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OCR for page 9
Chapter 2
BACKGROUND
,
ORIGIN OF THE: STUDY
This study of community~oriented primary care (COPC} came about as
a result of a conference on the subject sponsored by the Institute of
Medicine in March 1982 (Institute of Medicine, 1983). The conference
provided a forum for health professionals from a variety of disciplines
and countries to share their experiences and their ideas on ways of
organizing primary care services. The central theme of the conference
was the organization of health services to meet the identified health
care needs of a defined population.
A framework developed by Abrasion and Rark and their colleagues,
first in South Africa and then in Israel, was used at ache conference as
a basis for discussion and comparisons (Abramson and Eark, 1983~.
Their work builds on We definition of priory care formulated by the
Institute of Medicine (Institute of Medicine, 1978), which specified
five attributes essential to primary care, including accessibility.
comprehensiveness, coordination, continuity ~ and acc:ountability. To
the Institute's definition of primary care, Abramson and Bark add a
community focus. According to ~em, ~community~oriented primary care
(COPC) is a strategy whereby elements of primary health care and of
community medicine are systematically developed and brought together in
a coordinated practice. {Abrasion and Bark, 1983~.
At the conference, there was ~ consensus that although there are
few, if any, American examples that fit the Xarkian model precisely,
there is a body of experience in this country from practices and pro-
grams built on the same conceptual base. Although these examples were
presented as case reports in workshop sessions at the conference, the
conference participants noted the absence of any systematic efforts to
compile and document a broad range of domestic experience with COPC.
David Rogers noted this basic weakness in his summery remarks and urged
the development of ~ More vibrant and compelling da" base with which
to make a case for COPC. (Rogers, 19821.
After the conference, interest increased in developing a sound data
bare for COPC. In the economic climate of Me 1980s, the targeted and
apparently effective use of resources encouraged by COPC seemed a parti-
cularly appealing feature. In addition, elements of COPC have existed
in a number of public and private progr e-. (Indian Health Service,
9
OCR for page 10
10
community health centers, family practices, and health maintenance
organizations) for more than a decade. A systematic compiling of the
exper fences of these programs in a context broader than the ir individual
evaluation seemed attractive to several funding agencies.
In the fall of 1982, the U. S. Public Health Service awarded ache
Institute of Medicine a grant to develop a data base for COPC. As IOM
committee was appointed to guide the study. The committee was made up
Of practicing physician., health services researchers, epidemiologists,
academicians, and administrators, all with backgrounds in and demon-
strated concern for the organization and delivery of priory care. The
charge to the committee was threefold:
1) to assemble and organize the existing data/evidence that des-
cribe the operation, costs, and impact of the various ways COP C
has existed in the United States
2) to critically assess ache resulting cats base in relation to
various population groups, and in relation to ~ variety of
existing and projected organizational, administrative and
financing contexts
3) where evidence warrants it, to make recommendations about
pr for ities in areas of education, practice, research, and
public policy.
At their first meeting, the committee recognized that the notion of
COPC had not been defined precisely enough to permit systematic organi-
zation~of a data base on the operations, cost, and impact of COPC. The
committee further recognized that the published literature would not
yield ~ sube~ntial mount of information on the marginal costs and
effects of COPC. Consequently, "e committee and muff developed an
operational definition of COLIC and planned ~ series of case studies.
The case studies were to be directed at primary care practices or
program= that incorporated the basic elemen" of the operational
definition, and Gibe da" from ache case studies, in turn, were to be
examined for evidence of the marginal costs and effects of those acti-
vities that distinguish COPC from orthodox primary care. The case
studies were also expected to lead to adjustments in the model of COK:
to ensure that it was compatible with the everyday practice of COPC.
HISTORICAL CON~IE:XT
Co~unity-oriented primary care is not a revolutionary concept.
