Learning Objectives
By the end of this section, you will be able to:
- Describe primary health care
- Define secondary health care
- Explain tertiary health care
A patient’s level of care—primary, secondary, or tertiary—is determined by the complexity and amount of care they receive at any given time (Figure 3.2). Primary care is the most fundamental, and tertiary care is the most complex. Most individuals move smoothly between levels of care throughout their lifetimes but typically rely mainly on the primary healthcare arena. Individuals with multiple health concerns or complex needs will rely more heavily on the secondary level of care where they can access specialty care. At the same time, those with critical injuries will, at least temporarily, rely on tertiary care.
Primary Health Care
The most fundamental access level of health care is primary health care. Primary health care focuses on the prevention of illness and the maintenance of health of an individual. As such, it is the “primary” type of healthcare service used by most individuals most of the time. Suppose a patient needs an annual physical, a flu shot, or to have their seasonal allergies treated. In those cases, they will probably see a primary care provider (PCP). If an individual has a new concern or condition, they will also usually begin at the level of primary health care for foundational evaluation and treatment.
Like how the base of a pyramid supports the top, a strong primary healthcare foundation supports the rest of the healthcare system. Studies have consistently shown that patients with a primary healthcare provider have improved health outcomes because changes in health status are identified and managed early (Willis et al., 2021). Patients without a primary healthcare provider often enter the healthcare system at a higher level in the pyramid, which always results in poorer outcomes and higher overall costs.
Primary Healthcare Goals
The goals of primary health care are health promotion and disease prevention. In other words, to provide preventive care and screening for illness or the development of conditions, primary health care identifies conditions early enough to minimize their impact on a patient’s quality of life and financial resources, treats minor to moderately severe acute and chronic conditions, and coordinates care between higher levels on the pyramid. For example, PCPs order colorectal screening, monitor blood pressure and basic blood work, and manage childhood immunizations (Willis et al., 2021). Primary healthcare goals include the following:
- being a patient’s first contact with the healthcare system (Bodenheimer & Grumbach, 2016);
- supporting current health status (for healthy individuals) (Willis et al., 2021);
- preventing decline in health status, when possible;
- identifying early signs of declining health status;
- treating a wide variety of basic illnesses, conditions, and injuries;
- providing continuity of care over time with the same physician (Bodenheimer & Grumbach, 2016);
- referring patients to secondary or tertiary providers if they need more complex care (Bodenheimer & Grumbach, 2016); and
- functioning as a medical home, supplying comprehensive primary care, coordinating care across the other levels of health care, and ensuring patients’ quality of care and safety (Agency for Healthcare Research and Quality [AHRQ], 2022).
Link to Learning
The AHRQ offers a set of suggested assessments to be performed on all patients. In Appendix 4: Adult Health Assessment Sample Questions of Health Assessments in Primary Care, a checklist of these suggested assessments is offered. Content areas where patients provide affirmative answers can guide primary care visits and assist in identifying patient needs.
Primary Healthcare Providers
A primary care provider (PCP) includes any physician (medical doctor or doctor of osteopathic medicine), nurse practitioner, clinical nursing specialist, or physician assistant. PCPs provide, coordinate, or help patients access a range of healthcare services (Table 3.1) (Healthcare.gov, n.d.). Primary care providers include family practice physicians, general practitioners, pediatricians, geriatricians, internal medicine physicians, nurse practitioners, physician assistants, registered nurses (RNs), licensed practical nurses (LPNs)/licensed vocational nurses, and a wide variety of assistive personnel.
| Provider Type | Total Number in the United States | Number Working in Primary Care |
|---|---|---|
| Physicians | 730,026 | 228,936 |
| Nurse practitioners | 220,332 | 94,302 |
| Physician assistants | 118,195 | 42,195 |
Primary Healthcare Settings
While most people think “doctor’s office” when they consider seeing a primary care practitioner, primary care occurs in a variety of settings. Primary care can happen in walk-in clinics, urgent care centers, pharmacies, and schools (Figure 3.3). Any place actively seeking to manage minor illness or injury, to offer preventive care such as vaccinations, or to maintain an individual’s current health offers primary care (Table 3.2) (Healthcare.gov, n.d.).
