2

Integration: A View from the Ground

Recognizing that there are no broadly accepted or implemented models of primary care and public health integration, the committee sought to identify promising examples that would both demonstrate the potential for integration and guide the development and implementation of future integration models. To this end, the committee reviewed the published and gray literature. This chapter describes this literature review, presents key principles derived from the review, and highlights examples thus identified in communities across the United States that both embody the key principles and respond to the committee’s statement of task.

PREVIOUS REVIEWS OF INTEGRATION

As part of its literature review, the committee looked for previous reviews of primary care and public health integration. This search yielded only two major efforts that addressed this topic directly, undertaken by McMaster University (Martin-Misener et al., 2009) and the American Medical Association (Sloane et al., 2009). However, a study conducted by Lasker and the Committee on Medicine and Public Health (1997) provided valuable insights into the integration of medicine and public health. The committee believes all three of these studies are worth highlighting.



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2 Integration: A View from the Ground R ecognizing that there are no broadly accepted or implemented mod- els of primary care and public health integration, the committee sought to identify promising examples that would both demonstrate the potential for integration and guide the development and implementa- tion of future integration models. To this end, the committee reviewed the published and gray literature. This chapter describes this literature review, presents key principles derived from the review, and highlights examples thus identified in communities across the United States that both embody the key principles and respond to the committee’s statement of task. PREVIOUS REVIEWS OF INTEGRATION As part of its literature review, the committee looked for previous reviews of primary care and public health integration. This search yielded only two major efforts that addressed this topic directly, undertaken by McMaster University (Martin-Misener et al., 2009) and the American Medical Association (Sloane et al., 2009). However, a study conducted by Lasker and the Committee on Medicine and Public Health (1997) provided valuable insights into the integration of medicine and public health. The committee believes all three of these studies are worth highlighting. 45

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46 PRIMARY CARE AND PUBLIC HEALTH McMaster University Review of Primary Care and Public Health Collaborations In 2008, McMaster University conducted a literature review to gain an understanding of and derive lessons from examples of primary care and public health collaborations (Martin-Misener et al., 2009). A rigorous search resulted in a collection of 114 articles, published between 1988 and 2008, that described examples of such collaboration occurring across Can- ada, the United States, the United Kingdom, Australia, New Zealand, and Western Europe. After reviewing these examples, the authors drew a num- ber of conclusions about why primary care and public health entities have engaged in collaboration, the types of activities typically carried out in such collaborations, and the major facilitators of and barriers to collaboration. The authors note the wide variety of examples they collected. Differ- ences among localities in organizational structure and community health needs have led primary care and public health to connect in different ways. Collaborative efforts have arisen from policy mandates; from a natural alignment of goals; and in response to specific, shared challenges. These collaborations also have engaged in a broad range of activities. Box 2-1 lists the major areas of activity appearing in the McMaster literature review. The review also found that some collaborations were more successful than others. From the available literature, the authors derived a number of factors that tended to influence the success of collaborative efforts. Table 2-1 identifies some of the facilitators of and barriers to collaboration across different levels of the health care system. Successful collaborations were found to result in improvements in health service delivery, funding and resource allocation, and population health outcomes. The authors recommend further research and evaluation of methods for collaboration between primary care and public health. BOX 2-1 Areas of Activity in Primary Care and Public Health Collaborations • • Community activities Professional education • • Health services Social marketing and communication • • Information systems Steering and advisory functions • • Quality assurance and evaluation Evidence-based practice • • Prevention Health promotion and education • • Teamwork and management Needs assessment and planning SOURCE: Martin-Misener et al., 2009.

