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1 Introduction H ealth is influenced by an array of factors, including social, genetic, environmental, and other factors that cut across a number of dif- ferent sectors. Improving the health of populations therefore will require a collaborative, intersectoral effort that involves public and private organizations and individuals. At the same time, both health problems and community needs, resources, and circumstances vary among localities, so no single approach to combating health problems can be applied. Primary care and public health are uniquely positioned to play critical roles in tackling the complex health problems that exist both nationally and locally. They share a similar goal of health improvement and can build on this shared platform to catalyze intersectoral partnerships designed to bring about sustained improvements in population health. In addition, they have strong ties at the community level and can leverage their positions to link community organizations and resources. Thus, the integration of primary care and public health holds great promise as a way to improve the health of society. The purpose of this report is to explore how this promise can be realized. CURRENT OPPORTUNITIES It is well documented that the nation’s health system is expensive and does not translate into excellent outcomes for all (AHRQ, 2011; United Health Foundation, 2011). The opportunity currently exists to shift the system in significant ways to improve on this situation. Investments in the current model of health care are not focused in the most effective way. 17
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18 PRIMARY CARE AND PUBLIC HEALTH While these patterns of investment have produced what is arguably the best biomedical research and specialty care system in the world, the nation has failed to balance its investments in primary care, public health, prevention, and the broader determinants of health, a problem clearly demonstrated by its low rankings in overall health status. McGinnis and Foege (1993) estimated that nearly half of all U.S. deaths that occurred in 1990 were at- tributable to behavioral and environmental factors. It has repeatedly been shown that such factors have a substantial influence on health outcomes, yet the current health system devotes most of its resources to treating dis- ease and much less to the underlying causes of illness (CDC, 1992; Miller et al., 2012). Financial incentives and a medical culture focused overly on acute care and heroic cures encourage giving most attention to indi- viduals who are already sick rather than promoting an effective balance of treatment and personal and community-based prevention. As a result, the current health system is inadequately equipped to provide critical health promotion and preventive services. A number of relatively new developments have converged to create opportunities for improving the nation’s health. First, there is growing recognition that the status quo is unacceptable. The unsustainable rise in health care costs has created an urgent need for innovative ways to deliver health care more efficiently. This imperative has been evident not only in the activities of government health organizations but also in the private sector. As purchasers of health care, many employers have been exploring ways to reduce the growth in these costs. A recent survey by Towers Watson and National Business Group on Health (2010) found that many employers are incentivizing a number of healthy lifestyle activities for their employees, including weight management, smoking cessation, and screenings. The concern about health care expenditures has opened the door for innovative approaches to improving health and health care. Adding momentum to the recognition that the status quo is unac- ceptable, health research continues to clarify the importance of social and environmental determinants of health (Marmot and Wilkinson, 2006; McMichael, 1999) and the limitations of the acute care medical system in addressing prevention and care needs in chronic illness. At the same time, the science with respect to primary prevention has grown and developed (The New York Academy of Medicine, 2009). As a result of these factors, a shift in the way health is approached in the United States is taking place. Another development is the increased availability of health-related data. Advances in data collection techniques and health informatics have presented an opportunity to facilitate the utilization and sharing of data among health professionals. Recent endeavors have begun to capitalize on these opportunities. For instance, the Health Information Technology for Economic and Clinical Health (HITECH) Act encourages the collection
