Click for next page ( 48


The National Academies | 500 Fifth St. N.W. | Washington, D.C. 20001
Copyright Β© National Academy of Sciences. All rights reserved.
Terms of Use and Privacy Statement



Below are the first 10 and last 10 pages of uncorrected machine-read text (when available) of this chapter, followed by the top 30 algorithmically extracted key phrases from the chapter as a whole.
Intended to provide our own search engines and external engines with highly rich, chapter-representative searchable text on the opening pages of each chapter. Because it is UNCORRECTED material, please consider the following text as a useful but insufficient proxy for the authoritative book pages.

Do not use for reproduction, copying, pasting, or reading; exclusively for search engines.

OCR for page 47
Chapter 5 \ ANALYSIS OF CURRENT PRACTICES SCARY OF PRACTICES ENGAGED IN COPE ~ typical instance of pr imary health care delivery in Me United States begins with a person identifying a personal health problem and either self-treating the problem themselves or seeking help from a pri- mary care provider or a specialist. Primary care tends to be patient- initiated and episodic. This mode of practice is very different from the fully developed model of community-oriented primary care described in Chapter 4. The focus of attention is different in primary care it tends to be on individuals, whereas in COPE it is on a defined commu- nity or population, many of whom do not present themselves for care. Moreover, the services thenmel~res and the trays they are organized and provided are often very different when the target of those cervices is an entire community rather than an aggregate of patients. Despite the apparent discrepancy between the ideal COPC described in the conceptual model and what i. known to be the prevailing mode of primary care practice, there are examples of primary care practices that approach the ideal, i.e., practices or programs that have assumed responsibility for ache health of a population defined more broadly than ache patients who present themselves for treatment and, having assumed that responsibility, are regularly performing some COPC functions. One objective of this study was to locate such practices and programs and determine the extent of knowledge about the operations, costs, and benef its of COPC in the United States. The study set out to find some of the best examples of COPC being practiced in this country today . As descr ibed in the methods chapter, identifying these examples was an open-ended process. Inquiries were made of individuals considered to be familiar with the concept of COPC, who had knowledge of health service program, both public and private, that might include COPC type programs, andiron who had knowledge of the published and unpublished literatire relevant to COPC or its major definitional components. About 185 letters were sent out and inquiries were made in person at several meetings and Conferences. As a result, there were 147 sites suggested as places engaged in COPC-type ac~ci~rities. The suggestions ranged from solo practices in rural West Virginia to community health centers in San Franci~co to 47

OCR for page 47
48 large multispecialty group practices in the Midwest. Further infor- mation was obtained on 84 of the suggested sites, both from written materials sent to us and from personal contacts. This group reflected the broad range of sites elicited by the initial inquiries. Out of these, 58 met the three criteria for COPC: the provision of primary care services, a defined community, and systematic efforts to identify and address the major health problems of the community. It was not the objective of the study to determine the prevalence of COPC in the united States, rather the intent was to find and study the best examples of COPC. Therefore, the sites identified above were not the result of an exhaustive search to uncover all the practices and programs engaged in COPC-type activities and they should not be inter- preted as the sum total of such practices. However, it is interesting to review the pool of potential COPC sites. It helps to put in perspective the seven sites that were selected for case studies. The 58 sites found to be engaged in son COPC activities included both public and private arrangement';. For 34 sites, ache major source of operating revenue was from public grants or contracts, whereas 24 sites were not dependent on public grants for operation. Ten of the 24 practices, however, were part of the Rural Practice Network; originally funded by the Robert Wood Johnson Foundation in their initial phase of development. Several of these practices also have received indirect subsidies in the form of National Bealth Services Corps physicians. There were several different types of practices and program Mung the 58 suggested sites. There were 17 community health center program (5 rural and 12 urban}, 15 median Health Service units, 3 health main- tenance organizations, 12 nonprofit private practices, 7 for-profit private practices, 2 hospital-based programs, ~ consortium of neighbor- hood heals cen~cers, and a union health program. Of Me S8 sites, 18 were located in urban areas, 37 were in rural areas, and only the 3 EMOs were located in areas "at included both urban and suburban co'—unities. AS indicated above, all S8 sites claimed that they were responsible for the health of a population defined more broadly than ache patients who use their practice. They usually defined their community in goon graphic or geopolitical terms or, in the case of Boos, in membership terms. The COPC-type activities =at were reported by these sites tended to cluster at ache early stages of identification and character- ization of their community, the identification of Me community's health needs, and Edification of the heals care program. Specific and cam- parable details of these activities across the 58 sites were difficult to obtain without a Ire elaborate survey or site visits. From the 58 sites identified as barring some of the characteristics of COPC, seven were chosen an canes for study. The final seven were selected to represent COPC practices that evolved in very different environments--single specialty as well as multi~pecialty, rural as well as urban, public as well as private, and fee for service as well as capitation. The seven were selected after contact either by telephone or in person with the principals in the practice. It appeared from these inquiries that these seven sites were performing several of the COPC functions at a mare advanced stage than the other practices

OCR for page 47
49 contacted. None of ache Biter was performing all the COPC functions cons intently at Me h ighest stage of development . C8ARACTE:RISTICS OF COPC STUDY SITES The seven COPC study sites were selected not only on the basis of how well they were performing COPC functions, but also on some external characteristics. Efforts were made to find practices and programs engaged in COPC activities that were situated in different parts of the country and organized in different ways. These efforts proved succe~- ful, and suitable COPC sites were found in a variety of situations and c ircu~tances {Table 5 .1) . An effort was made to select sites so that there would be fair geographic distribution. Three of the seven sites are on ache east coast, two in urban areas, and one in rural North Carolina; the other four are west of the Mississippi, including sites in ache mountains outside of Denver, the rural southwest, and the area around Portland, Oregon. With the exception of Raiser/Oregon, whose community includes urban and suburban residents, the COPC communities studied either were inner city (e . g ., East Boston and Monte f tore ~ or more than 50 miles away from a large metropolitan area (e.g., Checkerboard, Crow Mill, Sells, and Tarboro}. The extreme differences in the size of the communities served (ranging from 7,000 to 255,0001, reflects the full spectrum from urban to rural. Ownership of the practice or program and predominant sources of revenue were two other factors of concern to the committee. An effort was made to find COPC study sites that met the basic structural and functional criteria for COPC but that also practiced in different fiscal environments. Only one of the study sites, Sells, is a totally publicly owned program. Crow Hill is a private family practice, owned by two physicians and operating for profit. Four sites are privately owned but have not-for-profit status, and Tarboro represents a mix of all of the above, i.e., a publicly owned county health department, a private, for-profit multispeczalty group practice association, and a pr ivately-owned not-for-prof it community foundation. Private owner- ship, however, does not necessarily mean independence from public support. With the exception of Raiser/Oregon, which generates revenues from member dues, the four sites (Checkerboard, East Boston, Montefiore, and Tarboro} that exist all or in part as not-for-profit operations have public grants and contracts as one cuff the ma jor sources of revenue . In was noted, however, that for several of these sites, third-E,arty payment is becoming an increasingly more significant source of revenue. Finally, there is var iation across COPC practice sites on the size of the practice. The range is from a two-physician family practice at Crow Hill to a 250-physician, multispecialty practice at Raiser/Oregon. There does seem to be a clustering, however, around the small groups, e.g., Crow Bill with two, Checkerboard with four, Mantefiore with six, and Sells with seven.

