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OCR for page 97
Chapter 6
CONCLUSIONS AND RECOMMENDATIONS
CONCLUSION 1
The conceptual model of COPC developed in this report in terms of
,
s tru_ture and function holds promise for a or imarY care system that
t . ,
is Sore responsive than current primary care Practices in meeting the
- — ~ _
health needs of communities. To what extent application of this model
will result in changes in health status and C08+ are Questions worth
testing.
This study of community~oriented primary care grew out of a confer-
ence on the subject sponsored by the Institute of Medicine in 1982.
The conference provided an opportunity for health professionals from a
variety of disciplines and countries to share their ideas and experi-
ences in organic ing pr imary care services in response to the identif fed
needs of a defined population or community.
,. The model developed by
Sidney Kark and his colleagues, first in South Africa then in Israel.
was used at the conference as a basis for discussion and comparisons.
Sixteen case reports illustrating some practical applications of COPC
principles contributed to a consensus among the conferees that COPC is
f eas ible in the United States.
There was some coalescence around Rark's model but there was at the
same time recognition that it should be modified for application in
this country. ~^~ '~= ~
ours nea to ne unaerscooa in relation to the current
practice of primary care in the United State=, Ed the concept of
community had to be defined in a systematic way. Moreover, there
seemed to be a need to account theoretically or conceptually for the
variety of forms COPC has taken and could take in the United States.
In the early phase of this study, a conceptual model was developed
for COPC in the united States. It is a Edification of Rark's model
based on an understanding and appreciation of how primary care, commu-
n ity or ientation , and epidemiologic investigation are likely to develop
in the United States in the 1980s. The basic elements of the COPC
model are:
practice or service program active in primary care
· defined community for which the practice has accepted responsi-
bility for health care
97
-
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98
set of functions by which the practice, with the participation
of the community, identif ies and addresses the ma jor health
problems of the community ; the functions include:
definition and characterization of the community
identif ication of the community' s health problems
Edification of the health care program in response to the
community health needs
monitoring the impact of program modifications.
In the judgment of the committee, if these four functions were
performed systematically and routinely for a defined population in
conjunction with the clinical practice of pr ~ ry care, the result
would be a fully developed practice of COPC. Such a practice would
hold promise for a more responsive approach to the health needs of a
population and , therefore, one that 'should produce dividends in
improved health status.
Elements of COPC have been and continue to be present in the
American health care system. Practices or programs exist that either
contain several of the elements of COP C. in ~ fairly developed way or
contain all of the elements in a limited way. The model developed as
part of this study includes a staging mechanism that can be used to
estimate the extent to which elements of COLIC are present in any
particular health care program.
CONCLUSION 2
COPC is not the prevailing mode of practi<:e in United States nor was
the study able to find an example of the COPC model that is fully
developed, wherein all the COPC functions are Performed sYstematicallv
and routinely. There are, however, examples of Practices that do Per-
form some of ache COPC functions reqularly.
-
-
General knowledge of the American health care system leads the
committee to conclude that COPC is not the prevailing mode of primary
care delivery. The current practice of primary care is characterized
by individual patients identifying a personal health problem and
seeking help for that problem from ~ priory care provider or a
specialist. As currently practiced, primary care often is patient-
initiated and episodic. Bowever, some providers have assumed respon-
sibility for ache health of a population defined more broadly than the
patients who present themselves for treatment and are regularly per-
forming some of the functions of COPC.
This study has attempted to identify, both in the literature and
through personal contacts, practices and programs engaged in CO9C. The
1982 Institute of Medicine conference identified, from among its parti-
- ~~ ~ ~~-~ - ~ the United States.
Additional inquiries about the existence of other COPC-like practices
were made of the conference participants, other persons in the federal
government who are responsible for administering primary care progress
and professional associations likely to have members engaged in primary
cipants, 22 programs with COPC characteristics in
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99
care and community medicine. Another 125 practices were suggested as
sites that might fit the COPC model, making a total of 147 potential
COPC practices or programs.
