2-3 page essay with reference page APA format

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Human services do not offer a one-size-fits-all approach. Determining what type of help to provide depends on a client's individual needs. In some cases, the client may need medical treatment rather than social or emotional intervention. In other cases, the reverse is true. And in many cases, a combination of both is needed.

The three primary models of human services delivery—medical, public health, and human services—delineate these treatments. A patient with bipolar disorder, for instance, might best be treated under the medical model by taking an antipsychotic drug. On the other hand, a single teenage mother who has no health problems but is struggling to afford shelter and food might be treated under the human services model with the help of a social worker who can help her find employment and day care services for her child. Furthermore, AIDS workers in Africa might utilize the public health model, combining both medical treatment and social intervention, giving medicine to victims of the disease and teaching prevention practices to help stop the spread of HIV. In some cases, a human services professional may need to apply more than one delivery model. The model, or combination of models, that a professional uses is based on the client's specific situation.

  • Review the article, "A Science of Connectedness." Stanga K.pdf
  • Consider which model or models of human services delivery might be utilized in effectively organizing health care via the "holarchy" of health care that is discussed.
  • Select two models of human services delivery (medical, public health, or human services) discussed in the readings to use for this Application. This may be based on which models resonate most with you, or which models are most applicable to the domain in which you would like to work.
  • Think about the characteristics of each model that you selected and how both could be integrated in real-world situations.

2–3 pages in APA format

  • Describe, in your own words, the two models of human services delivery you selected and why you chose each.
  • Then explain how the two models might be integrated in practice. Be specific and use examples to support your explanation.

WHAT I HAVE COME UP WITH

The Human Service Model- focuses on providing services (assistance with housing, anger management, medication management, mental health/substance abuse treatment, unemployment, ect.) to assists clients solve problems within the context of the environment.

I choose this model because I am familiar with this model’s characteristics. I use this model consistently in my professional position.

The Medical Model- treats clients individually for a diseases and illnesses using a symptom-diagnosis-treatment-cure system, and is the oldest treatment model.

I choose this model because similar to my first choice I am familiar with the practices of this model.  Most of my clients suffer from mental health illnesses such as PTSD, Schizophrenia, ADHD, or some type of Bipolar Disorder or Depression. With each of the clients battling one or multiple mental health issue they are prescribed Psychiatric prescriptions. It is my job to become familiar with each diagnosis, drug information, discuss the benefits and encourage clients to take them as prescribed, observe for side effects and behavior changes from the drugs either being too high in dosage or not at a therapeutic level, and able to answer any questions the clients may have about the medication because most often they don’t feel comfortable asking the prescribing doctor due to intimidation of a authority figure and not wanting to be classified uneducated.

The two models are integrated in practice because they both focus on treating the individual.


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ED I T O R I A L S decisions for nontraumatic complaints of arm, neck, and shoulder.9 In a poignant essay, Blevins reminds us that research is a valuable but distant source of knowledge. When it comes to clinical practice, patients remain our greatest teachers.10 To read or post commentaries in response to this article, see it online at http://www.annfammed.org/cgi/content/full/7/5/386. 4. Klein Woolthuis EP, de Grauw WJC, van Gerwen WHEM, et al. Yield of opportunistic targeted screening for type 2 diabetes in primary care: the Diabscreen study. Ann Fam Med. 2009;7(5):422-430. 5. Reuland DS, Cherrington A, Watkins GS, Bradford DW, Blanco RA, Gaynes BN. Diagnostic accuracy of Spanish language depressionscreening instruments. Ann Fam Med. 2009;7(5):455-462. 6. Lin EHB, Heckbert SR, Rutter CM, et al. Depression and increased mortality in diabetes: unexpected causes of death. Ann Fam Med. 2009;7(5):414-421. 7. Mainous AG III, Everett CJ, Post RE, Diaz VA, Hueston WJ. Availability of antibiotics for purchase without a prescription on the Internet. Ann Fam Med. 2009;7(5):431-435. References 8. Barnet B, Liu J, DeVoe M, Dugan AK, Gold MA. Motivational intervention to reduce rapid subsequent birth of adolescent mothers: a community-based randomized trial. Ann Fam Med. 2009;7(5):436-445. 1. Glazier RH, Agha MM, Moineddin R, Sibley LM. Universal health insurance and equity in primary care and specialist office visits: a population-based study. Ann Fam Med. 2009;7(5):396-405. 9. Feleus A, Bierma-Zeinstra SMA, Bernsen RMD, Miedema HS, Verhaar JAN, Koes BW. Management decisions in nontraumatic complaints of arm, neck, and shoulder in general practice. Ann Fam Med. 2009;7(5):446-454. 2. DeVoe JE, Tillotson CJ, Wallace LS. Children’s receipt of health care services and family health insurance patterns. Ann Fam Med. 2009;7(5):406-413. 3. Stange KC. A science of connectedness. Ann Fam Med. 2009;7(5): 387-395. 