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Toward a System
of
Integrated Primary Care
ALEXANDER BLOUNT, Ed.D.t
JOSE BAYONA,
M.D.,
M.P.H.t
Though integrating mental health
ser-
vices into primary medical care seems
worthwhile
as a way of
implementing
a
biopsychosocial
model of health
care,
it has
happened
in
only
a few
settings.
Our
article explains this situation by consider-
ing
the
health care system
to be a ''self-
maintaining" system.
It
looks
at
elements
that underlie
any
domain
of
expertise
about which there
is
some social consen-
sus:
(a)
the model of the phenomena and
(b)
organization
of the
relationships
in the
domain;
and
(c) routines
in
the practice of
the expertise. This allows
us to
describe
what changes
in
each element might lead
to
the
evolution
of an
alternative,
self-
maintaining system
of
health care: inte-
grated primary care.
One
example
of a
setting
in
which
an
alternative model,
organization,
and
practice have been
at-
tempted is described.
Fam SystMed 12:171-182, 1994
I
N
the
mid-1970s, two novel approaches
to providing health care were devel-
oped, each of which seemed to offer
a
basis
for
a
broad restructuring
of the
health
delivery system. The first was the develop-
ment
of
what
we
would call integrated
primary care teams
at an
HMO
in New
t Director, Family Center
of the
Berkshires,
741
North St., Pittsfield
MA
01201.
t Director,
El
Centro de Salud Familiar de Roches-
ter; Clinical Assistant Professor, University
of
Roch-
ester Medical School, Rochester NY.
Haven, Connecticut (10);
the
second
was
the articulation
of the
"biopsychosocial
model" in Rochester, New York (14).
Colman
and
Patrick
(10)
describe
a
project that integrated mental health
ser-
vices into primary medical care. This
was
done by developing primary care teams
in
which patient care responsibilities
are
shared among physicians, nurse practitio-
ners
or
physicians' assistants,
and
mental
health clinicians. The article spells out the
steps involved and
the
challenges
in
orga-
nizing integrated teams.
The
project
was
funded
by a
federal grant
in
conjunction
with
a
prestigious university.
One
might
expect this study
to be the
beginning
of a
movement toward integrated primary care
in
an
HMO setting. Yet, after HMOs have
existed
for a
number
of
years
and the
benefits of biopsychosocial care paradigms
have been documented in terms of effective-
ness
and
cost containment
(9,
11,
22, 28,
29),
there
are few
current, published
examples
of
integrated primary care
in
HMO settings
(19). In
many ways,
the
article
by
Coleman
and
Patrick could
be
published today
and
seem fresh and inno-
vative: when Dym
and
Berman
(12) pub-
lished their article on "the primary health
care team" 10 years later, the idea was still
new.
The biopsychosocial model with
its em-
phasis on understanding a patient in his or
her context provides
a
conceptual basis
for
integrating
the
biomedical
and
psychoso-
cial primary care
of
patients into
one
service.
It
focuses
on
training
the
physi-
171
Family Systems Medicine, Vol. 12, No. 2, 1994
©
FP, Inc.
172 /
cian in psychosocial understandings in
addition to biomedical knowledge, and it
provides a hierarchical systems model for
integrating these ideas. While the model
has received broad discussion and numer-
ous attempts to outline its application (13,
15,
16), some believe that it has tended to
remain in the realm of ideology rather
than becoming a general guide to daily
practice (32).
It is true that although Coleman and
Patrick articulated the organization of
integrated primary care in their setting,
they did not offer an integrated model of
the phenomena around which care is built,
nor did they offer much detail on the
patterns of interaction between team mem-
bers and patients. Likewise, while Engel
(14-16) offers what might be called a
model, there is much left to do in order to
articulate how care might be organized
and what routines of interaction might
constitute such care.
This article will first attempt to develop
a theoretical framework for understanding
why ideas that seemed so timely, even
inevitable, have had such a limited impact
on overall health care delivery, and what
elements must be arrayed in the develop-
ment of a system that can support the
long-term evolution of these ideas. Second,
we will offer one example of the organiza-
tion of services that might be called
"integrated primary care."
We suggest that the reader approach
this discussion in accordance with his or
her interests and ways of learning. If
interested in proceeding from theory to
application, one should continue reading
this article sequentially. If, however, one
prefers to start with applications and look
at theory only if the application is compel-
ling, the place to begin reading is at the
section called "El Centro de Salud Famil-
iar de Rochester."
