Levels of Care Primary Secondary and Tertiary Framework

Key Points

• Primary care emphasizes prevention, early identification, and routine management.
• Secondary care addresses focused acute or specialty needs and stabilizes patient status.
• Tertiary care provides highly specialized and often intensive interventions for complex conditions.
• Safe care requires planned movement between levels with clear referral and return-to-primary pathways.

Pathophysiology

Levels of care represent a healthcare delivery design, not a biologic disease process. Patients move between levels based on complexity, acuity, and required expertise.

Care failures commonly occur at transition points when referral intent, treatment goals, and follow-up responsibilities are not clearly communicated.

Classification

• Primary care: Health promotion, prevention, screening, and routine chronic care.
• Secondary care: Specialist evaluation and management of more complex acute/chronic problems.
• Tertiary care: Advanced specialty or procedural care in high-capability settings.
• Transition pattern: Escalation for complexity, then de-escalation back to continuity care.

Nursing Assessment

NCLEX Focus

Prioritize where the patient should receive care now and what transition details are required for safety.

• Assess current acuity, stability, and urgency to determine care-level fit.
• Assess whether current setting can provide required diagnostics/interventions.
• Assess referral indications and urgency for specialist or tertiary services.
• Assess discharge/readiness factors for return to lower level with follow-up.
• Assess patient understanding of why transitions are occurring.

Nursing Interventions

• Coordinate timely referrals with complete clinical context and rationale.
• Clarify goals of each level and expected handoff outcomes.
• Educate patient/family about where to seek routine vs urgent vs specialized care.
• Confirm return pathway to primary care after specialty episodes.
• Document transition decisions and contingency instructions.

Transition Fragmentation

Escalating care without a clear return and follow-up plan increases readmission and missed-care risk.

Pharmacology

Medication regimens often change during secondary/tertiary episodes; reconciliation and clear post-transition instructions are essential before return to primary care.

Clinical Judgment Application

Clinical Scenario

A patient seen in primary care for worsening dyspnea requires urgent specialist intervention and possible procedural management.

Recognize Cues: Symptoms exceed routine management threshold. Analyze Cues: Secondary or tertiary resources are needed for definitive workup/treatment. Prioritize Hypotheses: Immediate safe escalation is priority. Generate Solutions: Arrange urgent referral and communicate risk details to receiving team. Take Action: Transfer with complete handoff and stabilization steps. Evaluate Outcomes: Specialized care is delivered, then follow-up is reconnected to primary care.

Related Concepts

• patient-care-coordination-interdisciplinary-referrals-and-case-management - Operational pathway for transitions.
• continuity-of-care-during-evaluation-phase - Ensures stable follow-through after level changes.
• nurse-licensure-compact-and-multistate-practice - Relevant when care transitions cross jurisdictions.

Self-Check

1. What clinical factors most strongly determine escalation from primary to secondary care?
2. Why must tertiary episodes include explicit return-to-primary planning?
3. Which handoff elements prevent avoidable transition-related harm?