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5
Conclusions and Recommendations
I
n approaching its statement of task, the committee reviewed the relevant
literature; assessed the current policy context; listened to testimony;
engaged in multiple discussions with CDC, HRSA, and other stakehold-
ers; and drew on its members’ own experiences. Through this process, the
committee reached a number of conclusions about the integration of pri-
mary care and public health and formulated five recommendations whose
implementation could advance integration to improve population health.
CONCLUSIONS
The committee developed the following overarching conclusions:
• The principles identified by the committee in Chapter 2 represent
an aspirational yet actionable framework for accelerating progress
toward achieving the nation’s population health objectives through
increased integration of primary care and public health services.
• The committee finds that in its current state, the infrastructure for
both primary care and public health is inadequate to achieve the
nation’s population health objectives.
• Current patterns of health policy focus and investment lack the
alignment necessary to develop an integrated and enduring national
infrastructure that can broadly leverage the assets and potential of
primary care and public health.
• To address this need adequately, agencies both within and outside
of the Department of Health and Human Services (HHS) will have
143
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144 PRIMARY CARE AND PUBLIC HEALTH
to be engaged. The committee notes that there are precedents for
this kind of systematic strategy development and investment in
national programs, such as the Hill-Burton program to build the
nation’s hospital infrastructure, investment in the National Insti-
tutes of Health and its extramural programs to build the nation’s
biomedical research infrastructure, and preferential funding for
specialty medicine to build high-tech clinical capacity. There has
never been an analogous comprehensive and sustained investment
in the nation’s primary care and public health infrastructure.
• While national leadership and prioritization will be needed if the
necessary infrastructure is to be built, the committee believes that
emerging organizational and funding models for the personal health
care delivery system and unprecedented investment in public health
and community-based prevention can be leveraged to promote the
necessary alignment. However, no single best solution for achieving
integration can be prescribed. Community-level application of the
framework represented by the principles for integration identified
by the committee will require substantial local adaptation and the
development of specific structures, relationships, and processes.
• Academic health centers often are well positioned to facilitate the
integration of primary care and public health and the development
of improved means of engagement and integration, as they are
often located in communities of need and draw both their patients
and their employees from these communities. As illustrated by
several of the examples highlighted in Chapter 2, academic health
centers can serve as effective partners with both health centers and
local health departments in sharing data; aligning clinical, research,
and educational programs; and sustaining integrated operations
aimed at improving the health of the entire community. Some
academic health centers appear to be actively engaged in this role;
however, many are not. The evidence in this area is sparse, but
the committee believes that creating an interface for the Health
Resources and Services Administration (HRSA) and the Centers
for Disease Control and Prevention (CDC) to work with academic
health centers, their primary care programs, and their local health
departments to promote the integration of primary care and public
health is an opportunity that should be explored.
• The committee believes that a starting point for catalyzing and
promoting greater integration of primary care and public health is
leveraging existing funds and policy initiatives. Table 4-1 in Chap-
ter 4 highlights opportunities in the Patient Protection and Afford-
able Care Act (ACA) that HRSA and CDC can exploit for greater
integration. Of particular note is the amendment to the Internal
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CONCLUSIONS AND RECOMMENDATIONS
Revenue Code that requires local hospitals seeking tax exempt
status to conduct community benefit assessments. This effort could
be linked with primary care providers and local health departments
to build on local expertise and other assessments already under
way, forging stronger relationships and encouraging stakeholders
to work toward the common goal of improving the community’s
health.
RECOMMENDATIONS
As stated above, the committee regards the principles for integra-
tion outlined in Chapter 2 as a framework for action. Implementation
of the following recommendations—aimed at the agency and department
levels—would assist the leadership of HRSA, CDC, and HHS in creating
an environment that would support 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;
• reate an environment in which staff 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.
