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Chapter 4 AN OPlE:RATIO~ MEL OF C~I= - RI~ WILY ~ community~oriented primary care is ~ process by which primary health care services are systematically directed at the health needs of a particular community. Abramson and Bark have identified five essen- tial and fire desirable features of COPC (Abr^'Peon and Hark, 1983). Among these, ached emphasize the complementary use of clinical and , . . . . . . . . . . . . , _ ~ _ motion of its health. ep~Oemtol~lc 118, "e aez~n~tzon on the country For wnlan me practice is responsible, and involvement of the oom~unity in the pro- Writing on the U.S. experience, Hadison and Shenlcin define the community-responsive practice as cone which assumes a larger than ordinary share of responsibility for safeguarding the health of a community, and that follows through on this responsibility by taking action beyond ache traditional mode of treating the complaints and problems of patients as they approach the practice one by one. (Madison and Shenkin, 1978~. While these and other authors (Abramson, 1983 ; Abrasion et al., 1983 ; Mullan, 1982} have added substance to the general concept, there is no precise operstzone1 definition upon which to base an analysis of We empirical data on COPC in He United Stances. In order for this study to assemble and critically analyze the prac- tice experience with COPC, a more precise operational definition was developed. The model was constructed to incorporate the variety of organizational and financial environments in which COPC may exist, and ~ . . ~ ~ ~ _ ~ permits an analysis of the en~r~ronmen"1 influences on use aevelopmen~ of a COPC practice. The model accounts for partis1 expressions of the COPC concept and provides a mechanism for defining the sage of develops ment of COPC activities for each of several functions. This model defines COPC in its most geners1 form as the provision of urimarY care services to ~ defined community, coupled with systematic efforts to identify and address ache major health problems of that commu- nitv through effective modifications both of the primary care servicer and other appropriate co_~. Therefore, the tounua- ~=~ _ ~ _ucturs1 elements: the practice of primary care and ~ defined community; and one functiona1 element that consists of ache four activities required to systematically address the community's health problems. The major components of the COPC model can be arrayed as follows: 27

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28 . a practice or service program actively engaged in pr try care def ined community for which the practice has accepted responsi- b ility for health care . a systematic process by which the practice, with the partici- pation of the community, identifies and addresses the major health problems of the community; this process consists of four activities: ~ ~ def inition and character ization of the community 2) identification of the community ' s health problems 3' modification of the health care program in response to the community health needs 41 monitoring the impact of program modifications. Both the pr imary care practice and the community can be organized into a variety of form, and the model does not preclude any form that may be engaged in COPC. The characteristics; of the primary care prac- tice and the community constitute the environment in which COPC is practiced. Thus, Me environment will vary in several dimensions, such as the organization of the practitioners, the organization of the commu- nity, and the manner in which revenue in 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 the way in which the COPC model is expressed in any given setting. T~-.STRIJCTURAL EVENTS OF COPC The Practice of Priory Care It is important to be very clear on the distinction between COPC and orthodox primary care, and to be able to Mote precisely those activities observed in the practice setting that are components of primary care and those Vat are co - Patents of COPC. Therefore, it is instructive to begin winch ~ very general model of health care, add to it the specificity that characterizes primary care, and finally apply the primary care definition to form the model of COPC. The mast general model of hesith care would have a practitioner interacting with ~ patient that is bilateral and consists of a flow of information and services. Cros--cutting the interaction is ~ time dimension to account for the practitioner ts sequential interaction with multiple patients, and likewise to account, from the patient's perspec- tive, for the multiple interactions with one or several practitioners over tin. Thus, the generic model represents health care as one or more health services transferred from a practitioner to a patient. It includes a time dimension upon which multiple or continuous transfer of services may occur within an episode of illness, an episode of care, or a life event (e.g., pregnancy, childhood, etc.~. This simplified model accept es that both ache practitioner and the patient may be a functional member of one or more groups and organizations. Bowever, the model does

