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Chapter 1 SCARY, C=CLOSIONS AND RE COMENDATIONS In March 1982, the Institute of Medicine sponsored a conference on co~nmunity~oriented primary care that had participants from the United States and six foreign counts ins. The common thread that linked the participant was an interest in health care programs that tailored a primary care practice or program to the particular health needs of a defined population. One of the recommendations that emerged from the conference called for the development and critical analysis of the knowledge base der inured from the var fed exper fences with the practice of COPC in the United States. With funds from Me Bealth Resources and Services Administration of the U.S. Public Health Service, the Institute of Medicine assembled a committee and study staff to undertake the study reported in these two volumes. The charge to the committee was threefold: - 1) to a.semble and organize the exinting dats/evidence t;hat describe the operation, costs, and impact of the various expressions of COPC in the United States 2) to critically assess the resulting data base in relation to various population groups, and in relation to a variety of existing and projected organizational, administrative, and financing contexts. 3) where evidence warrant';, to make recommendations about priorities in areas of education, practice, research, and public policy. - The con~mittee early recognized that the lack of a precise opera- tional definition and the lack of published data on the operations, costs, and impact of COPC would be the major obstacles to the study. Consequently, the committee worked with the study staff to develop an operational model and to conduct a series of case studies examining primary care practices and programs that incorporate the principal elements of COPC. The study staff developed an operational model that was subsequently modified as the analysis of the case studies provided empirical data on the everyday practice of COPC. In the most general sense, COPC was 1

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2 def ined as the provision of or imarv care services co a def ined co~u- nity, coupled winch systematic efforts to identify and address the major ~ ~ : ~ tent elements were isolated to form the basis for an operational model and to act as the criteria for COPC: 1} a practice or service program actively engaged in primary care a community for which the practice has accepted responsibility for health care 3, a process by which the practice, with the participation of the co% - unity, identifies and addresses the major health problems of the community; this process consists of: -- def ining and character in ing the community -- Identifying the community ' 8 health problems; -- Edifying the health care program of the practice in response to the identified community health needs -- monitoring the impact of the program Edifications. Therefore the operational definition of COPC is based on three compo- nent=: a primary care practice, an involved and definable community, and a set of activities that systematically address the major health issues of the community. Both ache primary care practice and the community can be organized into ~ variety of forms, and the model placer no constraints on the forms that may be engaged in COPC. The characteristics of the primary care practice and of the community constitute He environment in which COPC in practiced. Thus the environment will vary in several regards, such as is the organization of the practitioners, ache organization of the community, and the manner in which revenue is generated from the community (directly or indirectly) and used to finance the health care program. These Environmental variables. are assumed to be important determinants of ache way in which ache COPC model is expressed in any given setting, and formed the basis for selecting the sites visited in thin study and for character izing the environmental constraint. that shaped their development as ~ COPC practice. The third element of the operational model is He process try which the major health problem of the community are identified and "y~tem- atically addressed. In order to assess the level of development of a COPC practice, a Edging format was incorporated into the model. For each of ache functional activities, f ice Edges {from Edge O to stage IV) were described. Stage O described activities that, although perhaps characteristic of exemplary primary care, did not meet the basic requirements for COPC. Stage IV described component activities for each function that represented the full expression of the principles of COPC. The intermediate stages include activities that constituted successive levels of development for that function, based in pert on ache data from the case studies.

