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Chapter 3 STILLY METHODS PURPOSE AND SCOPE OF ThE; STUDY The purpose of this study was to assemble what in known about the operations, costs, and impact of COPC as it is currently expressed in the United State.. To do that involved reducing the ambiguity around the concept by teasing out some of the key elements that make COPC dis- tinguishable from primary care, looking for examples of practices or programs where COPC or some combination of its key elements have been expressed, and examining carefully what those examples reveal about the forms COPE can take, Me functions it per for - , the costs it incurs, and the effects it has on the health of the c:o~unity. METHODS AND APP=AC~3S Development of an Operational Def inition Construction of the operational definition of COPC was accomplished by the Institute of Medicine study staff and ache committee. The model was developed in an iterative process that began win a careful review of the modest literature that describes the features and characteristics of COPC. The work of Hark and Abramnon (Abramson, 1979, 1983a,b; Abrasion and Rark, 1983 Abramson et al., 1973 , 1981, 1983 , 1983 ; Kark, 1974a,b, 1981; Rark and Abramson, 1981; Rark et al., 1973) was reviewed along win the writings of Hart (1974, 1981}, Geiger (1967, 1969, 1974, 19831, Deuschle {19821, Madison (1983), Mullan {1982}, Sheps {1978 ; Sheps and Bachar, 1981; Sheps et al., 1983), and White (1967, 1972a,b, 1976, 1980~. The proceeding from Me 1982 IOM conference also were studied and provided a conc~eptus1 base on which to construct the model. From the published literature and discussions winch the principal advocates of COPC, the basic elements common to all descriptions were identified. A preliminary model was constructed and used to organize the site trinity. Finally, the results of the case studies provided a wealth of empirical data with which the operational model was Edified to reflect the actual practice of COPC. 19

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20 Study Site Selection The study set about to gather data on COPC by collecting published and unpublished material describing the operations, cost, and impact of COPC, and by identifying practices engaged in COPC that could serve as study sites. This was done by developing a network of persons who were familiar with ache notion of COPC, who had knowledge of health service program - s that might include COPC practice", or who had knowledge of the published and unpublished literature relevant to COPC or its major defi- nitional components. Beginning with a lint of the participants of the 1982 IOM conference on COPC, a letter was sent describing the concept of COPC and the nature of the current study. In addition, the letter requested information about the literature on COPC or its components, practices that night be based on COPC principles, and other persons who might be able to Supply S Similar information. Dur ing the late spr ing and seer of 1983, a progressively wider network of potential sources were contacted by letter, telephone, or in person at meetinq~ and conferences, thus generating a body of literature and a listing of practices and health service progress engaged in some aspects of COPC. Altogether this process resulted in mare than 600 references and 147 potential study sites. The published literature yielded very little information on community~oriented primary care per se. Very little is written about the operations, costs, and impact of com~wnity~oriented primary care practices. Of the practice sites suggested, further information was gathered about 84 in order to get a sense of ache extent to which COPC was oper- ational. Three criteria were used to identify potential study sites: 1) the presence of an active medical practice that placed emphasis on (but was not necessarily limited to} primary care ache assumption of responsibility for ache health care of ~ defined community, the definition of which extended beyond the active users of the practice 3) The use of systematic {though not necessarily quantitative) efforts to identify the community and to address its major health problems through combination of priory care and community health Of forts . The first two make up the structural elements of the COPC definition, while the third is derived from the aggregate of ache four COEC func- tions. As his process was carried out it became apparent Rabat there were a number of sites that included elements of ache COPC model, but no ites were ~textbook. examples of COPC. Before any site visits were made, it was decided that the set of study sites selected should, as a group, illustrate the manner in which COPC was expressed under a variety of environmental conditions. For this purpose, the health care environment consisted of three primary dimensions: (1) the manner in which ache practice group was organized. t2) the type of community to which the practice was addressing itself,

