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5 Conclusions and Recommendations I n approaching its statement of task, the committee reviewed the relevant literature; assessed the current policy context; listened to testimony; engaged in multiple discussions with CDC, HRSA, and other stakehold- ers; and drew on its members’ own experiences. Through this process, the committee reached a number of conclusions about the integration of pri- mary care and public health and formulated five recommendations whose implementation could advance integration to improve population health. CONCLUSIONS The committee developed the following overarching conclusions: • The principles identified by the committee in Chapter 2 represent an aspirational yet actionable framework for accelerating progress toward achieving the nation’s population health objectives through increased integration of primary care and public health services. • The committee finds that in its current state, the infrastructure for both primary care and public health is inadequate to achieve the nation’s population health objectives. • Current patterns of health policy focus and investment lack the alignment necessary to develop an integrated and enduring national infrastructure that can broadly leverage the assets and potential of primary care and public health. • To address this need adequately, agencies both within and outside of the Department of Health and Human Services (HHS) will have 143
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144 PRIMARY CARE AND PUBLIC HEALTH to be engaged. The committee notes that there are precedents for this kind of systematic strategy development and investment in national programs, such as the Hill-Burton program to build the nation’s hospital infrastructure, investment in the National Insti- tutes of Health and its extramural programs to build the nation’s biomedical research infrastructure, and preferential funding for specialty medicine to build high-tech clinical capacity. There has never been an analogous comprehensive and sustained investment in the nation’s primary care and public health infrastructure. • While national leadership and prioritization will be needed if the necessary infrastructure is to be built, the committee believes that emerging organizational and funding models for the personal health care delivery system and unprecedented investment in public health and community-based prevention can be leveraged to promote the necessary alignment. However, no single best solution for achieving integration can be prescribed. Community-level application of the framework represented by the principles for integration identified by the committee will require substantial local adaptation and the development of specific structures, relationships, and processes. • Academic health centers often are well positioned to facilitate the integration of primary care and public health and the development of improved means of engagement and integration, as they are often located in communities of need and draw both their patients and their employees from these communities. As illustrated by several of the examples highlighted in Chapter 2, academic health centers can serve as effective partners with both health centers and local health departments in sharing data; aligning clinical, research, and educational programs; and sustaining integrated operations aimed at improving the health of the entire community. Some academic health centers appear to be actively engaged in this role; however, many are not. The evidence in this area is sparse, but the committee believes that creating an interface for the Health Resources and Services Administration (HRSA) and the Centers for Disease Control and Prevention (CDC) to work with academic health centers, their primary care programs, and their local health departments to promote the integration of primary care and public health is an opportunity that should be explored. • The committee believes that a starting point for catalyzing and promoting greater integration of primary care and public health is leveraging existing funds and policy initiatives. Table 4-1 in Chap- ter 4 highlights opportunities in the Patient Protection and Afford- able Care Act (ACA) that HRSA and CDC can exploit for greater integration. Of particular note is the amendment to the Internal
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145 CONCLUSIONS AND RECOMMENDATIONS Revenue Code that requires local hospitals seeking tax exempt status to conduct community benefit assessments. This effort could be linked with primary care providers and local health departments to build on local expertise and other assessments already under way, forging stronger relationships and encouraging stakeholders to work toward the common goal of improving the community’s health. RECOMMENDATIONS As stated above, the committee regards the principles for integra- tion outlined in Chapter 2 as a framework for action. Implementation of the following recommendations—aimed at the agency and department levels—would assist the leadership of HRSA, CDC, and HHS in creating an environment that would support broader application of these principles. Agency Level Recommendation 1. To link staff, funds, and data at the regional, state, and local levels, HRSA and CDC should: • dentify opportunities to coordinate funding streams in selected i programs and convene joint staff groups to develop grants, re- quests for proposals, and metrics for evaluation; • reate an environment in which staff build