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Suggested Citation:"Analysis of Current Practices." Institute of Medicine. 1984. Community Oriented Primary Care: A Practical Assessment, Vol. 1: Report of a Study. Washington, DC: The National Academies Press. doi: 10.17226/671.
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Suggested Citation:"Analysis of Current Practices." Institute of Medicine. 1984. Community Oriented Primary Care: A Practical Assessment, Vol. 1: Report of a Study. Washington, DC: The National Academies Press. doi: 10.17226/671.
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Page 48
Suggested Citation:"Analysis of Current Practices." Institute of Medicine. 1984. Community Oriented Primary Care: A Practical Assessment, Vol. 1: Report of a Study. Washington, DC: The National Academies Press. doi: 10.17226/671.
×
Page 49
Suggested Citation:"Analysis of Current Practices." Institute of Medicine. 1984. Community Oriented Primary Care: A Practical Assessment, Vol. 1: Report of a Study. Washington, DC: The National Academies Press. doi: 10.17226/671.
×
Page 50
Suggested Citation:"Analysis of Current Practices." Institute of Medicine. 1984. Community Oriented Primary Care: A Practical Assessment, Vol. 1: Report of a Study. Washington, DC: The National Academies Press. doi: 10.17226/671.
×
Page 51
Suggested Citation:"Analysis of Current Practices." Institute of Medicine. 1984. Community Oriented Primary Care: A Practical Assessment, Vol. 1: Report of a Study. Washington, DC: The National Academies Press. doi: 10.17226/671.
×
Page 52
Suggested Citation:"Analysis of Current Practices." Institute of Medicine. 1984. Community Oriented Primary Care: A Practical Assessment, Vol. 1: Report of a Study. Washington, DC: The National Academies Press. doi: 10.17226/671.
×
Page 53
Suggested Citation:"Analysis of Current Practices." Institute of Medicine. 1984. Community Oriented Primary Care: A Practical Assessment, Vol. 1: Report of a Study. Washington, DC: The National Academies Press. doi: 10.17226/671.
×
Page 54
Suggested Citation:"Analysis of Current Practices." Institute of Medicine. 1984. Community Oriented Primary Care: A Practical Assessment, Vol. 1: Report of a Study. Washington, DC: The National Academies Press. doi: 10.17226/671.
×
Page 55
Suggested Citation:"Analysis of Current Practices." Institute of Medicine. 1984. Community Oriented Primary Care: A Practical Assessment, Vol. 1: Report of a Study. Washington, DC: The National Academies Press. doi: 10.17226/671.
×
Page 56
Suggested Citation:"Analysis of Current Practices." Institute of Medicine. 1984. Community Oriented Primary Care: A Practical Assessment, Vol. 1: Report of a Study. Washington, DC: The National Academies Press. doi: 10.17226/671.
×
Page 57
Suggested Citation:"Analysis of Current Practices." Institute of Medicine. 1984. Community Oriented Primary Care: A Practical Assessment, Vol. 1: Report of a Study. Washington, DC: The National Academies Press. doi: 10.17226/671.
×
Page 58
Suggested Citation:"Analysis of Current Practices." Institute of Medicine. 1984. Community Oriented Primary Care: A Practical Assessment, Vol. 1: Report of a Study. Washington, DC: The National Academies Press. doi: 10.17226/671.
×
Page 59
Suggested Citation:"Analysis of Current Practices." Institute of Medicine. 1984. Community Oriented Primary Care: A Practical Assessment, Vol. 1: Report of a Study. Washington, DC: The National Academies Press. doi: 10.17226/671.
×
Page 60
Suggested Citation:"Analysis of Current Practices." Institute of Medicine. 1984. Community Oriented Primary Care: A Practical Assessment, Vol. 1: Report of a Study. Washington, DC: The National Academies Press. doi: 10.17226/671.
×
Page 61
Suggested Citation:"Analysis of Current Practices." Institute of Medicine. 1984. Community Oriented Primary Care: A Practical Assessment, Vol. 1: Report of a Study. Washington, DC: The National Academies Press. doi: 10.17226/671.
×
Page 62
Suggested Citation:"Analysis of Current Practices." Institute of Medicine. 1984. Community Oriented Primary Care: A Practical Assessment, Vol. 1: Report of a Study. Washington, DC: The National Academies Press. doi: 10.17226/671.
×
Page 63
Suggested Citation:"Analysis of Current Practices." Institute of Medicine. 1984. Community Oriented Primary Care: A Practical Assessment, Vol. 1: Report of a Study. Washington, DC: The National Academies Press. doi: 10.17226/671.
×
Page 64
Suggested Citation:"Analysis of Current Practices." Institute of Medicine. 1984. Community Oriented Primary Care: A Practical Assessment, Vol. 1: Report of a Study. Washington, DC: The National Academies Press. doi: 10.17226/671.
×
Page 65
Suggested Citation:"Analysis of Current Practices." Institute of Medicine. 1984. Community Oriented Primary Care: A Practical Assessment, Vol. 1: Report of a Study. Washington, DC: The National Academies Press. doi: 10.17226/671.
×
Page 66
Suggested Citation:"Analysis of Current Practices." Institute of Medicine. 1984. Community Oriented Primary Care: A Practical Assessment, Vol. 1: Report of a Study. Washington, DC: The National Academies Press. doi: 10.17226/671.
×
Page 67
Suggested Citation:"Analysis of Current Practices." Institute of Medicine. 1984. Community Oriented Primary Care: A Practical Assessment, Vol. 1: Report of a Study. Washington, DC: The National Academies Press. doi: 10.17226/671.
×
Page 68
Suggested Citation:"Analysis of Current Practices." Institute of Medicine. 1984. Community Oriented Primary Care: A Practical Assessment, Vol. 1: Report of a Study. Washington, DC: The National Academies Press. doi: 10.17226/671.
×
Page 69
Suggested Citation:"Analysis of Current Practices." Institute of Medicine. 1984. Community Oriented Primary Care: A Practical Assessment, Vol. 1: Report of a Study. Washington, DC: The National Academies Press. doi: 10.17226/671.
×
Page 70
Suggested Citation:"Analysis of Current Practices." Institute of Medicine. 1984. Community Oriented Primary Care: A Practical Assessment, Vol. 1: Report of a Study. Washington, DC: The National Academies Press. doi: 10.17226/671.
×
Page 71
Suggested Citation:"Analysis of Current Practices." Institute of Medicine. 1984. Community Oriented Primary Care: A Practical Assessment, Vol. 1: Report of a Study. Washington, DC: The National Academies Press. doi: 10.17226/671.
×
Page 72
Suggested Citation:"Analysis of Current Practices." Institute of Medicine. 1984. Community Oriented Primary Care: A Practical Assessment, Vol. 1: Report of a Study. Washington, DC: The National Academies Press. doi: 10.17226/671.
×
Page 73
Suggested Citation:"Analysis of Current Practices." Institute of Medicine. 1984. Community Oriented Primary Care: A Practical Assessment, Vol. 1: Report of a Study. Washington, DC: The National Academies Press. doi: 10.17226/671.
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Page 74
Suggested Citation:"Analysis of Current Practices." Institute of Medicine. 1984. Community Oriented Primary Care: A Practical Assessment, Vol. 1: Report of a Study. Washington, DC: The National Academies Press. doi: 10.17226/671.
×
Page 75
Suggested Citation:"Analysis of Current Practices." Institute of Medicine. 1984. Community Oriented Primary Care: A Practical Assessment, Vol. 1: Report of a Study. Washington, DC: The National Academies Press. doi: 10.17226/671.
×
Page 76
Suggested Citation:"Analysis of Current Practices." Institute of Medicine. 1984. Community Oriented Primary Care: A Practical Assessment, Vol. 1: Report of a Study. Washington, DC: The National Academies Press. doi: 10.17226/671.
×
Page 77
Suggested Citation:"Analysis of Current Practices." Institute of Medicine. 1984. Community Oriented Primary Care: A Practical Assessment, Vol. 1: Report of a Study. Washington, DC: The National Academies Press. doi: 10.17226/671.
×
Page 78
Suggested Citation:"Analysis of Current Practices." Institute of Medicine. 1984. Community Oriented Primary Care: A Practical Assessment, Vol. 1: Report of a Study. Washington, DC: The National Academies Press. doi: 10.17226/671.
×
Page 79
Suggested Citation:"Analysis of Current Practices." Institute of Medicine. 1984. Community Oriented Primary Care: A Practical Assessment, Vol. 1: Report of a Study. Washington, DC: The National Academies Press. doi: 10.17226/671.
×
Page 80
Suggested Citation:"Analysis of Current Practices." Institute of Medicine. 1984. Community Oriented Primary Care: A Practical Assessment, Vol. 1: Report of a Study. Washington, DC: The National Academies Press. doi: 10.17226/671.
×
Page 81
Suggested Citation:"Analysis of Current Practices." Institute of Medicine. 1984. Community Oriented Primary Care: A Practical Assessment, Vol. 1: Report of a Study. Washington, DC: The National Academies Press. doi: 10.17226/671.
×
Page 82
Suggested Citation:"Analysis of Current Practices." Institute of Medicine. 1984. Community Oriented Primary Care: A Practical Assessment, Vol. 1: Report of a Study. Washington, DC: The National Academies Press. doi: 10.17226/671.
×
Page 83
Suggested Citation:"Analysis of Current Practices." Institute of Medicine. 1984. Community Oriented Primary Care: A Practical Assessment, Vol. 1: Report of a Study. Washington, DC: The National Academies Press. doi: 10.17226/671.
×
Page 84
Suggested Citation:"Analysis of Current Practices." Institute of Medicine. 1984. Community Oriented Primary Care: A Practical Assessment, Vol. 1: Report of a Study. Washington, DC: The National Academies Press. doi: 10.17226/671.
×
Page 85
Suggested Citation:"Analysis of Current Practices." Institute of Medicine. 1984. Community Oriented Primary Care: A Practical Assessment, Vol. 1: Report of a Study. Washington, DC: The National Academies Press. doi: 10.17226/671.
×
Page 86
Suggested Citation:"Analysis of Current Practices." Institute of Medicine. 1984. Community Oriented Primary Care: A Practical Assessment, Vol. 1: Report of a Study. Washington, DC: The National Academies Press. doi: 10.17226/671.
×
Page 87
Suggested Citation:"Analysis of Current Practices." Institute of Medicine. 1984. Community Oriented Primary Care: A Practical Assessment, Vol. 1: Report of a Study. Washington, DC: The National Academies Press. doi: 10.17226/671.
×
Page 88
Suggested Citation:"Analysis of Current Practices." Institute of Medicine. 1984. Community Oriented Primary Care: A Practical Assessment, Vol. 1: Report of a Study. Washington, DC: The National Academies Press. doi: 10.17226/671.
×
Page 89
Suggested Citation:"Analysis of Current Practices." Institute of Medicine. 1984. Community Oriented Primary Care: A Practical Assessment, Vol. 1: Report of a Study. Washington, DC: The National Academies Press. doi: 10.17226/671.
×
Page 90
Suggested Citation:"Analysis of Current Practices." Institute of Medicine. 1984. Community Oriented Primary Care: A Practical Assessment, Vol. 1: Report of a Study. Washington, DC: The National Academies Press. doi: 10.17226/671.
×
Page 91
Suggested Citation:"Analysis of Current Practices." Institute of Medicine. 1984. Community Oriented Primary Care: A Practical Assessment, Vol. 1: Report of a Study. Washington, DC: The National Academies Press. doi: 10.17226/671.
×
Page 92
Suggested Citation:"Analysis of Current Practices." Institute of Medicine. 1984. Community Oriented Primary Care: A Practical Assessment, Vol. 1: Report of a Study. Washington, DC: The National Academies Press. doi: 10.17226/671.
×
Page 93
Suggested Citation:"Analysis of Current Practices." Institute of Medicine. 1984. Community Oriented Primary Care: A Practical Assessment, Vol. 1: Report of a Study. Washington, DC: The National Academies Press. doi: 10.17226/671.
×
Page 94
Suggested Citation:"Analysis of Current Practices." Institute of Medicine. 1984. Community Oriented Primary Care: A Practical Assessment, Vol. 1: Report of a Study. Washington, DC: The National Academies Press. doi: 10.17226/671.
×
Page 95
Suggested Citation:"Analysis of Current Practices." Institute of Medicine. 1984. Community Oriented Primary Care: A Practical Assessment, Vol. 1: Report of a Study. Washington, DC: The National Academies Press. doi: 10.17226/671.
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Page 96

Below is the uncorrected machine-read text of this chapter, intended to provide our own search engines and external engines with highly rich, chapter-representative searchable text of each book. Because it is UNCORRECTED material, please consider the following text as a useful but insufficient proxy for the authoritative book pages.

