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Chapter 2 STUDY METHODS , . . SITE SELECTION In order to identify a universe of practices from which to select the sites for case studies, contact was made with a large number of individuals who had knowledge of health service programs that might include COPC practices, or who had knowledge of the published and unpublished literature relevant to COPC or its major definitional components. During the late spring and early summer of 1983, a pro- gressively wider network of individuals were contacted, thus generating a list of practices and health service programs that incorporated elements of COPC in their practice. Altogether, 147 practices were suggested as potential case study sites. Seventy sites were contacted by telephone and the enquiries centered around the three elements of the definition of commmunity-oriented primary care: 1) the presence of an active medical practice that placed emphasis on (but was not necessarily limited to) primary care 2) assumption of responsibility for the health care of a defined community, the definition of which was not limited to the active users of the practice 3) the use of systematic (although not necessarily quantitative) efforts to characterize the community and address its major health problems through an appropriate configuration Of or~marv care and community health strategies. _ _ ~ _ , The seven sites finally selected were intended to illustrate the manner in which QOPC was expressed under differing environmental con- ditions. For this purpose, the health care environment was viewed in three primary dimensions: the manner in which the practitioners were organized, the type and organization of the community, and the manner in which the practice was financed. Because the concept of COPC often is associated with publicly financed health service programs aimed at nerving medically indigent populations, the study made a particular effort also to identify and include practice 'sites from the private sector. In particular, study sites were sought to exemplify providers 17

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18 in small, single speciality groups as well as large multispecialty ones, and where the source of practice revenue was derived in large part on a fee-for-service basis. Sites were sought that addressed urban communi- ties as well as rural, communities with a strong social or cultural identity, and communities formed from membership in a prepaid health plan. Table 2.1 shows the seven study sites characterized in terms of a number of enviroronental var tables. Site selection was not a random process, nor did it occur at a single point in time from a final list of all potential sites. The networking process yielded a relatively large number of publicly financed practice programs early in the summer, but practice sites in the private sector were identif fed only after more intensive searching . The study's time limits meant that some of the sites were selected and visited before other sites had been selected. This may have worked to the advantage of the study, because the early site visits helped to identify environmental variables that should be highlighted. For example, early site visits pointed up the need to examine COPC in an environment characterized by a fee-for-service mechanism of financing and a multispecialty group practice, and resulted in the inclusion of the Tarboro-Edgecombe program in the study late in October. THE SEVEN CASES The Checkerboard Area Health System serves a widely scattered. largely rural community in northwestern New Mexico, earning its name from the checkered pattern of land ownership, divided among the federal and state government, Navajo Indians, and the Spanish and Anglo popula- tions. The Checkerboard program is supported by Presbyterian Medical Services , a pr ivate, nonprof it organization, and is unique in the manner by which it has found innovative mechanisms for rallying varied resources from public grants, contracts with state and local govern- ments, and fee-for-service to support the practice of COPC for its community . ffl e Crow Hill Family Medicine Center is a two-physician, private family practice located in Bailey, Colorado, a mountainous rural area just outside the metropolitan area of Denver. COPC is often associated with federally funded health programs located in underserved communi- ties, but the Crow Mill practice illustrates an application of COPC in the private sector. As a case study, this practice illustrates some of the opportunities and difficulties involved in expressing the principles of COPC in an environment that is not particularly supportive. The East Boston Neighborhood Health Center is a private group practice, wholly owned by a community board of directors, and serves the multiethnic community of East Boston. The East Boston program has a long-term commitment to epidemiologic research in hypertension as a collaborator in the Hypertension Detection and Follow-up Program. Thus, East Boston represents the blending of community control and the concentration of skills in population-based research within a primary care program--a blend of elements that have Supported an innovative program of COPC.

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20 The Kaiser-Permanente Medical Care Program of Oregon is a federally qualified health maintenance organization serving approximately 250,000 enrollees in the Portland area. The innovative programs developed at Kaiser/Oregon make it an instructive case study for demonstrating the manner in which an HMO can implement the major of principles of COPC to address the health needs of its enrolled population. The Montefiore Familv Health Center is a federally funded community health center serving a multicultural urban community in the Bronx. m e Health Center is the practice Rite for the family practice track In the Residency Program in Social Medicine of Montefiore Hospital, and is the youngest of the study sites, currently entering its fourth year of operation. As a case study, the Health Center illustrates the potential for practicing COPC in a densely populated urban community, and in an environment with a strong commitment to postgraduate medical education. The Sells Service Unit is the direct health services component of the Indian Health Service (U.S. Department of Health and Human Services, Public Health Service) with responsibility for assuring comprehensive health services to the Papago Indian community in rural southern Arizona. Closely associated with the Sells program is the health ser- vices research program of the Indian Health Service, a factor that has created an environment particularly conducive to the development of a COPC model. AS a case study, the experience of the Sells program is useful for examining the internal constraints of COPC, i.e. those related principally to the concept, rather than to the environment. The Tarboro-Edgecombe Health Services System represents an innova- tive approach to mounting a community-oriented primary care program from the components of the health care system that already exist within many communities. The Tarboro program consists of an informal coali- tion of which the major original components are the Tarboro Clinic, a private, fee-for-service, multispecialty group practice, and the Edge- combe County Health Department. In sequential manner, other components have been added to form a system of care that has assumed responsibility for the health care of an entire county in rural North Carolina. me existence of this unique program in what otherwise resembles the main- stream of health care organization in the United States makes it an important experiment in COPC and an excellent case study. DATA COLLECTION METHODS A set of data requirements was developed to guide the conduct of the site visits. The data requirements were derived from the concep- tual model and sought to collect information in three general areas. First, data were gathered to confirm the presence of and describe the two structural criteria, i.e., the practice of primary care and a defined community. Because the varying characteristics of the struc- tural elements across the study sites were expected to influence the expression of~the COPC model, information was sought to characterize the organization of the provider group, organization of financing, and the type of community addressed. Second, ef forts were made to gather data describing the manner in which the study site accomplished the