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47 INTEGRATION TABLE 2-1 Facilitators of and Barriers to Primary Care and Public Health Collaboration Facilitators Barriers • Government endorsement of • Lack of stable funding for Systems Level the value of collaboration collaborative projects • Sustained government • Lack of adequate funding for funding evaluation of collaboration • Resources available through innovations • Separate, entrenched bureaucracies pooling and sharing • Professional education for medical services and public emphasizing a system- health • Lack of an adequate information wide approach to working collaboratively structure Organizational • Multiprofessional • Lack of a common agenda or vision • A focus on individuals and short- Level involvement • Joint planning by primary term results • Resource limitations care, public health, and the • Lack of capacity to coordinate and community • Clear lines of accountability manage disparate, diverse, and large • Use of a standardized, shared teams • Limited understanding of the needs system for collecting data and disseminating information of communities • Clear roles and • Resistance to change Interactional • Competing priorities and agendas Level responsibilities for all • Poor rapport between primary care partners • Trust, tolerance, and respect and public health, as well as with for partners the community • Effective communication • Inadequate understanding of specific roles and interdisciplinary teamwork SOURCE: Martin-Misener et al., 2009. American Medical Association Review of Partnerships Between Primary Care Practices and Public Health Agencies In 2009, the American Medical Association and the University of North Carolina conducted a review of partnerships between primary care practices and public health agencies (Sloane et al., 2009). Through a review of the published literature and a qualitative study of 48 programs, the authors examined the structure of successful collaborations and the factors that led to partnership formation. They found that most of the partnerships they reviewed addressed one of three issues: increasing access of underserved in- dividuals and populations to primary care, enhancing prevention resources for individuals and communities, and improving the quality of care for people with chronic diseases (Sloane et al., 2009). Partnerships typically

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48 PRIMARY CARE AND PUBLIC HEALTH were initiated by public health professionals. Primary care physicians who were receptive to partnership generally embraced a community-based ap- proach to medicine. Incentives for primary care practices and public health agencies to interact included grant requirements that encouraged collabo- ration, a mutual benefit from collaboration or a shared goal, and positive experiences in prior professional relationships. The more successful part- nerships often developed a shared mission with a formalized structure and clearly defined roles. They were driven by strong leadership and established ongoing communication between the two sectors. Lasker and the Committee on Medicine and Public Health Review of Medicine and Public Health Collaborations In 1997, Lasker and colleagues conducted a study of collaborations between medicine and public health to support the Medicine and Public Health Initiative (Lasker and Committee on Medicine and Public Health, 1997). Examples of such collaborations were solicited from medicine and public health professionals, government health agencies, and other relevant stakeholders. The authors collected and reviewed more than 400 examples, and assessed their structure and the relationships involved. A wide variety of organizations were found to have a role in these collaborations. Box 2-2 lists some of the types of organizations that were identified. These organizations were found to interact in different ways and for different purposes. The authors identified six “synergies” describing the most prominent ways in which resources and skills were combined in a medicine and public health collaboration. Table 2-2 presents these syner- gies, along with examples of how they are carried out. It is important to note that the synergies were not exclusive of one BOX 2-2 Types of Organizations Involved in Medicine and Public Health Collaborations • • Medical practices Academic institutions • • Community-based clinics Professional associations • • Laboratories and pharmacies Voluntary health organizations • • Hospitals Community groups • • Managed care organizations The media • Foundations SOURCE: Lasker and Committee on Medicine and Public Health, 1997.

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49 INTEGRATION TABLE 2-2 Synergies of Medicine and Public Health Collaboration Synergy Examples • Bring new personnel and services to Improving health care by coordinating services for individuals existing practice sites • Establish “one-stop” centers • Coordinate services provided at different sites • Establish free clinics Improving access to care by establishing • Establish referral networks frameworks to provide care for the • Enhance clinical staffing at public health uninsured facilities • Shift indigent patients to mainstream medical settings • Use population-based information to Improving the quality and cost- effectiveness of care by applying a enhance clinical decision making • Use population-based strategies to population perspective to medical practice “funnel” patients to medical care • Use population-based analytic tools to enhance practice management • Use clinical encounters to build Using clinical practice to identify and address community health problems community-wide databases • Use clinical opportunities to identify and address underlying causes of health problems • Collaborate to achieve clinically oriented community health objectives • Conduct community health assessments • Mount health education campaigns Strengthening health promotion • Advocate health-related laws and and health protection by mobilizing community campaigns regulations • Engage in community-wide campaigns to achieve health promotion objectives • Influence health system policy Shaping the future direction of the health • Engage in cross-sector education and system by collaborating around policy, training, and research training • Conduct cross-sector research SOURCE: Lasker and Committee on Medicine and Public Health, 1997.