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

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

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.

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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

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.

~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 · ~ ~

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: ~

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.

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

~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.

58 c Is c o A: - c o . - ; - A A o - a e" ¢, CC ]~00 0 ~ ~ O ~ S15 i C O C S ° C ~ ~ ~ He ~ ~ C C C, ~ ~ ~ ~ ~ ~ C S ~ ~ . So lB doll ~ · ~ u If _ "c 0 - =- ~ U e ~ ~ 0 ~ 8 ° 0 0 ~ c 0 ~4 u =_ ~ ~ ~ ~ ~ ~ ~ > - ~ ~ .= _ - _ ~ ~ ~ 0 " - 0 ~ O 0 ~ 4, · D. · c 0 ~ O ~ .~4 ~ ~ u_ .4 :' ~ O 0 ~ c ~ ~ O 0 ~ ~ 0 _ - ~_ ~ ~ e O O ~ a" - _ ~ ~ ~ ~ ~ ~ ~ ~ . . ~ ~ 3 C r~ ~ mv~ ~ · C ~ :, m~ o o ~ ~ ~ o ~ —~ O ~ ~ ~ de dC :~: ~ ~ ~ ~ · ~ o_ 0 _e ~o ~ ~ ~ CI, .~, _ ·~ ~ ~ _ a" 0 ~ ~ 0 ~ ~ Q 0 ~ e _ ede_ O ~ . - e ~ _—~ :~. ~: ~ ~ C ~ ~ ~ 0 ~ de — ~ C_ ~ 0 o. a~ O ~ ~ ~ t? _ C 0 C, ~ ~ ~ ~ ~ ~ ~ . _ x: · 0 ~ ~ ~ e Y ~ z c dC O C) Ch ~ z — e _ ~~ ~~ ~ ~ ~ dO ~ ~ ~ _ O ~ ~ ~ ^e ~ d~ ~ ~ O ~ ~ dC ~ te) ~ ~ ~ · a~ ~ · ~ ~ ~ ~ 0 ~ ..e ~ ~ ~ ~ dO — ~ ~ ~ ~ ~ ~ _ ~ ~ ~c 0 ~ ~ ~ Q O ~o ~ 0. d~ ~ e ~ ~ ~ ~ ~ ~ ~ O dC ~ ~ ~ ~ C _ ~ O ~— ~ .4 40 _~ 0 e ~ ~ 0 ~ 0 ~ dC ~ C — — U ~ ~ '0 _ e de ~ ~ ~_ ~ 0 81 ~ dC ~ ~t O ~ ~ ~ ~ ° 0 0 0 - m O -4 0 — ~ C ~ ~ O ~ o - U e v o ~ dC 1 ~ ~ dC ~ ~ ~ ~ ~ O C _1 C~ - _ ~ O 0 1 ~ ~ ~ ~q ~— Q — ~ _ O ~ ~ d.— ~ C C ~ ~ de ~ U ~ ~— ede c ~ 0 ~ ~ 0 - O V ~ ~ ~ Cl C U O _ ~ ~ — ~ O ~ ~_ e dC— O C~ :, e 0 ~ 0 ~ ~ - 81 ~ ° ~ O — — ~ ~ O _ ~ _ _ _ ~o~ ~ ~ ~ ~ ~ O O C ~ dC d~ ~ ~ ~ ~ ~ O ~ O cLe ~— a~ a~: ~ ~o :, ~ ~ ~ e ~ o. c u 0 C ~ ~ 0 ~ ~ V ~ 0 _ o O u 3 ~ V ~ 0 - C, u~c .4 u e "c ~ ~ c~ _ ~ ~d ~ ~ ~ O ~ ~ ~ O C e~ a~ c ~ c_~ - ~ .~ - ~ — es ~ ~ q ~ O ~ ~ ° o— ~ D U v O O ~c ~ ~ ~ ~. ~ O ~ 81 ~ :. ~ ~ ~ q O ~ o ~—— O C ~ C cC ~I tc U— ~ ~ o ~ ~ - "= :, c~. e ~ c 0 c o 0 _ ~ ~ ~ ~ c c 0 ~ ~ q 0 f' q t: ~ C ~ ~ ~ q ~ U ~ ~ ~— o ~o c _ ~ _ "_ ~ O _ a" o" o— c ~ ~ c o_ ~ ~ c a~ ~ O " - ~ 0 - _ m=_ o_ ~ ~ O q O ~e c ~ ~ _ &, ~ _ 0 O ~ ~ c c Ch— ~ 0 0 __ ~ c ~ 0 u q _ O 0 o~: "o ~ ~_ ~ O O c~ ._ O ". ~ ~ ~ q c ~ g q O c. ~ v · ~ e. 1 c ~ c — c ^:) 0 ~ ~ ~ _ ~ _ r~ 0 ~ ~ e 0 _ ~ ~ ~ ~ 0 2' 1 c _ c 0 ~ ~ ~ ~ · c ~ ~ a" ~ · c >,_ 0 u ~ ~ __ ~ ~ 0 ~ ~ ~ ~ o u ~ a_ 0 ~ c _ 0 ~ ~ c O ~ _ ~ ~ ~; c_ ~ ~ ~ e q u ~ q O ~ ~ v v_ co O_ ~ ~ ~ C ~ 8 C U ~— o O ~ ~ q ~ —_ C~ ~ ~ C ~ :' q 0 - 4 _ ~ O o ~ C— ~ ~ 0 O" q q—~ ~ o~ ~ u ~ ^, ~ ~ ~ _ U U ~ ~ C C :> ~ C _ ~ ~ C" ^= ~ ~ ~ O Q O :' 0~ O ~ ~ ~ ~ ~ "S ~ ~ V · ~ ~ ~ ~. - C ~ C ~ ~ w ~ ~ ~ O E S ~ S O ~ S Cl o o O o ~ ~ C v C _ O o ~ :' q O ~ ~: ~ C I U C _ . · : C O ~ _ ~ _ m_ ~ _ q __ Ch ~ ~ ~ ~ ~ Cho e c ._ m. O ~ 0 e ~ ~ ~, - _ — c ~ Q O "~ - — O q ^4g O c ~4 B. _ — a. O ~ 0 _ c _ _ ~ . ~ _ 8o S a0 :. O c _. ~ o ~ U . ~d ~ C, a_ C o U o - C ~ — U ~ ~. C O ~ C,, _ _ ~ ~C O :~. Y ~ Q~ O U c Q ~ e q ~: c ~ :, O ~ Ds C *, D ~ ~ C · ~

Be 2 o TIC ~ o ad o ~ TIC a .8 .! ~ C.' u . ' . ~ c e , a y 8 oC o ~ =,=a · ~o ~ _ o - u :, 8 ~: tr _ o ~: C o. _a s C ~ ~ ~ ~ ~ ~o O c ~ ~ ~ o' ~ ~ O c a' ~ ~ ~ ~ ~ ~ ~ C 0 ~ ~ 0 .~ -4 C 0 C ~ C 0 o— cr'~— ~ c 4~! ^~ ~~ _ ~ 0 ~ ~ ~ _4 _ ~ V O ~ C C) ~ — · ~ ~C ~ ~ ~ .. _ _ _ ~ ~ O C ~ ~ C 0 C ~ ~4 ~ ~ ~ _ .3C C, ~ ~ ~ ~ ~ ~ ~ ~ ~ _ ~ ~ C. ~ O~ ~ ^0 ~ ~ ~ V _ ~ ~ 4-, _ ~ :, C ~ ~ _ 1 _ U C 0 - ~ C ~C . 0 ~ ~J O ~ ~ ~ 0 ~ C Ch_ V ~ C !~ ,C =_ ~o S ~ ~ ~ ~ ~ ~ ~ O ~ ma ~ ~ ~ O ~ ~m _ ~ ~ ~ ~ <, ~ O C, O ~ ~ ~ ~ ~ U —S t} ~ ~ ~ ~ ~ ~ C ~ _ ~ ~ ~ c :, c 0 ~ a, "_ e c - ~ c o_ a=_ a t~- ~ c~ ~ ~ u ~ ~ ~ _ 0 c :, C — ~ D. ~ ~ C ~ ~ ~ o ~ ~ ~d D~ _ O ~ ~ oa ~— .= ~ C) De · ~ ~ ~ ~ 1 _ ~ ° O ~ ~ t! I ~ I ~ 0 ~ o_ _ ~ ~ - _ 0 ~ ~ ~ ~ V o, u. ~ _ ~ ~ ~ ~ ~ ~ ~ ~ 0 ~ ~ ~s ~ ~ ~ _ C 0 . U ~ C ~ ~ ~ ~ ~ ~ ^e ~ ~ 0 C 0 o~ ~ ~ ~ ~ _ ~ ~ ~ ~ ~ ~ ~ eC C ~o ~ ~ C _ ~ :~ o. ~ ~ C V ~ V ~ :, ~ ~ ~ - _ ~ ~ _— 0 ~ C ~ ~ ~ 0 K C ~ ~ ~ O ~ U C ~ ~ — — O ~ ~ ~— O o ~ ~ C ~ ~ ~ ~ O ~ ~C ~ ~ O ~ ~ ~ O 8, g_ ~ C ^0 ~ ~ ~ .~ - .—~— ~ -~ ~ O ~C ~ V ~ ~ O ~ ~ O_ =e ~ ~ ~ O ~ ~ O e —— ~ ~ ~ ~ ~ ~ ~ O ~ O O C _ _ _ ~ ~ _ ~ ., ~c ~ c U ~ 0 ~ ~ ~ 0 :1 e ~ ~ c t, ~ c, :> _ :, ~ ~ ~ ~ ~ O ~ ~ _ ~ " - O ~ b' ~ O __ O ~ P" ~ ~ C _. ~ ~ H ~ U ~ ~ O 08 ~ — q q O C ~ ~ ~ O ~ O ~ ~ C_ ~ ~; ~ ~ ~ ~ o "_ o. e~ c ~ e - ~ - a~o ~ O a" C ~ ~ 0 ~ 0 ~ ~ ~ ~ ~ ~ ~ ~ o ~ O Ch ~ ~ 0 .° ~ Fo c ~ 0 ° U "~' 8.^o ~ r° t,—~ e c= 0 ~ ~ u~c ~ ~ O _'_ ~ q ~ C ~ ~ ~ C O ~ ~ _ ~— ~ ~ ~— ~ ~ D ~ _ ~ q ~ ~ q ~ 0 ~ 0 ~ u ~ ~ 0 ~ e. 0 ~ c a~ 9 ~ C_ - ~O ~ a. C" 00= 0 ~ O ~ O ~ O— ~ ~ ~— ~ ~ ~ O ~ ~— O C :> 41 ~ 06 ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ C C ~ ~ ~ e ~ c ~ O :, ~ ~ 0 0—~ ~ ~ ~ ~ c: ~ ~ 0 ~ ~ ~ ~ 0 ~ e c~ ~ ~ c ~ ~ ~ c e ~ ~ ~ V ~ ~ 0 0 - 0 _. ~ 0 ~ c ~ ~c c · ~ ~ ~ ~ ~ ~ ~ ~ ° C C 0 ~ ~ ~ 0 n_ ~ ~ —- - 0 - ~ ~ ~ 0 ~ ~ C 0 ·4 :~ q ~ O ~ ~ ~ O ~ ~ ~ O O :, O m.0 C O O O 0 .1 O N O O ~ ~ ~ ~ ~ O — ~ ~ ~ 41 .1 0 ~ — _ a, a,_ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ C ` - ~ ~ ~ ~ ~ ~ O ' - O ~— ~ ~ ~ O _ e ~ ~ ~ b. ~ ~ D "eC ~ hd ~ ~ ~ ~ ~ o ~ :> ~ _ ~ v ~ ~ e u ~ ~ q u ~ ~ ~ ~ ~ ~ ~ o ~ _ ~~ _ _ o _ v q 0 _ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ O ~ ~ ~ ~ ~ _ ~ cr 0 ~ ~ ~ _ 0 ~ q ~ t) ~ q ~ ~ 0 ~ ~ 0 ~ _ 0 q ~ ~ ~ ~ .c c ~ o ~— ~ a_ ~ ~ ~ ~ _ ~ ~ ~ ~ ~ v 5_ q ld ~ O ~ O ~ _ ~ _ ~ ~ ~ ~ ~ ~ ~ O.~ q a. ~ q 0 v c ~ o 0 ~ ~ ~ 0 ~ ~ 0 c c 0 ~ ~ Q O v c ~ ~ C .1 U U O ~ ~ n C ~ _ ~ o :. ~ q ~ ~ ~ ~ ~ t: ~ ~ O C, 41 ~ O ~ ~ — O C ~ ~ <. ~ ~ ~ O C ~ ~ _ ~ co c~ he ^~~ :> ~ :~ _ O ~ U o C q ~ ~ V g ~ q C 81 ~ 8 ac ~ ~ o ~ o ~ ~ ~ o s ~ - ~ o_ ~ c ~ ~ 0 ~ a_ ~ 0 c q C ~ ~ a~ ~ ~ o~ ~ ~ ~ ~ ~ q o _ ~ ~ ~ o V o ~ ~ o ~ U ~ q ~ ~ ~ ~ C ~o q ~ q ~ ~ o ~ _ ~ ~ = = C ~ ~J ~ q ~o o a" oc ~ ~ ~ c ~ . - ~ c e ~ ~ ~ 0 ,~, ~ o :~, _ ~; 0 ~ ~ ~ ~ ~ ~ u ~c CI 0 ~— · 0 _ m~ ~s c v ~a _ q v _ . - U~ ~ _ _ ~ ~ O Z C _ S V' ~ ~ ~ . ~ 0 c. 0 ~ ~ ~ 0 e s: o o. ~ ~

