Levels of Healthcare

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Original Editors - Kirenga Bamurange Liliane and Naomi O'Reilly and ReLAB-HS

Top Contributors - Naomi O'Reilly, Chelsea Mclene, Tarina van der Stockt, Kim Jackson, Oyemi Sillo and Lucinda hampton      

Introduction

Within the broader health system there are various levels or domains of health care practice. They are often described as a pyramidal structure, with three or sometimes four tiers of health care representing increasing degrees of specialisation and technical sophistication, generally with increasing costs of care. The greatest number of patients are seen at the first level of primary care that is typically their first contact with the health-care system, with diminishing numbers of patients seen as they are filtered out of this first level into higher levels of specialised care at secondary, tertiary and now even quaternary care.

Primary, secondary, tertiary and quaternary care refer to the complexity and severity of health challenges that are addressed, as well as the nature of the patient-provider relationship. The healthcare providers who are part of these four levels of healthcare, together provide medical services such as evaluation, diagnostics, provision of treatment or onward referrals to the next level of care based on the specific health needs.

Primary Care

Primary health care is a people-centred rather than disease-centred service that addresses the majority of a person’s health needs throughout their lifetime including physical, mental and social well-being. Primary care is generally the first level of care that patients receive when they have medical concerns or needs, and takes a whole-of-society approach that includes health promotion, disease prevention, treatment, rehabilitation and palliative care. In most cases for patients this means being seen by a primary care physician, also called a general practitioner or family physician, although first contact care can also occur across a wide range of other health care professionals including a pharmacist, physiotherapist, speech and language therapist, etc depending on the specific health care system within your country. In many parts of the world, particularly in developing countries, people may currently access their first-contact care, where available at all, from non-medically personnel; who may have received some basic training in health promotion.

As health care systems attempt to meet the needs of populations living longer and with more complex health needs, and with health service delivery being shifted to the community, there has been an increasing emphasis on primary health care and it is generally recognised as the part of the health system that people use most and may be provided by a wide range of health care professionals. Continuity of care is a key characteristic of primary care, as patients usually prefer to consult the same practitioner for routine check-ups and preventive care, health education, and every time they require an initial consultation about a new health problem. So in many cases the relationship between the patient and provider can often occur over a long period of time in primary health care versus secondary and tertiary care settings, with providers often following a patient’s development and medical history for several years and sometimes most of their lifetime.

A primary care practitioner must possess a wide breadth of knowledge in many areas given that primary care involves the widest scope of health care, including patients of all ages, all socioeconomic and geographic origins, as well as patients seeking to maintain optimal health, and patients with all types of acute and chronic physical, mental and social health issues, including multiple chronic diseases. A primary healthcare service may diagnose and treat common health conditions within their area of expertise and have the ability to assess the urgency of the condition and refer the patient to other medical specialists where needed. Studies have shown that primary care providers benefit the healthcare system as a whole by offering enhanced access to healthcare services, better health outcomes, which tend to lead to a decrease use of emergency department visits and hospitalisation.

The World Health Organization attributes the provision of essential primary care as an integral component of an inclusive primary health care strategy and suggests that a primary care approach should include the following three components:

• meeting people’s health needs throughout their lives;
• addressing the broader determinants of health through multisectoral policy and action; and
• empowering individuals, families and communities to take charge of their own health.

Settings for Primary Care

Primary care is also delivered in outpatient settings, as the low-level care and consultations provided to patients do not require hospitalisation. Primary care is provided at a doctor’s office, health center or Urgent Care center. The Emergency Room is also often a source of primary care for the un- or under-insured.

Benefits of Rehabilitation in Primary Care

Primary health care is where the diagnosis of a large majority of health conditions, the identification of problems in functioning, and referral to other service delivery platforms need to occur.  The following benefits can be listed among others:

• Better quality of life.
• Reduction of the prevalence and minimization of the disabling effects of chronic conditions among adults and children.
• Facilitation of the continuity of care that supports full recovery.
• Helps to lessen the risk of preventable complications and secondary conditions.
• It can also help to avoid costly hospitalizations and re-admissions

Early access to rehabilitation through integration in primary health care helps to optimize outcomes, mitigate disability and improve people’s ability to live independent lives. WHO’s emphasis on universal health coverage and its recent launch of the Rehabilitation 2030 Call for Action are encouraging steps towards the goal of strengthening rehabilitation within the health system and in particular within primary health care.

Secondary Care

When your primary care provider refers you to a specialist, you are then in secondary care. Secondary care simply means you will be taken care of by someone who has more specific expertise about your condition.

Secondary care is more specialized and focuses on helping patients who are struggling with more severe or complex health conditions requiring the support of a specialist. Secondary care is typically delivered in inpatient settings, and is best defined as care for patients who require intensive specialist care but whose vital signs are stable. Examples of medical situations needing secondary care services include cancer treatment, medical care for pneumonia and other severe and sudden infections, and care for broken bones. Adult gerontology acute care nurse practitioners, adult acute care nurse practitioners, and pediatric acute care nurse practitioners tend to work in these settings; however, certified primary care nurse practitioners can also work in secondary care settings depending on their previous work experiences, the regulations in their state, and the specific needs of their employer.

Medical specialists and other health professionals, who typically don’t have initial contact with patients, provide secondary care. For example, a primary care physician might refer a patient to a cardiologist, rheumatologist, or a urologist or other specialty physician. Some secondary care physicians do not require a patient to have a referral from a primary care practitioner.

