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Chapte r 4 CROW HILL FAMILY MEDICINE CENTER a The Crow Hill Family Medicine Center* is a two-physician, fee-for- service family practice located in a mountainous rural area just out- s ide the metropolitan area of Denver, Colorado. Although COPC is often associated with federally-funded health programs located in underserved communities, the Crow Hill practice illustrates an application of COPC in the private sector. AS a case study, Crow Hill points out the problems and potentials encountered by a private, fee-for-ser~rice primary care practice ernestly attempting to apply the principles of community~oriented primary care. The nature of the Crow Hill practice is closely linked to the history of Dr. Frank Reed, who founded the practice in 1977. Dr. Reed is a gr aduate of Yale University and the Chicago Medical School and completed his residency in family practice at the University of Colorado. Before coming to Crow Hill, Dr. Reed was a member of the faculty of the Department of Family Medicine at the University of Colorado, most recently acting as the Residency Director for the Department. While on the faculty, Dr . Reed was active in the develop- ment of a family medicine information system, an encounter-based patient care management information system serving the dual purposes of monitoring the business aspects of family practice and monitoring several of the important indices of medical care. Dr. Reed was also involved in the development of the ~ountain/Plains Outreach Program (~/POP) , a project with funding from The U.S. Department of Health, Education, and Welfare and the Rose Medical Center in Denver. The M/POP had the dual purposes of encouraging innovations in health care delivery and assisting physicians in locating in rural areas of Colorado. This program also assisted practicing physicians by providing physician back-up and consultive liaison with the Rose Medical Center. During his career on the faculty at Colorado, Dr. Reed felt the need to practice primary care in order to become more effective in teaching it. He was anxious to try to gain first-hand experience in developing the kind of practice that he envisioned for family primary *Hereafter referred to as Crow Hille 51

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52 care. During.this time, Dr. Reed lived just beyond the western suburbs of Denver along U.S. Highway 285 in the same mountain valley in which the Crow Hill Family Medical Center is now located. Having lived in the area, Dr. Reed was familiar with its medical needs and medical resources. He was also aware that a National Health Service Corps site in Bailey, Colorado was scheduled for phasing out. Dr. Reed considered becoming a National Health Service Corps physician and taking over the practice in Bailey, but instead decided to estab- lish a private family practice in the community. From its initiation, the practice was intended to encompass many of the elements of community-oriented primary care. The catchment area is well circumscribed geographically by the mountain ranges and pattern of highways. It is essentially a corridor leading from the western suburbs of Denver and stretching upward and over a major moun- tain pass. Between the Denver suburbs and the town of Fairplay on the f ar s ide of Kenoshe pass, no other medical practice existed within the corridor. Thus Dr. Reed began the private practice of medicine in a geograph ically def ined car~nunity wi th no other source of pr imary medical care. Having the desire to meet the health needs of the community, a zeal for family practice, an educational background and experience based solidly in high quality primary care, and a data System capable of monitoring both the health status and health care utilization of his active patients, Or . Reed began a con~unity- oriented pr unary care practice . Initially, he suffered many of the trials of a solo practitioner in a rural area, including long working hours and a Certain amount of professional isolation even though he maintained his professional ties with the Univers ity of Colorado. Mach were alleviated early in the practice by the addition of a nurse practitioner to the practice staff and in July 1982 by the addition of a second residency-trained family practitioner, Dr. Tom Syzek. In June of 1983, the practice initiated a program of expanded hours providing essentially 24-hour coverage for emergency services and scheduled evening off ice hours, through an arrangement with the Rose Medical Center in Denver that provided add itional physician back-up. THE PRIMARY CARE PRACTICE Organization Staff and Facilities The staff of the practice group consists of two physicians, four nurses, a receptionist, a typist, and a bookkeeper. Until the summer of 1983, a family nurse practitioner was included on the staff. At the time of the site visit the nurse practitioner was on maternity leave and it was doubtful that she would be returning to full-time position in with the practice. A physician is on call 24-hours a day, a responsibility shared by the two physicians until recently. Since the spring of 1983, the practice has expanded hours including five

