Why is it important to use improvement methods to address chronic care priorities in primary care?

Primary healthcare covers a broad range of healthcare services and involves the basic, first-contact care for patients. As the first level of care, primary healthcare also bears the burden of delivering longterm care to patients [1-2]. For this reason, access to quality primary healthcare for all individuals is essential. With long-term chronic care conditions representing over 80% of the global burden of illness, the capacity and quality of primary healthcare to address this burden is even more clear [3-7].


Introduction
Primary healthcare covers a broad range of healthcare services and involves the basic, first-contact care for patients. As the first level of care, primary healthcare also bears the burden of delivering longterm care to patients [1][2]. For this reason, access to quality primary healthcare for all individuals is essential. With long-term chronic care conditions representing over 80% of the global burden of illness, the capacity and quality of primary healthcare to address this burden is even more clear [3][4][5][6][7].
In primary care, especially with chronic conditions, factors outside of healthcare, including social and family considerations must be addressed. This requires a multidisciplinary team to address the complex health needs of primary care patients. This also requires the engagement of patients and their families in managing their chronic conditions. Given the broad range of providers required to deliver primary care, maintaining quality of care between different services becomes complex, particularly when the services are not integrated. Many of the defects in delivering healthcare occur in handovers between professional functions at different steps in the processes of the healthcare delivery system. Quality improvement methods reorganize processes of healthcare delivery using multidisciplinary teams, care integration, and engagement of providers, patients, and families. Quality improvement also recognizes healthcare as complex adaptive systems and provides the means for healthcare processes to be organized in a way that responds and adapts to context [8][9][10][11]. This paper emphasizes the need to better utilize and integrate quality improvement approaches to address the growing needs in primary healthcare delivery.

The burden of chronic care conditions
80% of the global burden of illnesses is due to chronic care conditions. Included in this burden is the need to address long-term care for patients suffering from infectious diseases such as HIV/AIDS. As reflected in the Chronic Care Model in Figure 1 below, addressing the chronic care burden requires the health system to be organized in a way that integrates health processes at multiple levels and allows patients to be informed and activated in their care [12][13]. To have a health system operate in this way requires healthcare processes to be reorganized in a way that supports integrated multidisciplinary teams and the engagement of patients in their care [14][15][16][17][18][19].
Quality improvement provide the means of reorganizing care delivery to achieve these goals. By testing and implementing changes in healthcare processes, guided by real-time data, quality improvement gives providers the tools to improve the way in which inputs into the system are used, with the goal of improving health system outcomes. Along the way to testing and implementing health system processes, quality improvement methods focus on teamwork. Engaging those involved in healthcare delivery processes creates a vibrant multidisciplinary team capable of suggesting, testing, and implementing changes needed in care processes, with a common goal of yielding improved outcomes.

An essential role for patients and multidisciplinary teams in primary care chronic care management
Factors outside of the healthcare system, such as food security, poverty, homelessness, and other social considerations play a role in primary healthcare, particularly when caring for patients with chronic conditions. To adequately address the complex needs of primary care patients, multidisciplinary teams must involve traditional healthcare professionals, in addition to other clinical and social services professionals on the care team that can work together to design, improve, and manage care delivery processes in the best interest of patients. Improvement Methodology focuses on the importance of teamwork in reaching improved care outcomes.
Chronic care conditions require long-term treatment options and the patients to manage their own care outside of the healthcare system. Due to their involvement in management of their longterm care, patients and their families play a huge role in the quality improvement team. By recognizing the important role of patients, quality improvement methods create opportunities for increased patient engagement and empowerment in healthcare processes. Including patients on improvement design teams allows healthcare providers to design care delivery from the patient and family perspective. Involvement of patients and their families also breaks the power differential between patients and providers, allowing patients to more directly provide feedback regarding their care to their providers.

Understanding and improving processes in healthcare delivery
Improvement methodology involves the iterative nature of testing changes to see if they yield improvements, and readjusting based on the results achieved. Iteration and adaptation is necessary in the complex setting of healthcare delivery. Flexibility allows for evidence-based medicine to be reliably delivered to patients -constant analysis and reevaluation allows for changes to be made when healthcare delivery processes are not effectively delivering evidence-based medicine to patients in need, when they need it.
By testing and evaluating changes, healthcare delivery processes can be streamlined to ensure that only value-added steps are taking place and that steps that are not value added are removed from the care delivery process. In this way, improvement methodology not only yields better results, but reduces waste resulting from unnecessary steps in the care delivery processes.