OCR for page 47
so - cn oD v o c) o u - 0 - s J E" - ~ ~ 0 q ~ _ 3 ~ :> C E C ~: Z O C C ~ _ O C' _ 0 3 tS Z P. C _ ~ C 0 C _ — ~ £ O ~ ~ o: 3 O ~ c5 0 C C O _ _ oo ~ P. ~ O N l~q _ V U]— C £— O ~ Q ~ :> C~ ~ 0 ~n o - 0 C o :~'— _ _ E ~ U . 0 ~ ~d :- ~ :~'— as 0 ~d ~ ~ ~ U ~ ~ ~ ~ O — C ~ ~ U lu — O ~ ~ ~ O — dV a4 £ 0 ~C C ~ ~: 0 ~ ~ 0 c O :.,— _ - 4 ~ · :~ _ _ X E ~ O q— U c5 ~_ Q. ~o _ ~ ~ (U ~ :~— ~d h4 cs ~ 0 C 111 _ C _ O ~4 D U ~ 0 3 o v c ~ _ _ - - ' - ~ O ~ O JJ ~ 4J ~ De ~ ~ _ ~ _ ~ O ·4 O m ~2 ~ _ 0 0 OQ 0 0 ~ ~ ~ _ ~ _ · _ ~ :> X ~ :' ~ ~ O ~ ~ ~ _ U U ~ C} ~ 0 C ~ 0 a. ~— 0 ~ ~ 0 o ~ _ _ ~ ~ ~ _ =~ ~ ~ 0~! 0. ~ ~ 0 00 1 0 ~ V o' 3 ~ ~ cn _ oe oe C ~ _ O ~ o' ~ ~ ~ ~ :>,— ~, _ _ ~ _ ~ ~ ~ _ ~ ~ #, _ —— E ~ 0 3 ~ 115 E ~ —~ C— ~— ~ U ~ t' 0 ~ E ~ C — ~ _ ~ CL =. ~— tn _ _ ~ a' ~ ~ ~ 0 ~ U :~_ ~ U ~ D ~S ~ ~ L~ ~ _ ~4 ~S 0 C, 0. 0 — C O U ~— 0 3 - - ". ~: ~ _ V :> n~ D ~ O ~: C ~ ~ ~ ~2 _ :: :' o ~ :l ~ ~ 0 - ~ F ~ C _ C :~: — ~ _ O ~ ~: ~5 C O ~ O O C S 0 O Q s s — Z 0 C O C 0 C ~ ~ O E h4 O 1 _1 0 U ~ 0— CP _ ~ O ' X O ~ :, - E ~ ~: O - ·4 ~: C ~S O s: S :~ — eo u~ C -: O · _ C, r' E _ E. _ o U) _ O - c =' E ~ =: V U _ U, ~ S U, C ~ os ~ _ _ _ _ ~ ~ u, ~ ~n - Z ~2 E ' O ~ U V C :' O O C' ~ _ :> 1 tQ o s O D _ h4 ~ S ~ D _ 07 ~ C _ O ~ ~ O V Eo :s O l_ O _ _ 0- V o O? _ oe ~ 0 £ ~C o 0 E - 0 o, 0 0 D o E o E o ~C _ — a, ~ C) ~ _ _ V ~ C) C) C V 0 h4 _ O o. _ C O? - E" O ~ v E ~D _ E Z · — C ~ _ s _ _ 3 ~ L. 0 ~ C _ o, ~ - 0 - - :> - c - - ~ . O ta 0 0 - _ O O ~d ~ E C :, O o o. -

OCR for page 47
sl It is interesting to keep in mind the variations in the practices when reading the cross-case analysis that follows. Thin is not a ho~- geneous group engaged in COPC; rather it is an assortment of practices and programs that, in different ways and in different environments, have approximated some elements of the fully~operational model of COPC. THE: SEVEN STORY S ITES This section provides a brief sketch of each of the seven Rites, describing their organization, where they are located, and how they have approximated the COPC model. In each site, there is ~ tabular display summarizing selected examples of COEC activities. The full case study report for each site is presented in volume II. Checkerboard Area Bealth System* The Checkerboard Area Besith System is a primary care program composed of ~ health center and four satellite clinics serving culturally diverse population in northwestern New Mexico. The approximately 14,000 residents are widely dispersed over 4,000 square miles in small villages or family camps. ___ ~ . _, Navajo Indians represent about 63 percent of the population served by the system sod the remaining 37 percent is made up of Spanish Americans and Anglos. The Checkerboard area, so need because of the pattern of land ownerships by federal and state government, railroad, Navajo, and private organizations and individuals, shares posse of the character- istics of an underdeveloped rural area. The only signif icant local sources of income, other than cattle ranching and sheepherding, are natural resource extraction, small service businesses and trading posts, and go~rernmente1 service system= such as school, health, and highway departments. In some communities, over one half of the work force is unemployed. The maioritv of ares residents depend for survival on subsistence agriculture and stock raising, along with Approximately 85 percent of the governmental f inancial assistance. area families live on incomes below the federal poverty level. Geographic isolation and minimal communication facilities charac- terize the area. Communicable disease and poor nutrition expressed in the high prevalence of diseases such as shigella, enteritis, trachea, impetigo, pneumonia, and otitis media reflect ache relatively hostile physical en~riron~nt. Recognizing these factors Checkerboard has developed ~ health care program tailored to the needs of the population living in the area, including diagnostic and treatment procedures for acute and chronic conditions, screening and health assessments, dental programs, health *Hereafter referred to BS Checkerboard

OCR for page 47
S2 education, transportation ser~rices, and ~ variety of outreach programs. {See Table 5.2 for some examples of COPC activities at Checkerboard.) Consolidating and integrating pre~renti~re and curative services in the Checkerboard ares has been made possible in part through coordina- tion of ~ series of grants and contracts negotiated over the last decade. Checkerboard contracts with the Indian Bealth Service to provide inpatient, outpatient and dental services to the Navajo residents in the catchment population. Checkerboard receives grants from federal agencies {U.S. Public Health Service and U.S. Department of Agriculture) to provide comprehensive services to the non-~avejo population. PUbliC health services, previously provided by a branch health office of the state health agency, are currently provided by Checkerboard under contract with the state health agency. Likewise, health promotion and disease prevention responsibilities for all school children in the Checkerboard population have been assumed by Checker- board under contractus1 arrangements with 10C81 school districts. These servicer and program. are provided through a system of four satellite clinics supported by a central health center. Limited hospital (Medicare certified} and emergency medical services are available 24-hours per day, seven days per week at the centrs1 health center. Both preventive and curative services are provided in continuous and Coordinated way. Crow Bl11 Family Medicine Center. The Crow Bill Family Medicine Center, a priorate family practice begun in 1977, is located on a major highway in Bailey, Colorado, 60 miles west of Denver. The ares served by Crow Bill stretches from the far western suburbs of Denver to Fairplay, ~ town on the far west side of ~ major mountain pass. Crow Bill is the only medical practice in the area. Until July 1982, the practice was ache responsibility of one family practitioner committed to ache ides of meeting ache health needs of this community. Currently, Crow }fill is shared by two family practitioners with the assistance of four nurses, a receptionist, typist, and a bookkeeper. The population served by Crow Bill tends to be white, middle class and employed or retired. One subset of the population is made up of young families who cosmwee to Denver for work and in some cases medical care. There also are many retirees in He community, many of whom cone tinge to travel to Denver for shopping and medical services. (According to the 1980 census 60 percent of senior citizens of Park County live in Bailey/Crow Bill area). A third subset of Me population served by Crow Bill are E - 3ple who have Tiered in the ares for many year';, who identify strongly winch the local community and tend to support volunteer efforts *hereafter referred to as Crow Hill.