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53 evenings and Saturday, with physician back-up under an arrangement with the Rose Medical Center in Denver. In January, 1981, the practice opened a new office with a fully equipped emergency roan. Both physicians are well trained in emer- gency care, and the capability to provide sophisticated trauma care in Ba iley has made i t an important 1 ink in the emergency care system of the area. me practice has managed an increasing number of patient-visits, increasing from just over 5,000 in 1979 to 9,000 in 1983 with a staff of two physicians. In general, the active patients tend to be distri- buted among younger age groups than the community at large. Both Dr. Reed and Dr. Syzek hold clinical appointments at the Department of Family Medicine at the University of Colorado. In this regard, Dr. Reed is slightly more active in that he spends approxi- mately one day a week in Denver engaged in teaching activities. Medical Records The medical records are organized in family units, and each indi- vidual medical record is f fled in a family jacket. On the inside of the family jacket is a form that contains a variety of information on the family unit, including the listing of all family members with identifying demographic data and several items of information regarding the insurance coverage of the various family members. When a patient arrives to be seen at the off ice the entire family jacket is presented to the provider. The only exception to this is when one or more mem- bers of the same family are being seen by a provider simultaneously. The medical records are problem oriented and all progress notes a re indexed accord ing to the problem 1 ist . Both phys ic fans d ictate their progress notes immediately after seeing the patient. They are transcribed and will appear in the medical record within 24 hours. Data Sys tem Until September of 1983 the practice subscribed to the Family Medicine Information System (nlIS) operated by a commercial medical information f irm in Denver. The FMIS is an encounter-based data system designed to capture a variety of information on each patient encounter and to provide feedback to the subscribing practice on a monthly basis. This system is oriented primarily to the business management of the practice and secondarily to monitoring the medical care provided. For each encounter the data system incorporates the age, sex, identifying data for the patient, the date of the encounter, major provider of service, all diagnostic information (coded to ICHPCC) and all services provided (coded to CPT-4 ~ . Fbr those patients not paying for services rendered at the time of the visit the IMIS prints out a statement to be sent to the patient for payment. On a monthly basis, the HIS provided Crow Hill with a variety of reports. One report counted the number of active and inactive

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S4 families that in sum described the registered families. The informa- t ion sys tem also provided an annual morbid) ty report that 1 isted the diagnostic categories in order of f requency of presentation to the medical practice. me number of encounters and the number of patients seen for each diagnostic category were also shown along with the percent of the total patients within the practice. These statistics could be broken down by individual provider within the practice as well as aggregated for compar ison among the several other practices in the Denver area participating in the EMIS. Similarly, the system provided a series of reports describing the service statistics. These reports listed in rank order the services provided by the medical practice, along with the number of times each services was provided and the amount that was billed. The service statistics could be disaggregated by individual provider within the practice as well as aggregated and compared across the several prac- tices participating in the FMIS. Within the service statistics there were more detailed breakdowns of the radiologic studies done, laboratory tests performed, emergency room visits, as well as a series of other special medical services (the latter includes such items as immunizations, electrocardiogram, puretone audiometry, well-child care, eta . ~ . The EMIS could produce a listing of all familes registered in the Crow Hill practice. Such a list could be sorted by demographic variables, diagnostic variables, and service utilization variables. Active patients were defined as all members of a family of which any single member had received services at the practice within the previous two years. Organization of Financing Crow Hill Family Medicine Center is a private, for-profit, fee-for- service family practice very much in the traditional mode of American medical care. Revenues for the practice are generated exclusively from provision of patient services. Crow Hill has no service contracts or grants and obtains money for capital investments such as building and maj or equ ipment purchases through bank loans . Revenues come predominantly as direct payment from patients as shown in Table 4. 1. Ear the last four years direct, out of pocket payment for services has constituted over 80 percent of the total practice revenues. It should be noted, however, that although patients themselves pay for the services a number of them (actual f igure is not known) are subsequently reimbursed by private insurance and various other third parties. m e 15 to 20 percent of the revenues that come directly from third parties is distributed among a variety of payors. The largest single third party has been Medicare and yet it never represented more than 9 percent of total revenues. Over several years, at an average of about 1 percent of total revenues, Medicaid has been an almost incon- sequential source of revenue. Similarly, the revenues from Comprecare, the prepaid plan in which Crow Hill partic mates , are relatively insig- nif icant.

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55 TABLE 4 .1 Total Annual Revenues1 for Crow Hill Family Medic ine Center by Source and by Year FY 83 FY 82 EY 81 EY 80 EY 79 PATIENT SERVICES 314, 237 239, 443 169, 870 123, 899 101, 631 roTAL REVENUE (100~) (1008) (100%) (100%) (100%) Direct. pay2 268~222 203 J806 139~913 105,243 74,551 (858) (851) (82%) (851) (73%) Thi rd Party Prepaid 7, 811 7, 934 12, 627 4, 896 1, 719 (2%) (3%) (71) (4%) (21) Medicare 8,283 9,780 14,664 16,188 26,161 (81) (8%) (9~) (7~) (8~) Medicaid 5, 233 3, 790 2, 184 969 615 (2%) (2%) (196) (. 8%) (. 6%) Other (including 6,810 7,725 482 3,011 16,464 Blue Shield, (29~) (39~) ( . 3%) (28) (16%) Wor kmen ' s Compensation, etc. Revenues here ref er to charges that are actually h igher than revenues. For actual revenues one must adjust for Abed debt. charges that never became revenue} that has tended to be between 10-20%. 2Although this category refers to out of pocket payment there is a considerable portion of this total for which the patients are reimbursed by a third party. In the last few years, Crow Hill has been moving further in the direction of direct payment for services and away from third party billing. Since 1980, the practice has not participated in the local Blue Shield service plan and as of July 1, 1983, it no longer accepts Medicare assignment. Currently the only third party reimbursement the practice receives is from Medicaid and Comprecare. Dr . Reed expressed some anxiety about refusing Medicare assignment, g iven the large number of Hover 65s. in the Crow Hill service area. He thought that this switch might turn away some of his el derly patients. Early impressions suggest that it has not discouraged this population, however, the prac- tice continues to monitor the potential effect.

