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Community Oriented Primary Care New Directions for Health Services Delivery Conference Proceedings Edited by Eileen Connor and Fitzhugh MulIan Division of Health Care Services Institute of Medicine NATIONAL ACADEMY PRESS Washington, D. C. 1983

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The Institute of Medicine was chartered in 1970 by the National Academy of Sciences to enlist distinguished members of the appropriate professions in the examination of policy matters pertaining to the health of the public. In this, the Institute acts under both the Academy's 1863 congressional charter responsibility to be an adviser tO the federal gov- ernment and its own initiative in identifying issues of medical care, research, and education. Supported by the United States Public Health Service Contract No. 282-80-0043, T.O. 10, The Commonwealth Fund, and The Henry J. Kaiser Family Foundation. Library of Congress Cataloging in Publication Data Conference on Community Oriented Primary Care (1982: Washington, D.C.) Community oriented primary care. 1. Community health services Congresses. I. Connor, Eileen. II. Mullan, Fitzhugh. III. In- stitute of Medicine (U.S.). Division of Health Care Services. IV. Title. {DNLM: 1. Community health services- Congresses. 2. Delivery of health care Congresses 3. Primary health care- Congresses. 4. Community medicine Congresses. RA422.C6397 1982 362.1'0425 ISBN 0-309-03339-X Available from NATIONAL ACADEMY PRESS 2101 Constitution Ave., NW Washington, DC 20418 Printed in the United States of America WA 546.1 C7245} 82-25977

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COMMI'l~l'~E ON COMMUNITY ORIENTED PRIMARY CARE JOYCE C. LASHOF, Chairman: Dean, School of Public Health, University of California (Berkeley) H. JACK GEIGER, Professor of Community Medicine, Center for Biomed- ical Education, City College of New York CLARK HANSBARGER, State Director of Health, State of West Virginia MARGARE~r C. HEAGARTY, Director of Pediatrics, Harlem Hospital Center SIDNEY L. KARK, Professor and Chairman, Department of Social Medicine, Hadassah-Hebrew University School of Medicine DONALD MADISON, Associate Professor of Social Medicine, University of North Carolina HANS MAUKSCH, Behavior Sciences Section, Department of Family and Community Medicine, University of Missouri JACK H. MEDALIE, Professor and Chairman, Department of Family Med- icine, Case Western Reserve University S. SCOTT OBENSHAIN, Assistant Dean of Undergraduate Medical Educa- tion, School of Medicine, University of New Mexico LISBETH B. SCHORR, Adjunct Professor, School of Public Health, Uni- versity of North Carolina SIRES R. SHANNON, Associate Professor, Community Health Nursing, Rush- Presbyterian-St. Luke's Medical School AARON SHIRLEY, Project Director, Jackson-Hinds Comprehensive Health Center FREDRICK.~. WENZEL, Executive Director, Marshf~eld Clinic Conference Convener FITZHUGH MULLEN, M.D., Scholar-in-Residence Conference Staff EILEEN CONNOR AZORA L. IRBY RAYMOND JARRIS Member of the Institute of Medicine . . .

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Preface The Conference on Community Oriented Primary Care, held in March of 1982 under the auspices of the Institute of Medicine, represented an im- portant historical point in the development of primary care in the United States. Set as it was against a backdrop of 20 years of vigorous efforts to provide more equitable health services to the entire population of the United States, it was nonetheless firmly rooted in the realities of the 1980s. The antecedents of the conference were several. I~rge-scale federal com- mirment to the provision of medical care was one. That began in the 1960s with the OEO Neighborhood Health Centers, the Children and Youth and Maternal and Infant Care Programs, and the Migrant Health Program. It continued in the 1970s with the authorization and growth of the National Health Service Corps and its scholarship program. A second factor was the reemergence of general practice medicine in the form of family practice as called for in the Millis and Willard Reports, both published in 1966.~ The faintly medicine movement grew apace from the sentiments that these documents articulated. By the late 1970s some 13 percent of American medical graduates were pursuing careers in family medicine many prac- ticing in rural and traditionally underserved areas. Citizens' Commission on Graduare Medical Educarion, Report, The Graduare Educarion of Physicians, John S. Millis, Chairman (Chicago: American Medical Associarion, 1966); Ad Hoc Committee on Educarion for Family Practice of the Council on Medical Educarion of the American Medical Associarion Report, Meeting the Challenge of Family Practice, William R. Willard, Chairman (Chicago: American Medical Associarion, 1960).

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V1 Preface Finally, during the 1970s, the concept of primary care gained prominence and acceptance as an anchor against the subspecialty drift of the major medical disciplines. Not only was family practice included in the concept of primary care, but general internal medicine and general pediatrics and some elements of psychiatry and obstetrics and gynecology were included as well. The Institute of Medicine (IOM) helped to solidify the concept with its 1978 publication, A Manpower Policy for Primary Health Care, which clearly defined the field and made specific policy recommendations perti- nent to it. All these developments had taken place in an environment of greater community participation. From the civil rights movement of earlier years to the consumerism of the 1970s, the role of the community and the patient had become more prominent in the delivery of health services. Departments of community and social medicine had grown up in medical schools, and increasing numbers of medical students and young health professionals . . . . . . . soug It career opportunities in communlty-responslve practice settings. The conference occurred at a time when the difficult economic, social, and political circumstances of the 1980s were being experienced for the first time in all sectors. The nation's economy was hard-pressed. Serious cutbacks in governmental support for health care were a reality. The en- ergetic efforts of medical schools in previous years had succeeded in pro- ducing a vastly expanded pool of physician graduates whose availability was unquestionable but whose ultimate place and type of practice was uncertain. The historical trends in health service delivery, set against the political and economic realities of 1982, provided the backdrop for the meeting. The National Academy of Sciences supplied a small program initiation fund that enabled the Institute of Medicine to assemble a planning com- mittee to examine issues emerging out of these events. This group met for 2 days in June 1981 and then continued to deliberate by phone, letter, and subcommittee meeting for the balance of the year. The planning committee played an important role in formulating the questions for the conference and supplying a format for the answers. They selected the term "community oriented primary care" (COPC) over a number of other possibilities because they felt it represented an amalgam of the main themes of their delibera- tions. The term itself had been coined by Dr. Sidney Kark of Hadassah- Hebrew University in Jerusalem to describe his well-established program of training and research in the area of population medicine and primary care. Dr. Kark, who was visiting in the United States, served as a member of the planning committee and played an important part in framing the concept. The committee further agreed on two important points that shaped the substance of the conference. The first was that, while COPC had major