relationships with each c other and local stakeholders by taking full advantage of opportu- nities to work through the 10 regional HHS offices, state primary care offices and association organizations, state and local health departments, and other mechanisms; • oin efforts to undertake an inventory of existing health and j health care databases and identify new data sets, creating from these a consolidated platform for sharing and displaying local population health data that could be used by communities; and • ecognize the need for and commit to developing a trained work- r force that can create information systems and make them efficient for the end user. HRSA and CDC should take a number of leadership actions to encour- age local integration efforts. For example, involving representatives from each agency in the development of grants and other funding mechanisms would assist in aligning funds for a common purpose. Likewise, HRSA and CDC should leverage staff at the state, regional, and local levels to promote integration efforts. Either working through health.data.gov, an
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146 PRIMARY CARE AND PUBLIC HEALTH effort to compile various health data sets, or directly (U.S. Government, 2012), the agencies should commit to convening data experts to undertake a thorough inventory of their databases, identify new data sets, compare the findings, and seek opportunities to consolidate these assets. These ef- forts should lead to the creation of a consolidated platform for sharing health care and population health data. This platform could ensure that communities can use these data in assessments, intervention planning, and evaluation. The platform would not be “owned” by primary care or public health, but would constitute local neutral space where both sectors could come together to use data that would support the achievement of better health outcomes. The 2011 Institute of Medicine (IOM) report For the Public’s Health: The Role of Measurement in Action and Accountability provides recommendations that would be relevant to this endeavor. Also needed is a workforce that is trained in developing information systems and making them work for the end user. HRSA and CDC both have a role in the creation of this workforce. The committee recommends that appropriate incentives to encourage integration be developed at the national level (see Recommendation 5). In some cases, however, such incentives will be developed locally. HRSA and CDC should work with local partners to recognize and learn from these cases. Recommendation 2. To create common research and learning networks to foster and support the integration of primary care and public health to improve population health, HRSA and CDC should: • upport the evaluation of existing and the development of new s local and regional models of primary care and public health integration, including by working with the Centers for Medi- care & Medicaid Services (CMS) Innovation Center (CMMI) on joint evaluations of integration involving Medicare and Medicaid beneficiaries; • ork with the Agency for Healthcare and Research Quality’s w (AHRQ’s) Action Networks on the diffusion of best practices related to the integration of primary care and public health; and • onvene stakeholders at the national and regional levels to share c best practices in the integration of primary care and public health. Substantial opportunities exist to understand models of successful and sustainable integration taking place in local communities and diffuse that knowledge. Through their role as conveners, HRSA and CDC should take the lead in facilitating a better understanding of the lessons of successful integration from the field. The agencies might consider holding an annual
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147 CONCLUSIONS AND RECOMMENDATIONS summit; creating a learning collaborative; publishing key findings in vari- ous venues, including peer-reviewed journals; and using other mechanisms for sharing findings with stakeholders to foster greater understanding of integration and encourage it at the local, state, and national levels. In addi- tion, the two agencies should work with other agencies, such as the Centers for Medicare & Medicaid Services (CMS) and the Agency for Healthcare Research and Quality (AHRQ), to encourage ongoing evaluation of integra- tion efforts and the diffusion of best practices. Recommendation 3. To develop the workforce needed to support the integration of primary care and public health: • RSA and CDC should work with CMS to identify regulatory H options for graduate medical education funding that give priority to provider training in primary care and public health settings and specifically support programs that integrate primary care practice with public health. • RSA and CDC should explore whether the training component H of the Epidemic Intelligence Service (EIS) and the strategic place- ment of assignees in state and local health departments offer ad- ditional opportunities to contribute to the integration of primary care and public health by assisting community health programs supported by HRSA in the use of data for improving community health. Any opportunities identified should be utilized. • RSA should create specific Title VII and VIII criteria or prefer- H ences related to curriculum development and clinical experiences that favor the integration of primary care and public health. • RSA and CDC should create all possible linkages among HRSA’s H primary care training programs (Title VII and VIII), its public health and preventive medicine training programs, and CDC’s public health workforce programs (EIS). • RSA and CDC should work together to develop training grants H and teaching tools that can prepare the next generation of health professionals for more integrated clinical and public health func- tions in practice. These tools, which should include a focus on cultural outreach, health education, and nutrition, can be used in the training programs supported by HRSA and CDC, as well as distributed more broadly. A retooled workforce is one of the most promising ways to model and encourage more complete integration. This retooling will require that primary care providers be educated about public health; that public health workers be educated about primary care; and, most important, that a