60 ares, a continuing trend which in confirmed periodically by the Medical Economics Department and by the Bealth Services Research Center. Despite the propensity for EMOs to be made up primarily of employed populations, the various Medicare and Medicaid arrangements developed at Raiser/Oregon have balanced its membership to reflect the demogra- phic and socioeconomic composition of greater Portland. For Rainer/Oregon and, some might argue, for all EMOs because of the contractual relationship with members, there are economic and socialincentives to being community-oriented, i.e., using knowledge of the population and We population's health needs to plan services. At Raiser/Oregon there has been and continues to be a strong sense of accountability to and responsibility for the community of plan members. Montef tore Family Bealth Center* The Montefiore Family Health Center is an urban community health center established in 1980 and affiliated as a primary practice with the Department of Family Medicine at Mantefiore Bospitel and Medical Center. The center is financed chiefly through Medicaid reimbursement and federal grants from the Bureau of Bealth Care Delivery and Assis- tance (BECDA). The center provides comprehensive medical services to persons living in ~ geographically defined area in the west central Bronx comprised of a racially and ethnically mixed population the majority of whomli~re et or below the poverty level. Montefiore has Rude a deliberate effort to establish itself as a community oriented primary care practice. Considerable staff and student energy has been put into defining and characterizing the community served and into identifying its major health needs. Ilouse- hold surveys were conducted and several screening studys were done in the f irst years of the center ' s operation. These efforts resulted in the identification of a subset of the population of Cambodian origin with a substantial number of pressing health problems. In response to these identified need';, the center modified its service mix and added Cambodian outreach workers to the ~staff. In addition to the surveys and studies community health needs are identified through the input of the community board and local ethnic associations as well as involvement in community activities outside the health center. Given the relative infancy of the Montefiore program little or no effort has been made to systematically document or evaluate the impact of the COPC efforts. (Some of the examples of COPC activities at Montefiore have been s War ized in Table ~ .6 . ~ *hereafter referred to as Montef lore.

61 o c Is ~5 - o - v - - - A 8 o -~. .,, ~ ^' He -. . o 0 ~ ~ ~ o ~ ~ ~= I Y u 0 ~ ~ ~ ~ ~ ~ ~ e _ V ~ ~ ~ e. ~ - 0 ~ 0 0 ~ 57 ~— ~ ~ ~ ~ ~ ~ ~ ~ ~ 0 - U ~ ~ ~ ~ A: ~ ~ ~ ~ ~ - 4 ~ _ ~ ~ ~ Cal e ~ ~ u ~ ~ ~ 0 a :> ~ c, e 0 ~ c e ~ c~ ~ c _ _ o e ~ ~ o b' ~ ~ ~ ~ D O _ ~ — O -4 C ~— ~ ~ ~ O ~ ~ ~ ~ O aO —~ S— ~ :, ~ ~ ~ ~ c: ~ ~ C :' ~ ~ ~ ~ :l ~ ~ C O V ~ ~ ~ ~ ~ ~ V O ~ ~ C . - C ~ ~ C e ~ ~ ~ v c ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ° c ~ ~ ~ ,. ., _ e ~ ~ ~ :5 ~ ~ c ~ ,~— ~ ~ 0 ~— c ~ ~ ~ e" ~ c _~: ~ o v 0 a CR ~ ~ 0 C ~ ~ ~ ., ~ ~ ~ ~ ~ e ~ .~ ~ . c ~ ~ — ~ ~ —c - a c~ mc ~ O D ~ ~ ~ ~ ~ ~d ~ ~ O ~ ~ 81 ~: ~ ~ ~ ~ C O C ~ —0 -—~; - ~ ~C —=~ O C - O ~V Y : ~ ~ Y t c —~ u - - · ~ ~ ~ - 68 ~ ~ ~ eaV ~ ~ 0 c 0 ~ ~ C O ~ _ ~ ~ ~ O C ~ C ~ —~ ~ ~— U ~ C ~ ~ ~ O ~ O ~ ~ ~ O V C— C U C.— CR~ m~ C O :' O ~— ~ C O u o~ "~~ 0°\ ~ ~ O ~ ~ o~ "~~ 0 C. ~ ~ :' e c ~ e_ - ~ e c ~ ~ .~ - ~ - ~ - ~< ~ uo. a_ c~ ~ _ ~ ~ _ ~ ~ 0 ~ ~— ~ ~ ~ 0 _. 0 ~1 ~ _' ~ C— ~ ~ :> 40 ~ .C O ~ 1 1 O n: _ 1 ~ :, C.) ~ ~ U ~ ~ 60 ~ ~ P ~ 1 1 1 04 ~ · ~ .~e ~ ~ ~ · 0 V CI. ~— 1 ~ ~ ~ _ ~ .~- ~ O— O O ~ ~ ~ C. C] c~ ~ 4~ ~ C~ V C O O v ~ s. C ~ ~ s ~ ~ ea' ~ ~ Ce) 81 _ _ ~ V :. O Clt ~ ~ ~ C c: v C ~ o C ~ V O ~ _ , _ ~, ,,, ~ ~ _ Z ~ :1 0 C ~ ~ ~— S ~ .4 ~ C O ~ — C) ~ ~ ~ o ~ ~ O_ O C ~ ~ ~— l | ~ ~ e a 0 0 e °~ 0 ° ~ ~ a ~ °' ,, e c ~ a e ~ 1 S 1 ~ ~ ~ ~ C ,' ~ 4 ~ U e ~ ~ C ~ ~ 4 g _ 0 3 ~ _ ~ ~ ~ s ~ ~ ~ o c ~ ~ ~ Y ~ ms ~ v cr o ~ ~ V _ _ q ~ 0 0 ~ _ _ ~ - _ ~ ~ ~ ~ ~ ~ ~ 0 v ~ v ~ ~ ~ · ~ r~s v c ~ 0 c ~ 0 c 0 o~v ~ ~ 0 ~ c ~ C mo C ~ e "~4 - ~c ~ ~ ~ ~ ~ ~ ~ o ~ ~ ~ ~ ~ ~ o o" ~ ~ ~ ~ _ ~ U ~ ~ C q C ~ ~ O ~ O ~ hd ~ V ~ ~ C ~ _ - - O ~ > - ~ ov ~ ~ c q c ~ "~ - - a. ~ .~ ~ ec~e ~ 1 ~ 1 · · · · · ~ s . V a: T ~ U g ~ O S ~ ~ i 5 0 ,e, s . Oc - _ ~ e ~ ~ e ° ~ e q ~ ° 0 v c o - _ ~ ~ ~ a~ ma c m=" ~ ~ qY ~ ~ c ~ ~ _ c ~ ^ - ~ ~ ~ _ ~ ~ ~ ~ 0 __ ~ ~ ~ 0 O er' ~d S ~ C ~ ~ ~ O ~ O ~ —— _ -. v a" - - s v~ _ _ ~ ~ ~ ~ _ V '~ ~: 5 00 S · O O Q o o q i! ~ ~ _ ,~ ~ ~ a~ c a~ 0 c ~~ " - q e .4 ~ _ e 0 a_ a~ ~ ~ - ~_ .. a~v ~ s ~ ~ s 0 ~ ~ ~ c ~ ~ ~ ~ ~ · q~ ~ _ ~ 0 q u ~ u _ ~ _ v o_ ~ :1 . ~ ~ ~ ~c °> ° ~ 0 ~ ~ O ~ ~ ~ e ~ ~ ~ ~, ~s ~ 4 Q q o~c ~ ~ ~ 0 ~ 0 c~ S_ 0 c., ~ ~ ~ ~ - - C ~ V ~ q 0~ qol a._ - ~ - ~ c ~ ~ _ ~ ,` _ q ._ _ q 0 ~ z ~ .4 ~ - _ c _ n; — ~ . ~ "o ~ =e

62 Sells Service Unit of the Indian Bealth Service* The Sells Service Unit is one of more than US service units of the Indian Beal~ch Service (IHSl, the agency of the U.S. Public Bealth Service responsible for assur ing comprehensive health services to American Indians and Alaskan natives. Sells is located 70 miles west of Tucson, Arizona, and provides comprehensive health services both directly and indirectly to ~ community of 14,000 Papago Indians, many of whom live on or near a 2.8 million acre reservation. An IES operated system including a 40-bed hospital, extensive outpatient clinics, ~ 24-hour emergency rcom, two field clinics and one mobile health unit provides genera1 medical services directly to the Papagos. Specialist care, surgery, and high risk obstetric. are referred out to local practitioners under a contractus1 arrangement with the IES. In addition to general medical care and specialist care, a wide array of services are available through tribal health programs administered by the Papago tribe and supported by THS monies under Contract. The tribal health program at Sells include ~ nutrition program, ~ disease control program, psychologica1 services, an alcoholism program, ~ program for the elderly, a community health representative program {outreach workers}, a program for traffic and highway safety, and the Papago Children ' ~ Ilome. Life on the Papago reservation is a combination of treditiona1 lifestyle with an ever increasing presence of modern influences. Many Papagos raise cattle, some engage in dry and irrigated farming and still others work for the federal and tribal government. The Papago community is highly organized and functions as a political entity. Lee Papago Tribe is governed by a Tribal Council that meets monthly and conducts the business of the Papago tribe. Until recently, the heads of all the tribal health programs were organized into an Executive Health Staff which advised Sells on tribal health priorities, served as an advocate for Indian health legislation and represented the tribe at national Indian meetings on health issues. Over the last ten years, this group has been influential in identifying community health needs and in overseeing programs designed to address those needs. For example, a collaborative effort between Sells and ache Executive Bealth Staff was initiated to reduce the prevalence of severe diarrhea among young Papago children. A tremendous success, the program continues to the present tome with modifications based on program results. {See Table 5.7 for other examples of COPC activities at Sells.) Although similar to most THS service units in general design, the _ Sells program is distinguished from other IMS programs in gnat z~ us closely allied to the Office of Researab and Development of the IES. This program hen been actively engaged in health services research and development, focusing on the tools And techniques for performing some of the QOPC functions. As part of the research and development effort. *Hereafter referred to as Sells.

