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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

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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.

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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

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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

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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

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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 REFERENCES l Abrasion, J.~., and Mark, S.L. 1983. Community oriented primary care: Meaning and scope. Pp. 21-59 in Community Oriented Primary Care-- New Directions for Bealth Services. Washington, D.C.: National Academy Press. Freeborn, D.R., Mullooly, J.~., Colombo, T., and Burnham, fir. 1978. The effect of outreach workers' services on the medical care utilization of a disadvantaged population. Journal of Community Health 3 :30 6-320 . Geiger, B.J. 1969. Beal~ch center in Mississippi. Bospital Practice 4:68. Geiger, H.J. 1967. The neighborhood health center. mental Health 14:912-916. Archives of Environ- Geiger, H.~. 1974. Community control--or community conflict? Pp. 133-143 in Neighborhood }lealth Centers, R.~. Bolister, B.M. Kramer, and S.S. Bellin, eds. Lexington, Mass.: D.C. Beath and Co. Geiger, B.~. 1983. The meaning of community oriented primary care in an American context. Pp. 60-103 in Community Oriented Primary Care-- New Directions for Bealth Services. Washington, D.C.: National Academy Press. Gibson, C.D. 1968. The neighborhood health center: The primary unit of health care. Amer ican Journal of Public Bealth 58 :1188-1191. Greenlick, M.R. 1975. Randomized clinical trials: An application for BMOs. Pp. 46-50 in Proceedings, 2Sth Annual Group Bealth Institute, Chicago, Illinois, June 23-2S, 1975. Washington, D.C.: Group Bealth Association of America, Inc. Greenlick, M.R., and Pope, C.R. 1974. The use of patient records and survey data to develop measures of health status. Pp. S6~71 in Health Care Research: A Symposium, D.E. Larsen and E.J. Eve, eds. Calgary: Oni~rersity of Calgary.

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1 7 Institute of Medicine. 1978. A Manpower Policy for Primary Health Care. Washington, D.C.: National Academy of Sciences. Institute of Medicine. 1983. Community Oriented Primary Care--Hew Directions for Bealth Services, E. C. Connor and F. Mullan, eds. Washington, D.C.: Nations1 Academy Press. Rark, S.~. 1981. Ccnmaunity~Oriented Primary Bealth Care. New York: Appleton~Century~Crof ts . garland, L.T., and Malgard, C.A. 1981. The patient record in epidemi- ology. Scientific American 245:54-63. McDermott, W., Deu$chle , R., Adair, J., Fulmer, B., and Laughlin, B. 1960. Introducing modern medicine in a Navajo community. Science 131: 197-205. McDermott, W., Deuschle , R., and Bernett, C. R. 1972 . Health care exper i- ment at M - ny Farm. Science 175:23-31. Millis , J. S., ed. 1966 . The Graduate Education of Physicians. Report of the Citizens' Commission on Graduate Medical Education. Chicago: American Medical Association. Mullen, F. 1980. Community practice: The cake-bake syndrome and other trial-. Journal of the American Medical Association 243:1832-1835. Mullen, F. 1982. Community~oriented primary care: An agenda for the '80s. New England Journal of Medicine 307:-1076-1078. National Association of Community Bealth Centers (NA=CI. 1980. A Community Health Center Information Guide and Documentation Resource (National Center for Elealt:h Services Research, Dams, Grant No. 1-PO3-E;-03404-011. Nutting, P.A., Short, G.I., and Burkhalter, B.R. 1981. Assessing the performance of ~nedica1 care systems: A method and its application. Medical Care 19:281-296. Pickles, W.N. 1938. Epidemiology in Country Practice. Bristol: John Wr ight and Sons, Ltd. Rogers, D.g. 1982. Community~oriented priory care. Journal of the Amer lean Medical A$soc iation 24 8 :1622-1625 . Schorr, L.B., and English , J.T. 1968 . Background , context , and signif i- cant issues in neighborhood health center programs. Milbank Memor ial Fund Quarter ly 46: 289~296 . Seipp, C. 1963. Health Care For The Community: Selected Papers of Dr. John B. Grant. realtime: Johns Bopkins University Press.

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18 Shapiro, S., Jacobziner, B., Densen, P.~., and Weiner, L. 1960. Further observations on prematurity and perinatal mortality in a general population and in the population of a prepaid group practice medical care plan. American Journal of Public Health 50:2307-1317. Shapiro, S., Weinblatt, E., Frank, C.W., and Sager, R.V. 1965. The B.~.P. study of incidence and prognosis of coronary heart disease--Preliminary findings on incidence of myocardis1 infarction and angina. Journal of Chronic Diseases 18: 527-558. Shapiro, S., Weiner, L., and Densen, P.M. 1958. Comparison of prema- turity and perinata1 mortality in ~ general population and in the population of a prepaid group practice medical care plan. American Journal of Public Bealth 48:170-187. Sheps, C.G. 1977. Education for what? A decalogue for change. Journal of the American Hedical Association 238:232-235. Steps, C.G. 1978. Primary care--The problem and the prospect. Annals of the New York Academy of Sciences 310:265-274. Sheps, C.G. 1981.. The modern crisis in health aervices--Professional concerns and the public interest. Israel Journal of Hedica1 Science 17: 71-79 . Sheps, C.G., and Bachar, M. 1981. Rural areas and personal health service.: current strategies. American Journal of Public Bealth 71:71-82. Short, G.~., and Nutting, P.A. 1977. A population-based assessment of the continuity of ambulatory care. medical Care 15:455-463. White, R.L. 1972a. Epidemiologic intelligence requirements for planning personal health services. Acta $ocio-n~edica Scandina~rica 2:143-152. White, R.L. 1972b. Beal~ch care arrangement in ache United States: AD 1972. Milbank Memorial Fund Quarterly 50:17-40. White, R.L. 1974. Contemporary epidemiology. International Journal of Epidemiology 3:295-303. White, R.L. 1976. Primary care research and the new epidemiology. Journal of Family Practice 3:S79-580. Willard, W.R., ed. 1966. Meeting the Challenge of Family Practice. Report of the Ad lloc Committee on Education for Family Practice of ache Council on Medical Education of the American Medical Associa- tion. Chicago: American Hedica1 Association. Zwick, Deb. 1972. Some accomplishments and findings of neighborhood health centers. Milbank Memorial Fund Quarterly S0:387-4200