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29 not constrain the manner in which the practitioner or the patient i. organized, nor does it specify any character istics of the systems of which the practitioner and patient may be a part. The model also is open to the concept that there are C08tS associated win the services and that money is transferred either directly or indirectly from the patient to the practitioner. The model does not, however, constrain the manner in which the financing of primary care services is organized The character istics of pr imary care add specif icity to this gener ic health care model. In a study by the Institute of Medicine, primary care was described as heals care consisting of five attributes of the specific array of services {Institute of Medicine, 1978~. These inclu- ded accessibility, comprehensiveness. coordination, continuity, and accountability. This def inition spoke directly to the character istics of the services and not to those of either the practitioner or the patient. Accessibilitv refers to the ease with which ~ patient can initiate an interaction win the practitioner and the extent to which services provided are acceptable. Although the general notion of accessibility could be expanded to include the notion of a nonuser of health care gaining access into the health care system, the Institute of Medicine definition clearly places its emphasis on the ease and convenience with which an active patient may make an appointment, travel to the service location, and be served within a reasonable period of time. Comprehensive refers to the scope of service provided and may be expressed in the model as an array of services that include all of the appropriate health care activities. The broad array of services is one of the characteristics that distinguishes primary care from secondary and tertiary care, which tend to be more limited in scope. Coordination and continuity of services together refer to the main- tenance of a logical order of the flow of information and the process of care from one interaction with a practitioner to the next during the full episode of care. In order to receive the full range of servicer inherent in comprehensive care, the patient may be required to interact sequentially with one or more specialized practitioners over time. The characteristics of coordination and continuity are meant to ensure that the array of services received over time will in the aggregate result in an appropriate process of care. Unlike the first four attributes, accountability does not describe the array of services per se, but rather directs the responsibility for that array of services to the practitioner and holds the practitioner accountable to the patients for both the quality of and the potential benefits and risks of the services provided. The mechanism to assure that the services provided to the patient population are accessible, comprehensive, coordinated, and continuous is quality assurance and is an integral component of the primary care process. Thus, as a basic structural element of COPC, primary care can be defined as that array of health services provided by a practitioner to a patient that is accessible and acceptable to the patient, compre- hensive in scope, coordinated and continuous over time, and for which the practitioner is accountable for the quality and potential effects of the services. The primary care model does not limit the manner in

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30 which either ache practitioners or the patients may be organized, nor does it specify the manner by which the costs of providing the pr imary car e services are met, directly or indirectly, by the patient or patient groups. The Community The second structural requirement for COPC is a def ined community for whose health and health care the practice has assumed responsibil- ity. Such a community may take a variety of form ranging from com- munities that share a combination of social, cultural, economic, and political systems, communities that come together for a c:ommon purpose such as the workplace, the church, schools, etc., to aggregates of indi- viduals who are enrolled in a corn health plan. The only requirement of the COPC Ides is that the community is not defined in such a way as to systematically exclude nonusers of heal~ch services. Among ache different types of communities for which COPC practices may assume responsibility, a coon element is that they are unactionable, ~ that is they can be addressed in a systematic manner by the health care system. In the context of COPC, it is useful to view the community as ~ denominator, in the epidemiologic sense, which consists of subsets or numerators, ache most important of which is that group of individuals within the community who are active users of the health care system. Thus, primary care outside of Me COPC model strives to provide its active patients (the ~numerator. in a COPC context} with effective and appropr late health services that are accessible, comprehensive, contin- uous, coordinated, and accountable. In contrast, the COPC Mel (which includes a priory care component) is systematically addressing the major health problems of the entire community, i.e., the denominator. The community may be organized in a number of different patterns and may participate to varying degrees in ache health care program. The COPC model does not specify the type or level of participation and many forms may evolve. The nature of the co~unity's role will vary with the ~distance. between the practitioner group and the community . Other e the two are based on vastly different social or cultural background", the total health care program can be improved in ways that heighten the practitioner's sensitivity to social and cultural habits. Where the community itself consist. of several distinctly different cultural subpopulations, community participation can promote a synthesis or a composite of the varied expectations, perceptions, and needs for health care. However, there roles become less critical in communities that are culturally homogeneous and in which the practitioners have a social and cultural background smiler to that of the community. The varying forms of community involvement can be categorized by type of organization, the level of involvement, and the focus of atten- tion. First, communities may be organized with boards or committees that have the specific mission to advise their heals program, or in other examples the existing political structure may focus on health issues. During the 1960s and 1970s, a considerable experience accuam- lated in the varying roles, costs, and impacts of community boards.