Conceiving a System
Any area of expertise that is practiced in
the same way by a number of people may
be understood as consisting of three defin-
ing elements: a model of the phenomena
under consideration, whether formally
represented or implicit; an organization of
social roles and relationships involved in
practicing the expertise; and the routines
involved in the repetitive practice of the
expertise (8). These elements are mutually
supportive, recursively validating, and in-
extricably linked. They might be consid-
ered to be the elements (though they are
processes, not entities) of a self-maintain-
ing social system.1 The more one perceives
that the world in a particular domain
works in a certain way (model), the more
one will see certain actions as appropriate
for achieving one's goals (practice), and the
more one will see certain types of roles or
relating patterns as supportive of those
actions (organization). As we will show,
this sequence can begin with any of the
elements.
In order to make the case that model,
organization, and practice are inextricably
linked, we offer a brief discussion of
learning. If the description is credible, it
will make a stronger case for the need for
the changes we will outline, and it will
make clear how difficult the task is.
Sinking of Premises
An understanding of how the evolving fit
between a system and its environment can
be related to the evolving structure of the
system itself has been central to the work
of Gregory Bateson (4), who first described
the "sinking of premises" in the general
way we will use here. This idea, couched in
1 We use the term "self-maintaining" in the sense
used by Hejl (20): "self-maintaining systems are
systems whose components maintain each other, and
by maintaining each other uphold the whole cycle" (p.
63).
BLOUNT and BAYONA/ 173
slightly different terms, has been used by
Sluzki (33) to recount the way residents
learn to think interactionally in a systems-
oriented family practice residency.
As with any system that might be said to
"learn," a person must make generaliza-
tions about what in the environment is
predictable and therefore does not need
attention, and what is unpredictable and
does need attention. What is generalized
over time in a particular context is stored
in a more abstract coding, that is, more
generally applicable premises are "sunk,"
making them less accessible to conscious-
ness.
This process has been called the
"progressive refinement of knowledge
structures" (7), the development of a
"specific organization" by an expert in a
field (2), or a "top down processing" (35).
The generalizations about experience,
which a person (or any learning system)
makes over time, gradually come to struc-
ture perception (5, 24, 36). They become,
therefore, self-validating. They constitute
the understanding of the contingencies of
any relationship in which a person deter-
mines his or her own behavior. These
generalizations, or experiences of the con-
tingencies of relationship, lead to regulari-
ties of behavior, which represent the
observational consistencies about that per-
son. These are regularities of behavior that
an observer would call the "personality"
or "character" of a person being observed.
Experiences that cannot be fitted into
the usual categories of perception and
understanding cause one to be alert for
danger. The most fundamental security of
operation in one's environment is chal-
lenged until the new experience can be
integrated into one's system of expecta-
tions.
To describe how fundamental the
term "expectation" is when we use it, these
are unconscious expectations that struc-
ture whatever counts as data and, there-
fore,
what is perceivable. They are built on
generalizations drawn from many itera-
tions of day-to-day practice, and on the
basic assumptions and metaphors of the
language of exchange in this practice (18).
"Self-maintaining system," then, is the
systems-level description of regular pat-
terns of interaction that are otherwise
generalized in attributions about the per-
sonalities of certain groups of providers of
health care. Expectations of finding the
cause of the patient's dis-ease (model) will
support expectations of the physician's
role as arbiter of scientific truth in the
network of helpers (organization), which
support expectations about how the physi-
cian will interact with the patient and
other providers (practice).
In the field of health care, these ele-
ments
are:
a model (biomedical), an organi-
zation (a network of primary care physi-
cians as gatekeepers to more specialized
physicians, mental health providers, and
the "high-tech" hospital), and a practice
(the basic routines of interaction between
health care providers and their patients).
The replacement of the biomedical model
by a more integrated model, such as the
biopsychosocial model, will be successful
only when it is translated into an organiza-
tion and a set of practices that will support
and validate it.
We
believe the biopsychoso-
cial model must be joined with integrated
biomedical and psychosocial services, inte-
grated both in the network of providers
and at the level of the patterns of interac-
tion in the consulting room, before a true
alternative to the present system can
evolve.
