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Below are the first 10 and last 10 pages of uncorrected machine-read text (when available) of this chapter, followed by the top 30 algorithmically extracted key phrases from the chapter as a whole.
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OCR for page R1
COMMUNITY ORIENTS PRIMARY CARE:
A PRACTICAL ASSESSMENT
Volume I
The Committee Report
Division of Besith Care Services
INsTIT.Dq,E OF ME:DICIttE
Apr il 1984
National Academy Press
Washington, D.C.
OCR for page R2
NOTICE The project that is ache subject of this report was approved by
the Governing Board of the National Research Council, whose members are
drawn from the Councils of the National Academy of Sciences, the
National Academy of Eng ineer ing, and the Institute of Medicine . The
members were chosen for their special competencies and with regard for
appropr late balance .
This report has been reviewed by a group other than the authors accord-
ing to procedures approved by a Report Review Committee consisting of
members of the National Academy of Sciences, the National Academy of
Engineering, and the Institute of Medicine.
The Institute of Medicine was chartered in 1970 by the National Academy
of Sciences to enlist distinguished members of the appropriate profes-
sions in the examination of policy matters pertaining to the health of
the public . In this, the Institute acts under both the Academy ' s 1863
Congressional charter responsibility to be an advisor to We Federal
Government, and its own initiative in identifying issues of medical
care, research, and education.
Supported by the Department of }lealth and Buman Services
Contract No. 282-80-0043, T.O. 15
2101 Constitution Avenue, N.W.
Washington, DC 20418
{202) 334-2356
Publication TOM-84-0 2
OCR for page R3
INSTITUTE OF MEDICINE
COMMITTEE ON COMMUNITY ORIENTS PRIMARY CARE
Chairman
,
*MAURICE WOOD, Department of Family Medicine, Medical College of
Virg inia, Richmond, Virg inia
Member s
*RALPH L. ANDREANO, Department of Economics, University of Wisconsin,
Madison, Wisconsin
*R. OWN BLTH, Pediatrics Associates, Ransas City, Missouri
*ROBERT H. BROOK, The Rand Corporation, Santa Monica, California
JORN W. PETGHTNER, Department of Family Medicine, MacMaster
University, Hamilton, Ontar lo, Canada
MARGARET H. JORDAN, Health Plan, Inc., The Raiser Foundation, Oakland,
California
*JOYCE: C. LASHOF, School of Public Beal~ch, University of California.
Berkeley, California
GRANT MOE}?ETT, American Farm Bureau Federation, Park Ridge, Illinois
FITZHUGH MORAN, Office of Medical Applications, National Institutes
of }lealth, Bethesda, Maryland
*ERNEST W. SHARD, School of Medicine and Dentistry, University of
Rochester, Rochester, New Yor k
*LISBETH BAMBERGER SClIORR, School of Public Health, University of
North Carolina, Chapel Bill, Norm Carolina
111
OCR for page R4
HE:~3ERT C. SCHULBERG, School of Medicine , University of Pittburgh,
Pittsburgh, Pennsylvania
W. JACK Sq?E:~SE, Family Practice Residency Program, Baptist Memorial
Hospital, Kansas City, Missouri
*PAUL D. sTorts? School of Medicine, University of Pennsylvania,
Ph i ladelph is, Pennsy lvan ia
JAMES D. TAYLOR, East Boston Neighborhood Health Center, Boston,
Massachusetts
STEPHEN BRADY TRACKER, Consolidated Surveillance and Communications
Activity, Centers for Disease Control, Atlanta, Georgia
TOM Staff
Paul Nutting and Eileen Connor, Study Directors
Cheryl Hailey, Text Processor
Mireille Mesias, Administrative Secretary
Michael McGeary, Professional Associate
Donald Tiller, Senior Secretary
Daniel Zwick, Research Consultant
*Member of the Institute of Medicine
iv
OCR for page R5
COWTENTS
PREFACE
Chapter 1 - SUlMARY, CONCLUSIONS AND RECO - ENDATIONS, 1
Chapter 2 - BACKGROUND, 9
Origin of the Study, 9
Historica1 Context, 10
References, 16
Chapter 3 - STUDY METHODS, 19
Purpose and Scope of the Study, 19
Methods and Approaches, 19
Limitations of the Study, 22
References, 24
Chapter 4 - AN OPERATIOlLAL MODEL OF C - WNITY~ORIEN~ PRETTY CARE, 27
The Structural Elements of COE,C, 28
Functional Elements of the COPC Process, 32
Implications of the Model, 41
References, 45
Chapter 5 - ANALYSIS OF CURR=T PRACTICES, 47
Sugary of Practices Engaged in COPC, 47
Character istics of COPC Study Sites, 49
The Seven Study Sites, 51
Crosn-Case Analysis, 6S
References, 94
Chapter 6 - CONCLOS$0NS AND REC~DATIONS, 97
Conclusion I, 97
Conclusion 2, 98
Conclusion 3, 99
Conclusion4, 99
Conclusion 5, 101
Recommendation 1, 10 2
Recommendation 2, 102
Additional Individual Comments, 103
References, 106
OCR for page R6
PREFACE
This volume is the first of two in a report by a committee of the
Institute of Medicine that examined the body of knowledge on the U.S.