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31 Their roles have varied widely from advising the practitioners on issues related to Satisfaction and acceptability of health services to owning and governing the primary care program. Second, the level of community participation may range from pr imar fly advisory to governance of the program. There is considerable disagreement as to the importance of this dimension in ~x~izinq the health of the entire community within the capability of the health care program. Some argue that the level of community control is independent of the extent to which the health program meets the health needs of the community, while others argue that community governance is a central ideologic feature of community-oriented primary care. Finally, there often is a great deal of variation in the extent to which community groups define the community they represent--there is variation in the Denominator bias. of the community participants. Ideally, the community participates in all of the functions of COPC, e . g ., def ining and character iz ing the community , identifying the community ' s health problems, modifying the health care program, and monitoring the effectiveness of program Edifications. Often, however, just as practitioners have a tendency to focus their attention on the numerator of ~active. patients, community boards (or other forms of community representation) may also develop a numerator bias. C)cca- s tonally, they focus on the same numerator as the practitioner as illustrated by their frequent role in advocating for issues in patient satisfaction with services. While producing results that my benefit the active patient population and thus greatly improve the primary care program, such activities do not promote the central notion of COPC. In the ideal COPC practice, the focus of the community participation involves the entire community and grapples with identifying health problems and setting priorities Dung them for subsequent program modifications. Thus, a critical function for the community board is to represent the interests of the denominator in participating in the COPC process. In this ~de, community participation can add a distinctly new dimension to the identification of community health problems, partic- ularly when nonquantitative approaches are used. Community partici- pation also can be invaluable in setting priorities among competing health needs and in allocating constrained resources among competing health program. Finally, an important community role is in promoting primary care services among those individuals in the denominator who are hesitant to seek care. Although the COPC model does not specify the balance of numeratDr- and denominator-oriented activities are most appropriate to COPC, it is easily seen that the denominator-oriented activities are directly supportive of COPC, while the numerator~oriented activities are suppor- tive of the primary care component of COPC. The latter potentially could be an impediment to the attainment of COPC if the distinction were not appreciated, and the extent of community participation were constrained to numerator-oriented activities.

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32 FUNCTIONAL EVENTS OF TV: COPC PROCESS I t is through activ ities of the four functional elements of COPC that a pr imary care practice msy systematically address the health needs of a defined community. It is possible to describe the progression from orthodox primary care to COPC by constructing a scale for each of the four functions. Each scale is based on a central var table that increases as one moves along the sages of development front priory care to COPC. Each scale is constructed with a stage 0, which represents the absence of the central variable of COPC, and ranges to stage IV, which describes the idealized level of COPC for that function. Although stage 0 represents the absence of CON: characteristics, the related activities in any given practice may be characteristic of exceptional primary care. For each scale, there is a basic requirement that distinguishes COPC from orthodox primary care, and it is this requirement that separates stage 0 from the higher stages. Therefore, the two end stages of each scale are based on the definitions of primary care and COPC, and the intermediate stages reflect empirical stages, based in part on the results of the case studies. Def ining and Character iz ing the Community The COPC process begins with defining and characterizing the community for which the practice has accepted responsibility. The resulting knowledge of the total community forms the foundation upon which the subsequent functions of COPC are based. The practice of medicine in any pr ivory care setting has traditionally stressed the importance of understanding the community from which patients present for care. COPC extends this notion to systematically examining the community, recording health problems, and analyzing the results with the same rigor that the practitioner uses when understanding a partic- ular patient. Many primary care practitioners through years of practice and observation will have developed a basic knowledge of the community, based on subjective analysis of information gained from patients and the fact of the practitioner's living and even raising a family in the community. In the absence of rigorous methods for collecting and analyzing ache data on ache community, ache primary care practitioner may often erroneously generalize patterns of health and health behavior from his patient population {the numerator' to the total community (the denominator). In a COPC practice, the practi- tioner needs to know more precisely who and where are the individuals and households who make up his community, how they live and behave in ways that influence Weir health, where and when they seek care for ailments, and how they perceive and finance their care. Ideally, the practitioner would be able to enumerate and actually generate a list of all the individuals in the community as a basis for subsequent iden~ci- fication and focus on high risk groups. The scale for this function is shown in Table 4.1. The major requirement and the criterion that separates orthodox primary care

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33 (stage O) from the higher stages of COPC development is that the methods employed are directed toward a denominator population that is consistent with the t~ unity for which the practice has accepted re- sponsibility. The centrs1 Variable underlying the scale in Me rigor and precision of the methods used to gather information on the commu- nity. Methods that yield ~ wide scope of detailed and relevant data are placed higher on the scale. Although the frequency with which methods are applied and the currency of the resulting information is important to this function, Mete elements are not included in the scale. At stage 0, for example, the practice may be using methods with a great deal of rigor that yield ~ great deal of information, but if they are used to characterize only the user population (e.g., the active patient. of the practice} they are characteristic of excellent primary care but not of COPC. TABLE 4.1 Staging Criteria for COPC Function~De fining and Character- izing ache Community STAGE 0: No effort has been made to define or charac~cerize ~ commu- nity beyond the active users of the practice. STAGE: I: There is no enumeration of the individuals who constitute the community. The community is characterized by extrapo- lation from large area census data. STAGE II: There is no enumeration of the community, but it is char- ac~cerized through the use of sec:ondery data that carrel spend closely to the community for which the practice has accepted responsibility. STAGE III: The community can be enumerated and is actively character- ized through the use of a data base that includes all member s of the community, and that contains information to describe its demography and socioeconomic status. (Often such a data system is constructed over time from the active users of services, but approximates the community closely, e.g., at or above 90 percent coverage of the community). STAT: IV: Systematic efforts assure a current and complete enumera- tion of all individuals in the community, including per tinent demc~graph ic and socioeconomic data . For each individual, information exists that facilitates targeted outreach , e .g ., address , telephone number, eta .

