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Chapter 1
INTRODUCTION TO TEE CASE STUDIES
ORIGINS OF THE STUDY
defined population.
In its most general form, community-oriented primary care (COPC)
is the application of primary care to meet the health care needs of a
It has been characterized as population-based
medicine. (Lipkin and Lybrand, 1982), the combination of personal
primary care and community medicine (Madison, 1983), and as the appli-
cation of epidemiology to primary care (Mullen, 1982~. Although COPC
has found expression for many years in widely separated parts of the
world, much of the current content and philosophy can be traced to the
writings of John Grant (Seipp, 1963), Will Pickles (Pickles, 1938), and
Walsh McDermott and Kurt Deuschle (McDermott et al., 1960; McDermott et
al., 1972~. More recently, Sidney Hark has further developed the con-
cept with specific applications in South Africa and Israel {Rark, 1974;
Kark, 19811.
Although originating under different names, several COPC models
have been evolving in the United States for many years. Within the
public sector, community health center programs, which grew out of the
original Neighborhood Health Center experiment of the Office of
Econamic Opportunity, provide primary care services to medically
underserved populations.
.
Beginning in 1955, the Indian Health Service
nas Developed a comprehensive program of primary care and community
health services to assure health services to American Indians and
Alaskan natives. Within the private sector, prepaid group practices
have flour ished over the Past decade following the patterns established
Dy one Ka~ser-Permanente organization in the 1940s. Each represents a
particular variation on the general model of community oriented primary
care, although each stresses different aspects of the model and uses
quite different methods to address the particular health needs of their
~ . ~ .
communities.
In 1982, the Institute of Medicine (TOM) sponsored a conference on
coJmnunity~oriented primary care with participants frown many COPC-like
programs in six countries. The common thread that linked the partici-
pants was an interest in health care programs that tailored a primary
care practice or program to the particular health needs of a defined
population. The conference noted that there was no compelling data
base upon which to judge the value of COPC as an important improvement
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2
in the organization of primary care (Rogers, 1982) . One of the recom-
mendations from the conference called for the development and critical
analysis of the knowledge base derived from the varied experiences with
the practice of COPC in the United States. Late in 1982, the Institute
of Medicine initiated a study of COPC with funds provided by the U.S.
Department of Health and Human Services. The study was designed to
assemble and critically analyze the body of knowledge in the united
States that describes the operations and the marginal costs and effects
of community-oriented primary care. The specific charge to the study
committee was threefold:
1) to assemble and organize the existing data/evidence that
describe the operation, costs, and impact of the various
expressions of COPC in the United States
2) to critically assess the resulting data base in relation to
various population groups, and in relation to a variety of
existing and projected organizational, administrative, and
financing contexts
where evidence warrants, to make recommendations about
priorities in areas of education, practice, research, and
public policy.
In order to conduct the study, an operational def inition of COPC
was developed and a series of case studies were conducted to examine
the expression of COPC in several relevant health care environments.
The report of the full study is presented in Volume I.
THE CASE STUDY APPROACH
The case study approach was felt to be a particularly important com-
ponent of the study for several reasons. First, there was no clear and
concise definition of COPC that made the concept amenable to systematic
observation. Much of the written material advocated the COPC approach
and speculated on its advantages, but did not carefully differentiate
COPC from orthodox primary care, or from any of its variants. The case
study approach was felt to be an important avenue through which empiri-
cal data from the U.S. experience could be channeled into an operational
model of COPC. Second, it became clear early in the course of the study
that the literature was not extensive nor organized in a way to provide
a wealth of information on the operations, costs, and impacts of COPC in
the United States. There is a sizable body of literature examining pri-
ma ry care, comprehensive care, community health care, the role of the
community in planning and managing health programs, and the community
health centers. This literature is supportive but somewhat peripheral
to the central purposes of this study. Third, it was hoped that through
a case study approach, a sizable body of experience could be assembled
to be of use to practitioners who are trying to engage in community-
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3
oriented primary care. Case studies describing the manner in which
COPC is practiced in environments that present financial,
philosophical, and organizational barriers should be of value to
practitioners seeking wider expression of COPC in their own practices
OPERATIONAL DEFINITION OF COPC
In its most general form, community-oriented primary care can be
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 effective modifications in
both the primary care services and other appropriate community health
programs. From this definition, the important elements can be isolated
to form the basis for an operational model and to act as the criteria
for COPC:
.
