities in health care outcomes and perpetuate inequities across the world. A person-centered approach ensures that these five health care system shortcomings are both mitigated against but dialed in for appropriate care at the person and family level.

3 Proactive Versus Reactive Approaches in Person-Centered Care

As the world continues to develop and progress, the focus of health care systems must also progress away from reactive disease-oriented systems to proactive health care services that improve the populations health. As populations age, become more urbanized, face climate change, and confront the social determinants of health such as obesity for many and food insecurity for others, there must be an organized effort to address these challenges from a proactive and comprehensive systems perspective instead of from a reactive and fragmented individual perspective.

The excessive focus on disease and curative procedural interventions distracts attention from the realities and values of people in the context of their families, lives, and communities. This disease centered approach has kept systems from being more equitable, effective, and efficient and people from better health. In many ways, the business of disease has trumped the profession of medicine and health [5]. Albert Einstein once famously said, “Insanity is doing the same thing over and over again and expecting different results” [6]. This speaks powerfully to a failing health care system needing a different health care systems solution and not a temporary remedy or bandage. The Commonwealth Fund determined that two things improve health care outcomes for populations the most. First, some type of universal health insurance coverage and secondly, access to a usual source of care [7]. It is through this usual source of care that a relationship can be developed which leads to mutual trust and respect between the provider and the patient which leads to behavior change which is the majority of the causes of premature deaths in the world [1, 8]. Primary care as manifested in family medicine general practice, general internal medicine, general pediatrics, and geriatrics serves as a primary care integrator and a hub of coordination. This coordination and integration, as the usual source of care, helps lead to the triple aim of better health, better health care, and lower costs [9]. Primary care is integrative in nature by possessing a broad knowledge of all sectors of healthcare and a strong understanding of community resources and other social and structural determinants of health. It is unfortunate that one’s postal code is more important than one’s genetic code in determining one’s health. Primary care through trusted and continuous relationships, through a person and family centered approach over time can start to achieve the required integration and coordination of care that can both start to understand but also diminish the impact of those social determinants of health.

4 Person Centered Approaches in Family Medicine and General Practice

Aspects of care that distinguish disease centered health care from person centered primary care can be seen in Table 19.1. The basic distinction as noted here is that a person and people centered primary care focus on people’s health needs through comprehensive, continuous, and person-centered care in which people are partners in managing their own health. This leads to enduring and continuous personal relationships. The combination of continuity, comprehensiveness, and person-centered care produce better health for all people in the community as well as addressing the social determinants of health for better population health. Clarification of the key terms used in describing the various elements and layers of the complex healthcare system is essential. Primary care connotes health care professionals who act as a first point of contact and consultation for all people within the health care system. All people should have a primary care professional as their usual source of care. Secondary care involves health care services provided by medical specialists and other health professionals who provide limited access and services. Tertiary care is specialized consultative health care, usually provided in hospital or specialty clinics. Quaternary care is used sometimes to refer to services that are highly specialized and not widely accessed. Experimental medicine and some types of uncommon diagnostic or surgical procedures are considered quaternary care. Preventative care includes measures taken to prevent diseases or injuries before occurrence rather than curing them or treating them afterwards. End-of-life or palliative services involve care for those with terminal illnesses or advancing disease that is progressive an incurable.

Table 19.1 Aspects of care that distinguish disease-centered care from person-centered primary care
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5 The Seven Shared Principles of Person-Centered Primary Care

The seven Shared Principles are listed in Table 19.2. They include the four classic Starfield Principles [12]: continuous, comprehensive, coordinated, and accessible—along with several other concepts.

Table 19.2 The seven shared principles of primary care [11]
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  1. 1.

    Person and Family Centered

    The decision to replace “patient-centered” with the term “person and family centered” was a very intentional one, responsive to concerns expressed by consumer advocates that the word “patient” objectified individuals in a sick or dependent role. The principles sought to move beyond the narrow framework of a disease care system to one promoting health. This first of the Shared Principles affirms an empowered partnership role for individuals and families. For example, the principal asserts that “primary care is grounded in mutual beneficial partnerships among clinicians, staff, individuals and their families, as equal members of the care team. Care delivery is customized based on individual and family strengths, preferences, values, goals and experiences using strategies such as care planning and shared decision making. There are opportunities for individuals and their families to shape the design, operation, and evaluation of care delivery [12].”

