Primary Care and Public Health: Exploring Integration to Improve Population Health (2012)

2

Integration: A View from the Ground

Recognizing that there are no broadly accepted or implemented models of primary care and public health integration, the committee sought to identify promising examples that would both demonstrate the potential for integration and guide the development and implementation of future integration models. To this end, the committee reviewed the published and gray literature. This chapter describes this literature review, presents key principles derived from the review, and highlights examples thus identified in communities across the United States that both embody the key principles and respond to the committee’s statement of task.

PREVIOUS REVIEWS OF INTEGRATION

As part of its literature review, the committee looked for previous reviews of primary care and public health integration. This search yielded only two major efforts that addressed this topic directly, undertaken by McMaster University (Martin-Misener et al., 2009) and the American Medical Association (Sloane et al., 2009). However, a study conducted by Lasker and the Committee on Medicine and Public Health (1997) provided valuable insights into the integration of medicine and public health. The committee believes all three of these studies are worth highlighting.

McMaster University Review of Primary Care
and Public Health Collaborations

In 2008, McMaster University conducted a literature review to gain an understanding of and derive lessons from examples of primary care and public health collaborations (Martin-Misener et al., 2009). A rigorous search resulted in a collection of 114 articles, published between 1988 and 2008, that described examples of such collaboration occurring across Canada, the United States, the United Kingdom, Australia, New Zealand, and Western Europe. After reviewing these examples, the authors drew a number of conclusions about why primary care and public health entities have engaged in collaboration, the types of activities typically carried out in such collaborations, and the major facilitators of and barriers to collaboration.

The authors note the wide variety of examples they collected. Differences among localities in organizational structure and community health needs have led primary care and public health to connect in different ways. Collaborative efforts have arisen from policy mandates; from a natural alignment of goals; and in response to specific, shared challenges. These collaborations also have engaged in a broad range of activities. Box 2-1 lists the major areas of activity appearing in the McMaster literature review.

The review also found that some collaborations were more successful than others. From the available literature, the authors derived a number of factors that tended to influence the success of collaborative efforts. Table 2-1 identifies some of the facilitators of and barriers to collaboration across different levels of the health care system.

Successful collaborations were found to result in improvements in health service delivery, funding and resource allocation, and population health outcomes. The authors recommend further research and evaluation of methods for collaboration between primary care and public health.

TABLE 2-1 Facilitators of and Barriers to Primary Care and Public Health Collaboration

SOURCE: Martin-Misener et al., 2009.

American Medical Association Review of Partnerships Between
Primary Care Practices and Public Health Agencies

In 2009, the American Medical Association and the University of North Carolina conducted a review of partnerships between primary care practices and public health agencies (Sloane et al., 2009). Through a review of the published literature and a qualitative study of 48 programs, the authors examined the structure of successful collaborations and the factors that led to partnership formation. They found that most of the partnerships they reviewed addressed one of three issues: increasing access of underserved individuals and populations to primary care, enhancing prevention resources for individuals and communities, and improving the quality of care for people with chronic diseases (Sloane et al., 2009). Partnerships typically

were initiated by public health professionals. Primary care physicians who were receptive to partnership generally embraced a community-based approach to medicine. Incentives for primary care practices and public health agencies to interact included grant requirements that encouraged collaboration, a mutual benefit from collaboration or a shared goal, and positive experiences in prior professional relationships. The more successful partnerships often developed a shared mission with a formalized structure and clearly defined roles. They were driven by strong leadership and established ongoing communication between the two sectors.

Lasker and the Committee on Medicine and Public Health
Review of Medicine and Public Health Collaborations

In 1997, Lasker and colleagues conducted a study of collaborations between medicine and public health to support the Medicine and Public Health Initiative (Lasker and Committee on Medicine and Public Health, 1997). Examples of such collaborations were solicited from medicine and public health professionals, government health agencies, and other relevant stakeholders. The authors collected and reviewed more than 400 examples, and assessed their structure and the relationships involved. A wide variety of organizations were found to have a role in these collaborations. Box 2-2 lists some of the types of organizations that were identified.

These organizations were found to interact in different ways and for different purposes. The authors identified six “synergies” describing the most prominent ways in which resources and skills were combined in a medicine and public health collaboration. Table 2-2 presents these synergies, along with examples of how they are carried out.

It is important to note that the synergies were not exclusive of one

TABLE 2-2 Synergies of Medicine and Public Health Collaboration

SOURCE: Lasker and Committee on Medicine and Public Health, 1997.

another; rather, an example often reflected more than one synergy. In fact, some of the most successful examples were ones in which partners combined their resources to address multiple concerns.

THE COMMITTEE’S LITERATURE REVIEW

The purpose of the committee’s literature review was twofold: to gain an understanding of the prevalence of and methods employed by current and recent integration efforts, and to identify a small set of illustrative programs from which key principles for successful integration could be derived. To meet those aims, the review was limited to articles describing an operational (not a theoretical) program that was active in 2000 or later and involved some level of interaction between primary care and public health with the goal of improving population health. Both domestic and international examples were included.

To identify such programs, the committee conducted a search of peerreviewed journal articles using the PubMed and Medline databases. Keywords relating to the overarching topic areas of primary care, public health, integration, and population health were linked in various combinations using Boolean operators. To supplement the formal literature search, the committee also conducted a grey literature search using the New York Academy of Medicine’s grey literature database and the National Technical Information Service database. Additionally, examples of integration were solicited by querying committee members, stakeholders (including the Health Resources and Services Administration [HRSA ] and the Centers for Disease Control and Prevention [CDC]), advocacy and professional organizations, and researchers who had done work in the field). After an initial scan of titles and abstracts for basic relevancy, more than 3,000 articles or case descriptions were identified. Abstracts and summaries of those articles were reviewed for general appropriateness, and any article or case description that potentially included a useful example of primary care and public health integration was identified for further review. This process yielded 632 articles.

Finally, these remaining articles were carefully read and evaluated based on the strength of linkages between primary care and public health, as well as the robustness of population health outcomes. Preference was given to examples that involved interaction between distinct primary care and public health entities, with an emphasis on the inclusion of health departments. This process yielded a final 100 articles or case descriptions that contained examples of integration for further review.

