“Integrated primary care” lacks individuality and continuity

Integrated Primary Care is a somewhat confusing book, but with some constructive parts. The book is based on a concept from the United States of America, where “primary behavioral health care” was a means to support public health efforts and where behavioral health counselors train staff and patients in health centers on healthy behavior. The concept is similar to the concept of “integrated behavioral health” that was launched in Sweden, which was also launched as a way to integrate psychologists and psychotherapists into primary care.

The book is divided into two parts: organizational activities and clinical activities. After a very short history of the development of health centers, primary care and general medicine, it is reported that primary care and health center work is chaotic, availability is low, staff do not cooperate in the health center and doctors, nurses and other therapists change workplaces, mutual support. But by completely reorganizing the health center according to the principles of integrated primary care, the problems of lack of availability, unequal access to care and long waiting times for behavioral therapeutic interventions will be resolved. This is by screening directly into more occupational groups, increasing the number of times available each day, keeping multiple times unbooked at the start of the day, setting up waiting lists for behavioral health professions and not making return visits. We who participated in the 1980s and 1990s acknowledge the “red, yellow and green times” and other solutions launched, such as “good reception”.

However, there are interesting parts in the book related to the increased screening of behavioral health professionals. The book provides good advice on how the health center can facilitate screening procedures and increase knowledge about the different roles of professional groups in the activities of the health center and how team cooperation and cooperation should be developed among them.

The second part of the book is about working with the patient to bring about behavioral changes. Introduced the Prochanska model, a model that is well-known and often applied in health promotion activities, here it explains how care personnel can apply visiting arrangements and how conversational techniques can affect the clinical outcome. Each visit should begin with a brief introduction explaining the health center routine and the purpose of the day’s visit, and “avoid following the patient’s own story, which is often disorganized to filter the required information”. The authors are negative for starting to listen to the patient’s desires, fears and thoughts before the visit. This contrasts with the person-centered methodology for visiting patients in (primary) care, which is currently supervised in all universities in Sweden, Denmark and the United Kingdom. Instead, the “contextual interview” is launched as a history of behavioral changes in primary care.

The authors then move on to recommending new knowledge in conversation techniques and behavioral health: Motivational Conversations, CBT, ACT and FACT. A lot is related to shortening the visit time and reducing the number of return visits. Continuity and follow-up is not recommended.

The book also provides guidance and advice meaning that the health center’s ability to follow, for example, the “National Guidelines for Depression and Anxiety” and “National Guidelines for Unhealthy Lifestyles” are severely limited and the ability of staff to provide person-centered care and provide continuity is undermined. The book did not mention the central role of the district nurse regarding poor physical and mental health associated with behavior, counseling, support, care, and care coordination and prevention.

Swedish primary care development and research work on work with behavior-related ill health are not included in the book’s overview of history. On the one hand, it is recommended to give good advice when starting groups and replace some one-on-one visits with group activities and instructions on how the health center should operate through open lectures, informal groups and skills training.

The main issue not addressed is how continuity can be maintained, how at-risk patients should be followed up and how individuals requiring more long-term contact should be able to access this. The essence of integrated care is stated to be high availability, group collaboration, and the use of individual and beneficial interventions. But the essential screws for primary care, continuity, human-centered care, and follow-up are missing as an important part of the recommended activities. This means that the book does not release anything that could lead to the development of quality primary care, but rather a return to a situation in which care was not person-centered but not particularly focused on increasing production without being able to provide continuity and the greatest opportunity to address complex issues.

Lakartidningen.se 2021-05-21