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148 PRIMARY CARE AND PUBLIC HEALTH new cadre of workers who can bridge both sectors in pursuit of improved population health be developed. To achieve significant advances in popu- lation health, these efforts must span the life course from preconception through conception, birth, childhood, adolescence, young adulthood, and adulthood and into later life. To this end, joint Title VII/VIII applications could be used to create medicine/nursing workforce training opportunities with the ultimate goal of preparing an integrated workforce capable of working across primary care and public health. In a similar vein, Epidemic Intelligence Service officers could act as a bridge between primary care and public health by helping to transform public health data into information that primary care providers could use at the local level. Department Level Recommendation 4. To improve the integration of primary care and public health through existing HHS programs, as well as newly legis- lated initiatives, the secretary of HHS should direct: • MMI to use its focus on improving community health to sup- C port pilots that better integrate primary care and public health and programs in other sectors affecting the broader determinants of health; • he National Institutes of Health to use the Clinical and Trans- t lational Science Awards to encourage the development and dif- fusion of research advances to applications in the community through primary care and public health; • he National Committee on Vital and Health Statistics to advise t the secretary on integrating policy and incentives for the capture of data that would promote the integration of clinical and public health information; • he Office of the National Coordinator to consider the develop- t ment of population measures that would support the integration of community-level clinical and public health data; and • HRQ to encourage its Primary Care Extension Program to cre- A ate linkages between primary care providers and their local health departments. As stated earlier, the committee believes that current opportunities in the health system could be leveraged to create greater integration of primary care and public health. A number of existing and newly created programs could be used as a starting point for strengthening integration, and the committee encourages the secretary of HHS to take full advantage of these opportunities. While the above list is not complete, the committee believes
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149 CONCLUSIONS AND RECOMMENDATIONS it could be used to begin the effort, but also urges the secretary to look for other opportunities. Recommendation 5. The secretary of HHS should work with all agen- cies within the department as a first step in the development of a national strategy and investment plan for the creation of a primary care and public health infrastructure strong enough and appropriately integrated to enable the agencies to play their appropriate roles in fur- thering the nation’s population health goals. By engaging HHS agencies to work together in creating an infra- structure to facilitate the integration of primary care and public health, the secretary could create momentum around this topic. To achieve a truly national strategy and infrastructure, however, agencies beyond HHS should be involved. The National Prevention, Health Promotion and Public Health Council, chaired by the Surgeon General, could undertake this task. Alternatively, the Domestic Policy Council, which is currently leading the Obama administration’s policy on place-based initiatives, could be engaged on this topic. To improve the population’s health and meet national health goals, such as those of Healthy People 2020, the committee encourages the secre- tary to explore ways of leveraging funding through existing programs, pool existing resources, and create incentives that will encourage a willingness to integrate among local stakeholders. BROADER OPPORTUNITIES FOR INTEGRATION While its task was to assist HRSA and CDC in identifying opportuni- ties to integrate primary care and public health, the committee believes it would be remiss if it failed to note some broader opportunities for integra- tion. Although the opportunities touched on below are not the focus of this report, the committee encourages those working in primary care and public health to explore them. The patient-centered medical home, discussed in Chapter 4, has been endorsed by primary care providers and others (American Academy of Fam- ily Physicians et al., 2007; IOM, 2010; National Partnership for Women & Families, 2012). As a model that emphasizes care coordination facilitated by increased data sharing, as well as the role of the patient’s family and community, it provides a clear-cut opportunity for integrating primary care and public health. Given the provisions in the ACA that promote the expan- sion of the patient-centered medical home concept for Medicaid patients, more primary care practices are expected to move toward this model. As