This set of examples was delivered to commissioned authors Philip Sloane and Katrina Donahue, who assessed them based on:

•   Scope of the population served;

•   lenth of time the program was/has been in operation;

•   degree of collaboration between primary care and public helth;

•   robustness of the evaluation and outcomes; and

•   degree of inovation (using the author's subjective assessments).

The committee supplemented this analysis with additional examples from its members’ own expertise to create a final portfolio of examples.

Limitations

The most striking aspect of the committee’s literature review was the relatively limited number of articles that described robust examples of primary care and public health integration supported by outcomes. This lack of strong examples may be attributable in part to limitations of the review itself. First, an article describing an example of primary care and public health integration may not identify itself as such; rather, integration examples often are presented as a potential solution to a specific health problem or organizational challenge. Therefore, a search tailored to identifying instances of terms related to primary care, public health, and integration used in conjunction with one another potentially could miss many relevant examples. At the outset, in recognition of this potential limitation, the initial search cast a broad net, yielding more than 3,000 results; however, relevant articles may have been overlooked. In an effort to fill some of these gaps, stakeholders, including HRSA and CDC, and committee members were asked to submit additional relevant examples.

A second limitation is that the review was restricted to published articles. There may be a number of effective integration examples in practice that have neither been described nor evaluated in the peer-reviewed literature.

A third limitation is that the articles reviewed often provide brief or incomplete descriptions of programs. Many of these articles were written to highlight a program’s impact on specific health outcomes or to describe specific program elements, and articles often were tailored to the perspective of the audience for which they were written—for example, clinical and public health audiences. As a result, it was often difficult to assess the degree and breadth of integration in a program or obtain a complete understanding of the program’s impact.

Finally, it is possible that there are fewer examples of integration under way than the committee anticipated, so that fewer were uncovered than was expected.

Based on these limitations, the committee believes that the integration

of primary care and public health could be facilitated by increased evaluation efforts. A series of thorough evaluations of integration efforts currently under way would assist in building a knowledge base, which in turn would enable a richer understanding of the processes by which integration can occur successfully and of the outcomes associated with integration.

Breadth of Examples

Even with the limitations outlined above, the literature contained many promising examples of integration. These examples reflect a wide variety of approaches and highlight a number of ways in which primary care and public health can be aligned to address community health concerns.

Focus Areas for Integration

Many of the integration examples uncovered by the literature review converged around a specific health issue that was identified as a community area of concern. At times these issues were identified by formal community assessments, but more commonly they were recognized by leaders of one or more of the partners using supporting data. The focus of nearly all of these examples fell into one of three categories: chronic disease, prevention and health promotion, or the health of specific populations.

Chronic disease Chronic diseases often have a large public health impact and can require the application of a diverse array of care and management techniques. A number of communities have discovered that the actions of primary care or public health alone are not sufficient to effectively mitigate the impact of chronic diseases on population health. Instead, they have endorsed collaborative, coordinated efforts focused on prevention, care, and outreach that have had some positive results. For example, in response to a statewide increase in the prevalence of diabetes and associated complications, the Michigan Department of Community Health implemented the Michigan Diabetes Outreach Network. The network consists of six independent, regional networks that carry out the Department of Community Health’s mission to “create innovative partnerships to strengthen diabetes prevention, detection, and treatment” (Constance et al., 2002, p. 54). The regional networks partner with and support health professionals, businesses, and community groups to identify and reduce disparities in diabetes care, strengthen community resources, enhance knowledge of the disease among health care professionals, raise community awareness, and facilitate data collection and use. Activities of the regional networks have included public awareness campaigns; the development of systems for use in medical practice to promote adherence to established care guidelines; the

implementation of health professional education and certification programs in diabetes care; and the initiation of a data collection and reporting system for use by home care providers, physician offices, and diabetes support groups. The program has demonstrated improved health outcomes for Michigan residents with diabetes, as well as a dramatic expansion of the reach and prevalence of community awareness events and health professional education programs (Constance et al., 2002).

Prevention and health promotion Chapter 1 highlights the importance of prevention and health promotion activities for improving population health. The impact of these types of activities depends on the ability to reach as much of the target population as possible in a meaningful way. Both primary care and public health have critical roles in prevention and health promotion and are positioned to carry out these roles with different sets of resources and relationships within the community. Many of the examples from the literature review show that, by linking primary care, public health, and the community, coordinated, cooperative approaches to prevention and health promotion can expand the reach and effectiveness of such endeavors.

In a number of cases, a public health partner would seek the involvement of primary care providers to assist in a key public health campaign. These collaborative efforts sought to utilize the individual relationship between provider and patient to complement population-level interventions. Some examples include public health personnel training primary care providers to deliver evidence-based behavioral interventions and linking primary care providers to public health and community resources such as tobacco quit-lines (Larson et al., 2006; Rothemich et al., 2010).

Another approach for integrating around prevention involves primary care, public health, and community groups combining efforts to ensure the broad delivery of clinical preventive services at diverse venues throughout communities. Sickness Prevention Achieved through Regional Collaboration (SPARC), a nonprofit agency, implemented this type of method in the New England area (Shenson et al., 2008). In response to low rates of adult vaccination and cancer screening rates in the area, SPARC leadership recognized that primary care alone could not bear the responsibility of ensuring the community-wide delivery of preventive services. Instead, SPARC positioned primary care providers as partners in a community-spanning coalition of public health and community resources. The program brought together public health agencies, hospitals, social service organizations, and advocacy groups to form a network of prevention activities. Coordination among these groups and with primary care helped ensure a broader reach for prevention services and avoided duplication of effort. The inclusion of a variety of community partners led to the development and widespread

implementation of innovative approaches tailored to community needs. SPARC’s initiatives have been associated with regional improvements in rates of vaccination and cancer screening, and the SPARC coalition-based model has been replicated successfully in other communities (Shenson et al., 2008).

Health of specific populations Providing for the health of certain populations, such as the uninsured, who can be difficult to reach, or older persons living alone who require care outside of a health care delivery setting can present challenges that are difficult for either primary care or public health to handle alone. The Iowa Department of Public Health developed its 1st Five Initiative to address gaps in service provision for young children with risk factors for and evidence of developmental delay during the first years of life (Silow-Carroll, 2008). The program links primary care providers to public health resources and mental and behavioral health services. Features of the program include training primary care providers in assessment of social and emotional development, providing a public health care coordinator to whom the primary care providers could refer children who screened positive, using the coordinator to link the child and family to intervention services, and providing feedback to the primary care provider on the status and outcomes of the referral. This system fostered a coordinated, collaborative approach to care for the developmental needs of at-risk children. Building on its early successes, the initiative had recruited 39 practices serving 41,000 children by 2008 (Silow-Carroll, 2008).