HRSA and CDC should take a number of leadership actions to encour-
age local integration efforts. For example, involving representatives from
each agency in the development of grants and other funding mechanisms
would assist in aligning funds for a common purpose. Likewise, HRSA
and CDC should leverage staff at the state, regional, and local levels to
promote integration efforts. Either working through health.data.gov, an
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146 PRIMARY CARE AND PUBLIC HEALTH
effort to compile various health data sets, or directly (U.S. Government,
2012), the agencies should commit to convening data experts to undertake
a thorough inventory of their databases, identify new data sets, compare
the findings, and seek opportunities to consolidate these assets. These ef-
forts should lead to the creation of a consolidated platform for sharing
health care and population health data. This platform could ensure that
communities can use these data in assessments, intervention planning, and
evaluation. The platform would not be “owned” by primary care or public
health, but would constitute local neutral space where both sectors could
come together to use data that would support the achievement of better
health outcomes. The 2011 Institute of Medicine (IOM) report For the
Public’s Health: The Role of Measurement in Action and Accountability
provides recommendations that would be relevant to this endeavor. Also
needed is a workforce that is trained in developing information systems and
making them work for the end user. HRSA and CDC both have a role in
the creation of this workforce.
The committee recommends that appropriate incentives to encourage
integration be developed at the national level (see Recommendation 5). In
some cases, however, such incentives will be developed locally. HRSA and
CDC should work with local partners to recognize and learn from these
cases.
Recommendation 2. To create common research and learning networks
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
integration, including by working with the Centers for Medi-
care & Medicaid Services (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.
Substantial opportunities exist to understand models of successful and
sustainable integration taking place in local communities and diffuse that
knowledge. Through their role as conveners, HRSA and CDC should take
the lead in facilitating a better understanding of the lessons of successful
integration from the field. The agencies might consider holding an annual
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CONCLUSIONS AND RECOMMENDATIONS
summit; creating a learning collaborative; publishing key findings in vari-
ous venues, including peer-reviewed journals; and using other mechanisms
for sharing findings with stakeholders to foster greater understanding of
integration and encourage it at the local, state, and national levels. In addi-
tion, the two agencies should work with other agencies, such as the Centers
for Medicare & Medicaid Services (CMS) and the Agency for Healthcare
Research and Quality (AHRQ), to encourage ongoing evaluation of integra-
tion efforts and the diffusion of best practices.
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.
• 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.
A retooled workforce is one of the most promising ways to model
and encourage more complete integration. This retooling will require that
primary care providers be educated about public health; that public health
workers be educated about primary care; and, most important, that a
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148 PRIMARY CARE AND PUBLIC HEALTH
new cadre of workers who can bridge both sectors in pursuit of improved
population health be developed. To achieve significant advances in popu-
lation health, these efforts must span the life course from preconception
through conception, birth, childhood, adolescence, young adulthood, and
adulthood and into later life. To this end, joint Title VII/VIII applications
could be used to create medicine/nursing workforce training opportunities
with the ultimate goal of preparing an integrated workforce capable of
working across primary care and public health. In a similar vein, Epidemic
Intelligence Service officers could act as a bridge between primary care and
public health by helping to transform public health data into information
that primary care providers could use at the local level.
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.
As stated earlier, the committee believes that current opportunities in
the health system could be leveraged to create greater integration of primary
care and public health. A number of existing and newly created programs
could be used as a starting point for strengthening integration, and the
committee encourages the secretary of HHS to take full advantage of these
opportunities. While the above list is not complete, the committee believes
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CONCLUSIONS AND RECOMMENDATIONS
it could be used to begin the effort, but also urges the secretary to look for
other opportunities.
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
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.
By engaging HHS agencies to work together in creating an infra-
structure to facilitate the integration of primary care and public health,
the secretary could create momentum around this topic. To achieve a
truly national strategy and infrastructure, however, agencies beyond HHS
should be involved. The National Prevention, Health Promotion and Public
Health Council, chaired by the Surgeon General, could undertake this task.
Alternatively, the Domestic Policy Council, which is currently leading the
Obama administration’s policy on place-based initiatives, could be engaged
on this topic.
To improve the population’s health and meet national health goals,
such as those of Healthy People 2020, the committee encourages the secre-
tary to explore ways of leveraging funding through existing programs, pool
existing resources, and create incentives that will encourage a willingness
to integrate among local stakeholders.
BROADER OPPORTUNITIES FOR INTEGRATION
While its task was to assist HRSA and CDC in identifying opportuni-
ties to integrate primary care and public health, the committee believes it
would be remiss if it failed to note some broader opportunities for integra-
tion. Although the opportunities touched on below are not the focus of this
report, the committee encourages those working in primary care and public
health to explore them.
