Table 3.

Implications for Primary Care Practice and Policy

Implications for primary care practice teams

Identification of patients at high risk for hospitalization for ACSCs by complementing predictive modeling with assessment of patients’ social situation, medication adherence, and self-management capabilities

Regular medication review (what medication is taken and how?), easy-to-read medication schedules, and shared treatment plan among patients, caregivers, and physicians to improve adherence

Regular (telephone-) monitoring of symptoms and treatment adherence in high-risk patients

Self-management training of patients and caregivers (eg, should enable them to manage acute deterioration or to seek timely help of primary care resources)

Identification of existing social support systems (eg, family, friends, neighbors) and community resources

Health technology systems (eg, recall system for monitoring, updated links to community resources and ambulatory services, shared medical records between primary care practices and hospitals/after-hours care)

Enhanced communication between physicians across sectors (eg, treating physicians and external physicians in after-hours care, admission and discharge management, easy access to colleagues to ask for advice in case of diagnostic uncertainty)

Implication for policy and management

Accountability for hospitalization is shared across all sectors, including primary care, secondary care, hospitals, communities, and patients

Hospitalizations for ACSCs do not automatically reflect poor quality of care and should be measured either on a highly aggregated level (large geographic areas) or with sufficient adjustment for its complex causality

Selection of defined ACSCs that may in future be refined to primary care–sensitive conditions based on evidence rather than expert view

Communication skills including cultural-sensitive medicine may be emphasized in physician education and training

ACSC=ambulatory care–sensitive condition.