The organization in biomedical practice
is presently toward specialization and
certainty, and the premises enacted in the
interactions are likely to be of a similar
order. Certainty is one of the main goals in
a biomedical model. Specialization is de-
signed to contribute to certainty. Specializa-
tion is the relational embodiment of reduc-
Fam.
Syst. Med., Vol. 12, Summer, 1994
174 /
tionist science. In looking for the ultimate
certainty, the problem is broken into its
component parts and addressed by people
who are more and more expert in smaller
and smaller areas.
In the translation of this organization
into practice, given the large number of
situations in which patient collaboration
in treatment is wanted and needed, such
certainty can be problematical (1). The
more that certainty is expected, and the
more that certainty exists in the provider
group, the more the structure and routines
of the interaction will cue the patient to
discount his or her own certainty, and the
less responsibility the patient is likely to
take.
Thus, the basic model and organiza-
tion of biomedical science can make it
harder to develop the routines of practice
that are being called for by so many writers
(21,
23, 27, 30, 31, 34). These routines
involve eliciting a careful description of the
patient's experience and understanding of
the problem, and highlighting the thera-
peutic and caring aspects of the physician's
behavior in response.
Developing an Alternative System
An integrated system of primary care is
a system that has the capability to make an
assessment of a person's problems from a
biopsychosocial perspective, with access to
this capability from any entry point in the
system. It also has the ability to protect a
biopsychosocial assessment from being
attenuated by specialized perspectives as a
person moves around the system.
If a self-maintaining system arises
through the recursive interrelationship of
model, organization, and
practice,
we
would
expect an alternative to the present system
to develop as an evolutionary result over
several years. A small change in practice
leads to a small change in the organization
or in the model. To keep the evolution
going, any change in one of the three
elements needs to be sustained by a change
in the others.2
THE BIOPSYCHOSOCIAL MODEL
The biopsychosocial model is fundamen-
tally an alternative to the biomedical
model in that the biomedical model is a
model of the workings of natural phenom-
ena while the biopsychosocial model is a
blueprint for how to think about natural
phenomena. It assumes a hierarchically
related structure of interacting systems,
but is does not provide a model of what
might be called "biopsychosocial pro-
cesses."
When one tries to understand the pa-
tient in a wider context, one values
different sets of phenomena. The picture
changes. In addition, the change in view
influences the patient's experience, often
changing what phenomena are to be
understood.
A
patient who comes to under-
stand his or her situation differently may
be less anxious, for example, significantly
influencing the severity of physical symp-
toms.
The reality to be understood arises
in the conversation between patient and
care provider.
Organization
An integrated system is organized so
that all primary care (meaning, the first
response to almost any perceived problem
of health or living a person can present)
can be found in one place. This does not
mean that one person has to be the one to
provide such a broad range of care. An
integrated system has collaborative conver-
sation as the central entity. This is the
process between providers that brings the
system into being just as it is the process
between provider and patient that brings
service into
being.
It is the process between
2 There are a few examples of small-scale alterna-
tive systems being implemented all at once, but most
have been too different from the dominant understand-
ings and practices to be sustainable over time (3).
BLOUNT and BAYONA
provider, patient, and family that creates
options for new meanings and new ways of
approaching a situation. The biopsychoso-
cial model is built on an integration of
what were previously disparate worlds of
explanation. The human system, which
will be the realization of this model, will be
a team made up of members from these
worlds of explanation (6).
The notion of a team is far from new in
medical care. Many disciplines and subdis-
ciplines have a legitimate claim to being a
part of the medical care team. Teams can
be assembled teams (all at one place at the
same time) or distributed teams (cooperat-
ing in a task by contributing from different
locations or at different times). Teams can
be hierarchical (one person in charge) or
collaborative (each person contributing
with generally equal status). The relation-
ship structure of the team in health care
typically has been either assembled and
hierarchical or distributed and collabora-
tive. An assembled and hierarchical team
might best be exemplified by the team
involved in surgery. Many people can be
gathered around the operating table, each
with a different role, but they are all
working on a single, well-defined task and
with a single, designated leader determin-
ing direction. In a distributed team struc-
ture,
each discipline does its aspect of the
care separately on a referral basis, such as
physical therapy or radiology. Each profes-
sional is much more "in charge" while
providing his or her portion of the service.