.
a practice or service program actively engaged in primary care
· a defined community for which the practice has accepted
responsibility for health care
a process by which the practice, with the participation of the
community, identifies and addresses the major health problems
of the community; the process includes the following functions:
· defining and characterizing the community
· identifying the community's health problems
· modifying the health care programs in response to the
community's identified health needs
· monitoring the impact of the program modifications.
Therefore, the operational definition of COPC is based on two structural
elements and the processes required to address the community health
needs.
Both the primary care practice and the community can be organized
into a var iety of forms, and the model places no constraints on the
forms that may be engaged in COPC. m e variation in the character-
istics of the primary care practice and the community constitute the
environment in which COPC is practiced. Thus, the environment will
vary in several regards such as the organization of the practitioners,
the organization of the cam~unity, and the manner in which revenue is
generated from the community (directly or indirectly} and used to
finance the health care program. ffl ese Environmental variables" are
assumed to be important determinants of the way in which the COPC model
is expressed in any given setting.
The Practice of Primary Care
Primary care was defined in a study by the Institute of Medicine as
health care consisting of five attributes of the specific array of
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4
services (Institute of Medicine, 19801. These include accessibilitY,
comprehensiveness, coordination, continuity, and accountability. This
definition addressed the characteristics of the services themselves and
did not specify the characteristics of either the practitioner or the
patient.
At is important to emphasize that community-oriented primary care
is a particular application of primary care rather than an extension of
it. The practice of COPC is not dependent upon an unusually
well-developed primary care base, and good primary care and COPC may
develop simultaneously. There may exist a number of other appli-
cations of primary care that are not COPC, and conversely any practice
or service program may be practicing excellent primary care without
demonstrating any of the important features of COPC.
The Community
The second structural element of COPC is a defined community for
whose health and health care the practice has assumed responsibility.
Such a community may take a variety of forms ranging from traditional
communities to combinations that come together for a common purpose
such as the work place, the church, schools, to aggregates of individ-
uals who are enrolled in a common health plan. The only requirement of
the COPC model is that the community cannot be defined in such a way as
to systematically exclude nonusers of health services. A common element
among the different types of communities for which COPC practices may
assume responsibility is that they are ~actionable., that is, they can
be addressed in a systematic manner by the health care system.
In the context of COPC, it is useful to view the community as a
denominator, in the epidemiologic sense, which consists of subsets or
numerators, the most important of which is that group of individuals in
the community who are active users of the health care system. Thus,
primary care outside of the COPC model strives to provide its active
patients (the ~numerator. in a COPC context) with effective and
appropriate health services that are accessible, comprehensive, con-
tinuous, coordinated, and accountable. In contrast, the COPC model
(which includes a primary care component) systematically addresses the
major health problems of the entire community, that is, the denominator.
The community may be organized in a number of different patterns
and may participate to varying degrees in the health care program. The
COPC model does not specify the type or level of participation and many
forms may evolve. The varying forms of community involvement can be
categorized by the type of organization, the level of involvement, and
the focus of attention.
The Functional Elements of the COPC Process
The COPC process consists of four functional elements by which the
practice identifies and addresses the major health issues of the com-
munity. As an aid for describing the development of the functions in
the study sites, it is useful to describe the progression from orthodox
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s
primary care to COPC by constructing a scale for each of the four func-
tions. for each scale, there is a basic requirement that distinguishes
COPC from orthodox primary care , and it is this requirement that sepa-
rates stage O f rom the subsequent stages of COPC. Each scale is based
on a central variable that increaser as one moves along the stages of
development from primary care to COPC. Stage O represents the absence
of the central variable of COPC, and stage IV describes the idealized
level of COPC for that function. The two end stages of each scale are
based on the definitions of primary care and COPC, and the intermediate
stages reflect increasing levels of development, based in part on the
results of the case studies.
Defining and Characterizing the Community
m e COPC process begins with defining and characterizing the commu-
nity for which the practice has accepted responsibility. The resulting
knowledge of the total community forms the foundation on which the
subsequent functions of QOPC are based. In a COPC practice, the prac-
titioner needs to know who and where are the individuals and households
who compose his community, how they live and behave in ways that influ-
ence their health, where and when they seek care for ailments, and how
they perceive and finance their care. Ideally, the practitioner would
be able to enumerate or list the name, address, age, and sex of all the
individuals in the community, an a basis subsequently for identifying
and focusing on high risk groups.