Although the number is small relative to the total number of pr in ry
care providers in the United States, an initial effort through personal
contact to determine the extent to which the COPC model fit these prac-
tices yielded S8 sites that reported to be responding to the primary
care needs of a population defined more broadly than the patients who
presented themselves for treatment. These sites, a mixture of public
and private programs, were performing~some of the COPC functions to
varying degrees and in some cases under very adverse conditions.
In the case studies, seven COPC programs were examined in detail
for an analysis of their level of development of ache four functions of
COPC. For each of the functions, one or more of the study sites were
able to achieve the highest level (stage IV} of development. }Iowever,
in each case study the attainment of the fully developed model was not
maintained across the variety of health issues addressed. Consequently,
the case studies demonstrate that it is possible to accomplish the
functions of CONIC in a variety of settings, but also demonstrate the
difficulty in consistently and routinely maintaining the full
operational model of COPC.
CONCLUSION 3
Because fully developed examples of the COPC model were not found,
definitive statements cannot now be made about the impact of a fully
developed COK: model on health status, costs, or cost effectiveness.
Of the S8 potential COPE sites about which information was gathered,
none was performing all four COPC functions fully, systematically and
routinely. However, they all were providing primary care services to a
defined community and were engaged in some of the COPC functions to
some extent.
In the practices actively engaged in some elements of COPC their
involvement tended to be with the early stages of identification and
characterization of the community, the identification of the community's
health problems, and the codification of the health care program in re-
sponse to the community health need=. Very little data were available
on the impact of COPC on the health status of a community, ache costs to
the provider, or the cost-effectiveness for both the provider and the
community.
CONCLUSTON 4
In Practices identified as performing some of the functions of COPC
there are examples of improved health outcomes. No evidence was found
regar d inn the cost impact of ache elements of COPC .
From the 58 COPE sites identified as having some of the functional
character istics of COPC, seven were selected for site visits. The seven
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100
were chosen after the study group made contact either by telephone or
in person with the principals in the practice. From these inquiries it
appeared that these sites were performing several of the COPC functions
at a more advanced stage than the other practices contacted.
For the seven sites visited, examples of COPC functions being asso-
ciated with positive effects on health were cited and, where available,
internal practice data related to these examples were shared. For
example, identifying a community health problem and modifying services
in response to that problem was followed by a beneficial health outcome
in the following instances:
Screening for streptoccocal infection among school age children
and high rick families was followed by a reduction in ache inci-
dence of rheumatic fever at the Sells Service Unit.
Among Me children in school'; ';er~red by the Checkerboard Area
Bealth System, screening for dental caries and recommending
treatment where necessary was followed by a substantial reduc-
tion in the amount of tooth decay in that area.
Noticeably high rates of morbidity and mortality from infant
gastroenteritis both at Sells and at Checkerborad led to special
co~unity-wide programs that were followed by a marked reduction
in the incidence of dehydration from gastroenteritis, hospitali-
zation because of diarrhea, and deaths from gastroenteritis.
Reduction of chronic hearing loss among school children in the
Checkerboard area was observed by the school health staff after
implementation of a program involving routine school screening,
referrals to ENT clinics, and, where necessary, referral for
tympanoplasty. Children participating in ache program had a
reduced prevalence of hearing loss, while new students failed
audiometric screening at a steady rate.
The published literature on the health effects of COPC is not large,
but some of the studies by park and his colleagues in Israel (Abr~son
and Hark, 1983; Eark, 1981} and Julian Tudor }fart and Graham Watt in
Wales {Watt, 1983, support ache hypothesis; that COPC can have a positive
impact on health. The literature about the United States experience
with COPC primarily describes the evolution of the concept and discusses
its potential advantages and disadvantages. It does not report data on
the cost and benefits of a fully developed model practice. There are,
however, examples in ache literature of programs such as community
health centers and the Indian Bealth Service containing some elements
of COPC that have reported positive effects on the reduction of infant
mortality {Chabot, 1971; Davis and Schoen, 1978; Goldman and Grossman,
1982; Nutting et al., 1975), the prevention of rheumatic fever {Gordis,
1973), the trea~cmer~t of hypertension (NACEC, 1980), and the improvement
in the quality of prenatal care {Nutting et al., 19791. The evidence
is partial and incomplete but does suggest a testable hypothesis:
COPC, if fully operational, will lead to mproved health.