  2. 2.

    Continuous

    This principle reiterates the long-standing concept that “dynamic, trusted, respectful, and enduring relationships between individuals, families and their clinical team members are hallmarks of primary care.” The secret sauce of primary care is the ongoing trusting relationship between clinicians and the primary care team and individuals and families that is a healing process unto itself. This allows the importance of a sustained incremental approach over time to be foundational to dealing with acute, chronic and prevention-based health care problems and issues [13]. This process also allows a thoughtful approach to the integration of a person/family into the health care system [12].

  3. 3.

    Comprehensive and equitable

    This principle emphasizes important contemporary aspects of comprehensive primary care, such as behavioral and mental health as well as oral health. The principle also ties comprehensiveness to emerging concepts in health equity, calling on primary care to “seek out the impact of social determinants of health and social inequities. Primary care practices partner with health and community-based organizations to promote population health and health equity, including making inequities visible and identifying avenues for solution.” [12] Current research demonstrates that health care influences only approximately 10–20% of a person’s health, a person’s behaviors, environment, genetic makeup and social conditions being the most powerful determinants of health, illness and death [13].

  4. 4.

    Team-based and collaborative

    This principle affirms that individuals and families are critical members of primary care teams. In recognizing the multidisciplinary nature of team-based care, it also asserts that “health care professional members of the team are trained to work together at the top of their skill set, according to clearly defined roles and responsibilities [12]”. This principle broadens the importance of relationships to include the entire primary care team. Many team members, from nurses, medical assistants, receptionists, as well as clinicians, form relationships with the persons and families cared for by the practice. All primary health care team members are important in delivery of team-based collaborative care [12].

  5. 5.

    Coordinated and integrated

    The Shared Principles largely reiterate the central emphasis on contemporary issues such as “transitions of care to achieve better health and seamless care delivery across the lifespan.” The term “integrated” refers to how the individual’s health data and records can inform care within the primary care team and with other health care professionals in the medical neighborhood. The term “coordinated” refers to how healthcare is seamlessly arranged with others participating with the individuals care outside of the primary care practice in the medical neighborhood. With the emergence of evolving health information technology new and dynamic ways of integrating and coordinating health care information and data can be performed both synchronously and asynchronously with individuals to optimize their health care and health [12].

  6. 6.

    Accessible

    This principle acknowledges the changing nature of access in a digital communication era, asserting that “primary care is readily accessible, both in person and virtually for all individuals regardless of linguistic, literacy, socioeconomic, cognitive or physical barriers. This accessibility goes far beyond the concept of face to face visit. Meeting patient’s health and health care needs electronically, telephonically, and in other technologically empowered ways in both achieving person and family centered care but accessible care that is of high value. Primary care provides individuals with easy, routine access to their health information.” Moreover, person and family centered access means that “clinicians and staff are available and responsive when, where, and how individuals and families need them [12].”

  7. 7.

    High value

    This principle goes further than most prior formulations by asserting that primary care has a responsibility for both the “numerator” (quality and patient experience) and “denominator” (cost) components of health care value, and once again highlights the importance of a person and family centered approach. “Primary care achieves excellence, equitable outcomes for individuals and families, including using healthcare resources wisely and considering cost to patients, payers, and the system. Primary care practices employ a systematic approach to measuring, reporting and improving population health, quality, safety and health equity, including partnering with individuals, families and community groups.” Additionally, you cannot place enough value on the importance of the trusting relationship to drive quality and patient safety into appropriately lower healthcare costs [12].