10. Blevins SM. Gazing at the future. Ann Fam Med. 2009;7(5):463-464. EDITORIAL A Science of Connectedness Kurt C. Stange, MD, PhD, Editor Ann Fam Med 2009;7:387-395. doi:10.1370/afm.990. H ow can health care reform approach the holy trinity of equitable access, controlled costs, and high value? How can the sweet spot be found in the midst of the politically charged and personally wrenching trade-offs? The sweet spot is where increasing access to health care creates a sense of commonality rather than division, where choices about the use of services are prioritized based on personalized knowledge rather than crude administrative rationing, and where cost control happens in ways that add value and diminish waste. Previously, this editorial series examined the problem of fragmentation,1 a generalist solution,2 and the paradox of primary care.3 This fourth piece in the series explores an integrated way of understanding how the components of health care can work together to balance access, cost, and quality. This framework is not so much a cookbook as a way of making sense of the current situation and a guidepost for traveling hopefully to a better future. ANNALS O F FAMILY MED ICINE ✦ CONNECTING THE PARTS AND THE WHOLES In the summer of 1968 in the Austrian mountain hamlet of Alpbach, author Arthur Koestler convened a scientific symposium intended to challenge “the insufficient emancipation of the life sciences from the mechanistic concepts of nineteenth-century physics and the resulting crudely reductionist philosophy.” 4(p2) The participants’ task then is highly relevant to health care today, which is stuck in a similarly old-fashioned worldview that does not fit the reality of how health is lost and created, and how the pieces of health care evolve together to create value. At the Alpbach Symposium, scientists from a variety of fields, including biologist Paul Weiss, biochemist Holger Hydén, developmental psychologists Jean Piaget and Bärbell Inhelder, psychopharmacologist Seymour Kety, humanist psychiatrist Viktor Frankl, evolutionary biologist C. H. Waddington, and the father of general systems theory, Ludwig von Bertalanffy, presented data from vastly diverse experiments and observational studies. The common thread—actually WWW.A N N FA MME D.O R G 387 ✦ VO L. 7, N O. 5 ✦ SE P T E MBE R /O CTO BE R 2009 ED I T O R I A L S more of a chain of evidence—was that biological and social phenomena, like molecular and physical occurrences, evolve as events with many degrees of freedom, but with “ordering restraints exerted upon them by the integral activity of the ‘whole’ in its patterned systems dynamics.” 5(9) Symposium participants described life in different ways—observations, scientific experiments, mathematical formulae. But they agreed on the concept that the phenomena of life (as well the physical world) are best understood as both parts and wholes. Koestler called these wholes that simultaneously are parts of other wholes holons.6 The world, be it atoms, cells, or social phenomena, is made up of holons. Holons are arranged in nested hierarchies that Koestler called holarchies. For example, subatomic particles are included in atoms, which are subsumed by molecules, which make up crystals, and so on. Each higher level transcends and includes the one below. A decade later, psychiatrist George Engel identified similar relationships in health care and health. Seeing that “all of medicine is in crisis” from “adherence to a model of disease no longer adequate for the scientific tasks and social responsibilities of either medicine or psychiatry,” 7(p129) Engel8 articulated a similar hierarchy to the one proposed at Alpbach. As displayed in Figure 1, each higher level in this holarchy (atom, molecule, organelle, cell, and on) transcends but includes the level below. More recently, understanding of complex adaptive systems has further evolved9-21 in ways that put the useful concepts of holons and holarchies into a richer context for understanding how health care can be improved. Ken Wilber has synthesized much of this evolved understanding,22,23 including the following principles24: • Reality is composed “of wholes that are simultaneously parts of other wholes, with no upward or downward limit.” • Holons can be understood both horizontally and vertically. At the horizontal level, they balance selfpreservation and adaptation, conserving themselves with time, while adjusting to other holons at their level. Vertically, they balance the possibility of selfdissolution to a lower level, and transcendency— becoming part of another holon—at a higher level. Extensive pathologies can appear when these balances are not right. • Emergent holons transcend but include their predecessors. As they do so, new properties emerge that are more than the sum of the properties that came before. Furthermore, each higher level of evolution produces greater depth (but smaller numbers of holons). Thus, lower level holons are more fundamental; higher levels are more evolved. ANNALS O F FAMILY MED ICINE ✦ Figure 1. Systems hierarchy (levels of organization). To view this figure, please see the print version of the September/ October Annals of Family Medicine, page 388. WWW.A N N FA MME D.O R G 388 ✦ VO L. 7, N O. 5 ✦ SE P T E MBE R /O CTO BE R 2009 ED I T O R I A L S • Holarchies coevolve with other holons and holarchies in their environment, but each level continues to depend on a network of relationships with other holons at the same level. • Evolution of holons moves toward greater differentiation, variety, complexity, and organization. How can these concepts help us understand the provision of high-value health care? As in any holarchy, there are other levels above and below. Levels lower than those depicted likely relate to instrumental factors (such as scheduling and record keeping) that enable health care. Higher levels likely relate to spiritual dimensions of care. The holons of health care in the 4 related levels in Figure 2 are described below. Fundamental Health Care Fundamental health care relates to addressing patient A HOLARCHY OF HEALTH CARE concerns, acute and chronic illnesses, prevention, and The