OCR for page 101
101
At the seven sites visited, there was ~ ittle or no information on
the marginal cost of ~ fully developed COPC program or on the costs of
the specific elements of COPC. The literature on the various
components of COPC or surrogates for those components, such as needs
assessment or c:oshmunity participation, also is deficient in the area of
costs. There is no evidence for the committee to draw conclusions
Tout the costs of COPC and the effects those costs might have on the
health of the community.
CONCLUSION 5
Many methods and techniques, developed in and for over disciplines,
are potentially adaptable and applicable to a move from primary care to
COPC. However, there currently are no descriptive materials that
explain or document how these methods can be or have been adapted and
used to perform COPC functions and thereby assist practitioners in
moving from primary care to COPC.
As defined in the conc:eptus1 model (Chapter 4) COPC is the clinical
practice of primary care in a defined population coupled with systematic
efforts to identify and address the major health problems of that popu-
ration through effective smOificationn in both priory care services
and other appropriate community heals programs. Combining these COPC
functions with the practice of primary care is not a simple process and
specific ways to accomplish this linkage have not been made e~licit.
There are numerous ways to accomplish the individual functions of
COPC. For example, the community health needs might be identified,
with varying degrees of reliability Ed validity, by careful obeerva-
tion {field study), by extrapolating from the user population, by
surveying all the households in the defined area, or by surveying a
representative sample of the total population. Many of these methods
have been developed, tested, and applied in circumstances other than
primary care. From interviews with the stuff at the COPC sites visited
and from discussions winch educators and researchers attempting to teach
and study COPC, difficulties arise in adapting these techniques and
tools developed in and for other discipliners for use by the COPC
practitioner. In addition to survey research and field study some of
the tools that seem potentially useful to COLIC are needs assessment,
setting program goals or priorities, cats processing, coding systems
for clinical information in primary care settings, assessment methods.
and epidemiologic concepts such as depopulation at risk,. numerator, and
denominator.
On the basis of the information gathered the committee concluded
that materials should be produced to explain how these tools and
technique'; can be used to perform COPC functions. These materials need
to be prepared in ~ way that is acceptable to and usable by primary
care practitioners; they 'should serve as ~ guide to providers who want
to Moe from primary care to COPE.
OCR for page 102
102
RECC~ENDATION 1
The fully developed COPC model should be made operational
of selected clinical settings so as to test it rigorously in terms of
.
1 ts impact on health and cost.
a variety
-
As a result of this study the co~mnittee has concluded that the
conceptual model of COPC promises to be nor e respons ive to the health
needs of a population than current primary care practices and that the
extent to which the application of this model will improve health is a
question worth testing. To date this hypothesis has cone untested
Decause no practice or group of practices has been able to put in place
a fully developed model.
The committee agreed that to test the impact of COPC both on health
and on cost it is necessary first to produce fully operational models.
Fully developed COPC practices or programs such as suggested by the
model are not likely to evolve in a way conducive to rigorous testing
if left exclusively to the innovative practitioners. Therefore, the
committee recommends that substantial financial support be made avail-
able for selected primary care practices or programs committed to the
full development of COPC. The recipients should use this support to
implement a fully developed COPC practice by applying the tools and
tecnn~ques developed for particular COPC functions. A principal
objective of such an effort should be to assess the value of COPC by
determining its marginal costs and benefits. The assessment needs to
be done in a scientifically rigorous way such as by means of a
controlled trial. In addition, ache committee believes Cat practices
currently engaged in COPC activities should be encouraged to continue
these activities with special emphasis on measuring and documenting
their costs and Weir benefits.