OCR for page 47
~3 ~: q z y P: .l ~ o o o sO o _ o _ o o 3, q _ _ o _ q C U _ o C ~ C ~ _ o q ~d O ~ O c~ ~ C ~ C ~ ~ :, o c V U o. C 82 ~ ~ c C ~ ~ C, ~ CS ~ ~ ~ ~a V q~ _ q s ~ ~ q <, U 0 q ~ ~ ~ q "CO · ~ _ ~o ~: ~ ~ ~ _ `_ q _ C ~ ~ o # Q o ~ _ t_ C 1 ~ 0 1 _ o s o |,, ~ _ V _ o V ~ o o - C ~ ~ U ~ ~ i~ ~ "a ~ o— ~—~ ~ ~ ~ ". em o ~Q De ~ ~ _ q ~ ~ ~ I q ~ ~ ~ aC C) l: ~ ~ ~— r" v :> U c' , _. ~ ~ a _ q —a ~ a~ u~ · . - s 0 _ 0 0 ~ _. 0 ~ ~ ~c ~ c 0 c _. 0 u ·~ · b. _ O e4 _ ==a.8 ~ x. _ v ~ q c q ~ ~ u ~ 0 ~ mo s ~ 0 ~ as ~ V _ ~ o~ ~ C Q ~—~ c ~ O P_ s O_ ~ ~ o_ C C c~ . 1 0 ~ O C _ ~ _ ~ a c u ~ e o~ Q ~ ~ a_ _ ~ _~_ v ~ ~ ~ ~o ~ ~ q ~ u t~ ~ ~ ~ _ ~ c,- _~ .C 1 0 C o~ c: c ~ c: ~ ~ _ q ., a~ o ~ a' ~ _ ~ ~ e`, _ . c, ~ ~ e q u ~ ~ _ ~ ~ ~ — Z ~ . - ~ ~ O ~ _ _ _ _ ~ :1 q 0 c U~ _ "c ~ ~ O O ~ ~ O ~ U ~ >- C _ ~ ~ U q - O 0 . - _ C ~ C ~ _ ~ c, _ C ~ ~ :3 ~ ~ ~ ~ C u. s q o. U ~ ~ C C ~ ~ ~ ~ 8 v 8 ~ e · ~ ~ 0 U ~ c ~ U 0 ~ om U · 1 c,, a4 — _ 1 ~ O a4 C U . ' CI, ~ I U ~ ~ ~ ~C C Io 0 g. t. ~ -= ~ ~ ~ ~ ~ _ _ ~ C ~ ~ ~ ~ 0 ~ ~. q e "s 0 ~— ~ ~ "~ 1 ~ ~ O — :~ ~~ ~ O O ~ cm ~ ~ ~ . o ~ _ a~ 0 ~ ~ ~ ~ a c ~ ~ 0 ~ c ~ ' ~ ~ ~ ~ ~ ~ 0 4J _ ~ ~ .~—a: 0 ~ a. ~ ~ _ ~ ~ ~ c · ~ ~ ~d ~ c~ ~ ~s~ 8 ~ ~ q o .4 S O ~ 1 8 0 U_ O 0. _ q ~ ~ O U ~ ~ q O _ mm C e~~ O 00 _ ~ q ~ O— s: ~ ~ C — :. ~ ~ ~ ~d :I C 0. . O y q C C :1 O J:= ~ ~ _ ~ 8 O S C V :, O C: ~ q . - C ~ e 0— : , -! r: ~ ~: ~ ~ - ~ o ~ ~ 3 ,, ~ g ~ ~ c e ~ c " - o T~ ~ ~ ~ 5 ~ 0 0 8 3 _ u ~ e ~ _ ~ u ~ 0 ~ 0 m. ~ 0 · I ^ - a" c u ~ ~ ~ q c 0 ~ ~o 0 c_ 0 0 c c u 0 0 c u ~_ _ == v _ ~ ~ ~ c · u O d ~ C ~ ~ ~ ~ 0 q o ~ u ~ ~ _ C ~ ~ O — C C 1 U c ~ ~ s e e ~ 0 ~ _ u ~e ~ "_ ~ ~ ~ _ o ~ ._ c ~ o. >. q c~ u ~ ..s ~ o ~ c 0 ~ _ c ~ ._ ~ u _ ~ 0 0 0 ~ e ~ 8 ~. C~ ~—O ~ Ch ~ ~ ~ _ ~ ~ co ~ t,— 8 ~ ~ ~ ~ - ~ ~ u 0 c q c_ u ~ >. ~ q ~. ~ ~ ~ ~ ~ c ~ 0 4 ~ :1 _ ~ es ~ ~ C ~ O ~ ~ O ~— ~ q 0 s 0 0 q ~ _ ~ ~4 44 - ~ ^~ ~4 · · · ~ · — m~ ~ ,,' ~ C U co _ q ~ _ as ·" u ~ 6 ~ o. ._ — ~ ~ 0 ~ z v ~ ~ ~ ~ _ c — s ~ _ ~ ~ ]-o ~ ~ q b. O 0 u c ~ · Ql c ~ c c— 0 ~ _ _' — _ _ ~ u a c ~ v ~ c~ ~ 0 _ 0 ~ u o~ u 0 ~ 0 c q 0 ~ 0 ~ u ~ ~ _ _ ~ ~q 0 u~ ~ ~ ~ 0 _ ~ _ >' _ ~ ~ e. _ ~ ~ c 0 ~ >~ ~ ~ u u e ~ I "e ~ :' ~ ~ ~ ~ - ms e e ~ o. _ ~ 0 _ ~ ~ ~ ~ c ^~ 0 0 c q ~ a_ ~ o_ s a~ y—SV o~ C, - ~ ~ g_~ - c ~ a_ 0 0 0 ~ ~ ~ 0 ~ c ~ ~ c ~ . ~ 0 ~ ~ ~ ~ ~ ~ o_ ~ ~ c · o o~ e ~ ~ c _ ~ ~ ~ _ e_ ~ u u ~d .4— O V ~ ~ Q ._ 0 ~ ". =. ve a_ o_ c = - ~ _ :' ~ _ ~: ~ ~ 0 ~ _ 0 0 _ ,~ ~ v . . v c q ~ _ I c ~ 0 c c_ o. _ q u "e ~ 0 ~_ ~_ u ~ ~ q—~ .4 ~ ~ ~ q ~ v 0 ~ ~ _ 0 ~ ~ ~ 0 Yo 1 ~= ~ C ~ _ o - _ o ~ ~ CL ~ a~ __ O ~ - = ~ O ~ 8 U ~ V C _' ~ O _ ~ ~ C ~ q ~ ~: ~ _ O _ ~ h~ ~o ~ ~ ~ q O ~ C ,~~ c~ ·e ~ O O :^ 8 ~ ~ ~ O ~ ~ ~ O ~ :> ~ C ~ ~; q _ ~ ~ I _. ~ ~ ^' O O ~ ~ ~ q ~ I O q 01 a~ O ~ ~ ~ - ~ - - _ - ~ ~ U q .Q hd ~ ~— ~ O O ~ O ~ == ~ 1 . I q I ~ m- _ ~ 1 ~ I ~ ~ ~ ~ e ~ ~ ~ c _ c~ - ~ 0 q ~ ~ ~ ~ D - O C ~= ~ ~ q C— ~ ~ ~ V ~— ^o ~ o o ~ ~ C 0 h4 0 ~ C ~ ~ ~ O. ~ ~— ~ _ q 0 ~ a. ~ ~ ~ ~ .4 ~ U ~ C C ~ _ V V U :' ~ 0 ~ q._ ~ 0 ~ a~ ~, ~ ~ ~ _ ~ _ ~ q c ~ _ ~ ~ ~ 0 ~ m~ ~ 0 c _ _ ~ ~ ~ a, ~ ., _ q ~c ~ ~ ~ _ ~ ~ c c 0 ~ c ~ ~ ~ 0 v ~ a_ q · ~ ~

