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Summary
E
nsuring that members of society are healthy and reaching their full
potential requires the prevention of disease and injury; the promotion
of health and well-being; the assurance of conditions in which people
can be healthy; and the provision of timely, effective, and coordinated
health care. A wide array of actors across the United States—including
those in both primary care1 and public health—contribute to one or more
of these elements, but their work is often carried out in relative isolation.
Achieving substantial and lasting improvements in population health2 will
require a concerted effort from all of these entities, aligned with a common
goal. The integration of primary care and public health could enhance the
capacity of both sectors to carry out their respective missions and link with
other stakeholders to catalyze a collaborative, intersectoral movement to-
ward improved population health.
In recognition of this potential, the Health Resources and Services Ad-
ministration (HRSA) and the Centers for Disease Control and Prevention
(CDC) requested that the Institute of Medicine (IOM) convene a committee
of experts to examine the integration of primary care and public health.
The 17-member Committee on Integrating Primary Care and Public Health
comprises experts in primary health care, state and local public health, ser-
1 The committee recognizes that mental health is an inextricable part of primary care. When
primary care is discussed in this report, the committee means it to be inclusive of mental
health.
2 When discussing the term “population health,” the committee chose to adopt Kindig and
Stoddart’s definition (2003, p. 381): “the health outcomes of a group of individuals, including
the distribution of such outcomes within the group.”
1
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2 PRIMARY CARE AND PUBLIC HEALTH
vice integration, health disparities, health information technology, health
care finance, health care policy, public health law, workforce education and
training, organizational management, and child health. The committee was
charged to:
• Identify the best examples of effective public health and primary
care integration and the factors that promote and sustain these
efforts. These examples were to illustrate shared accountability;
workforce integration; collaborative governance, financing, and
care coordination; and the effective use of information technology
to promote integration and achieve high-quality primary care and
public health.
• Examine ways by which HRSA and CDC can use provisions of the
Patient Protection and Affordable Care Act (ACA) to promote the
integration of primary care and public health.
• Discuss how HRSA-supported primary care systems and state and
local public health departments can effectively integrate and coor-
dinate to improve efforts directed at cardiovascular disease preven-
tion, as well as other issues relevant to health disparities or specific
populations, such as maternal and child health and colorectal can-
cer screening, and describe actions HRSA and CDC should take to
promote these changes.
Funding for this study was provided by HRSA, CDC, and the United
Health Foundation.
In conducting the study, the committee held five formal meetings, as
well as three subgroup meetings, and used a variety of sources: the pub-
lished literature, discussions with HRSA and CDC, presentations from
practitioners, and commissioned papers. In drawing on these sources, the
committee developed a list of key principles for the integration of primary
care and public health, which are outlined below and discussed in detail
in Chapter 2. These principles were used as a guiding framework in pre-
senting examples of successful integration, identifying opportunities for
interagency collaboration, and formulating the recommendations presented
in this report.
KEY TERMS
Primary Care
The committee adopted an earlier IOM definition of primary care: “the
provision of integrated, accessible health care services by clinicians who
are accountable for addressing a large majority of personal health care
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3
SUMMARY
needs, developing a sustained partnership with patients, and practicing in
the context of family and community” (IOM, 1996, p. 1). Primary care
in the United States is delivered through both private providers and those
supported by government agencies, such as the Veterans Health Adminis-
tration and HRSA. HRSA-supported health centers serve over 19 million
patients a year (HRSA, 2011) and provide a safety net for society’s most
vulnerable populations. Although most primary care is delivered through
the private sector, both private and government-supported primary care
share common features: both are person- rather than disease-focused, pro-
vide a point of first contact for whatever people might consider a health
or health care problem, are comprehensive, and coordinate care (Starfield
and Horder, 2007).
Public Health
The committee adopted a definition of public health that likewise was
borrowed from an earlier IOM report: “fulfilling society’s interest in as-
suring conditions in which people can be healthy” (IOM, 1988, p. 140).
