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COMMUNITY ORIENTED PRIMARY CARE: A PRACTICAL ASSESSMENT Volume I I Case Studies Paul A. Nutting Ei leen M. Connor Division of Health Care Service INSTITUTE OF MEDICINE April 1984 National Academy Press Washington, D. C.

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NOTICE The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the Councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members were chosen for their special competencies and with regard for appropr late balance. m is report has been reviewed by a group other than the authors accord- ing to procedures approved by a Report Review Committee consisting of members of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The Institute of Medicine was chartered in 1970 by the National Academy of Sciences to enlist distinguished members of the appropriate profes- sions in the examination of policy matters pertaining to the health of the public. In this, the Institute acts under both the Academy's 1863 Congressional charter responsibility to be an advisor to the Federal Government, and its own initiative in identifying issues of medical care, research, and education. Supported by the Department of Health and Human Services Contract No. 282-80-0043, T.O. 15 2101 Constitution Avenue, N.W. Washington, DC 20418 (202) 334-2356 Publication TOM-84-0 2A

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INSTITUTE OF MEDICINE COMMITTEE ON COMMUNITY-ORIENTED PRIMARY CARE rman *MAURICE WOOD, Department of Family Medicine, Medical College of Virginia, Richmond, Virginia Members *RALPH L. ANDREANO, Department of Economics, University of Wisconsin, Madison, Wisconsin *R. DON BLIM, Pediatrics Associates, Kansas City, Missouri *ROBERT H. BROOK, The Rand Corporation, Santa Monica, California JOHN W. FEIGHTNER, Department of Family Medicine, MacMaster University, Hamilton, Ontar lo, Canada MARGARET H. JORDAN, Health Plan, Inc., The Kaiser Foundation, Oakland, California *JOYCE C. LASHOF, School of Public Health, University of California, Berkeley, California GRANT MOFF~TT, American Farm Bureau Federation, Park Ridge, Illinois FITZHUGH MULLAN, Office of Medical Applications, National Institutes of Health, Bethesda, Maryland *ERNEST W. SAWARD, School of Medicine and Dentistry, University of Rochester, Rochester, New York *LISBE,rH BAMBERGER SCRORR, School of Public Health, University of North Carolina, Chapel Hill, North Carolina HERBERT C . SCHULBERG, School of Medic ine, Uniters ity of Pittburgh, Pittsburgh, Pennsylvania iii

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W. JACK STELMACH, Family Practice Residence Program, Baptist Memorial Hospital, Ransas City, Missouri *PAUL D. STOLLEY, School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania JAMES D. TAYLOR, East Boston Neighborhood Health Center, Boston, Massachusetts STEPHEN BRADY THACXER, Consolidated Surveillance and Communication Activity, Centers for Disease Control, Atlanta, Georgia IOM Staff Paul Nutting and Eileen Connor, Study Directors Cheryl Halley, Text Processor Mireille Mesias, Administrative Secretary Michael McGeary, Professional Associate Donald Tiller, Senior Secretary Daniel Zwick, Research Consultant *Member of the Institute of Medicine iv

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CONTENTl; PREFACE, Pi i Chapter 1 - INTRODUCTION TO THE CASE STUDIES, 1 Or ig ins of the Study, 1 me Case Study Approach, 2 Operational Definition of COPC, 3 References, 15 Chapter 2 - STUDY METHODS, 17 Site Selection, 17 The Seven Cases, 18 Data Collection Methods, 20 Limitations of the Case Studies, 21 Organization of the Case Reports, 22 Chapter 3 - THE CHECKERBOARD AREA REALTH SYSTEM, 25 The Primary Care Program, 27 The Community, 33 COPE Activities of Checkerboard Area Health System, 35 Analyz ing Checkerboard as a COPC Practice, 42 Summary, 48 Interviews, 49 References, 50 Chapter 4 - CRoW HILL FAMILY MEDICINE CENTER, 51 The Primary Care Practice, S2 me Community, 56 COPC Activities of Crow Hill Family Medicine Center, 57 Analysis of Crow Hill as a COPC Practice, 62 Summary, 67 Interviews, 69 Re ferences, 70 v