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19 INTRODUCTION and use of patient-level data through electronic health records.1 In addition to improvements in how data are collected and used, more data sets are becoming available for widespread use. And the Health Data Initiative, led by the Department of Health and Human Services (HHS), has made a wide array of health-related data available to the public (HHS, 2011b). These newly available data are providing communities, health care providers, and researchers with an unprecedented opportunity to access and analyze information that can aid in understanding and addressing community- level health concerns. The new opportunities presented by these data give primary care and public health a solid foundation upon which they can initiate integration. Finally, and most important, the recent national focus on health care reform and the adoption of the Patient Protection and Affordable Care Act (ACA) present an overarching opportunity to change the way health care is organized and delivered. The ACA is discussed in more detail later in the report. The convergence of these opportunities makes this a pivotal time to achieve sustainable improvements in population health. 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.” In this report, population health is viewed as an ultimate goal toward which the strategies and reforms discussed in subsequent chapters would move the health system. THE PATH TO IMPROVING POPULATION HEALTH Improving population health will require activities in three domains: (1) efforts to address social and environmental conditions that are the primary determinants of health, (2) health care services directed to individuals, and (3) public health activities operating at the population level to address health behaviors and exposures. There is abundant evidence for the benefit and value of activities in each of these domains for achieving the aim of better and more equitable population health (Andrulis, 1998; Commission on Social Determinants of Health, 2008; WHO, 2003). A clear challenge for achieving improved population health is gener- ating an appropriate balance in investment across and within these three domains, clarifying the appropriate roles and tasks for stakeholders in each domain, and improving the integration of activities at the interfaces among the domains. It is in this context that primary care and public health have 1 American Recovery and Reinvestment Act of 2009 (ARRA), HR1, Section 13001, 111th Cong. (February 17, 2009).
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20 PRIMARY CARE AND PUBLIC HEALTH critical roles. Their integration can not only improve the efficiency and ef- fectiveness of each of their functions but also lead to collaboration with other entities that will assist in the improvement of population health. Integration of primary care and public health can serve as a catalyst for cooperation across the entire health system, connecting key stakeholders in communities nationwide. KEY TERMS To discuss the integration of primary care and public health, it is neces- sary to understand what these terms mean broadly and how they are used in this report. Primary Care In 1996, the IOM Committee on the Future of Primary Care defined primary care as “the provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of per- sonal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community” (IOM, 1996, p. 1). The committee emphasized that “primary” means care that is first and fundamental, and declared that primary care is not a specialty or a discipline but an essential function in health care systems. The inclusion of the words “integrated,” “sustained partnership,” and “context of family and community” reflects a prominent population perspective, as well as a responsibility to connect with other actors in the health system. Also embedded in the 1996 report is the inextricable link between mental health and primary care. A paper commissioned for that report, and included as an appendix, asserts that “a sensible vision of primary health care must have mental health care woven into its fabric” (IOM, 1996, p. 285). Primary care providers address a broad range of health issues to which mental health concerns are integral. Mental, behavioral, and physical health are so closely entwined that they must be considered in conjunction with one another. While the nature and role of primary care have been debated and studied at length, it is generally recognized that primary care has the four key features listed in Box 1-1. The importance of primary care is well known and researched. In their review of the literature, Starfield and colleagues (2005) found that areas with the highest numbers of primary care providers have the best health outcomes; people who consistently receive care from a primary care provider have better health outcomes than those who do not; and the characteristics themselves of primary care are associated with good health. Additionally, primary care was found to be associated with a reduction of