To meet this definition, public health has shifted its primary focus from
addressing infectious disease to tackling chronic disease. To ensure healthy
conditions, public health encompasses a diverse group of public and private
stakeholders (including the health care delivery system) working in a variety
of ways to contribute to the health of society. Uniquely positioned among
these stakeholders is governmental public health. Because health depart-
ments are legally tasked with providing essential public health services,
they are required to work with all sectors of the community. This allows
them to serve as a catalyst for engaging multiple stakeholders to confront
community health problems. In addition, their assessment and assurance
functions put them in close contact with the community and in touch with
the community’s health needs. While public health defined broadly in this
report goes beyond governmental public health, the committee recognized
that health departments play a fundamental role in creating healthy com-
munities and focused on them when possible.
Integration
While integration can be an imprecise term, integration of primary care
and public health was defined for this report as the linkage of programs and
activities to promote overall efficiency and effectiveness and achieve gains
in population health. The committee conceived of integration in terms of
multiple variables—levels, partners, actions, and degree. For this report, the
agency and local levels are discussed. Partners for the agency level include
HRSA, CDC, and other agencies as necessary; partners for the local level
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4 PRIMARY CARE AND PUBLIC HEALTH
Mutual
Awareness Collaboration
Isolation Merger
Cooperation Partnership
FIGURE S-1 Degrees of integration.
include a primary care entity, a public health entity (with a preference for
health departments), the community, and other stakeholders as necessary.
The variable of actions required a shared goal of improved population
health; a willingness and ability to contribute to that goal; and, ideally,
a commitment to an ongoing process and continual dialogue. Finally, the
committee conceived of integration as degrees on a continuum ranging from
isolation to merger (Figure S-1) and focused on mutual awareness, coopera-
tion, collaboration, and partnership, with a preference for activities moving
toward greater integration.
CONTEXT FOR INTEGRATION OF PRIMARY
CARE AND PUBLIC HEALTH
The opportunity currently exists to shift the health system in significant
ways. A number of relatively new developments have converged to create
this opportunity. The dramatic rise in health care costs has led many stake-
holders to explore innovative ways of reducing costs and improving health.
As health research continues to clarify the importance of social and environ-
mental determinants of health and the impact of primary prevention, there
is growing recognition that the current model of investment in the nation’s
health system is unacceptable. At the same time, an unprecedented wealth
of health data is providing new opportunities to understand and address
community-level health concerns. And most important, the passage of the
ACA presents an overarching opportunity to change the way health is ap-
proached in the United States.
This pivotal time makes it possible to achieve sustainable improvements
in population health, a key goal for health system reform. Pursuit of this
goal will require a balance of investment and clarity of roles across activities
that address the broad determinants of health, population-level behaviors,
and individual health care—activities in which primary care and public
health have prominent roles.
Primary care and public health presently operate largely independently,
but have complementary functions and the common goal of ensuring a
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5
SUMMARY
healthier population. By working together, primary care and public health
can each achieve their own goals and simultaneously have a greater impact
on the health of populations than either of them would have working in-
dependently. Each has knowledge, resources, and skills that can be used to
assist the other in carrying out its roles. They should be viewed as “two
interacting and mutually supportive components” of a health system de-
signed to improve the health of populations (Welton et al., 1997, p. 262).
Among agencies within the Department of Health and Human Services
(HHS), HRSA and CDC have especially important roles to play in improv-
ing population health. Both have articulated a vision of how their work can
impact the broader determinants of health (Frieden, 2010; HRSA, 2010),
and both see themselves as having a public health mission. HRSA plays a
strategic role in helping to ensure access to personal health services for un-
insured and vulnerable populations through its support for the provision of
primary care and preventive services at health centers, Ryan White clinics,
and rural health clinics, as well as training programs for the primary care
and public health workforces and maternal and child health programs. And
with its focus on health promotion, disease prevention, and preparedness,
CDC is recognized as a global leader in public health. The agency works
with local and state health departments on a number of efforts, includ-
ing implementing disease surveillance systems, preventing and controlling
infectious and chronic diseases, reducing injuries, eliminating workplace
hazards, and addressing environmental health threats. It is significant that
these agencies have come forward to pursue integration.