63 C i 8 o ~D - o _ v _ ~ ~ _ ~ C a ~ c" ~ c~ V o o 8 o° ~C ~ U. o' _ Io ~ ~ _ C :' _E - U ~ C o C, 1 ~ = , 1 ~ ~ I e 0 ~ C ~ :> c ~: ~ ~ ~ ~ q 0 1 0 1 — c, ~ c~ c `, O v ~— ~ _ o ~ ~ ~ o ~ ~ 0 ~ q ~ 1 ~ ~ ~ c1 ~ ~ I ~ _ c ~ o ~ ~ ~ ~c ,~ ~: ~~ ~~ ~ ~ o 0 ~, q _ _ c ~ ~ ~ ~ ~ ~ _ ~ . C ~ O o~ ~ ~ "= ~ ~ ~ ~— ~~ O 0 ~ a~ ~ ~ ~ I q _ ~ c: .~. ~ I _ —~ e 0 ~ q c' ~ ~ ~ c ~ q ·_ e4_ C C _ _ ~ ~ ~ ~ ~ ~, t, co ~ O q ~ Q q q _ ~ a— 0— _ c t ~ ~ O ~ C _ _ ~ ~ ~ ~ ~ ~ V ~ ql _ ~ ~ ~ C ~ q V C ~ O O ~ u~ ~ ~ ~— ~ —— ~ ~ ~; ~ U ~ ~ ~ ~ _ ~d ~ ~ U O ~ ~ ~ ~ q C ~ O ~ O ~ C V C~ O 81 V 81 C O _ :> ~ 0e, 0 C q ~ _ :- _ _ C ~ tr~ ~ ~ o. 41 _~ ~ ~ _ ~ O ~ ~ ~ - O q ~ ~c ~ C ~—~ ~ D O _ _ o ~ _ ~ _ O r~ :' ~ ~ ~ ~ ~ ~ ~ O ~ ~ ~ ~ ~ ~ ~ ~ ~ c o. ~ a' q _ 0 ~ ~ ~ ~ c c ~ 0 ~c q ~4 ;. ~ ~ ~ _ ~ C ~ ~ ~ ~ ~ C m~— ~ O · ~ ~ ~ ~ oC ~ ; C ° O ,, ,, C O ~ q— ~ — O ~ ~ O C C O ~ Q O ~— ~ _1 ~ _. 41 0—~ t) ~ ~ l: o o ~ ~ o q ~ o ~ . 8 ~ ~ ~ ~ ~ ~—~ ~— 0. q.~..c - ~q. ~ ~ ~.a ~ c.. ~' O ~ ~ ~ ~ ~ O ~ ~ O ~ O ~ ~ ~ ~ . ~ C ~ O ~ ~ . ~ ~ ~ O ~ ~ ~ C, ~ ~ ~ O ~ O q ~ ~ 0 ~ a ~ V 0 ~ ~ U ~ ~ ~ V ~ _ 0 ~ = - ~d · 0 _ ~ q a~ ~ O ~ ~ ~4 o~ 0 ~ ~ ~ c ~ 0 ~ ~ ~ 0 0 ~ CL- ~ m~ cI_~ ~ C~ al q ~ ~ ~ ~ ~o ~ O ~ U ·— P. ~ ~ ~ C ~ ~ 1 D. ~——~ o ~ ~ ~ c. _ — O ~ <. . o o ~ - q t 0e ~d Q ~ ~o ~ ~ ~ O C ~ C— ~ ~ ~ ~ ~ ~ O O O C ~— ~ ~ ~ ~ _ O :> ~ ^1 :^ ~ ~ ~ q ~ ~— ~ ~ ~ ~ S —~4 ~ ~ ~ C ~ ~ ~ ~ ~ ~ C ~ _4 S1 3 ~ ~ —1 _ ~ _ ~ ~ _ :> ~ O ~ q ~ &. ~ O :' _1 ~ ~ 40 0 ~ ~ ~ O ~ q ~ C q Q ~I C ~ c 5~- ~ ~ c ~ a. ~-~ a~g3. °~& :g ~ -~. _ · · ~ · · · ~ ~ · . ~ o _ C C o _ ~ o'' ~ . o ~ ~ o o ~ h~ ~C ~ C · ~ C.. _ ~ ^ - ~ ~ C ._. ~ "~ - ~ ~ c _ ~ C. "m c ~ o _ ~ o ~ q ~ — ~ ' ~ C "~_ ~ o "o o C_ ~ ~ c .~ o._ ~C ~ ~ ~ U ~ U C ~ o U ~ ~ ~ ~ .. q ~ ~ ~ C ~ ~ O ~ C] ~ ~ ~ ~ ~d ~ C ~ c~ ~ ~ I c 0 ~e ~ e ~ :~.— ~ ^ 0 ~ 0 CI. _. ~ ~ ~ V ~ ~ c q ~ :~ ·d ~ -4 ~ _ ~ _ 1 ~~ a~ 0m 0 0~. 0. o : ~ c ~ o ~ ~ c . ~c ~c..a - ~ - ~ ~ ~ ~ c o :' D U~ q ~ _ q ~ 0 ~= _ ~d ~ _ 0 ~ ~ ~ C) ~ O . o - V 0 :, . - C ~ 0 a_ _ :, ~ ~ ~ ~ _ C C ~ 0 ~ q a_= V V~ - ~ C __ q ~ ~ 0 0 _ _. C _ o~ ~ ~ 0. 0 _ ~ 0 C 0 _ ~C . 0 ~ ~ ~ ~ ~ O t ~ ~ C o ~ V ~ ~ ~ —— ~ O ~ c q _ ~ ~ a, ~ o - - u~_ 0 ~ ~ = - ~ ~ ~ ~ ~ ~ c ~ q ~ a_ c q c ~ ~J ~ O ~ ~ 3 ~ _ ~ ~ _ C) O > ~ _~ _~ · - ~C ~ ~ ~ ~— C ~ ~— O ~ O ~ ~ . ~ _1 _ ~ 41 U O ~ C ~ O 10 ~ O ~ 61 3 ~ _ _ ~ ~ _ C ~: D C :. ~ ~ u U O ~ ~ ~ V <, :^ U _ _ ~ _ n 0 ~ c C ~ c _ ~ ~ 0 ~ ~ C 0 ~ ~ ~— 0 ~ _ O ~ C c q ~ c _ ~ o. ~ u 0 ~ ~ ~ ~ ~ ~ ~ ~ 0 _ 0— ~ ~ C ~ a ~ q ~ ~—— o. ~ c c ~ ~ v c~.,~ a, ~ ~ ·. .- · ~ :~—~ o ~ o v_ a ~ ~ o :, ~ ~ ~ ~ ~ ~ __ _ c ~ ~ ~ o ~ ~ ~ ~ ~ V 0 ~ 0 ~ _ _ 0 ~ ~ ~ ~ ~ ~ C _ ~ ~ O O O ~ ~d ~ ~ :, C O ~— ~ :, C aQ O ~ ~ ~ S 0 "= U ~ "q ~o ~ U ~ ~ ~ ~ ~ ~ 0 U ~ - ~~ · ~ ~ · ~ ~ C 0 O o' ~ C ~U ° O _ ~ ~ r~ ~ :1 ~ ~ C ~ O o ~ · ~ ~ l: q :, C 0 ~ C ~ ~ 0 0 ~ ~ C ~ ~ ~: ~ q _ ~ ~ ^ - ~ ~ ~ _ C ct ~ 0 C ~ ~ C ". ~ ~ q ~ _ C q :# ~ ~ m" O O U Q ._ ~ _ O ~ ~ O q S O q _ ~ O C ~ q ~ ~ ~— ~ D. ~ O O ~ V— _ ^= q ~ ~ q m~ O ~; q V ~ q ~ ~ ~ q ~ ^ - ~ C ~ — co_e o_ ~ ooev _ a_ ~ O ~ ld ~ cr' ~ c c ~ ~ _ _ ~ c ~ c 0 _ o~ ~ ~ ~ ~ ~ q—=~_ ~ c ao, _ ~ 0 ~ ~ ~ ~ ~ ~ ~ ~ z S ~ .8 ~ ~ E ~ O C 2~ ~ ~ :' ~ ~ ~ c · ~ ~ · ~ ~ ~ ~ 5 ~u _ ~ h. _ u a_ _ 0 ° ~ z ~ ~ ~ ~ - c —~ c ~QC Q~ ] - O ~— s: O ~ q

64 Sells has been supper ted by a large scale population-based health infor- mation system for some than ten years. This has greatly increased Sells' accessibility to the kind of data that are needed to practice COPC. Tarboro-Edgecombe Health Services System* The Tarboro-}3dgecombe Bealth Services System is an informs coali- tion of health care providers and administrators who relate to one another in such a way as to make available to the people of 13dgeco~e County, Norwich Carolina, a coordinated system of comprehensive health services. The system is centered largely around Tar bore Clinic, a traditional private, fee-for-service multispecialty group practice association consisting of 18 physicians. With the exception of two, independent solo practitioners, all the medical manpower for Edgecc)mbe County is affiliated with the Tarboro Clinic. The other components of Terboro are the county health department providing ~ broad array of public health services, the Ares Belch Education Center providing medical education, continuing education and recruitment of health manpower for E:dgecombe County, the Tarboro-Edgecombe Bospital, which was operated by the county until its recent acquisition by Bospital Corporation of America, and the Community Medicine Foundation, a nonprofit corporation with ~ board of directors drawn from Tstboro Clinic physicians Id local community leaders, which receiver grants from several sources ~ conduct health services research and to operate four satellite facilities thereby extending ~ program of services to underserved areas. Edgecombe County lies in the coastal plains of eastern North Carolina in an area that is based predominantly on an agr~cultura1 economy with tobacco as the major cash crop. There also is light industry in the county that, by some accounts, is increasing. According to ache 1980 census, ache county has approximately SS,OOG residents of whom 48 percent are black and 52 percent are white. From its early days {the late 1920s), the Tarboro Clinic has been well integrated into the community. For many years, one or more members of the medical staff have been active community leaders. In ache 1930s, Me clinic tried to establish a prepaid group practice which never succeeded financially but which formed a solid bond between the commu- nity and the Tarboro Clinic. There has also been ~ strong history of cooperation with the Edgecombe County Bealth Department and for many years the clinic physicians had office space An the Edgecombe County Mospi~l. This level of community interest and concern contributed to more recent efforts to address identified health needs of the community such as access to care for those outside a 10-mile radius of Tarboro, control and treatment of hypertension, and reduction of the high rate of *Hereafter referred to as Tarboro.

65 unwanted pregnancies among adolescents. (For a sundry of these and other examples; of COPC activities at Tarboro, see Table 5.8.) Modifications to the various components of Tarboro were made in response to the identified health needs of the community. Plans are underway to determine the effectiveness of these modifications on the health setup; of the entire community. CROSS—CASE ANALYSIS The Structural Elements All seven study sites met the two structural criteria of the COPC definition: they were providing primary health care and tailoring their practice or program to the identified health need" of a defined population. Among the sites, there was considerable variation in the specific characteristics of the community and the primary care program and the variation in t~hose characteristics was the major determinant of the particular expression of the COPC model in each site. Therefore, it is instructive to examine the results of the site visits in terms of the characteristics of the structural elements of the COPC definition fiche community and the primary care practice} followed by an analysis of the manner in which the study sites accompliabed each of the COPC functions. The Community The case studies suggest that COPC can be practiced in many different types of communities. Some communities served by the study sites are urban, others are rural. Some are communities of predomi- nantly single ethnicity, others are mixed. Some are defined by geo- graphic and political boundaries, others by membership in ~ health plan. Although the concepts of COPC here often been associated with health programs designed to serve poverty populations, se~rera1 of the practices studied operate in middle class communities. Thus, COPC is not an approach to health care that can be applied only in medically indigent communities. Dearly all of the sites have a degree of practice exclusivity in their community. Sells, Crow Bill, and Checkerboard are located in isolated rura1 communities in which there is virtually no competition from other sources of primary care. Although it operates in ~ large metropolitan area, Raiser/Oregon has an exclusive relationship with its member community through its prepaid plan. The Tarboro Clinic was rapidly becoming the only active practice in E:dgecombe County until the mid-1970s when it began actively to recruit new practitioners into ache area using the private group practice structure as the core of the system. Superficially, this is in contrast to both Hontefiore and East Boston which operate in inner city areas. However, the East Boston is the only source of primary health care in ache geographic area, and Montefiore is the only regular provider of primary care services in its