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21 INTRODUCTION BOX 1-1 Four Key Features of Primary Care It is person- rather than disease-focused. This focus entails sustained rela- • tionships between patients and providers in primary care practices over time, often referred to as continuity. It provides a point of first contact for whatever people might consider a • health or health care problem. In properly organized health care systems, primary care ensures access to needed services. It is comprehensive. By definition, it can encompass any problem. Many prob- • lems in primary care are ambiguous and defy precise diagnosis. Nonetheless, primary care meets a large majority of patient needs without referral. It coordinates care. Primary care adopts mechanisms that facilitate the • transfer of information about health needs and health care over time. Highly personalized solutions to patients’ problems can be implemented when sus- tained relationships permit deeper knowledge and understanding of individu- als’ habits, preferences, and goals. SOURCE: Starfield and Horder, 2007. health disparities both in the United States and among international popula- tions (Starfield et al., 2005). Primary care is the foundation of the U.S. health system. In the United States, more individuals receive care in primary care settings than in any other setting of formal health care. On average, primary care settings see 11 percent of the entire population each month, compared with 1.3 per- cent for emergency departments and 0.07 percent for academic medical center hospitals (Green et al., 2001). Of interest, these proportions have not changed substantially since the 1950s and 1960s despite the stunning progress of medical knowledge, new technology, and expansion of health services (White et al., 1961). The primary care system in the United States comprises both private providers and those supported by government agencies, such as the Veter- ans Health Administration and the Health Resources and Services Admin- istration (HRSA). HRSA-supported health centers serve nearly 20 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. For example, in its policy paper on primary care, the National Business Group on Health, which represents more than 300 large employers providing health care coverage for 55 million people, asserts that primary care should be the key to efficiency, effectiveness,
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22 PRIMARY CARE AND PUBLIC HEALTH and quality improvement in the nation’s health system (National Business Group on Health, 2010). Both sectors also share the same challenges. As a whole, primary care currently is facing a workforce shortage. The primary care workforce remains a relatively small proportion of the overall workforce compared with other health fields (Bodenheimer et al., 2009; Canadian Labour and Business Centre, 2003; European Observatory on Health Systems and Policies, 2006). During the last decade, the propor- tion of primary care providers fell from nearly a third to now less than a fourth of the output of the graduate medical education system (COGME, 2010; Phillips et al., 2011; Salsberg et al., 2008). This decline goes beyond physicians to include nurse practitioners and physician assistants as well (HRSA, 2010; Jones, 2007). Primary care also faces a chronic problem of relative shortage due to workforce maldistribution (Zhang et al., 2008). Regional shortages have seen little improvement despite federal and state loan repayment programs and the rapid growth of safety net clinics over the last decade (GAO, 2003). In addition to workforce shortages, the increase in chronic diseases has posed challenges for primary care and served to motivate its transformation. Chronic diseases are linked to a number of unhealthy behaviors, such as lack of physical activity, poor nutrition, and tobacco use, but primary care often has struggled to address these behaviors adequately. In recognition of the difficulties associated with treating chronic diseases, the Chronic Care Model (Wagner et al., 2001) was implemented. This initiative emphasized a systematic and more efficient means of improving chronic care management for individual patients (Coleman et al., 2009). In its fullest expression, the Chronic Care Model contained six critical elements—community resources and policies, health care organization, self-management support, delivery system design, decision support, and clinical information systems—and ef- fectively bridged patient care across the practice setting, the delivery system, and the broader community (Bodenheimer et al., 2002) The success of the Chronic Care Model in revitalizing the management of patients with chronic conditions by relying on an interdisciplinary pri- mary care team with aligned objectives and methodology generated interest in redesigning the entire practice of primary care. This interest in reinvent- ing primary care led in turn to interest in the “medical home,” a model first proposed in the 1960s for providing care for children with special needs (Rosenthal, 2008). In the last few years, intensive activity has focused on implementing the “patient-centered medical home,” spurred by funding and research supported by the Centers for Medicare & Medicaid Services (CMS), the Commonwealth Fund, HRSA, and a number of other groups. These efforts are aimed at stimulating new models of care delivery, with primary care teams at the core of the delivery structure. A fully realized patient-centered medical home encompasses the prin-