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34 At stage I, the practice has begun to examine the character istics of its community through the use of secondary data. Large area sta- tistics may be useful as ~ first sage of development of the function, but have se~rere1 drawbacks. large area da" often do not describe exactly the community for which the practice has accepted responsi- bility, often do not facilitate further analyst. of issues of particular interest, and do not enable an enumeration of all individual within the comity. Stage II differs from "sage I only in that the secondary data employed correspond more closely to the community. This might be the case, for example, when Me community is def ined as all persons living in a geograhic area that corresponds to a current census tract. Alter- nati~rely, the practice may survey a random sample of the community on health and health care relevant topics, thus gaining an understanding of important characteristics of the community, but not resulting in a listing of all individuals. At stage III in the development of this function, the community can be enumerated through the use of a cats base that includes all individ- uals in the community. The data base conning information for each individual and enables analysis of ache demography and socioeconomic status of the community. Data bares of this sort are often those constructed from active users of health services that evolve over time to include the majority of Me community, and must include 90 percent of the community to be considered at this sage. The major drawback of a data base constructed in this fashion is the inconsistency and lack of currency of data elements for those individual'; who have sought care infrequently. Ideally such a data base would be constructed through an initial survey of the community. Finally, at stage IV, the practice makes an effort to maintain a current and complete data blase that includes all individuals in ache community. The practice is active in analyzing the data to gain a more complete understanding of the community, its patterns, and trends that influence health. The data base includes for each individual that information which in subsequent COPC activities will facilitate tar- geted outreach to higher isk individuals , e .g ., address , telephone number . Clearly, the mere existence of a data base does not contribute to the COPC process unless it is being used actively to describe and characterize the community. Some practitioners may be able to extract more information about their community from large area data Man the more nonchalant use of a sophisticated data base. Although not speci- fied for each stage in the scale, it is assumed that the practice is actively using the available data to understand the health-relevant characteristics of the community. Identifying Community Health Problems The second function in the COPC process is to identify the major health problems of the community, characterize their determinants and correlates, and set priorities among them. As in the previous function,

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35 the requirement for and the criterion that separates orthodox primary care (stage Of from the higher stages of COPC development is that the methods used for examining the community health issues are based on a denominator that is compatible with the definition of the community. The scale for this function is shown in Table 4.2. The centre1 variable upon which the scale is constructed tn the precision and rigor of the methods for identifying community health problems. As in the previous scale, stage O represents orthodox primary care, and at this stage no attempts have been made to identify health problems of the community. Although many practices may be examining the patterns of health and health care problems among their active patient population, such practices are engaged in quality assurance and as such may be practicing excellent priory care, but that alone does not mean they are practicing COPC. Similarly, the practices that attempt to identify community health problem- solely by generalizing from the health problems of their patient population are not practicing COPC a" it relates to thin function. TAB" 4.2 Staging Criteria for COPC Functions--Identifying Community Bealth Problem STAGE: 0: No systematic efforts have been made to under sand the health statue or health needs of the community. Alter- natively, the results from studies of the patient popula- tion are assumed to reflect the health Problem in the community as ~ whole. STAGE: I: Community health problems are identified through general consensus of the providers and/or community groups. S1~GI3 II: Community heals problems are identified by extrapolation from systematic review of secondary data, such as vita1 statistics, census data, large area epidemiologic data, etc. STAGE: III: Community health problems are examined through the use of data nets that are specif ic to the community, but tend to focus on single health problems or health care issues. STAGE Iv: Formal mechanisms {usually but not always epidemiologic techniques) are used to identify and set priorities among ~ broad range of potential health problems in the c~ommu- nity, identify their correlates and determinants, and characterize the existing patterns of heals care related to the problem.

