PRIMARY CARE AND PUBLIC HEALTH

Exploring Integration to Improve Population Health

Committee on Integrating Primary Care and Public Health

Board on Population Health and Public Health Practice

INSTITUTE OF MEDICINE
OF THE NATIONAL ACADEMIES

THE NATIONAL ACADEMIES PRESS

Washington, D.C.

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Committee on Integrating Primary Care and Public Health Board on Population Health and Public Health Practice

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THE NATIONAL ACADEMIES PRESS 500 Fifth Street, NW Washington, DC 20001 NOTICE: The project that is the subject of this report was approved by the Govern- ing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineer- ing, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropri- ate balance. This study was supported by Contract Nos. 200-2005-13434 and HHSH250200976014I between the National Academy of Sciences, Centers for Disease Control and Prevention and the Health Resources and Services Adminis- tration and funding from the United Health Foundation. Any opinions, findings, conclusions, or recommendations expressed in this publication are those of the author(s) and do not necessarily reflect the view of the organizations or agencies that provided support for this project. International Standard Book Number-13: 978-0-309-25520-2 International Standard Book Number-10: 0-309-25520-1 Additional copies of this report are available from the National Academies Press, 500 Fifth Street, NW, Keck 360, Washington, DC 20001; (800) 624-6242 or (202) 334-3313; http://www.nap.edu. For more information about the Institute of Medicine, visit the IOM home page at: www.iom.edu. Copyright 2012 by the National Academy of Sciences. All rights reserved. Printed in the United States of America The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history. The serpent ad- opted as a logotype by the Institute of Medicine is a relief carving from ancient Greece, now held by the Staatliche Museen in Berlin. Cover design by LeAnn Locher. Suggested citation: IOM (Institute of Medicine). 2012. Primary Care and Public Health: Exploring Integration to Improve Population Health. Washington, DC: The National Academies Press.

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“Knowing is not enough; we must apply. Willing is not enough; we must do.” — Goethe Advising the Nation. Improving Health.

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The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Acad- emy has a mandate that requires it to advise the federal government on scientific and technical matters. Dr. Ralph J. Cicerone is president of the National Academy of Sciences. The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of outstanding en- gineers. It is autonomous in its administration and in the selection of its members, sharing with the National Academy of Sciences the responsibility for advising the federal government. The National Academy of Engineering also sponsors engineer- ing programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. Charles M. Vest is presi- dent of the National Academy of Engineering. The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Insti- tute acts under the responsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Harvey V. Fineberg is president of the Institute of Medicine. The National Research Council was organized by the National Academy of Sci- ences in 1916 to associate the broad community of science and technology with the Academy’s purposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in providing services to the government, the public, and the scientific and engineering communities. The Council is administered jointly by both Academies and the Institute of Medicine. Dr. Ralph J. Cicerone and Dr. Charles M. Vest are chair and vice chair, respectively, of the National Research Council. www.nationalacademies.org

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COMMITTEE ON INTEGRATING PRIMARY CARE AND PUBLIC HEALTH PAUL J.WALLACE (Chair), Senior Vice President and Director, Center for Comparative Effectiveness Research, The Lewin Group, Falls Church, VA ANNE M. BARRY, Deputy Commissioner, Minnesota Department of Human Services, St. Paul JO IVEY BOUFFORD, President, New York Academy of Medicine, New York SHAUN GRANNIS, Director and Principal Investigator for DRI-ICE and Assistant Professor, Department of Family Medicine, Indiana Center of Excellence in Public Health Informatics, Regenstrief Institute, Inc., Indianapolis LARRY A. GREEN, Epperson-Zorn Chair for Innovation in Family Medicine, University of Colorado at Denver KEVIN GRUMBACH, Professor and Chair, Department of Family and Community Medicine, University of California, San Francisco, and Chief, Family and Community Medicine, San Francisco General Hospital FERNANDO A. GUERRA, Public Health Consultant and Director of Health, City of San Antonio and the San Antonio Metropolitan Health District, Texas JAMES HOTZ, Clinical Services Director/Medical Director, Albany Area Primary Health Care, Georgia ALVIN D. JACKSON, Director (former), Ohio Department of Health, Fremont BRUCE E. LANDON, Professor of Health Care Policy, Department of Health Care Policy, Professor of Medicine, Harvard Medical School, Boston, MA DANIELLE LARAQUE, Chair, Department of Pediatrics, Maimonides Medical Center, Brooklyn, NY CATHERINE G. McLAUGHLIN, Senior Research Fellow, Mathematica Policy Research, Ann Arbor, MI J. LLOYD MICHENER, Professor and Chairman, Department of Community and Family Medicine, and Director, Duke Center for Community Research, Duke University Medical Center, Durham, NC ROBERT L. PHILLIPS, JR., Director, Robert Graham Center, American Academy of Family Physicians, Washington, DC DAVID N. SUNDWALL, Clinical Professor of Public Health, School of Medicine in the Division of Public Health, University of Utah, Salt Lake City v

