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Chapter 1 INTRODUCTION TO TEE CASE STUDIES ORIGINS OF THE STUDY defined population. In its most general form, community-oriented primary care (COPC) is the application of primary care to meet the health care needs of a It has been characterized as population-based medicine. (Lipkin and Lybrand, 1982), the combination of personal primary care and community medicine (Madison, 1983), and as the appli- cation of epidemiology to primary care (Mullen, 1982~. Although COPC has found expression for many years in widely separated parts of the world, much of the current content and philosophy can be traced to the writings of John Grant (Seipp, 1963), Will Pickles (Pickles, 1938), and Walsh McDermott and Kurt Deuschle (McDermott et al., 1960; McDermott et al., 1972~. More recently, Sidney Hark has further developed the con- cept with specific applications in South Africa and Israel {Rark, 1974; Kark, 19811. Although originating under different names, several COPC models have been evolving in the United States for many years. Within the public sector, community health center programs, which grew out of the original Neighborhood Health Center experiment of the Office of Econamic Opportunity, provide primary care services to medically underserved populations. . Beginning in 1955, the Indian Health Service nas Developed a comprehensive program of primary care and community health services to assure health services to American Indians and Alaskan natives. Within the private sector, prepaid group practices have flour ished over the Past decade following the patterns established Dy one Ka~ser-Permanente organization in the 1940s. Each represents a particular variation on the general model of community oriented primary care, although each stresses different aspects of the model and uses quite different methods to address the particular health needs of their ~ . ~ . communities. In 1982, the Institute of Medicine (TOM) sponsored a conference on coJmnunity~oriented primary care with participants frown many COPC-like programs in six countries. The common thread that linked the partici- pants was an interest in health care programs that tailored a primary care practice or program to the particular health needs of a defined population. The conference noted that there was no compelling data base upon which to judge the value of COPC as an important improvement

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2 in the organization of primary care (Rogers, 1982) . One of the recom- mendations from the conference called for the development and critical analysis of the knowledge base derived from the varied experiences with the practice of COPC in the United States. Late in 1982, the Institute of Medicine initiated a study of COPC with funds provided by the U.S. Department of Health and Human Services. The study was designed to assemble and critically analyze the body of knowledge in the united States that describes the operations and the marginal costs and effects of community-oriented primary care. The specific charge to the study committee was threefold: 1) to assemble and organize the existing data/evidence that describe the operation, costs, and impact of the various expressions of COPC in the United States 2) to critically assess the resulting data base in relation to various population groups, and in relation to a variety of existing and projected organizational, administrative, and financing contexts where evidence warrants, to make recommendations about priorities in areas of education, practice, research, and public policy. In order to conduct the study, an operational def inition of COPC was developed and a series of case studies were conducted to examine the expression of COPC in several relevant health care environments. The report of the full study is presented in Volume I. THE CASE STUDY APPROACH The case study approach was felt to be a particularly important com- ponent of the study for several reasons. First, there was no clear and concise definition of COPC that made the concept amenable to systematic observation. Much of the written material advocated the COPC approach and speculated on its advantages, but did not carefully differentiate COPC from orthodox primary care, or from any of its variants. The case study approach was felt to be an important avenue through which empiri- cal data from the U.S. experience could be channeled into an operational model of COPC. Second, it became clear early in the course of the study that the literature was not extensive nor organized in a way to provide a wealth of information on the operations, costs, and impacts of COPC in the United States. There is a sizable body of literature examining pri- ma ry care, comprehensive care, community health care, the role of the community in planning and managing health programs, and the community health centers. This literature is supportive but somewhat peripheral to the central purposes of this study. Third, it was hoped that through a case study approach, a sizable body of experience could be assembled to be of use to practitioners who are trying to engage in community-