Organization for Integration

A striking feature that emerged from the literature review is the number of different ways in which integrated efforts were organized. A wide variety of entities were involved in activities and programs that linked primary care and public health. These entities included not only a range of primary care and public health actors but also a number of other contributors, such as businesses, hospitals, academic institutions, and community groups. Additionally, integrated projects were initiated by public health entities, by primary care entities, and by neutral third-party conveners of the two fields, and across examples the extent of the contribution from primary care and public health was varied. Much of this variation is attributable to differences in communities across the country in terms of available primary care, public health, and community resources, as well as in their populations’ makeup and health priorities. Successful integration efforts often were tailored to the community’s strengths and needs.

A number of examples were initiated and led by public health entities, often health departments. For instance, the health department of

Alachua County, Florida, joined with the local public school system and the University of Florida to initiate a program designed to increase rates of influenza vaccination among school-aged children (Tran et al., 2010). A critical component of the program’s success, however, was establishing linkages with primary care providers. Through the vaccination program, children received a free nasal-spray flu vaccine in school, regardless of their insurance status. Children who were ineligible for this vaccine because of underlying medical conditions were referred to their provider for evaluation and the flu shot. This kept private pediatricians in the medical care loop for children with underlying medical conditions, a key component of the medical home concept, as well as a key element in maintaining strong support from community physicians. Both pediatricians and the health department input flu vaccination status into the state’s registry so both groups could share information about their patients.¹ In the 3 years since the program became fully operational, immunization rates have increased. In 2009-2010, the program was able to immunize approximately 55 percent of the student population, and an additional 10 percent who could not receive the nasal-spray flu vaccine for medical reasons were immunized by their care providers. In schools where 80 percent or more of the students were eligible for free or reduced-price lunches, the immunization rate went from 12 percent in the 2006 pilot program to 47 percent in 2009-2010 (Tran et al., 2010). Immunization rates for 2010-2011 were similar.²

While a majority of the integration examples examined by the committee featured public health-led ventures, there were instances of primary care entities initiating successful collaborations. In Milwaukee, the Sixteenth Street Community Health Center initiated a Community Lead Outreach Project designed to assist in the Milwaukee Health Department’s efforts to reduce lead poisoning rates in children by reaching out to an underserved neighborhood. The program employed a team of community outreach workers, led by a nurse-coordinator from the health center. The team conducted home visits, provided blood testing, performed environmental surveys, and reported results to both the health center and the health department for follow-up care and possible intervention. The program resulted in significant decreases in the prevalence of lead poisoning in the area (Schlenker et al., 2001).

In some instances, primary care and public health were brought together by a neutral convener, often a nonprofit organization or academic institution. In the SPARC initiative, discussed previously, a nonprofit organization formed a coalition of primary care, public health, and community groups to take a comprehensive approach to expanding the delivery of

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¹Personal communication, C. Tran and Parker Small, University of Florida, November 2011.

²Personal Communication, C. Tran, University of Florida, December 2011.

clinical preventive services (Shenson et al., 2008). Organizing the endeavor as a coalition allowed each entity to contribute toward a common goal as befit their respective resources and role in the community.

In North Carolina, the Linkages for Prevention project brought together primary care practices and departments of health in one county to improve health outcomes for low-income mothers and infants (Margolis et al., 2001). The partners formed an advisory board, which included the Medicaid director, community agencies, primary care practices, and county government. The program sought to improve services in both primary care and public health, as well as to enhance communication and coordination of efforts between the two. The program worked to improve the delivery of preventive care in primary care practices and to assist the public health department in implementing intensive home visits to low-income pregnant women and their infants. The home visiting component included conducting two to four visits per month in the infant’s first year of life, providing parental education, and linking parents with needed health and human services. To evaluate outcomes, 103 mothers with infants were compared with 105 controls. Improvement was seen in preventive service outcomes, including a higher number of well-child visits by age 12 months (57 percent versus 37 percent), and children were less likely to be seen for injuries and ingestions compared with controls (2 percent versus 7 percent) (Margolis et al., 2001).

Opportunities for Integration

The literature revealed some promising opportunities for integrating primary care and public health.

Data A key opportunity for integrating primary care and public health is sharing data, the focus of a number of examples gleaned from the literature review. Primary care and public health each generate data that can be leveraged by the other to support their respective functions more effectively. Through individual patient visits, primary care generates data that can be used to create population data useful to public health in conducting surveillance or community assessments. Public health assessment data can in turn be tailored to provide valuable information on the health needs and risks of the community served by a particular primary care entity, as well as to allow providers to gauge their clinical performance.

However, several factors hinder sharing data across practices and institutions, including incompatible data systems, varying use of measures, and lack of a trained workforce to develop and implement data sharing strategies. The Indiana Network for Patient Care (INPC) has approached this challenge by creating a united data aggregation hub that receives data

from many sources and standardizes them for reuse. While primary care stakeholders and local and state public health organizations are governing members, INPC is separate from primary care and public health systems, and operates by interfacing with these systems and the Indiana community at the data level. INPC is anchored by the Regenstrief Medical Record System, which collects data from a variety of sources, including hospitals, clinics, health departments, and laboratories (McDonald et al., 2005). These data are used to integrate information that can be accessed by providers, researchers, and public health workers participating in the network. A number of provisions ensure that these data are shared safely and appropriately. For clinicians—currently numbering more than 19,000 across the state³—INPC provides a community-wide database that enables access to a patient’s comprehensive medical record, which includes information that has been generated across multiple sites. The network also receives patient data generated in a wide variety of clinical settings, notifies any of the patient’s providers of these reports, and makes the information contained in the reports available to those providers. For public health and research, INPC provides population-based data for epidemiological research and helps identify candidates for particular studies. In addition, it facilitates automated reporting of laboratory results that involve notifiable conditions to state and county health departments. A recent study showed that this automated reporting process helped greatly improve public health efforts in disease surveillance compared with the traditional process of health department notification by clinicians (Overhage et al., 2008).