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MARY WELLIK, Community Health Services Administrator (Retired), Olmsted County Public Health Services, Rochester, MN WINSTON F. WONG, Medical Director, Community Benefit Disparities Improvement and Quality Initiatives, National Program Office, Kaiser Permanente, Oakland, CA Consultants SARA ROSENBAUM, George Washington University School of Public Health and Health Services, Washington, DC PHILIP SLOANE, University of North Carolina at Chapel Hill KATRINA DONAHUE, University of North Carolina at Chapel Hill FEDERAL FUNDS INFORMATION FOR STATES, Washington, DC RONA BRIERE, Briere Associates, Inc., Felton, PA Staff MONICA N. FEIT, Study Director JOSHUA JOSEPH, Associate Program Officer TREVONNE WALFORD, Research Associate ANDRES GAVIRIA, Senior Program Assistant (from August 2011) KATHLEEN McGRAW-SHEPHERD, Senior Program Assistant (until August 2011) RACHEL MIRIANI, Intern, Summer 2011 ROSE MARIE MARTINEZ, Director, Board on Population Health and Public Health Practice vi

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Reviewers T his report has been reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise, in accordance with procedures approved by the National Research Council’s Report Review Committee. The purpose of this independent review is to provide candid and critical comments that will assist the institution in making its published report as sound as possible and to ensure that the report meets institutional standards for objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confiden- tial to protect the integrity of the deliberative process. We wish to thank the following individuals for their review of this report: Bobbie Berkowitz, Columbia University School of Nursing and Columbia University Medical Center Kurtis Elward, Family Medicine of Albemarle Barbara Ferrer, Boston Public Health Commission Michael Katz, March of Dimes Foundation Mitch Katz, Los Angeles County Department of Health Services Paula Lantz, The George Washington University David O. Meltzer, University of Chicago James W. Mold, University of Oklahoma Health Sciences Center Joshua M. Sharfstein, Maryland Department of Health and Mental Hygiene William Welton, University of Washington Steven H. Woolf, Virginia Commonwealth University Center on Human Needs vii

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viii REVIEWERS Although the reviewers listed above have provided many constructive comments and suggestions, they were not asked to endorse the report’s conclusions or recommendations, nor did they see the final draft of the report before its release. The review of this report was overseen by Susan J. Curry, The University of Iowa, and Mark R. Cullen, Stanford University. Appointed by the National Research Council and Institute of Medicine, they were responsible for making certain that an independent examination of this report was carried out in accordance with institutional procedures and that all review comments were carefully considered. Responsibility for the final content of this report rests entirely with the authoring committee and the institution.

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Acknowledgments T he Institute of Medicine (IOM) Committee on the Integration of Primary Care and Public Health would like to express its sincere gratitude to everyone who assisted with this report. This work would not have been possible without the support of our sponsors. The committee would like to thank the Health Resources and Services Administration (HRSA), the Centers for Disease Control and Pre- vention (CDC), and the United Health Foundation for their generous spon- sorship. We appreciate the time taken by Mary Wakefield, Ph.D., R.N., administrator of HRSA; Sarah Linde-Feucht, M.D., chief public health officer, HRSA; Judith Monroe, M.D., director, Office for State, Tribal, Lo- cal and Territorial Support, CDC; Chesley Richards, M.D., M.P.H., FACP, director, Office of Prevention through Healthcare, Office of the Associate Director for Policy, CDC; and Reed Tuckson, M.D., FACP, executive vice president and chief of medical affairs, UnitedHealth Group for meeting with the committee to clarify its charge. In addition, we would like to acknowledge the following staff for their assistance throughout the study: HRSA Natasha Coulouris, M.P.H. Matthew Burke, M.D. Chris DeGraw, M.D., M.P.H. Seiji Hayashi, M.D., M.P.H. Suzanne Heurtin-Roberts, Ph.D., M.S.W. Michele Lawler, M.S., R.D. ix