Elements or specific features of COPC have been developing and evolving
in a variety of program and practices in the United S=tes and abroad
over the past fifty years. Some of the basic elements of COPC can be
traced back to the works of John Grant {Seipp, 1963, in Cnina and Will
Pickles (Pickles, 1938) in Britain. The efforts of Sidney Dark, John
Cassel, and others in South Africa (park, 1981}, as well as the work of
Walsh McDermott, Kurt Deuschle, and their colleagues on the Cornell
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11
team working with the Navajo Indians (McDermott et al., 1960, 1972)
have significantly influenced the evolution of COPC. The writing of
H. Jack Geiger {1967, 1974), Cecil Sheps (1977 , 1978, 1981; Sheps and
Bachar , 1981; ), and Rerr white (1972a,b, 1974 , 1976), have added impor-
tant conceptual elements to the uniquely U.S. models of COPC that have
developed ~ ince the 1960 ~ .
The 1960s were a period of growing federal commitment to the provi-
sion of medical services. It began with the OEO Neighborhood Bealth
Centers, the Children and Youth and Maternal and Infant Care Programs,
and the Migrant Health Program. The commitment continued in the 1970 s
with the authorization and growth of the National Bealth Service Corps
and its scholar strip program. At the same time, there was a reemergence
of general practice medicine in the form of family practice as called
for in the Millis and Willard reports {Millis, 1966; Willard, 1966~.
The family medicine movement grew apace from the sentiments that these
documents articulated. By the late 1970s, some 13 percent of American
medical graduates were pursuing careers in family medicine--many prac-
ticing in rural and traditionally underserved areas.
Finally, during the 1970s, the concept of priory care gained prom
eminence and acceptance as an anchor against the subspecialty drift of
the major medical disciplines. Not only was family practice included
in the concept of primary care, but also general internal medicine and
general pediatrics and some elements of psychiatry and obstetrics and
gynecology were included. The Institute of Medicine helped to solidify
the concept with its 1978 publication, A Manpower Police for Primarv
Health hare (Institute Of Dicing - . 1978~. which clearly defined the
field and made specific policy recommendations pertinent to it.
All these developments had taken place in an environment of greater
community participation. From We civil rights movement of earlier
years to the consumerism of the 1970s, the role of ache community and
the patient had become more prominent in the delivery of health ser-
vices. Departments of community and social medicine had grown up in
medical schools, and increasing number. of medical students and young
health professionals sought career opportunities in community-responsive
practice settings.
Paralleling these particular developments was a widespread and
growing concern over the accessibility, appropriateness, and exceed-
ingly high cost of medical care. This has been and continues to be
true not only for poor and disadvantaged groups or geographically
isolated groups but also for the mainstream of the American population.
There have been a variety of responses incorporating some of the basic
features of COPC.
· The original Office of Economic Opportunity neighborhood health
centers {Schorr et al., 1968; Zwick, 1972) attempted to address
the accessibility issues and had an emphasis on community
involvement (Geiger, 1969; Gibson, 19681. They tended to place
less emphasis on the application of epidemiologic methods for
the identification of specific community health problems. Many
of today's community health center- are direct descendants of
OEO neighborhood health centers.
OCR for page 12
12
The federally-funded Community Health Center Program, adminis-
tered by ache Bureau of Health Care Delivery and Assistance
(D~IS}, in cooperation with local communities provide primary
health care era ices for medically under served populations
(NAC~IC, 19801. Community health centers now number about 565.
Like its predecessor, the OEO Neighborhood Health Center pro-
gram, the community health center program tends to emphasize
accessibility of primary care services and community involvement
rather than the routine application of quantitative techniques
for identifying community health problems.