Given the varied composition of the American health care system,
the committee advises that the COPC model be tested in a variety of
organizational, f inancial, and geographic setting';. Efforts should be
node to test the COPC model and its various components in urban as well
as rural practices, fee-for-ser~rice and prepaid practices, multi-
specialty and single specialty groups, large groups and small groups,
and public programs as well as private both for-profit and not-for-
profit. ~ variety of approaches to testing ache COPC model and its
components should provide greater insight into the general feasibility
and applicability of the model in the American context.
REC~DATTON 2
in order to accomplish Recommendation 1, methods for performing CO9C
functions must be developed and tested. These methods should be
developed and Presented in a wav that makes them usable by providers
wish ing to move pr imarY care to COPC.
The committee also concluded that a ma jor obstacle to a f ully
operational model is the absence of tools and methods designed to aid
OCR for page 103
103
practitioner s in per forming the functions of COPC. Recogniz ing the
d iff iculty that even the most committed COPC practitioner has had in
accomplishing all the COPC functions, the committee agreed that the
necessary next step in determining the value of COPC is to develop
usable methods for carrying out the COPC functions. There is a par ti-
cularly vital role for population-based data systems technology in the
quantitative activities inherent in COPC. The advent of microprocessor s
9 reatly expands the potential for low cost data systems to supper t the
application of epidemiologic methods in the busy pr imary care practice
setting. Therefore, the committee recommends that a multidisciplinary
team be financially supported in a major effort to design the best ways
to adapt and apply epidemiologic, social science, and health services
research tools to COPC. The team should be mode up not only of persons
knowledgeable about these tools and techniques, such as academics and
researchers, but also of practitioners who have been working to make
COPC fully operational. This ef fort should include testing the tools
in multiple s ites .
ADDITIONAL INDIVIDUAL CANTS
Four members of the committee wish to make the following additional
continents .
There are two areas in which we wish to add specific components that
are the conclusions of the signatory committee members. The two areas
are: (1) the inclusion of community involvement as one of the basic
elements of the definition of COPC; and (2) support for the continued
development of COPC activities and practices while the carefully-
structured COPC research effort called for by this study is being
carr fed out.
Community Involvement
An outstanding, relatively constant, and important feature of com-
munity medicine as it has been practiced in this country since the early
1960s has been the formal involvement of community members in the gover-
nance of the practice. The civil rights movement, the OEO community
health centers, the philosophy and ethos of emerging departments of
community medicine in academic medical centers in the 1960s--all
supported the involvement of patients and community members in the
structure and management of c~o~unity-based health centers. While the
level of sophistication and degree of involvement of community members
has varied significantly, the principle has been articulated in a
variety of ways and written into regulation for most of the federal
programs (community health centers, migrant health, Title X) that
provide serv ices for under served populations.
It is difficult to measure the impact or effectiveness of this
level of community participation. Community board selection processes.
board education, Community control. versus Worker control. and similar
issues have been discussed informally and in the medical literature over
OCR for page 104
104
the past 20 years. As might be expected with an issue that is as
socially and politically sensitive, no single study or declaration has
settled the issue. Nonetheless, community involvement in medical
practices has attracted suf f icient adherents and captured the loyalties
of patients, administrators, and clinicians enough to remain a strong
theme in co~mnunity-based practices in the United States.
Community involvement appeals to democratic and populist instincts
that are important themes in Amer ice . Likewise, the participation of
patients in the decisions that influence their health care speaks to
consumer ism in a very basic way. The recent past in the IJnited States
as well, one thinks, as the immediate future are per iods where the
general affluence and educational level of the population promote con-
sumer ism. Even in health care, an enterpr ise both of ar t and
technology, consumers are anxious for a more knowledgable and, in some
cases, more active role. Community involvement promises to meet that
need.