INPC is an example of an entity separate from primary care and public health acting as a data hub. While the committee’s statement of task included exploring the possible role of health departments as data hubs, the INPC model demonstrates the advantages of having a third party administrate such a hub. In this example, the data hub not only provides a health information exchange for use in individual patient services but also is used for population health analyses that serve public health functions. Health information exchanges achieve sustainability by delivering a broad range of cost-effective clinical data services to multiple stakeholder groups across a region or community. Many of these services may not be within the direct purview of traditional public health processes. Thus, while public health may serve as a data hub in some instances, in others it may make more sense for a third party to administer the hub.

Workforce Some of the examples from the literature review touch on the need to develop a workforce capable of working in an environment that integrates features and functions of primary care and public health or serving

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³Personal communication, S. Grannis, Regenstrief Institute, November 2011.

as a bridge between primary care and public health activities. In the REACH-Futures program, aimed at reducing infant mortality in inner-city communities in Chicago, registered nurses were teamed with public health–trained community health workers for an infant home-visiting program, managed by a community clinic. The community health workers served to link the clinic’s care initiative to public health principles and the community. In the first 4 years of the program, 666 mothers were recruited. Comparison of the REACH-Futures program with a home visiting program using only nurses showed improved retention and immunization rates (Barnes-Boyd et al., 2001).

The George Washington University School of Public Health and Health Services gives its master of public health students a perspective on primary care through its community-oriented primary care (COPC) program (George Washington University School of Public Health and Health Services, 2012). The program is designed to train health and public health professionals in implementing the concept of COPC in practice. As a part of the curriculum, students learn community definition and characterization, problem prioritization, detailed assessment, intervention, and evaluation. As a part of the required practicum, students are expected to work 120 hours in a community setting that offers health services to gain experience in integrating public health initiatives and practices into primary care. To this end, students of this program have participated in practicum experiences covering a wide variety of topics, including hospice care, childhood obesity, community-based rehabilitation, and medication coverage for the elderly.

The Primary Care Leadership Track at Duke University School of Medicine offers emerging physicians a unique opportunity to be trained as leaders capable of engaging the community and to learn various techniques for communicating and practicing to improve health outcomes (Duke University School of Medicine, 2012). Building on partnerships among Duke, the local health department, and the community, the track focuses on matriculating physicians who understand the causes of health disparities, and are driven to create a strong research focus on community engagement and to redesign clinical programs to better meet patient needs at the individual and local population levels. A requirement for the track is a scholarly third year focused on community-engaged research, population studies, or other forms of investigation of health systems and their improvement in collaboration with the Duke Center for Community Research, in partnership with the Durham County Health Department.

Nongovernmental Public Health

Given the broad nature of public health, a number of organizations, such as academic health centers, research networks, or nonprofit groups,

are performing public health functions in various contexts. These organizations can interact meaningfully with primary care to pursue population health improvement, and indeed, many such entities appear in the examples discussed previously as third-party contributors to integration efforts. In areas without a strong governmental public health presence, these organizations can substitute for a health department’s role in integration, although they usually are not responsible for the breadth of public health services that a health department typically provides. Some examples from the literature review demonstrate promise for integration but do not fit neatly into the committee’s criteria for inclusion; these examples illustrate creative engagement of community resources in addressing community health concerns by working with primary care.

In an effort to better meet the needs of the state’s rural population, which suffers from high rates of chronic disease, the University of New Mexico Health Science Center developed the Health Extension Rural Office (HERO) program in 2008 (Kaufman et al., 2010). Modeled after the agricultural extension service, the HERO program engages local agents who live in rural communities in New Mexico and work with the local health system to both foster improvements in the delivery of health services locally and facilitate access to additional services provided by the Health Science Center. These local agents are supported by regional coordinators and Health Science Center staff and work with local partners, including health planning councils, public health clinics, local health clinicians and hospitals, and area health education centers, in each community. The agents work to improve local health services and systems, help recruit a local health care workforce, and strengthen local capacity to address community health problems. In addition to helping secure medical care, HERO agents engage the community to address underlying social issues, such as school retention, food insecurity, and local economic development. They also have trained and deployed community health workers who focus on linking community members to available local resources. These efforts are tightly linked with local primary care providers, and in many cases, the HERO agent also holds a position within the local health care delivery system.

The High Plains Research Network (HPRN) is a community-and practice-based research network located in eastern Colorado. The network engages 16 hospitals/emergency departments, 58 ambulatory clinical practices, and 150 medical providers (University of Colorado, 2008). Housed in the Department of Family Medicine at the University of Colorado School of Medicine, the network is governed by an active Community Advisory Council of rural community members and medical providers (University of Colorado, 2011). The Community Advisory Council comprises 11 community members who live in the High Plains region and includes farmers, ranchers, educators, and retirees. The goal of the Community Advisory

Council is to ground the network’s research and programs in the real-life experiences of patients and community members (Van Vorst et al., 2007).

Since its creation in the late 1990s, the HPRN has focused on ameliorating a number of community health problems, including cardiovascular disease, underinsurance, colon cancer, and asthma. Given the high prevalence of asthma (nearly one in six) in the region,⁴ the network decided to develop a broad program aimed at increasing knowledge and awareness of asthma and improving the capacity to manage the disease. Led by the Community Advisory Council, the HPRN engaged primary care providers, public health professionals, community members, and university researchers to create two separate asthma toolkits. First, a practice toolkit, which included a spirometer, software, and on-site training, was developed to build capacity in the primary care practices. Two nurse coaches visited every practice, training providers and office staff in evidence-based guidelines for the evaluation and management of asthma and in communication techniques to encourage patient self-management (Bender et al., 2011). Second, a patient toolkit, which included a peak flow meter, an action plan, and culturally relevant educational materials, was developed and distributed to practices for use with asthma patients. Three months after the coaching, practices reported a significant increase in inhaled corticosteroid prescriptions (from 25 percent of practices before the intervention to 50 percent after) (Bender et al., 2011).