OCR for page 47
54 1 _ _ ~ ~ ~ ~ o ~ C _ o C ~ ~ ~ ~ C o ~: ~ ~ _ _ ~ ~ q ~ q o q s q ~ ~ ~ o ~ _ o_ o _ ~ _ ~ o ~ ~ ~ ~ n ~ ~ ~ ~ ~ _l ~ s ~ O O ~ ~ ~ ~ ~ ~ C~ Q t, ~5 u O _ ~C ~ ~ U O ~ ~ 0 ~4 ~ ~ ~d ~ ~ c_ ~ ~ ~ ~ m~ ~ ~ ~ c _ c~ ~ :. ~ ~ ~ c ~ ~ s ~ ~ ~ _ ~ O ~ ~ ~ t' ~ 3 ~ ~ ~ ad c ~ :' ~ `: O ~ ~ c ~ u a~ O x 0 c _ ~ ~ ~ _ dJ ~ ~ _ _ ~ ~: a `: ~ u ~ c~ ~ ~ C V C ~ ~ 0 ~ o ~ ~ C _ ~ ~ c~ _ ~ ~ ~ — 0 ~ ~ ~ ~ _ ~ t) O _~ CL :e ~— — O —~ ~ c ~ ~ ~ ~ 0 0 ~ o—~ ~ ~ ~ ~ C ~ ~ 0 0 :> ~— ~ :, ~ 1: q ~ ~ ~ ~ ~ :, S cs" c 0e,, ~ ~ 8282 ~ - ° - ~ · C ~s — CP ~ c :, 0 · 0 ~_ J: · C "5: - _ ~ ~ ~ ~ o ~ a: ~ !. C s U ~ :' 0 5: "D ~ ~ S _ - ~ ~. _ a_ C .~ O . . 3 C O _ _ X ~ C — C, ~ ~ C Z o O ~ _ _ :, ~ _ _= .' C c , _ _ C ~ h4 ~ e_ _ ~ o. 0 ~ ~O C ~ . q - ~C ~ ~ ~ _ ^ - _ ~ ~ 0 _. ~ 1 — .4 C~ ~ s ~ 0 -4 ~ ~ ~ C 0 _ C, s~ a~ ~ — :. C ~ ~ C 0 C - 4 ~ ~ ~ _ _ ~ .4 c e ~ 0 0 I — q O ~ ~ eJ _ ~ 1~ ~ ~ 1 C C C — C _ ~ V ~ O— —— C—~ C— 10 ~ O d~ ~ _ ~ _ ~ ~ ~ ~ ~ ~—~ ~ ~ ~ O ~ O e~s ~ C ~ChI:~>— · ~ ~ C ~ ~ q _ ~ 3 C. O ~ O _ _. ~ ~ ~ O C ~ ~ ~ _ _ ~ ~ O O ~ O ~ ~ ~: 0. C ~ C ~_ ~ ~ O U O ~ ~ O O _ C O O ' m_ _ ~ ~ ~ _ U ~ ~ ~ O ~ O O. .d ~ ~ .C ae O a_m 0 ~ ~ O C ~ :, ~ H ~ ~ 0 41 O O ~ _ _ ~ hd Q C ~ ~ ~ ~ :" q _ _ r~ ~ O ~ C .4 ~ C U "e ~ ~ O _ ~ ~ O ~ C 0. C ~ 4} h~ ~ V 0 61 :> O ~ ~ ~d :~ :~ ~ O C 1 :e O ~ ~ O O ~ ~ ~ · ~ ~ cC C O _ C C, 1 0 0 _ 10 q _ :, De" O C O =_ _' _ _ O ) ~: _ ~: C C O _ e4 ~n . C C, _ O ~ ~ - C ~ O C s: ~

OCR for page 47
55 with in the community. This latter group is descr ibed as self-reliant; they scud not to be heavy utilizers of pr imary care services. En',mer- ating ache individuals or families that make up this community and identifying the health needs of ~ community this diverse hen presented a challenge to the staff at Crow Hill. Through their Family Medicine Information System (FISTS}, the practice has been able to precisely define a practice community that extends beyond the users of services. They can, and do for Various screening purposes, enumerate all members of registered families, i.e., families from which any single meter has visited the practice within the previous two years. Severs1 community health needs have been identified, e.g., emergency care, extended office hours, vulnerability to strep throat, etc. and services have been modified in response to those needs. (See Table 5.3 for ~ sunmury of some of the examples of COPC activities at Crow }lill.) No attempt has been made ~ document or monitor the effects of these Edifications. East Boston Neighborhood Health Center* East Boston Neighborhood Bealth Center is a large community owned and operated health center that provides comprehensive primary care services to the residents of East Boston, - ~sachusette. The health center has been operating since the late 1960 s under the direction of a community board that decides on major policy questions, owns the building , is responsible for hiring and firing staff, and is the grantee and/or contracting agent in awards of this kind. The board is assisted in program planning and in the day-t~day operations by a five person executive committee. East Boston is a part of Boston that is physically cut off from the rest of the city try Boston Barbor. It shares t" geography with Logan International Airport. The population of "at Boston, which n''mhers approximately 32,000 people, is predominantly working class Italian Americans with ~ strong community identification. With the exception of a few aging solo practitioners, the East Boston Neighborhood Health Center is the only source of medical care located in East Boston. There are, of course, a multiplicity of medical resources on the other side of the harbor. The health center staff estates that about half of the residents of East Boston here actually registered with the health center. Since its early days the East Boston Neighbor he Health Center has been committed to pra',iding priory care services to all the residents of East Boston. East 80~10n was assisted in enumerating its population and identifying its health needs when the center became a practice site an a national study of hypertension detection and follow up. This survey and subsequent surveys have revealed a good deal of information . *hereafter referred to as East Boston.