Another category of secondary care is hospital care, or acute care. The term covers care as an admitted patient in a hospital, a visit to a hospital ER, attendance in childbirth, medical imaging (radiology) services and care within an intensive care unit.

Physical therapists, respiratory therapists, speech therapists, occupational therapists and other allied health professionals often work in secondary care.

S.econdary Health Care is the specialist treatment and support provided by doctors and other health professionals for patients who have been referred to them for specific expert care, most often provided in hospitals. Secondary care services are usually based in a hospital or clinic, though some services may be community based. They may include planned operations, specialist clinics such as cardiology or renal clinics, or rehabilitation services such as physiotherapy. Secondary healthcare includes a wide range of specialists such as psychiatrists, cardiologists, obstetricians, dermatologists, pediatricians and gynecologists.

• Secondary Healthcare includes specialists such as cardiologists, dermatologists, urologists and other specialists.
• Individuals reach out to the secondary medical care providers through the referral of the primary healthcare professionals.
• In few countries, the individuals cannot consult the specialists without the referral of the medical practitioner at the primary care level.
• The secondary healthcare providers act as a liaison between the patient and the advanced medical care.

Tertiary Care

Tertiary care, is a level above secondary health care, that has been defined as highly specialised medical care, usually provided over an extended period of time, that involves advanced and complex diagnostics, procedures and treatments performed by medical specialists in state-of-the-art facilities . As such Consultants in tertiary care centres have access to more specialised equipment and expertise.

Tertiary care can be available either at a Regional or National level, dependant on the size and resources available in the country. Aa a result most people may have to travel to reach a tertiary care centre, which may result in delayed diagnosis and treatment and increase the costs for health care. Referral for tertiary care services can come from both primary and secondary care health professionals and care is generally provided as an inpatient based service, although there are elements of care that can also be performed on an outpatient basis.

Examples of tertiary care services include specialist cancer management, neurosurgery, cardiac surgery, transplant services, plastic surgery, treatment for severe burns, advanced neonatology services, palliative, and other complex medical and surgical interventions.

• This is the care comes into the picture as a referral to patients by the primary and healthcare providers.
• The individuals may require advanced medical procedures such as major surgeries, transplants, replacements and long-term medical care management for diseases such as cancer, neurological disorders.
• The specialized consultive medical care is the highest forms of healthcare practices and performs all the major medical procedures.
• Advanced diagnostic centers, specialized intensive care units and modern medical facilities are the key features in the Tertiary Medical Care.
• The practices that provide tertiary medical care could be part of the government or a combination of both public and private sectors.

Settings for Tertiary Care

Tertiary care is delivered in settings such as the intensive care unit (ICU), emergency room, trauma, organ transplant, and critical care units.

Quaternary Care

Quaternary care has been defined as an extension of tertiary care in reference to advanced levels of medicine which are highly specialised and not widely accessed, and usually only offered in a very limited number of national or international centres. Experimental medicine and some types of uncommon diagnostic or surgical procedures are considered quaternary care.

Like tertiary care, quaternary care also tend to have large catchment areas, often catering for individuals not only country wide but world wide, particularly when providing care for very rare health conditions with small numbers of patients globally. This may have significant impacts for the patient with large distances delaying diagnosis and teatment with complications in coordaintion of care between all healthcare providers involved in the patients care, particulalry after discharge when the responsibility for care typically returns to the patient’s primary care physician. Given the complexity or rarity in conditions of patients attending qurternary centres longer hospital stays and increased mortality may also be a seen at this level of care.

Conclusion

The cost of treatment at the various levels can be dramatically different, and generally the cost of treatment for patients at the primary health-care level is usually only a small fraction of that at the third level. Ideally, provision of health care at all levels of care and in all settings should be available to all patients; such health care is referred to as universal health care.

Resources

World Health Organisation

Technical Series on Primary Health Care

• A Vision for Primary Health Care in the 21st Century: Towards Universal Health Coverage & Sustainable Development Goals
• Building the Primary Health Care Workforce of the 21st Century
• Operational Framework for Primary Health Care
• Quality in Primary Health Care
• Primary Health Care and Health Emergencies
• The Transformative Role of Hospitals in Primary Health Care
• Access to Rehabilitation in Primary Health Care: An Ongoing Challenge
• Digital Technologies: Shaping the Future of Primary Health Care
• Why Palliative Care is an Essential Function of Primary Health Care
• Primary Health Care: Closing the Gap between Public Health and Primary Care through Integration

Country Case Studies on Primary Health Care

• Progressing Primary Health Care: A Series of Country Case Studies
  • Brazil: The Mais Médicos Programme
  • China: Multidisciplinary Teams and Integrated Service Delivery across Levels of Care
  • Egypt: Health Sector Reform
  • El Salvador: Territorial Community Teams
  • Estonia: the development of family practice to support universal health coverage
  • Ghana: community engagement, financial protection and expanding rural access
  • Islamic Republic of Iran
  • Jamaica: development of workforcefor first level of care
  • Kazakhstan: use of mobile technologies in primary health care as part of state-run reforms in the health sector
  • Samoa: engaging people for health promotion
  • Sri Lanka: community-based workforce development for maternal and child health
  • Thailand: The Development of Primary Health Care
  • Turkey: Family Practice for Quality in Universal Health Coverage
  • Viet Nam: Improving Equity in Access to Primary Care