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56 Having the practice ' s f inancing organized in a private, fee-for- service mode has important implications for the practice of COPC. Financial viability depends upon providing enough reimburseable ser- vices to cover the costs of practice overhead and provide an income for the two physicians. The cost of providing nonreimbursable ser- vices to the community necessarily must be taken ultimately from the physicians' incomes. Recently, this has resulted in some economizing changes in the practice. For example, the FMTS data system used in the practice for six years was terminated in July of 1983 because, at a cost of 32, 000 per month, it was felt to be too expensive. THE COM4UNITY Demog r aphy Al though the general geogr aph ic area conta ins nea r ly 14, 000 people, the practice directs itself to two different communities. The first is the community of f amities registered with the practice, def ined as all members of families within which any single member has made use of the services of the Crow Hill Family Medicine Center within the prev- ious 24 months. AS of July 1, 1983, this group numbered 2,183 families and consisted of 7,280 individuals. The second and larger community to which the practice addresses itself is defined geographically and includes those individuals living along the ~Highway285 corridor. from the small town of Shaffer's Crossing on the east to the small town of Fairplay on the west. His population group resides along several valleys that are interspersed with small mostly nonincorporated villages. The population is largely Caucasian, middle class, and numbers approximately 14,000. A dramatic increase in population over the last decade has been caused by large numbers of middle class families moveing in, still, with one or more adult members employed in Denver. Among the majority of the population, there is little sense of community. However, there are some major community activities, notably volunteer efforts that are supported and maintained by long time residents of the Valley. Thus, Crow Hill addresses a practice community" composed of the 7, 280 people who are members of the 2,183 families registered with the practice, which includes both active patients and nonusers of service. Me geographic community, on the other hand, consists of the 14, 000 people living along the Highway 285 corridor. The age and sex distribution of the two communities differ considerably, with the notable absence of representation in the practice community of individuals over the age of 65 years. Other sources of pr imary care available to members of the geo- graphic community include a two-physician family practice group in the town of Conifer (approximately 12 miles to the east on Highway 285 toward Denver) and the 7-bed McNamara Hospital located in Fairplay (approximately 43 miles west on Highway 2851. me McNamara Hospital in Fairplay also has a 14-bed nursing home. In addition, there are a

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57 large number of Sources of primary care available in the Denver Metropolitan Area that are approximately 45-60 minutes traveling time from the Crow Hill Family Medical Center, when road conditions perm it . There are several cc~uuanity groups that exist and are very active in health issues. Perhaps the most notable among them is the all- volunteer rescue squad that has been closely connected with the practice since Dr. Reed arrived in the community. Other community health related programs include a local La Leche league, a remake group, Alcoholics Anonymous, the county health department that also offers a mental health program, and the school nurse at the Platte Canyon High School. Although not specif ically focused on health issues, two groups do exist for senior citizens, the Just folks, and the Silver Set Senior Citizen groups. Commun i ty Involvement The Platte Canyon Health Council was set up by the county commis- sioner for liaison with the National Health Service Corps practice. When the clinic in Bailey was closed, the community health council considered disbanding. However, Dr. Reed convinced them to continue , citing his practice's need for community input. At the present time, it consists of eight members who are for the most part the original members who have remained active, in addition to the school nurse of the Platte Canyon School System, the nutritionist for the county health department, as well as one member each from the two senior groups in the community. Although the health council acts in an advisory capacity to both the Crow Hill Family Medical Center and the several health related agencies of the county government, the health council has no gover- nance function in either case. The activities of the council members are voluntary and board members receive no compensation for their activities. In general Crow Hill receives moral support from the health council, but little in the way of substantive guidance in assisting the practice in identifying community health needs, or in acting as educational outreach to increase the community utilization of the pract ice . COPC ACTIVITIES AT CROW HILL FAMILY MEDICINE CENTER The Crow Hill practice addresses the community at two distinct levels with a different sense of responsibility for each. In the first instance, the practice feels the greatest responsibility for the practice c=`u``unity. that consists of all members of all registered families, i.e., families in which any single member has visited the practice within the previous two years. In characterizing and addressing the major health problems of this community, the practice was aided by the use of the PHIS, which contains a listing of all members of the practice con~unity~ including both the active patients and the nonusers of service.