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3 oriented primary care. Case studies describing the manner in which COPC is practiced in environments that present financial, philosophical, and organizational barriers should be of value to practitioners seeking wider expression of COPC in their own practices OPERATIONAL DEFINITION OF COPC In its most general form, community-oriented primary care can be defined as the provision of primary care services to a defined commu- nity, coupled with systematic efforts to identify and address the major health problems of that community through effective modifications in both the primary care services and other appropriate community health programs. From this definition, the important elements can be isolated to form the basis for an operational model and to act as the criteria for COPC: . . a practice or service program actively engaged in primary care a defined community for which the practice has accepted responsibility for health care a process by which the practice, with the participation of the community, identifies and addresses the major health problems of the community; the process includes the following functions: defining and characterizing the community identifying the community's health problems modifying the health care programs in response to the community's identified health needs monitoring the impact of the program modifications. Therefore, the operational definition of COPC is based on two structural elements and the processes required to address the community health needs. Both the primary care practice and the community can be organized into a var iety of forms, and the model places no constraints on the forms that may be engaged in COPC. m e variation in the character- istics of the primary care practice and the community constitute the environment in which COPC is practiced. Thus, the environment will vary in several regards such as the organization of the practitioners, the organization of the cam~unity, and the manner in which revenue is generated from the community (directly or indirectly} and used to finance the health care program. ffl ese Environmental variables" are assumed to be important determinants of the way in which the COPC model is expressed in any given setting. The Practice of Primary Care Primary care was defined in a study by the Institute of Medicine as health care consisting of five attributes of the specific array of

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4 services (Institute of Medicine, 19801. These include accessibilitY, comprehensiveness, coordination, continuity, and accountability. This definition addressed the characteristics of the services themselves and did not specify the characteristics of either the practitioner or the patient. At is important to emphasize that community-oriented primary care is a particular application of primary care rather than an extension of it. The practice of COPC is not dependent upon an unusually well-developed primary care base, and good primary care and COPC may develop simultaneously. There may exist a number of other appli- cations of primary care that are not COPC, and conversely any practice or service program may be practicing excellent primary care without demonstrating any of the important features of COPC. The Community The second structural element of COPC is a defined community for whose health and health care the practice has assumed responsibility. Such a community may take a variety of forms ranging from traditional communities to combinations that come together for a common purpose such as the work place, the church, schools, to aggregates of individ- uals who are enrolled in a common health plan. The only requirement of the COPC model is that the community cannot be defined in such a way as to systematically exclude nonusers of health services. A common element among the different types of communities for which COPC practices may assume responsibility is that they are ~actionable., that is, they can be addressed in a systematic manner by the health care system. In the context of COPC, it is useful to view the community as a denominator, in the epidemiologic sense, which consists of subsets or numerators, the most important of which is that group of individuals in the community who are active users of the health care system. Thus, primary care outside of the COPC model strives to provide its active patients (the ~numerator. in a COPC context) with effective and appropriate health services that are accessible, comprehensive, con- tinuous, coordinated, and accountable. In contrast, the COPC model (which includes a primary care component) systematically addresses the major health problems of the entire community, that is, the denominator. The community may be organized in a number of different patterns and may participate to varying degrees in the health care program. The COPC model does not specify the type or level of participation and many forms may evolve. The varying forms of community involvement can be categorized by the type of organization, the level of involvement, and the focus of attention. The Functional Elements of the COPC Process The COPC process consists of four functional elements by which the practice identifies and addresses the major health issues of the com- munity. As an aid for describing the development of the functions in the study sites, it is useful to describe the progression from orthodox

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s primary care to COPC by constructing a scale for each of the four func- tions. for each scale, there is a basic requirement that distinguishes COPC from orthodox primary care , and it is this requirement that sepa- rates stage O f rom the subsequent stages of COPC. Each scale is based on a central variable that increaser as one moves along the stages of development from primary care to COPC. Stage O represents the absence of the central variable of COPC, and stage IV describes the idealized level of COPC for that function. The two end stages of each scale are based on the definitions of primary care and COPC, and the intermediate stages reflect increasing levels of development, based in part on the results of the case studies. Defining and Characterizing the Community m e COPC process begins with defining and characterizing the commu- nity for which the practice has accepted responsibility. The resulting knowledge of the total community forms the foundation on which the subsequent functions of QOPC are based. In a COPC practice, the prac- titioner needs to know who and where are the individuals and households who compose his community, how they live and behave in ways that influ- ence their health, where and when they seek care for ailments, and how they perceive and finance their care. Ideally, the practitioner would be able to enumerate or list the name, address, age, and sex of all the individuals in the community, an a basis subsequently for identifying and focusing on high risk groups. The scale for this function is shown in Table 1.1. The major requirement and the criterion that separate orthodox primary care (stage O) from the higher stages of COPC development is that the methods employed are directed toward a denominator population that is consistent with the community for which the practice has accepted res- ponsibility. m e central variable underlying the scale is the rigor and precision of the methods used to gather information on the commu- nity. Methods that yield a wide scope of detailed and relevant data are placed higher on the scale. Although the frequency with which methods are applied and the currency of the resulting information is important to this function, these elements are not included in the scale. At stage 0, for example, the practice may be using methods with a great deal of rigor that yield a great deal of information, but if they are used to characterize only the user population (such as the active patients of the practice) they are characteristic of excellent primary care, but not of COPC. At stage I, the practice has begun to examine the characteristics of its community through the use of secondary data. Large area stati- stics may be useful as a first stage of development of the function, but has several drawbacks. Large area data often do not describe exactly the community for which the practice has accepted responsi- bility, often do not lend themselves to further analysis of issues of particular interest, and do not permit an enumeration of all individuals within the community.