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3 In order to identify sources of unpublished studies of COPC and to select practices or programs appropr late for case study, contact was made with a large number of persons who had knowledge of health service program that might include COPC practices, or who had knowledge of the published and unpublished literature relevant to COPC or its major def initional components . Our ing the late spr ing and early summer of 1983, a progressively wider network of persons were contacted, thus generating an expanding list of practices and health service programs that incorporated elements of COPC in their practice. Altogether, 147 sites were suggested AS potential case studies. Seventy sites were contacted and inquiries made mainly about their congruence with the three elements of the definition of comm~unity~oriented primary care. The sites selected as case studies were, as a group, intended to convey an expression of COPC under differing environmental constraints. For the purpose of structuring the case studies, the environment was characterized in term of (1) the organization of the practice or prom gram, (2) the nature and organization of the community, and (3} the manner in which the practice was financed. Sites with different en~ri- ronmental characteristics were sought. In particular, study sites were sought in which the provider group was organized both in s~11 single speciality and large multispeciality groups, and in which the source of practice revenue was derived in large part on a fee-for-service basis. Sites were sought that served communities both in urban and rural areas, communities with a strong social or cultural identity, and communities formed from membership in a prepaid beal~ch plan. Because ache concept of COPC often is associated with public financed health service program aimed at serving medically indigent populations, the study made a parti- cular effort to include practice sites from the pr ivate sector . Study site. were not selected in a random manner. The networking process yielded a relatively large number of publicly financed practice programs early in the summer; a smaller number of practice sites in the priorate sector were identified only after more intensive searching. Because of time constraints, some of the study sites were selected and visited before other sites were selected. This may have worked to the advantage of the study, because the early site visits began to identify more clearly ache environmental variables that should be highlighted. For example, early site visits pointed up the need to examine COPC in an environment characterized by a fee-for-ser~rice mechanism of financing and by a multispecialty group practice, and resulted in ache inclusion of the Tarboro-Edgecombe program in ache study late in October. Seven heals services delivery programs were selected for the case studies. The site trinity were conducted by the staff and members of the committee between August and October of 1983. Site visits generally were of two days duration, but the development of the case study usually required extensive telephone follow-up with study site principals. The Checkerboard Area Bealth System serves a widely scattered, largely rural community in northwestern New Mexico. The program is supported by the Presbyterian Medical Services, a private, nonprofit organization, and provides camprehensive primary care services to the 14,000 residents of the checkerboard area, which earns its name from the checkered pattern of land ownership, divided among the federal And

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4 state government, Navajo Indians, and the Spanish and Anglo populations. The Checkerboard program has developed the financial base to support COPC activities by rallying resources from public grant;, contracts with sate and local governments, and fee-for-service pr Try care . The Crow Hi3~1 Fa~nil~j _ ~ is a two~physician, private family practice located in Bailey, Colorado, a mountainous rural area just outside the metropolitan area of Denver. They serve a Practice community. of 7,280 people (which does not exclude nonusers of ache prac- ticel, defined as all members of all families for which any individual has visited the practice within the last 24 months. Although COPC often is associated with federally funded health programs located in underserved communities, the Crow Hill practice illustrates an sppli- cation of COPC in the private sector, which could be widely copied by other family practice programs. The East Boston Nei~e~ is a private group prac- tice, why _ Rectors, that serves the multiethnic community of East Boron. This program has ~ long-term commitment to epidemiologic research in hypertension as a collaborator in the federal government's Hypertension Detection and Follow~up Prom gram. East Boston represents the blending of community control and the concentration of skills in population-based research within ~ primary care program--a fortunate combination of elements that have contributed to an innovative program of COPC. The Raiser-Per~nente Medical Care Programs is a federally qualified health maintenance organization serving approximately 2S0,000 enrollees in ye Portland area. The programs developed at Esi$er/Oregon make it an instructive case study for demonstrating the manner in which an DO can implement ache major principles of COPC to address the health needs of its enrolled population. The Montefiore Fami~ is a federally-funded community health clan community in ache Boors. The health center is the precative site for the family practice track in the residency program in social medicine of Montefiore Hospice., and is ache youngest of the study sites, currently entering its fourth year of oper- ation. As a case study, the health center illustrates ache potent - 1 for practicing COPC in a densely populated urban community, and in an environment with a strong condiment to postgraduate medical education. The Sells Service Unit ts the direct health services co - - nent of the Indian BeaLth Servi (Department of Bealth and Burn Services, Public Health Service) with responsibility for assur ing comprehensive health services ~ the Papago Indian community in rural Concern Arizona. With a clearly defined and well organized sociocultura1 community, a mandate and a financial base for addressing the co~u- nity's health needs, and the coexistence of ~ health services research program, the Sells Service Unit operates in an environment particularly conducive to the development of a COPC model. The Tarboro-Edgecombe ~ represents an unusus1 approach ~ rosary care program from the components of the health care system that normally exist in many commu- nities. The Tarboro program consists of an informal coalition of which the major original components are the Tarboro Clinic, a private,