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58 With a lesser Sense of responsibility the practice attempts to address the health problems of the geographic community, consisting of the 14, 000 people living along the Highway 28S corridor. This com- munity includes both the active patients and the nonusers of service who constitute the practice community, as well as individuals who have a regular source of health care outside the immediate geographic area and those who elect not to receive health services. Dealing with health issues at this level of the community presents considerable difficulty for the Crow Hill practice, as there is no reliable data base that includes this population, and even the available census data is believed to be incomplete. Both levels of orientation to the community meet the criteria of a community for the purposes of COPC and it is instructive to examine the section examples of COPC activities directed at both communities. The f i rat two examples descr ibe activities directed primarily at the practice community, but including elements intending to reach the larger geographic community as well. In these two efforts, the data system (FMIS ~ allowed relatively close monitoring of program impact on the practice community, but monitoring the impact of the program in the larg er com~.unity was incomplete and costly . Finally the last two examples describe efforts that were directed predominantly at the larger geographic Unity, and while difficult to document precisely, were f elt by both the practice and the community at large to be ef fec- tive. Immunization in the School-Age Child In 1978, Colorado passed a law requiring immunization of children to attend public school. AS the school year approached it became apparent that over 50 percent of children ready to enter school in the fall lacked a portion of their required immunization. A review of the data from the FMIS showed that of the 317 children (ages 2 to 6 years in the practice community, only 30 percent were in compliance with immunization criteria. A printout was obtained from the FMIS listing all children in the practice community under the age of 16 years. The nurse from the Crow Hill practice added to the list all children registered with the school. m e medical records at the practice and the school health records were audited to capture ilranunization status of all children on the list. Each family was contacted by telephone or letter, reminding them of the statute requiring immunization and requesting that they furnish any missing immunization information. AS this was done, the computer listing was annotated. Children who were not fully immunized, received the required immunizations either in the practice or at the school and an updated listing of immunization status was produced. 8y July of 1979, there were 384 children in the practice community between the ages of 2 and 6 years, and a repeat survey of their immunization status revealed that 91 percent were in compliance.

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Be Influenza in the High-Risk Subset of the Community In 1978, the practice began an effort to provide influenza immuni- zation to all high-risk members of the practice community. In order to identify those specif ic individuals at risk a search was made of the E?4IS data base to create a list of individuals at r isk as a function of age and diagnoses. To each individual on the list, a letter was sent explaining the potential danger of inf luenza for individuals at risk, and encouraging an office visit for immunization. This target group consisted of 130 individuals, many of whom were not active patients of the practice. In the first year, only 62 people (48 percent) received flu vaccine from the practice, and a similar effort was mounted in 1982. In the second year, the identified risk group consisted of 242 individuals, of whom 55 (23 percent) presented to the practice and received the vaccine, and in the third year, 73 people from a risk group of 295 (25 percent) were immunized. After the second year of the effort, the practice developed a short question- naire to investigate the basis for the weak response. The results suggested that in 1979 an additional 23 individuals had received the vaccine elsewhere (for a total compliance rate of (55 + 23} /242 or 32 percent), but that many individuals were concerned about the potential side effects of the vaccine and were confusing the current effort with the swine f lu campaign and its adverse publicity. Bared on the previous exper fence and the data, the practice in 1983 decided to try to reach the high-risk people in the larger geographic community by collaborating with the public health nurse of the county health department. According to the 1980 census, the geographic community contains a distribution of elderly individuals that is three times greater than the general U. S. population; thus, a collaborative expansion to the larger community seemed especially appropriate. In the subsequent program, flu shot clinics were conducted at several locations within the community including the Crow Hill Family Medical Center. One of practice physicians wrote an article for the two local papers and the two senior citizens groups mounted publicity campaigns. m e flu vaccine was obtained at reduced cost by the county health department, and by continuing to provide the vaccine at their cost, the practice was able to reduce the charge for their patients from S8.00 to S3.00 per dose. . By a variety of accounts, the overall ef fort was judged to be successful. Although data are not available for impact among the geographic community, data from the FMIS for the 1983 effort show that of the total practice community of 7,280 people, 300 or 4 percent were determined to be at high risk, and of these 95 or 32 percent received the flu vaccine from the practice. Trauma Several environmental factors conspire to produce a large amount of serious trauma for the geographic community served by the Crow Hill