PRINCIPLES FOR INTEGRATION
To gain an understanding of current and recent efforts to integrate
primary care and public health, the committee reviewed past integration
efforts to identify some of the ways in which primary care and public
health can interact, as well as the benefits of and barriers to successful
collaboration. The committee gathered examples of integration by search-
ing peer-reviewed journal and grey literature databases, querying relevant
stakeholders, and drawing on its members’ own experiences. A thorough
review of these examples revealed some prominent themes and lessons and
made it possible to select case studies that reflect the major components
of successful integration. The review informed the development of a set of
principles that the committee believes are essential for successful integration
of primary care and public health:
• a shared goal of population health improvement;
• community engagement in defining and addressing population
health needs;
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6 PRIMARY CARE AND PUBLIC HEALTH
• aligned leadership that
— bridges disciplines, programs, and jurisdictions to reduce frag-
mentation and foster continuity,
— clarifies roles and ensures accountability,
— develops and supports appropriate incentives, and
— has the capacity to manage change;
• sustainability, key to which is the establishment of a shared infra-
structure and building for enduring value and impact; and
• the sharing and collaborative use of data and analysis.
While the committee believes that all of these principles are ultimately nec-
essary for integration, it also believes that integration can start with any
of these principles and that starting is more important than waiting until
all are in place.
EXAMPLES OF INTEGRATION
From the literature review, the committee identified a number of ex-
amples of successful integration efforts. These examples appear in a diverse
array of communities and help demonstrate the breadth of possibilities for
primary care and public health interactions. Drawing on these experiences,
the committee derived some lessons about the composition and focus of
recent efforts to integrate primary care and public health:
• In many of the examples, integration was driven by a specific
health issue that was identified as a community area of concern,
such as chronic disease, prevention, or the health needs of a specific
population.
• Participants in integration initiatives varied widely, including an
array of primary care and public health entities and other con-
tributors, such as community organizations, academic institutions,
businesses, and hospitals.
• Key opportunities for integration included the sharing and use of
data and the development of a workforce capable of functioning
in an integrated environment.
Through its review of the literature, the committee sought examples
to use as case studies that would demonstrate well-developed relationships
between public health and primary care. With these examples, the commit-
tee wished to highlight ongoing linkages between primary care and public
health entities that extend beyond a single project, demonstrate a commit-
ment to an ongoing relationship between the two disciplines, and reflect the
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7
SUMMARY
above principles for integration. The committee selected three communities
to showcase:
• Durham, North Carolina;
• San Francisco, California; and
• New York, New York.
AREAS IN WHICH HRSA AND CDC CAN
STRENGTHEN INTEGRATION
To explore the potential for interagency collaboration to foster the
integration of primary care and public health, the committee examined
how HRSA-supported primary care systems and public health departments
could integrate efforts in three specific areas: maternal and child health
(specifically the Maternal, Infant, and Early Childhood Home Visiting
Program), cardiovascular disease prevention, and colorectal cancer screen-
ing. These areas were selected because they lend themselves to a life-course
perspective, include elements of mental and behavioral health, and touch on
issues relevant to health disparities. They also represent a mix of programs
led by HRSA and CDC.
In its review of these three areas (discussed in Chapter 3), the com-
mittee was struck by two things. First is the vastly different organizational
structures of HRSA and CDC, which create logistical barriers to the for-
mation of partnerships. These structural differences mean there often is no
natural link between the agencies. This situation is not necessarily negative.
In fact, like puzzle pieces that fit into place, these structural differences can
actually assist in promoting better coordination. In the short run, however,
the differences can mean that staff from one agency do not always have a
natural counterpart in the other. Second, despite these barriers, there is a
genuine willingness among the two agencies to work together.
The committee’s examination of the above three areas revealed some
key ways in which integration can be encouraged. They include the value of
using community health workers, the opportunities provided by data shar-
ing, and the possibility of a third party to foster integration. The committee
encourages HRSA and CDC to explore these possibilities in the three areas
examined by the committee, as well as others.
POLICY AND FUNDING OPPORTUNITIES
Federal policy and funding are the greatest levers available to HRSA
and CDC for encouraging the integration of primary care and public health
on the ground. As the most ambitious health policy in a generation, the
ACA provides an unusual opportunity to work toward that goal. While the
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8 PRIMARY CARE AND PUBLIC HEALTH
ACA does not explicitly address the integration of primary care and public
health, it provides a menu of initiatives that agencies and communities can
exploit to make gains in improving population health.
The ACA authorizes HRSA and CDC to launch a number of new
programs that on their own merit promise to be noteworthy, but if coor-
dinated and managed collaboratively from their inception could generate
significant momentum in population health at the national, state, and local
levels. Particularly promising provisions of the act (highlighted in Chapter
4) fall into four categories—community investments and benefits, coverage
reforms, health care transformation, and reshaping the workforce. These
provisions are summarized in Table S-1.