components of health care, much as the phenomena mental health. The reasons patients seek health care of the natural world, also can be understood as both services have been empirically classified as desire for parts and wholes—as holons. The holons of health care, medical information, psychological assistance, therasuch as services, structures, and relationships, are more peutic listening, general health advice, and biomedical than isolated commodities to be delivered, bought, and treatment.25 Addressing the reasons for the visit obvisold. They are related to each other in observable ways ously is fundamental to meeting patients’ needs. that include hierarchies of holons, ie, holarchies. More than one-third of all outpatient visits26 and Figure 2 depicts 4 levels of health care, ranging nearly two-thirds of visits to family physicians27 are for from fundamental to healing and transcendence. The care of acute illness. In such specialties as dermatollower, more fundamental, holons in this holarchy enable ogy or cardiology, the top 6 diagnosis clusters account higher-order functions, such as integrating, prioritizing, for 70% to 90% of patient visits.28,29 In primary care, and personalizing. The higher-order functions of health reasons for visits are so diverse that only one-half can care transcend but include the lower—adding new be classified in the top 20 diagnosis clusters.27-29 Many emergent properties that build on, but are more than, of these acute illnesses are self-limited and thus require the sum of those below. medical care only to the degree to which they cause patient concern or have symptoms that the patient needs help Figure 2. Holarchy of health care. managing. Instrumentally, care of such conditions may be well Holarchy of Health Care managed by allied health professionals or in urgent care settings. What is not known is the degree to which providing acute illness care in a single medical home Abiding even when or with a personal clinician fosHealing and healing cannot Transcendence ters the trust and interpersonal be fostered relationships that are needed Fostering healing to fully perform higher-order health care functions. Balancing individual, family, community, and system needs Chronic illnesses account and opportunities for a substantial and growing Prioritized Care Iterating between biotechnical and biographical based on proportion of health care—37% deep knowledge of both and of all outpatient visits in the connections to others United States in 2006.26 This proportion is increasing subIntegrating care across acute and chronic illness, prevention, and mental health stantially as the population Integrated Care Management of multimorbidity ages and as behavioral risk factors and obesity increase the Psychosocial care prevalence of chronic diseases, Proactive management of chronic illness and prevention Fundamental such as diabetes, hypertension, Health Care Care of acute illness osteoarthritis, and cancer.30 PreManagement of patient concerns ventive care is the main focus of 19% of all outpatient visANNALS O F FAMILY MED ICINE ✦ WWW.A N N FA MME D.O R G 389 ✦ VO L. 7, N O. 5 ✦ SE P T E MBE R /O CTO BE R 2009 ED I T O R I A L S its,26 and in primary care, one-third of visits for illness involve preventive service delivery,31 often tailored to risk factors32-34 or teachable moments.35,36 Both chronic illness management and effective delivery of preventive services require a proactive approach and supportive systems that go beyond reacting to patient concerns and providing acute illness care.37 Thus, much current health care systems research and development is focused on increasing the ability of primary care to prevent and manage chronic illness.38,39 Recent efforts to control costs and increase quality by “carving out” mental health care have led to increasingly fragmented care.40,41 There are, however, great opportunities for both controlling costs and improving care and outcomes by integrating primary medical and mental health care.40,42-44 Psychosocial care also involves helping patients manage life events and the stresses and joys of daily living that do not cross the threshold to a mental health diagnosis.40,45 An ongoing patient-physician relationship developed over time can provide a basis for integrating mental and physical health care.46,47 Integrated Care Multimorbidity (the co-occurrence of multiple medical conditions) and comorbidity (the co-occurrence of conditions beyond a particular index condition)48 are seen in one-half of all outpatient visits.26 Multimorbidity, particularly common in the aging population49,50 is the rule rather than the exception among primary care patients,48-54 and the typical primary care visit addresses 3 to 4 problems.51,52 Most scientific evidence explicitly excludes people with comorbid conditions, however.49,53 Thus, because of limitations in the current scientific paradigm, the care of multiple conditions, particularly the care of whole people with multiple conditions, is relegated to the art rather than the science of medicine. Evidence-based guidelines are not helpful; in fact, they are potentially harmful for a large proportion of patients seen in primary care.49,53-55 Higher-level health care involves not only attending to multiple chronic medical conditions, but also requires the integration and personalized prioritization of care across acute and chronic illness, prevention, and mental health.2,3,56-58 Prioritized Care The ability to prioritize and integrate care based on an inclusive view and personal knowledge is a crucial primary care function that is only beginning to be recognized. Although recent research has begun to provide evidence on how preventive services can be prioritized at the level of the population,59 prioritization of care at the level of the person and across acute ANNALS O F FAMILY MED ICINE ✦ and chronic illness, prevention, and mental health has received scant attention in medical science.56 Prioritization and