The scale for this function is shown in Table 1.1. The major
requirement and the criterion that separate orthodox primary care
(stage O) from the higher stages of COPC development is that the
methods employed are directed toward a denominator population that is
consistent with the community for which the practice has accepted res-
ponsibility. m e central variable underlying the scale is the rigor
and precision of the methods used to gather information on the commu-
nity. Methods that yield a wide scope of detailed and relevant data
are placed higher on the scale. Although the frequency with which
methods are applied and the currency of the resulting information is
important to this function, these elements are not included in the
scale. At stage 0, for example, the practice may be using methods with
a great deal of rigor that yield a great deal of information, but if
they are used to characterize only the user population (such as the
active patients of the practice) they are characteristic of excellent
primary care, but not of COPC.
At stage I, the practice has begun to examine the characteristics
of its community through the use of secondary data. Large area stati-
stics may be useful as a first stage of development of the function,
but has several drawbacks. Large area data often do not describe
exactly the community for which the practice has accepted responsi-
bility, often do not lend themselves to further analysis of issues of
particular interest, and do not permit an enumeration of all individuals
within the community.
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6
TABI`E 1.1 Staging Criteria for COPC Function--Def ining and Character-
i z ing the Commun ity
STAGE 0: No effort has been made to define or characterize a commu-
nity beyond the active users of the practice.
STAGE I: There is no enumeration of the individuals who comprise the
community. The community is characterized by extrapolation
from large area census data.
STAGE II: There is no enumeration of the community, but it is charac-
terized through the use of secondary data that correspond
closely to the community for which the practice has accep-
ted responsibility.
STAGE III: The cam unity can be enumerated and is actively character-
ized through the use of a data base that includes all mem-
bers of the community, and that contains information to
describe its demography and socioeconomic status. (Often
such a data system is constructed over time from the active
users of services, but approximates the community closelY,
e.g., at or above 90 percent coverage of the community.)
STAGE IV: Systematic efforts assure a current and complete enumer-
ation of all individuals in the community, including
pertinent demographic and socioeconomic data. For each
individual, information exists that facilitates targeted
outreach, e.g., address, telephone number, etc.
Stage II differs from stage I only in that the secondary data used
corresponds more closely to the community. This might be the case, for
example, when the community is defined as all persons living in a
geographic area that corresponds to a current census tract. Alterna-
tively, the practice may survey a random sample of the community on
health and health care relevant topics, thus gaining an understanding
Of important characteristics of the community, but not resulting in a
listing of all individuals.
At stage III in the development of this function, the community can
be enumerated through the use of a data base that includes all individ-
uals within the cam unity. me data base contains information for each
individual and enables analysis of the demography and socioeconomic
status of the Unity. Data bases of this sort often are those
constructed from active users of health services, whose number grows
over tome to include the majority of the community, and must include
90 percent of the community to be considered at this stage. The major
drawback of a data base constructed in this fashion is the inconsis-
tency and lack of currency of data elements for those individuals who
have sought care inf requently. Ideally, such a data base would be
constructed through an initial survey of the community.
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7
Finally, at stage IV the practice makes an effort to maintain a
current and complete data base including all individuals in the com-
munity. The practice is active in analyzing the data to gain a more
complete understanding of the community, its patterns, and trends that
influence health. The data base includes for each individual that
information which in subsequent COPC activities will facilitate tar-
geted outreach of high risk individuals, such as address and telephone
number.
The existence of a data base does not contribute to the COPC pro-
cess unless it is being used actively to describe and characterize the
ca.~.unity. Some practitioners may be able to extract more information
about their community from large area data than the more nonchalant use
of a sophisticated data base. Although not specified for each stage in
the scale, it is assumed that the practice is actively using the avail-
able data to understand the health-relevant characteristics of their
community.
Identifying Community Health Problems
The second function in the COPC process is identifying the major
health problems of the community, characterizing their determinants and
correlates, and setting priorities among them. AS in the previous
function, the criterion that separates orthodox primary care (stage 0)
from the higher stages of COPC development is that the methods used for
examining the community health issues are based on a denominator com-
patible with the definition of the community.
The scale for this function is shown in Table 1.2. me central
variable upon which the scale is constructed is the precision and rigor
of the methods for identifying community health problems. As in the
previous scale, stage 0 represents orthodox primary care, and at this
stage no attempts have been made to identify health problems of the
community. Although many practices may be examining the patterns of
health and health care problems among their active patient population,
such practices are engaged in quality assurance and as such may be
practicing excellent primary care, but that alone does not mean they
are practicing COPC. Similarly, the practice that attempts to identify
community health problems solely by generalizing from the health pro-
blems of their patient population are not practicing COPC as it relates
to this function.