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23 INTRODUCTION ciple that individual patients are members of a broader community, and that activity within the construct of individual clinical encounters includes links that can be leveraged to generate wellness and prevention beyond the individual patient. A systematic approach to population health, called community-oriented primary care (COPC), is employed in other health systems and has previously been studied by the Institute of Medicine (IOM, 1984). This approach to primary care helped launch the community health center movement in the United States and is still used in some communi- ties. COPC, which is discussed in more detail later in the chapter, offers a model of primary care that more fully embraces public health. There is al- ready some evidence that the foundational relationship between patient and primary care provider can generate dividends for the broader community. Several integrated service delivery networks, such as the Geisinger Health System, Group Health Cooperative of Puget Sound, and HealthPartners, are providing early evidence that accountable care for patient panels and populations can reduce mortality, costs, and unnecessary utilization, and in some cases can improve the fiscal health of hospitals as well (Flottemesch et al., 2011; Grumbach and Grundy, 2010; IOM, 2010). Primary care is well positioned to work with public health on im- proving the health of local populations. The research networks of major primary care provider groups could assist in this effort. Some of primary care’s major concerns include factors that are not present in a clinical set- ting, such as circumstances at the onset of illness, predisposing factors that increase the risk of death and disease, and precipitating factors that lead people to seek care (White, 2000). One of its strengths is that primary care often holds a position of trust in communities and is able to leverage that position in addressing community concerns. This community relationship is exemplified by health centers and other primary care delivery systems, particularly those that use a community-oriented approach. Thus, primary care is working in areas that largely overlap with public health and is stra- tegically placed at the interface of people in communities and the rest of the health care system. Public Health Public health is a dynamic field that continues to evolve to meet the needs of society. While the concept of modern public health emerged in response to the conditions that resulted from industrialization and the subsequent rise in infectious diseases (Rosen, 1993), the issues confront- ing public health look very different today. Although the primary focus of public health has shifted from infectious to chronic diseases, which are more prevalent in today’s society, its emphasis has remained on improving conditions where people spend their lives outside of health care settings.
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24 PRIMARY CARE AND PUBLIC HEALTH While it is generally recognized that a critical component of public health is the services provided under the legal authority of government through health departments, articulating broadly what public health is and does is no easy task. A number of key reports published over the last few decades have presented a vision for public health. The 1988 IOM report The Future of Public Health provides two critical definitions. The first is the mission of public health, defined as “fulfilling society’s interest in assuring conditions in which people can be healthy” (IOM, 1988, p. 140). The second is the substance of public health, defined as “organized community efforts aimed at the prevention of disease and promotion of health. It links many disci- plines and rests upon the scientific core of epidemiology” (IOM, 1988, p. 41). Although the report emphasizes the importance of government health agencies and argues that strengthening the role of health departments would be crucial in moving public health forward in the future, its overall conception of public health is much broader, involving the private sector, community organizations, public–private partnerships, and others. In 2002, the IOM released The Future of the Public’s Health in the 21st Century, which reinforces the idea that public health’s broad mission of ensuring healthy communities requires interactions among a number of health-influencing actors, such as communities, businesses, the media, governmental public health, and the health care delivery system (IOM, 2002). The report notes that health departments are not alone in carrying out the essential public health services listed in Box 1-2. Figure 1-1 depicts BOX 1-2 Essential Public Health Services • Monitor health status to identify community health problems. • Diagnose and investigate health problems and health hazards in the community. • Inform, educate, and empower people about health issues. • Mobilize community partnerships to identify and solve health problems. • evelop policies and plans that support individual and community health D efforts. • Enforce laws and regulations that protect health and ensure safety. • ink people to needed personal health services, and assure the provision of L health care when otherwise unavailable. • Assure a competent public health and personal health care workforce. • valuate effectiveness, accessibility, and quality of personal and population- E based health services. • Research for new insights and innovative solutions to health problems. SOURCE: Public Health Functions Steering Committee, 1994.