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x ACKNOWLEDGMENTS Beverly Wright, C.N.M., M.S.N., M.P.H. Audrey Yowell, Ph.D., M.S.S.S. CDC Paula Staley, M.P.A., R.N. Wanda Barfield, M.D., M.P.H., FAAP Peter Briss, M.D., M.P.H. Lydia Ogden, Ph.D., M.P.P., M.A. Marcus Plescia, M.D., M.P.H. Michael Schooley, M.P.H. United Health Foundation Shelly Espinosa, M.P.H. The committee would like to acknowledge and thank the many indi- viduals who presented to the committee and provided insight on various topics throughout the study. These individuals include many of the staff listed above as well as those listed below. Charlie Alfero, M.A. (Hidalgo Medical Service) Alina Alonso, M.D. (Palm Beach County Health Department, Florida Department of Health) Katherine Brieger, M.A., R.D., CDE (Hudson River Health Care) Helen Darling, M.A. (National Business Group on Health) Ralph Fuccillo, M.A. (DentaQuest Foundation) M. Chris Gibbons, M.D., M.P.H. (Johns Hopkins Urban Health Institute) Ben Gramling (Sixteenth Street Community Health Center) Jean Johnson, Ph.D., FAAN (The George Washington University School of Nursing) David B. Nash, M.D., M.B.A., FACP (Jefferson School of Population Health) Robert Resendes, M.B.A. (Yavapai County Community Health Services) Barbara Safriet, J.D., L.L.M. (Lewis & Clark Law School) Ellen-Marie Whelan, Ph.D., N.P., R.N. (Center for Medicare & Medicaid Services Innovation Center) Steven Woolf, M.D., M.P.H. (Virginia Commonwealth University Center on Human Needs)

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xi ACKNOWLEDGMENTS Finally, the committee would like to recognize the consultants who aided in the creation of the report, Sara Rosenbaum, Philip Sloane, Katrina Donahue, and the Federal Funds Information for States organization. Their efforts proved invaluable to the committee. The committee is also grateful to Rona Briere and Alisa Decatur of Briere and Associates, Inc., for their assistance in editing the report and to LeAnn Locher for her work in creat- ing the cover and the design elements throughout the report.

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Preface I n 2010, the Institute of Medicine (IOM) was asked by the Centers for Disease Control and Prevention (CDC) and the Health Resources and Services Administration (HRSA) to convene a committee to study and prepare a report providing recommendations on how they, as national agencies, could work collectively to improve health through the integration of primary care and public health. The CDC and HRSA sponsorship was reinforced by support from the United Health Foundation. To conduct this study, the IOM formed the Committee on Integrating Primary Care and Public Health. This effort is not the first, nor will it likely be the last, to explore how these two sectors can complement each other and align their resources to improve population health. At the same time, the committee had a strong appreciation for the unique contributions, accountabilities, and perspectives of both sectors and respected those attributes in proposing opportunities for expanded collaboration. Several factors contribute to the timeliness of this report with respect to both the demand for and an environment conducive to meaningful progress. Key among these factors is the sponsorship of this effort by organizations with national perspective and influence that are motivated to find ways to leverage their resources in a more collaborative manner. All of the study’s sponsors are increasingly focused on various aspects of population health, including maternal and child health; cancer prevention; and management of noncommunicable chronic diseases, such as obesity, diabetes, and heart disease. The science of management of these conditions is continually being refined, and innovations in population-focused care xiii

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xiv PREFACE services are rapidly evolving. The accelerating use of health information technologies has the potential to extend access to high-quality, evidence- based care to all members of the population. Finally, investments under the American Recovery and Reinvestment Act, together with the passage and ongoing implementation of the Patient Protection and Affordable Care Act, support widespread and increasingly consequential change in how health care is delivered to and accessed by Americans. In addressing its charge and producing this report, the committee sought to find the right balance between a grand vision of enhanced popu- lation health and the need to offer actionable recommendations for the sponsoring organizations. The committee appreciated the sponsors’ leader- ship and commitment to pursuing this endeavor, as well as the thoughtful and enthusiastic participation of many agency staff members in testimony on and discussion of existing services and considerations for future change. The committee acknowledges the complexity and challenges of effecting large-scale change in organizations with rich histories, traditions of advo- cacy and leadership at the agency level, and ongoing responsibilities for traditional activities. The committee also had the opportunity to examine and learn from many initiatives designed to better align and integrate the targeted ser- vices at the local and community levels. This experience highlighted a key challenge: across the nation, most efforts to integrate care delivery and improvement in primary care and public health are locally led and defined, and there are very few examples of successful integration on a larger scale. Consequently, the committee sought to draw key principles from these local and community successes and to propose how those principles might guide actions at the national level. Overall, the committee sought to provide strategic and practical guid- ance that could be implemented with anticipated resources and leadership commitment while fully leveraging emerging opportunities in the knowl- edge, policy, funding, and information technology environments. This guid- ance is built on the committee’s conclusions with respect to how population health can be improved by implementing and expanding integration now, with the belief and intent that the momentum achievable through these changes can catalyze future progress toward a truly transformed, robust, and equitable population health system. Paul J. Wallace, Chair Committee on Integrating Primary Care and Public Health