66 E o ~o U - ~C ~4 1 O ~ ~ C ~ q o O ~ _ ~ _ V Y ~ o C. o o - o 2 C' c c u o o ~; o o q o _ o o c o - b. o ~ Y ~ 1 _ ~ ~2 C o ~ o ~ &, ~ ~ c,_ C o ~ ~ ~ , o o o ~ ~ ~ ~ o o ~ o _ ~ y ~ ~ ~ ~d— V C :~ t) o ~ ~ ~ ~ __ o ~ a~ ~ ~ ~ ~ "= ~ C V o _' ~ _ _~. o ~ O ~ ~ Q ;- _. C, ~ ~ ~ - 0 0 0 ~ O ~ Y ~ ~ ~ C O ~ ~ ~ O q I_ ~ o o ~ VS a~ ~ " - ~ V ~ o ~ ~ ~ ~ O O ~ ~ ~ ~ O a o ~ ~ ~ q u 0 0 o `: ~ o :^ ~ O ~ ~ O ~ E S— <' q ~ ~ :^ ~ o ~ ~ ~ ~ ~ U V :' ~ ~ U ~ u ~ ~ s ~ ~ ~ c ~ q o `~ ~ 0 as :' _ o ~ o ~ ~ ~ cr ~ ~ o 0 o o ~ ° ~ ~ ~ ~ ~ 8 ~ ~ ° c ~ _ oC ~ s E — 0m ~ ~— ~ ~ ~ ~ ~ — ~ ~ O O ~ ~ ~ V _ ~ ~ ~ C ~ C ~ ~ _ C ^_ O ~ ~ ~ ~ C ~ ~:— ~ ~ o V _ ~ ~ q ~ O _ ~ — O O V ~ S. ~ ~ :, ~ ~ O—q _. e ~—_ ~— ~ ~ ~ ~ 0 ~ ~ ~ o~ s V ~ ~ es ~ ~ 0 C~ ~ :' O ~ ~ ~ o O O C ~ U— O 0-4 :> ~ ~ ~ Q~ e or~ "_'n =" ~ a~ - s De ~—.= · 1 ~ C o O q ~c - u ~ ~ ~ s 0 0 ~— v 0 ~ _ ~ V 0 ~ ~—~ ~ o D~ C O :^ C E :^ — ~ ~ ~ C ~ O D _ ~— ~, q ~ ~ O ~ ~ ' ~ ~ _ E 0, C S ~ O O ~ ~ ~ t —~ :, ~ ~ ~ ~ Ch : - ~ ~ C ~ U 0~ 0 U ~ ~ ~ ~— O e u ~ 0 ~ ~ ~ ~ _ 0 _ ~ ~ as ~ ~ ~ C C 0 ~ 0 ~ ~ _ ~ 0 ~ C U ~ :, 0 ~ ~ ~ ~ ~ V ~ V :^— ~— ~ E— ~— q ~ _ a" ~ 0 - ~ 1 ~ ~_ - ~ "` C,, ". ~ ~ ~ ~ ~ O ~ ~ ~_= O ~ ~ — ~ ~ e ~ 0 v ~ ~ ~ I ~ ., ,, ~ 0 e~ "_~_ ~ ~ e"—~ ~ me :>' O ~ O :> 1 ~ ~ _ O ~ ~ ~ ~ ~ O O _ .C _ ~ o _ o ~ _ ~ ~ s ~ :, ~ ~ o ~ ~ "V .~ - ~ 0 ~~ - 0 ~ m" · ~ ~ ~ 1 81 =~ o ~ C ~ ~ o~ C~ e4 ~ 0 e ~ e ~ 0 ~ 0 c 0 ~ ~ t)_ .4—~C O O ~ V a.4—— ~ >, 0 ~ ~ 0= ~ e. ~ c— ~ ov_ o e — ~—e ~ ~ ~ rL ~ ~ _ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ _ u. ~ ~ ~ ~ ~ ~ C q ~ ~ ~ ~ ~ O ~ ~ 41 ~ C ~ E —~ V ~ ~ D. :, c~ o~ e ~ ~ ~ ~ u ~ ~ ~ `, O __ ~,,0 0 81 · E :' ~ V 06 0 e 0 ~c 0 ~ ~ s. c q u e o ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ _ ~ _ ~ C~ ~ _ :^ ~ ~ ~: ~ ~ ~ - . ~ _ 0 ~ ~ ~c ~ ~2 c ~ c ~ ~ er' ~ ~ ~ ~ c 0 ._ ~ ~ om ~ ~ ~ ~ ~ C 0 s 0 0 ~ ~ - _ o_ - ~ ~ 0 0 ~ ~ ~ - ~__ 0 ~ ~ ~ ~ C ~ ~ ~ q C 0 o~ ~ ~ 0 ~ ~ ~ o eCI ~-~ O q O ~ ~ ~ ~ 0 ~ 0 ~ —_ s_ ~ C ~ s ~ _ ~ _ _ 0 ~ m_ ~: ~ 0 u q ~ ~ >, C .' 0 C ~ q ~ ~ 0 C ~ ~ V ~ V ~ ~ ^_ ~ V s :, ~ C ~ ~— C ~ ~ ~ ~ ~ 0 0 ~ .. ~ ~ .~~ ~ ~ ~ am s ~ ~ V ~ am ~ ~V - _ C ~ ~ ~ ~ 0 V C ~ ~ 0 V q ~ o ~: U ~ U ~ :> ~ 0 ~ _ s C ~ _ C :: ~ ~ ~ ~ 0 ._ ~ ~ C ~ ~ a" ~— s m" ~ s h. _. :> ~ ~ c. D. ~ ~ ~ ~ q ~ V 0 ~ ~ t, D4 _ ~e ~ ~ ~ 0 ~ ~ ~ O ~ e ~ ~ D ~ D ~ O · o _ mv ~= C _ q ~ _ . - V— O_ — ~ ~ O E Z v ~ |: — Sl: ~ _ ~ ~ .0 C O Q ~ a: ~ ~ —~ s: 81

67 immediate neighborhood. Both operate in communities in which public transportation offers geographic alternatives to the members of the community . The communities also differed dramatically in the extent to which they functioned as an entity. Clearly ache community served by Sells exists as a definite social entity with distinct cultural, political, and economic systems. The community of Tarboro is coterminous with Edgecombe County and thus is represented by a county governmental structure with a defined revenue base. The community of East Boston is a recognized geographic entity, but has no political organization and consists of several distinct sociocultural subgroups. Similarly, the scattered rural community of Checkerboard consists of several distinct smaller communities, as does the urban inner city community of Monte- fiore. The community served by Crow Bill is not defined by specific geographic or political boundaries, but rather largely by terrain features. Finally, the community served by Raiser/Oregon has none of the usual attributes of a community, but rater is a collective group of individuals and families who have elected Raiser/Oregon as their health care plan. The manner and extent to which the communities are organized have rather important implications for the ways in which they can parti- cipate in the health program. Table 5.9 compares the organizations] entities through which community involvement has been mediated in the study sites. The manner in which the community's participation is organized influences the potential to affect change, both in community behavior and in ache performance of the system of medical care. It also affects the extent to which the community can generate and control a revenue base, and, in turn, is us important determinant of their ability to participate in and contribute to the COPC activity. The level of participation also varied greatly Mung the study sites, as shown in Table 5.10. The most common pattern was that of advisor to the provider group on the organization, convenience, acces- sibility, and Acceptability of primary care services. The board of directors of East Boston actively governs the practice and meets at the health center each week for 3 to 4 hours to review all administrative and soanagement matters. The community served by Sells participates in the health program through Me activities of the Executive Bealth Staff, with authority over all health matters delegated from the tribal govern- ment. The E:'cecuti~re Bealth Staff plays an active role in establishing policy for the overall health program and operates several important components of the health services delivery system. Both Checkerboard and Tarboro have advisory groups drawn from the communities in which their satellite clinics are located, which advice the practice on operations of the clinics, on issues of particular interest to patients, and often are Able to raise money for needed equipment. They do not however provide major input into the need for or design of major health initiatives. The community group at Crow Bill is not particularly active and would have disbanded except for the insistence of the physi- cians. If more active, this community group could contribute greatly to the COPC activities of the overall health care program and thus

68 I ~ 8 ~ o o _ o a o 1 B o B o ~ o o ~ o o ~ B e 0 By o o = 0 o o o F : o o o ~ o ~ g o ~ o ~ B a

69 lIJ - U) : :' CQ 1 an O ~ ~ O Q V ~2 -A Al As Ed 0 A: CD o o - As A £ o P. TIC 0 :: 0 s A: - o - - V - Ld P. o lo in X 0 0 O O a: A: ~ O _ 0 AS Al O o 0 o O ~ _ :e V 0 05 X X X 0 Ls ~ O _ 1 0 _ _ ~ 0 o O Ash O ~ ~ V 0 0 ~ 0 :. _ :~ 0 a ~ ~ o ~c ~ ~ eC V ~ ~ s ~ ~ ~ ~ ~s 0— U~ ~ 0 0 0 ~ V 0 0 ~ ~ aC 0 ~ 0 s ~ 0 _ ~ ~ 0 o ~ 0 ~ ~ ~ ~ ~ ~ ~ ~ s al ~ ~ O ~ ~ ~ ^= ~ Q :- ~ _ ~ ~ `: ~: ~ ~ ~ ~ ~ >~_ 0 ~ 0 0 ~ m _ _ ~ ~ 0 ~ ~ ~ ~: c: ~ 0 ~ 04 ~ ~ ?~ t) E— :> ~ c: ~ ~ o ~ ~ O ~ ~ 0 ~ ~ ~— ~ ~ — £ ~ O4 ~ — ~ 0 ~ — ·,} c, c: ~ ~ ~ ~ _ ~ ~ 0 X ~ £ 0 ~ ~ O ~ O ~ ~O ~ ~ 0 ~ ~ ~ O

70 avoid the appearance of the practice ~advertising. for patients, which the physicians fear could be ache mistaken view of more aggressive outreach efforts . In general, a great deal of the community participation among the study sites focused on issues limited to the users of the health care program. Bowever, two important exceptions were noted. One is Raiser/ Oregon in which the employer benefits representatives serve to promote the interest of the denominator group, i.e., the total group of plan members including both users and nonusers of service. The second exception is the community served by Sells. The Papago tribe is highly organized and has been active in dealing with health issues in the community for more than a decade. The Executive Bealth Staff of the tribal government is active in virtually all aspects of community participation in health, ranging from representing the interests of the ~numerator. to identifying major health problems in the community to mounting major health programs to address priority health problems. Community participation also takes on several meanings as a function of the potential distance between the provider and consumer groups. Beightening provider sensitivity to cultural and social norms can be vitally "portent if the provider and consumer groups are of different socis1 and ethnic backgrounds as is the case at Sells, Checkerboard, and ISontefiore. Also the community group can be impor- tant in synthesizing the varied needs of ~ community that consists of several distinctly different cultural groups as is the case at East Boston, Checkerboard, and H=ntefiore. Bowever, scheme roles become less important in communities where the providers ~ch~elve'; are perceived as legitimate meters of the community as in Tsrt~oro, Crow Bill, and Raiser/Oregon. Among all the study sites, COPC appeared to be driven by the provider group rather than by the community. In none of Me study sites did ache community play a major role in the denominator-based COPC activities. Provider philosophy appears to be relatively more important as a determinant of success of COPC than community participation. The Primary Care Practice The Organization of Services All seven of the study sites were - a :~ively e—~ in the provision of primary care services, ano ma~ e concerted effort ~ promote accessibility, comprehensiveness, Coors, nation, continuity, and accountability within their program. All study sites Make an effort to assure that services are accessible to their patient population. In mast sites, practitioners are available around the clock, although the mix of office hours, scheduled appointments, and drop~in or emergency room care varies con- siderably. Several sites {East Boston, Crow Hill, and Tarboro) have extended office hours, i.e., weekday evenings and weekends. Others include 24-hour emergency room services in their program (East Boston, Tarboro, Sells, Raiser/Oregon, Cheakerboard}, while Montefiore arranges for patients to be seen in another emergency room after office hours .

71 All of ache sites are relatively conveniently located so that geo- graphic accessibility is enhanced. In some of the rural sites with more scattered populations, the practices have opened satellite clinics (Sell=, Checkerboard, Tarboro} and some provide special transportation for segments of the population {Sells). In all of the sites but one {Montefiore), the patients can receive ancillary services (e.g. , lab, X-ray, social service, etc.) in the same location as the practice. Many of ache sites have also made attempts to reduce cultural as well as financial barriers to access. Where a significant number of the patient population speak a language other than English, translators are available. Translators are readily available at East Boston ~ Italian and Spanish), Checkerboard {Navajo and Spanish), Sells (Papagol, and Montefiore {Khmer and Spanish}. A number of the sites also are attempting to understand the predominant cultural values that influence health care. At Sells, new physicians joining the staff receive orientation from the tribal officials on a broad range of issues from organization of the tribal government to relevant cultural patterns. Checkerboard contracted with a group of social scientists to present a series of seminars on the value orientations of the Navajo. East Boston conducted several in-service training sessions in the culture of Southeast Asians, and Montefiore requires that all staff and residents gain at least a rudimentary understanding of Spanish. Reduction of financial barrier'; to health care are approached in a variety of ways. All but one of the sites (Crow Bill} have received special grants or have special contractura1 arrangements with public agencies {federal, state and local) to provide health care to those unable to pay for services. Sells and Ratser/Oregon have an obligation to provide all the medical care of ~ designated population and thereby drastically reduce the financial barriers to care, although each faces administrative problems in administering comprehensive care free a finite budget. East Boston, Checkerboard, Montefiore, and Tarboro have a sliding fee scale for their patients. Crow Bill, which has no special arrangements for those unable to pay, does care for Medicaid patients and has made significant efforts to reduce financial barriers to care. For example, when it came to their attention that some people in the community winch pharyngitis were not getting timely throat cultures because of hesitance to pay for the office visit, they agreed to do Cultures only. and treat if positive, and charge for ~ visit only if the patient was toxic or wished to be seen. In ~ rural private prac- tice, totally dependent on patient revenues, the provider must exercise responsibility over payment structure or face economic disaster. Crow H ill seems to be struggling to f ind a workable compromise between their own financial viability and concern for the economic status of their patients. All study sites were making efforts to provide comprehensive primary care services and were providing or assuring ~ wide array of services. Some services were provided directly by the practice while others were provided outside the practice, but coordinated by the primary care provider. The larger practice organizations (Kaiser/ Oregon, Sells, Checkerboard, East Boston) provide outreach services, home health services, social services, menta1 health services, and