integration of care may help explain the paradox3 that primary care–based systems result in better population health and lower costs60,61 and higher (or similar) quality of care62 at lower cost,63,64 despite evidence that evidence-based guidelines are followed at lower rates. At the individual level, prioritization can involve protecting patients from overuse of tests with high false-positive rates that begin a cascade of interventions and procedures of marginal benefit.65 At the system level, prioritizing care may involve efficient care of families66,67 and use of equally effective but lower-cost treatments.68 Primary care benefits the individual and the health care system by balancing biotechnical and biographical care.69,70 This balance is a complex function that results in the personalized application of the best scientific evidence, tempered by the best evidence from personal context.71 Limiting resource use at the system level can only be done crudely, where it is widely seen as rationing. Selective use of resources, however, based on firstcontact access, a comprehensive whole-person family and community focus, care integration, and continuous relationships,72,73 results in prioritized care that protects patients from overtreatment.65 Personalized care that is prioritized based on knowledge of the person, family, and community rather than crude system-level rationing is most likely to enhance benefit to the person and the population. Healing and Transcendence Healing sometimes involves more than cure. It involves the transcendence of suffering.74-76 For optimal healing, clinicians must identify and develop knowledge of opportunities for cure, the values of the patient, connection with community, and possibilities for transcendence. Sometimes healing cannot be fostered. A difficult and important aspect of health care is to stick with the patient and family even when “success” is not forthcoming. This is a higher, noninstrumental level of caring. The healing and transcendence level of the holarchy of health care is particularly important during key moments in the life cycle, such as life-threatening illness or a major personal or family event. Death and dying45,77 in particular are poorly handled by the US health care system, both in terms of cost78 and human suffering.79,80 High-order healing functions can be fostered by specific short-term approaches to care81 and by longitudinal relationships and abiding over time.74-76 Patients particularly recognize the value of healing relationships when they include both going through a key event together and abiding over time.46,47 WWW.A N N FA MME D.O R G 390 ✦ VO L. 7, N O. 5 ✦ SE P T E MBE R /O CTO BE R 2009 ED I T O R I A L S Although much is made of the importance of medical professionalism,82,83 there is a role that surpasses that of clinician or even healer. This role involves being a friend, and when it is appropriate, it represents not a loss of professionalism as much as an expression of unselfish love that is the mark of the healer.2 APPLYING THE HOLARCHY OF HEALTH CARE A previous article in this series2 told the story of a patient, Jim Bauer. Jim received fundamental care over time, which enabled moving to the higher level of an integrated approach to diagnosis and treatment when he developed a complicated illness. The ongoing relationship helped difficult therapeutic decisions about treatment for 2 cancers and an aortic aneurysm to be prioritized in a way that was congruent with Jim’s values, avoided individual risk, and maximized value for the system. A temporary break in this relationship diminished the opportunity for healing and transcendence during the time immediately before his death. The therapeutic relationship, however, was resumed with the “hidden patient,” 45 Jim’s wife, Doris, who received care across the entire continuum of the holarchy of care. Understanding the holarchy of health care can help us organize health care more effectively. For example, if information systems, which currently function at the fundamental level, were expanded to include information on patient preferences and individual medical risks, reminder systems would better enable care integration, personalization, and prioritization across multiple illnesses and domains. Systems that balance convenience of access with enhancing access to a personal clinician and health care team during key transitions and life events could change health care from an isolated commodity into a relationship-centered continuum that maximizes integration, prioritization, and when needed, healing and transcendence. If we take seriously the need for time to develop person-focused relationships that are required for development up the health care holarchy, we would minimize the unhelpful distraction of disease-specific coding and incentives for fundamental primary care,84-86 reimbursing instead for accessibility, comprehensiveness, integration, and personalization functions that provide the added value of primary care.58,73,87 A holarchy-informed system would engage primary care clinicians as a first contact and an ongoing resource for integrating and prioritizing care, engaging specialty care selectively when it can be most effective.62,88-90 An effective system to enable individuals, families, and communities to evolve along the holarchy would have at least a 50-50 mix of generalists ANNALS O F FAMILY MED ICINE ✦ and specialists, rather than the current and worsening imbalance found in the United States. LIMITATIONS The holarchy of health care displayed in Figure 2 interacts with other holarchies and evolves with time. Thus, an accurate depiction of the holarchical system of health care needs to consider its interactions with other systems. The biological and social processes that cause health and illness (some of which are included in Figure 1) are an important factor in how health care works, just as economic and environmental systems affect both health care and health. In