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60 practice. The rugged terrain and severe winter conditions, coupled with the outdoor lifestyles and occupations of the residents produce a large number of occupational and recreational injuries. Highway 285 traverses several valleys and ridges as it courses through the cosmou- nity and becomes very hazardous during stormy weather. Other than the Crow Hill practice, the nearest source of emergency medical care is the hospital in Fairplay, 40 miles to the west over Kenoshe Pass, or 6 0 miles to the east in Denver . The strong practice impress ions of both Dr. Reed during his f irst year in Bailey and the impression of the National Health Service Corps physician who preceded him was the need for sophisticated emergency medical services in the immediate area. In 19 77, Dr . Reed began to work closely with the volunteer rescue squad, which existed for some time in Bailey. However, the assem- blage of both training and equipment had been haphazard, and the rescue squad functioned inefficiently or not at all. Largely with the support of Or . Reed, this organization has become well equipped, well trained, and well known within Colorado as an outstanding program. Shortly before the site visit, the Rescue Squad had placed f irst in their category in state-wide competition and had received several awards for excellence. When the practice began to plan for a new building in the late 197 Us, provisions were made to include a fully equipped emergency room. In addition an area was cleared for a helicopter landing pad to accon~ate airevacuation service. When a second physician was sought for the practice in 1982, an effort was made to find a physician with both an interest and skill in emergency and trauma care. With the only fully equipped emergency rocks within a very large area, the practice treats not only emergency patients from within the immediate community, but also is called upon to stabilize patients in transit (by ambulance or helicopter) from an accident site in the mountains to a hospital in Denver. Streptococcal Pharyng i t i s Colorado is known to be within an area in which streptococcal pharyng itis is endemic, and is naturally of some concern to both the practice and the county health department. According to the practice impressions of the county health nurse, there is a s izable subset of geographic population served by the county health program who cannot afford or are hesitant to pay for an of f ice visit for a throat culture, and subsequently pay for an of f ice vis it for treatment if the culture is positive. Many of these people are eligible to receive cultures f tom the county health nurse, but the log istics of process ing the cultures often require an unavoidable delay in treating those with pos itive results. The county health nurse brought this problem to the attention of the practice. For same time, the practice had in place a policy to take throat cultures for referred patients, and charge only for the culture ($8} rather than for the office visit. Thus an office visit is charged

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61 only when the culture is positive and the patient returns for treatment. However, this policy had not been adequately publicized in the community. Closer collaboration with both the county health nurse and the school nurse made the policy more widely known. Although there has been no ef fort to monitor the impact, the impress ions of both the county and the school nurse suggest that a larger number of people in the community are receiving throat cultures and more timely tr ea t:ment . Miscellaneous Activities The practice has utilized the FINIS in several targeted efforts to reach a specif ic subset of the practice community with either a parti- cular service or educational material. For example, several years ago there was a great deal of publicity on the epidemic of herpes infection in this country. Subsequently the practice received a number of calls from patients who were concerned about the relationship between cold sores and genital herpes. In order to get information to an interested subset of the patient community, the practice obtained an EMIS pr intout listing all individuals who had been seen in the practice for cold sores. To each of these individuals a packet of educational material was sent. Similarly, a number of efforts have been mounted to reach a high-risk subset of the practice population with preventive health services. In addition to the examples described above addressing immunization of school children and influenza vaccine for the high-risk population, an effort was directed toward immunizing pre-adolescent girls for rubella. A printout was obtained from the FMIS listing al' the non~mmunized and between certain ages; a letter was sent to their homes describing the importance of protection against rubella and encouraging an office visit. In an effort to reach a population-based group of the larger geographic community, Crow Hill has turned frequently to the Platte Canyon School. Each year one of the physicians volunteers time to teach at the school on various topics of mutual interest to the school and the practice. Dr. Reed has found it particularly helpful to take this opportunity to ~de-sensitize. the school age child of their fear and distrust of the physician. Noting the large number of injuries among the high school athletes, the practice put together a clinical team from Denver to do comprehensive orthopedic exams on the athletes of the Platte Canyon High School. Each child was examined by a team of specialists who offered a comprehensive evaluation and prescribed a specific regimen of exercise and precautions geared to the individual's risk of injury. Offered at cost to the school, each child had the benef it of a highly sophisticated sports physical and treatment plan, at a cost substantially lower than a comparable service offered in Denver. By the time of the site visit (approximately three weeks into the high school football season) the only athletic injuries reported by the coach ing stat f were in athletes who had elected not to follow the prescribed regimen.

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62 Often the practice expands its efforts at health promotion and prevention beyond the practice community. For example. the practice developed a parent's guide to well child care and care of minor acute problems. Popular immediately among the practice, the popularity soon spread to the general community. Subsequently, the practice has dis- tributed this guide widely to both users and non users of the practice, at a cost to the practice of about S7 per copy. Often the practice provides general information to the community at large, based on requests generated from within the practice commu- nity. me office nurse keeps track of the questions asked on phone calls and periodically one of the doctors writes an article for the local papers. Topics covered just prior to the site visit included chicken pox, altitude s ickness, and tick feve r . ANALyS IS OF CROW HILL AS A COPC PRACTICE The Functions of COPC Def ining and Character iz ing the Community In general, the Crow Hill practice made good use of the Family Medicine Information System (EMIS) to def ine and characterize the pr actice community . The system includes data not only on active patients ~ individuals seen in the practice within the previous 24 months ~ but also on all members of all families that include an active patient. ThuS, the FMIS includes a large number of nonusers of health services for whom the practice has assumed a sense of responsibility. The FMIS has the capability to produce on demand a listing of all individual members of the practice community. Because the data system included for all individuals information on age, sex, and residence. it can play a major role in characterizing and developing a profile of the practice community. The practice appears to be at stage IT of development for this function of COPC. me practice encounters a great deal of difficulty in defining and characterizing the geographic community. Although census data is available, the census tracts in the area do not correspond to the geographic bounder ies of the community . The Crow Hill practice has made use of the census data of 1980 and has noted in particular that the age and sex distribution of the geographic community is consider- ably different from that of either the active patients of the practice or the practice community. In general the practice feels that there are a large number of elderly in the geographic community who are not involved with the practice. Although, the practice believes that a large number of the elderly are retired couples who may continue to receive care f ran a physician in Denver, the practice has made an ef fort to be vis ible to this subset of the community. In sum, the practice must be content to def ine and character ize the geographic community by extrapolation from large area data, the hallmark of stage I for this function.