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21 and {3) the manner in which the practice was financed. The study examined Me ways COPC practices evolved under different environmental conditions in order to find out what variables promoted or constrained the full realization of the COPC model. Certain environmental variables were of particular interest. Because elements of COPC are frequently associated with publicly financed program aimed at serving medically indigent patient populations, the study made a particular effort to locate and include practice sites from the private sector. Study sites included provider groups organized in small single speciality as well as large multispeciality groups, and practices where revenue was in large part derived on ~ fee-for-service basis. With regard to the type of community addressed, the study sought sites serving urban and rural communities, communities with a strong social or cultural identity, and communities composed of members of a prepaid health plan. The mite selection was not a random process, nor did it occur at a single point in time from a finalized list of all potential sites. The networking process of identifying potential study sites yielded a rela- tively large number of publicly financed practice program early in the summer, but a smaller number of practice sites in the private sector were identified only after Ire intensive searching. Because of the constraints, some of the study sites were visited before other sites were selected. This may have worked to the advantage of the study, because the early cite visits more clearly identified the importance of particular environmen=1 variables. For example, early site visits highlighted the need to examine COPC in an environment characterized by a fee-for-service mechanism of financing and a multispecialty group practice. The search was intensified for such a site and resulted in the inclusion of the Tarboro program in the study late in October. Site trisit He~chods A set of specific data requirements was developed to guide the conduct of the site trinity. The data requirements derived from the conceptual model and sought to confirm the presence of the two struc- tural criteria, i.e., the practice of primary care directed at a defined community. Because the varying characteristics of the struc- tural elements across ache study sites wan expected to influence the expression of the COPC model, information was sought to characterize the three dimensions of the environment (organization of the provider group, organization of financing, and the type of community served). Finally, the data requirements included that information necessary to describe ache manner in which the study site accomplished the four functional elements of the definition. The site visit format was structured to enlist the study site in providing either hard data or estimates of both the marginal cost and impact of the COPC activities. It was anticipated that these data would be per titularly difficult to obtain in the site trinity since practice sites would have no reason to account for cost or impact of those components of their program that are uniquely COPC, as distinct from simply good primary care practice.

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22. The site visits were conducted by the staff and members of the come mittee between August and October, 1983. Site visits generally were of two days' duration, followed by extensive telephone communication with study site principals. LIMITATIONS OF ME STUDY Throughout the study, in the course of making decisions about how to proceed in the da" gathering, numerous decisions had to be made on the bases of judgment. Judgment calls often introduce bias into a study, and this COPC study is no exception. As the study progressed, several such decisions were made and biases introduced. The reader should be aware of this at the outset so as to better understand and appreciate the conclusions that are for can be) drawn and the recommen- dations that can be made. First, for the purposes of thin study a medical practice or program consisting of at least one physician was ache unit studied. The sources tapped (the literature and unpublished reports and documents) and the inquiries made were targeted at the medical. community. It was assumed that the delivery of the full range of primary care services, a struc- tura1 Opponent of C:OPC, requires a physician. The specialty did not matter as long as the physic fan did not limit services to a particular field of interest, such as cardiology or endocrinology. Using the practice as the unit of study influences ache types of sites or C:OPC examples that are likely to emerge they are more likely to look like physician-dominated or at least physician-~naged programs. Theoretically, according to the general conceptual framework, any one of a namer of entities has the potential for doing community~or tented primary care. Theoretically, a community group could put together all the elements of a COPC--define their community, assess Me health needs of that population, contract with a primary care provider to tend to those needs, and monitor the effectiveness of these services. One might find that some of the communities that applied for and received a National Health Service Corps physician might be examples of this. Similarly, a local gavernment agency like the public health department could theoretically be ~ COPC by combining their public health and community medicine functions with the actual provision of a full range of primary care service';. Bowever, these groups were not the focus of this study. A second bias introduced into the study had to do with definition of the community for which the physician or provider group assumed rem sponsib~lity. The practices that emerged as a result of our inquiries were those that tended to define their community in geopolitica1 terms. The exception in our study sites was Raiser/Oregon, which defines its community by membership in its prepaid health plans. There are other ways to define ~ community for COPC. A community could consist of members of a particular group formed for reasons; other than health care, such as members of a union, employees of ~ company, students in a school, etc. Theoretically, and very probably, there are some COPC programs that define their population or community in those term.

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23 Third, there is an underlying assumption that pr imary care--care that is accessible, comprehend ive, continuous, coordinated, and for which the prodder in accountable~is desirable. It also is assumed that in many instances there is a mismatch between priory care services and primary care needs. Because primary care is the one part of medical care that is left to the consumer or the patient to initiate and direct, it is important that the providers under stand the needs of the entire group and the group understands what services being provided by the practitioners. If one does not assume that pr ivory care services ar e desirable, and feels that episodic and disconnected ambulatory services are adequate until specialists are required, then he/she will see little if any advantage in COPC. Such an assumption may seem obvious, but it also is basic to the whole concept of community~oriented primary care. A fourth matter to be kept in mind while reading this report is that the eventual study sites were not selected because they were typical of a practice type. In fact, for the most part, COPC rites were chosen because they were exceptional. Our purpose was not to measure how well COPC could be achieved in a variety of settings. Rather, it was to seek out practices or program that seemed to be doing an e:`ceptions1 job of COPC, scrutinize them, describe and analyze their operations, and try deco understand what it is about them that permit. and/or encourages COPC. Unless this objective is understood, it is very easy to misinterpret the findings and conclude that COPC is not generalizable because the sites studied were not typical. Our purpose in doing the study was not to establish the prevalence of COPC nor to project the prevalence for the future. Rather, it was to ase- - le and assess what is known about COPC and make recommendations based on that assessment.