| Setting/Type | Reason | Scheduling |
|---|---|---|
| Primary care office | Annual physical, new complaints, acute illnesses, vaccinations, blood work | Usually scheduled, may be unscheduled |
| Walk-in clinic/urgent care | Usually freestanding; immunizations, sports or occupational physicals, acute illness, injury | Usually unscheduled, may be scheduled |
| Pharmacy | Some testing (such as COVID or flu) and immunizations | Either scheduled or unscheduled |
| School | Medical care for students who take medications for acute or chronic illnesses or who become ill while at school | Either scheduled or unscheduled |
| Community settings such as health fairs or community centers | May offer blood pressure screenings, other basic well patient care, and education and encouragement for patients to be mindful of their health | Either scheduled or unscheduled |
Primary Healthcare Procedures and Services
Although the keystone of primary care is preventive care and screening, primary healthcare professionals perform the broadest range of procedures and offer the most services of all levels of care (Hopayian, 2022). At the primary care level, patients may receive laboratory tests, injections, x-rays, minor wound care/procedures, nutritional counseling, and/or referral for additional screening, specialty treatment, or home health care. Primary care procedures also include ordering colorectal screening recommended for all people past a certain age, monitoring blood pressure and basic blood work, and managing childhood immunizations. In addition to preventive care and screening, primary care practitioners offer frontline treatment for common illnesses such as strep throat, flu, or injuries, such as a sprain or a cut needing basic stitches. They also manage many conditions their patients experience that are mild to moderate in severity. For example, in 2019, more people visited their PCP to manage hypertension, diabetes, or asthma than sought secondary care for the same issues (Willis et al., 2021). Finally, and very importantly, PCPs aid patients in accessing higher levels of care by making referrals and ensuring that all patient needs are being met.
Patient Conversations
Referral to a Higher Level of Care
Scenario: A 49-year-old male patient recently had x-rays ordered from his PCP related to long-term pain in his back. At the provider’s request, the nurse calls the patient to offer the results and next steps. The nurse is polite, introduces herself, states the reason for the call, and ensures the patient can speak with her. She is friendly with the patient and does not make him feel rushed. She establishes a partnership with the patient and provides him with the opportunity to decline care. Finally, she finishes with one topic before she begins another.
Nurse: Good afternoon, Mr. Smith. This is Sandy, Dr. Collier’s nurse. Dr. Collier asked me to call you about your recent x-ray. Is now a good time to talk?
Patient: Sure, Sandy, I’ve got a few minutes. How are you today?
Nurse: I’m doing great. How are you feeling? Did the steroids and medication Dr. Collier prescribed for you help your back?
Patient: I’ve been taking them just like she ordered, and my back does feel better.
Nurse: Excellent! That’s what we were hoping to hear. The x-ray of your back shows some age-related changes and arthritis like you discussed in the office. Dr. Collier would like to refer you to physical therapy to see if we can get your back stronger and more mobile now that the inflammation is calming down. I think she mentioned this to you at your appointment. Can I make that referral?
Patient: That would be great! Thank you.
[In addition to the information the doctor expected to find regarding the patient’s back, the doctor also noted an unexpected finding of a large kidney stone on the x-rays. The nurse changes to this new topic and proceeds to discuss next steps with the patient.]
Nurse: We will give physical therapy a call to get that first appointment set up for you today. Now, in addition, when the doctor looked at your x-ray, Dr. Collier also noticed a large kidney stone in your left kidney. Are you having any pain in your lower back?
Patient: Well, it has been aching back there a lot, but I just assumed it was related to the other issues in my back.
Nurse: Dr. Collier would like to refer you to a urologist about that stone. As I mentioned, it is quite large and may give you more problems in the future. May I make that referral?
Patient: Yes, please, and thank you. Do I need to worry about surgery?
Nurse: It is a possibility, but the urologist has many treatment options, and I am sure that they will work with you to find the best one for you. I will get that referral made today. Do you have any questions for me?