At stage I, the practice is attempting to identify health problems
of the entire community, but is doing so based on the subjective impres-
sions of the practitioner and/or community groups. Such an approach
has the advantage of being both inexpensive and continuous' but lacks
the rigor of more systematic quantitative approaches and is less likely
to identify hidden problems within the community. On the other hand,
the practice that uses formal group consensus techniques can approach
this function in a more systematic and rigorous manner, with the
advantage that consensus techniques can be constructed so an not to
constrain the range of potential problems to be considered, as is the
tendency of many quantitive approaches.
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8
TABLE 1.2 Staging Criteria for COPC Functions--Identifying Community
Health Problems
STAGE 0: No systematic efforts have been made to understand the
health status or health needs of the community; the results
from studies of the patient population are assumed to
reflect the health problems in the community as a whole.
STAGE I: Community health problems are identified through general
consensus of the providers and/or community groups.
STAGE II: Community health problems are identified by extrapolation
from systematic review of secondary data, such as vital
statistics, census data, large area epidemiological data,
etc.
STAGE III: Community health problems are examined through the use of
data sets specific to the community, but perhaps focusing
on single health problems or health care issues.
STAGE IV: Formal mechanisms (usually but not always epidemiologic
techniques) are used to identify and set priorities among
broad range of potential health problems in the community.
identify their correlates and determinants, and character-
ize the existing patterns of health care related to the
problem.
At stage lI, the practice uses data to identify community health
problems, but must do so by extrapolation from large area statistics.
The validity of the approach is largely dependent on the extent to
which the large area corresponds to the community for which the prac-
tice has assumed responsibility. The use of secondary data, such as
vital statistics and census data, makes it difficult for the practice
to conduct further detailed analysis as general problem areas are iden-
tified.
At stage III, the practice identif ies and examines community health
problems with data sets specific to that community. Activities at
stage III, however, tend to focus on specific health issues, and may
run the risk of overlooking a major problem simply because it was not
included within the scope of the data set. For example, an epidemio-
logic study of diastolic blood pressure within the community may yield
sophisticated data on the distribution, correlates, and determinants of
hypertension, which in turn may lead to highly effective interventions.
However, the detail in the data set for hypertension is gained at the
expense of a broader scope of the data set. Consequently, use of this
data to identify the ca~unity's health problems may allow the practice
to overlook other (possibly more critical) health problems.
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9
Finally, at stage IV the practice is using systematic methods to
identify and set priorities among the range of health problems within
the community. An important feature of the methods that should be used
at this stage is the likelihood that they will identify health problems
that are not already known. The methods used also should characterize
the correlates and determinants of the problem and identify the compo-
nents of the problem that may be vulnerable to a health care solution.
Generally, the components of the problem may be those related to the
severity of the problem, those related to the distribution and patterns
of health care, those related to health promoting behavior, and those
related to environmental variables. At stage IV the practice is
employing methods that consider all of the problem components.
Modifying the Health Care Program
Once a priority health problem has been identified, the practi-
tioner of COPC should strive to modify the health care program to
better address the problem. For most health problems, modif ication
in the primary care program alone would be inadequate and thus the
practitioner would advocate appropriate modification in other local
community/public health programs. There being very few instances in
which all components of the health care program for a community are
under a single governing structure, the function probably will require
a great deal of cooperation among programs.
The central variable upon which the scale for this function (shown
in Table 1.3) is constructed is the specificity of the program modifi-
cation to the identified needs of the community. Thus in the ideal
situation program modifications will be targeted appropriately at a
subset of the denominator community {rather than focused on active
patients) and will often require some form of outreach or a combination
of primary care and community health program strategies.
At stage 0, the practice is not modifying the health program in
response to health problems of the larger community, although a good
primary care program will be correcting program deficiencies in the
care of the active patient population as part of their quality assur-
ance effort.
At stage I, the practice is making modifications in the health
program to address community problems, but is doing so largely in
response to local, national, or organization-wide initiatives. Thus,
while an important problem is being addressed, the specific modifica-
tions are not necessarily tailored to the unique needs and character-
istics of the particular community.
Stage II modif ications also address important health problems, but
do so largely because of the availability of special resources to
address that problem. Special resources may appear, for instance, in
the form of a practitioner with a special interest, who joins the
practice to mount a community-based health program along that special
interests Or, special resources may take the form of a grant
initiative with guidelines to address a particular health problem. In
either example, the resulting program may address an important community
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TABLE 1.3 Staging Criteria for COPC Functions--Modifying the Health
Care Program
STAGE O No modifications are made in the primary care program in
specific response to health needs of the larger community.