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63 Identif ication of Cc; Impunity Health Needs In general, Crow Hill identif ies problems in the community at large without heat reliance on quantitative evidence. Hany of the health efforts directed both at the practice community and the co~ranu- nity at large hate been based on practice impressions. Input from the county health nurse was the major source of information to identify the need to improve access of the geographic community to streptococcal scr eening services. The magnitude of the problem of trauma in the community was largely based on the subjective impressions of both practitioners and community. Thus, these efforts were identified from practice impressions rather than from the use of specific data sources arm are characteristic of stage ~ in the development of this function. On the other hand, the need to address the group at risk to complica- tions of inf luenza and the need to improve the compliance with i~mnuni- zat ion cr. i te r ia to r the school-aged chi ldren were dete rmined f ram the results of specific studies that examined all relevant individuals in the practice community, including non users of the practice. The effort to improve the coverage of the group at risk to influenza com- plications, illustrates a particularly diligent effort to monitor the impact of different program strategies, despite generally disappointing results. Certainly the activities that identified the need to provide f lu vaccine to the at risk group and the required immunizations to the school children represent stage ITI efforts. Modifying the Health Care Program There is a great deal of variation in the level of development of the Crow Hill practice concerning the manner in which modif ications are made in the health care program to address identif fed health problems of the community. Perhaps the best example is the effort to f ind a workable program to reach the high-risk individuals with influenza vaccine. In the two years the practice generated a list of speci f ic h igh-r isk individuals --and targeted services at this group. After two annual attempts to reach this group and monitoring the response, the practice attempted to investigate the weakness of the particular strategy. A questionnaire shed light on the problem and in the third year a col].aborati~re effort was mounted with the county health department, and the enlistment of several community groups in supporting and publicizing the program. This program modification incorporated all the important features of COPC in specifying (at the level of individuals) the high-risk group, collaborating with other community agencies {county health department, senior citizens groups), and mounting an active outreach ef fort (mailings to all high-risk individuals within the practice community). This effort is characteristic of stage IV in the development of this function. The practice developed a program modif ication to address the pro- blem of trauma in the geographic community with a ma jor (and very costly) change in the mix of primary services provided and by working closely with the community rescue squad. Clearly the overall effort

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64 was tailored to the specif ic needs of the community for this problem and this effort would score at stage III for this function. Similarly, the activities required to increase the compliance with immunization cr iteria frown 30 percent to 91 percent were tailored to the specif ic conditions in the co~ranunity and are evidence of stage I II development as well. In contrast, the program modif ication for streptococcal pharyngitis was made largely in response to a need identif fed exter- nally to the practice and would be evidence of stage I of development. Crow Hill does not see its role as the initiator or pr imary sponsor of cc unify health programs as do several of the other study sites. Rather, it prefers to collaborate with community programs, especially the county health department and the school health program, to be an advocate for needed programs, and to be supportive of current programs by providing medical back-up and consultation for health issues and cononunity-based programs. Monitor ing the Ef festiveness of Program Modif ications Through the use of the EMIS, the practice was able to monitor its success in reaching the target groups for the school child inununiza- tion and influenza vaccination campaigns within the practice community. With the manual addition of the school children f rom the larger geogra- phic community, monitoring of program's impact on the larger community was accomplished as well. These efforts are characteristic of stage III for this function. In contrast, the impact of the extensive efforts to address the problem of trauma in the community were not evaluated specif ically. This impact along with the impact of the modif ication to facilitate screen ing for streptococcal pharyng itis was assessed largely on subs j active grounds and thus are scored at stage I . Envi ronmental Inf luences Organization of the Practice The organization of the practice is typical of that of a two- physician family practice unit. Because the two physicians must corer for each other there is no economy of scale and very little f legibility to permit COPC activities by one of the physicians. During most of the history of Crow Hill, the situation was even more cliff icult when Or . Reed was practicing alone. More recently the situ- ation has been somewhat alleviated through an ag reement with the Rose Medical Center in Denver to provide physician coverage for expanded hours at the Family Medicine Center. Perhaps the most important ingredient for the practice of COPC in the Crow Hill practice is the dedication and commitment to the concept by the practice staff. The majority of the success of the COPC process has been the direct result of the philosophy and ef forts of the professional staff. Despite their work within an environment