PRINCIPLES FOR SUCCESSFUL INTEGRATION

From the literature review described above, the committee was able to distill a number of principles for successful integration. These principles are listed below and then illustrated through the case studies that follow. The committee believes that to better integrate primary care and public health, the following principles must be in place:

•   a shared goal of population health improvement;

•   community engagement in defining and addressing population health needs;

•   aligned leadership that

–   bridges disciplines, programs, and jurisdictions to reduce fragmentation and foster continuity,

–   clarifies roles and ensures accountability,

–   develops and supports appropriate incentives, and

–   has the capacity to initiate and manage change;

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⁴Personal communication, J. Westfall, High Plains Research Network, June 2011.

•   sustainability, key to which is the establishment of a shared infrastructure and a foundation for enduring value and impact; and

•   the sharing and collaborative use of data and analysis.

CASE STUDIES

Through its review of the literature, the committee sought examples to use as case studies that demonstrate well-developed relationships between primary care and public health. Rather than highlighting programs designed to manage a single health issue, as is the case for many of the examples discussed previously in this chapter, the committee wanted to showcase linkages between primary care and public health entities that allowed them to join together to overcome a variety of community health challenges. The committee sought such examples that would demonstrate a commitment to an ongoing relationship between the two sectors and reflect the principles for integration outlined above. Case studies from Durham, North Carolina; San Francisco, California; and New York, New York, were selected and are described in this section.

Local communities serve as a laboratory for understanding the principles underlying successful integration of primary care and public health. The case studies described in this section illustrate how communities across the nation are attempting to bring diverse stakeholders together from the primary care and public health sectors to forge alliances aimed at tackling pressing community health problems and promoting population health. Evaluations of these case studies demonstrate that integration can produce improvements in at least some meaningful measures of system performance and patient-oriented outcomes. However, the case studies are as informative for what they reveal about the process of forging comprehensive and durable cross-sector collaborations as for their outcomes. These examples illustrate innovative practices and important elements of integration that the committee believes are worth highlighting.

Durham, North Carolina

Durham, North Carolina, is a small city with numerous medical and social resources that have not always translated into improved health outcomes for its inhabitants. Durham’s population of 267,000 is about 38 percent African American, 46 percent white (not Latino/Hispanic), and 14 percent Latino/Hispanic (U.S. Census Bureau, 2009), and while the median household income is slightly higher than that for the state of North Carolina, Durham residents also experience poverty at a higher than average rate. Furthermore, although Durham possesses a wealth of highly skilled primary care entities, including a top-10 ranked medical school and quickly

rising school of nursing (Michener et al., 2008), Durham residents experience rates of chronic disease and health disparity that are only slightly lower than those statewide (Michener et al., 2008). To better align the needs and resources of Durham, a number of partnerships have been created with the assistance of the state and through local determination to improve the health of the city’s residents.

Community Care of North Carolina/Durham Community Health Network

Community Care of North Carolina (CCNC) is an example of a statewide organizational structure developed to coordinate and improve the quality of care for Medicaid recipients through a series of local networks that span the entire state. Guided by a steering committee of primary care physicians, public health professionals, and other stakeholders, CCNC focuses on elements of the patient-centered medical home and chronic care models (Steiner et al., 2008). Although the networks are statewide, each of the 14 local networks is permitted and encouraged to take local actions that build on local strengths and reflect local needs. Each of the networks—including the Durham Community Health Network—is organized and operated by community physicians, hospitals, health departments, and departments of social services under the auspices of the state Medicaid program and with the support of the state medical, hospital, and public health organizations. The networks are funded by small per capita payments from Medicaid, and are responsible for improving outcomes and achieving net savings. The participating primary care practices receive additional per capita payments from Medicaid to support their work toward achieving the network goals.

In Durham, the network is led by a coalition of primary care groups, including the head of the federally qualified health center (FQHC), academic and community primary care practices, the heads of the county departments of health and social services, and the local mental health entity. Locally developed programs include common patient education materials for children with asthma that are used in all health care settings, from school clinics to emergency rooms and specialty practices. A common information technology system is used to track patients and coordinate care management. Programs go beyond the traditional medical model. For instance, the Durham Community Health Network developed the Medicaid In-Home Aide Service. This program uses occupational therapists to conduct home visits to determine whether a personal care assistant is needed, or independent living can be achieved through enhanced behavioral techniques and inexpensive medical devices. From 2008 through 2009, the Medicaid In-Home Aide Service was able to foster independent living for 61 percent of

patients requesting aide services, for less than $150 for many individuals (Cook et al., 2010).

Just for Us

The success of the Durham Community Health Network led to the creation of other coordinated and integrated programs. The Just for Us program is a parallel partnership involving Duke University School of Medicine; Lincoln Community Health Center (an FQHC); the county senior centers; county social, public health, and mental health agencies; and the city housing authority. The program provides coordinated primary care and care management to older adults and adults with disabilities in Durham’s public and subsidized housing facilities and group homes. The services are delivered by a multidisciplinary team that includes onsite physician assistants, nurse practitioners, and social workers. Services are supported by Medicaid billings through the FQHC for clinical services and social services provided, and by financial support from Duke Hospital, including payment for social services not reimbursed by Medicaid and funding in recognition of uncompensated emergency room visits avoided (Yaggy et al., 2006). By the end of its second year, Just for Us had expanded to serve nearly 300 patients over 10 locations. The program is demonstrating improvement in individual indexes of health. Medicaid expenditures for enrollees are shifting from ambulance and hospital services to pharmacy, personal care, and outpatient visits (Yaggy et al., 2006).

Durham Health Innovations

The public health department, community partners, and Duke University School of Medicine collaborated most recently on the Durham Health Innovations (DHI) project to improve health outcomes for the county as a whole. DHI is working in neighborhoods across the county to identify assets for and barriers to care and develop interventions that bring disease prevention, health promotion, and clinical services closer to where citizens live, work, pray, and play. In 2009, DHI funded 10 planning teams charged with developing new methods for reducing morbidity and mortality from diseases identified by the health department as priorities. The 10 teams of community members and clinicians, working with an oversight committee, co-led by the director of public health, and supported by data from the health department and the clinicians’ practices, identified seven common elements that could improve health and health care delivery in Durham: (1) increase health care coordination, and eliminate barriers to services and resources; (2) integrate social, medical, and mental health services; (3) expand health-related services provided in group settings; (4) leverage

information technology; (5) use “social hubs” such as places of worship, community centers, salons, and barbershops as sites for clinical and social services and information; (6) increase local access to nurse practitioners, physician assistants, and certified nurse midwives; and (7) use traditional marketing methods to influence health behavior (Duke Center for Community Research, 2010).