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36 At stage I, the practice is attempting to identify health problems o f the entire community , but is doing so based on the sub jective impre-- sions of the practitioner and/or community groups. Such an approach has the advantage of being both inexpens ive and continuous, but lacks the rigor of Ore "yste~tic qu~titive approaches and is less likely to identify hidden problems within the community. On the other hand, the practice that uses formal group consensus techniques, such as routine priority setting sessions, can approach this function in a Ore systematic and rigorous manner, with the advantage that consensus tech- niques can be constructed so as not to constrain the range of potential problems to be considered, as is the tendency of many quentitive approached. At stage II, the practice uses data to identify the community health problem, but must do so by exttspolation from large ares statistics. The validity of the approach is largely dependent on the extent to which the large area corresponds to the community for which the practice has assumed responsibility. The use of secondary data, such as vital statistics and census data, makes it difficult for the practice to conduct further detailed analysis as general problem areas are identif led. At stage III, the practice identifies and examines community health problems with data sets that are specific to that community. Activities at siege TII, however, tend to focus on specific health issues, and runs the risk of overlooking a major problem simply because it was not included in the scope of the cats set. For example, an epidemiologic study of diastolic blood pressure within the community may yield sophis- ticated data on the distribution, correlates, and determinants of hypertension, and may lead further to highly effective interventions. However, the detail in the data set for hypertension is gained at the expense of a broader scope of the data set. Consequently, use of this data to identify the community' health problems may allow the practice to overlook other (possibly more critical} health problems that also exist in the community. Finally, at stage IV, the practice is using systematic methods to identify and set priorities =~ng ache range of health problems within the community. An important feature of ache methods that should be used at this stage is the likelihood that they will identify health problems not already known. The methods used also should characterize the cor- relates and determinants of the problem and identify the components of the problem that may be vulnerable to a health care solution. Gener- ally, the components of the problem may be those related to its severity, Dose related to the distribution and patterns of health care, those related to health promoting behavior, and those related to environmental variables. At stage Iv, the practice is employing methods that admit all of the problem components. The quanti~cative approaches used at stages IlI and IN will generally employ some combination of epidemiologic tools based on a denominator that is compatible with the definition of the community. It is the way in which the denominator is constructed in the analytic tasks that distinguish this function from quality assurance in primary care. With the use of an appropriate denominator, this function will focus on

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37 examining the distribution of health problems and the distribution of health care within the community. In a general sense, the problems to be addressed with modifications in the health program will be identi- fied by the discrepancy between the two distributions. The use of epidemiology will differ somewhat in application from many of the traditional tasks to which it is applied. Traditional epidemiology usually leads to changes in the manner in which health care is delivered through 8 rather long feedback loop, in which the data are gathered, analyzed, and presented to the scientific community by means of publications and professional meetings. The findings that have important Implications for the practice of primary care will lead to modifications in the standards of care and eventually be adopted by primary care practitioners who modify their practice patterns accordingly. In contrast, the applications of epidemiology for this function will occur largely within the practice and with a relatively short feedback loop. The primary purpose is not to generate new know- ledge about the etiology of the disease, but rather to lead to changes in ache local health care program that will make it specific to the health needs of the community. Although there is not the same emphasis on the elegance of the design, the method. must be sound enough to produce valid results upon which the health program may confidently modify its practices. Modifying the Bealth Care Program Once a priority health problem has been identified, the practi- tioner of COPC should strive to modify the health care program to better address ache problem. For most health problems, modification in the primary care program alone would be inadequate and thus the practi- tioner would advocate appropriate edification in other co~unity/public health programs in the community. There are very few situations in which all ca..~ponents of the health care program for a community are under a single governing structure, the function will undoubtedly retire a great deal of cooperation Mung multiple programs. The central variable upon that the scale for this function (shown in Table 4.3) is constructed is the specificity of the proq~sm ~difi- cation to the identified needs of the community. Thus, in the ideal situation program modifications will be targeted appropriately at a . subset of the denominator oom~unity {rather than focused on active patients} and will often require some form of outreach or a combination of primary care and community health program strategies. At stage 0, the practice is not modifying the health program in response to health problems of the larger community, although a good primary care program will be correcting program deficiencies in the care of the active patient population as part of their quality assur- ance effort. At stage I, the practice is making modifications in the health pro- gra~ to address community problems, but is doing so largely in response to local, national, or organization-wide initiatives. Thus, although an important problem is being addressed, the specific modifications are

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38 not necessar fly tailored to the unique needs and character istics of the particular community. Stage II modifica~cions also address important health problems, but do so largely because of the availability of special resources to address a problem. Special resources may appear in the form of a practitioner with ~ specialized interest who joins the practice and works to Bunt a community-based health program dealing with his area of special interest or expertise. Similarly, special resources may take the form of a grant initiative with guidelines to address a parti- cular health problem. In both examples, the resulting program may address an important community need, but will not necessarily address the problem in the most effective manner, nor be bared on the unique characteristics of the problem in that community. The practice at stage II] in its development for this function is modifying the health care program in a manner that is tailored to the needs of the community and to the particular characteristics of the health problem. Where appropr late to the problem, modif ications are made in both the primary care program and the community and/or public health programs that exist in the community. TABIE 4 . 3 Staging Cr iter is for COPC Functions--Modifying the Bealth Care Program STAGE 0: No modifications are made in the primary care program in specific response to health needs of the larger community. STAGE I: Modifications address health problems believed to exist in the community, but are made more in response to a national or organization-wide initiative than in response to a par- ticular problem specifically identified in the community. STAGE II: Modifications address important community health problems, but are chosen largely because of the availability of special resources to address that particular problem, and closely follow guidelines that may not be tailored to the community needs. STAGE: IlI: Edifications in ache health care program are tailored to the unique needs of the community and involve twhere appropriate} both the primary care and the community/ public health components of the program. STAGE IV: Modifications in the program involve both primary care and community/public health components and are targeted to spe- cific high rick or priority groups, with active efforts (e.g. , outreach) made to reach specific high risk or pri- ority groups within the community.