TABLE S-1 Selected Provisions of the Patient Protection and Affordable
Care Act That Offer Opportunities for HRSA and CDC
Affordable Care Act
Provision HRSA and CDC Opportunities
Community • iven that Community Transformation Grants can be
G
Transformation Grants viewed as the public health counterpart to the Centers for
(ACA §§ 4002 and 4201) Medicare & Medicaid Services (CMS) Innovation Center
The provision authorizes (CMMI) pilots, HRSA and CDC should be aware of the
and funds community communities where both of these programs are involved.
transformation grants to • s community resources for wellness improve through
A
improve community health the Transformation Grant system, it may be possible to
activities and outcomes. encourage state and local health department recipients to
develop linkages with primary care providers as a central
focus of their program planning.
• DC could also begin to link those resources to CMMI
C
pilots, which must be able to link their patients and
physician practices with community resources.
Community Health Needs • RSA and CDC could engage with community
H
Assessments hospitals and national hospital associations to develop
(ACA § 9007) approaches to hospital community benefit planning, as
The provision amends the well as promote approaching jointly the selection of
Internal Revenue Code by interventions and implementation strategies to address
adding new section 501(r), identified problems—for example, the extension of
“additional requirements primary care services into nontraditional settings; the
for certain hospitals.” The formation of collaboratives among community primary
new requirements apply care providers and local public health and other agencies;
to all facilities licensed as and community health promotion activities involving
hospitals and organizations diet, exercise, and injury risk reduction, as well as other
recognized by the Treasury population-level interventions.
secretary as hospitals and
spell out new obligations
for all hospitals seeking
federal tax exempt status.
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9
SUMMARY
TABLE S-1 Continued
Affordable Care Act
Provision HRSA and CDC Opportunities
Medicaid Preventive • rimary care providers and public health departments
P
Services could become participating Medicaid providers and
(ACA §§ 4106 and 2001) collaborate in designing programs to furnish preventive
(ACA § 4108) services to adult and child populations.
The provision gives states • RSA and CDC could collaborate with CMS on the
H
the option to improve development of joint guidance regarding coverage of
coverage of clinical preventive services. Such guidance might explain both the
preventive services for required and optional preventive service provisions of the
traditional eligibility law, as well as federal financing incentives for coverage
groups, as well as of those services. Such guidance also might describe best
Medicaid benchmark practices in making preventive services more accessible
coverage for newly eligible to Medicaid beneficiaries through the use of expanded
persons, redefined to managed care provider networks and out-of-network
parallel the act’s definition coverage in nontraditional locations such as schools,
of essential health benefits, public housing, and workplace sites; qualification criteria
which includes coverage for participating providers; recruitment of providers;
for preventive services. It measurement of quality performance; and assessment of
also provides Medicaid impact on population health.
incentives for prevention of • RSA and CDC have a crucial role to play in the
H
chronic diseases. implementation of state demonstrations, particularly in
outreach to community providers to enlist them as active
participants in such demonstrations, training and technical
support to state Medicaid agencies, outreach to public
health departments and health centers in demonstration
states, and collaboration with CMS on the development of
outcome standards and scalability criteria.
Community Health • n imperative for HRSA is to preserve and strengthen
A
Centers the role of health centers as core safety net providers of
(ACA § 5601) clinical care and prevention in the communities they serve.
The provision expands Incentives could be built into funding for these centers to
funding for health centers. promote activities and linkages with local public health
departments and encourage community engagement and
partnerships for community-based prevention.
• utreach campaigns to promote clinical preventive
O
services in underserved communities, as well as initiatives
aimed at improving the quality of primary care for
populations with serious and chronic health conditions,
could focus on how to improve the performance of health
centers.
continued
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10 PRIMARY CARE AND PUBLIC HEALTH
TABLE S-1 Continued
Affordable Care Act
Provision HRSA and CDC Opportunities
National Prevention, • RSA and CDC could use the Council as a mechanism
H
Health Promotion and for working with other agencies around the integration of
Public Health Council and primary care and public health.
the National Prevention
Strategy
(ACA § 4001)
The provision creates
the National Prevention,
Health Promotion and
Public Health Council
to create a collaborative
national strategy to
address health in the
nation.