OCR for page 47
56 ~! I3; o - Y 8i o 0 on ~ u e :, C ~ ~ ~_ 0 ~ _ :, 0 _ ~ ~ ~ 0 ~ s :1 ._ a_ ~ am ~ ~ ~ ~ ~ C ~ "_ ~ — — 0 ~ on _ an ~ ~ · C C U 0 ~ ~ 0— 0 C ~ ~ _ ~ _ ~ _ ~ ~ 0 _ _ ~ ~ 8: ~ ~ ~ ~ ~ ~ `: _ ~ ~ ~ 0 ~ ~ ~ _ MY— off: -—~ 0 ~ ~ ~ ~ e ~ _ 0 ~ · ~ O ~ ..C— c, ~ _ ~ ~ ~ ~ ~ ~ _ o ~ V ~ ._ - _ a, - ~ ~ ~ ~ ~ O O ~— ~ ~ ~ O · _ ___ _ ~= O ~ " - ~ ~ ~ ~ "= ~ ~S. i. ~ ~ o 5~; ~ ~ ~ ~ · ~ ~ ~ ~ , ~ ~ ~ _ o ~ _ ~ U ~ · ~ I {, · ~ .C 0 C e o ~ ~ `: C 81 _ ~ he ~ ~ _ ~ ~ —_ 0 01 ~ _ O ~ ~ ~ ~ ~ . _ ~ U - - ~ ~ ~ ~ ~ m_ q O ~—O ~ ~ ~ C ~ O - 0 C :- —~ ~—U -— eJ ~ dJ O ~ ~ —~— ~ ~ ~— ~ O C q ~ ~ ~ ~ ~ ~C C ~ ~ C ~ _. ~ ~ ~ ~ ~— _1 _ O ~ ~ :, .1 ~ ~ .1 ~ q ~ O Q :~ :~_ ~ ~ _ :~ ~ O—~ ~ t:l. O ~— ~ _ hd O— ~ C ~ 04 S: ~ ~ 0. _ ~ 1 1 :> o O ~ ~ ~—~ ~ U ~ ~ ~ ~ c ~ ~ ~ ~ ~ 8 ~ ° o ~ u ~ ~ _ ~ ~ ~ ~ ~ ,~ _ ~ _ ~ ~ . ~ _ ~ ~ ~ _ · ~ ~ ~ ~ ~ ~ ~ g ~, ~ o 8 1 ~ - _ ~ "_ U ~ ~ 1 ^ - ~ C— ~ u 0 c ~ ~ c c ~ 0 o.4— ~ ~ g ~ e ~d u c ~u ~ ~ 0 ~ ~ ~ ° ~ 0 ~ g ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ _ ~ %. ~ 0 _ ~ ~ _ ~ ~ ~ .11 8 _ c ~ ~ e ; ^! ~ ~ ~ ' ~ o~ ~ e ° _ ~ c, ~ e c ~ ~ ~ ~ ~ 0 ~ u U . ~ ~ ~ U ~ ~ y O ~ l l ~ ~ O ~ t ? ~ ~ ~ - ~. =o ~ C ·e ~ ~ .. ~C ~ C ° 8 ° ~ ~.e o o ~ ~ ~ ~ ~ 8 ~ aU C ~ ~ ~ 0 ~ 3_; 8 ~Y ~: 0 e' ~ _ _ C— ~ C ~ ~ ~ ~ I ~ ~ ~ ~ ~ _ ~ ~ 0 ~ ~ ,' O V ~ _ J: ~ _ · ~ ~ C ~ o o~ _ C ~ ~ ~ ~ ~ cll ~ ~ ~ 0 ~ e O a.°:c .~: °. ~ ~ ~ ~ ~ V ~ _ ,,, 4,, ~ '>o i. '.87 i~o · ~ ~ ~ ~ - ~ ~ o ~ z ~ ~ an. - l~ lo ia

OCR for page 47
~7 about the health needs of the East Boston community. When fees ible, as in the case of identifying a need for congregate housing for ache depen- dent elderly, the community board has taken action and modified the program in response to community needs. (For other examples of COPC activities at =st Boston, see Table 5.4.} However, there has been no systematic documentation or monitoring of the effects of these changes. Kaiser-Permanente Medical Care Program of Oregon. The Raiser-Per~nente Medical Care Program in Portland, Oregon is one of the nine regional programs of the nationwide Raiser-Permanente Medical Care Program, the largest health maintenance organization in the United States. Raiser/Oregon, like the other eight regions is a joint endeavor involving representatives of the professions of medicine and management, "baring responsibilities for organizing, financing and delivering health care service on ~ prepaid basis. Approximately 2S0 salaried physicians are organized as ~ separate and independent medical group known as Northwest Permanente, and management functions through the Raiser Foundation Health Plan and the Raiser Foundation Bospitals. The Oregon region of the program has been in operation since the early 1940s and currently serves a community of enrollees numbering approximately 25G,000. In addition to ache organizing, financing, and delivery of health services Xaiser/Oregon has had, since 1964, an active health services . . . . . . research division and ~ very rich cats base specifically designed to study ache effects of changes in the organizaton of health services and to improve understanding and appreciation of the theoretical issues of medical care utilization. Although it functions semisutonomously in the Oregon region, the research center has had a profound Impact on the direction and operations of the health program. Many of the innovative ways the Raiser/Oregon membership has been expanded (e.g., Medicare and Medicaid groups brought into the plan), needs identified (e.g., preventive services for the indigent population and home health services), services modified {e.g., outreach programs, home health agency) and effectiveness measured trace their origins to the Health Services Research Center. (See Table S.5 for examples of COPC activities at Raiser/Oregon.} The community for which Raiser/Oregon is responsible is made up of the approximately 2S0,000 plan oaember-, those individuals with whom the plan has a contractual relationship to provide health care. By virtue of this contractual relationship, Raiser/Oregon' ~ population i. clearly and specifically defined and the individual members can, at any time, be enumerated. Raiser/Oregon has as its community approximately 20 percent of the population of greater Portland. The demographic char- acteristics of the membership are almost identical to the Portland *Hereafter referred to as Raiser/Oregon.