experience with co~munity-or tented primary care {COPC, . The concepts
of COPC have been stated previously in the writings of Sidney Hark,
drawn from his work and that of his colleagues in South Africa and
Israel. Bowever, there also is a substantial body of experience in the
United States where several different model" of COPC have evolved from
the prepaid group practice movement, the federally funded community
health centers, and the service units of the Indian Health Service. As
this study demonstrates, the fundamental concepts of COPC can be imple-
mented in a much wider variety of health care environments than have
been considered before now. Solve II of this report presents seven
case studies that demonstrate the adaptation of the COPC Eden in both
the private and the public sectors, under differing organizations of
financing, and addressing vastly different concepts of ~community..
Very early in the course of this study, it became apparent that the
notion of COPC meant different things to different people. Because the
term ~cosomunity~oriented primary care. is so fundamentally embraceable.
many people associate with it whatever they believe to be an important
innovation in ache delivery of primary care. Thus, an early but funda-
mentally important task in the study involved the construction of an
operational definition of conmunity~oriented primary care. Although it
could be argued that COPC is the logical extension of good primary care,
the committee adopted the view that COPC is one (of many possible}
application of primary care. Community-oriented primary care was
defined as the provision of primary care services to a defined commu-
nity, coupled with systematic efforts to identify and address the major
health problems of that community through ef fective modif ications in
both the primary care services and other appropriate community health
programs. An operational model was developed as the conceptual under-
pinninq of the study and was constructed initially from the writings of
others and the aggregate exper fence of the committee . our ing the course
of the study, the model was modified repeatedly to reflect ache realities
of COPC practice which became evident during the conduct of the case
studies.
Hi
OCR for page R7
The model should be viewed as preliminary and eminently suitable
f or modif ications by others. In particular, one feature of the model
will become the target of debate. As presented in Chapter Four of this
volume, the model descr ibes the car iety of communities that appropr i-
ately may be addressed by a COPC practice. Specifically the model
accommodates as a ~community. any aggregate of individuals that the
practice or program may reasonably expect to cover. Excluded, however,
is the community that is def ined to include only active patients of the
practice .
A strong counter-argument has been made that the pr inciples of COPC
could be applied to the collectivity of active patients of a practice,
and as such would represent an important innovation in the practice of
pr ivory care. It has also been argued that by requir ing the practice
to address a community beyond its active patient population, the defi-
nition places COPC beyond the reach of many practices. The model
developed for this study could admit the functions of COPC directed to
the active patients of a practice, and the fact that such an arrange-
ment may lead to improvements in the health of the patient group. Such
a practice should be encouraged to monitor and address the health and
health problems of its active patients, and as such would be practicing
exceptional pr imary care. However, to include this type of practice in
the scope of COPC begins to chip away at the central concept of COPC,
and reduces it to a catch-all that may include a variety of unrelated
activities and innovations in primary care. By maintaining a strict
definition of community, this study has isola~ced and examined the body
of knowledge related to directing the capabilities of primary care to
the health needs of c:ommunitie~; that may include both users and nonusers
of priory care services. As the study demonstrates, activities are
underway that meet the more limited definition of COPC. The require-
ment of COPC to expand the scope of concern beyond the circle of active
patients does not necessarily limit the ability of many to practice COPC
as attested by the case studies presented in Volume II of this report.
It is recognized however, that the application of the functions of COPC
to the active patient population, may be an important f irst step for
the practice attempting to shift from orthodox primary care to COPC.
This and other features of the operational def inition should focus
a lively debate on the precise nature of COPC. It is hoped that We
COPC model presented in this study will be subject to modification and
improvement by others working in primary care. At the time Mat this
r apart is going to press, we continue to receive Moments on the Hooded
both from the study sites and a wide variety of others whose advice has
been instrumental in fore.~ulating the operational def inition. If the
ensuing debate serves to add precision to Me concept of COPC, then the
model will have served its purpose and will continue to evolve. Most
Important, it will provide a solid foundation for the additional work
needed to more fully develop and test the contribution that COPC may
remake to the largely f ield of primary care.
Paul A. Nutting
Eileen M. Connor
e e
At eL eL
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