CMS Innovation Center • RSA and CDC could engage with CMMI in the
H
(CMMI) implementation of its community health innovation
(ACA § 3021) program to develop models that would leverage clinical
The provision establishes care to achieve a broader impact on population health.
CMMI to develop, • n the CMMI provisions of the ACA and elsewhere in the
I
conduct, and evaluate act, a major thrust of health care reform is attention to
pilots for improving dually eligible Medicare/Medicaid beneficiaries. HRSA and
quality, efficiency, and CDC could develop an initiative aimed at improving the
patient health outcomes health and health care of this population.
in both the Medicare
and Medicaid programs,
with an emphasis on dual
enrollees.
Accountable Care • RSA could encourage health centers to form ACOs and
H
Organizations (ACOs) link with public health departments in this endeavor.
(ACA § 3022) • RSA and CDC could develop models of collaboration
H
The provision authorizes between public health departments and ACOs that include
the secretary of the safety net providers. Such models might emphasize the
Department of Health and role of public health in needs assessment, performance
Human Services (HHS) measurement and improvement, health promotion, and
to enter into agreements patient engagement, all of which are central elements of
with ACOs on a shared ACOs.
savings basis to improve
the quality of patient care
and health outcomes and
increase efficiency.
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11
SUMMARY
TABLE S-1 Continued
Affordable Care Act
Provision HRSA and CDC Opportunities
Patient-Centered Medical • RSA and CDC could collaborate on further development
H
Homes of the medical home model and its team-based approach
(ACA § 3502) to care and encourage the inclusion of local public health
The provision authorizes departments in that model.
state Medicaid programs • RSA and CDC could provide technical support to
H
to establish medical homes state Medicaid agencies seeking to pursue the medical
for Medicaid beneficiaries home model, imparting best practices in the design and
with chronic health development of a medical home that is comprehensive,
conditions, and authorizes efficient in care delivery, and patient/family-centered.
the secretary of HHS This support also could be expanded to include the
to award grants for the development of performance measurement tools for
establishment of health measuring progress in these areas.
teams to support primary • RSA and CDC could develop a sustainable model
H
care. for the medical home in Medicare and Medicaid that
encourages inclusion of local public health departments,
supports multiple population types, and can be translated
for private health insurance as well.
Primary Care Extension • RSA and CDC could work with AHRQ to ensure that
H
Program Primary Care Extension Programs include a public health
(ACA § 5405) orientation and integrate community health issues into
The provision authorizes practice- and clinic-based primary care improvement
the Agency for Healthcare activities.
Research and Quality • RSA and CDC, working jointly with AHRQ, could seek
H
(AHRQ) to award collaboration with CMMI to fund Primary Care Extension
competitive grants to states Program models for which there is evidence for improving
for the establishment of personal and population health.
Primary Care Extension
Programs to improve the
delivery of primary care
and community health.
National Health Service • RSA and CDC could collaborate in prioritizing the
H
Corps recruitment and placement of National Health Service
(ACA § 5207) Corps resources and developing linkages with existing
The provision expands Epidemic Intelligence Service (EIS) officers placed in state
funding for the National and local health departments.
Health Service Corps.
continued
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12 PRIMARY CARE AND PUBLIC HEALTH
TABLE S-1 Continued
Affordable Care Act
Provision HRSA and CDC Opportunities
Teaching Health Centers • RSA could work with teaching health centers to adopt
H
(ACA § 5508) the patient-centered medical home curriculum and ensure
The provision that any curriculum used to train residents includes strong
authorizes and funds community and public health components—ideally with
the establishment of and residents working on projects that concretely promote
ongoing operational primary care-public health integration.
support for teaching health • RSA and CDC could work with the centers on training
H
centers, which must be programs that would be aimed at producing competency
community-based. to work in community health teams, given the emphasis
placed on teams under the ACA.
NOTE: ACA = Patient Protection and Affordable Care Act.
Despite these opportunities, the current funding system for primary
care and public health is not well positioned to promote integration. For
example, competing funding streams have the effect of creating silos at the
local level rather than encouraging cooperation across entities. Similarly,
most funding streams from HRSA and CDC are inflexible, limiting what
local entities can do with the funds and how they could be used for inte-
gration. Finally, it should be noted that the funds available to HRSA and
CDC for supporting and integrating primary care and public health are
quite small relative to the funds available to the Centers for Medicare &
Medicaid Services (CMS). By joining forces, the three agencies could create
much greater momentum toward integration.