OCR for page 47
86 v ~4 o e - ~d o i: o - C, - - o solo 1 ~ FlaL Pi ~ EM to Ig 's 9- . ~ So ~ ll' Of ~ o Cl _ Via ~ I~ of al IS ~4 o o o - id v - o - so q o 3- E~ i~ , ~ ~ 55 Iglll ~ ~ ~ to _ ~ o o to o ~: ~ — e c ~ 0 _ v ~ F a ~.c ~ ~ _ — ~ ~ c 0 _ ~ ~ c, ~ `: a _ ~ ~ O a_ 0 ~ . ~ 0 C 0 - _ O ~ O ~ ~ ~ O_ ~ - _ · as O o O — O l: o ~ K ~ ~ .0 s ~ ~ ~ ~ E ~ ~ O ~ ~ ~ ~ ~ ~ 8: C ~ ~ ~ ~ ~ ~ ~ D— O ~ ~ 1~ ~ ~ ~ ~ ~1 C O ~ ~ O :1 :~ C O ~— Cl. O ~ ~ C ~ ~ `: a__ ~ ~ . ~ ~ O ~ ~ ~ ~~ o ~ a~ O ~ ~ ~ __ o a~s ~ ~ ~ ~ ~ ~ :, ~ ~ _ — ~ ~ V ~ ~ ~ _ ~ ~—q5 _ _ ~ . ~ ~ - _ ~ ~ o C ~ ~ V ~ ~ ~ ~ O _ ~ o ~ ~ O ~ ~ ~— ~ ~ ~ ~ ~— ~ C O— ~ o —~ ~ O ~ ~ ~ ~ ~ ~ q ~ C O _e _ ~ ~ o ~ ~ ~ ~ ~ ~ V V ~ · ~ ~ s ~ ~ ~ ~ O c: ~ ~ O S 1~. ~ ~d O ~ ~ ~ O ~ q c4 ~ gL ~ ~ ~ O o U · ~ ~ ~ ~ ~ ~ ^= ~ ~ o ~ ~ ~ "~ o —— ~ o ~ ~ _ ~ ~t ~ ~ o ~ ~ q ~ V ~ ~ ~ ~ q ~ ~ ~ ~ ~ ~ 0 5 ~ ~ ~ ~ ~ ~ _ ~ ~ ~ ~ ~ 0 ', ~ ~ S— ~ ~ o ~ ~ ~ ^. ~D ~ ~ _ ~ o ~ 8 ~ _ ~ ~ ~ ~ v a_ ~ m~ . O - ~ ~ ~ ~ O ~ c E 5 e c ~ o e ^o O O q ° "' l a~= °~ - ~—~ K ~ O O ~— ~ ~J — ~ ~ ~ — C V ~ ~ O ~ C ~ _ 01 _ ~ _ ~ ~ . ~ q ~ _ ~ ~ I :l _ ^~ s ~ ~ 8 ~ o ~ o ~ ~ ~ O ~ O E ~ c E — u v ~ :, ~ ~ Ch ~ E ~ ~ ~ ~ ~ ~ ~ ~ ~ _ ~ ., ~ _ ~ ~ ~ ~ ~ ~ _ e'` ~ ~ ~ q Ch O O :> ~ ~ O c O ~ 0 .4 ~ q ~ ~ ~ O ~ ~ ~ q ~ ~ ~ ~ ~ ~ ~ ~ u O ~ cr' _ C ~ ~ O ~ V ~ ~ ~ ~ ~ _ ~ ~ U E C ~ .-S ~ ~ ~ 0 -. ~ ._ ~ ~ ~ 0~ 08 ~ ~ ~ ~ ~ a_ c 0 0 0 ~

OCR for page 47
87 cost implications. Virtually all of the study sites made use of information available from local health and planning agencies, and a few relied almost entirely on this type of secondary data. Both East Boston and Tarboro side a substantial special effort to characterize their community, going considerably beyond the data available from local agencies. while neither site is able exactly to determine the cost of their efforts, they would probably have been unable to accom- plish them without the special funding support each had received for specif it: research activities. Whether primary or secondary data is used, additional analysis was necessary in order to tranform the data into useful information. With the exception of the sites that routinely engaged in research (East Boston, Sells, Raiser/Oregon, Tarboro} most of the time-consum~ng analysis and interpretation of. the raw data fell to the physician. Several of the principals pointed out that they were not following a definite protocol, and thus it was easier to deal with the data themselves than to teach someone else to ass ist. The task of identifying and character iz ing the community is considerably simpler (and relatively less costly ~ in the sites with ~ population-based data system. Both Checkerboard and Sells are able to maintain a reasonably up-to-date demographic description of their comm~- n ity from their data system. Raiser/Oregon expends considerable effort and expense to closely monitor the characteristics of their community, and their performance far exceeds all other study sites in precision and timeliness which would not be feasible without ~ data system. Among the study sites, monitoring the impact of the program modifications was relatively ache weakest of the COPC activities. Virtually all sites acknowledged the importance of this function but cited the cost and lack of personnel skilled in evaluation techniques as the major impediment. Thus, on the surface, it would appear that the perceived cost of the monitoring function exceeded the resources in most sites. The exceptions of course were generally among the sites with strong research affiliations, in which case the cost of the moni- toring function was covered within the research activity. The costs associated with the function of community participation varied widely song the study sites. Conceptually, the cost of commu- nity participation includes those direct and indirect costs born by the primary care program and not the cost to the community as a whole. For example, if a particular community board meets regularly with the professional staff, the cost must account for the time of the professional staff, but not for the board members unless they are paid by the program. Similarly, the cost of community participation also must include the time-value of the professional staf f who participate in the activities of community health programs and serve on ache board of community agencies, even if they do do on their own time. Of all the COPC functions, the cost for the modification of the health care program is most difficult to estimate . This set of costs generally falls into two categories--the cost of planning and imple- menting the Edification and the differential cost to the 'system of operating over time with the Edification. The costs of planning and implementing a Edification in the program are particularly difficult

OCR for page 47
88 to estimate. For the most part, these are time-costs for the health professionals to consider the range of alternative changes that can be made, selecting one particular approach, planning its implementation, and working with other personnel to affect the change in program modification. This set of nativities is closely associated with the activities that are an integral part of managing a primary care program and it is difficult to identify the .margin. that in attributable to the COPC process. For example, at East Boston much of the cost of the weekly meeting with the Board would be attributable to the operation of the primary care program. Given this cost, the marginal cost of planning and implementing the COPC program modification probably would be small. Generally Tong the study sites, these costs are probably less than those associated with the quantitative processes of COEC, and certainly would involve fewer rout of pocket. expenses than conducting a household survey to characterize the community. On the other hand, the costs associated with the modification itself can be substantial. Tong the study sites most of these costs were positive, that is;, the modification involved ~ new program with additional costs rather than a realignment of an existing program within ~ fixed budget. Notable exceptions included Checkerboard, which adjusted its screening procedures for children based on ache prevalence of selected health problems in the community and discontinued several screening procedures while adding emphasis to several priority health problems of children. Sells instituted a fundamental change in its approach to infant gastroenter itis involving both ache pr zmary care and several community health program with no appreciable change in budget, However, it is dangerous to conclude that such programs had no asso- cisted increase in cost, since it is difficult to attribute the trade- off involved in making a program Edification. One wonders to what extent the costs of such an effort are in fact borne by other emphasis areas within ache total health care program. Of the program modifications identified in the study sites, most clearly involved an incremental cost, and often were identifiable as separate budget categories. The study 'sites usually implemented the program Edification win an increase in Heir revenue base, often sought through external grunts and contracts. Although the case studies offer little new information on the costs associated winch the practice of COPC, some general points can be offered regarding the relative magnitude of He costs and who bears ached under different financing arrangements. The COPC functions ~chemselves are not inherently expensive, and if embedded in a large heals care organi- zation pose marginal costs not large relative to the cost of the total program. Clearly, there is an economy of scale because the costs asso- ciated with the COPC probably are not linearly related to the size of the community. It it; unlikely to cost twice as much to identify and address the major health issues of a community of 20,000 as a community of 10,000. Thus, within limits, the cost per capita of the COPC func- tions would probably decrease as the size of the community increases. The total costs of a COPC practice may not necessarily be higher than that of orthodox primary care and in fact may be less Costly overall to society. If successful, a COP C practice may achieve savings