Scenario follow-up: The patient is understandably concerned about the potential of surgery related to his kidney stone. The nurse provides him with honesty and reassurance, without providing any treatment information or telling the patient what the urologist will do, which would be outside of her scope of practice. The conversation is closed after asking the patient if he has any other questions.
Secondary Health Care
The second level of the healthcare pyramid is secondary health care, sometimes referred to as acute care or hospital care (Hopayian, 2022). Secondary health care encompasses most of the specialties, practices, providers, and settings to which primary care practitioners provide referrals. Secondary care is the next step when a PCP is unable to assist a patient with successfully managing a healthcare problem (Hopayian, 2022). For example, a patient who continues to have severe episodes of asthma despite being on regular medications would probably be referred to a lung specialist (pulmonologist). Patients also access the secondary healthcare system if they go to the emergency department for an acute illness, an injury, or exposure to an environmental toxin (Figure 3.4). Some patients do not have a primary care provider (PCP), so the secondary healthcare level may be where they enter the system. While not ideal, patients can enter the healthcare system at the secondary level for several reasons. Fear, lack of transportation, limited access to primary care appointments, or lack of insurance may cause a delay in seeking care until the situation is urgent. Or having few PCP offices in a rural community may affect if and when a patient seeks health care. Sometimes patients choose to enter the healthcare system at the secondary level when they are self-pay or when their insurance company or payer allows it (Bodenheimer & Grumbach, 2016).
Secondary Healthcare Goals
Secondary healthcare goals are to manage an acute problem in order to return a patient to baseline function, to ensure a condition is well controlled, to provide education about the condition in order to decrease the chances of it becoming a problem again, and to return care to the PCP (Bodenheimer & Grumbach, 2016). Often a visit or two may be enough to address an issue; however, with complicated or chronic issues, secondary treatment may last for extended periods.
Consider an example of a primary healthcare service of ordering a patient referral for a routine screening colonoscopy. This screening is recommended by the U.S. Preventive Services Task Force for all adults over the age of 45 years (Centers for Disease Control and Prevention, 2023). The PCP sent that referral to a secondary care provider, probably a gastroenterologist (a practitioner who deals specifically with issues involving the digestive tract). The gastroenterologist scheduled and performed the colonoscopy, which was the only time the patient saw that physician because the results were normal. The issue was managed, and the patient returned to baseline. No further secondary care was needed. Primary care resumed responsibility for the patient’s continued care going forward (Figure 3.5).
Sometimes the process of moving from primary to secondary care and back to primary care can be more complicated. For example, a 16-year-old was admitted to an acute psychiatric facility (a secondary setting) with feelings of profound depression and suicidal thoughts. They stay there for one week, begin medication, and attend a few group sessions. After discharge, they are assigned to a psychiatrist (secondary provider) for medication management and a psychotherapist (secondary provider) for talk therapy. They see the psychotherapist weekly for nine months and the psychiatrist every three months until they relocate to attend college. In this case, the patient’s acute problem was managed by a team of secondary healthcare providers over an extended period of time. While this secondary care was occurring, the patient’s PCP managed all the other routine health care needs the patient had. The PCP remained as the patient’s healthcare provider in the long term, while special secondary providers entered and exited as specific problems arose.
Link to Learning
Transitions of care, moving between one provider to another, can be very complicated and may even have deadly consequences. The problem is serious enough internationally that the World Health Organization issued guidance to assist facilities in providing safer transitions. Consider how as a new nurse you can ensure safe transitions.
Secondary Healthcare Providers
A secondary care provider falls into one of several groups: medical (physician, nurse practitioner, physician assistant), mental health (psychiatrist, psychologist, counselors), and allied health professionals (physical, occupational, speech therapy, social workers, and case managers) (Hopayian, 2022; MedlinePlus, 2022). Secondary care providers are specialists in their area of expertise and have had additional training to reach that level of expertise. Specialists are chosen for referral based on the scope of their practice. For instance, a cardiologist treats disorders of the heart, a urologist treats disorders of the urinary tract system, a pulmonologist treats conditions of the lungs, and a dermatologist treats disorders of the skin.
