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Hicks belted a two-run shot in the first inning and Higashioka hit a solo drive in the second inning off Atlanta starter Sean Newcomb , who lasted just 2 2/3 innings as his control evaporated. New York scored twice without a hit in the third inning, working five walks, including bases-loaded free passes to Brandon Drury and Higashioka.

Video: [email protected]: Drury draws a bases-loaded walk in the 3rd

A run-scoring wild pitch by Luke Jackson in the fourth allowed Brett Gardner to race home with what seemed to give the Yankees a comfortable six-run cushion, but the Braves swung back against starter Domingo German , who permitted three runs and six hits over 4 1/3 innings.

Video: [email protected]: Gardner races home on a wild pitch in 4th

"We're obviously capable of those nights where we have a big night and can run away from a team, but we've seen time and time again that we can scratch and claw our way," Boone said. "I think the one thing about this club that they've shown through the first 80-plus games is that we've shown an ability to win games in a lot of different ways."

Ender Inciarte and Ozzie Albies homered on consecutive pitches in the fifth, with Inciarte lifting a two-run shot, and German was out of the game two batters later. Appearing in his first big league game since June 19, A.J. Cole extinguished the blaze, striking out three around a walk and an infield hit.

"I like to show my team that I can be there for them, at any time," Cole said. "I love those situations."

Video: [email protected]: Cole escapes bases-loaded jam with a K

Nick Markakis drew the Braves within a run in the seventh, mashing a two-run homer off Adam Warren that struck the top of the right-field wall and bounced into the seats. Stanton slammed into the wall as he pursued Markakis' drive, prompting a visit from an athletic trainer, who asked Stanton the inning, the number of outs and the day of the week.

"I didn't know any of them," Stanton said, with a laugh.

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Chasen Shreve entered and recorded two key outs in the eighth before Stanton launched a two-run shot to right field off Evan Phillips in the home half of the frame. Pitching for a third consecutive game, Aroldis Chapman retired the side in the ninth for his 24th save.

"I think we're just driven. We want to win," Shreve said. "We don't ever give up. That's kind of hard to find, honestly, with these types of games. I think we're never going to give up. We want to be back where we were last year, and even further."

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Perspective

July 7, 2011 N Engl J Med 2011; 365:5-8 DOI: 10.1056/NEJMp1104942

Article

Clinica Family Health Services is a community health center serving a low-income, largely Latino population near Denver. Since its inception 30 years ago in founder Alicia Sanchez's kitchen, Clinica has grown to serve 40,000 patients at four sites. Fifty percent of these patients are uninsured; 40% have Medicaid. Like many community health centers, Clinica is financed by augmented Medicaid fees, federal grants, sliding-scale payments from uninsured patients, and energetic local fundraising.

Clinica's story reveals that U.S. primary care is undergoing two revolutions. The first, catalyzed by the Chronic Care Model, targets specific diseases such as diabetes or asthma. The second, coming on the heels of the first, entirely transforms primary care delivery. Starting in 1998, Clinica was an activist in the first primary care revolution with its work on diabetes. After 2000, Clinica initiated the second revolution, redesigning its entire care model to become a patient-centered medical home. Clinica's experience demonstrates how such medical homes can be constructed out of three fundamental building blocks — continuity of care, prompt access to care, and care provided by teams — and the ways in which primary care practitioners (physicians, nurse practitioners [NPs], and physician assistants [PAs]) adapt to the resulting changes in their work life.

Clinica's medical director, family physician Carolyn Shepherd, grasped early on that continuity of care between patients and their primary care practitioner is associated with better preventive and chronic care, improved experiences for both patient and practitioner, and lower costs. Implementing a culture of continuity requires that patients be assigned to the panel of a specific practitioner, who is available most days of the week. These clinicians must be willing to squeeze their patients — but not other clinicians' patients — into their schedules if same-day attention is needed. Staff members answering the phone must prioritize such continuity.