STAGE I: Modifications address health problems believed to exist in
the community, but are made more in response to a national
or organization-wide initiative than in response to a parti-
cular problem specifically identif fed within the community.
STAGE II: Modifications address important community health problems,
but are chosen largely due to the availability of special
resources to address that particular problem, and closely
follow guidelines that may not be tailored to the community
needs.
STAGE III: Modifications in the health care program are tailored to
the unique needs of the community and involve (where appro-
priate) both the primary care and the community/public
health components of the program.
STAGE IV: Modifications in the program involve both primary care and
community/public health components and are targeted to
specific high risk or priority groups, with active efforts
(e.g., outreach) made to reach specific high risk or prior-
ity groups within the community.
need, but will not necessarily address the problem in the most
effective manner, nor be based on the unique characteristics of the
problem in that community.
m e practice at stage III in its development for this function is
modifying the health care program in a manner that is tailored to the
particular needs of the community. Where appropriate to the problem,
modifications are made both in the primary care program and the
community and/or public health programs.
Finally, stage IV represents the idealized situation in which
mod if ications address priority health problems in the community,
involve both the primary care and community health programs, and use
active outreach strategies to focus on specific high risk or high
priority groups within the community. At this level of development.
program modifications should address several companion issues. First,
most program modifications are not intended to be directed at all
members of the community, nor are they intended to be limited to all
individuals from the community who present for or request certain ser-
vices. An integral component of modifying the health program is to
specify those individuals in the cc~unity who are the intended recipi-
ents of the new strategy. Second, modif ications in a health program
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11
are seldom achieved without some reduction in level of effort in other
areas. Particularly in small practices, the practitioners' collective
attention and energies are finite and nearly saturated. Thus, program
modifications may create Opportunity costs. even when program modifi-
cations do not involve the reallocation of funds from one effort to
another. Third, changes in the operation of a program rarely can be
accomplished by a single person. The practitioner who attempts to
modify the health care program must be adept at achieving a consensus
among fellow practitioners, support staff, and the community. Finally,
the intended target group for the program should be specified, and a
clear statement of the expected impact on the problem should be fonmu-
lated, including both negative and positive impacts.
Monitoring the Impact of Program Modifications
In the final function, the practice must monitor the effectiveness
of the program modifications, in order to determine the extent to which
it has addressed and resolved the original problem. In the design of
the evaluation, it is Critical to use a denominator that is consistent
with the definition of the community, or with the stated objective of
the program modification if it was focused on a subset of the community.
The central variable in the scale (shown in Table 1.4) is the rigor and
precision of the methods used. In this function, rigor includes the
ability of the methods to suggest both positive and negative effects of
the modification as well as the ability to pinpoint the relative defi-
ciency in the modification, e.g., the reasons that the impact was less
than anticipated.
At stage O. the practice is assessing program effectiveness by
examining the impact on the active users of health care cervices. The
denominator of such an evaluation does not reflect the entire community,
and while evaluations of this type are appropriate to orthodox primary
care, they do not meet the requirement for COPC.
At stage I, assessment of program effectiveness considers impact on
the coup unity as a whole, but is based on the subjective impressions of
the practitioners and/or community groups. While better than focusing
on active patients, this approach suffers from lack of rigor and
questionable validity of the results. A possible exception is when the
health problem being addressed includes issues of the acceptability of
the health care program to the community.
The practice at stage II of its development for this function
assesses program impact by extrapolation from large area data. AS in
earlier functions, the validity of this approach is a function of the
concordance between the population upon which the data is based and the
community being addressed.
At stage III, the practice assesses program impact by systematic
examination of data that are specific to the community. Most commonly,
these data have been collected by the practice either as a part of a
plan for routine monitoring, or as a special data collection effort to
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12
TABLE 1.4 Staging Criteria for COPC Functions--Monitoring the
Effectiveness of Program Modifications
STAGE O: Examination of program effectiveness is limited to the
impact on the active users of health services.
STAGE I: Program effectiveness is viewed in terms of impact on the
community as a whole, but is based on subjective impres-
sions of the practitioners and/or community groups.
STAGE II: Program effectiveness is estimated by extrapolation from
large area data or vital statistics.
STAGE III: Program effectiveness is determined by systematic examina-
tion of a data set that is specific to the community.