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39 Finally, stage IV represents the idealized situation in which modif ications address pr for ity health problem in the community, involve both the primary care and community health programs, and use active outreach strategies to focus on specific high risk individuals or groups within the community. At this level of development, program modif ications address several companion issues. First, most program modifications are not intended to be directed at all members of the community, nor are they intended to be limited to those individuals from the community who present for or request certain services. An integral component of modifying the health program is to specify those individuals in the community who are the intended recipi- ents of the new strategy. The priority group can be specified in several ways, each successively more precise. For example, if the program modification is intended to reduce a complication of pregnancy (e.g., pre-eclampsia) then the priority group certainly could be char- acterized at one level as the pregnant women within ache community. More precise targeting of the intervention strategy can occur by speci- fying the intended recipient group in term of r ink factor. (e.g ., age, gravidi~cy, socioeconomic statues. The highest level of precision can be attained through the use of risk models that identify the specific ;_a;~5 a._ _ _ - - ; ~~ `~4V`~. "" Andre Such models have been developed Id tested for several health problems (Bobel, 1979; Nutting et a1., 19751. Second, modifications in a health program are seldom achieved without some reduction in level of effort in ocher areas. A program to screen for hypertension may result in less aggressive follow-up for diabetes; a strategy to improve the immunization rate in children may result in less attention to care for ache elderly. In most Small prac- tices, the practitioners ' collective attention and energies are f inite and nearly saturated. Reduction of indi~ridus1 effort can create Opportunity costs. even when program modifications do not involve the reallocation of funds from one effort to another. Third, changes in the operation of a program can rarely be accost plished by a single person. The practitioner who is attempting to modify the health care program must be adept at achieving a consensus among fellow practitioners, support staff, and members of the community. Failure to recognize the importance of this step has resulted in many modifications that were planned, but never executed. Finally, the intended target group for the program should be speci- fied, and a clear statement of the expected impact on the problem should be formulated, including botch negative and positive impacts. Maving done so one can proceed logically to ache final function-- designing a mechanism for monitoring the impact of the program modif ications . Monitoring the Impact of Program Modifications In the final function, the practice must monitor the effectiveness of the program modifications in order to determine ache extent to which it has addressed and resolved the original problem. In the design of the evaluation, it is or itical to use a denominator that is consistent

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40 with the definition of the community, or with the stated objective of ache program modification if it was focused on a subset of the community. The central variable in the scale (shown in Table 4.4) is the rigor and precision of the methods used. In this function, rigor includes the ability of the methods to suggest both positive and negative effects of the modification as well as the ability to pinpoint the relative defi- ciency in the Edification, e.g., the reasons that the impact was less than anticipated. At stage 0, the practice is assessing program effectiveness by examining the impact on the active users of the health care services. The denominator of such an evaluation does not reflect the entire community, asked although evaluations of this type are appropr late to orthodox prosy are, they do not meet the requirement for COPC. At stage I, assessment of program effectiveness considers impact on the community as a whole, but is based on the subjective Impressions of the practitioners and/or community groups. This is an improvement over focusing on active patients, but it suffers from lack of rigor and questionable validity of the results. A possible exception is when the health problem being addressed includes issues of the acceptability of the health care program to the community. The practice at Loge II of its development for this function assesses program impact by extrapolation from large area da=. AS in earlier functions, the validity of this approach is ~ function of the concordance between the population upon which ache data is based and Ache community being addressed. TABIE 4 . 4 Staging Cr iter is for COPC Functions--Honitor ing the Ef fecti~reness of Program Modif ications STAGE: 0: Examination of program effectiveness is limited to the Ipecac on the active users of health Services. STAGE: I: Program effectiveness is viewed in terms of impact on the Immunity a~ a whole, but is based on subjective impres- sions of the practitioners and/or community groups. STAGE:.II: Program effectiveness is estimated by extrapolation from large area data or vital statistics. STAGE: IIT: Program effectiveness is determined by systematic exam~- nation of a data set that is specific to the community. STAGE Itr: Program effectiveness is determined by techniques which are specific to the program objectives, account for dif ferential impact among r isk groups, and provide information on the positive and negative impacts of the program.