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25 INTRODUCTION Health Care Communities Delivery System Government Ensuring the Employers and Conditions for Public Health Businesses Population Health Infrastructure Academia The Media FIGURE 1-1 The intersectoral public health system. SOURCE: IOM, 2002. Figure 1-1.eps an interconnected system of sectors that influence a population’s health, with government public health being one of several actors (IOM, 2002). More recently, the IOM published two in a series of reports called For the Public’s Health, looking at public health in the context of measurement and law (IOM, 2011a,b). A third report, on financing, was published in 2012 (IOM, 2012). These reports provide an opportunity to revisit public health in light of changes in health status in the United States since the IOM’s 1988 report was published. For example, obesity tripled among children and doubled among adults between 1980 and 2008 (CDC, 2011). Recognizing the complex nature of health challenges facing society today, the IOM committee responsible for the report on measurement noted that it is the “complex interactions of multiple sectors that contribute to the production and maintenance of the health of Americans” (IOM, 2011b, p. 21). The prevention of disease, which is a pillar of public health’s work, requires the engagement of all segments of a community. For instance, com- bating the rise in obesity requires encouraging individuals to improve their
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26 PRIMARY CARE AND PUBLIC HEALTH diet and increase physical activity. These efforts require multiple partners, such as schools, employers, urban planners, and policy makers. These vari- ous stakeholders may provide one or more of the essential public health services. For example, a community-based organization may implement a health outreach campaign to educate people about health issues, or a public–private partnership may be engaged to mobilize the community to solve a particular health problem. Traditionally, public health has worked with systems, policy, and the environment to reduce the burden of infectious disease. Improvements in sanitation, food preparation, and water treatment are successful examples of this work. To address more current concerns, public health has turned its attention to fighting chronic disease. Community-based interventions undertaken by public health for the prevention of chronic diseases have proven to be effective (The New York Academy of Medicine, 2009). In addition, some research suggests that making system, policy, and envi- ronmental changes may be effective; for example, French and colleagues (2004) found that an intervention aimed at the school environment resulted in students purchasing healthier foods. In general, the field would benefit from additional efforts to evaluate the effectiveness of these interventions in terms of implementation and outcomes. Public health faces a number of challenges, including insufficient fund- ing to fulfill its mission, a shrinking workforce, and inadequate invest- ments in health information technology (HIT). In its report on public health funding, the Trust for America’s Health found that public health funding had been reduced at the federal, state, and local levels (ASTHO, 2011; NACCHO, 2011; Trust for America’s Health, 2011). Not surpris- ingly, a reduction in the public health workforce has also been documented (ASTHO, 2011; NACCHO, 2011; Trust for America’s Health, 2011). Another concern for public health is the lack of investment, relative to the health delivery system, in HIT. This disparity is exemplified by the distribu- tion of HIT funding in the American Recovery and Reinvestment Act of 2009, which designated $17.2 billon of the total $19.2 billion appropriated for HIT for incentives to be paid to physicians and hospitals to promote the use of electronic health records (Steinbrook, 2009). This lack of investment could pose challenges for public health in managing population-level data. Despite these challenges, public health today continues to meet the changing needs of communities. It encompasses a diverse group of public and private stakeholders (including the health care delivery system) work- ing in a variety of ways to contribute to the health of society. Uniquely positioned among these stakeholders is governmental public health. Because health departments are legally tasked with providing the essential public health services, they are required to work with all sectors of the community.
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27 INTRODUCTION 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 its health needs. Public health defined broadly is much more than governmental public health, yet health departments play a fundamen- tal role in creating healthy communities. Integration Integration is an imprecise term that encompasses a wide variety of definitions. Accordingly, the committee decided it would be too limiting and not helpful to use a narrow definition. For this report, integration of primary care and public health is defined as the linkage of programs and activities to promote overall efficiency and effectiveness and achieve gains in population health. Because integration can take many forms, the committee chose to think conceptually about the variables that influence integration, which include the level at which it takes place, the partners involved, the actions entailed, and the degree to which integration occurs. Levels Integration can take place on many different levels. For this report, two major levels—the agency and local community levels—are addressed. The agency level refers to HRSA, the Centers for Disease Control and Preven- tion (CDC), and other federal agencies. Integration at this level involves largely joint efforts among the leadership of these agencies, as well as the appropriate programmatic staff working together. At the local level, integration efforts are responsive to local health needs and relate to local resources and partners available and willing to work together. While innovative actions are being taken at the local level, many of which are improving the health of local populations, the committee attempted to distinguish clearly between which of these initiatives involve primary care–public health integration and which are innovative but do not necessarily involve integration. The other variables discussed below were used to make this distinction. It should also be noted that at one extreme, either primary care or public health can adopt approaches typical of the other, thereby integrating these functions within an organization. For ex- ample, some public health departments deliver primary care. This report, however, focuses on more formal integration efforts between local primary care and public health organizations.