Secondary Healthcare Settings
Patients seek secondary health care for a wide variety of reasons, in many locations, and on a scheduled or unscheduled basis. While reading through Table 3.3, consider why it matters if the health care is scheduled or unscheduled (hint: consider the differences between primary and secondary care).
| Setting/Type | Reason | Scheduling |
|---|---|---|
| Specialty care office | Meet with a specialist, such as a cardiologist, urologist, physical therapist, or obstetrician, for first or follow-up appointment | Scheduled |
| Emergency room | Manage an urgent or emergent illness, condition, or injury | Unscheduled |
| Hospital admission | Manage an urgent or emergent illness, condition, or injury; general surgical procedures (not complex); give birth; receive mental health care after a crisis | Either scheduled or unscheduled |
| Same-day procedure center | Have a low-risk, basic procedure or surgery, after which discharge is expected the same day, such as colonoscopy or cardiac stress test | Scheduled |
| Medical imaging center | Receive a wide range of medical imaging services; may be affiliated with an emergency department or hospital or may be freestanding | Either scheduled or unscheduled |
Secondary Healthcare Procedures
Secondary healthcare procedures are procedures performed by secondary providers that usually are focused on a specific body part or organ and are noninvasive or minimally invasive (such as requires no more than topical numbing of the skin). Secondary procedures include the following:
- most medical imaging services (i.e., computed tomography [CT] scan or ultrasound);
- therapeutic techniques, such as chiropractic or dry needling (a technique similar to acupuncture that healthcare providers use to manage pain and mobility issues);
- nonsurgical management of fractures, such as setting and casting;
- organ-specific laboratory work, such as cardiac enzymes, liver functioning, or urine osmolality;
- skin and tissue biopsies (sampling); and
- tests, such as cardiac stress test (treadmill test) or pulmonary function test (blow into tube or machine).
Tertiary Health Care
The top level in the healthcare pyramid is tertiary health care (Figure 3.6). When patients have healthcare problems, illnesses, or injuries that cannot be managed by primary or secondary care, they move into the tertiary healthcare level. Tertiary care may involve invasive medical procedures and major surgery. Tertiary health care is offered using specialty tools and medical staff and involves advanced medical treatments and diagnostics (Hopayian, 2022; MBA Healthcare Management, n.d.). Patients may also go to the tertiary healthcare level when they have rare conditions or multiple comorbidities (many conditions occurring at the same time and requiring secondary care) (Hopayian, 2022). There are fewer tertiary healthcare facilities and hospitals than secondary healthcare ones, and severely ill patients are often transported to distant locations to receive tertiary services.
Tertiary Healthcare Goals
The goals of tertiary health care are similar to the goals of secondary health care: manage a severe illness, condition, or injury; return a patient to baseline function; ensure a condition is well controlled; and provide all care possible until it is clear that the patient will not survive. Tertiary care is specific and temporary. The patient receives a service, surgery, or supportive treatment and returns to their PCP (Bodenheimer & Grumbach, 2016).
A previous example of primary health care was a referral for a colonoscopy. An example of secondary health care was when the patient received the colonoscopy, and care returned to the primary level when the procedure resulted in normal findings. An example of tertiary care is what happens if the colonoscopy is not clear. Consider Susan from a rural area in the Midwest where she has a long relationship with her local PCP and receives annual physicals consistently. Her PCP orders a colon screening for her when she is 45 years old per national guidelines, and Susan sees a secondary care provider in a nearby midsize town for the test. During the test, polyps are discovered, removed, and sent to pathology for testing. The pathology results reveal that Susan has colon cancer. Her PCP and secondary provider communicate and decide together to refer Susan to a tertiary facility in the closest metropolitan area. The facility is specifically dedicated to treating cancer. Over the next several months, Susan receives tertiary health care that includes a surgical procedure and chemotherapy and radiation therapy. When Susan is deemed to be cancer-free, her care is returned to her secondary provider for intermittent follow-ups and her primary physician for general health care (Figure 3.7).