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Preface . . V11 implications for health services delivery, its implementation would be im- possible without education and training programs that would prepare phy- sicians and other health providers for the demands of community practice. Therefore, any deliberations on the subject should recognize the issues of education as well as service. Second, there was a strong sense that the COPC discussion should not be limited to the United States because much could be gained from and exchanged with other nations who had undertaken similar approaches tO the delivery of health services. Many committee mem- bers felt that the rapid developments of the previous years in the United States had taken place without the benefit of the experience of similar efforts around the world. Therefore, it was decided that the conference should attempt to incorporate representatives of community oriented pro- grams in progress in other countries. The committee stated four goals for the conference: . to refine the concepts and techniques of COPC and to trace its de- velopment in the United States in comparison with that of other nations; . to examine the theories and practices that have been applied in COPC; . to consider the means of incorporating the theory and practice of COPC into the education and training of health care providers; and . to publish and disseminate the results of this conference in order to facilitate further developments in COPC. In summary, the conference was intended as a forum in which the practice of community medicine in the United States could be reassessed, codified, and, as appropriate, redirected. This volume represents the record of that undertaking. It is our hope that it will be of assistance to health care practitioners, planners, and teachers in the decade to come. And, finally, a word of thanks. Conference participants were drawn from many walks of professional and community life in an effort tO provide broad and varied contributions to the deliberations. Although many participants raised their own funds to enable them to attend the conference, crucial financial assistance for others, as well as for the undertaking as a whole, was provided by the U.S. Public Health Service, the Commonwealth Fund, and the Henry J. Kaiser Family Foundation. The COPC committee wishes to thank them for their trust and their support. FITZHUGH MULLAN

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Contents Overview and Summary Eileen Connor Community Oriented Primary Care: Lessons Learned in Three Decades Kart W. De~schle PART I THEORETICAL ISSUES Community Oriented Primary Care: Meaning and Scope Joseph H. Ahrarmson and Sidney L. Kark The Meaning of Community Oriented Primary Care in the American Context H. Jack Geiger DISCUSSANTS/9 1 David! A. Kindig Fred Ritz Nora Piore Community Oriented Primary Care: An International Perspective Rodrigo G~ewero DISCUSSANTS/1 12 Stephen C. Joseph Keith Bolden 1X 1 6 19 21 60 104

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x Opportunities and Constraints for Community Oriented Primary Care Donald L. Madison DISCUSSANTS/1 3 1 Litany Reyes Karen Davis Health Worker Roles in Community Oriented Primary Care form Hatch and E~ger~ia Eng DISCUSSANTS/ 1 5 8 Richard Smith Fay W. Whitney Medical Education and Training for Community Oriented Primary Care lo Ivey Boafford DISCUSSANTS/1 90 Robert Tranq~ada Richard Kozoll Thoughts on Community Oriented Primary Care David E. Rogers PART II PRACTICAL APPLICATIONS Promoting COPC Through a Rural Health Care Network: Marshfield Clinic David L. D raves COPC in the Texas Valley Stanley 1. Fisch Elements of COPC in the UMWA Health and Retirement Funds Program George S. Goldstein COPC and a State Health Department: West Virginia's Experience L. Clark Hansharger Columbia University-Harlem Hospital Primary Care Network Margaret C. Heagarty COPC in a Hospital-Aff~liated Health Center Harvey A. Holzberg Denver Health and Hospitals Experience J. L. Karowski Contents 119 138 167 198 207 209 214 217 222 225 227 230

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Contents Partnership for Health: The Family Nurse Practitioner/Family Physician Tearn Mary O'Hara Devereaz~x The Patient Advisory Council Concept Milton H. Seifert, Jr. The Application of COPC Principles in a Welsh Mining Village Graham Watt Training for COPC in the Netherlands and Around the World Jacoloas M. Greep Can Area Health Education Centers Promote COPC? The Colorado Experience Karen F. Hansen Departments of Family Practice as Vehicles for Promoting COPC Thomas M. Mettee and Jack H. Medalie New Mexico's Primary Care Curriculum S. Scott Oloenshain The Beersheva Experience in COPC Archer Segall, Carmi Margolis, and Moshe Prywes The Upper Peninsula Medical Education Program Daniel S. Mazz~chi and W. Donald Weston PART III WORKSHOP DISCUSSION SUMMARIES X1 234 239 243 250 258 264 269 272 276 281 Workshop A DeWitt C. Baldwin, Jr. 283 Workshop B Janice Robinson 285 Workshop C Patrick Mattingly 287 Workshop D Lisbeth Schow 289 Workshop E Robert S. Lawrence 291 Participants 293

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Community Oriented Primary Care New Directions for Health Services Delivery

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