72 health education within their own organization; the smaller practices tend to coordinate patient care using outside agencies for extended services. Nearly all sites attempt to coordinate patient care services that are provided outside the practice. In all the sites, except Raiser/ Oregon and Sells (botch of which have sizable home health services) the priory care practitioners see patients at home when necessary. In many of the practices a member of the primary provider group continues to care for the patient when hospitalized {Sells, Checkerboard, Tarboro. Montefiore) and a few Visit patients in nursing homes {Tarboro, Sells, Raiser/Oregon, Ilontef lore) . All of the study sites were accountable for the quality of their primary care services in that all conducted routine chart audits. An interesting form of accountability occurs at East Boston where the primary care providers are directly responsible to the community board that owns and governs the health center. The board holds them account- able for the quality of care provided and pays a great deal of atten- tion to patient problems and complaints. Although the board does not get directly involved in systematic quality assurance activities, its governing style tends to keep the medical staff alert to issue. of patient satisfaction. Fire sites {Checkerboard, Sells, Montefiore, Tarboro, and Crow Hill) have data systems with the capability of producing disease specific registers. The degree to which this capability has been utilized for quality assurance purposes varies considerably. Sells, Crow Bill, and Checkerboard have used the registry capability to actively identify and follow up on patients in need of attention {e.g., children without immunizations, diabetics who beve not been seen in a year, women over due for Pap smears, etc.~. Organization of the practitioners At the level of the overalihealth care program, several of the study sites vary markedly from the norm of mainstream U.S. medical care organization. Although all of the sites began with and continue to emphasize physician-~anaged direct patient care service, four of the study sites have generated an organization that functions far beyond the traditional bounds of one-on-one medical care. Tarboro, Raiser/Oregon, Checkerboard, and Sells include co~po- nents that fulfill the direct service primary care, the public health, and the community medicine roles. Raiser/Oregon and Sells have accom- plished this through the institutionalization of the components in a larger organization, both of which have ~ number of other practice groups borne of the same concept. Tarboro and Checkerboard are both one~of-a-kind organizations that have exercised a principle of Planned opportunism. in forming a functioning program from available components. Yet beyond the general organizational similarities, these four programs contrast sharply in their specifics. Tarboro exists as a coalition of virtually all component'; of the health care program in a ';ingle county, yet with a very orthodox fee-for-service multispeciality group practice at its core. The Raiser/Oregon program is organized on a three-way relationship between the physician-owned Northwest Permanente Profes- sional Corporation, the Kaiser Foundation Bealth Plan, and the Kaiser

73 Foundation Hospitals. Checkerboard functions as a single not-for- profit system, which has bridged the transition from total grant funding to a combination of fee-for-service, contract, and grant supported care. By developing contractual arrangements with the Indian Health Service, the state health department, and the local school sy=- tems, it has developed both the revenue base and ache mandate to perform several important public health and community Medicine functions in its community. Finally, Sells is a component of a federally supported and operated health care program, which has evolved over nearly 30 years with ache specific charge to meet ache health needs of a defined popula- tion. Many of the organizational characteristics that Tarboro and Checkerboard have sechie.`red through innovation and 'planned opportunism. are already institutionalized in the Indian Health Service. The manner in which the providers were organized for patient care services varied widely among the study sites. In sheer volume, the sites ranged from Kai.ser/Oregon with some 250 physicians to Crow Hill with two family practitioners. All of the practice groups included physician extenders, except Crow Bill which had until recently included a fierily nurse practitioner. Many of ache programs included additional nonphysician primary care services. For example, East Boston, Checker- board, Sells, and Raiser/Oregon per ovide dental services and include an active outreach program. The two largest practice.s, lCai.ser/Oregon and East Bo.s ton were organized by clinical department along traditional medical speciality lines, although East Boston had recently incor.nor- _ e . _ _ ~ e ~ _ t J _ _ e ~ ated internal medicine and ob/gyn Into a Department of Adult Medicine. Both Sells and Kaiser/Oregon had recently organized or revitalized departments of community medicine to deal specifically with health care issues beyond ache confines of the outpatient clinic, and We Community Medicine Foundation of Tarboro was organized to develop and operate health services beyond the domain of the Tar boro Clinic itself. Perhaps the critical challenge Tat COPC offers to the organization of the practice group is the need for flexibility in carrying out those functions of COPC for which medical care traditionally been neither organized nor financed. In this regard there appears to be a critical mass phenomenon related both to the numbers and the organization of the practitioners. Crow Bill, with only two physicians, is faced with the most difficult obstacle, lacking botch the volume of practitioners and the flexibility of organization to . - eintz~in COPC efforts when other impediments at ise . With only two physicians in the practice, both ar e usually engaged in patient care activities in order to maintain ~ flow of revenue into the practice. Since the two physicians share on-call responsibilities, the burden on their time is even greater. With four physicians, Checkerboard is the next smallest practice, but has a con- siderably 1eerger total staff, which includes physician extenders, public health nurses. and a .`rarietv of ocher health Personnel. This affords a e ~ e . e _ e . e ~ e ~ _ e _ _ ~ · _ ~ ~ considerable degree of flexibility in assigning tasks required In the COLIC activities. An obvious difference between the two study sites is the revenue base, which at Crow Hill is nearly entirely derived from fee-for-service. One wonders, however, if We diversity of program effort of Checkerboard, funded in large part from grants and contracts, is incompatible with a practice group operating solely in a fee-for- -

74 service ~de. Certainly, the impressive program developed by Tarboro would suggest that a COPC effort can be constructed by melding fee-for- service practice with a grant supported effort to extend the primary care and community health services to a defined community. Each of the study sites had at least one physician who was an advocate of the principles of COEC and who continually challenged the organization to maintain a focus on the health problem and needs of the entire community. Without exception, this individual occupied a leadership position both within the administrative and the professional hierarchies of ache organization. Bowever, in Raiser/Oregon and Sells the institutional philosophy that promoted COPC also served to attract professional staff with an unusual sensitivity to the denominator popu- lation to be served. It was equally apparent, particularly in the larger organizations, that all practitioners did not share the same zeal for C:OPC, although there was no evidence thet any of the professional staff opposed the efforts made within the organization to identify and address the health problems of the denominator population. Thus, to operationalize COPC in most health care settings probably requires at least one physician who is committed to its tenets, but also probably can thrive even in a practice in which many of the physicians are indifferent to it. Four of the study sites are closely associated with major research activities. Both Raiser/Oregon and Sells are organizationally related to health ~ervi<:es research components of their larger institution. The BSRC at Raiser/Oregon was established in the mid-1960s specifically to engage in research activities relevant to ~Os and the organization of medical care. The ORD of the Indian Bealth Service was es~shlished in the late 1960s to conduct heal~ch services research and development activities to enhance the ability of the IES health care program to meet the unique health service needs of the American Indian people. In both Rites the marriage of the service delivery program and the research component was intended to produce techniques and under';tanding of health care that would not only benefit the local delivery program but improve the delivery of service; throughout the larger institution. Many of the programs and activities that are cited as examples of COPC in both sites were initiated by and/or enhanced considerably by the involvement of the research components. Similarly, research activities are highly visible in both the East Boston and Tarboro. These differ from Sells and Raiser/Oregon in that the individual research project'; were initi- ated specifically by the delivery site, and studied the population rather than the delivery of services per se. Sloth East Boston and Tarboro are engaged in collaborative epidemiologic research in which an age-sex subset of the community is being followed over time. The research activities in all four sites are aided at a dust audience. The activities are designed to produce techniques and knowledge for consumption Bong the professional community at large as well as to be directed back into the immediate practice for the purpose of improving care to the local community. In addition to the direct benefits that the products of research may have on the ability of the primary care program to improve its service to the community, the presence of the research component brings

75 into the program a wider range of personnel and thus increases flexi- bility in the program. Also a more subtle benefit may accrue. The close association of the skills involved in patient care and those involved in quantifying relevant dimensions of health, disease, and health care delivery may begin to impart to the patient core program an appreciation of health and disease in the aggregate and widen somewhat the focus which practitioners have on the individual patient. Over time, such an association may begin to develop in the practitioners an appreciation of the ability to quantify and address health problems in the aggregate. Similarly, many of the sites are heavily involved in medical edu- cation. The relationship is perhaps most obvious at Montefiore where the program was orginially established with the dual purpose of medical education and service to the community. Medical education for medical students and residents is clearly a priority and a major activity for the program. Tarboro felt so strongly Bout the need for a medical education component that it developed an area Health Education Center (ALEC} as the initial phase in expanding beyond the Tarboro Clinic. All of the study sites serve as a full or part-time practice site for residents in family practice, pediatrics and/or internal medicine and all have one or more health professionals who are engaged in teaching through a clinical appointment to a major academic center in the area. Personnel at Raiser/Oregon and Sells also have linkages with academic centers for research activities and serve as preceptor sites for students in various research fields. Sells, Checkerboard, and Tarboro view their teaching activities as an important investment in recruiting health professionals to the ares. An advantage that accrues to all the sites is the additional manpower of students and residents, which can be directed in pert to some of the activities of COPC. Montefiore per- haps best capitalizes on this advantage by requir ing all residents to complete ~ project, which often contributes to a current COPC activity or initiates a new one. Data Systems All of the study sites have data systems which are activitely used to support the quantitative activities inherent in COPC. Of these four were essentially community-~ased. Raiser/Oregon nair~tains a clinically rich data base on ~ five percent sample of all enrollees. Checkerboard and Sells have developed and maintain clini- cally rich cats bases from patient encounter records. Bowever, both have been in existence long enough to include virtually all of the community. Crow Bill has been ~ pioneer in the development of ~ cats system that registers all members of a family when any single member contacts the practice for services. Thus, the date system contains at least minimal data (e.g., name, sex, age, and address} on all members of the practice con munity. ~ntefiore and Tarboro have also developed clinically rich cats bases that include records for those individuals in the community who have received health services from the practice. Both sites have uti- lized the data systems principally for practice management, but have found them useful in augmenting assessments of the community health problems .

76 Although Raiser/Oregon, Crow Bill, Sells, and Checkerboard all have taken advantage of their data system in probating their COPC activi- ties, none have been able to mace maximal use of their data system for one or more reasons. The Raiser/Oregon data base is among all the study sites the most population~based in that it is developed from a random fire percent sample of all enrollees in the health plan, rather than being laced to those enrollees who have used health services. Kaiser/Oregon has repeatedly used this data base both for identifying health problems in their community and in evaluating the impact of program modifications made. Bowever, the fact that the data base represents a sample rather than the total community limits its role in the operation of the program. At times this data base has been aug- mented to include all members of relevant subsets of the population. For example, all individuals enrolled in the health plan under the OEO demonstration project~in the early 1970s were included in the cats base. Subsequently the data base was put to full use in identifying the health problems of this subset of the community, designing and implementing program interventions, and monitoring the impact of program Edifications. Although the data bases developed and maintained by Sells and Checkerboard consist primarily of users of service, they nonetheless include virtually all members of the community and therefore have been useful in all three of the data-intensive activities of C'OPC. Bowever, the range and scope of clinical data in the Checkerboard system and ache accuracy of the data in the Sell'; system limit Weir utility somewhat and both systems have been developed for operation on large mainframe hardware. Thus ache time lapse between ache need for data at the practice and the response of the system is cited by both practices as a serious impediment to full use of the data system to sup~rt COPC. Organization of Financing Nearly all of the study sites expressed general ~n:ern Over the manner in which COPC activities were financed and among the sites Several approaches were evident. Raiser/Oregon and Sells demonstrate the most direct approach as both are organized with the specific charge to provide for the health service needs of a specific population. Although We program revenues are generated in different ways, both program= operate with a relatively fixed budget and are free to allocate program resources Bong a variety of activi- ties. Thu';, to the extent that the program managers view COPC activi- ties as a priority, program resources can be devoted to identifying community problems, modifying the program, and monitoring the impact on the health problem. Because both program include a variety of none clinic based health services, they also have the additional flexibility of initiating nonclinical interventions. The problem of financing COPC activities was greatest for Crow Bill where the practice revenue was derived largely from direct patient services. Thus all efforts, particularly those of ache two physicians, directed toward nonclinical COPC activities resulted in a loss of potential practice revenue. In summary, it appears that the particular way in which COPC evolves in any given setting is highly dependent on the environmental variables.