addition, the levels of the holarchy of health care proceed to both higher and lower levels of development beyond those levels that are shown. Higher levels likely involve spiritual dimensions. Lower levels likely involve factors that enable fundamental health care. A full depiction of these multiple holons, interactions, and levels defies simple visual representation. Further, although the holarchy hypothesized here meets most of Wilber’s tenets,24 it is not clear that destroying lower holons would obliterate all of the holons above. It may be possible to provide abiding, transcendent health care without addressing all of the lower levels of care. A similar critique has been leveled against Maslow’s hierarchy of need,91, 92 namely, that higher levels sometimes are possible without having achieved the lower levels.93 This limitation likely results from the coevolution of this holarchy with other related holons and hierarchies that are not depicted. Thus, the holarchy of health care depicted here is a simplification of the true complexity of effective levels of health care. Recognizing these additional interactions, however, does not negate the simple usefulness of understanding that phenomena in health care and the natural world are both parts and wholes (holons), and that hierarchies of these holons (holarchies) can be recognized. Recognizing the interaction of these and other holons and holarchies can help explain surprises94,95 and reconcile silos of understanding that misrepresent the world in ways that block advancement. For example, Glass and McAtee recently have used systems concepts and their evolution to try to reconcile the fields of sociobehavioral science and public health.96 Others have called for both vertical and horizontal integration to achieve high-value health care.97-101 IMPLICATIONS The holarchy presented here leads to a number of useful implications and hypotheses for understanding the WWW.A N N FA MME D.O R G 391 ✦ VO L. 7, N O. 5 ✦ SE P T E MBE R /O CTO BE R 2009 ED I T O R I A L S nature of health care and for organizing and improving care. • Since the phenomena of health care and health are context dependent, it is helpful to understand their nature as holons—part/wholes that are simultaneously part of other wholes that coevolve over time. • Understanding the components of health care as related holons rather than isolated commodities can help us to develop systems that foster care which is more relationship centered, less fragmented, and of greater value. • Lower-level tasks, done faithfully over time, can build relationships that enable higher-level tasks. • Higher-level tasks in the holarchy provide an important frame and boundary for lower-level tasks. Lower-level tasks set the possibilities from which higher-order health care holons can emerge.65 • Even within levels of the health care holarchy, integration is possible and desirable, eg, at the fundamental level, integrating mental health with other basic care rather than carving it out. • With most current crude quality assessment tools and information systems, we know how to measure only the fundamental holons of health care.102 • Measuring and incentivizing only the lowest level of the holarchy may unintentionally disincentivize and block progression toward higher levels. • Even though the higher level tasks are less instrumental and therefore less easily specified, they could be enabled by systems and information technology (IT). For example, IT could prioritize prompts based on epidemiological data, thus using the fundamental care level to enable the integrated care level. IT could prioritize prompts based on information on patient preferences and societal costs or benefits, thus enabling the next level of prioritized care. IT could provide a mechanism for ongoing self-reflection about patients’ evolving preferences, thus moving from our current static approach to living wills to an evolutionary approach that better reflects the reality of how patient’s preferences work, and preventing us from getting locked into health care approaches that push technology in the final days of life way beyond what people want, and that drain our coffers with unwanted, unneeded, unhelpful, and sometimes cruel care that is done to people rather than provided in partnership with them. • Care organized to foster development along the holarchy may help to reframe health as more than the absence of disease,103 but as a foundation for achievement,104 and as relationships and the meaning derived from them.105,106 • Primary care often is thought to be simple; however, the holarchy of health care reveals increasing ANNALS O F FAMILY MED ICINE ✦ complexity. Lower-order functions are the building blocks that develop the relationships necessary to accomplish higher-order functions. Lower-order functions relate to managing individual problems based on various kinds of evidence. Higher-order functions involve more sophisticated prioritizing, personalizing, integrating, and abiding. • Although current incentives and systems often obstruct development toward the higher levels in the holarchy of health care, high-quality primary care need not be limited to fundamental functions; with support it can incorporate the higher levels of integrating and prioritizing and thereby foster healing. • Knowing this holarchy can help in the design of flexible, personalized health care delivery systems that foster the most developed care necessary for a given situation while providing cost-effective simple care when appropriate. • Both specialist and generalist approaches are needed for effective health care. The broader scope of generalists can help focus the more narrowly construed work of specialists. • Ongoing care based on understanding and acting on this holarchical organization of health care is likely to lead to lower costs, less waste, greater personalization, greater effectiveness, and greater value in health care. • Understanding and acting on this holarchy