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50 PRIMARY CARE AND PUBLIC HEALTH another; rather, an example often reflected more than one synergy. In fact, some of the most successful examples were ones in which partners com- bined their resources to address multiple concerns. THE COMMITTEE’S LITERATURE REVIEW The purpose of the committee’s literature review was twofold: to gain an understanding of the prevalence of and methods employed by current and recent integration efforts, and to identify a small set of illustrative programs from which key principles for successful integration could be derived. To meet those aims, the review was limited to articles describing an operational (not a theoretical) program that was active in 2000 or later and involved some level of interaction between primary care and public health with the goal of improving population health. Both domestic and international examples were included. To identify such programs, the committee conducted a search of peer- reviewed journal articles using the PubMed and Medline databases. Key- words relating to the overarching topic areas of primary care, public health, integration, and population health were linked in various combinations using Boolean operators. To supplement the formal literature search, the committee also conducted a grey literature search using the New York Academy of Medicine’s grey literature database and the National Techni- cal Information Service database. Additionally, examples of integration were solicited by querying committee members, stakeholders (including the Health Resources and Services Administration [HRSA] and the Centers for Disease Control and Prevention [CDC]), advocacy and professional orga- nizations, and researchers who had done work in the field). After an initial scan of titles and abstracts for basic relevancy, more than 3,000 articles or case descriptions were identified. Abstracts and summaries of those articles were reviewed for general appropriateness, and any article or case descrip- tion that potentially included a useful example of primary care and public health integration was identified for further review. This process yielded 632 articles. Finally, these remaining articles were carefully read and evaluated based on the strength of linkages between primary care and public health, as well as the robustness of population health outcomes. Preference was given to examples that involved interaction between distinct primary care and public health entities, with an emphasis on the inclusion of health departments. This process yielded a final 100 articles or case descriptions that contained examples of integration for further review. This set of examples was delivered to commissioned authors Philip Sloane and Katrina Donahue, who assessed them based on:

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51 INTEGRATION • scope of the population served; • length of time the program was/has been in operation; • degree of collaboration between primary care and public health; • robustness of the evaluation and outcomes; and • degree of innovation (using the authors’ subjective assessments). The committee supplemented this analysis with additional examples from its members’ own expertise to create a final portfolio of examples. Limitations The most striking aspect of the committee’s literature review was the relatively limited number of articles that described robust examples of pri- mary care and public health integration supported by outcomes. This lack of strong examples may be attributable in part to limitations of the review itself. First, an article describing an example of primary care and public health integration may not identify itself as such; rather, integration ex- amples often are presented as a potential solution to a specific health prob- lem or organizational challenge. Therefore, a search tailored to identifying instances of terms related to primary care, public health, and integration used in conjunction with one another potentially could miss many relevant examples. At the outset, in recognition of this potential limitation, the initial search cast a broad net, yielding more than 3,000 results; however, relevant articles may have been overlooked. In an effort to fill some of these gaps, stakeholders, including HRSA and CDC, and committee members were asked to submit additional relevant examples. A second limitation is that the review was restricted to published articles. There may be a number of effective integration examples in prac- tice that have neither been described nor evaluated in the peer-reviewed literature. A third limitation is that the articles reviewed often provide brief or incomplete descriptions of programs. Many of these articles were written to highlight a program’s impact on specific health outcomes or to describe spe- cific program elements, and articles often were tailored to the perspective of the audience for which they were written—for example, clinical and public health audiences. As a result, it was often difficult to assess the degree and breadth of integration in a program or obtain a complete understanding of the program’s impact. Finally, it is possible that there are fewer examples of integration under way than the committee anticipated, so that fewer were uncovered than was expected. Based on these limitations, the committee believes that the integration