In 2010, DHI moved into the implementation phase, with the goal of improving health outcomes and access to care for all Durham residents. Current implementation strategies are focusing on two communities identified by the teams and a countywide implementation committee as both ready for change and likely to benefit, and detailed planning for integrated community-based care that connects the residents of these communities to local resources is now under way.

Principles of Community Engagement

The growing array of programs in Durham involving community groups, the health department, and academic and community physicians led to the establishment of a set of Principles of Community Engagement that includes specific rules for designing and planning such programs, whether clinical, educational, or research oriented (Michener et al., 2005, 2008). The Durham experience highlights the importance of using an approach to integrating primary care and public health centered on the needs of local communities. By coordinating assets through strategic partnerships, Durham leverages existing resources, improves access to and quality of care, and lowers costs.

San Francisco, California

San Francisco is a city and county with a population of about 800,000, notable for its rich ethnic and cultural diversity. As in most urban areas in the United States, health status varies widely across San Francisco’s racialethnic and socioeconomic groups and neighborhoods. San Francisco has traditionally had a strong department of public health that is involved extensively in the direct delivery of patient care to uninsured and other vulnerable populations through the operation of San Francisco General Hospital and nearly a dozen FQHCs. The safety net system also includes several unaffiliated HRSA-funded health centers operated as nonprofit organizations. The department of public health has a close relationship with the University of California, San Francisco, in the delivery of patient care, contracting with the university to provide physician staffing at San Francisco General Hospital.

In 2007, San Francisco launched the Healthy San Francisco program

to promote universal access to care (Katz and Brigham, 2011) following passage of the San Francisco Worker Health Security Ordinance of 2006. Rather than providing insurance coverage, Healthy San Francisco serves as a structured system for providing uninsured adults with affordable and relatively comprehensive health care services, offered largely at department of public health clinics, San Francisco General Hospital, and federally funded health centers. A cornerstone of the program is linking patients to a primary care medical home. An external evaluation found that Healthy San Francisco was associated with improved access to care, as well as reductions in the use of emergency departments and potentially avoidable hospitalizations (McLaughlin et al., 2011).

Healthy San Francisco has served as an exemplar of a local health department promoting access to health care built on a primary care model; the initiative focuses largely on patient care services rather than on intervention in more upstream determinants of health and illness. The department of public health also is engaged with other stakeholders in broader efforts to integrate primary care and public health to improve population health. One such effort is the San Francisco Health Improvement Partnerships initiative. This initiative originated in 2010 in discussions between leaders in the department of public health and representatives from the National Institutes of Health (NIH)–funded Clinical and Translational Science Institute at the University of California, San Francisco, about how to build more productive collaborations to apply university research assets to solving local public health problems. Diverse constituents in addition to the public health department and the University of California, San Francisco, now participate in the Health Improvement Partnerships, including the San Francisco Hospital Council, the mayor’s office, community-based organizations, community clinics, private medical groups and independent physician associations, and the school district. Representatives of many of these constituents serve on a coordinating council, and the Clinical and Translational Science Institute provides staffing and research support to the council and workgroups and pilot funding for the workgroups. Initial projects of the Health Improvement Partnerships are focused on three issues that emerged as priorities from a systematic review of San Francisco health needs assessments, described below.

High Users of Multiple Services

This project focuses on what have come to be known as “hot spotters” (Gawande, 2011), identifying individuals with extreme social risk factors, such as a combination of homelessness, substance use, and mental illness, that predispose them to unusually high and costly use of emergency, medical, mental health, criminal justice, and related services. The project has created

a data warehouse derived from 13 separate databases, which includes data on emergency medical, substance abuse, mental health, medical care, criminal justice, and other services and sectors, to create an individual-level file for each such person. Analyses of these data revealed that the top 10 high-use individuals collectively generated more than $2 million annually in costs for urgent and emergency services alone. The data warehouse is now being used by the department of public health, local Medicaid managed care health plans, and other collaborating agencies to inform strategies for better coordinating services across the primary care, community care, and social services sectors to care for this population more effectively and efficiently.

Hepatitis B Quality Improvement Collaborative

San Francisco was one of the first cities in the United States to launch a major public health campaign to promote screening for hepatitis B among populations at high risk for chronic hepatitis B. Leaders from the Asian community partnered with the department of public health to develop San Francisco Hep B Free; evaluations have demonstrated the success of this public awareness campaign in increasing screening rates among Asian immigrant populations in San Francisco, about 1 in 10 members of which are chronically infected with hepatitis B (Bailey et al., 2010). The initial public health outreach efforts of Hep B Free led to an appreciation that the primary care clinical system was not adequately prepared to respond to the screening campaign. Initial audits in health department clinics found that many patients were not being screened with the appropriate set of tests and that those testing positive were not consistently receiving follow-up care meeting evidence-based guidelines (Khalili et al., 2010). In response, the initiative developed the Hepatitis B Quality Improvement Collaborative in partnership with Hep B Free and the Health Improvement Partnerships. The Quality Improvement Collaborative has brought together quality improvement leaders from all the major medical groups in San Francisco, including the department of public health, FQHCs, Kaiser Permanente, researchers, and private medical groups, to improve the quality of care in hepatitis B screening and chronic care management for the entire city. One of the first activities has been to share best practices in developing registries of patients with chronic hepatitis B in all the participating medical groups as a cornerstone for more systematic chronic care quality improvement. The collaborative is exploring whether the public health department’s mandatory data reporting system for infectious disease surveillance might serve as a substrate for hepatitis B chronic care registries that could be applied in clinical settings by primary care physicians and their medical groups.

Physical Activity and Healthy Eating

The Health Improvement Partnerships’ work in this area has focused largely on advancing the Shape Up San Francisco campaign, initiated in 2006 by former mayor Gavin Newsom to achieve the population health aim of reducing obesity and chronic disease. An important goal of this work is enhancing coordination of activities across sectors. For example, the Health Improvement Partnerships have facilitated engagement between members of the San Francisco Board of Supervisors and the department of public health, community organizations, and researchers at the University of California, San Francisco, to identify regulatory and tax policies that could be implemented at the local level to promote healthier eating. Other cross-sector projects include Safe Routes to School and facilitation of linkages between primary care clinics and community resources for walking groups, cooking classes, and other wellness activities. These efforts set the stage for the department of public health’s successful application for a CDC Community Transformation Grant award in 2011. Interventions under this grant are just starting to be developed, so it is too early to report on specific implementation.