may lead to less emphasis on health care and more emphasis on related holarchies of health and the social determinants of health107 that are not about the health care industry. • Understanding and acting on this holarchy is likely to lead to health care that involves greater caring, and serves as a force for greater personal development and interpersonal and societal solidarity. JOIN THE EXCHANGE OF IDEAS We invite readers from diverse fields to comment on and provide examples that challenge or support the concept of holons and the holarchical organization of physical, biological, and social systems. We encourage readers to consider and comment on the implications of this knowledge for understanding and improving health care and health. Please join the discussion at: http://www.AnnFamMed.org. To read or post commentaries in response to this article, see it online at http://www.annfammed.org/cgi/content/full/7/5/387. Key words: Systems theory; models, theoretical; delivery of health care; primary health care Funding support: Dr Stange is supported in part by a Clinical Research Professorship from the American Cancer Society. WWW.A N N FA MME D.O R G 392 ✦ VO L. 7, N O. 5 ✦ SE P T E MBE R /O CTO BE R 2009 ED I T O R I A L S Acknowledgments: Paul Thomas and William Miller provided substantial input on earlier drafts of this manuscript. I regret that I was not able to fully incorporate their important ideas on this topic. Robin Gotler, Robert Phillips, Andrew Bazemore, Martey Dodoo, Frank deGruy, Larry Green also provided helpful comments. 25. Like R, Zyzanski SJ. Patient requests in family practice: a focal point for clinical negotiations. Fam Pract. 1986;3(4):216-228. References 26. Cherry DK, Hing E, Woodwell DA, Rechsteiner EA. National Ambulatory Medical Care Survey: 2006 Summary. Hyattsville, MD: National Center for Health Statistics; 2008. 1. Stange KC. The problem of fragmentation and the need for integrative solutions. Ann Fam Med. 2009;7(2):100-103. 24. Wilber K. The pattern that connects. In: Sex, Ecology, Spirituality: The Spirit of Evolution. Boston, MA: Shambala Publications; 1995:40-85. 27. Stange KC, Zyzanski SJ, Jaén CR, et al. Illuminating the ’black box’. A description of 4454 patient visits to 138 family physicians. J Fam Pract. 1998;46(5):377-389. 2. Stange KC. The generalist approach. Ann Fam Med. 2009;7(3): 198-203. 28. Schneeweiss R, Cherkin DC, Hart LG, et al. Diagnosis clusters adapted for ICD-9-CM and ICH-2. J Fam Pract. 1986;22(1):69-72. 3. Stange KC, Ferrer RL. The paradox of primary care. Ann Fam Med. 2009;7(4):293-299. 29. Schneeweiss R, Rosenblatt RA, Cherkin DC, Kirkwood CR, Hart G. Diagnosis clusters: a new tool for analyzing the content of ambulatory medical care. Med Care. 1983;21(1):105-122. 4. Koestler A, Smythies JR, eds. Beyond Reductionism: New Perspectives on the Life Sciences. Boston, MA: Houghton Mifflin Co; 1971. 5. Weiss PA. The living system: determinism stratified. In: Koestler A, Smythies JR, eds. Beyond Reductionism: New Perspectives on the Life Sciences. New York, NY: Beacon Press; 1969. 6. Koessler A. The Ghost in the Machine. New York, NY: The Macmillan Company; 1967. 7. Engel GL. The need for a new medical model: a challenge for biomedicine. Science. 1977;196(4286):129-136. 8. Engel GL. The clinical application of the biopsychosocial model. Am J Psychiatry. 1980;137:535-544. 9. Stacey RD. Complexity and Creativity in Organizations. San Francisco, CA: Berrett-Koehler Publishers; 1996. 10. Goldberger AL. Non-linear dynamics for clinicians: chaos theory, fractals, and complexity at the bedside. Lancet. 1996;347(9011): 1312-1314. 30. Mokdad AH, Marks JS, Stroup DF, Gerberding JL. Actual causes of death in the United States, 2000. JAMA. 2004;291(10):1238-1245. 31. Stange KC, Flocke SA, Goodwin MA. Opportunistic preventive services delivery. Are time limitations and patient satisfaction barriers? J Fam Pract. 1998;46(5):419-424. 32. Jaén CR, Crabtree BF, Zyzanski SJ, Goodwin MA, Stange KC. Making time for tobacco cessation counseling. J Fam Pract. 1998;46(5): 425-428. 33. Podl TR, Goodwin MA, Kikano GE, Stange KC. Direct observation of exercise counseling in community family practice. Am J Prev Med. 1999;17:207-210. 34. Eaton CB, Goodwin MA, Stange KC. Direct observation of nutrition counseling in community family practice. Am J Prev Med. 2002;23:174-179. 35. Flocke SA, Stange KC, Goodwin MA. Patient and visit characteristics associated with opportunistic preventive services delivery. J Fam Pract. 1998;47:202-208. 11. Griffiths F, Byrne D. General practice and the new science emerging from the theories of ’chaos’ and complexity. Br J Gen Pract. 1998;48(435):1697-1699. 36. Lawson PJ, Flocke SA. Teachable moments for health behavior change: a concept analysis. Patient Educ Couns. 2009;76:25-30. 12. Zimmerman B, Lindberg C, Plsek P. Edgeware: Insights From Complexity Science for Health Care Leaders. Irving, TX: VHA, Inc; 1998. 37. Glasgow RE, Orleans CT, Wagner EH. Does the chronic care model serve also as a template for improving prevention? Milbank Q. 2001;79:579-612. 13. Miller WL, McDaniel RR, Jr, Crabtree BF, Stange KC. Practice jazz: Understanding variation in family practices using complexity science. J Fam Pract. 2001;50(10):872-878. 38. Wagner EH, Austin BT, Von Korff M. Organizing care for patients with chronic illness. Milbank Q. 1996;74:511-544. 14. Sturmberg JP. Systems and complexity thinking in general practice. Part 2: application in primary care research. Aust Fam Physician. 2007;36(4):273-275. 39. Wagner EH, Glasgow RE, Davis C, et al. Quality improvement in chronic illness care: a collaborative approach. Jt Comm J Qual Improv. 2001;27:63-80. 15. Sweeney K, Griffiths F, eds. Complexity and Healthcare: An Introduction. Abingdon, UK: Radcliffe Medical Press; 2002. 40. deGruy F. Mental health care in the primary care setting. In: Donaldson MS, Yordy KD, Lohr KN, Vanselow NA, eds. Primary Care: America’s Health in a New Era. Washington, DC: National Academy Press; 1996:285-311. 