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6 TABI`E 1.1 Staging Criteria for COPC Function--Def ining and Character- i z ing the Commun ity STAGE 0: No effort has been made to define or characterize a commu- nity beyond the active users of the practice. STAGE I: There is no enumeration of the individuals who comprise the community. The community is characterized by extrapolation from large area census data. STAGE II: There is no enumeration of the community, but it is charac- terized through the use of secondary data that correspond closely to the community for which the practice has accep- ted responsibility. STAGE III: The cam unity can be enumerated and is actively character- ized through the use of a data base that includes all mem- bers of the community, and that contains information to describe its demography and socioeconomic status. (Often such a data system is constructed over time from the active users of services, but approximates the community closelY, e.g., at or above 90 percent coverage of the community.) STAGE IV: Systematic efforts assure a current and complete enumer- ation of all individuals in the community, including pertinent demographic and socioeconomic data. For each individual, information exists that facilitates targeted outreach, e.g., address, telephone number, etc. Stage II differs from stage I only in that the secondary data used corresponds more closely to the community. This might be the case, for example, when the community is defined as all persons living in a geographic area that corresponds to a current census tract. Alterna- tively, the practice may survey a random sample of the community on health and health care relevant topics, thus gaining an understanding Of important characteristics of the community, but not resulting in a listing of all individuals. At stage III in the development of this function, the community can be enumerated through the use of a data base that includes all individ- uals within the cam unity. me data base contains information for each individual and enables analysis of the demography and socioeconomic status of the Unity. Data bases of this sort often are those constructed from active users of health services, whose number grows over tome to include the majority of the community, and must include 90 percent of the community to be considered at this stage. The major drawback of a data base constructed in this fashion is the inconsis- tency and lack of currency of data elements for those individuals who have sought care inf requently. Ideally, such a data base would be constructed through an initial survey of the community.

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7 Finally, at stage IV the practice makes an effort to maintain a current and complete data base including all individuals in the com- munity. The practice is active in analyzing the data to gain a more complete understanding of the community, its patterns, and trends that influence health. The data base includes for each individual that information which in subsequent COPC activities will facilitate tar- geted outreach of high risk individuals, such as address and telephone number. The existence of a data base does not contribute to the COPC pro- cess unless it is being used actively to describe and characterize the ca.~.unity. Some practitioners may be able to extract more information about their community from large area data than the more nonchalant use of a sophisticated data base. Although not specified for each stage in the scale, it is assumed that the practice is actively using the avail- able data to understand the health-relevant characteristics of their community. Identifying Community Health Problems The second function in the COPC process is identifying the major health problems of the community, characterizing their determinants and correlates, and setting priorities among them. AS in the previous function, the criterion that separates orthodox primary care (stage 0) from the higher stages of COPC development is that the methods used for examining the community health issues are based on a denominator com- patible with the definition of the community. The scale for this function is shown in Table 1.2. me central variable upon which the scale is constructed is the precision and rigor of the methods for identifying community health problems. As in the previous scale, stage 0 represents orthodox primary care, and at this stage no attempts have been made to identify health problems of the community. Although many practices may be examining the patterns of health and health care problems among their active patient population, such practices are engaged in quality assurance and as such may be practicing excellent primary care, but that alone does not mean they are practicing COPC. Similarly, the practice that attempts to identify community health problems solely by generalizing from the health pro- blems of their patient population are not practicing COPC as it relates to this function. At stage I, the practice is attempting to identify health problems of the entire community, but is doing so based on the subjective impres- sions of the practitioner and/or community groups. Such an approach has the advantage of being both inexpensive and continuous' but lacks the rigor of more systematic quantitative approaches and is less likely to identify hidden problems within the community. On the other hand, the practice that uses formal group consensus techniques can approach this function in a more systematic and rigorous manner, with the advantage that consensus techniques can be constructed so an not to constrain the range of potential problems to be considered, as is the tendency of many quantitive approaches.