New York, New York

The most populous city in the United States, New York City provides a unique example of public health in America. Overseeing a city with more than 8 million residents, more than a third of whom are foreign born and nearly 20 percent of whom live below the federal poverty level, the New York City Department of Health and Mental Hygiene (NYC DOHMH) is a local health department with many of the resources and much of the regulatory authority of a state health administration. Over the past decade, many NYC DOHMH programs have embodied the principles of Take Care New York, New York City’s comprehensive health policy, which sets goals for population health improvement, generates targeted programs, and monitors their impact and progress toward success (Frieden, 2004). Since the early 2000s, Take Care New York has guided a number of NYC DOHMH initiatives designed to improve the health of city residents. These initiatives focus on the collection and analysis of citywide epidemiological data, the prevention of chronic diseases, and improvements in the social determinants of health. A number of these initiatives have engaged local health care providers and communities.

Using Electronic Health Records to Support High-Quality Primary Care

In line with the Take Care New York agenda, NYC DOHMH has taken aggressive steps to support high-quality health care and the active management of chronic diseases. At the center of this effort is the Primary Care Information Project, which supports physicians in adopting the use of electronic health records to improve population health. The Primary Care Information Project helped initiate the New York City Regional Electronic Adoption Center for Health (REACH) to assist providers in achieving meaningful use of electronic health records, with the capacity to support 4,500 providers. More than 3,500 providers have already enrolled in REACH to meet the meaningful-use criteria and better serve their communities (NYC Reach, 2011).

To further its promotion of effective use of information technology, NYC DOHMH launched Health eHearts, a pay-for-performance incentive program that rewards small practices and community health centers for achieving excellent heart health among their patients. Designed to reduce health disparities, Health eHearts uses clinical quality outcomes generated from electronic health records and provides incentives up to $25,000 per quarter to practices showing qualifying improvements in the use of aspirin, blood pressure and cholesterol management, and the promotion of smoking cessation to improve cardiovascular health. By the end of 2010, 42 practices had received an average of $38,000 each for their efforts in these areas (Marcello et al., 2011). Also in 2010, NYC DOHMH launched the Panel Management Program to help primary care providers maintain continuity of care for high-risk patients and those with chronic disease. Using registry features of electronic health records, prevention outreach specialists identify patients who are at risk for diseases associated with hypertension, high cholesterol, smoking, and diabetes, and then contact them with reminders about disease management activities such as making appointments, filling prescriptions, and receiving vaccinations (New York City Department of Health and Mental Hygiene, 2011).

Monitoring and Surveillance

The Panel Management Program’s capacity for monitoring and evaluation is grounded in the Community Health Survey, which regularly surveys 10,000 New York City residents to gather data on a variety of health measures. In 2004, a community-level Health and Nutrition Examination Survey was conducted, modeled after the nationwide survey conducted by CDC. The data thus collected resulted in several publications released by NYC DOHMH, including Health Bulletin, which directs its public health messages to city residents (Frieden et al., 2008). In addition, NYC

DOHMH was one of the first local health departments to implement syndromic surveillance—the routine surveillance of health care encounters to detect public health threats—in part to address the threat of a potential bioterrorist attack. NYC DOHMH has partnered with health care facilities to implement systems that provide its staff with nonconfidential data for daily analysis aimed at identifying disease trends and outbreaks by scanning for clustering by symptoms or health care-seeking behavior. NYC DOHMH currently monitors visits to 48 city emergency departments. Every day, hospitals transmit an electronic file to NYC DOHMH containing patients’ chief complaint, age, sex, zip code, and time of visit. The chief complaint is automatically coded as one of four syndromes (respiratory, fever-flu, vomiting, or diarrhea), and standardized analyses are performed 7 days a week by a corps of analysts at NYC DOHMH. Syndromic surveillance has enhanced the ability of public health to monitor community illness in a way that is timelier, though less specific, than traditional surveillance based on laboratory or provider reports (Heffernan et al., 2004).

Community Outreach

NYC DOHMH actively engages with local communities to promote health education and access to care. It is participating in two home visiting programs for new mothers. One of these programs, the Nurse-Family Partnership, aligns nurses with first-time mothers for weekly to biweekly visits until the child is 2 years old (Nurse-Family Partnership, 2011). The second program, the Newborn Home Visiting Program, is localized to Brooklyn, Harlem, and the Bronx. A health worker attempts to visit every new mother to promote health education, breastfeeding, and the reduction of environmental risks in the home.

NYC DOHMH also conducts community outreach to promote cancer screening. In 2003, it established the Colonoscopy Patient Navigator Program to ensure that populations facing greater screening obstacles receive a colonoscopy. The navigators are tasked with helping patients navigate the health system and overcome barriers to screening. By 2007, the Colonoscopy Patient Navigator Program had assisted more than 25,000 New Yorkers in undergoing colonoscopies. Through this program and other initiatives of Take Care New York, NYC DOHMH has seen remarkable gains in cancer screening, attributable mainly to its ability to partner with local care providers and communities. Overall rates of colon cancer screening have increased substantially since the introduction of Take Care New York—by 43 percent from 2002 to 2006; by 2009, 66 percent of adults over age 50 had been screened for colon cancer within the previous 10 years (Frieden et al., 2008; Marcello et al., 2011).

Principles of Integration Embedded in the Case Studies

The case studies described here illustrate the principles, presented earlier, that form the foundation for integrating primary care and public health.

Each of these case studies exemplifies a shared goal of population health improvement. This goal was realized in different ways in different locations. In New York, for example, the department of public health took the initiative, but only through joint efforts with primary care providers were improved outcomes possible. In San Francisco, collaborative efforts built on the success of Healthy San Francisco as a health access innovation, and then evolved to embrace a broader vision of population health.