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52 PRIMARY CARE AND PUBLIC HEALTH of primary care and public health could be facilitated by increased evalua- tion efforts. A series of thorough evaluations of integration efforts currently under way would assist in building a knowledge base, which in turn would enable a richer understanding of the processes by which integration can occur successfully and of the outcomes associated with integration. Breadth of Examples Even with the limitations outlined above, the literature contained many promising examples of integration. These examples reflect a wide variety of approaches and highlight a number of ways in which primary care and public health can be aligned to address community health concerns. Focus Areas for Integration Many of the integration examples uncovered by the literature review converged around a specific health issue that was identified as a community area of concern. At times these issues were identified by formal community assessments, but more commonly they were recognized by leaders of one or more of the partners using supporting data. The focus of nearly all of these examples fell into one of three categories: chronic disease, prevention and health promotion, or the health of specific populations. Chronic disease Chronic diseases often have a large public health impact and can require the application of a diverse array of care and management techniques. A number of communities have discovered that the actions of primary care or public health alone are not sufficient to effectively mitigate the impact of chronic diseases on population health. Instead, they have endorsed collaborative, coordinated efforts focused on prevention, care, and outreach that have had some positive results. For example, in response to a statewide increase in the prevalence of diabetes and associated com- plications, the Michigan Department of Community Health implemented the Michigan Diabetes Outreach Network. The network consists of six independent, regional networks that carry out the Department of Com- munity Health’s mission to “create innovative partnerships to strengthen diabetes prevention, detection, and treatment” (Constance et al., 2002, p. 54). The regional networks partner with and support health profession- als, businesses, and community groups to identify and reduce disparities in diabetes care, strengthen community resources, enhance knowledge of the disease among health care professionals, raise community awareness, and facilitate data collection and use. Activities of the regional networks have included public awareness campaigns; the development of systems for use in medical practice to promote adherence to established care guidelines; the

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53 INTEGRATION implementation of health professional education and certification programs in diabetes care; and the initiation of a data collection and reporting system for use by home care providers, physician offices, and diabetes support groups. The program has demonstrated improved health outcomes for Michigan residents with diabetes, as well as a dramatic expansion of the reach and prevalence of community awareness events and health profes- sional education programs (Constance et al., 2002). Prevention and health promotion Chapter 1 highlights the importance of prevention and health promotion activities for improving population health. The impact of these types of activities depends on the ability to reach as much of the target population as possible in a meaningful way. Both primary care and public health have critical roles in prevention and health promotion and are positioned to carry out these roles with differ- ent sets of resources and relationships within the community. Many of the examples from the literature review show that, by linking primary care, public health, and the community, coordinated, cooperative approaches to prevention and health promotion can expand the reach and effectiveness of such endeavors. In a number of cases, a public health partner would seek the involve- ment of primary care providers to assist in a key public health campaign. These collaborative efforts sought to utilize the individual relationship between provider and patient to complement population-level interven- tions. Some examples include public health personnel training primary care providers to deliver evidence-based behavioral interventions and linking primary care providers to public health and community resources such as tobacco quit-lines (Larson et al., 2006; Rothemich et al., 2010). Another approach for integrating around prevention involves primary care, public health, and community groups combining efforts to ensure the broad delivery of clinical preventive services at diverse venues throughout communities. Sickness Prevention Achieved through Regional Collabora- tion (SPARC), a nonprofit agency, implemented this type of method in the New England area (Shenson et al., 2008). In response to low rates of adult vaccination and cancer screening rates in the area, SPARC leadership recognized that primary care alone could not bear the responsibility of en- suring the community-wide delivery of preventive services. Instead, SPARC positioned primary care providers as partners in a community-spanning coalition of public health and community resources. The program brought together public health agencies, hospitals, social service organizations, and advocacy groups to form a network of prevention activities. Coordination among these groups and with primary care helped ensure a broader reach for prevention services and avoided duplication of effort. The inclusion of a variety of community partners led to the development and widespread