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8 TABLE 1.2 Staging Criteria for COPC Functions--Identifying Community Health Problems STAGE 0: No systematic efforts have been made to understand the health status or health needs of the community; the results from studies of the patient population are assumed to reflect the health problems in the community as a whole. STAGE I: Community health problems are identified through general consensus of the providers and/or community groups. STAGE II: Community health problems are identified by extrapolation from systematic review of secondary data, such as vital statistics, census data, large area epidemiological data, etc. STAGE III: Community health problems are examined through the use of data sets specific to the community, but perhaps focusing on single health problems or health care issues. STAGE IV: Formal mechanisms (usually but not always epidemiologic techniques) are used to identify and set priorities among broad range of potential health problems in the community. identify their correlates and determinants, and character- ize the existing patterns of health care related to the problem. At stage lI, the practice uses data to identify community health problems, but must do so by extrapolation from large area statistics. The validity of the approach is largely dependent on the extent to which the large area corresponds to the community for which the prac- tice has assumed responsibility. The use of secondary data, such as vital statistics and census data, makes it difficult for the practice to conduct further detailed analysis as general problem areas are iden- tified. At stage III, the practice identif ies and examines community health problems with data sets specific to that community. Activities at stage III, however, tend to focus on specific health issues, and may run the risk of overlooking a major problem simply because it was not included within the scope of the data set. For example, an epidemio- logic study of diastolic blood pressure within the community may yield sophisticated data on the distribution, correlates, and determinants of hypertension, which in turn may lead to highly effective interventions. However, the detail in the data set for hypertension is gained at the expense of a broader scope of the data set. Consequently, use of this data to identify the ca~unity's health problems may allow the practice to overlook other (possibly more critical) health problems.

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9 Finally, at stage IV the practice is using systematic methods to identify and set priorities among the range of health problems within the community. An important feature of the methods that should be used at this stage is the likelihood that they will identify health problems that are not already known. The methods used also should characterize the correlates and determinants of the problem and identify the compo- nents of the problem that may be vulnerable to a health care solution. Generally, the components of the problem may be those related to the severity of the problem, those related to the distribution and patterns of health care, those related to health promoting behavior, and those related to environmental variables. At stage IV the practice is employing methods that consider all of the problem components. Modifying the Health Care Program Once a priority health problem has been identified, the practi- tioner of COPC should strive to modify the health care program to better address the problem. For most health problems, modif ication in the primary care program alone would be inadequate and thus the practitioner would advocate appropriate modification in other local community/public health programs. There being very few instances in which all components of the health care program for a community are under a single governing structure, the function probably will require a great deal of cooperation among programs. The central variable upon which the scale for this function (shown in Table 1.3) is constructed is the specificity of the program modifi- cation to the identified needs of the community. Thus in the ideal situation program modifications will be targeted appropriately at a subset of the denominator community {rather than focused on active patients) and will often require some form of outreach or a combination of primary care and community health program strategies. At stage 0, the practice is not modifying the health program in response to health problems of the larger community, although a good primary care program will be correcting program deficiencies in the care of the active patient population as part of their quality assur- ance effort. At stage I, the practice is making modifications in the health program to address community problems, but is doing so largely in response to local, national, or organization-wide initiatives. Thus, while an important problem is being addressed, the specific modifica- tions are not necessarily tailored to the unique needs and character- istics of the particular community. Stage II modif ications also address important health problems, but do so largely because of the availability of special resources to address that problem. Special resources may appear, for instance, in the form of a practitioner with a special interest, who joins the practice to mount a community-based health program along that special interests Or, special resources may take the form of a grant initiative with guidelines to address a particular health problem. In either example, the resulting program may address an important community

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10 TABLE 1.3 Staging Criteria for COPC Functions--Modifying the Health Care Program STAGE O No modifications are made in the primary care program in specific response to health needs of the larger community. STAGE I: Modifications address health problems believed to exist in the community, but are made more in response to a national or organization-wide initiative than in response to a parti- cular problem specifically identif fed within the community. STAGE II: Modifications address important community health problems, but are chosen largely due to the availability of special resources to address that particular problem, and closely follow guidelines that may not be tailored to the community needs. STAGE III: Modifications in the health care program are tailored to the unique needs of the community and involve (where appro- priate) both the primary care and the community/public health components of the program. STAGE IV: Modifications in the program involve both primary care and community/public health components and are targeted to specific high risk or priority groups, with active efforts (e.g., outreach) made to reach specific high risk or prior- ity groups within the community. need, but will not necessarily address the problem in the most effective manner, nor be based on the unique characteristics of the problem in that community. m e practice at stage III in its development for this function is modifying the health care program in a manner that is tailored to the particular needs of the community. Where appropriate to the problem, modifications are made both in the primary care program and the community and/or public health programs. Finally, stage IV represents the idealized situation in which mod if ications address priority health problems in the community, involve both the primary care and community health programs, and use active outreach strategies to focus on specific high risk or high priority groups within the community. At this level of development. program modifications should address several companion issues. First, most program modifications are not intended to be directed at all members of the community, nor are they intended to be limited to all individuals from the community who present for or request certain ser- vices. An integral component of modifying the health program is to specify those individuals in the cc~unity who are the intended recipi- ents of the new strategy. Second, modif ications in a health program