77 and of these the organization of f inancing would appear to be the most or itical. The success of the sites in achieving elements of COPC are in large part dependent on their ability to manipulate ache environmental variables so that they are conducive to COPC activities. Checkerboard and Tarboro best represent the innovative ways in which a COEC- supportive environment can be created. Bow sites have an individual with an unusual commitment to meeting the health needs of their co~u- nity. By incorporating into their system other elements of the health care program, they have been able to build an organization and ~ finan- cial base that supports COPC activities. Thus, it would seem that further examination of the innovations developed in these sites would help to formulate mechanisms by which the environmental variables can be manipulated to support COPC. An unusually fertile environment for COPC is found at Sells. The community is defined, circumscribed, and well organized to deal effec- tively with health care issues. The provider organization includes elements of primary care, public health, and comreunity medicine. Finally, the financial base i. flexible and not linked to the provision of specific patient services. Thus, the Indian Health Service might serve as an ideal study s ite for further examining the internal impedi- n~ents to COPC, i.e. those related to the concept rather than to the environmental constraints, the comic and impact of COPC, and as ~ site to further develop the specific quantitative techniques required in COPC. The Functions of COPC Definition and Characterization of the Community Table ~ .11 compares the level of development, by stage, Hong the case studies of ache activities for defining and characterizing He co~uni~cy. Crow Bill is unique among the study sites in that it attempts to address two communities simultaneously, with ~ different sense of responsibility for each. In the first instance, the practice feels the greatest responsibility for the practice community. which consists of all members of s11 registered families, as defined as any family for which a member has received services from the practice within the previous 24 months. The practice also addresses a geo- graphic community of approximately 14,000 people living in the area. For their practice community they are able to enumerate all individuals and to develop a age/sex profile through the use of the Famlly Medicine Information System (FMIS). Bowever they have ~ great des1 of difficulty in addressing the larger geographic community, And must rely on the use of large area data. All of the study sites have been explicit in def ining the community for which they assume responsibility and in all cases that community extends beyond those individuals who are active patients of the prac- tice . All study sites could describe the character istics of their community and knew the number of individuals constituting the denomi- nator population. However, they had varying degrees of difficulty in

78 1 ~ o ~ o U o ~ ~ 1 v o o - ~s ~: 3 - C, s~ c - 8 In o - v c C ~ o o _ ~ ~C o V o _ ~ _ ~ sr s o ~ D K K _ >, ~C ~ c,_ ~ :' x ~— _ C V :, ~ U ~ .04 ~ ~ . ~ E O ~ :~. ~— o— ~ 1 v ~ ~ ~ C V V 1 S ~d ~— ~ O ~ e4 ~ 0 81 ~. ~d ~ ~ 40 ~I C I ~ ~ :- ~ O—~ t~ E O v ~ ~: - E ~ ~ ~ O O ~ .4 ~ _. ~ t, c O— ~ ~ O ~ ~d O ~ ~ ~ ~ ~ _ ~ ~ O ~ ~ C ~ ~ O ~ C O S ~ ~ v ~ C _ U ~ 41 ~ ~ ~ O _ O ~ ~ ' :3 ~ ~ C ~ ~ .0 — ~ ~ ~ C O E 0 ~ ~ _ _ C v l: O O ~d ~ ~ V ~ O O O S— ~ _. ~ ~ V · ~ _ c, V O ~ a_ · _ ~ 0 - ~ · ~ ~ ~ — t) ~ ~ ~ ~ ~ ~ ^0 m~ _ ~ _ v ~ ~ S ~ ~ ~: - ~ t) ~ ~ v ~ 3 ~ ~ ~ ~ ~ '0 ~ ~ E v_ ev ~ U ~ 0 "v q S a ~ 0 ~ ~ ^e ._ ~ q 3 o ~ ~ ,~ _t ~ ~ ~ O 08 _ C ~ cI V E o ~ _ v ~ o E ~ ~1 o v C r. ~ ~ eV O ~ ~ ~ ~ ~ ~ ~ ~ ~ C ~ >~ O ~ ~ ~ ~ 3 O ~ — CI. ~—~d t~ ~— ~ ~ ~ ~ O :- ~ O ~ C C} ~ ~ ~ ~ O ~ C ~ o ~ O ~ ~ t) ~ O ~ ~ V ~ :' o ~ _ ~ `: C~ a~_ ~ C =~= ~ E. ~ ~ >~ O _ o ~ V o ~ _ ~ ~ o ~: - q ~ _ as O ~ ~ o ~ ~ ~ _ _ ~ s o ~ :' ~ O X C ~ C s C _ _. ~ ~—~ ~ o o' ~ V S eC ~ ~ O ~ ~ O ~ O C ~ ~ ~ O ' ~ O ~ ~ ~ CL C— ~J O ~ ~ C ~ - ~ ~ ~ ~ O D C ~ ~ ~ ~ ~ ~ _ _ U :. C 2q ~ ~ ° ~ ~ _ ~ _ . ~ ~ ~ ~ _ · ~ ~ — a_ ~ a~ ~ O S ~ ~ ~ ~ ~ ~ ~ o V ~ C O _ V tS O ~ ~ V ~ _ ~: ~ _ . ~ ~, ~ t) O ~ V ~ ~ ~ ~ ~ ~ . ~ C U ~ O ~ ~ _ ~ ~ ~ b~ ~ ~ ~ u ~ ~ c v e ~ ~ ~ E _ . - . S ~ :, ~ ~ ~ ~ S O O ~ —~ O O q O :' 81 ~d ~ ~ ~ ~ ~ _ ~ ~ ~ ~ O ~ O ~ U V V ~ ~ ~ _ V ~ O ~ V _ · _ ~ ~ e :, v ~ _ ~ ~ _ ~ ~ v 0 c 0 c ~: . ~ ~ ~ ~ ~ ~ :' 0 ~ ~ ~ ~ v s: ~ ~ ~ :, ~ ~ ~ ~ D c O ~ ~ ~ _ ~ ~ &, l,, ~ ~ ~ ~ ~ o ~ ~ ~ _ _ ~ v ~ ~ c ~ v .0 _ V o ~ ~ _ tU C C ~ _ D — ~— q V ~ IU ~ om_ c c u~ ~~ c ~ ~ 0 m~ c_ u Ic c_ c 0 a e c v _ ~ .' _ ~ ~ ~ ~ ~ ~ ~ ~ O - _ .,, _ . v _ _ O U ~ ~ E - 4 ~ O _ ~CJ O — U . ~ · ~ ~ _ ~ q O e4 :^ 81 ~ ~ ~ ~ ~ ~ ~ V ~ ~ ~ ~ a ~ ~ O ~ O ~ — ~ ~ ~ = ~ ~ — J: S ~ S ~ ~ ~ ~ ~ C ~ ~ ~ "S ~ · S ~ ~ ~ ~ X - =~ ~ ~ V U" ~ - _= ~S ~ a - _ a. ~ 0 - ~ ~ V ~ o~ - . ~ ~

79 developing an enumeration of the individuals within ache community {a criterion for stages III and IV). Checkerboard, Crow Hill, East Boston, Raiser/Oregon, and Sells could develop a listing with reasonable accu- racy and varying currency. Raiser/Oregon had the most complete and current enumeration in the form of the listing of their enrollees. They also carefully monitored the data on the demographic and socioeconomic composition of their community, motivated in part from ~ concern for the presence of adverse selection. Among all the study sites, Kaiser/ Oregon had the best data, both empirical and projected, on the health status and utilization of servicer of their community. Checkerboard, Crow Mill, and Sells could generate 8 listing of their communities based on their respective data systems. For Checkerboard and Sells, the number of individuals in the data base exceeded the total popu- lation of the community and it was assumed that the data base included nearly all current members of the community. Although both sites could do so neither had devoted a great deal of attention to defining the precise subset of their data base which corresponded to their current community. This may be in part because both sites served communities with a substantial transient portion and neither wished to exclude occasional or transient members of the community from the process of identifying health problems. Both suspected that some of the Sopor ten t health pro may have a higher prevalence/incidence in the transient component of the community. The community served by Sells {the Papago tribe) conducts a routine census and main- thins ~ tribal role (the latter includes tribal members who do not live in the community) but Sells has not made use of these lists. Without the benefit of a community-based data system, Esst Boston and Tarboro have made the most vigorous efforts to characterize their communities. East Boston conducted complete door-to-door surveys in 1973 and 1983, collecting on each individual the date of birth, sex, occupation, and relationship within household. This cats base was believed to capture 90 percent of all members of the community and from it East Boston was able to do several detailed studies of the health status of particular subsets of the community. The most complete study was the Senior Bealth Survey which collected extensive data on all individuals over the age of 6S years and included physiologic measures such as blood pressure and a screening test of pulmonary function. Tarboro developed household maps of Edgecombe County, which showed all households linked to a substantial set of environmental data. The maps formed the basis of subsequent attempts to characterize geographic patterns of morbidity and mortality in ache community. For example, clusters of selected types of cancer were observed and these data are currently under further analysis in an attempt to identify causative factors which might be addressed by the health care system. The household maps of the community also formed the basis for a household surrey of 1,000 randomly selected households in the county. These surveys were conducted in 1979 and again in 1983 and collected data on all adult members of the household in terms of health behaviors, health status, utilization of services, and also ~ blood pressure recording.

80 Among all the study sites, Monte flare attempts to serve the most diverse community. Composed of many ethnic minorities and a substantial transient population, the community is difficult to precisely character- ize, and generating a specific listing of the denominator population would be an overwhelming task. Montefiore has instead attempted to identify subsets of their community with particular health needs and attempt a more careful definition and charcterization of those subsets, e.g., the recent Indochinese refugee group that has been relocated in the South Bronx. Also age-sex subsets, such as the elderly, adoles- cents, and the prenatal population have been singled out for focused of forts to character ize the denominator population for subsequent identif ication of pr for ity health needs . Identification of Community Bealth Problems Table 5.12 enables ~ comparison of the stages of development among the case 'studies for the activities required to identify community health problems. In general, the case studies demonstrated ~ variety of activities based on co~unity-specific cats and thus most operate predominantly at stage III for this function. The Kaiser/Oregon prom gram stands out among the case studies for its use of formal mechanism to routinely monitor several health issues in its enrolled community. Through the Health Servicer Research Center and the Medical Economics Department a variety of measures of service utilization and satisfaction with care have been carefully followed. With the recent formation of a Department of Community Medicine, Raiser/Oregon elects to monitor an even wider set of indicators of community health Lotus Ed need for service. All of the study sites had done at least one population-based assessment of the community's health needs in the last five years. East Boston, Arbors, and Montefiore had all conducted household ~ surveys either contacting every household (Ea';t Boston) car a sample drawn at random from the total community {Tarboro and Hontefiore}. Kaiser/Oregon routinely samples its enrollees through its annual membership survey, and also carefully tracks a number of measures of utilization of services and morbidity profiles. Sells and Checkerboard bad completed at least one population-based study focusing on either a particular problem or on a subset of the Community. SeU'; had examined the medical data base to examine the prevalence of diagnoses and labora- tory evidence of diabetes mellitus and Checkerboard had examined all childhood mortality based on an analysis of all death certificates for children in their ~unity. Many of the sites also rely heavily on large area Statistics and generalize to their communities. Due to its large urban and difficult- to~define community, this is predominant strategy employed at Honte- fiore. Monte fiore also collaborates with the other ten community health centers in Me Bronx to compile city , state, and federal health data that can be disaggregated for the specific census tracts corre- sponding to their community. Checkerboard makes use of data from both the Public Health Service and the State of New Mexico to estimate Me