STAGE IV: Program effectiveness is determined by techniques that are
specific to the program objectives, account for differential
impact among risk groups, and provide information on the
positive and negative impacts of the program.
assess the effectiveness of the program modifications. Usually, evalu-
ation efforts at this stage are simple before-and-after designs, and
the results are subject to the weakness of this particular approach.
Finally, at stage IV the practice assesses program impact with
methods that are specific to the program objectives. Assessment tech-
niques are sensitive both to positive and negative impacts and also
attempt to identify the relative deficiency in the program and thus
support subsequent fine-tuning of the modification. Although before-
and-after designs may be used in evaluations at this stage, more
sophisticated designs are f requently employed. Ideally , assessments
take into account not only the impact on the target health problem, but
also consider the impact of potential competition for resources on a
var iety of other problems that were not addressed. Finally, although
evaluations at lesser stages for this function may emphasize improve-
ments in the processes of care (e.g., percent of pregnant women in the
community who receive adequate prenatal caret , stage IV activities
should also examine outcomes (e.g., a change in the rates of perinatal
morbidity).
In the following chapters, the case studies are presented as
expressions of COPC in several dramatically different health care
environments. In making the transition from a conceptual model to
the analysis of real world practices, it is necessary to distinguish
between activities of COPC and those that simply are reflections of
good primary care. The distinction between primary care and COPC
hinges on the manner in which the community is defined. When the COPC
practice addresses a True community, in the sociologic sense, there
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~3
is little basis for confusion. Such a community usually includes both
active patients and nonusers of service and generally has a number of
health issues on which the COPC activities can focus. However, if the
practice addresses a ~community. that consists largely of active
patients, a considerable amount of confusion arises. A" the definition
of the community approaches the simple collectivity of active patients,
the activities of COPC become synonymous with those of quality assur-
ance, and there is little difference between COPC and good primary care.
For example, the practice that is actively identifying the major health
problems of its ~active. patient population, modifying its primary care
activities to address the problems, and monitoring the impact of program
modifications may be practicing excellent primary care. It is not, how-
ever, necessarily engaged in COPC, and will not lead to better health
care for the larger community. Similar efforts can only be considered
to be COPC if they are directed at the health or health care problems
of a distinct community for which the practice has assumed responsibil-
ity. The exception would be the practice that originally accepted res-
ponsibility for a distinct community and subsequently was successful in
converting the entire community into a numerator of users of health
services.
m e distinction between primary care and COPC has some additional
considerations in the case of family practice. Many family practi-
tioners consider their patient population to be all members of all
households in which any single member is an active user of services.
A practice population defined in this manner has several of the charac-
teristics that make it a particularly well suited for the COPC process:
the ca~u.`unity is not by def inition limited to active users of
primary care services
the households are entities with health problems that af feet
all household members, but do not necessar fly reside wholly
with any single member (e.g. , environmental hazards, poor
family dynamics, etc.
· the households represent entities that are ~accessible. and
~actionable. through the COPC activities.
The family practice group that fulfills the COPC functions to
address major health problems of this type of practice community would
not only be a model of family practice but also would be practicing
COPC. Other primary care practices could extend the group to whom they
are responsible for health care to include components that would be
considered a community. For example, the pediatr to practice that
considers its community to include all of its active patients and all
of the children enrolled in the local school system also would be in a
position to practice COPC. Therefore, any primary care program could
begin to approach the practice of COPC with a rational expansion of its
community beyond the sample inclusion of its active patients.
During the site visits for these case studies, many of the prac-
tices offered as examples of COPC a variety of activities that had all
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14
the characteristics of quality assurance for a population of active
patients. For the most part, the case studies made a distinction
between activities that focused on the active patient population and
those that addressed health problems of the total community. Often,
however, this distinction was not entirely clear and some elaboration
on the distinction at this point is appropriate. In general, quality
assurance focuses on the user population to identify problems in the
provision of health services, modify the services to correct deficien-
cies, and monitor the impact of the modifications on the resolution of
the original problem. Quality assurance deals with the structures, pro-
cesses, and outcomes of care to assure that effective and appropriate
primary care services meet the basic definitional criteria of accessi-
hility, continuity, comprehensiveness, coordination, and accountability
The important feature to emphasize is that quality assurance focuses on
the ~active. patients of the practice. COPC also is a quality assur-
ance activity but has an added concern for a broader community consist-
ing of nonpatients as well as active users of primary care services.
The COPC process strives to assure that the primary care services system
is directing its primary care capability toward the health problems that
are most important for the health of the overall community, including
both ~users. and ~nonusers. of service.
.
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15
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Representative terms from entire chapter:
care program