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11 are seldom achieved without some reduction in level of effort in other areas. Particularly in small practices, the practitioners' collective attention and energies are finite and nearly saturated. Thus, program modifications may create Opportunity costs. even when program modifi- cations do not involve the reallocation of funds from one effort to another. Third, changes in the operation of a program rarely can be accomplished by a single person. The practitioner who attempts to modify the health care program must be adept at achieving a consensus among fellow practitioners, support staff, and the community. Finally, the intended target group for the program should be specified, and a clear statement of the expected impact on the problem should be fonmu- lated, including both negative and positive impacts. Monitoring the Impact of Program Modifications In the final function, the practice must monitor the effectiveness of the program modifications, in order to determine the extent to which it has addressed and resolved the original problem. In the design of the evaluation, it is Critical to use a denominator that is consistent with the definition of the community, or with the stated objective of the program modification if it was focused on a subset of the community. The central variable in the scale (shown in Table 1.4) is the rigor and precision of the methods used. In this function, rigor includes the ability of the methods to suggest both positive and negative effects of the modification as well as the ability to pinpoint the relative defi- ciency in the modification, e.g., the reasons that the impact was less than anticipated. At stage O. the practice is assessing program effectiveness by examining the impact on the active users of health care cervices. The denominator of such an evaluation does not reflect the entire community, and while evaluations of this type are appropriate to orthodox primary care, they do not meet the requirement for COPC. At stage I, assessment of program effectiveness considers impact on the coup unity as a whole, but is based on the subjective impressions of the practitioners and/or community groups. While better than focusing on active patients, this approach suffers from lack of rigor and questionable validity of the results. A possible exception is when the health problem being addressed includes issues of the acceptability of the health care program to the community. The practice at stage II of its development for this function assesses program impact by extrapolation from large area data. AS in earlier functions, the validity of this approach is a function of the concordance between the population upon which the data is based and the community being addressed. At stage III, the practice assesses program impact by systematic examination of data that are specific to the community. Most commonly, these data have been collected by the practice either as a part of a plan for routine monitoring, or as a special data collection effort to

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12 TABLE 1.4 Staging Criteria for COPC Functions--Monitoring the Effectiveness of Program Modifications STAGE O: Examination of program effectiveness is limited to the impact on the active users of health services. STAGE I: Program effectiveness is viewed in terms of impact on the community as a whole, but is based on subjective impres- sions of the practitioners and/or community groups. STAGE II: Program effectiveness is estimated by extrapolation from large area data or vital statistics. STAGE III: Program effectiveness is determined by systematic examina- tion of a data set that is specific to the community. STAGE IV: Program effectiveness is determined by techniques that are specific to the program objectives, account for differential impact among risk groups, and provide information on the positive and negative impacts of the program. assess the effectiveness of the program modifications. Usually, evalu- ation efforts at this stage are simple before-and-after designs, and the results are subject to the weakness of this particular approach. Finally, at stage IV the practice assesses program impact with methods that are specific to the program objectives. Assessment tech- niques are sensitive both to positive and negative impacts and also attempt to identify the relative deficiency in the program and thus support subsequent fine-tuning of the modification. Although before- and-after designs may be used in evaluations at this stage, more sophisticated designs are f requently employed. Ideally , assessments take into account not only the impact on the target health problem, but also consider the impact of potential competition for resources on a var iety of other problems that were not addressed. Finally, although evaluations at lesser stages for this function may emphasize improve- ments in the processes of care (e.g., percent of pregnant women in the community who receive adequate prenatal caret , stage IV activities should also examine outcomes (e.g., a change in the rates of perinatal morbidity). In the following chapters, the case studies are presented as expressions of COPC in several dramatically different health care environments. In making the transition from a conceptual model to the analysis of real world practices, it is necessary to distinguish between activities of COPC and those that simply are reflections of good primary care. The distinction between primary care and COPC hinges on the manner in which the community is defined. When the COPC practice addresses a True community, in the sociologic sense, there