The patient-centered medical home, discussed in Chapter 4, has been
endorsed by primary care providers and others (American Academy of Fam-
ily Physicians et al., 2007; IOM, 2010; National Partnership for Women &
Families, 2012). As a model that emphasizes care coordination facilitated
by increased data sharing, as well as the role of the patient’s family and
community, it provides a clear-cut opportunity for integrating primary care
and public health. Given the provisions in the ACA that promote the expan-
sion of the patient-centered medical home concept for Medicaid patients,
more primary care practices are expected to move toward this model. As
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150 PRIMARY CARE AND PUBLIC HEALTH
they do so, health departments could be poised to work with them, diffus-
ing the benefits of care coordination into the community.
Another opportunity created in the ACA, and discussed in Chapter 4, is
accountable care organizations (ACOs), groups of hospitals and clinicians
that work together to provide care for a panel of Medicare beneficiaries (at
least 5,000). While the role of ACOs is to provide primary care and other
health care services, partnering with health departments would broaden
the range of services available to the patient panel. As the first ACOs begin
operating in 2012, they should reach out to health departments to forge
links to community programs and public health services.
Employer groups provide another opportunity for integration. Busi-
nesses are increasingly concerned about the health of their own workers
and their social responsibility in the communities in which they are located
and in which their markets exist. The National Business Group on Health
and regional groups such as the Pacific Business Group on Health and the
Midwest Business Group on Health are active in developing initiatives in
which businesses can contribute to local community health. Primary care
providers could have a role in working with these groups.
While health departments have responsibility for providing public
health services in most places in the United States, they do not exist in some
places. In those cases, public health services are provided by other entities,
such as community organizations or academic health centers. Primary care
groups should consider partnering with these entities in places that lack
formal health departments.
Finally, two large-scale policy initiatives could support integration: the
place-based initiatives supported by the White House and the National Pre-
vention Strategy issued by the National Prevention, Health Promotion and
Public Health Council. As discussed in Chapter 4, place-based initiatives
focus resources in areas such as economic development, transportation,
education, or health promotion to create coordinated action. Coordination
of the delivery of these resources creates alignment that impacts the com-
munity as a whole. The emphasis of these initiatives on local communities
echoes the principles necessary for integration. Through its implementa-
tion, this policy could encourage primary care and public health to work
together to improve population health. The National Prevention Strategy
is an integrated national strategy designed to improve the health of the na-
tion by encouraging partnerships among government entities, businesses,
community-based organizations, individuals, and others. With its focus
in four areas—healthy communities, clinical and community preventive
services, empowered people, and the elimination of health disparities—the
strategy aligns closely with the principles for integration. This strategy also
could serve as a catalyst for promoting the integration of primary care and
public health.
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CONCLUSIONS AND RECOMMENDATIONS
These final two policy examples represent the type of broad, inter-
sectoral collaboration that is necessary to realize significant, sustained
improvements in population health. Through an improved understanding
of the broad determinants of health, it has become abundantly clear that
a wide array of public and private actors contribute directly or indirectly
to the health outcomes of the nation’s population. By establishing a uni-
fied focus on health, these actors can work with one another to produce a
greater impact than any could achieve on its own. With explicit missions
to foster healthy populations, primary care and public health have critical
roles in population health. Through integration, both sectors can increase
their capacity to directly improve the health and health care of people in
communities nationwide. And by linking with other organizations, institu-
tions, and community resources, the leadership of primary care and public
health can set the pace for interdisciplinary, intersectoral cooperation and
help establish a national focus on the health of communities.
REFERENCES
American Academy of Family Physicians, American Academy of Pediatrics, American Col-
lege of Physicians, and American Osteopathic Association. 2007. Joint principles of the
patient-centered medical home. http://www.pcpcc.net/content/joint-principles-patient-
centered-medical-home (accessed December 15, 2011).
IOM (Institute of Medicine). 2010. The future of nursing: Leading change, advancing health.
Washington, DC: The National Academies Press.
IOM. 2011. For the public’s health: The role of measurement in action and accountability.
Washington, DC: The National Academies Press.
National Partnership for Women & Families. 2012. National Partnership for Women &
Families. 2012. http://www.nationalpartnership.org/site/PageServer (accessed February
14, 2012).
U.S. Government. 2012. Health data community. http://www.data.gov/health (accessed Febru-
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