In the day-to-day realities of primary
care,
however, the task is often far from
clear. A hierarchical team, in which the
point of view represented by a particular
type of training is likely to be the outcome
of the team conversation, will be much less
effective than a collaborative team in which
the fit of point of view to the situation can
be the main test of usefulness. It will
require an assembled and collaborative
I lib
team to develop an assessment that can
truly be called biopsychosocial.
A collaborative team will make descrip-
tions of the patient in his or her life context
easier to generate. The psychosocial de-
scriptions of the patient will be acceptable
and expected at the same time that
biomedical descriptions are being gener-
ated (17). For example, when a collabora-
tive team is expected to develop a biopsy-
chosocial description of a patient, it is
much easier to make a place for "culture"
in that description. Not every member of
the team needs to be of the same culture as
the patient and family. If every lens is
valued, the cultural lens becomes impor-
tant and is much easier to integrate into
the picture of the patient. In a hierarchical
structure in which one provider makes the
most important determination of which
problems should be addressed, it is crucial
that this particular person be of the same
culture or extremely knowledgeable about
the culture of the patient.
In a different mode, the risk of a loss of
richness in a biopsychosocial assessment
exists whenever a patient must move from
one service provider to another. Each
provider is likely to redefine the problem
through the lens of his or her own
specialty. To maintain a contextually in-
formed or robust description, there must
be someone with authority to manage the
information flow that surrounds the pa-
tient in the system. This person would
have the authority to assemble the team
if collaboration in problem solving were
needed. Such an arrangement would consti-
tute a distributed and hierarchical team.
Practice
When the structure of the system is
fundamentally collaborative and no one
person expects to carry all responsibility
for the ideas involved, the interaction in
the consulting room is more likely to
embody collaborative premises. On the
other hand, without routines that show a
Fam.
Syst. Med., Vol. 12, Summer, 1994
176 /
physician and team members exactly what
each one should do in an interaction with a
patient, it is difficult to begin to put these
premises into practice (26).
Biopsychosocial practice requires (a) the
development of routines for eliciting infor-
mation from a patient in a way that does
not separate the person into biomedical
and psychosocial spheres; (b) determining
which team members should first meet a
patient who presents with a specific sort of
problem; (c) determining when additional
team members should assemble to discuss
a case or meet a patient, (d) and determin-
ing when and how to involve additional
members of the patient's network in the
conversation about treatment. These are
difficult routines to develop, but defining
the task of developing them gives us a way
of assessing our progress in facilitating the
evolution of an alternative, self-maintain-
ing system. Practice has received the least
amount of attention of the three elements
we are discussing.
In the final part of the article, we offer
an example of the organization of a system
in which collaboration is a central feature.
We give examples of consulting routines
that support and enact collaborative pre-
mises.
The system and the routines we
describe are not meant to represent the
best way of organizing or the best ways of
interacting; rather, they are examples
intended to demonstrate the level of detail
involved in developing the routines and
organization of an integrated system.
EL CENTRO DE SALUD FAMILIAR DE
ROCHESTER
"El Centro de Salud Familiar de Roches-
ter" was established by Saint Mary's
Hospital in Rochester, New York. The
Center serves primarily the Latino popula-
tion of Rochester, most of whom live in the
neighborhood in which the Center is
located. Its physical facilities (an office for
each health provider, four examining
rooms, nurses' station, and waiting room)
are pleasant and well laid out. The full-
time staff includes a family physician, a
graduate nurse, a secretary, and an out-
reach worker. The part-time staff includes
a nutritionist, a family nurse practitioner
and a network therapist. The network
therapist is a social worker trained in
systemic family therapy.
The Center is financed through the
Division of Ambulatory Services at St.
Mary's Hospital, which negotiates reim-
bursement rates for primary care services
with Medicaid, Medicare, and private insur-
ance and managed-care companies. The
practice has the flexibility to organize its
services as the providers think best within
the centralized financing and economic
practice analysis of the hospital. The goal
of the Center is to break even financially.
Organization
The Center is organized to provide
services at the individual, family, and
community levels. On the individual level,
it provides medical services for acute and
chronic conditions and disease prevention/
health promotion. On the family level, it
provides family interviewing for health
maintenance or restoration, family therapy,
consultation with other health providers,
and networking with other service agen-
cies.
On the community level, its staff
members frequently teach and make pre-
sentations in schools and community fo-
rums about health-related issues, and also
act as advocates for the population that the
Center serves.