Many practice associations and health maintenance organizations
have responded to the need for accessible pr imary care and to a
growing consumer interest in disease prevention and health pro-
motion. Although many of these associations and organizations
have enrolled populations that can be readily identified and
enumerated, for the most part they have not fully exploited
their ability to specificy the health needs of their enrollees
and to tailor services to meet these needs. There are ~ few
exceptions where attempts have been made in #his direction.
including Shapiro's work at the Bealth Insurance Plan of Greater
New York {=P, (Shapiro et al., less, 1960, 1965~; work done by
Greenlick and colleagues at Kaiser/Oregon (Freeborn et al.,
1978; Greenlick, 1975; Greenlick and Pope, 1974~; and some of
the work done by Kurland and colleagues at the Mayo Clonic
{Rurland and Mblgerd, 19811.
Family practices, rural practice sites, and ocher organized
settings of primary care that are the sole or major provider
of care for defined communities because of geography, social
circumstances, or economic arrangement have also attempted to
alleviate problems of access; and appropriateness of care. They
tend not to have the time or expertise to systematically iden-
tify the community's health needs and develop a practice that
anticipates those needy.
.
· The National Bealth Service Corps is a federally-funded program
aimed at supplying health care providers {physicians, nurses.
dentists) to medically underserved communities. Although all
ache practitioners are based in specif ic communities;, little
effort has been made to encourage or assist scheme providers in
systematically identifying and addressing the health needs of
their communities {Mullen, 19801.
The Indian Bealth Service (IESl, a federally-funded program to
assure comprehensive health services to American Indian and
Alaskan native communities, through their system of local
service units, provides community-based primary care to a
defined population. In addition to primary care services, the
IlIS also has the responsibility for the public health of the
Indian community. Through its Office of Research and Develop-
ment, the I}IS has undertaken to employ epidemiologic pr inciples
OCR for page 13
13
in the assessment and improvement of health care delivery
(Nutting et at., 1981; Shorr and Nutting, 1977~. The SES, as
an organized provider of health care services, appears to have
come the closest to employing a COPC response to concerns about
the appropriateness and accessibility of health care.
An these programs evolved, the United States ha. undergone rapid
advances in medical technology and tertiary care medicine, resulting in
a continuing and predominant emphasis on individual interventions
rather than on population-based primary care and prevention of the
occurrence of morbid or premorbid states. The escalating expense of
this approach as well as increasing concern about its cost effective-
nese have refocused attention to the need to Improve and augment primary
care services. Both the 1982 conference and this study reflect this
increased interest and attention.
issues in COPC
There are questions that ar ise in discuss ions of community-or tented
primary care that need to tee presented at the outact of this report so
as to alert ache reader to the basic issues surrounding COPC. These
questions include:
· Gnat is COPC?
· How is COPC practiced?
· Are acme environments more conducive to the emergence of COPC?
· Mow does COEC affect the health of ache community?
· What does COPC cost?
· What i. next for COPC?
These are the questions the Institute committee faced in embarking on
this study.
What is COPC?
The 1982 conference described many characteristics of COPC. The
paper by Abramson and Hark {1983} listed two cardinal features, five
essential features, and f ice mother elements. ~ Geiger {19831 descr ibes
what COPC is not when he delineates ache Isis Fallacies in Search of a
Def inaction. ~ Geiger then suggests that COPC is a synthesis, ~ . . . the
insistence that all [these] elements of community orientation, de~-
graphic study, epidemiologic investigation, personal medical services,
environmental intervention, community organization, and health educa-
tion be performed by the flame practice or ted, or at least by a ~11
number cuff Practices and health agencies working as ~ single system (not
~ ~ _ ~
just 'coordinated".. Mullan characterizes COEC as the reunion of the
traditions of public health Ad personal clinical health services
{Mullen, 1982~. As helpful AS scheme descriptions are to ache general
understanding of COPC, they do not constitute an operational definition
OCR for page 14
14
of COPC. They leave questions: What constitutes a community? Wnat
does it mean to be community~oriented? Mow is community orientation
expressed? Is community orientation a sensitivity to the community's
mores or is it knowledge of the community based on data, or both? Does
primary care include only medical services? This study has developed
an operational definition (Chapter 4) that, it is hoped, will be used
and refined by researchers and practitioners engaged in ache study and
practice of COPC.
