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INTRODUCTION

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Dr Jones knocked on the exam room door, where her last patient of the day awaited her. “Enter,” a voice said within. She did and found Mr White assembling his medication bottles on the desk to his right. Dr Jones met Mr White 7 years ago when she was an internal medicine resident rotating on the inpatient cardiology service. She became his primary care physician after that first hospitalization, but until recently, she rarely felt that she added any value to his well-being.

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“How are you today, Mr White?” she asked, sitting next to him at the desk. “I am happy to report that I have just one concern!” he replied. He looked well. His bare ankles were slim, not swollen, and he spoke without needing to take a breath between every couple of words—a vast improvement from prior visits.

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In the early days of their relationship, Mr White had spent nearly as much time in the hospital as he did at home. His heart failure and its episodic exacerbations were his identity: swollen legs and shortness of breath tethered him to a hospital bed when he missed a day’s pills or ate too much salt. Dr Jones tried desperately to help him, but years of rushed visits and occasional phone calls did little to keep him out of the hospital. The helplessness she had felt frustrated her and her colleagues; most chose to become specialists rather than stay in primary care.

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The frustrations ended when Dr Jones’ clinic went through a transformation. Inspired by a new model of primary care—the “patient-centered medical home”—the clinic management reorganized the practice to facilitate team-based care, better access, and more contact with patients between visits. The days of delivering care through 15-minute appointments spaced out over months were over. Dr Jones and her team—a nurse, medical assistant, and clerk—began meeting weekly to figure out the best way to improve the well-being of the entire group of patients assigned to her team.

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Mr White was a special case, given how often he was hospitalized. The team decided that he needed weekly phone calls from someone with time to ensure that he knew exactly how to take each of his medications and their purpose. Malik, the team’s medical assistant who was also trained as a “health coach,” used protected time each week to call Mr White. Each week, they would discuss Mr White’s symptoms, medications, and anything else that came up. Within weeks, the intervention was successful: Mr White was able to adhere to his diet and medications and no longer required stints in the hospital. Malik calls Mr White weekly to this day.

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“Well then,” Dr Jones said, “Let’s spend this visit discussing what matters to you.”

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Robust primary care is critical to any healthcare system delivering high-value care. In systems with greater numbers of primary care providers, ...

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