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41 At stage III, the practice assesses program impact by systematic examination of data that is specif ic to the community. Most commonly these data have been collected by the practice either as ~ part of a plan for routine monitor ing, or as ~ special cats collection effort to assess the effectiveness of the program Edifications. Usually, evaluation efforts at this stage are simple before~and-after des igns, and result. are subject to the weakness of this particular approach. Finally, at stage IV, the practice assesses program impact with methods that are specific to the program objectives. Assessment tech- nique. are sensitive both to positive and negative impacts and also attempt to pinpoint the relative deficiency in the program as the object of subsequent fine~tuning of the modification. "though before-and-after designs may be used in evaluations at this stage, more sophisticated designs are frequently employed. Ideally, assess- ments take into account not only the impact on the target health problem, but also consider the impact of potential competition for resources on a variety of other problems that were not addressed. F inally, while evaluations at lesser stages for this function may emphasize improvements in the processes of care (e.g., precept of pregnant women in the community who receive adequate prena - 1 care) it is expected that stage IV activities also will examine outcomes (e.g., a change in the r ates of per inatal morbidity} . _ In Canary, COPC in Its most generic form 18 defined as me pr~l- sion of primary care services to a defined community, coupled with systematic efforts to identify and address the major health problems of that community through effective modifications in both the primary care services and other appropriate community health programs. The definition is quite generic and allows for the evolution of a number of specific COPC models, each varying in the organization of the practitioners, the type and organization of the community, and the f inancial arrangements that support the program. Although usually associated in the United States with publicly funded program serving medically indigent populations, the model itself does not preclude a much wider expression of the basic elements of COPC. IMPLICATIONS OF TEE: MODEL Five implications of the COPC model are important to understanding the organization of this study and its results. First, in making the transition from a conceptual model to the analysis of real-world practices, it is necessary to distinguish between activities of COPC and Chose that are simply reflections of good primary care. If the distinction is allowed to blur, activities will be mistakenly ascribed to COPC and thereby encourage an overestimation of the prevalence of COK: in the United States. The distinction between primary care and COPC hinges on the manner in which the community is defined. When the COPC practice addresses a true community, in the sociologic sense, there is little basis for confusion. Such ~ community usually includes both active patients and nonusers of service and generally has a number of health issues upon which the COPC activities can be

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42 focused. However, if the practice addresses a ~community. that con- sists largely of active patients, a considerable amount of confusion ar ises. For example, the practice that is actively identifying the major health problems of its Captives patient population, modifying its primary care activities to address the problems, and monitoring the impact of program modifications may be practicing excellent pri- mary care. It is not, however, necessarily engaged in COPC and its activities, while greatly improving the health care provided to the patient population, may or may not lead to better health care received by the larger community. Similar efforts can only be considered COPC if they are directed at the health or health care problems of a dis- tinct community for which the practice has assumed responsibility. The exception would be the practice that originally accepted respon- siblity for a distinct community and later managed to convert the entire community into a numerator of users of health services. The distinction between primary care and COPC has some additional considerations in the case of family practice. Many family practi- tioners consider their patient population to be all members of all households in which any single member is an active user of services. A practice population defined in this manner has severed character- istics that make it a per titularly suitable object of the COPC process: The community is not by definition limited ~ active users of pr Try care services. The households are entities with health problems that affect all household members, but do not necessarily reside wholly with any single member, e.g., environmental hazards, Tar family dynamics, etc. The households represent entities that are ~accessible. and unactionable. through the COPC activities. The family practice group that employs the COPC functions to address major health problem in this type of practice community would not only be a Ides of family practice but also would be practicing COPC. Other primary care practices could enlarge the group to whom they are respons ible for health care to include components that could be considered a community. For example, the pediatric practice that considers its community to include all of i" active patients and all of the children enrolled in the local school system also would be in a position to practice COPC. Therefore, any primary care program could begin to approach the practice of COPC with ~ rational expansion of its community beyond ache simple inclusion of its active patients. The second implication of the model for this study is that COPC is an application of primary care, not an extension of it. The functions of primary care and COPC are relatively independent, and partial expressions of COPC and primary care may coexist. In other words, a primary care practice may begin to develop c~- ponents of COPC while the practice is still developing according to primary care criteria. This is particularly important in ache light of