Who practices COPC?
Once COPC is defined in operational term, the next set of questions
revolve around who practices COPC. Is COPC the responsibility of indi-
~ridus, practitioners? Does COPC require an organized delivery system
with multiple providers? Can community agencies, such as the public
health department or the local medical society, function as COPC?
These and other questions about the principal ~doers. of COPC are
considered and deliberated in this report. The seven case studies
describe several different types of practice environments that support
COPC activities.
Bow is COOK: Practiced?
Throughout this study, the committee and ~ ~ ff tried to understand
and then describe how practitioners perform the C4PC functions. Bow do
they define and characterize their community? Bow do they identify its
health needs? What methods or tools do they employ to accomplish these
functions? Are there common methods used by all practitioners? Are the
methods for carrying out the COPE functions described anywhere? The
seven case studies as presented in Volume II describe in considerable
detail the different ways these practice sites have approximated COPC.
Are Some Environments More Conducive to COPC?
Much of the writing about COPC cites examples of practices or pro-
grams in countries with health care systems very different from those
in the United States. The question of the feasibility of putting COMIC
into practice in this country continues to be raised. Bar dependent is
COPC on a nationally organized health care system? Does the public
sector provide an environment more supportive of COPC than the private
sector? Are large, organized health service systems more conducive to
COPC than small group" or solo practices? Does the reimbursement system
affect the ability to conduct COPC? Is it easier to perform the COPC
functions in a capitated system than in a fee-for-service system? The
answers to mat of these questions are dependent upon our ability to
understand ache various stages of COPC development and to measure a
practice's progress along these stages. Chapter 4 of this volume
describes stages of COPC Ad the cross-case analysis in Chapter 5
OCR for page 15
15
attempts ~ to measure the level of development of seven COPC practices
existing. in very different environments in terms of these stages.
Although very little can be concluded about what environments are mar e
conducive to COPC based on seven canes, the results of the case studier
suggest some hypotheses.
How Does COPC Affect the Health of the Community?
One of the fundamental questions confronting COPC proponents is
whether it contributes to a healthier community. What in the impact of
COPC on the health of a def ined community? Does this approach to pr i-
mary care improve ache overall health of the community? Does it improve
the health of a subset of the community? Does it improve the health of
one subset of community at the expense of another? Do some elements of
COPC contribute more to improved health than others? These questions
should be raised about every innovation in health care. They are,
however, among the most difficult to answer due to measurement pro-
blems, and ~ scarcity of information and documentation about effects of
changes in health programs. These were present throughout this study
and contr ibuted to the committee ' ~ inabil ity to draw def inite
conclusions about the impact of COPC. There are, however, acme sugges-
tions of improved health related to COPC activities reported in the
seven case studies in Volume II.
What Does COPC Cost?
The extent to which COPC improves the health of the community must
be considered in light of what it costs. Every activity has costs
associated with it and these costs must be considered when assessing
the value of an activity. What are the marginal costs of COPC? Does
COPC cost more or less than the current practice or primary care? And
most important, do the benefits derived from COPC outweigh its cost?
Like questions regarding COPC ' ~ impact on the health of a community,
the questions related to costs are extremely difficult to answer. They
depend on the ability to differentiate between activities specific to
COPC and those associated with any primary care. Although the Odes
developed in Chapter 4 of Volume I draws so~ distinctions between COPC
and the current practice of primary care, there is very little informa-
t ion in We literature about the associa~ced costs and angst no documen-
tation at the various study sites.
What Next In COPC?
The cumulative effect of the above questions is to generate yet
other questions: Is there a future for community-oriented primary care?
What are the next steps in the evolution of COPC? What needs to be done
first and by whom? The committee in its conclusion. and recommendations
(Chapter 6, suggests some answers.
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16
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1
7
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OCR for page 18
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Representative terms from entire chapter:
neighborhood health