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34 PRIMARY CARE AND PUBLIC HEALTH shared space where primary care and public health come together routinely and automatically to identify problems and opportunities, plan together, coordinate their work, and undertake joint efforts. In terms of informatics and data collection, primary care and public health often lack interoper- able information systems both within the delivery system and between the delivery and public health systems. This internal fragmentation and external siloing often means that even when entities are willing to integrate, they lack the infrastructure to do so. These challenges notwithstanding, the committee believes that the po- tential benefits of greater integration of primary care and public health are sufficiently promising to merit action now, taking these challenges into account. The call to better integrate primary care and public health is not new. The National Commission on Community Health Services, in a report known as “The Folsom Report” (1966), raised this issue half a century ago by calling for a more comprehensive model of health including both primary care and public health elements; Kerr White’s Healing the Schism revisited this idea in 1991 (White, 1991). While examples of long-term, successful models of integration are not abundant, there appears to be an interest in communities in bringing primary care and public health together to improve population health (see Box 1-3 and Chapter 2). However, the sustainability and scalability of models of integration have been lacking. The key task now is to focus on the challenge of sustainable implementa- tion of community-based models of primary care and public health integra- tion. Critical elements for this task are providing sustained resources and incentives for these models and supporting the infrastructure necessary to weave together the diverse stakeholders across multiple sectors that must participate in their implementation. BOX 1-3 Interest in Collaboration A willingness to collaborate is evident among diverse health disciplines. In 2011, the National Committee on Vital and Health Statistics focused on com- munities as learning health systems and explored a convenience sample of con- temporary examples of local efforts in multiple states to use data to identify and monitor local health needs and problems. Many examples were readily identified and studied in sufficient detail to conclude that, even without formal programs and sufficient infrastructure, these efforts were successful and demonstrated widespread interest in collaboration among community leaders, clinicians, public health departments at various political levels, and academicians to identify local health and health care concerns and new, collaborative ways of responding to them (HHS, 2011a).
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35 INTRODUCTION PREVIOUS INTEGRATION EFFORTS Previous examples of integration of primary care and public health can be found both in the United States and abroad. Efforts in the United States Some prior initiatives have focused on bridging the gap between pri- mary care and public health and the community. For example, efforts have been made in some areas within the United States to adopt COPC models. COPC has been defined as a continual process by which primary health care teams provide care to a defined community on the basis of its assessed health needs through the integration in practice of primary care and public health (IOM, 1984). It is a dynamic, interdisciplinary model for planning, implementing, and evaluating primary care, health promotion, and disease prevention in the community that generally has appealed to practitioners working in underresourced areas with limited access to health care services. The application of COPC in the United States has not been widespread. A recent systematic review found that most articles about COPC did not adhere strictly to the model as originally described (Thomas, 2008). Even with modified models, however, a number of COPC initiatives have been found to generate notable improvements in the delivery of primary care (Merzel and D’Afflitti, 2003; Pickens et al., 2002). COPC models have been implemented internationally as well, with some success (Epstein et al., 2002; Iliffe and Lenihan, 2003). In 1994 the American Medical Association and the American Public Health Association created the Medicine and Public Health Initiative. This effort began with a task force that met for 2 years and outlined shared agendas in several areas. The task force developed seven major recom- mendations for collaboration between primary care and public health: (1) engaging the community, (2) changing the education process, (3) creating joint research efforts, (4) devising a shared view of health and illness, (5) working together in health care provision, (6) jointly developing health care assessment measures, and (7) translating initiative ideas into action (Beitsch et al., 2005, p. 150). Other activities of note included a national congress in 1996, the development of a grant program funded by the Robert Wood Johnson Foundation (Cooperative Actions for Health Program, 2001), and a monograph of examples of collaboration (Lasker and the Committee on Medicine and Public Health, 1997).While the initiative was successful in promoting and showcasing efforts at the local level, commitment at the state and national levels ultimately faltered (Beitsch et al., 2005). Since the Medicine and Public Health Initiative, other, more limited efforts to catalogue and analyze integration initiatives on the ground have