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43 recent evidence that suggests the full expression of primary care remains an elusive goal, even among programs with a commitment and - funding base to develop and teach primary care {Fink and Rosecoff, 1983 , Goldberg, Brook , and Pica, et.al., 1983) . This f inding would have grave implications for COPC if full expression of the primary care model were a prerequisite for COPC. Third, the processed of quality assurance for primary care and COPC are generically similar in that both examine the way in which health care is delivered, identify deficiencies in the process, modify the process of care, and monitor the extent to which the modifications here corrected the original problem.* In general, quality assurance focuses on the user population to identify problems in the provision of health services, modify the services to correct deficiencies, and monitor the impact of the modifications on the resolution of the orig- inal problem. Quality assurance deals with the structures, processes, and outcomes of care to assure that effective and appropriate primary care services meet the basic definitional criteria of accessibility, continuity, comprehensiveness, coordination, and accountability. The important feature to emphasize is that quality assurance focuses on the ~ active. patients of the practice . COPC also i. a quality assur- ance activity, but with a concern for a broader community that consists of nonpatients as well as active users of primary care services. COPC is a set of activities to assure that the priory care services system is directing its pr injury care capability toward the health problems that are most important for the health of the overall community, including both users and nonusers of service. Fourth, the practice of COPC is associated with certain marginal costs--those incurred beyond the baseline costs of planning, managing, and operating an or thodox pr imary care program`. Each of ache four COPC functions has a certain cost, and in addition to the cost of the prom cess of modifying the health care program, ache changes made in program operation over time br ing still further costs. Usually these will be positive, but in theory negative costs (or savings) may occur if a particular program is scaled down or discontinued as a result of the COPC process. Finally, there are several types of impacts associated with the practice of COPC that also may be viewed as marginal to the baseline effect achieved by orthodox priory care. The COPC activities may influence the process of care by changing the array of services offered or affecting the distr ibution of health services within the community. There changes in turn may influence the outcomes of care by changing the health status of the entire community or particular subsets. Depending on the precision of the tools used to measure impact, improving the health of a subset of the community or affecting a single disease entity will not necessarily show up as an overall *Some regard quality assurance as primarily an evaluative or accredi- tation activity. The similarity noted here will be apparent only when quality assurance is viewed in its broader context.

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~4 improvement in the community ' health. Rather, major improvements in one subset may be accompanied by deterioration in another, with a net effect for the community as a whole, which may be either positive or negative. Thus, within a system of finite resources and a limited capability of primary care to influence overall health Lotus, the role of CO9C may be to shift the attention of the health care program toward health issues and 'subsets of ache community in which additions] benef it is possible . COPC also may have an impact, either positive or negative, on the total cost of health care for the community. In theory, the effici- ency gained by targeting particular services on high risk individuals in the community will eliminate redundant and unnecessary services and thus reduce cost. Likewise, change in the health status of the entire community will change the future need and thus the future cost of care for the community.

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45 REFERENCES Abramson, J. B. 1983 . Broadening the scope of clinical epidemiology . International Journal of Epidemiology 12: 376-378 . Abramson , J . H., Gof in , J ., Mopp , C ., Ban , R. 1983 . Control of cardio- vascular r isk factor s in the community: The CHAD program in Jerusalem. Paper presented at Franco~Israeli Symposium on Epide- miology and Community Health Planning, Paris, December, 1983. Abrasion, J.~., and Park, S.~. 1983. Community oriented primary care: Meaning and scope. Pp. 21-S9 in Community Oriented Primary Care- New Directions for Bealth Services. Washington, D.C.: National Academy Press. Fink, A., and Kosecoff, J. 1983. An Evaluation of the Structure of Primary Care Practices: Scary. Unpublished report submitted to the Robert Wood Johnson Foundation Teaching Mospi~cal General Medicine Group Practice Program by ache OCIA Group Practice E,ralu- a tion Ted. Goldberg, G., Brook, R.H., Pico, R., et.al . 1983 Preliminary Evaluation Report: Medical Record Abstraction Data, Robert Wood Johnson Foundation Teaching Bospital General Medicine Group Practice Program Evaluation, UCLA School of Medicine, L:os Angeles, CA. Hobel, C.J. 1979. A dynamic maternal risk factor scale. Paper presented at the International Workshop on the Hat Risk Infant,. Tel Aviv, Israel, July 25-31, 1979. Institute of Medicine. 1978. A Manpower Policy for Primary }lealth Care. Washington, D.C.: National Academy of Sciences. Madison, D.L., and Shenkin, B.N. 1978. Leadership for Com~unity-Respon- sive Practive--Preparing Physicians to Serve the Underserved. Chapel Bill, N.C.: The Rural Practice Project. MUI, an , F . 1982 . Community-oriented pr imary care : An agenda for the '80s. New England Journal of Medicine 307:1076-1078. Nutting, P.A., Strotz, C.R., and Short, G.I. 197S. Reduction of gastro- enteritis morbidity in high-risk infants. Pediatrics S5:354-3S8.

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