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COMMUNITY ORIENTED PRIMARY CARE:
A PRACTICAL ASSESSMENT
Volume I I
Case Studies
Paul A. Nutting
Ei leen M. Connor
Division of Health Care Service
INSTITUTE OF MEDICINE
April 1984
National Academy Press
Washington, D. C.
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NOTICE The project that is the 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 Engineering, and the Institute of Medicine. The
members were chosen for their special competencies and with regard for
appropr late balance.
m is 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 the Federal
Government, and its own initiative in identifying issues of medical
care, research, and education.
Supported by the Department of Health and Human Services
Contract No. 282-80-0043, T.O. 15
2101 Constitution Avenue, N.W.
Washington, DC 20418
(202) 334-2356
Publication TOM-84-0 2A
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INSTITUTE OF MEDICINE
COMMITTEE ON COMMUNITY-ORIENTED PRIMARY CARE
rman
*MAURICE WOOD, Department of Family Medicine, Medical College of
Virginia, Richmond, Virginia
Members
*RALPH L. ANDREANO, Department of Economics, University of Wisconsin,
Madison, Wisconsin
*R. DON BLIM, Pediatrics Associates, Kansas City, Missouri
*ROBERT H. BROOK, The Rand Corporation, Santa Monica, California
JOHN W. FEIGHTNER, Department of Family Medicine, MacMaster University,
Hamilton, Ontar lo, Canada
MARGARET H. JORDAN, Health Plan, Inc., The Kaiser Foundation, Oakland,
California
*JOYCE C. LASHOF, School of Public Health, University of California,
Berkeley, California
GRANT MOFF~TT, American Farm Bureau Federation, Park Ridge, Illinois
FITZHUGH MULLAN, Office of Medical Applications, National Institutes
of Health, Bethesda, Maryland
*ERNEST W. SAWARD, School of Medicine and Dentistry, University of
Rochester, Rochester, New York
*LISBE,rH BAMBERGER SCRORR, School of Public Health, University of
North Carolina, Chapel Hill, North Carolina
HERBERT C . SCHULBERG, School of Medic ine, Uniters ity of Pittburgh,
Pittsburgh, Pennsylvania
iii
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W. JACK STELMACH, Family Practice Residence Program, Baptist Memorial
Hospital, Ransas City, Missouri
*PAUL D. STOLLEY, School of Medicine, University of Pennsylvania,
Philadelphia, Pennsylvania
JAMES D. TAYLOR, East Boston Neighborhood Health Center, Boston,
Massachusetts
STEPHEN BRADY THACXER, Consolidated Surveillance and Communication
Activity, Centers for Disease Control, Atlanta, Georgia
IOM Staff
Paul Nutting and Eileen Connor, Study Directors
Cheryl Halley, 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
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CONTENTl;
PREFACE, Pi i
Chapter 1 - INTRODUCTION TO THE CASE STUDIES, 1
Or ig ins of the Study, 1
me Case Study Approach, 2
Operational Definition of COPC, 3
References, 15
Chapter 2 - STUDY METHODS, 17
Site Selection, 17
The Seven Cases, 18
Data Collection Methods, 20
Limitations of the Case Studies, 21
Organization of the Case Reports, 22
Chapter 3 - THE CHECKERBOARD AREA REALTH SYSTEM, 25
The Primary Care Program, 27
The Community, 33
COPE Activities of Checkerboard Area Health System, 35
Analyz ing Checkerboard as a COPC Practice, 42
Summary, 48
Interviews, 49
References, 50
Chapter 4 - CRoW HILL FAMILY MEDICINE CENTER, 51
The Primary Care Practice, S2
me Community, 56
COPC Activities of Crow Hill Family Medicine Center, 57
Analysis of Crow Hill as a COPC Practice, 62
Summary, 67
Interviews, 69
Re ferences, 70
v
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Chapter 5 - EAST BOSTON NEIG B ORHOOD HEALTH CENTER, 71
The Primary Care Practice, 73
The Community, 78
COPC Activities at East Boston Neighborhood Health Center, 81
Analysis of East Boston as a COPC Practice, 85
Summary, 89
Interviews, 91
References, 92
Chapter 6 - KAlSER-PERMANENTE MEDICAL CARE PROGRAM OF OREGON, 93
The Primary Care Program, 94
The Community, 99
COPC Activities at Kaiser/Oregon, 101
Analysis of Kaiser/Oregon as a COPC Organization, 106
Summary, 110
Interviews, 112
References, 113
Chapter 7 - MONTEFIORE FAMILY HEALTH CENTER, llS
The Primary Care Program, 116
The Commun ity, 121
COPC Activities at Montef lore Family Health Center, 124
Analysis of the Montef lore Family Health Center
as a COPC Organization, 127
Sumanary, 133
Interviews, 135
References, 136
Chapter 8 - sEr Is SERVICE UNIT OF Tot; INDIAN HEALTH SERVICE, 137
The Primary Care Program, 138
The Conun unity, 145
COPC Activities at Sells Service Unit, 147
Analysis of the Sells Service Unit as a COPC Organization, 152
Summary, 157
Interviews, 159
References, 160
Chapter 9 - TARBORO-EDGECOMBE HEALTH SERVICES SYSTEM, 163
The Primary Care Practice, 166
The Community, 174
COPC Activities of Tarboro-Edgecombe Health Services System, 175
Analysis of Tarboro-Edgecombe Health Services System
as a COPC Program, 179
Summary, 182
Inte rviews, 18 5
References, 186
V1
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PREFACE
This volume is the second of a two-volume report by a committee of
the Institute of Medicine that assembled and examined the ~~~;~~^ -
the United States with community-oriented primary care (COPC). An oper-
ational definition of COPC was developed as part of this study and is
presented in Volume I. In summary, COPC is defined as the provision of
primary care services to a defined community, coupled with systematic
efforts to identify and address the major health problems of that com-
munity through effective modifications in both the primary care services
and other appropriate community health programs.
experience in
. . , ~ _ ~ _ , _ _ _
In assembling the pool of potential study sites, it became apparent
that COPC meant different things to different people. Often we were
directed to sites that were engaged in a variety of innovations in pri-
mary care or that had developed unusual collaborative relationships with
their community. Although noteworthy as innovators in the practice of
primary care, many of these sites were not specifically applicable to a
study of COPC.
This volume presents seven case studies selected specifically to
demonstrate the evolution of a COPC practice in vastly different health
care environments. The notion of COPC often has been associated with
publicly funded programs providing care to medically underserved popu-
lations, but these seven cases demonstrate that the fundamental pro-
cesses of COPC can evolve in either the public or private sector, under
differing financial structures, and by addressing different types of
communities. The case studies became a fundamental component of the
overall study and provided a heavy dose of reality against which to
refine an operational definition of COPC. We anticipate that the case
Studies will be useful as well to practitioners and educators who are
endeavoring to develop service delivery programs, research models, and
appropriate settings for introducing the concepts of COPC into post-
graduate medical education.
Each of the sites had a number of people who gave unselfishly of
their time to help us to understand the special characteristics of
their program. We came away from the site visits with the belief that
these were indeed very special people. Among them, a few stand out as
uniquely dedicated health professionals to whom a large measure of the
success of their program can be attributed. To Richard Rozoll, Frank
Reed, Stephanie Murphy, James Taylor, David Lawrence, Merwyn Greenlick,
Robert Massed, Felix Hurtado, and Lawrence Cutchin our gratitude and
deep respect is sincerely acknowledged.
Paul A. Nutting
Eileen M. Connor
· ~
VII
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