RECOMMENDATIONS
In the committee’s view, the principles for integration outlined above
serve as a framework for action. The committee developed five recommen-
dations—aimed at the agency and department levels—whose implementa-
tion would assist the leadership of CDC, HRSA, and HHS in creating an
environment that would support the broader application of these principles.
Agency Level
Recommendation 1. To link staff, funds, and data at the regional, state,
and local levels, HRSA and CDC should:
• dentify opportunities to coordinate funding streams in selected
i
programs and convene joint staff groups to develop grants, re-
quests for proposals, and metrics for evaluation;
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13
SUMMARY
• reate opportunities for staff to build relationships with each
c
other and local stakeholders by taking full advantage of opportu-
nities to work through the 10 regional HHS offices, state primary
care offices and association organizations, state and local health
departments, and other mechanisms;
• oin efforts to undertake an inventory of existing health and
j
health care databases and identify new data sets, creating from
these a consolidated platform for sharing and displaying local
population health data that could be used by communities; and
• ecognize the need for and commit to developing a trained work-
r
force that can create information systems and make them efficient
for the end user.
Recommendation 2. To create common research and learning net-
works to foster and support the integration of primary care and
public health to improve population health, HRSA and CDC should:
• upport the evaluation of existing and the development of new
s
local and regional models of primary care and public health inte-
gration, including by working with the CMS Innovation Center
(CMMI) on joint evaluations of integration involving Medicare
and Medicaid beneficiaries;
• ork with the Agency for Healthcare and Research Quality’s
w
(AHRQ’s) Action Networks on the diffusion of best practices
related to the integration of primary care and public health; and
• onvene stakeholders at the national and regional levels to share
c
best practices in the integration of primary care and public health.
Recommendation 3. To develop the workforce needed to support the
integration of primary care and public health:
• RSA and CDC should work with CMS to identify regulatory
H
options for graduate medical education funding that give priority
to provider training in primary care and public health settings and
specifically support programs that integrate primary care practice
with public health.
• RSA and CDC should explore whether the training component
H
of the Epidemic Intelligence Service (EIS) and the strategic place-
ment of assignees in state and local health departments offer ad-
ditional opportunities to contribute to the integration of primary
care and public health by assisting community health programs
supported by HRSA in the use of data for improving community
health. Any opportunities identified should be utilized.
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14 PRIMARY CARE AND PUBLIC HEALTH
• RSA should create specific Title VII and VIII criteria or prefer-
H
ences related to curriculum development and clinical experiences
that favor the integration of primary care and public health.
• RSA and CDC should create all possible linkages among HRSA’s
H
primary care training programs (Title VII and VIII), its public
health and preventive medicine training programs, and CDC’s
public health workforce programs (EIS).
• RSA and CDC should work together to develop training grants
H
and teaching tools that can prepare the next generation of health
professionals for more integrated clinical and public health func-
tions in practice. These tools, which should include a focus on
cultural outreach, health education, and nutrition, can be used in
the training programs supported by HRSA and CDC, as well as
distributed more broadly.
Department Level
Recommendation 4. To improve the integration of primary care and
public health through existing HHS programs, as well as newly legis-
lated initiatives, the secretary of HHS should direct:
• MMI to use its focus on improving community health to sup-
C
port pilots that better integrate primary care and public health
and programs in other sectors affecting the broader determinants
of health;
• he National Institutes of Health to use the Clinical and Trans-
t
lational Science Awards to encourage the development and dif-
fusion of research advances to applications in the community
through primary care and public health;
• he National Committee on Vital and Health Statistics to advise
t
the secretary on integrating policy and incentives for the capture
of data that would promote the integration of clinical and public
health information;
• he Office of the National Coordinator to consider the develop-
t
ment of population measures that would support the integration
of community-level clinical and public health data; and
• HRQ to encourage its Primary Care Extension Program to cre-
A
ate linkages between primary care providers and their local health
departments.
Recommendation 5. The secretary of HHS should work with all agen-
cies within the department as a first step in the development of a
national strategy and investment plan for the creation of a primary
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15
SUMMARY
care and public health infrastructure strong enough and appropriately
integrated to enable the agencies to play their appropriate roles in fur-
thering the nation’s population health goals.
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