OCR for page 47
89 that more than offset the incremental costs of special COPC-related activities. For example, savings may result from targeting interven- tion at high risk groups, from discontinuing services with no benefit, or from reductions in the need for hospitalization. Also, COPC can lead to more efficient operations and should lead to concentration of efforts on services that have higher priority and productivity in terms of the community's health. Decreased costs because of reductions in the future need for health services do not represent savings in all health care programs. If the program has a mandate to provide all necessary care to a community (e.g., as in the Indian Health Service or an EMO), then certain cost trade-offs can be made. However, a practice that generates revenue only when services are delivered cannot reduce their costs by activi- ties that reduce the future need for service, and in fact such activities may actually serve to reduce the future revenue base. The Impact of COPC The impact of COPC can best be expressed as the marginal effect of those activities that are unique to COPC and not considered to be activities of orthodox primary care. By its nature the COPC process directs the attention of the health care system to particular health problems and issues in the health of the community. At one level COPC activities would be expected to improve the status of the particular health issue being addressed. This micro effect is normally observed in the monitoring of impact activities, which constitute the fourth function of COPC. Bowever, the dynamic relationships among the activities of the health program and the expression of disease in a community are complex, and efforts to improve one aspect of health could draw resources from another effort. The activities of COPC themselves have a finite cost, which in a non-COPC practice would be directed toward providing more services. Thus, the macro effect of COPC would consider the net change in the health care or health status of the community and would consider both positive and negative effects. There is very little definitive information on the marginal impact of COPC. The literature contains no systematic studies of the orthodox primary care. The case studies generated very little new information on the marginal impact of that set of activities that belong uniquely to the domain of COPC rather than to orthodox primary care. Many of the sites demonstrated changes in the processes or outcomes of their programs, although it was rare that causality could be established (Colombo et al., 1979; Freeborn et al., 1978). None of the sites had data, however, which allowed an assessment of the marginal impact of the COPC activities. However, there is evidence in the literature on the impact of innovations in primary care which share some of the characteristics of COPC. For example, there have been a number of studies which attempt to examine the impact of comprehensive care using community health centers and health maintenance organizations. Still, determining whether primary care in a comprehensive framework has an impact remains an illusive and unanswered question {Lewis, 1971~.

OCR for page 47
so Although studies of comprehensive health centers have found posi- tive effects on specific disease entities. including rheumy tic fever {Gordis, 1973) and hypertension (NACHO, 1980}, general indicators of maternal and child care are the most frequently reported. Evaluations of the community health centers have frequently reported important effects on infant mortality (Davis and Schoen, 1978). Studies of health centers in rural areas of Alabama (Anderson and Morgan, 1973 and Mississippi (Seaeat, 1977), as well as urban neighborhoods in Denver (Chabot, 1971) and New York City (Gold and Rosenberg, 1974) have reported reductions in infant mortality ranging from 25 percent to 60 percent. A nation-wide analysis on a county basis confirmed the posi- tive impact of health centers on infant mortality, especially among black children; the estimated effect between 1970 and 1978 was one death per 1000 live births, about 12 percent of the total decline during those years. Quantitative Techniques for COPC The quantitative techniques required for the functions of COPC are drawn largely from several traditional disciplines. Identification and characterization of the community relies on the tools of demography, identification of community health problems draws from the traditional techniques of epidemiology, and the methods for monitoring ache impact of promos Edifications are provided by health services and evaluation research. Among ache principals of the study sites scheme was an mpres- sive capability to engage in quantitative activities, and several were ma jor figures in their respective research fields. However, the study s ites probably represent exceptions in this; regard and to ask that full facililty with the techniques of these fields become available to the primary care practitioner is not reasonable. either do the current problems and trends in the f inancing of health care encourage the addition of a COPC specialist into each primary care setting. Instead there is a need to develop a tool kit of quantitative techniques for use in the pr imary care setting that emphasizes an appropr late balance between scientif ic r igor and feasibility. For many of the quantitative activities inherent in the COPC functions, significant developmental work has been undertaken, often in diverse fields. Although a great deal of developmental work has to be done, some important efforts have been directed at defining and charac- terizing the community. Research in primary care family practice has dealt with the problem of determining an appropriate denominator for identifying the community. ~ The work was pioneered by Rilpatrick of Medical College of Virginia. The estimation of ache size and age sex composition of the population potentially served by a specific pr imary care practice became known as the Denominator problem. ~ In 1975, Kilpatrick proposed a negative binomial distribution of Episodes of illness" drawn from the Second National Morbidity Survey in the United Kingdom (Kilpatrick 1975a,b, 1977). This encouraged others to pursue the topic and the work still continues (Bass, 1976; Cherkin et al., 1982; Cronies 1977; Falk, 1977; Galazka and P=dr iguez, 1982;

OCR for page 47
91 Carson, 1976; Kretchmar and Shaklett, 1977~. Recently, Rilpatrick has said, .as yet the denominator problem has not been solved. Progress with research will be made by comparing methods at different sites over several years. It is not clear whether this commitment and the re- sources for these necessary studies exist. (Rilpatr ick and Boyle, 19841. Until then the concept that primary care practices equates with applied epidemiology is not tenable. If it is solved the evolution from primary care practice to COPC will be conceptually and logistically much more direct, and as the research unfolds perhaps the most comprehensive approach to defining and characterizing the primary care community is emerging from the work of Mettee (1981} at Case-Western Reserve Univer- sity. Techniques are needed that apply the rich heritage of epidemiology to the busy primary care setting in order to produce economical, yet scientifically sound, assessments of the important health indices of the community. In addition to identifying the patterns of illness in the community, this COPC function requires an understanding of the extent to which the current operations of the health care program is influencing those patterns. Thus, COPC must offer the clinician tech- niques for the simple examination of the extent to which his mix of primary care services is adequately serving the needs of his entire community. Methods must accommodate the community, made up of active patients, persons who are nonusers of health service=, and Chose who obtain services from other sources. Although a number of techniques for assessing the quality of care were developed in ache late 1960s and 1970s, many focused on single visits or on single sources; of care and only a few techniques were truly population based. Although techniques which examine ache quality of care for active user'; of health services are useful to the clinician, the practice of COPC requires techniques which examine the care received by the entire community and the distri- bution of critical health services therein (Nutting et al., 1981; Shorr and Nutting, 19771. Although modifying the health care program is not a function heavily dependent on quantitative techniques, it is often critical to target health services on the high r isk individuals within the com~u- nity. Classical epidemiology has contributed tremendously to the know- ledge of the correlates and determinants of disease, and has provided a basis for identifying those risk factors that characterize subsets of the population at increased risk to morbidity and mortality. In an operational 'letting, however, one needs to know Me specific individuals at risk and not simply their characteristics. There have been only a few applications of risk models to defined communities in an attempt to identify those specif ic individuals at increased r isk to a particular health outcome. Perhaps the best example comes from the Indian Bealth Service where a simple paper-and-pencil model enabled Practitioners to identify infants at increased risk for severe gastroenter it's (Nutting and Strotz, 1975} . Pinpointing individuals at r isk, rather than the characteristics of such individuals, allowed the health care system to target constrained resources on specific infants who would benefit from preventive services. Subsequent analysis showed the model to be highly sensitive and spoof in . Evaluation of the total program revealed that