6 The Value of Person-Centered Primary Care

Countries with stronger primary care have better overall health care outcomes and reduce per capita health expenditures than countries with weaker primary care systems [14]. Studies in the United States show that as the number of primary care physicians increase per ten thousand people, the quality of care improves and health care cost per person decrease [15]. Conversely, as the number of specialists per ten thousand increases in the United States, quality scores are reduced and cost increase [15]. Evidence also demonstrates that person-centeredness contributes to quality care and better outcomes. This can be seen in the improved treatment intensity and quality of life [16], better understanding of the psychological aspects of a patient’s problems [17], improved satisfaction with communication [18], improved patient confidence regarding sensitive problems [19], increased trust and treatment compliance [20], and better integration of prevention and curative care [21]. Evidence similarly shows that comprehensiveness leads to higher quality care and better outcomes [22,23,24].This is seen by better health outcomes, increased uptake of disease focused preventative care [25], and fewer patients admitted for preventable complications of chronic conditions [26]. Continuity of care also shows clear evidence of improving quality of care and better outcomes. This can be seen through lower all-cause mortality [27,28,29,30], better access to care [31, 32], less re-hospitalization [33, 34], fewer consultations with specialist [35], less use of emergency services [33, 36], and better detection of adverse effects of medical interventions [37, 38]. Finally, a regular entry point of care as provided in person-centered primary health care contributes positively to quality of care and better outcomes. These include increased satisfaction with services [39,40,41,42], better compliance and lower hospitalization rate [24, 39, 43, 44], less use of specialists and emergency services [24, 43,44,45,46], fewer consultations with specialist [43, 46], more efficient use of resources [23, 31, 47, 48], better understanding of the psychological aspects of patient’s problems [17], better uptake of preventative care by adolescents [11], and protection against over-treatment [10]. In fact, people’s perceptions of a high-quality, person-centered primary health care has been recently studied and supported in 34 countries as to why it is important to invest in strong primary health care as practiced by family medicine and general practice physicians [49]. The evidence showing that primary care leads to higher quality of care and better outcomes is summarized in Table 19.3 below.

Table 19.3 Rational for the benefits of primary care for health [14]
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There are several large gaps in national health care systems that will need to be addressed to advance person-centered care. Primary care needs greater capacity in and integration with behavioral/mental health, public health, end-of-life care, telemedicine and health information technologies, community health services, and patient activation and community engagement. These areas represent targets for improvement that will drive forward better health care for people, communities, and nations. Engaging people in their own health care through shared decision making and empowering their involvement should not be only their right, but their duty in the participation of the planning, the choosing, and the implementation of their health care and their health. The person-centered engagement framework of “inform me, engage me, empower me, partner with me, and stay by me” becomes pivotal to person-centered care for the future and essential to helping achieve better health care, better population health and lower cost care [50].

7 The Outcome of the 2015 Geneva Declaration of Person-Centered Primary Healthcare

The 2015 Geneva Declaration on Person-Centered Primary Health Care calls for the following ten principles to be endorsed and acted upon by all nations of the world [10].

  1. 1.

    Timely access to quality healthcare is a fundamental human right to all people.

  2. 2.

    All health care systems in all nations be designed with the person and people at the center of the health care system.

  3. 3.

    That all health care systems in all nations be built on the foundation of person-centered, community-based primary care as the entry point of first contact and the usual source of people’s care.

  4. 4.

    That all people have a relationship of trust with a person-centered primary health care professional, and their team, as that usual source of care.

  5. 5.

    That people are encouraged and empowered to be partners with their primary care professionals and their teams in their community in informed and shared decision making.

  6. 6.

    That people are educated to be engaged and responsible as partners in their own health care and in the design and development of health services so that their voice and view are always heard.

  7. 7.

    That persons’ voices be heard and respected around the framework of “inform me, engage me, empower me, partner with me, and stay by me”.

  8. 8.

    That nation’s medical, nursing, and other health professional schools are held accountable for producing a future health care work force that meet these person-centered primary health care goals in sufficient numbers to ensure that all people have access to this type of person-centered care.

  9. 9.

    That resources and payment be aligned to person-centered primary health care providers and practices that allow them to integrate and coordinate a person’s care that will produce the results of improved person-centered care, improved population health, and lower health care costs.

  10. 10.

    That health care leaders and health care policies are produced that support primary healthcare to provide person-centered and community/population-centered healthcare and achieve these goals.

8 The Rural Paradigm and Person-Centered Approach

There is no better place to understand the importance of family medicine and general practice in providing person and family centered primary care than in rural and frontier parts of our nations. This approach should be a five-step process with the following key attributes:

  1. 1.