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36 PRIMARY CARE AND PUBLIC HEALTH been undertaken in the United States. These include a review of public– private partnerships that brought together service delivery networks and coalitions of stakeholders focused on public health and community plan- ning (Bazzoli, 1997), an examination of how organizational characteristics and market conditions contribute to collaborations between either com- munity hospitals or community health centers and public health agencies (Halverson et al., 2000), and the American Medical Association’s analysis of effective clinical partnerships between primary care practices and public health agencies (Sloane et al., 2009). While these initiatives point to an enduring interest in integration, they were not part of a sustained effort to promote integration, and none alleviated a steady and persistent relative neglect of both primary care and public health. International Efforts There has been some international recognition of the need to coor- dinate primary care and public health efforts. In 2003, at a primary care strategic planning meeting held to assess the status of health improvement since the Declaration of Alma Ata (WHO, 1978), the World Health Orga- nization noted that “the emphasis placed on community participation and intersectoral collaboration is especially appropriate now, when so many health issues … cannot be effectively addressed by health systems working in isolation” (WHO, 2003, p. 16). The ensuing report on that meeting rec- ommended the strengthening of public health functions in primary health care settings. Likewise, a number of countries have made efforts to imple- ment the integration of primary care and public health. A restructuring of the National Health Service in England placed public health professionals in Primary Care Trusts in an attempt to change the way primary care oper- ates (The NHS Confederation, 2004). In 2000, New Zealand announced changes to its health care system that established District Health Boards with responsibility for both primary care and public health (New Zealand Ministry of Health, 2000). Attempts to reform public health currently are under way in Canada, where a 2005 workshop called for the Public Health Agency of Canada to develop stronger collaboration between primary care and public health (Rachlis, 2009). In addition, McMaster University in Ontario initiated a research program to explore the potential for collabora- tion between primary care and public health and the extent to which such collaborative partnerships currently exist (StrengthenPHC, 2011). STUDY PURPOSE AND APPROACH This study originated in a joint request from HRSA and CDC. With the passage of the ACA, these two agencies, further described in Appendix A,
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37 INTRODUCTION have a unique opportunity to ensure that the provisions they are charged with implementing line up in a way that promotes population health and contributes to an enhanced health system with increased access, improved quality, and reduced costs. These agencies asked the IOM to convene the Committee on Integrating Primary Care and Public Health, whose 17 mem- bers include experts in primary health care, state and local public health, service integration, health disparities, HIT, health care finance, health care policy, public health law, workforce education and training, organization management, and child health. Biographical sketches of the committee members are presented in Appendix D. In clarifying the committee’s charge at its first meeting, the sponsors reiterated their interest in receiving practical, actionable recommendations that could assist both agencies in establishing linkages with each other and with other relevant agencies. Box 1-4 presents the committee’s statement of task. Funding for the study was provided by HRSA, CDC, and the United Health Foundation. In conducting the study, the committee held six open and two closed meetings. The open meetings were held in Washington, DC, and Irvine, California, and included 34 presentations. Four of the open meetings were focused on HRSA and CDC and their work in the areas of maternal and child health, cardiovascular disease prevention, and colorectal cancer screening. The agendas for the open meetings can be found in Appendix C. Members of the general public made comments at the open meetings and submitted documents to the committee. The committee also reviewed the published literature, held discussions with HRSA and CDC, and commis- sioned papers on relevant topics. Finally, a number of consultants assisted the committee; they are listed at the front of the report. While cardiovascular disease prevention was identified as a required area for the study, the committee’s statement of task (Box 1-4) included selecting one or two additional areas. The committee selected maternal and child health (further refined to focus on maternal, infant, and early childhood home visiting) and colorectal cancer screening to complement cardiovascular disease prevention. These three areas flow across the life course and include elements of mental and behavioral health, while also reflecting many of the issues related to health disparities. ORGANIZATION OF THE REPORT This report is organized into five chapters. Chapter 2 summarizes the committee’s literature review, presents a set of principles identified by the committee as necessary for the integration of primary care and public health, and highlights examples from around the country of innovative integration programs. Chapter 3 focuses on the Maternal, Infant, and