16. Holt TA, ed. Complexity for Clinicians. San Francisco, CA: Radcliffe; 2004. 17. Borrell-Carrio F, Suchman AL, Epstein RM. The biopsychosocial model 25 years later: principles, practice, and scientific inquiry. Ann Fam Med. 2004;2(6):576-582. 41. Nease DE, Jr., Aikens JE, Schwenk TL. Mental health disorders and their descriptive criteria in primary care: clarifying or confounding? Primary Care Companion J Clin Psychiatry. 2005;7:89-90. 18. Berkes F, Colding J, Folke C. Navigating Social-Ecological Systems: Building Resilience for Complexity And Change. Cambridge, MA: Cambridge University Press; 2008. 42. Bower P, Gilbody S, Richards D, Fletcher J, Sutton A. Collaborative care for depression in primary care—making sense of a complex intervention: systematic review and meta-regression. Br J Psychiatry. 2006;189:484-493. 19. Wilson T, Holt T, Greenhalgh T. Complexity science: complexity and clinical care. BMJ. 2001;323(7314):685-688. 20. Plsek PE, Greenhalgh T. Complexity science: The challenge of complexity in health care. BMJ. 2001;323(7313):625-628. 21. Sturmberg JP. Systems and complexity thinking in general practice: part 1—clinical application. Aust Fam Physician. 2007;36(4):170-173. 43. Bower P, Rowland N. Effectiveness and cost effectiveness of counselling in primary care. Cochrane Database Syst Rev. 2006;3: CD001025. 22. Wilber K. Sex, Ecology, Spirituality: The Spirit of Evolution. Boston, MA: Shambhala Publications; 1995. 44. Harkness EF, Bower PJ. On-site mental health workers delivering psychological therapy and psychosocial interventions to patients in primary care: effects on the professional practice of primary care providers. Cochrane Database Sys. Rev. 2009;21(1):CD000532. 23. Wilber K. The Integral Vision. Boston, MA: Shambhala Publications; 2007. 45. Medalie JH. Family Medicine: Principles and Applications. Baltimore, MD: Williams & Wilkins; 1978. ANNALS O F FAMILY MED ICINE ✦ WWW.A N N FA MME D.O R G 393 ✦ VO L. 7, N O. 5 ✦ SE P T E MBE R /O CTO BE R 2009 ED I T O R I A L S 46. Mainous AG, III, Goodwin MA, Stange KC. Patient-physician shared experiences and value patients place on continuity of care. Ann Fam Med. 2004;2(5):452-454. 68. Hoffman A, Pearson SD. ‘Marginal medicine’: targeting comparative effectiveness research to reduce waste. Health Aff (Millwood). 2009;28(4):w710-w718. 47. Nutting PA, Goodwin MA, Flocke SA, Zyzanski SJ, Stange KC. Continuity of primary care: to whom does it matter and when? Ann Fam Med. 2003;1(3):149-155. 69. Gunn J, Naccarella L, Palmer V, Kokanovic R, Pope C, Lathlean J. What is the Place of Generalism in the 2020 Primary health care team? Australian Primary Health Care Research Institute. 2008. http://www.anu.edu.au/aphcri/Domain/Workforce/Perkins_25_ final.pdf. Accessed Jan 12, 2009. 48. Valderas JM, Starfield B, Sibbald B, Salisbury C, Roland M. Defining comorbidity: implications for understanding health and health services. Ann Fam Med. 2009;7(4):357-363. 70. Heath I, Sweeney K. Medical generalists: connecting the map and the territory. BMJ. 2005;331(7530):1462-1464. 49. Tinetti ME, Bogardus ST, Jr., Agostini JV. Potential pitfalls of disease-specific guidelines for patients with multiple conditions. N Eng. J Med. 2004;351(27):2870-2874. 71. Weiner SJ. Contextualizing medical decisions to individualize care: lessons from the qualitative sciences. J Gen Intern Med. 2004; 19(3):281-285. 50. Fortin M, Bravo G, Hudon C, Vanasse A, Lapointe L. Prevalence of multimorbidity among adults seen in family practice. Ann Fam Med. 2005;3(3):223-228. 72. Starfield B. Primary Care: Balancing Health Needs, Services, and Technology. Rev ed. New York, NY: Oxford University Press; 1998. 51. Beasley JW, Hankey TH, Erickson R, et al. How many problems do family physicians manage at each encounter? A WReN study. Ann Fam Med. 2004;2(5):405-410. 73. Donaldson MS, Yordy KD, Lohr KN, Vanselow NA, eds. Primary Care: America’s Health in a New Era. Washington, DC: National Academy Press; 1996. 52. Flocke SA, Frank SH, Wenger DA. Addressing multiple problems in the family practice office visit. J Fam Pract. 2001;50(30:211-216. 74. Egnew TR. The meaning of healing: transcending suffering. Ann Fam Med. 2005;3(3):255-262. 53. Fortin M, Dionne J, Pinho G, Gignac J, Almirall J, Lapointe L. Randomized controlled trials: do they have external validity for patients with multiple comorbidities? Ann Fam Med. 2006;4(2):104-108. 75. Egnew TR. Suffering, meaning, and healing: challenges of contemporary medicine. Ann Fam Med. 2009;7(2):170-175. 54. Nutting PA. Why can’t clinical policies be relevant to practice? J Fam Pract. 1997;44(4):350-352. 76. Scott JG, Cohen D, Dicicco-Bloom B, Miller WL, Stange KC, Crabtree BF. Understanding healing relationships in primary care. Ann Fam Med. 2008;6(4):315-322. 55. Schwenk TL. Competing priorities and comorbidities. So much to do and so little time. Arch Fam Med. 1997;6(3):238-239. 77. Farber SJ, Egnew TR, Herman-Bertsch JL. Defining effective clinician roles in end-of-life care. J Fam Pract. 2002;51(2):153-158. 56. Woolf SH, Stange KC. A sense of priorities for the health care commons. Am J Prev Med. 2006;31(1):99-102. 78. Scitovsky AA. “The high cost of dying”: what do the data show? 1984. Milbank Q. 2005;83(4):825-841. 57. Stange KC. The paradox of the parts and the whole in understanding and improving general practice. Int J Qual Health Care. 2002;14(4):267-268. 79. Fisher ES, Wennberg DE, Stukel TA, Gottlieb DJ, Lucas FL, Pinder EL. The implications of regional variations in Medicare spending. Part 2: health outcomes and satisfaction with care. Ann Intern Med. 2003;138(4):288-298. 58. Stange KC, Jaén CR, Flocke SA, Miller WL, Crabtree BF, Zyzanski SJ. The value of a family physician. J Fam Pract. 1998;46(5):363-368. 80. Fisher ES, Wennberg DE, Stukel TA, Gottlieb DJ, Lucas FL, Pinder EL. The implications of regional variations in Medicare spending. Part 1: the content, quality, and accessibility of care. Ann Intern Med. 2003;138(4):273-287. 