COPC in the United States grows out of the community medicine ooove-
ment of the last 20 year s--the movement in which community involvement
has been a constant presence. As such, any def inition of COPC needs to
recognize the contr ibutions of democracy, consumer ism, and community
participation which are the legacy of community-based medical care in
the United States. Th is tradition, it should be recognized, may well
be different than other countries in which population-oriented,
conenunity-based medicine has been practiced. The work of Sidney Kark,
for instance, based largely on exper fences in Israel, places little
emphas is on th is element of COPC. I t is acknowledged, as well, that
COPC as an organizing principle applied to other American medical
settings such as private practice or prepaid group practices is
venturing into new terrain. Nonetheless, the reality and heritage of
community involvement in COPC is suf f iciently important to make it a
critical element of the definition. While this study report acknow-
ledges a role for community involvement and offers a thoughtful and
valuable discussion of issues such as "denominator bias. versus
"numerator bias" in this regard, it does not clearly delineate
community involvement as one of the key structural components of COPC.
We believe it should be recognized as such.
Shor t-term Development 0 f COPC
This report calls for the implementation of carefully-designed and
measured COPC practices in a variety of selected clinical settings to
carefully assess the impact of COPC on the heals of the population and
the cost of do ing medical bus iness . We f ully concur winch th is
recommendation.
However, we are concerned that the full scope of this undertaking--
including its cost and time--could be construed by practitioners,
administrators, community leaders, and politicians as representing an
embargo on further COPC activities until the results of this large-
scale exercise are available and published. COPC, in our judgment,
represents a marital, evolutionary development in the provision of health
care services in the United States. As this report documents, there
OCR for page 105
105
currently are many medical practices unself-consciously engaged in
various elements of COPC. Moreover, recent articulations of the COPC
concept has encouraged many others to restructure their practices in
such a way as to attempt to conform to COPC more rigorously.
In our judgment, these efforts are extremely important if the full
benef its of COPC are to be realized. It will be the pragmatic, real-
world, cost-sensitive, community-conscious practitioners and admin-
istrator s who will develop and adapt techniques of pr Wary care
epidemiology, con munity assessment, practice modif ication and impact
evaluation that will have a great deal to say about the v lability and
importance of COPC as a pr inciple in health services delivery. These
practitioners deserve support and encouragement.
The Controlled clinical tr ial. called for in this document needs
to be carried out. The signatories of the commentary, however, wish to
make it clear that in the meantime we support all manner of creative
efforts undertaken to implement, evaluate, and improve the practice of
cononunity~or tented pr imary care.
Fitshugh Mullan
Lisbeth Bamberger Schor r
Joyce Lashof
Paul Stolley
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106
REFERENCES
Abramson, J.H., and Kark, S.L. 1983. Community oriented primary care:
Meaning and scope. Pp. 21-59 in Community Oriented Primary Care--
New Directions for Health Services Delivery. Washington, D.C.:
National Academy Press .
Chabot, A. 1971. Improved infant mortality rates in a population served
by a comprehensive neighborhood health program. Pediatrics
4 7: 989-994 .
Davis , R., and Schoen, C. 1978 . Health and ache War on Poverty: A Ten-
Year Appraisal. Washington, D.C.: The Brookings Institution.
Goldman, F., and Grossman, M. 1982. Impact of Public Health Policy :
The Case of Community Health Centers (Working Paper No. 10201.
Car idge, Mass .: National Bureau of Economic Research.
Gordis, L. 1973. Effectiveness of comprehensive-care programs in
preventing rheumatic fearer. New England Journal of Medicine
289 :331-335.
Kark, S.L. 1981. Cowaunity~riented Primary Health Care. New York:
Apple ton-Century-C ro f ts .
Nutting , P., Barr ick , J., and Logue , S. 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.
Nutting, P.A., Strotz, C. R., and Shorr, G. I . 1975 . Reduction of gastro-
enteritis morbidity in high-risk infants. Pediatrics 55 :354-358.
National Association of Community Health Centers (N~CHC). 1980.
A Community Health Center Information Guide and Documentation
Resource (National Center for Bealth Services Research, Department
of Health and Human Services Grant Project No. 1-RO3-ES-03404-01).
Watt, G. 1983. The application of COPC principles in a Welsh mining
village . Pp. 243-249 in Community Or tented Pr imary Care--New
Directions for Health Services Delivery. Washington, D.C.:
National Academy Press.
Representative terms from entire chapter:
community health
