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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.

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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.

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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

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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

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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

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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.