OCR for page 47
92 a simple educational task targeted at the parents of Ache higher isk infant resulted in a drastic reduction in morbidity among the infants at r isk for severe gastroenter itis . Finally, the practice of COPC requires techniques that the practi- tioner may employ to determine if modifications in the health care program are achieving the desired result, and along the study sites, this appeared to be the weakest function. Evaluation techniques must avoid a narrow focus on the active tossers of service, but must examine the impact of program modifications on the magnitude of the problem among all members of the community, distinguishing among individuals of differential risk. Again, an example from the Indian Health Service illustrates such an application. A population-based examination of the adequacy of prenatal care demonstrated that a large number of high risk women were receiving either late or inadequate prenatal care. A seemingly appropriate modification was made in the primary care program aimed at improving prenatal services. In monitoring the impact of the edification, two parallel evaluation efforts were conducted. The traditional approach suggested a substantial and statistically signi- ficant Improvement in the quality of prenatal care provided. However, the population-based evaluation suggested no improvement in the pattern of care received by the community as a whole. More Important, when the data were disaggregated by risk groups, the results suggested that the care received by the average risk subset of the community had Improved slightly, but a deterioration was observed in the care received by the high risk group. Thus, the prenatal care program had a paradoxical effect: it resulted in a substantial improvement in care provided to program users, but led to a maldistribution of services away from the high risk prenatal group. Of note is that the adverse effect was not detected by a standard evaluation approach which was not population based (Nutting et al., 1979~. Data Systems for COPC The presence of a data base containing clinical data for all indi- viduals within the community would 'seem to greatly enhance the ability to conduct the activities of COPC. The value of such a data base in identifying the major health problems of a community would be sizable. The data base could be used either to conduct limited epidemiologic studies, limited only by the variety of clinical data available, and would be useful in identifying samples of the community for further epidemiologic investigation. The data base could be used similarly to monitor the impact of modifications made in We health care program by tracking the extent of application of the program Edification and observing outcomes, again limited only by the scope and specificity of the clinical data. Also, a population data base would be of immeasur- able value in the implementation of the intervention program itself. Population-based systems can be used to identify the high risk or target group for the program intervention and can be used to efficiently moni- tor the extent to which the new or modified health services are applied to the individuals who most need them. Where outreach is a component

OCR for page 47
93 of the program modification, a data base permits outreach workers to selectively target individuals in the community who will most benefit from their services, and thus a data system can greatly increase the efficiency of outreach efforts. Bigher-order COPC COPC is usually discussed as though the concept is limited to a single practice, and often the single practice is located in a commu- nity in which there are a number of other practices. Thus, there is a fatalistic sense that one cannot really deal with the community, since it also ~belongs. to a number of other practices, and must therefore focus on one's Active patients. *''to = ~ = ~~~~ . ma__ ~ _, ~ ~ ~ .. . . = ~ ~ ~ ~ ~ · . · _ - ^~l~uyr~ no, Juan `;U~c; practices were -__~-c", allege `~ nolulng inherent in the concept that precludes a COPC ,_~-~y ~-vm ~ Baron or pracezces, which cooperate in the COPC func- tions while maintaining independence in their direct service primary care activities. In this regard, the Montefiore Family Bealth Center was a member of a coalition of all of the community health centers in the Bronx, which gained an economy of scale in the quantitative func- tions of COPC through collaboration. This essentially also was accom- plished at Tarboro and Checkerboard. Although both incorporated other components of the health care system, neither attempted to incorporate other well-established and active physician practices. At another level of organization, a local health department could act as the focal point for COPC activities, by carrying out the quantitative functions and coordinating the primary care provider organizations and the commu- nity health organizations in programs which are indicated. Some of the 15 local health departments studied by Miller and Moos (Miller and Mods, 1981) are approaching the basic requirements of the COPC definition.

OCR for page 47
94 REFERENCES Anderson, R.E., and Morgan, S. 1973. Comprehensive health care: A southern view. Atlanta Southern Regional Council, Inc., p. 16 . Bass, M. J . 1976 . Approaches to the denominator problem in pr imary care research. Journal of Family Practice 3:193-19S. Chabot, A. 1971. Improved infant mortality rates in a population served by a comprehensive neighborhood health program. Pediatr ins 47: 989-994 . Cherkin, D., Berg, A., and Phillips, W. 1982. In search of a solution to the denominator problem. Journal of Family Practice 14:301-309. Colombo, T.J., Freeborn, D.R., Mullooly, J., and Burnham, V.R. 1979. The effect of outreach workers' educational efforts on disedvan- taged preschool children's use of preventive services. American Journal of Public Bealth 69 :465-468 . Crombie, D.L. 1977 . Total care usage of a fief ined population. Journal of the Royal College of General Practitioners 27:306-314. Davis, R., and Schoen, C. 1978. Bealth and the War on Poverty: A Ten- Year Appraisal. Washington, D.C.: The Brooking s Institution. Falk, W.A. 1977. A measure of Mobility of a general practitioner. Presentation at the 8th Annual Meeting of the International Epidemiological Association, Puerto Rico. Freeborn, D.R., Mullooly, J.P., Colombo, T., and Burnham, V. 1978. The effect of outreach workers' services on the medical care utiliza- tion of a disadvantages population. Journal of Community Health 3:306-320. Galazka, S.S. and Rodriguez, G.S. 1982. Integrating community medicine in a family practice center: An approach to urban lead toxicity. Journal of Family Practice 14 :333-338.

OCR for page 47
95 Carson, J.Z. 1976. The problem of the population research in primary care. Canadian Family Physician 22:871-874. Gold, M.R, and Rosenberg, R.G. 1974. The use of an emergency room by ~ population of a neighborhood heals center . Health Services Repor t. Gordis, L. 1973 . Ef festiveness of comprehend ive-care programs in preventing rheumatic fearer. New England Journal of Medicine 289 :331-33S. Kilpatrick, S.J. 1975a. Factors in morbidity: Interpractice variation of episodes of illness reported in 1970-71. Social Science Medicine 9 : 319-325. Kilpatrick, S.J. 1975b. The distribution of episodes of illness: A research tool in general practice. Journal of the Royal College of General Practitioners 25: 686-690 . Kilpatrick, S.J. 1977. The empirical study of the distribution of episodes of illness recorded in the 1970-71 National Morbidity Survey. Journal of the Royal Statistical Society 26:26-33. Rilpatrick, S.J. and Boyle, R.~. (ed.) Primary Care Research. New York: Praeger. Rretchmar, A. and Shaklett, G. 1977. The use of a probabilistic model to estimate the population base from practice statistics. Presen- tation at the 8th Annual Meeting of the International Epidemio- logica1 Association, Puerto Rico. Lewis, C.E. 1971. Does comprehensive care make a difference? what is the evidence? Amer. J. Dis. Child. 122 :469-473. Mettee, T. 1981. Community disqnosis--A concept for family practi- tioners. Paper presented at ache meeting of the North American Primary Care Research Group, March 17, 1981, Reno, Nevada. Miller, C.A., and Moos, M.R. 1981. Local Belch Depar~ents--Fifteen Case Studies. Washington, D.C.: American Public Bealth Association. National Association of Community Bealth Centers (NACEC}. 1980. A Community Bealth Center Information Guide and Documentation Resource (National Center for Health Services Research, Department of Bealth and Human Services Project Grant No. 1-RO3-ES-03404-011. Nutting, P.A., Barrick, J.E., and Logue, S.C. 1979. The Impact of a maternal and child health care program on the quality of prenatal care: An analysis by risk group. Journal of Community Health 4 :267-279.

OCR for page 47
96 Nutting, P.A., Shorr , G.~., and Burkhalter , B.R. 1981. Assessing the performance of medical care systems: A method and its application. Medical Care, 19 :281-296. Nutting , P. A., and Strotz , C. R. 1975 . Reduction of gastroenter itis morbidity in higher isk infants. Pediatrics SS :354-358. Seaeat, M. 1977. NECs--A decade of experience. Journal of Community Health, Carol. 3 . Shorr, G.I., and Nutting, P.A. 1977. A population-based assessment of the continuity of ambulatory care. Medical Care 15:455-463.