    Person and Family Centered—In rural areas future health care should start by putting the people and their families and their communities at the center of the health and health care system that surrounds and serves them. By doing this we can focus on high value activities that meet the peoples, families, and communities’ needs.

  2. 2.

    Required services—Once we have the conceptual reframing of putting people, families, and communities at the center of health care then we need to prioritize what primary care services are of value to them. By doing this we will ensure that we are preforming on the activities that the people of the community desire and not what the financial revenue generation of the health care system is intending to achieve.

  3. 3.

    Team Based Care—Once people and families have been put at the center of the system and appropriate primary care services are identified then integrated professional teams of people working together both in a practice and within the community must meet these needs. It is by the team preforming these services that people’s health and health care outcomes will be maximized. By doing this as well as a team-based activity it will decrease burnout and lesson the burden on any particular team member as long as all are working collaboratively to the tops of their professional licenses

  4. 4.

    Interprofessional Team Based Education—It should be a requirement that interprofessional team-based training and communication are taught at all professional schools. It is important that the team work effectively and efficiently work together to meet the people, families and communities primary care services needs in ways that are cost effective, high value and of high quality. In fact, this approach can bring great joy to the team members as they work together effectively and efficiently to produce these outcomes and to maximize population health.

  5. 5.

    Payment Reform—We must evolve the payment for health care and the acquisition of health to a different model. We must move away from fee for service payments to a value-based payment system that achieves health and health care outcomes as our goals. A combined payment system that is based on a per member per month capitation formula with quality outcomes and shared savings for health and health care outcomes must be at the center of this system. In that way these teams can be empowered to produce the results we want in a financially sustainable way to the practice and the community. This will move us away from reactive disease care to proactive health care and health maintenance. If the practices can move away from volume of patients seen as the currency of financial success, to the health of the people of their population as the health outcome success in a way that provides enough financial support to keep the teams intact then this should be the goal. This model of payment is within easy grasp and actually not only could be paid for in its entirety but would save the system billions of dollars.

These five things when taken together in the order listed would help transform both health and health care in rural sectors of our world as well as would reshape how health care is practiced in all areas of the world. Therefore, the rural paradigm is important to get right because in so doing it will create the model of how family medicine, general practice and primary care can be at the center of helping these five items be successful.

9 Key Factors for the Implementation of a Person-Centered Approach in Family Medicine and General Practice

Key factors for the implementation of a person-centered approach in family medicine and general practice can be seen in Table 19.4 below. These key factors are important when working with each other as outlined in the rural paradigm section above in achieving improved health care and health outcomes. All educational facilities teaching interprofessional team based care must focus on the interaction of these variables with graduates from their programs so that we can contribute interprofessional team members to help across silos within other members of the health care teams in ways that are truly meeting a person-centered, family-centered and community based population health need. By creating these teams not only will we be caring for ongoing chronic health care diseases but more importantly we will start to leverage the teams to move upstream to address in a proactive way the bigger factors that impact people’s health. These factors such as personal behaviors, environment, social determinants of health and others can be proactively addressed in communities to decrease downstream bad health care outcomes. By so doing the finances of health care can be reframed and re-leveraged in manners to achieve these outcomes.

Table 19.4 Key factors for implementation of PCM approach
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10 Conclusions

The most effective and efficient health care systems depend on a strong foundation of primary care as practiced by family medicine and general practice physicians. As health care systems become more complex, there is greater need for better integration and coordination. Now is the time to create and set in place the principles of high-quality, person and family centered primary care. Primary care is the glue that holds health care systems together and integrates their multiple complex parts. Providing all people foundation of accessible team-based primary care as the entry point into the health care system leads to improved coordination, continuity, and comprehensiveness of care. This process also leads to trusted relationships from which higher quality and safer person-centered care results. Primary care must be accessible, timely, and community based and is the main antidote to reduce disparities and inequalities of care. For all health care systems in the world, primary care must be valued, promoted, financed, and sustained in order to help deliver these benefits in uniform manner across all countries of the world. Only by working with people in a person-centered manner that reflects the wishes and desires of the people served will nations and communities create systems of quality health care for all people [10].

Acknowledgements and Disclosures

The authors do not report any conflicts of interest in the preparation of this manuscript.