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Chapter 5 - EAST BOSTON NEIG B ORHOOD HEALTH CENTER, 71 The Primary Care Practice, 73 The Community, 78 COPC Activities at East Boston Neighborhood Health Center, 81 Analysis of East Boston as a COPC Practice, 85 Summary, 89 Interviews, 91 References, 92 Chapter 6 - KAlSER-PERMANENTE MEDICAL CARE PROGRAM OF OREGON, 93 The Primary Care Program, 94 The Community, 99 COPC Activities at Kaiser/Oregon, 101 Analysis of Kaiser/Oregon as a COPC Organization, 106 Summary, 110 Interviews, 112 References, 113 Chapter 7 - MONTEFIORE FAMILY HEALTH CENTER, llS The Primary Care Program, 116 The Commun ity, 121 COPC Activities at Montef lore Family Health Center, 124 Analysis of the Montef lore Family Health Center as a COPC Organization, 127 Sumanary, 133 Interviews, 135 References, 136 Chapter 8 - sEr Is SERVICE UNIT OF Tot; INDIAN HEALTH SERVICE, 137 The Primary Care Program, 138 The Conun unity, 145 COPC Activities at Sells Service Unit, 147 Analysis of the Sells Service Unit as a COPC Organization, 152 Summary, 157 Interviews, 159 References, 160 Chapter 9 - TARBORO-EDGECOMBE HEALTH SERVICES SYSTEM, 163 The Primary Care Practice, 166 The Community, 174 COPC Activities of Tarboro-Edgecombe Health Services System, 175 Analysis of Tarboro-Edgecombe Health Services System as a COPC Program, 179 Summary, 182 Inte rviews, 18 5 References, 186 V1

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PREFACE This volume is the second of a two-volume report by a committee of the Institute of Medicine that assembled and examined the ~~~;~~^ - the United States with community-oriented primary care (COPC). An oper- ational definition of COPC was developed as part of this study and is presented in Volume I. In summary, COPC is defined as the provision of primary care services to a defined community, coupled with systematic efforts to identify and address the major health problems of that com- munity through effective modifications in both the primary care services and other appropriate community health programs. experience in . . , ~ _ ~ _ , _ _ _ In assembling the pool of potential study sites, it became apparent that COPC meant different things to different people. Often we were directed to sites that were engaged in a variety of innovations in pri- mary care or that had developed unusual collaborative relationships with their community. Although noteworthy as innovators in the practice of primary care, many of these sites were not specifically applicable to a study of COPC. This volume presents seven case studies selected specifically to demonstrate the evolution of a COPC practice in vastly different health care environments. The notion of COPC often has been associated with publicly funded programs providing care to medically underserved popu- lations, but these seven cases demonstrate that the fundamental pro- cesses of COPC can evolve in either the public or private sector, under differing financial structures, and by addressing different types of communities. The case studies became a fundamental component of the overall study and provided a heavy dose of reality against which to refine an operational definition of COPC. We anticipate that the case Studies will be useful as well to practitioners and educators who are endeavoring to develop service delivery programs, research models, and appropriate settings for introducing the concepts of COPC into post- graduate medical education. Each of the sites had a number of people who gave unselfishly of their time to help us to understand the special characteristics of their program. We came away from the site visits with the belief that these were indeed very special people. Among them, a few stand out as uniquely dedicated health professionals to whom a large measure of the success of their program can be attributed. To Richard Rozoll, Frank Reed, Stephanie Murphy, James Taylor, David Lawrence, Merwyn Greenlick, Robert Massed, Felix Hurtado, and Lawrence Cutchin our gratitude and deep respect is sincerely acknowledged. Paul A. Nutting Eileen M. Connor ~ VII

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