If achieving continuity is like climbing a 5000-ft mountain, sustaining prompt access to care is like scaling one of Colorado's 14,000-ft peaks. For 10 years, Clinica has provided most appointments within 6 days of patients' requests, and usually within 2 days. Clinica fills primary care practitioners' schedules from 8 a.m. to 10 a.m., leaving many slots for same-day access. Staff members who answer the phones are not allowed to say no to patients, whose requests are addressed with appointments, “squeeze-ins,” or visits with a registered nurse (RN). Schedules are created for only 2 weeks at a time, to ensure that appointment slots will remain open. If clinicians request appointments for their patients beyond the next 2 weeks, electronic reminders generate calls to those patients on the appropriate date.

Adequate access requires an equilibrium between demand for visits and capacity to provide them. At Clinica, this balancing act is accomplished by eliminating unnecessary demand and adding capacity. Continuity of care reduces demand because if patients see other clinicians, an additional appointment is often scheduled with their own clinician for the same problem. Demand is also reduced by increasing the intervals between visits, which has been shown in most cases not to harm the quality of care. Capacity is increased by offering patients visits with RNs for less complex problems and through group visits, which allow clinicians to see 30 to 40% more patients per hour.

Embracing continuity and improved access requires clinicians to accept a truly patient-centered approach to care: to see patients most days of the week, to cede to their patients control over their daily schedules, and to be willing to see their own patients who drop into the office and not expect other clinicians to do so. Why might clinicians agree to such changes in their work life? Clinica's practitioners have accepted the priorities of continuity and access partly because persuasive medical leaders had the courage to say “this is the way it's going to be,” partly because they see these policies benefiting their patients, and recently because Clinica has been recruiting new clinicians who already agree with these principles.

Clinica's Performance Data (as Compared with Average 2009 HEDIS Scores for All Medicaid Health Plans, Where Available).

Clinica has moved boldly from a doctor-based model to a team-based model. All clinical activity centers around the “pod” (care team), which includes at one location three primary care practitioners and three medical assistants (MAs, each working with a single clinician), plus an RN, a case manager, a behavioral health professional, and medical-records and front-desk staff. Clinicians don't have their own offices; each pod has a central area surrounded by exam rooms. Pod members easily interact with one another and can see all patient rooms, whose doors are marked with colored flags showing who is inside. In each pod, performance data are displayed on a wall, and any deficiencies are discussed at team “huddles.” Clinica's quality of care often exceeds national Medicaid performance (see Novica Sterling silver dangle earrings Floral Pear PBv9j
) — especially impressive given that Clinica's data include the 50% of its patients who have no insurance.

Every team member shares responsibility for the team's patients. MAs take histories using electronic medical record (EMR) templates and give immunizations according to protocols, without involving physicians, NPs, or PAs. Designated team members handle most preventive and much chronic care through panel management — combing registries and arranging for patients who are found to be overdue for mammograms, colorectal cancer screening, or diabetes laboratory work to receive these services. RNs, using standing orders, treat patients with ear infections or positive streptococcal, urine, gonorrhea, or chlamydia cultures and manage warfarin dosing — all without involving primary care practitioners, who sign off later in the EMR. As much as possible, clinicians spend their time providing complex diagnosis and management, with routine functions performed by other team members. Only through a team approach can primary care, with its clinician shortage, meet population-wide needs.

To make the transition to team care, Clinica reconfigured hundreds of workflows, detailing who would do what and how, for such functions as receiving incoming phone calls, updating clinician schedules, informing patients of laboratory results, and refilling prescriptions. For common clinical conditions and well-child care, specific workflows were created and job roles were redefined using standing orders, with the goal of standardizing guideline-driven care while dividing responsibility among team members.

Team-based care requires fundamental changes in clinicians' mindset. Many practices claim to have teams, but the physician provides all care and delegates specific tasks (fax this form, do an EKG) to others. At Clinica, the entire team shares responsibility for the health of the patient panel. Entire work areas, though overseen by an MD, NP, or PA, are performed independently by RNs, MAs, or case managers. For clinicians to accept this shift from “I” to “we,” team members must have their roles authorized through protocols and be trained to perform them competently. Clinicians must have confidence that all team members are doing a good job in order to feel relief that they have time for more complex tasks.

Clinica will next focus on controlling costs by reducing unnecessary emergency department visits and hospital admissions. Achieving this goal will require a deepening of team care, with care managers assisting patients who have complex, high-cost conditions. This step awaits a new funding stream, which requires participation in an accountable care organization in which Clinica will share the savings from reduced downstream costs.