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5 fee-for--ervice, multispeciality group practice, and the Edgecombe County Health Department. In sequential manner, other components have been added to form a system of care that has assumed responsibility for the health care of an entire county in rural North Carolina. The emer- gence of this program in what many would consider the virtual mainstream of health care in the United States makes it an important experiment in COPC and a valuable case study. The complete case studies are presented in a volume II of this report. In summary, the following are the major findings of the case studies. Because the findings derive from a nonrandom sample of seven study sites, extreme caution is urged in generalizing the observations beyond the case studies themselves. The study did not find a COPC practice site in a community served by multiple provider groups. However, in theory it would be possible in such a setting for several practices to collaborate in the COPC activities while maintaining indepen- dence in their primary care activities. In all the study s ites, COPC appeared to be dr iven by the provider group rather than by the community. In none of the study sites did the community play a major role in the COPC activities. It appears that provider philosophy is relatively more important than community participation as ache dr icing force behind COPC. Each of the study sites had at least one physician who was an advocate of the principles of COPC and who continually chal- lenged the organization to maintain a focus on the health problems and needs of ache entire community. To practice COPC in most health care settings probably requires at least one physician who is committed to its tenets, but probably can thrive even in a practice in which many of the physicians are indif ferent to it. It appears that the particular way in which COPC evolves in any given setting is highly dependent on the environmental vari- ables, and of these the organization of financing would appear to be the most critical. Specifically, financial constraints seem to exert ache greatest single influence on the modifica- tions of the health care program that eventually are made in a COPC practice. In all the health problems identified by the study sites, there were only a few that first came to light as a result of an epi- demiologic study. Mast problems had been previously recognized, although an epidemiologic study often nerved to identify the correlates of the problem and to provide information that enabled the practice to target its efforts on the individuals or the subset of the community at highest risk.

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6 . One subset of the community that is routinely addressed by virtually all the study sites is the school age child. School children represent a population-based subset of the community that is accessible to most practices. In all seven study sites, ache quantz~cative activities of COPC were, in large part, supported by an active data system. All sites stressed the central importance of their data base in making it feasible to carry out the epidemiologic techniques for character iz ing ache community and identifying its health problems . In general, the function of monitoring the impact of program madif ications in response to identif fed community health needs tended to be the least developed among the study sites. How- ever, the pr incipals at the study sites generally acknowledged the importance of this function, but noted the difficulty in doing so, due in large par t to the lack of resources and speci- fic skills. They also cited a paucity of evaluation techniques feasible for routine application in the busy priory care setting . The Committee on Community~Oriented Primary Care reviewed the da" that emerged from the case studies and reached the following conclu- s ions: . . The conceptual model of COPC, developed in this report in terms of structure and function, holds promise for a primary care system that is more responsive than current primary care prac- tices to meeting the health needs of communities. To what extent application of this model will result in additional zmpro~rements in health status, and at what cost, are questions worth testing. COPC is not the prevailing mode of practice In the United States nor was the study able to find an example of Me COPC model that is fully developed, wherein all the COPC functions are performed systematically and routinely. There are, however, examples of practices that do per form some of the COPC functions regularly. Because fully operations] examples of the COPC model could not be found, definitive statements cannot now be made about the impact of a fully developed COPC model on health status, costs, or cost effectiveness. In practices identified as performing some of the functions of COPC Mere are examples of improved health outcomes. No evi- dence was found regarding the cost impact of the elements of COPC.

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7 Many methods and techniques, developed in and for other disci- plines, are potentially adaptable and applicable to a move from primary care to COPC. flowerer, there currently are no descrip- tive materials that explain or document how these methods can be or have been adapted and used to perform COPC functions and thereby assist practitioners in moving from primary care to COPC . Based on their assessment of the knowledge base generated on the operations, costs, and impact of COPC, the Committee made two recommen- dations. They are: 1) The fully developed COPC model should be implemented in a variety of selected clinical settings so as to test it rigorously in terms of its impact on health and cost. 2) In order to accomplish Recommendation 1, methods for performing COPC functions need to be developed and tested. These methods should be developed and presented in a way that makes them usable by providers wishing to move priory care to COPC. .,

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