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21 four functional elements of the definition. This was usually accom- plished through detailed descriptions of specific examples of health issues in the community that had been addressed. Many sites described a large number of examples, but space allows only a subset of those to be included in the case studies. An effort was made to focus on those examples from each site that seemed best to exemplify the fundamental principles of COPC. Finally, the site visit format was structured to enlist the study site in providing either hard data or estimates of both the marginal cost and impact of their COPC activities. It was anticipated and eventually realized that these data would be particularly difficult to obtain in the site visits, because the practice sites would have no reason to account for cost or impact of those components of their pro- gram that are uniquely COPC, as opposed to simply good primary care practice. Me data requirements were revised by the committee and a site visit protocol was developed. All interviews were ~emistructured and the interviews generally were arranged prior to the actual site visit. The size and organization of the sites dictated the individuals who were interviewed. In the smaller practices, all physicians were inter- viewed, and in the large programs interviews were conducted with the medical director and major department chiefs. At all sites, represen- tatives of the community, usually members of the community board, were interviewed, but no effort was made to gather information from patients. Interviews were conducted with practice administrators in a concerted effort to discuss the financial base of the program, to identify budget areas that offered flexibility or provided rigidity to the program, and to describe those costs incurred by the COPC activities that would not otherwise have been attributable to routine practices. ffl e site visits were conducted by the staff and members of the committee between August and October, 1983. Site visits generally were of two days duration, but the development of the case study usually required extensive telephone follow-up with study site principals. Drafts of the case studies were mailed to the sites for correction of errors in fact and interpretation. All the sites were gracious and gave freely of their tome. For their patience and support we are grateful, but they are in no way responsible for errors, omissions, or misinterpretations. LIMITATIONS OF THE CASE STUDIES Although the case study approach is well-suited to examination of the current status of COPC in the United States, it nonetheless has several methodologic limitations that should be acknowledged. The initial search for potential study sites was conducted through a net- work of providers and health professionals, rather than through a com- parable network of consumers and community group';. The ';even sites for study were then selected in a nonrandom manner and their selection for the study does not imply that they are the best examples of COPC. Certainly, the study sites are impressive and demonstrate many of the

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22 important elements of a COPC practice, but comparative data are not available to relate them to the nor.., of primary care practice. Fey are not meant to represent a cro=~-section of primary care practices, nor are they meant to represent all primary care sites that attempt to practice COPC. The study attempted to select sites from different health care environments, yet no attempt was made to select sites that were typical of their particular setting. In many respects, the study sites are unique. Several are engaged in or collaborate in major research activities in epidemiology and health services research. In most sites, one or more charismatic and unusually dedicated clinicians were attempting to express COPC in their practices, and often they were Succeeding in the face of adverse conditions. Based on information gathered on potential study sites, it is likely that a similar study might have been done using seven other sites. The results might have suggested the same or similar patterns, but would undoubtedly have differed in detail. Consequently, caution should be exercised in generalizing what has been accomplished in the seven case studies to all practices that might attempt COPC. ORGANI ZATION OF THE CASE REPORTS The organization of the case reports follows that of the operational definition of COPC and corresponds to its three components. Thus, the descriptive portion of each case report is divided roughly into three parts: (1) descriptions of the primary care practice; {2) the commu- nity, and (3) several examples of community health problems that were addressed. First, the primary care program is described in terms of the organization of the practitioners, the organization of financing, and other characteristics of the primary care programs that may influ- ence the ability to implement COPC. At the outset it was assumed that the organization of data (availability of and capability to manipulate data) would be an important variable. Consequently the case studies describe the medical record and the practice data systems in detail. Finally, the relationship of the practice to academic or research pro- grams is explored, as a potential supporting condition for COPC. The community is described in teems of its demography, its alterna- tive sources of care, and the level and focus of its involvement in the COPC process. Next, for each site several examples of COPC activities are pre- sented. Although they tend to include most of the prc~inent activities, they do not represent an exhaustive listing of all CO PC activities at any given site. They are not meant to represent the actual volume of CO PC at the site. Those examples selected tend to be for relatively common problems that might be identified as priority health issues in many communities. me COPC model has both structural and functional components. The structural components, although meeting the basic requirements of the CO PC definition, may vary widely, and the ~environment. that any given configuration may form will influence the manner in which the COPC functions may be accomplished. Thus, it is useful to examine the case

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23 studies by first presenting the structural elements (the primary care practice and the ca~uuunity), describing the COPC activities, and finally analyzing the effect of the structural variables, e.g., the environmental influences, on the performance of the function. m e analytic portion of each case report examines the examples of COPC activities in terms of the five stages of development described in the operational model, and then analyzes the effect of the environmental variables on the performance of the COPC function. Staging the level of development of the COPC functions at each s ite helps to compare the development of COPC across study site, and across function within study site. However, the assignment of numbers to the stages imparts a false sense of precision. Clearly, the assessment of the development of CO PC function.is at best an estimate, and the reader is discouraged from making value judgments among sites.

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