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38 PRIMARY CARE AND PUBLIC HEALTH BOX 1-4 Statement of Task The Health Resources and Services Administration (HRSA) and the Centers for Disease Control and Prevention (CDC) have requested that the Institute of Medicine convene a committee of experts to examine ways to better integrate public health and primary care to assure healthy communities. The committee’s work would ultimately result in an evidence-based, integrated model and other recommendations that would help achieve successful linkages between public health and primary care. As part of its work, the committee will address the fol- lowing questions: 1. What does the evidence report as the best methods to improve population health and/or reduce health disparities through integrating or connecting public health and primary care? A. What are the models and factors that promote and sustain effective integration and connection between public health and primary care? B. What are the gaps in evidence? 2. What are the best examples of effective public health and primary care integration and connection that address: A. Demonstrated, shared accountability for population health improvement B. Optimizing the integration of the public health and primary care workforce C. Collaborative governance, financing, and care coordination models in- cluding optimizing reimbursement to health departments for clinical and case management (particularly STDs and TB models) D. Effective use of health information technology (explore the possible role of health departments as data hubs) a. This should include non-patient specific reporting of notifiable condi- tions and health department notification of primary care providers regarding key community health challenges b. This should include patient specific information on i. TB, HIV, HBV perinatal immunization—coordination of care and follow-up to improve outcomes ii. Primary care systems and public health departments as potential hubs (neutral brokers for the community) iii. Sentinel surveillance systems (e.g., autism, birth defects) Early Childhood Home Visiting Program, the Million Hearts initiative, and colorectal cancer screening as examples of how HRSA and CDC can foster and support integration. Chapter 4 describes the policy and funding levers that can promote integration. Finally, Chapter 5 offers conclusions and recommendations. In addition, the report contains four appendixes.
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39 INTRODUCTION c. This should include recommendations on the barriers and steps to make significant progress on exchanging electronic health record generated information E. Promotion of integration for the goal of achieving high quality primary care and public health 3. How can HRSA and CDC use Affordable Care Act provisions (e.g., community transformation grants, prevention strategy, quality strategy, community health center expansion, National Health Services Corps, and other workforce pro- grams) to promote integration of public health and primary care? 4. How can HRSA-supported primary care systems (e.g., Federally Qualified Health Centers, Rural Health Clinics, Ryan White Clinics) and state and lo- cal public health departments effectively integrate and coordinate to improve cardiovascular disease prevention (which would include obesity, tobacco use, aspirin use, blood pressure and cholesterol management) A. One to two additional topics based on Committee input that address issues relevant to health disparities or specific populations a. These should be chosen from among immunization, TB control, STD control, asthma management, falls prevention, behavioral health, SBIRT (screening, brief intervention, and referral to treatment), cancer screen- ing, diabetes mellitus prevention and care, and family planning 5. Within each care area, the committee should address potential actions, needs, or barriers regarding: A. Science B. Finance C. Governance D. Health information technology E. Delivery system and practice F. Policy G. Workforce education and training 6. What actions should CDC and HRSA take to promote these changes? The committee should engage relevant stakeholders and perform a com- prehensive literature review that includes international experiences, to identify promising practices and gaps in integrating public health and primary care. Appendix A provides a broad description of HRSA and CDC. Appendix B offers an overview of HRSA-supported primary care systems and health departments. Appendix C contains the committee meeting agendas. Finally, Appendix D contains the committee biosketches.
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