The case studies have been presented within the context of their local communities because one unifying theme is the local variability seen in sustainable examples of integration. Community engagement is required throughout the process. In San Francisco, the community was engaged in diverse ways—not only through the traditional primary care and public health sectors but also through community-based social service organizations, political leaders, and academic researchers. Community Care of North Carolina offers a statewide organizational structure, but provides for flexibility for each of the 14 local networks to take action based on local strengths and needs. In Durham, for example, community engagement guided integration efforts using an approach that recognizes and draws on the strengths of the local community.

The third principle, aligned leadership, is embodied in each of these case studies. Aligned leadership involves more than directing a program. It reflects the ability to bridge disciplines, programs, and jurisdictions, as in the case of Durham’s Just for Us, a partnership among a community health center, county social and mental health agencies, an academic health center, and a city housing authority. Aligned leadership also entails the ability to clarify roles and ensure accountability. Community Care of North Carolina reflects the development of incentives to encourage integration. The networks created through this partnership are funded by small per capita payments based on the achievement of improved outcomes and net savings. Primary care practices receive additional per capita payments to support their population health activities. Similarly, the public health department in New York City works with primary care providers to promote cardiovascular health by providing financial incentives. Developing and supporting appropriate incentives is another aspect of leadership. The final element of aligned leadership is the capacity to initiate and manage change. In moving from the status quo to an innovative approach, each of these examples reflects this element.

Making a commitment to sustainability is the fourth principle. This commitment to sustainability is illustrated by San Francisco, where resources

were pooled, and by Community Care of North Carolina, where dedicated funding streams ensure that the program will have an enduring value and an enduring impact.

Finally, integration requires that data and analyses be shared and used collaboratively. Integration of data has been central to the work in San Francisco, from linking data sets on high users of multiple services, to agreeing on uniform hepatitis B quality metrics, to identifying existing data sources with which to track progress on physical activity and healthy eating.

While the committee believes that all these principles are ultimately necessary to integrate and sustain integration efforts, it also believes that integration can start with any of these principles and that starting is more important than waiting until all the elements are in place.

HOW THE EXAMPLES AND CASE STUDIES ILLUSTRATE
EFFECTIVE PRIMARY CARE AND PUBLIC HEALTH INTEGRATION

The committee’s statement of task included identifying examples for a number of aspects of effective primary care and public health integration. Rather than identify a separate programmatic example for each aspect, however, the committee approached this task by looking for programs that illustrate multiple aspects. Table 2-3 highlights the examples and case studies that relate to each aspect identified in the statement of task.

LESSONS LEARNED

The literature review provided many valuable lessons about the state of primary care and public health integration. First, it highlighted that there are a wide variety of such activities taking place in communities throughout the United States. These activities embody many different approaches to integration, reflecting the needs of the local community, the available local resources, and the local partners that are willing and able to come together. This emphasis on local differences means there is no generalizable solution to integration that the committee can propose. However, the many impressive local efforts can influence action at the federal level.

The importance and difficulty of achieving sustainability is another lesson. Many of the partnerships described in the literature were short term, funded by grants and either decreasing in scope or disappearing altogether when the source of external funding dried up. Embedding integration activities in existing structures to ensure that they continue after external funding has stopped is key to sustaining these activities. Sustainability continues to challenge local partners and has limited the impact of successful primary care and public health integration efforts in the past.

TABLE 2-3 Aspects of Primary Care and Public Health Integration Illustrated by the Examples and Case Studies

Related to sustainability is the difficulty of achieving scalability. Integration activities in local communities rarely are able to move beyond their initial start-up site. There are some exceptions, including SPARC and the case studies. Overall, however, scalability is a challenge in promoting integration.

One of the positive lessons is that sharing data and a workforce appears to be a natural way in which primary care and public health can work together. In all of the case studies and many of the examples, sharing data to address community health concerns was foundational for integration efforts. Similarly, the possibility of sharing staff as a way to bring primary care and public health together was a frequent theme in the literature.

ROLE OF HRSA AND CDC

The examples and case studies provide some glimpses of HRSA and CDC involvement: the Community Transformation Grant awarded to San Francisco; health centers involved in various communities; and HRSA’s provision of funding to Regenstrief Institute, Indiana State Department of Health, and the Public Health Informatics Institute to develop guidance for better management of child health (Grannis et al., 2010). However, the agencies were not the genesis of the integration; the integration was already happening at the local level. As mentioned above, the committee believes there are some ways in which HRSA and CDC could make a greater contribution to these processes.

At a minimum, recognition of the overlapping contributions of the two agencies would be helpful. Whether it be prenatal care; childhood immunization campaigns; prevention, tracking, and treatment of sexually transmitted diseases; cardiovascular disease; or cancer, the work of the two agencies is bound together at the level of the community. But separate project requirements, data systems, and administrative structures complicate the coordination of needed services. Coordinated planning between the agencies would assist communities in linking their programs to serve their clientele better and more efficiently.

Coordination would assist in reducing the tensions that can exist with respect to which community agency “owns” an issue or program. Which agency or group is leading locally depends on local history and relationships. Allowing variation in structure while requiring the achievement of common goals would permit building on local strengths and successes and reduce unnecessary tensions.

More broadly, coordination between the agencies could create a space in which others could participate. Improving population health is a task requiring both agencies, but is larger than both combined. Private and academic medical practices, hospitals, schools, social services, mental health agencies, parks and recreation, and community groups all have perspectives, strengths, and resources to contribute. Several of the examples and case studies described in this chapter demonstrate the value of an initial primary care–public health partnership that expands to include others.

Similarly, the coordination of data collection and tracking would assist local efforts. If health departments and HRSA-supported health centers were tracking the same data and if these data were available locally, the data would provide a common understanding of opportunities for the community and a way in which stakeholders could gauge their performance in meeting community needs.

Another point that emerges from the literature is the need to develop the human capital required for integration. Bridging disciplines is not easy

in the best of times and is much more challenging when there are major stressors and uneven talent and skills. Fundamental shifts are necessary in the training of both primary care and public health practitioners so they can work together effectively in meeting the needs of their communities.

The examples and case studies also demonstrate that what is needed is less support for initial integration, although that is still helpful, and more the removal of barriers that impede the development and expansion of integration activities that are already taking place at the local level.

Finally, HRSA and CDC could assist in evaluating local integration efforts. This would help create a more robust evidence base with associated health and process outcomes. This evidence base, in turn, could illuminate potential benefits and best practices or methods for integration.

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