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~3 is little basis for confusion. Such a community usually includes both active patients and nonusers of service and generally has a number of health issues on which the COPC activities can focus. However, if the practice addresses a ~community. that consists largely of active patients, a considerable amount of confusion arises. A" the definition of the community approaches the simple collectivity of active patients, the activities of COPC become synonymous with those of quality assur- ance, and there is little difference between COPC and good primary care. For example, the practice that is actively identifying the major health problems of its ~active. patient population, modifying its primary care activities to address the problems, and monitoring the impact of program modifications may be practicing excellent primary care. It is not, how- ever, necessarily engaged in COPC, and will not lead to better health care for the larger community. Similar efforts can only be considered to be COPC if they are directed at the health or health care problems of a distinct community for which the practice has assumed responsibil- ity. The exception would be the practice that originally accepted res- ponsibility for a distinct community and subsequently was successful in converting the entire community into a numerator of users of health services. m e distinction between primary care and COPC has some additional considerations in the case of family practice. Many family practi- tioners consider their patient population to be all members of all households in which any single member is an active user of services. A practice population defined in this manner has several of the charac- teristics that make it a particularly well suited for the COPC process: the ca~u.`unity is not by def inition limited to active users of primary care services the households are entities with health problems that af feet all household members, but do not necessar fly reside wholly with any single member (e.g. , environmental hazards, poor family dynamics, etc. the households represent entities that are ~accessible. and ~actionable. through the COPC activities. The family practice group that fulfills the COPC functions to address major health problems of this type of practice community would not only be a model of family practice but also would be practicing COPC. Other primary care practices could extend the group to whom they are responsible for health care to include components that would be considered a community. For example, the pediatr to practice that considers its community to include all of its active patients and all of the children enrolled in the local school system also would be in a position to practice COPC. Therefore, any primary care program could begin to approach the practice of COPC with a rational expansion of its community beyond the sample inclusion of its active patients. During the site visits for these case studies, many of the prac- tices offered as examples of COPC a variety of activities that had all

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14 the characteristics of quality assurance for a population of active patients. For the most part, the case studies made a distinction between activities that focused on the active patient population and those that addressed health problems of the total community. Often, however, this distinction was not entirely clear and some elaboration on the distinction at this point is appropriate. In general, quality assurance focuses on the user population to identify problems in the provision of health services, modify the services to correct deficien- cies, and monitor the impact of the modifications on the resolution of the original problem. Quality assurance deals with the structures, pro- cesses, and outcomes of care to assure that effective and appropriate primary care services meet the basic definitional criteria of accessi- hility, continuity, comprehensiveness, coordination, and accountability The important feature to emphasize is that quality assurance focuses on the ~active. patients of the practice. COPC also is a quality assur- ance activity but has an added concern for a broader community consist- ing of nonpatients as well as active users of primary care services. The COPC process strives to assure that the primary care services system is directing its primary care capability toward the health problems that are most important for the health of the overall community, including both ~users. and ~nonusers. of service. .

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15 REFERENCES Kark, S.L. 1974. From medicine in the community to community medicine. Journal of the American Medical Association 228 :1585-1586. Rark S.L. 1981. Cononunity~Oriented Primary Health Care. New York: Appleton-Century~Crof ts. Institute of Medicine. 1980. A Manpower Policy for Primary Health Care. Washington, D.C.: National Academy of Sciences. Lipkin, M., and Lybrand, W.A. 1982. Population-Based Medicine. New York: Praeger Publishers. Madison, D.L. 1983. The case for couuanity-oriented primary care. Journal of the American Medical Association 249:1279-1282. McDermott, W., Deuschle, K., Adair, J., Fu}mer, H., and Loughlin, B. 1960. Introducing modern medicine in a Navajo community. Science 131:197-205. McDermott, W., Deuschle, K., and Barnett, C.R. 1972. Health care experiment at Many Farms. Science 175:23-31. Mullan, F. 1982. Co~rununity~oriented primary care: An agenda for the '80s. New England Journal of Medicine 307 :1076-1078. Pickles, W.N. 1938. Epidemiology in Country Practice. Bristol: John Wright and Sons, Ltd. Rogers, D.E. 1982. Community-oriented primary care. American Medical Association 248:1622-1625. Journal of the Seipp, C. 1963. Health Care For The Community: Selected Papers of Dr. John B. Grant. Baltimore: Johns Hopkins University Press. .

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