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65 that is not particularly conducive to COPC, a considerable amount of ca~nunity~oriented primary care occurs due largely to their efforts. Among the important ingredients of the COPC practice are the coord inating ef forts of Stephanie Murphy As the of f ice nurse, a substantial amount of her time is devoted to coordinating activities of the practice with those of the school nurse and the county health nurse. While the practice has no directed outreach program as such, this coordination proves to be extremely vital an a linkage between the primary care activities of the practice itself and the comounity- based activi ties of the school and county health programs. The use of the FKIS made a tremendous difference in the ability of the practice to characterize the practice community, identify problems, create a list of high risk or high priority patients, monitor the Impact of the effort in terms of the process of care. The THIS f igured prominently in the ef forts to address both immunization of school children and the influenza vaccination campaign. It was largely through the capability of the data system that the practice was able to produce lists of the specific individuals in the practice community and monitor the impact of the program in reaching the target individuals. At the time of the site visit, Crow Hill had recently discontinued the IMIS largely because of its cost. However, Dr. Reed bel ieves that the data system is a central component of the COPC activity, and efforts are underway to locate another data system for the pr actice . The Community There are several features of the geographic community that are not supportive of the practice of COPC. Even single visualization of the community is cliff icult because many small settlements exist in back canyons and other out-of-the-way places in the rugged terrain. In addition to being difficult to define' the geographic community consists of several distinct subgroups. There is a substantial segment of the population that has moved into the valley but continues to commute to Denver. Many of theme families continue to travel to Denver or i ts suburbs for medical care. Having recently moved into the valley specifically to escape the urban environment of Denver, many of these individuals neither identify themselves with the local community nor wish to be included. A second subset consists of retired couples who have moored into the valley, but continue to travel into Denver for shopping and visiting friends, and probably receive a majority of their health care from a previous practitioner. m e third component of the community consists of Those families who have lived in the valley for a number of years. Although many of these families earn their livelihood from jobs in Denver, many others do not. This subset of the community departs sociologically from the expatriates of Denver in that they identify with the community, are fiercely independent, quite conservative, and quite supportive of volunteer ef forts within the community.

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66 In she rp contrast, the practice community we'; def ined, charac- terized, and enumerated routinely with the use of the EMIS. If Crow Hill addressed itself only to the practice community, the environ- mental constraints offered by the community would be cons iderably less severe. Although the practice community contains elements of each of the subsets of the larger community noted above, the practice can enumerate them, he '3 had at least indirect contact with them, and feels more justified in communicating with them and in reaching out to offer Services. Crow Hill is the only local source of primary care for the resi- dents of this geographically def ined area. Yet many of the individuals in the area travel to Denver for their health services. Although Crow Hill is located in a rural area, they face a problem similar to that f aced by many pr ivate practices in a suburban area. mat is they attendant to address the problems of a geographic community that con- sists of individuals and families who belong to another practice. The Platte Canyon Health Council has been rather inactive in a var iety of activities that might be extremely useful to the practice. For example, the council is set up to represent the geographic commu- nity that contains a large number of people who are not users of the practice. The physicians have been somewhat hesitant to mount aggres- sive outreach efforts into the community at large, for fear that such ef forts might be perceived as attempts to market the practice. The council could play a vital role in community education and in mar- keting the services of the practice, but has not done so. For example, in the influenza campaign, an active council could have greatly facilitated the outreach effort and served as a more rapid mechanism for feedback on the programs ini tial weak response. Because the practice relies largely on subjective impressions for the identification of community health problems, the council could play an informant role in this regard as well. Org an ization of Financing me organization of f inancing of the practice is not conducive to co~mounity-oriented primary care. The vast majority of the practice revenue is on a fee-for-service basis, and the problems of attempting community-oriented primary care in a fee-for-service reimbursement system are well known. Crow Hill does not include personnel for whom the primary activity in outreach and health related work within the community itself, although a substantial amount of effort is directed toward coordination of practice activities with other health agencies in the community. For example, during the early years of the practice Dr. Reed invested a great deal of time and energy in support of up- gr acing the community rescue squad . The investment of his time brought a substantially improved prognosis to a number of accident victims in the semi-isolated mountain community, but generated no practice revenue. The only benefit to the practice was the good will and gratitude generated within the community.