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150 PRIMARY CARE AND PUBLIC HEALTH they do so, health departments could be poised to work with them, diffus- ing the benefits of care coordination into the community. Another opportunity created in the ACA, and discussed in Chapter 4, is accountable care organizations (ACOs), groups of hospitals and clinicians that work together to provide care for a panel of Medicare beneficiaries (at least 5,000). While the role of ACOs is to provide primary care and other health care services, partnering with health departments would broaden the range of services available to the patient panel. As the first ACOs begin operating in 2012, they should reach out to health departments to forge links to community programs and public health services. Employer groups provide another opportunity for integration. Busi- nesses are increasingly concerned about the health of their own workers and their social responsibility in the communities in which they are located and in which their markets exist. The National Business Group on Health and regional groups such as the Pacific Business Group on Health and the Midwest Business Group on Health are active in developing initiatives in which businesses can contribute to local community health. Primary care providers could have a role in working with these groups. While health departments have responsibility for providing public health services in most places in the United States, they do not exist in some places. In those cases, public health services are provided by other entities, such as community organizations or academic health centers. Primary care groups should consider partnering with these entities in places that lack formal health departments. Finally, two large-scale policy initiatives could support integration: the place-based initiatives supported by the White House and the National Pre- vention Strategy issued by the National Prevention, Health Promotion and Public Health Council. As discussed in Chapter 4, place-based initiatives focus resources in areas such as economic development, transportation, education, or health promotion to create coordinated action. Coordination of the delivery of these resources creates alignment that impacts the com- munity as a whole. The emphasis of these initiatives on local communities echoes the principles necessary for integration. Through its implementa- tion, this policy could encourage primary care and public health to work together to improve population health. The National Prevention Strategy is an integrated national strategy designed to improve the health of the na- tion by encouraging partnerships among government entities, businesses, community-based organizations, individuals, and others. With its focus in four areas—healthy communities, clinical and community preventive services, empowered people, and the elimination of health disparities—the strategy aligns closely with the principles for integration. This strategy also could serve as a catalyst for promoting the integration of primary care and public health.
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151 CONCLUSIONS AND RECOMMENDATIONS These final two policy examples represent the type of broad, inter- sectoral collaboration that is necessary to realize significant, sustained improvements in population health. Through an improved understanding of the broad determinants of health, it has become abundantly clear that a wide array of public and private actors contribute directly or indirectly to the health outcomes of the nation’s population. By establishing a uni- fied focus on health, these actors can work with one another to produce a greater impact than any could achieve on its own. With explicit missions to foster healthy populations, primary care and public health have critical roles in population health. Through integration, both sectors can increase their capacity to directly improve the health and health care of people in communities nationwide. And by linking with other organizations, institu- tions, and community resources, the leadership of primary care and public health can set the pace for interdisciplinary, intersectoral cooperation and help establish a national focus on the health of communities. REFERENCES American Academy of Family Physicians, American Academy of Pediatrics, American Col- lege of Physicians, and American Osteopathic Association. 2007. Joint principles of the patient-centered medical home. http://www.pcpcc.net/content/joint-principles-patient- centered-medical-home (accessed December 15, 2011). IOM (Institute of Medicine). 2010. The future of nursing: Leading change, advancing health. Washington, DC: The National Academies Press. IOM. 2011. For the public’s health: The role of measurement in action and accountability. Washington, DC: The National Academies Press. National Partnership for Women & Families. 2012. National Partnership for Women & Families. 2012. http://www.nationalpartnership.org/site/PageServer (accessed February 14, 2012). U.S. Government. 2012. Health data community. http://www.data.gov/health (accessed Febru- ary 14, 2012).
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