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Contents ACRONYMS AND ABBREVIATIONS xix SUMMARY 1 1 INTRODUCTION 17 Current Opportunities, 17 The Path to Improving Population Health, 19 Key Terms, 20 Benefits and Challenges of Integration, 30 Previous Integration Efforts, 35 Study Purpose and Approach, 36 Organization of the Report, 37 References, 40 2 INTEGRATION: A VIEW FROM THE GROUND 45 Previous Reviews of Integration, 45 The Committee’s Literature Review, 50 Principles for Successful Integration, 60 Case Studies, 61 How the Examples and Case Studies Illustrate Effective Primary Care and Public Health Integration, 71 Lessons Learned, 71 Role of HRSA and CDC, 75 References, 76 xv

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xvi CONTENTS 3 POTENTIAL FOR INTERAGENCY COLLABORATION 79 Maternal and Child Health, 80 Cardiovascular Disease Prevention, 87 Colorectal Cancer Screening, 94 Opportunities for Interagency Collaboration, 99 References, 101 4 POLICY AND FUNDING LEVERS 105 The Patient Protection and Affordable Care Act, 107 Key Policy Components, 127 Funding Streams, 134 References, 139 5 CONCLUSIONS AND RECOMMENDATIONS 143 Conclusions, 143 Recommendations, 145 Broader Opportunities for Integration, 149 References, 151 APPENDIXES A Health Resources and Services Administration (HRSA) and Centers for Disease Control and Prevention (CDC) 153 B HRSA-Supported Primary Care Systems and Health Departments 163 C Meeting Agendas 175 D Biosketches of Committee Members 183

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Boxes, Figures, and Tables BOXES 1-1 Four Key Features of Primary Care, 21 1-2 Essential Public Health Services, 24 1-3 Interest in Collaboration, 34 1-4 Statement of Task, 38 2-1 Areas of Activity in Primary Care and Public Health Collaborations, 46 2-2 Types of Organizations Involved in Medicine and Public Health Collaborations, 48 3-1 Benchmark Areas for the Maternal, Infant, and Early Childhood Home Visiting Program, 81 4-1 Strategic Directions and Priorities of the National Prevention Strategy, 117 4-2 Examples of Shared Community Resources, 134 FIGURES S-1 Degrees of integration, 4 1-1 The intersectoral public health system, 25 1-2 Degrees of integration, 29 xvii

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xviii BOXES, FIGURES, AND TABLES 4-1 Percentage of total annual funding for health centers by revenue source, 2010, 136 4-2 Percentage of total annual funding for state health departments by revenue source, 136 4-3 Percentage of total annual local health department revenues by revenue source, 137 A-1 Organizational structure of HRSA, 156 A-2 Organizational structure of CDC, 158 TABLES S-1 Selected Provisions of the Patient Protection and Affordable Care Act That Offer Opportunities for HRSA and CDC, 8 1-1 Perspectives of Medicine and Public Health, 31 2-1 Facilitators of and Barriers to Primary Care and Public Health Collaboration, 47 2-2 Synergies of Medicine and Public Health Collaboration, 49 2-3 Aspects of Primary Care and Public Health Integration Illustrated by the Examples and Case Studies, 72 4-1 Selected Provisions of the Patient Protection and Affordable Care Act That Offer Opportunities for HRSA and CDC, 123 A-1 HHS Outlays by Operating Division (Fiscal Year 2010), 154 A-2 HRSA Fiscal Year 2010 Budget Authority, 157 A-3 CDC Fiscal Year 2010 Budget Authority, 160 B-1 Snapshot of Health Centers, 165

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Acronyms and Abbreviations ABCS aspirin use, blood pressure control, cholesterol management, and smoking cessation ACA Patient Protection and Affordable Care Act ACF Administration for Children and Families ACO accountable care organization AHRQ Agency for Healthcare Research and Quality ARRA American Recovery and Reinvestment Act CBO Congressional Budget Office CCNC Community Care of North Carolina CDC Centers for Disease Control and Prevention CHIP Children’s Health Insurance Program CMMI CMS Innovation Center CMS Centers for Medicare & Medicaid Services COPC community-oriented primary care DHI Durham Health Innovations EIS Epidemic Intelligence Service FOBT fecal occult blood test FQHC federally qualified health center HERO Health Extension Rural Office HHS Department of Health and Human Services xix

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xx ACRONYMS AND ABBREVIATIONS HIT health information technology HITECH Health Information Technology for Economic and Clinical Health (Act) HPRN High Plains Research Network HRSA Health Resources and Services Administration INPC Indiana Network for Patient Care IOM Institute of Medicine IRS Internal Revenue Service MCH maternal and child health NACCHO National Association of County and City Health Officials NAS National Academy of Sciences NHSC National Health Service Corps NIH National Institutes of Health NYC DOHMH New York City Department of Health and Mental Hygiene PCEP Primary Care Extension Program PRAMS Pregnancy Risk Assessment Monitoring System PPS Prospective Payment System REACH Regional Electronic Adoption Center for Health SPARC Sickness Prevention Achieved through Regional Collaboration SSBG Social Services Block Grant UDS Uniform Data System WHO World Health Organization