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67 compared with the other study sites, the practice has an absolute shortage of resources for conducting the quantitative steps involved in the COP C process. With only two physicians on the staff and little or no access to either the resources of an active research group (as a source of funds and expertise) or a major training program (as a source of student labor ), Crow Hill relies almost entirely on the data system as the primary source of information to characterize the community, identify its major health problems, and monitor the impact of program modif ications. However, the EMIS is also a costly item for the practice, and unfortunately shortly after the site visit. Crow Hill was forced to discontinue its contract with the data system. Although the practice felt very strongly that the data system was an integral component of their ability to practice COPC, the S2,000-per-month charge was a strain on the practice finances. SUMMARY Table 4.2 compares the level of development of the CO PC functions at Crow Hill. Despite the problems of operating in an environment that is indifferent to COPC, the Crow Mill Family Medical Center, was quite successful in mounting a comounity~oriented primary care program. In attempting to address two levels of the community, the Crow Hill practice is particularly instructive as a case study. The practice developed a system of medical records and a computerized data system which enabled routine surveillance of a relatively large amount of data on the practice cononunity. The achievements of the practice in address ing this community are impressive. Although the practice is located in a rural a rea, the populace nonetheless seeks care f rom other practitioners in Denver, and thus, the practice has a c=.~`,onality with many family practices located in suburban areas. Thus, Crow Hill provides a general blueprint that would be of value to a variety of small private practices attempting to develop a com~T~unity-or tented primary care practice. However, the practice has considerable cliff iculty in achieving the same level of COPC practice in the larger geographic community. At this level, many of the environmental variables inherent in the small size of the practice group, the organization of financing, and the variability and dispersion of the unity make the practice of COPC a difficult undertaking. Dr. Reed attributes part of the successful practice of COPC to two important elements. First, he stresses that it was vitally important that the practice focused initially on the development of its image as a sophisticated and highly-competent medical care program before attempting to take on major community health problems. He feels that the biggest battle that had to be won at Crow Hill was overcoming its image as a public program, and assuring the the community that the practice offered top quality primary care. Among several motivating f actors underlying his work with the rescue squad and in setting up an emergency room at the practice was furthering the image of Crow Hill as a well-equipped and well-trained medical care program.

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68 TABLE 4.2 Comparison of the Level of Development of the Major Func- ~ional Elements of COPC in the Crow Hill Family Medicine Center Identify Modify Define and Community the Monitor Characterize Health Health Impact of the Community Problems Program Modifications STAGE O STAGE I Geographic Community STAGE II STAGE III STAGE IV Practice Community STREP STREP STREP TRAUMA TRAUMA IMMUN TRAUMA FLU FLU IMMUN IMMUN ELU FLU refers to the activity that addressed the problem of influenza in the high-risk subset of the community. MMUN refers to the effort to provide all school children with required immunizations. STREP refers to the effort to increase the financial access to strepto- coccal screening services. TRAUMA refers to the effort to address the problem of trauma with improved emergency medical care to the community. Second, Dr. Reed points out that the success of program modifica- tion was largely the result of serious efforts at consensus building, both within the practice and within the community. He stresses the need to identify f ram a larger set of health problems those that the community is either interested in, or for which interest can be genes ated. Although the council has not been particularly supportive, Dr. Reed made sure that he had reached some consensus within the community of the importance of initial ef forts at COPC. He notes that emphasizing health care for the elderly was an obvious area in which to start. However, he feels that it would have been a wasted effort to develop a program for the care of the elderly in a community that places a higher priority on its need for emergency services for trauma.

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69 INTERVIEWS , Frank Reed, M. D. * Tom syzek, M. D. Stephanie Mu rphy, L. P. N. Charlotte Johnson, Platte Canyon Rescue Squad Lynn Wadleigh, Platte Canyon Rescue Squad Terry Hardley, Platte Canyon Rescue Squad Mary Soucie , R.N., school nurse and member of Health Council Mary Dewey, R.N., Park County Health Department Cliff Lamaster, Silver Set Senior Group Lois Davis, The Bank of Park County Joel Edelmann, Rose Medical Center Mike Bernstein, Pose Medical Center . *As this volume was in the f inal stages of preparation' it was learned that Dr. Reed has joined the Rose Medical Center as Director of C1 inical Services in the Department of Family Practice. He has reduced his time at Crow Hill to two days a week.

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70 REFERENCES l- Blake, M. n.d. Market Analysis and Marketing Plan for Crow Hill Family Medicine Center. Paper prepared by Romed Corporation for Crow Hill Family Medicine Center. JRB Associates, Inc . 1979. Final Report, Mountain/Plains Outreach Program: Practice Development and Support System Evaluation. Submitted to Mountain/Plains Outreach Program, Denver, Colorado. JOB Associates, Inc . 1979. Final Report, Review of Operations at the Crow Hill Family Medicine Center. Submitted to Mountain/Plains Outreach Program, Denver, Colorado. JRB Associates, Inc. 1981. A Comparison of the Family Medicine Information System (EMIS ~ With Other Automated Medical Information Systems. Prepared for Public Health Service, MA, BCHS, DHHS, Reg ion VI I I , Denve r, Colo redo . Reed, F.~., Syzek, T.E., and Moore, J.~. Crow Hill Family Medicine, P.C--Patient Information Brochure (Bailey, Colorado) .