59. Maciosek MV, Coffield AB, Edwards NM, Flottemesch TJ, Goodman MJ, Solberg LI. Priorities among effective clinical preventive services: results of a systematic review and analysis. Am J Prev Med. 2006;31(1):52-61. 81. Epstein RM, Fiscella K, Lesser C, Stange KC. Defining and achieving patient-centered care: the role of clinicians, patients and healthcare systems. Health Aff (Millwood). In press. 60. Starfield B. Primary care and health: A cross-national comparison. JAMA. 1991;266(16):2268-2271. 82. McCullough LB. The physician’s virtues and legitimate selfinterest in the patient-physician contract. Mt Sinai J Med. 1993; 60(1):11-14. 61. Starfield B, Shi L, Macinko J. Contribution of primary care to health systems and health. Milbank Q. 2005;83(3):457-502. 62. Baicker K, Chandra A. Medicare spending, the physician workforce, and beneficiaries’ quality of care. Health Aff (Millwood). 2004;Suppl Web Exclusives:W184-W197. 83. Sox HC; ABIM Foundation. American Board of Internal Medicine; ACP-ASIM Foundation. American College of Physicians-American Society of Internal Medicine; European Federation of Internal Medicine. Medical professionalism in the new millennium: a physician charter. Ann Intern Med. 2002;136(3):243-246. 63. Greenfield S, Nelson EC, Zubkoff M, et al. Variations in resource utilization among medical specialties and systems of care. Results from the medical outcomes study. JAMA. 1992;267(12):1624-1630. 84. Sandy LG, Schroeder SA. Primary care in a new era: disillusion and dissolution? Ann Intern Med. 2003;138(3):262-267. 64. Greenfield S, Rogers W, Mangotich M, Carney MF, Tarlov AR. Outcomes of patients with hypertension and non-insulindependent diabetes mellitus treated by different systems and specialties: results from the medical outcomes study. JAMA. 1995;274(18):1436-1444. 85. Davis K, Schoenbaum SC, Audet AM. A 2020 vision of patient-centered primary care. J Gen Intern Med. 2005;20(10):953-957. 86. Davis K. Paying for care episodes and care coordination. N Engl J Med. 2007;356(11):1166-1168. 65. Franks P, Clancy CM, Nutting PA. Gatekeeping revisited—protecting patients from overtreatment. N Engl J Med. 1992;327(6):424-429. 87. Starfield B, Shi LY, Macinko J. Contribution of primary care to health systems and health. Milbank Q. 2005;83(3):457-502. 66. Flocke SA, Goodwin MA, Stange KC. The effect of a secondary patient on the family practice visit. J Fam Pract. 1998;46(5):429-434. 88. Starfield B, Lemke KW, Bernhardt T, Foldes SS, Forrest CB, Weiner JP. Comorbidity: implications for the importance of primary care in ‘case’ management. Ann Fam Med. 2003;1(1):8-14. 67. Orzano AJ, Gregory PM, Nutting PA, Werner JJ, Flocke SA, Stange KC. Care of the secondary patient in family practice. A report from the Ambulatory Sentinel Practice Network. J Fam Pract. 2001;50(2):113-116. ANNALS O F FAMILY MED ICINE ✦ 89. Starfield B, Lemke KW, Herbert R, Pavlovich WD, Anderson G. Comorbidity and the use of primary care and specialist care in the elderly. Ann Fam Med. 2005;3(3):215-222. WWW.A N N FA MME D.O R G 394 ✦ VO L. 7, N O. 5 ✦ SE P T E MBE R /O CTO BE R 2009 ED I T O R I A L S 99. Stange KC. Polyclinics must integrate health care vertically AND horizontally. Lond J Prim Care. 2008;1:42-44. 90. Starfield B, Shi L, Grover A, Macinko J. The effects of specialist supply on populations’ health: assessing the evidence. Health Aff (Millwood). 2005;(Suppl Web Exclusives):W5-97-W95-107. 100. Thomas P, Meads G, Moustafa A, Nazareth I, Stange KC. Combined vertical and horizontal integration of health care—a goal of practice based commissioning. Qual Prim Care. 2008;16(6):425-432. 91. Maslow A, ed. Motivation and Personality. New York, NY: Harper; 1954. 101. Lawn JE, Rohde J, Rifkin S, Were M, Paul VK, Chopra M. Alma-Ata 30 years on: revolutionary, relevant, and time to revitalise. Lancet. 2008;372(9642):917-927. 92. Maslow A. The Farther Reaches of Human Nature. New York, NY: Viking Press; 1971. 93. Wahba A, Bridgewell L. Maslow reconsidered: A review of research on the need hierarchy theory. Organ Behav Hum Perform. 1976;14:212-240. 102. Stange KC, Nutting PA, Miller WL, et al. Definging and measuring the patient-centered medical home. J Gen Intern Med. In press. 103. Declaration of Alma-Ata. International conference on primary health care, Alma-Ata, USSR, 6-12 September 1978. 1978. http:// www.who.int/hpr/NPH/docs/declaration_almaata.pdf, Accessed Sept 26, 2008. 94. McDaniel RR Jr, Jordan ME, Fleeman BF. Surprise, Surprise, Surprise! A complexity science view of the unexpected. Health Care Manage Rev. 2003;28(3):266-278. 95. Crabtree BF. Primary care practices are full of surprises! Health Care Manage Rev. 2003;28(3):279-283, discussion 289-290. 96. Glass TA, McAtee MJ. Behavioral science at the crossroads in public health: extending horizons, envisioning the future. Soc Sci Med. 2006;62(7):1650-1671. 104. Seedhouse D. Health: The Foundations for Achievement. 2nd ed. New York, NY: Wiley; 2001. 105. Berry W. Life Is a Miracle: An Essay Against Modern Superstition. Washington, DC: Counterpoint; 2000. 97. Van der Geest S, Speckmann JD, Streefland PH. Primary health care in a multi-level perspective: towards a research agenda. Soc Sci Med. 1990;30(9):1025-1034. 106. Fine M, Peters JW. The Nature of Health: How America Lost, and Can Regain, A Basic Human Value. Abingdon, Oxfordshire: Radcliffe Publishing Limited; 2007. 98. De Maeseneer J, van Weel C, Egilman D, Mfenyana K, Kaufman A, Sewankambo N. Strengthening primary care: addressing the disparity between vertical and horizontal investment. Br J Gen Pract. 2008;58(546):3-4. 107. World Health Organization. Commission on Social Determinants of Health—Final Report. 2008. http://www.who.int/social_determinants/final_report/en/index.html. Accessed January 30, 2009. ANNALS O F FAMILY MED ICINE ✦ WWW.A N N FA MME D.O R G 395 ✦ VO L. 7, N O. 5 ✦ SE P T E MBE R /O CTO BE R 2009
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