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COMMUNITY ORIENTS PRIMARY CARE: A PRACTICAL ASSESSMENT Volume I The Committee Report Division of Besith Care Services INsTIT.Dq,E OF ME:DICIttE Apr il 1984 National Academy Press Washington, D.C.

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NOTICE The project that is ache subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the Councils of the National Academy of Sciences, the National Academy of Eng ineer ing, and the Institute of Medicine . The members were chosen for their special competencies and with regard for appropr late balance . This report has been reviewed by a group other than the authors accord- ing to procedures approved by a Report Review Committee consisting of members of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The Institute of Medicine was chartered in 1970 by the National Academy of Sciences to enlist distinguished members of the appropriate profes- sions in the examination of policy matters pertaining to the health of the public . In this, the Institute acts under both the Academy ' s 1863 Congressional charter responsibility to be an advisor to We Federal Government, and its own initiative in identifying issues of medical care, research, and education. Supported by the Department of }lealth and Buman Services Contract No. 282-80-0043, T.O. 15 2101 Constitution Avenue, N.W. Washington, DC 20418 {202) 334-2356 Publication TOM-84-0 2

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INSTITUTE OF MEDICINE COMMITTEE ON COMMUNITY ORIENTS PRIMARY CARE Chairman , *MAURICE WOOD, Department of Family Medicine, Medical College of Virg inia, Richmond, Virg inia Member s *RALPH L. ANDREANO, Department of Economics, University of Wisconsin, Madison, Wisconsin *R. OWN BLTH, Pediatrics Associates, Ransas City, Missouri *ROBERT H. BROOK, The Rand Corporation, Santa Monica, California JORN W. PETGHTNER, Department of Family Medicine, MacMaster University, Hamilton, Ontar lo, Canada MARGARET H. JORDAN, Health Plan, Inc., The Raiser Foundation, Oakland, California *JOYCE: C. LASHOF, School of Public Beal~ch, University of California. Berkeley, California GRANT MOE}?ETT, American Farm Bureau Federation, Park Ridge, Illinois FITZHUGH MORAN, Office of Medical Applications, National Institutes of }lealth, Bethesda, Maryland *ERNEST W. SHARD, School of Medicine and Dentistry, University of Rochester, Rochester, New Yor k *LISBETH BAMBERGER SClIORR, School of Public Health, University of North Carolina, Chapel Bill, Norm Carolina 111

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HE:~3ERT C. SCHULBERG, School of Medicine , University of Pittburgh, Pittsburgh, Pennsylvania W. JACK Sq?E:~SE, Family Practice Residency Program, Baptist Memorial Hospital, Kansas City, Missouri *PAUL D. sTorts? School of Medicine, University of Pennsylvania, Ph i ladelph is, Pennsy lvan ia JAMES D. TAYLOR, East Boston Neighborhood Health Center, Boston, Massachusetts STEPHEN BRADY TRACKER, Consolidated Surveillance and Communications Activity, Centers for Disease Control, Atlanta, Georgia TOM Staff Paul Nutting and Eileen Connor, Study Directors Cheryl Hailey, Text Processor Mireille Mesias, Administrative Secretary Michael McGeary, Professional Associate Donald Tiller, Senior Secretary Daniel Zwick, Research Consultant *Member of the Institute of Medicine iv

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COWTENTS PREFACE Chapter 1 - SUlMARY, CONCLUSIONS AND RECO - ENDATIONS, 1 Chapter 2 - BACKGROUND, 9 Origin of the Study, 9 Historica1 Context, 10 References, 16 Chapter 3 - STUDY METHODS, 19 Purpose and Scope of the Study, 19 Methods and Approaches, 19 Limitations of the Study, 22 References, 24 Chapter 4 - AN OPERATIOlLAL MODEL OF C - WNITY~ORIEN~ PRETTY CARE, 27 The Structural Elements of COE,C, 28 Functional Elements of the COPC Process, 32 Implications of the Model, 41 References, 45 Chapter 5 - ANALYSIS OF CURR=T PRACTICES, 47 Sugary of Practices Engaged in COPC, 47 Character istics of COPC Study Sites, 49 The Seven Study Sites, 51 Crosn-Case Analysis, 6S References, 94 Chapter 6 - CONCLOS$0NS AND REC~DATIONS, 97 Conclusion I, 97 Conclusion 2, 98 Conclusion 3, 99 Conclusion4, 99 Conclusion 5, 101 Recommendation 1, 10 2 Recommendation 2, 102 Additional Individual Comments, 103 References, 106