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24 REFERENCES Abramson, J.~. 1979. Survey Methods in Community Medicine, 3rd ed. Edinburgh: Churchill Livingstone. Abramson, J.~. 1983a. The application of epidemiology in community- oriented primary care. Paper prepared for U.S.-~srael Binational Symposium on Interrelations of Epidemiology and Eleal~ch Policy, Bethesda, Maryland, October 17-19, 1983. Abra - non, J.~. 1983b. Broadening the scope of clinical epidemiology. International Journal of Epidemiology 12:376-378. Abrasson, ,J.H., Epstein, L.M., ECark, S.L.., et al. 1973. The con~cribution of a health survey to a family practice. Scan. J. Soc. Red. 1:33-38 . Abramson, Jell., Gofin, J., ElOpp, C., and Ban, R. 1983. Control of cardiovascular risk factors in the community: The CHAD program in Jerusalem. Paper presented at Franco-Israeli Symposium on Epidemi- ology and Community Bealth Planning, Paris, December, 1983. Abramson, J.~., Gofin, R., Bopp, C., Gofin, J., Donchin, M., and Ilabit,, J. 1981. Evaluation of a community program for the control of cardiovascular risk factors: The CEAD program in Jerusalem. Israeli Journal of Medical Science 17:201-212. Abrasion, J.~., and Rark, S.L. 1983. Community oriented primary care: Meaning and scope. Pp. 21-59 in Community Oriented Primary Care~- New Directions for Health Services Delivery. Washington, D.C.: National Academy Press. Abramson, Jell., Rark, S.L., and Palti, B. 1983. The epidemiologica1 basis for community-oriented primary care. Paper presented at Franc:o-Israeli Symposium on Epidemiology and Community Health Planning , Par is , December, 1983 . Deuschie, R.W. 1982. Community~or tented pr imary care: Lessons learned in three decades. Journal of Community Bealth 8:13-22.

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25 Geiger, B.J. 1967. The neighborhood health center. mental Bealth 14: 912-916 . Archives of En~riron- Geiger, B.J. 1969. Health center in Mississippi. Bospital Practice 4:68. Geiger, B.J. 1974. Community control--or community conflict? Pp. 133-143 in Neighborhood Bealth Centers, Rid. Molister, B.~. Rramer, and S.S. Bellin, eds. Lexington, Mass.: D.C. search and Co. Geiger, B.J. 1983. The meaning of community oriented primary care in an American context. Pp. 60~103 in Community Oriented Priory Care~- New Dir actions for Bealth Services Delivery . Washington , D. C.: Nations1 Academy Press. Eart, J.T. 1974. The marriage of primary care and epidemiology. Journal of the Roya1 College of Physicians London 8:299-314. Hart, J.T. 1981. A new kind of doctor. Journal of the Royal Society of Medicine 74: 871-883. Kark, S.L. 1974a. Epidemiology and Community Medicine. Hew York: Appleton~Century-Crof ~ . Rark, S.~. 1974b. From medicine in the community to community medicine. Journal of the American Medical Association 228:1585-1586. Park, S.L. 1981. Community~Oriented Primary Bealth Care. New York: Appleton~Century~Crof ts . Kark, S.L., and Abrasion, J.~. 1981. Co~unity-focused health care. Israeli Journal of Medical Science 17:65-70. Kark , S. L., Mainemer , H., Abrasion , J.~., Legal , I ., and Rurtz~n , C. 1973. Community medicine and primary health care: A field workshop on the use of epidemiology in practice. International Journal of Epidiomoliology 2 : 419-426 . Madison, D.L. 1983. The case for c:ommunity~oriented primary care. Journal of the American Medical Association 249:1279~1282. Mullan, F. 1982. Community-oriented primary care: An agenda for the '80~. New England Journal of Medicine 307:1076-1078. Sheps, C.G. 1978. Primary care--The problem and the prospect. Annals of the New York Academy of Sciences 310:265~274. Shep~, C.G. and Bachar, M. 1981. Bural areas and persona health services: Current strategies. American Journal of Public Bealth 71:71-82.

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26 Sheps, C.G., Wagner, E.EI., Schonfeld, W.~., et al. 1983. An evaluation of subsidized rural primary care programs: I. A typology of practice organizations. American Journal of Public Health 73:38-49. White, R.L. 1967. Improved medica1 care statistics and the health services system. Public Bealth Reports 82:847-854. White, R.L. 1972~. Epidemiologic intelligence requirements for planning personal health services. Acts socio-medica Scandinavica 2 143-1S2. White, K. L. 1972b. Bealth care arrangement in the United State-: AD 1972. Milbank Memorial Fund Quarterly 50:17-40. White, R. L. 1976 . Pr try care research and the new epidemiology . Journal of Family Practice 3:579-S80. White, R. L. 1980 . Information for health care: An epidemiological perspective. Tnguiry 17: 296-312.