Life-Stage Context
Managing Care for Patients with Multiple Chronic Illnesses
Older patients are the population most likely to use tertiary care and/or multiple secondary care providers related to having multiple chronic illnesses. Having a PCP who accepts the responsibility of functioning as a medical home can be most important for these patients. When patients have multiple specialty providers who are each prescribing medications and not communicating with each other, it is very easy for patients to become sicker due to their medications rather than their conditions. Having a medical home allows older patients and those with multiple chronic medical conditions to have higher quality, more efficient care, because it is coordinated through a single location (AHRQ, 2022).
Tertiary Healthcare Providers
There is a lot of overlap between secondary and tertiary care providers in terms of the care they provide. The key difference is the level of management (such as surgery) and expertise the provider can offer. A practice group made up mostly of secondary providers will often have a tertiary care provider available on staff to manage patients who require more advanced care. Table 3.4 offers a few examples of tertiary care providers.
| Secondary Provider | Tertiary Provider | ||
|---|---|---|---|
| Cardiologist | Treats cardiac issues | Cardiothoracic surgeon | Treats cardiac issues and performs cardiac surgery |
| Pulmonologist | Treats lung issues | Pulmonary intensivist | Manages respiratory arrest and life-threatening respiratory conditions in tertiary intensive care unit settings |
| Radiologist | Reads and diagnoses patients through medical imaging | Interventional radiologist | Uses medical imaging to actively visualize the internal bodily structures while performing surgery |
Tertiary Healthcare Settings
Much of the time, tertiary health care happens in large, urban hospitals (such as a level 1 trauma center) or specialty hospitals (such as cancer center hospitals or hospitals for children). However, tertiary care can take place in any medical location where highly specialized treatment and equipment are available (Table 3.5). For example, in the discussion of secondary health care goals, an example was given of a 16-year-old who was admitted to a psychiatric facility for secondary management of extreme depression and suicidal thoughts. If the patient had gone to an intensive outpatient treatment program after discharge (say five days a week, six- to eight-hour days, for several weeks), they would have been in a tertiary health care setting, working with professionals trained specifically to provide the most effective level of intensive long-term treatment for that age group.
| Setting/Type | Reason |
|---|---|
| Large urban hospitals with critical care specialties | Care and management of rare or complicated illnesses or traumas, including transplants, surgery, burn units, and intensive care units |
| Specialty hospitals focused on specific diseases or patient groups | Provide intensive management of specific disease processes, such as cancer or spina bifida |
| Specialty medical clinics | Provide intensive treatments for specific disease processes, such as dialysis for kidney disease |
| Specialty mental health facilities | Provide intensive treatments for mental health, such as intensive outpatient, day treatment, residential treatment for substance abuse, or electroconvulsive therapy |
Tertiary Healthcare Procedures
Tertiary healthcare procedures include any complex procedure or treatment that is performed by highly trained (or group of highly trained) practitioners with specialized equipment to manage complicated conditions (Astron, 2019). Such procedures may include the following:
- major surgeries;
- organ transplants;
- joint replacements;
- long-term care interventions, such as chemotherapy or substance-use treatment; and
- intricate medical services, such as serious burn and wound care, trauma management, and critical care (Hopayian, 2022).
Clinical Judgment Measurement Model
Take Action: Levels of Prevention versus Levels of Care
Just as there are primary, secondary, and tertiary levels of care, there are also primary, secondary, and tertiary levels of prevention. Unlike levels of care, which reflect the complexity of care a provider delivers, levels of prevention are types of actions that providers engage in to assist their patients to remain healthy:
- Primary prevention includes actions taken to prevent diseases from occurring, such as immunizations or tobacco cessation.
- Secondary prevention includes actions taken to identify diseases early, such as mammogram screenings or colon screenings to detect cancer or blood pressure screenings to detect hypertension.
- Tertiary prevention includes actions taken to mitigate the effects of illnesses once established, such as physical therapy for a patient with fibromyalgia or arthritis or foot care for patients with diabetes.
It is important to remember that the level of prevention and the level of care are not synonymous. A PCP can order or provide tertiary prevention such as physical therapy and diabetic foot care. The key to remember is that prevention levels are always action steps on the part of the provider, the patient, or both (Kisling & Das, 2023).