The organization of the Center is built
on the assumption of collaboration be-
tween provider and patient, between pro-
vider and family, between one provider and
another, and between providers, patients,
and other community networks. The job of
the outreach worker is to help patients
negotiate with the bureaucracies (welfare,
housing, and so on) that have so much
influence on the conditions of their lives.
The job of the network therapist is to
BLOUNT and BAYONA/ 177
provide individual and family therapy and
to foster collaboration among health pro-
viders, other service providers, patients,
their families, and the larger community
networks. The functions that the network
therapist performs highlight what is in-
volved in "integrated primary care," at
least for this particular Center.
Practice
For the family physician (second au-
thor),
the most important role of the
network therapist is to be available as a
consultant when he feels stuck by a case,
which often will involve meeting with the
patient and family. This usually occurs
when some problem in the fit between
patient and physician has led to misutiliza-
tion, noncompliance, or lack of agreement
on a treatment plan.
The role of consultant to a previously
established treatment relationship, how-
ever, can be played by any team member
for any other member(s). The providers
explain to the patient that the invitation of
the third person is for the purpose of
having an additional view about the situa-
tion or problem they have been trying to
define or solve. The consultant joins the
interview process and reflects to the pro-
vider and patient what was observed.
Usually some treatment plan evolves from
this interaction. These plans might include
a specific task for patient and/or providers,
a short followup as a group, and/or an
extended interview with the therapist and
the patient and family. Sometimes this
may be a "spot conference," a brief
meeting that happens spontaneously, and
sometimes it is an extended interview
made by appointment.
In our model, the network therapist does
hospital rounds with the physician. This
practice was begun for two reasons. First,
any hospitalization is likely to be a crisis
for both patient and family. It is a point at
which psychosocial intervention can be
most needed and most effective. It is a time
when one must acquire the information
and collaboration necessary for a smooth
transition back to home, or other setting,
for the patient at discharge. Second, an
additional psychosocial perspective is par-
ticularly useful at this juncture because
the routines of providing hospital care, as
opposed to office care, tend to make it
difficult for the medically trained providers
to stay in touch with a robust, contextual
picture of the patient.
In many cases, the network therapist
assembles and helps to organize the pri-
mary care system of a patient. This
involves identifying the agency personnel
and community helpers who are involved
with a particular patient or family, and
arranging a meeting to review the problem-
atic situation. In this meeting, a common
goal can be denned and the group can agree
on the function and accountability of each
person in relation to the goal. The network
therapist also tries to identify community
people, self-help groups, and former pa-
tients who are willing to be involved as
resources for patients and for team mem-
bers in situations where additional help
may be needed.
The network therapist provides direct
service to persons and/or families referred
to the Center. When there is direct referral
to the therapist, the evaluation of the
patient's situation is placed in the same
medical record that is used in the practice.
This record is a family record, and no
special part of it is designated solely for
behavioral assessment: therapist notes are
an integral part and alternate with physi-
cian notes. The evaluation description is
usually short, rarely exceeding a two-sided,
handwritten page.
The routine interactions of the Center
occur within a set of understandings or
beliefs on the part of the
providers,
namely:
1.
Understand that there will be repeti-
tive visits. Not everything needs to be
solved or even investigated in any one visit.
Fam.
Syst. Med., Vol. 12, Summer, 1994
178 /
2.
Relate the level of contextual inquiry
to the symptom. There might be much less
contextual inquiry when a child presents
with chicken pox than when she or he
presents with chronic headaches or exacer-
bations of asthma.
3.
Use all of the information available.
Read the notes of all other providers; read
the notes from the last visit; write notes
that will orient you to the person of the
patient, not just to the symptom.
4.
Always
be
able
to
answer: "What does
this patient want from this consultation
today? What sort of relationship in the
consulting room is expected and would
help to fulfill the expectations of the
patient?" These two questions could have
different answers, as when the patient
wants an authoritative and directive ap-
proach from the physician to a situation in
which the physician thinks such an ap-
proach would be counterproductive.
5.
Try to understand the context in
which the patients' expectations of outcome
and relationship arise. Two of the typical
contexts that must be investigated at the
Center are the context of migration and
the context of poverty. These contexts
yield stories that often make the presence
and the request of the patient much
clearer. They also allow for the discovery of
exceptions to these stories, which are
helpful in later developing the partnership
that is the core of treatment. These
exceptions concern successful coping with
the conditions of migration and poverty,
sometimes turning them into opportuni-
ties for enhanced self-development.
