TABLE 4-2Responsibilities of Primary Care Physicians in Managing Patients with Chronic Disease

1. Provide and/or coordinate comprehensive, continuous medical and health care as needed.
2. Learn the consequences and meanings of disease and illness to the patient.
3. Assess the trends and tempos of the disease clinically through collaboration with the patient and family.
4. Involve specialists as partners in initial evaluations and outcome monitoring over time while remaining the principal physician in most cases.
5. Educate patients concerning both the disease and its treatment and the value of and ways to develop a partnership method of managing the disease/illness.
6. Conduct joint decision processes with the patients, in which the physician explains disease consequences, prognosis, and treatment options while the patient assumes responsibility for assessing disease and treatment effects and choosing among treatment options.
7. Locate health care in the most appropriate site—be it office, home, hospital—employing the most efficient methods to determine disease tempos and trends, such as proactive and reactive telephone contact, remote monitoring, mobile services, and visits to any site of care.
8. Elicit assessments from patients and families concerning the quality of their health care, its efficiency, and their satisfaction with it.

From: 4, What Would Ideal Care Look Like?

Cover of Changing Health Care Systems and Rheumatic Disease
Changing Health Care Systems and Rheumatic Disease.
Institute of Medicine (US) Committee on Changing Health Care Systems and Rheumatic Disease; Manning FJ, Barondess JA, editors.
Washington (DC): National Academies Press (US); 1996.
Copyright © 1996, National Academy of Sciences.

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