Clinica has confronted basic primary care challenges and answered key questions: How can continuity of care be made the centerpiece of a medical practice's ethos? Can a policy of providing prompt access be sustained? Who should be included in care teams, who should perform which work, and how central to team function are colocation, workflows, and standing orders? How should care for common conditions be standardized?

Ultimately, clinicians' acceptance of the primary care revolutions will be sustainable only if their work life is more satisfying than it was before. Understanding that necessity, Clinica's leaders have created an organization that serves patients well while retaining a group of loyal clinicians.

Disclosure forms provided by the author are available with the full text of this article at NEJM.org.

From the Center for Excellence in Primary Care in the Department of Family and Community Medicine, University of California, San Francisco, School of Medicine, San Francisco.

Saultz JW, Lochner J. Interpersonal continuity of care and care outcomes: a critical review. ;3:-

Later Tuesday, Goldstein was also fired, White House press secretary Sarah Huckabee Sanders and Goldstein both confirmed to NPR's Tamara Keith.

A senior administration official says White House chief of staff John Kelly called Tillerson on Friday and notified him that he would be replaced and "that he was being asked to step down. It was made clear that it was imminent." The official added that Kelly and Tillerson had a follow-up conversation on Saturday.

"He was asked to step down," the official said, and he didn't.

Trump and Tillerson have been described as talking often but sometimes appeared quite out of step on major foreign policy decisions.

A White House official says the president wanted to have a new team in place in advance of upcoming talks with North Korea and ongoing trade negotiations.

Tillerson, who was traveling in Africa last week, was caught flat-footed when the surprise announcement came that Trump had accepted an invitation to meet with North Korean leader Kim Jong Un. Just a day earlier, he had told reporters that negotiations were a long way off.

Trump has named Gina Haspel, Pompeo's former deputy and a CIA veteran, to take the helm of the spy agency.

Haspel did not require Senate confirmation to serve in her deputy role but will to serve as the full-fledged director of the agency. Her hearing could exhume many CIA demons about the torture of terror suspects and the secret detention program that followed the 2001 terror attack.

National Security

New CIA Deputy Director's Past Intertwined With CIA's History Of Waterboarding

Democrats blasted what they called the nonstop chaos of the Trump White House, which they said meant it cannot focus on conducting business seriously.

"The instability of this administration in just about every area weakens America," said Senate Minority Leader Chuck Schumer, D-N.Y.

But another sometime-opponent of Trump's, Senate Foreign Relations Committee Chairman Bob Corker, R-Tenn., said he would move as quickly as possible to convene a confirmation hearing for Pompeo to run the State Department.

"I had a very good conversation with Director Pompeo this morning and look forward to meeting with him soon," Corker said. "As I shared with the president, the committee will consider his nomination as expeditiously as possible."

Slow burn

Tillerson said at the State Department on Tuesday afternoon that he was grateful for the chance to serve in government and he thanked the foreign service officers and others who work on behalf of the United States abroad.

Tillerson said he wants to arrange an orderly transition to Pompeo, whose Senate confirmation hearing is expected in April and appears to have the support to move into the State Department job.

Tillerson said he has begun delegating responsibilities from his office to that of Deputy Secretary of State John Sullivan.

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Definition of secondary

1 a : of second rank, importance, or value
b : of, relating to, or constituting the second strongest of the three or four degrees of stress recognized by most linguists
c of a tense : expressive of past time
2 a : immediately derived from something original, primary, or basic
b : of, relating to, or being the induced current or its circuit in an induction coil or transformer
c : characterized by or resulting from the substitution of two atoms or groups in a molecule ; especially : being, characterized by, or attached to a carbon atom having bonds to two other carbon atoms
d ( 1 ) : not first in order of occurrence or development
( 2 ) : dependent or consequent on another disease or condition
( 3 ) : produced by activity of formative tissue and especially cambium other than that at a growing point
3 a : of, relating to, or being the second order or stage in a series
b : of, relating to, or being the second segment of the wing of a bird or the quills of this segment
c : of or relating to a secondary school

secondarily

\ ˌse-kən-ˈder-ə-lē \ adverb

secondariness

\ ˈse-kən-ˌder-ē-nəs \ noun

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Winning is —we play for the fun of the sport.

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