6. Besides being able to elicit the expec-
tations of the patient, the provider must
be
ready to violate the expectations of the
patient in order to open space for new
experiences. As an example, the second
author will often sit on the examining
table while the patient sits in the interview-
ing chair. In this configuration, people are
often more willing to talk about topics or
entertain ideas that they usually do not
associate with an office visit.
The collaborative nature of the practice
is seen in the routines of interaction
between provider and patient. The interac-
tive routines of the examining room and
consulting room will structure the general-
izations formed by patients and providers
about the interaction we call primary care.
The second author and the staff of the
Center have developed a set of routines
that support and make inevitable the
generalizations that comprise an inte-
grated model of primary care. These
routines include the following:
1.
Exploring with all patients what
benefits they expect to receive from the
particular visit (though this may not be
asked directly).
2.
Asking the patients for their view of
the health problem.
3.
Exploring the interconnections of the
patient's illness/disease status with other
subsystems (relatives, work, friends, and
so on).
4.
Asking what the patient would accom-
plish once health status improved.
5.
Exploring the meanings associated
with the particular illness/disease status
presented by the patient.
6. Using a contractual agreement for a
working plan with each patient.
7.
Focusing on potential solutions to the
presented problems rather than on causes
that restrict change or maintain the prob-
lems.
8. Providing a meaning for the proposed
therapeutic intervention in a way that will
be useful to the patient. This involves
explaining why the intervention is being
suggested, and using language that fits the
understanding of the patient and the
people in the patient's network.
9. Trying to find the most conducive
BLOUNT and BAYONA/ 179
setting for a specific type of conversation.
There are times when a staff member
wants the patient to take more responsibil-
ity for the treatment, when the collabora-
tive nature of the relationship needs to be
highlighted. At these times she or he will
meet with the patient and/or the family in
the living room setting of one of the offices
rather than in an examining room.
While the case examples could be legion,
one is offered to show these practices in
action.
A
Case
Example
A 38-year-old woman came to her first
office visit complaining of severe knee pain.
In the middle of the physician's brief
exploration of the composition of her
nuclear family, the woman began to cry.
She described how lonely and desperate
she felt. She was trying to care for her
husband who was a paraplegic. He had
been in and out of the hospital several
times in the last year. The family's situa-
tion had been complicated by the termina-
tion of her husband's workers' compensa-
tion payments. They were behind in their
mortgage payments and the bank was
preparing to take over their home. Her
knee pain was taking up a great deal of her
attention and energy, making her less able
to help her husband or to respond to any
aspect of the family crisis.
The team (physician, nurse, network
therapist, and outreach worker) met to
discuss how to approach the case. It was
decided that the outreach worker would
visit the family in order to help address
legal and financial issues. The physician
would develop a protocol of tests to
determine a diagnosis for the woman's
knee.
The network therapist would lead
the team in a conjoint meeting with the
woman and her family in their home.
In the meeting with the woman, her
husband, and their children, it was the
perception of all team members that the
family was estranged from its network of
relatives, which should have been an
important source of support. It also seemed
important to involve certain friends of the
mother's whom she knew through her
church. Finally, it appeared that the
children could have been more helpful, but
that their struggles for independence hin-
dered them from being able to help.
In subsequent meetings with the family
and the network therapist, a series of
transgenerational issues were addressed
and a reconciliation ritual was con-
structed, using an impending birthday as
the occasion. The resources of the enlarged
network allowed foreclosure by the bank to
be delayed until the family could get its
own income reestablished. Help with the
care of the husband was insured. In
working with the physician, the woman's
knee pain was diagnosed as a degenerative
condition. In spite of her diagnosis, she
reported that her pain was significantly
decreased and her functioning restored—
without the use of pain medication.
Were these biomedical or psychosocial
interventions? Why would we want to
make any distinctions? In the routines of
integrated primary care, such distinctions
cease to be particularly relevant.