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PREFACE This volume is the first of two in a report by a committee of the Institute of Medicine that examined the body of knowledge on the U.S. experience with co~munity-or tented primary care {COPC, . The concepts of COPC have been stated previously in the writings of Sidney Hark, drawn from his work and that of his colleagues in South Africa and Israel. Bowever, there also is a substantial body of experience in the United States where several different model" of COPC have evolved from the prepaid group practice movement, the federally funded community health centers, and the service units of the Indian Health Service. As this study demonstrates, the fundamental concepts of COPC can be imple- mented in a much wider variety of health care environments than have been considered before now. Solve II of this report presents seven case studies that demonstrate the adaptation of the COPC Eden in both the private and the public sectors, under differing organizations of financing, and addressing vastly different concepts of ~community.. Very early in the course of this study, it became apparent that the notion of COPC meant different things to different people. Because the term ~cosomunity~oriented primary care. is so fundamentally embraceable. many people associate with it whatever they believe to be an important innovation in ache delivery of primary care. Thus, an early but funda- mentally important task in the study involved the construction of an operational definition of conmunity~oriented primary care. Although it could be argued that COPC is the logical extension of good primary care, the committee adopted the view that COPC is one (of many possible} application of primary care. Community-oriented primary care was defined as the provision of primary care services to a defined commu- nity, coupled with systematic efforts to identify and address the major health problems of that community through ef fective modif ications in both the primary care services and other appropriate community health programs. An operational model was developed as the conceptual under- pinninq of the study and was constructed initially from the writings of others and the aggregate exper fence of the committee . our ing the course of the study, the model was modified repeatedly to reflect ache realities of COPC practice which became evident during the conduct of the case studies. Hi

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The model should be viewed as preliminary and eminently suitable f or modif ications by others. In particular, one feature of the model will become the target of debate. As presented in Chapter Four of this volume, the model descr ibes the car iety of communities that appropr i- ately may be addressed by a COPC practice. Specifically the model accommodates as a ~community. any aggregate of individuals that the practice or program may reasonably expect to cover. Excluded, however, is the community that is def ined to include only active patients of the practice . A strong counter-argument has been made that the pr inciples of COPC could be applied to the collectivity of active patients of a practice, and as such would represent an important innovation in the practice of pr ivory care. It has also been argued that by requir ing the practice to address a community beyond its active patient population, the defi- nition places COPC beyond the reach of many practices. The model developed for this study could admit the functions of COPC directed to the active patients of a practice, and the fact that such an arrange- ment may lead to improvements in the health of the patient group. Such a practice should be encouraged to monitor and address the health and health problems of its active patients, and as such would be practicing exceptional pr imary care. However, to include this type of practice in the scope of COPC begins to chip away at the central concept of COPC, and reduces it to a catch-all that may include a variety of unrelated activities and innovations in primary care. By maintaining a strict definition of community, this study has isola~ced and examined the body of knowledge related to directing the capabilities of primary care to the health needs of c:ommunitie~; that may include both users and nonusers of priory care services. As the study demonstrates, activities are underway that meet the more limited definition of COPC. The require- ment of COPC to expand the scope of concern beyond the circle of active patients does not necessarily limit the ability of many to practice COPC as attested by the case studies presented in Volume II of this report. It is recognized however, that the application of the functions of COPC to the active patient population, may be an important f irst step for the practice attempting to shift from orthodox primary care to COPC. This and other features of the operational def inition should focus a lively debate on the precise nature of COPC. It is hoped that We COPC model presented in this study will be subject to modification and improvement by others working in primary care. At the time Mat this r apart is going to press, we continue to receive Moments on the Hooded both from the study sites and a wide variety of others whose advice has been instrumental in fore.~ulating the operational def inition. If the ensuing debate serves to add precision to Me concept of COPC, then the model will have served its purpose and will continue to evolve. Most Important, it will provide a solid foundation for the additional work needed to more fully develop and test the contribution that COPC may remake to the largely f ield of primary care. Paul A. Nutting Eileen M. Connor e e At eL eL

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