81 O E ~ O O ~ ID ~ a . al - a~ :^ ~ ~ 0 ~ _ ~ C Q a; O 1 3 Arc ~ ~ o a E, - D o S I; - C - - C U rat . C o v a O ~ _ s:: TIC V ~ Q D V Z to u: a: Us ~ ~ a; O ~ ~ q SI: ~ TIC IY a~ E~ ~ E~ Z; Z ~ ~ ~: ~ 3 Z ~ ~ _ _ _ 0s a V Z ~ z: P7 - s: .~! Eg Of R" "o ~ 2 ~: 9 ~: C] C V ~C - ,S C S ~ U OS u~ e4 :, ~ ~ ~ o a v e4 ~ ~ o v ~ o ~ o c c, :e o y o ~ q ~ c ~ o ~ - :, D ~ s D O O "C ~d S V ~S S - ~C C — ~ s V O— E E —I o O o ~ ~ D. ' c: ~ ~ :> S _ 4 C O b~ o ~ _' _ O ~ ~ :' o C C ~ O O— S C -4 S ~: cr —S C ~ - _ ~ ~ _ y O · >~ ~ ~ O ~ _ ~ ~ ~o C ~ .4 ~ ~ :3 D 81 0 E O I: ~ V O ~ U ~~ O; ~ S ~ ~ ~ O ~ - o_ _I O V o O— S ~ ~ ^IC ~V ~, t" ~ _ o — ~ :~ - - ~ ~ ~ ~ o ~ ~ - ~ ~ - ~ oc ~ - ~ · ~ ~ o ~ o — E 81 s ~ _ e ~ s 0 ~ ~ ~ C, .4 ~ ~ ~ :, 0 ~ ~ _ ~ ~ o o O D ~ O _ V - C, o - E - 0e o ~d S C b, q s ~ ~ ~ E O Q a; -4 CI U ZZ ~ ~ E. 0 O ~ Oo ~ ~ ~4 o _ , :~ ~ O _ S ~ ~ ~ 0 0= O O ~ ~ cD S V ~ ~ _ ^. S —S ~ C _ o :, O F a O ~0 X 0 C_ V— O V ~ ~ ~ ~: C a~ V 0 v _ 1 81 ~ _ _ :' 0 e ~— _ ~ ~Q r, ~ O a ~ _~ ~ 0 o. E— C o _ C~ ~ 0 - .C _ _ ~ ~ C £= _ ~ _ CI, _ E O ~ ~ V O ~ _ ~ :, :. _ ~ C ~ ~C 1 V b~ O U ~ ~ ~ ~4 a_ O - E ~S C o _ ~ ~ a ~D "D m0 ~ - ~ O C c,_ V C S C ~ C~ ~ V ~ C s Cl ~ ~ _ m O a~ ~ ~ ~ ~ ~— O == · ~ ~~ a~ ~ ~— a_. X a,_ C C ~ :' O C C a~ E O ~ C O O ~ o ~ CL _ ~ S ~ O _ ~S ~ U

82 magnitude of selected problems in the several ethnic components of their community. They do so cautiously with the full realization that the generalization is only valid to the extent that their community is similar in all relevant details to the larger population from which the data are drawn. Often Checkerboard confirms the presence and de~n- strates the severity and scope of ~ health problem by 8 specific study drawn from data specific to the community. In identifying priority health problems to be addressed in their community, virtually all of the sites rely heavily on the practice impressions of their clinicians, input from the community boards, and health problems emphasized in the medical literature. Among all the health problems identified by the study sites, there were only a few that first came to light as a result of an epidemiologic study. Most problems had been previously recognized, although an epidemiologic study often served to -identify the correlates of the- problem and to provide information to help the practice to target its efforts on the individuals or the subset of the community at highest risk. Several of the study sites attempt routinely to monitor the health problems of a subset of their community. For example, East Boston has begun a long-term effort systematically to address the needs of its elderly population and this effort has led to several important empha- sis program. Bowever, none of the study sites have mechanisms in place to monitor a wide variety of health issues of the community as a way of identifying health needs. Rsiser/Oregon has routine procedures for monitor ing satisfaction, demand for services, and the frequency with which health problems are seen at the facilities, although much of the analytic attention is directed at monitoring the presence of adverse selection among its enrolled community. Sells developed computer pro- grams to produce quarterly reports that would characterize the mix of health problems in We community based on a combination of diagnostic categories and laboratory and physiologic dead. Bowever, later madi- fications in the data system structure required that the programs be rewritten, a task not viewed as a high priority. The household surveys done at East Boston, Tarboro, and Monte flare have been repeated at least once, but they nonetheless are most accurately characterized as special studies rather than routine mechanism. with which to periodically moni- tor the community's health status. One subset of the community that is routinely addressed by almost all the study sites is the school age child. The school children represent a population-ba';ed subset of the community that has several advantages for most sites. They are a group that is accessible Ed most school systems welcome involvement by the local physicians. The health care of children is an undisputed priority in most communities and there are a number of health problems of this age group that lead to severe health, developmental, and educational difficulties if not diagnosed and treated early in their course. Most importantly for some practices, aggressive identification of health problems in the school children is not generally viewed by the medical community nor by the laymen as .marketing. the health services of the practice. This may be particularly important for practices that operate predominantly in the private sector, such as Crow Hill and Tarboro.

83 Modif ication of the Health Care Program In general, the case studies showed the highest level of develop- ment for the activities involved in modifying the health care program to meet identified needs of the community, as shown in Table 5.13. Nearly all of the study sites attain stage III for for this function and address health problems with modifications in both the primary care and community health programs. The study sites where clinical primary care, outreach, and community-based health programs are integrated J notably Checkerboard, Sells, and Kaiser/Oregon, showed the greatest propensity to rely heavily on the use of community health strategies in developing an emphasis program. Stage II in the development of this function describes modifica- tions made largely in response to the availability of special resources to address a particular problem, and are designed in accordance with guidelines established external to the project. None of the examples of COPC activities included in the case studies fell into this stage, and it would be tempting to eliminate the stage entirely. However, during ache site visits examples were cited of program modifications that were compatible with the stage II description, but were not included in the case studies because of the ample number of examples at stages III and IV. The stage II descr iption probably remains; useful to characterize program modifications that derive from sources such as categorical federal grants of the Department of Bealth and }lumen Ser- vices, the Women, Infant, and Children (WIC) grants of the Department of Agriculture, the American Indian Alcohol Progr - on, originally funded by the National Institute of Alcohol Abuse and Alcoholism (NLAAA), etc. Several of the study sites made major changes in the primary care program in response to medically underserved subsets of their community. The first major efforts undertaken by Tarboro were directed toward establishing primary care satellite facilities in the underserved periphery of the community. Raiser/Oregon has engineered innovative changes in their health plan to accommodate the elderly population of Portland under an expanded Medicare benefits package, and in the late 1960s, they pioneered the inclusion of a poverty population in a prepaid health plan. Both programs modified their primary care program in order to incorporate underserved populations into the mainstream of medical care in their area. Montefiore made several key personnel and procedural changes in both their clinical activities and outreach efforts in order to serve the Indochinese subset of their community. East Boston focused efforts on improving accessibility to services for the elderly subset of their community and is currently developing a transportation system. Many of ache major modifications accomplished by the study site" were financed with grant money rather than from in the existing revenue base. Bosch Tarboro and Checkerboard made use of grants and contracts to finance program improvements aimed at meeting particular health needs. Tarboro had recently begun to negotiate contracts with some of the major employers in the county to provide preventive and screening services and to initiate program in health promotion. The Sells program was the exception among the case studies in that program

84 o ~ o ~3 - 0 - ~ o To _ m ~ C C) o 8 - o o. - o s - ad - C: ~ o o _ o on V o ~ ~ _ sit a, ~ aC o ~ D Z E! P] ~ ~ ~ "~0 EYE Z ~ ~ Z ~ on _ Quip ~ ~~ 8 ~ o. ~ ~ 9 ° 8 o. ~ ~ ~ a ~ ! lE Z 3 _ ~ a. ~ ~ ~ ~ ~ o ' C S~ _ ~ ~ K O ~ ~ ~ 4 e ~ _ ~ c' O D ~ ~ ~ e O ~ ~ ~ c 0 ~ o_ ~ ~: ~ e c ~ ~ ~ ~ O :~ ~— E ~ ~ ~ s 0 "~ c O ~o E O :> ~ ~ ~ ~ ~ ~ e _ ~ ~ ~ _ ~ ~ ~ s ~ ~ ~— _ ~ ~ v ~ ~ ~ ~ ~ · ~ ~ ~ aS ~ ~ ~ ~ ~ ~ er ~ e d ~ :^ ~ _ 81 t:— ~ ~ ~ ~ ~ ~ ~ _ o ~ s V ~ _l O ~— ~ q ~ ~ ~ ~ o O ~ ~ — ~ ~ ~ —— ~— s - 4 _—s ~ ~ 0 0 0 c ~ :! ~ ~ ~ e4 0 ~ ~ ~ ~ _ e: :, o ~ ~— ~— C ~ ~ ~ ~ q O o. e ~ ~ C~~ o~ ~ D.a a~ _ 0 ~ ~ ~ c _— ~ 0 =0 ~ ~ ~ _ ~ >,.. ~ ~ ~ e~ ~ ~ . _ ~ 8: ~ ~ _ ~o ~ :1 ~ ~ ~ D O a ·4 ~J O q C— O ~ O— ~ E C O q O ~ _ — ~ ~ ~ V U C ~ 1 ~ _ ~ ~ S ~ V o ~ ~ _ ~ C ~ ~ O o ~~ O 0 ^. ~ - .c ~ O ~— ~ V 0 - ~e e ~ ~ 0 _ 0 _ · ~ s _ 0 e ~ c ~ ~ Q ~ ~ ~ E O _ o ~ q ~ V ~ ~ qC ~—D ~ O E— ~ ~d ·~ ~ ·~ ~ _ ~ ~ ~ ~ ~ ~ ~ ~ e ~ o._ e ~ ~ ~ ~ ~— ~ - ~ ~ _ ~ ~ ~e ~ ~ ~ ~ —~ ~ ~ ~ ~ ~ O _ ~ ~ _ 0 ~ ~ O ~ ~ "~ ~ ~ _ - ~ ~ e ~ e `. ~E ~ :> O ~ ac ~ ~ O ~ ~ _ _ O — ~ ~ D ~ ~ ~ ~ U 0 ~ 0 V ~ _ S ~ ~D - C C "s q ~ ~ a Q :- O ~ — O V — — C hd C ~ :' ~ _ s O ~ V~ ~ U D. _ O e" ~ ~ ~ s O V s 0~~ V ~ ~ a~v O ~ ~ e 0 q ~ s . ~ ~ ~ q ~ ~ — V o C V ~S 3 ~ ns v c, ~ O E "_ ~ _ q c ~ ~ ~ V :'— "s ~: ~ ~0 o c o - - - a 8 ~v J: V e~ve O ~ _ q. ~ c C1,= o C £ C ~V _ _ ~: V— q ~ C,) . e ~ s ~ 0 _ _ ~ ~ ~ "s a :, ~q 0 O ~ s ~ m" E v _ ~ ~ `a "_ ~ ~ O ~ ~ _ S ~ C, O c~ ~ _ - o~ q ~ ~ ~D :~. ~ O— — C q c: ~ ~C _ - ~d o - . O ~ - ~C C :, - C _ ~ S S _ C ~ _ _ S _ o 0~ 0 "S ~C O C, ~ o~ ~ O _ .4

85 modifications are developed and financed from a recurring federal budget with specif ic provisions for community health nursing, con~unity-based outreach programs, and programs of environmental health. In general, financial constraints seem to exert the greatest single influence on the modifications of the health care program which are eventually made in a COPC practice. Among the study sites, Crow Bill was the most constrained in making major program modifications and was also the site with the largest percentage of total practice revenue based on direct patient services. Instead, the Crow Hill practice developed collaborative efforts with the resources of the county health department and the school health program to extend their efforts into the community. They accomplished, in an informal way, the beginnings of a network of health resources, 8 notion more fully developed at Tarboro. Even those study sites with a great deal of flexibility in the manner in which they can use the ir revenue base often found it diffi- cult to make major program changes quickly in response to identified community needs. Both Raiser/Oregon and Sells have flexible programs capable of accommodating a number of program modifications. Neither, however, is free to radically change portions of their program if it involves substantial changes in personnel, facilities, or major equips ment procurement. Monitoring the Impact of Program Modifications In general, the weakest link in ache COPC process was that of sys- tematically monitoring the impact of modifications in the health care program. Table ~ .14 lists the levels of development for this function among the study sites. The programs associated with health services research activities generally had the best evidence of Impact of those program modifications in which the research component was involved. Raiser/Oregon was notable in this regard in frequently testing program modifications with a prospective study design, often using a control group. In the early 1970s, Sells conducted two populationrbased evaluations of program modifications, and in both demonstrated an impact that would have been undetected in an evaluation that focused on the users of service. The pr incipals at the study s ites generally acknowledged the importance of systematically monitoring the impact of modifications, but noted the difficulty in doing so, due in large part to the lack of resources and specific skills. They also cited ~ paucity of evaluation techniques feasible for routine application in the busy primary care setting. The Costs of COPC The quantitative activities required to identify and character ize the community and to identify its major health problems were axioms plished among the study sites in a variety of ways with vastly different

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 ~

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

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

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~.

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;

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

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

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.

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.

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.

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.

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