Recapitulation
Again, we want to stress that the setting
and practices we have described constitute
just one example of an attempt to imple-
ment integrated primary care. We expect
that, in the not very distant future, we will
look back and smile at how rudimentary
our efforts were. But even rudimentary
efforts at integration can cause substantial
perturbations in health care systems. In
larger systems, any occurrence of unex-
pected phenomena that cannot be identi-
fied and responded to will cause the system
to go on an alert for danger, which may
well lead to re-evaluation of the usual ways
of doing business and the beginning of a
search for new solutions. We hope that the
Fam.
Syst. Med., Vol. 12, Summer, 1994
180 /
idea of integrated primary care can become
a part of new expectations that will foster
the kind of evolution we are advocating.
We have learned many lessons through
our efforts. First, we have learned that an
integrated primary care practice team can
foster high morale among team members,
supporting them in effective functioning
even when biomedical or psychosocial
problems are extremely disheartening and
not fully resolvable. Second, we have seen
that it is often possible, when working as a
team and in consort with other community
agencies, to effect remarkable resolution in
somatic symptoms of patients even in the
context of significant family and social
constraints. Third, we have often been able
to avoid "medicalizing" psychosocial prob-
lems when this might otherwise have
occurred. Finally, we have been able to
accomplish all of the above and yet achieve
a high level of patient satisfaction.
We also encountered difficulties that we
were not fully able to overcome. While we
could bill for each professional's direct
service time, many of our tasks and
routines could not be billed as direct
services. This has meant that time spent
coordinating or collaborating with commu-
nity agencies was limited by our need to
generate income. The pressure for produc-
tivity has made the evolution of the model,
once set up, difficult. Time to discuss the
effectiveness of various approaches and to
evaluate patient outcome needs to be built
in. Finally, the part-time status of the
network therapist has not allowed us to
solidify the initial practice routines in the
new collaborative model as much as we
would have liked.
SPECULATIONS ABOUT THE FUTURE
As systems that might be considered
"integrated" in their organization and
practice
go
forward using a biopsychosocial
model or other "integrated" or "collabora-
tive"
models, there will certainly be recur-
sive development or evolution in unex-
pected directions. If our speculations about
the evolution of a self-maintaining system
are true, then model, organization, and
practice will mutually and recursively
evolve. The biopsychosocial model may
turn out to be the precursor of a different
sort of model. It is quite possible that
regular work on teams between people
trained in the different worlds of explana-
tion we now use could lead to a redefinition
of these worlds and a transfer of expertise
in interesting
ways.
The conceptual bound-
aries may shift or disappear. This would
have profound effects on the disciplinary
distinctions of a primary care team.
Integration of primary care is hampered
by conceptual distinctions that are instan-
tiated and made into areas of practice by
disciplinary conventions and distinctions.
We are not advocating the elimination of a
distinction between medical service and
mental health service in all settings. This
would certainly not fit with the realities of
training practitioners, with the expecta-
tions of funding sources, and with the
expectations of the users of services. We
are advocating the view that these distinc-
tions are conceptual and are not inherent
in the phenomena being considered. They
may or may not be useful in a given
situation.
If the same patterns are found on teams
involved in primary care practice as have
been seen in teams in other domains (8),
the distinctions between disciplines and
areas of practice "owned" by each disci-
pline will continue to blur. Already we
have seen family physicians trained as
family therapists, psychiatric nurse practi-
tioners and psychiatric physician's assis-
tants,
medical family therapists, and behav-
ioral medicine training for psychologists
and medical social workers. We suspect
that, in the future, training and certifica-
tion for team members will be modular and
fitted to the function they will serve more
than to disciplinary identification. In 10 or
BLOUNT
and
BAYONA/
181
20 years from now, it is likely that the roles
on a team will be unrecognizable to most of
us today.
In describing the model, organization,
and practice of primary care, it is difficult
to describe the practice and routines that
constitute integrated primary care. Like-
wise,
it is difficult to predict the evolution
of these routines of practice. It will be
important that this practice—the micro
patterns of interaction between providers
and patients—generates as much atten-
tion and study as the routines of patient
care have generated in the study of
biomedical practice.
In an integrated primary care system
with a substantial developmental history,
we could expect to see much more com-
monly the occurrence of elegant and
seemingly simple solutions to previously
intractable problems in service delivery.
These solutions occur now in isolated
instances, tracked mostly by accounts
exchanged between providers. We would
hope to see these solutions occurring
predictably in documentable and dupli-
cable patterns in an integrated primary
care system of the future.
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