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54 PRIMARY CARE AND PUBLIC HEALTH implementation of innovative approaches tailored to community needs. SPARC’s initiatives have been associated with regional improvements in rates of vaccination and cancer screening, and the SPARC coalition-based model has been replicated successfully in other communities (Shenson et al., 2008). Health of specific populations Providing for the health of certain popula- tions, such as the uninsured, who can be difficult to reach, or older persons living alone who require care outside of a health care delivery setting can present challenges that are difficult for either primary care or public health to handle alone. The Iowa Department of Public Health developed its 1st Five Initiative to address gaps in service provision for young children with risk factors for and evidence of developmental delay during the first years of life (Silow-Carroll, 2008). The program links primary care providers to public health resources and mental and behavioral health services. Features of the program include training primary care providers in assessment of social and emotional development, providing a public health care coordina- tor to whom the primary care providers could refer children who screened positive, using the coordinator to link the child and family to intervention services, and providing feedback to the primary care provider on the status and outcomes of the referral. This system fostered a coordinated, collabora- tive approach to care for the developmental needs of at-risk children. Build- ing on its early successes, the initiative had recruited 39 practices serving 41,000 children by 2008 (Silow-Carroll, 2008). Organization for Integration A striking feature that emerged from the literature review is the number of different ways in which integrated efforts were organized. A wide variety of entities were involved in activities and programs that linked primary care and public health. These entities included not only a range of primary care and public health actors but also a number of other contributors, such as businesses, hospitals, academic institutions, and community groups. Ad- ditionally, integrated projects were initiated by public health entities, by primary care entities, and by neutral third-party conveners of the two fields, and across examples the extent of the contribution from primary care and public health was varied. Much of this variation is attributable to differ- ences in communities across the country in terms of available primary care, public health, and community resources, as well as in their populations’ makeup and health priorities. Successful integration efforts often were tai- lored to the community’s strengths and needs. A number of examples were initiated and led by public health enti- ties, often health departments. For instance, the health department of

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55 INTEGRATION Alachua County, Florida, joined with the local public school system and the University of Florida to initiate a program designed to increase rates of influenza vaccination among school-aged children (Tran et al., 2010). A critical component of the program’s success, however, was establishing linkages with primary care providers. Through the vaccination program, children received a free nasal-spray flu vaccine in school, regardless of their insurance status. Children who were ineligible for this vaccine because of underlying medical conditions were referred to their provider for evaluation and the flu shot. This kept private pediatricians in the medical care loop for children with underlying medical conditions, a key component of the medi- cal home concept, as well as a key element in maintaining strong support from community physicians. Both pediatricians and the health department input flu vaccination status into the state’s registry so both groups could share information about their patients.1 In the 3 years since the program became fully operational, immunization rates have increased. In 2009- 2010, the program was able to immunize approximately 55 percent of the student population, and an additional 10 percent who could not receive the nasal-spray flu vaccine for medical reasons were immunized by their care providers. In schools where 80 percent or more of the students were eligible for free or reduced-price lunches, the immunization rate went from 12 percent in the 2006 pilot program to 47 percent in 2009-2010 (Tran et al., 2010). Immunization rates for 2010-2011 were similar.2 While a majority of the integration examples examined by the commit- tee featured public health-led ventures, there were instances of primary care entities initiating successful collaborations. In Milwaukee, the Sixteenth Street Community Health Center initiated a Community Lead Outreach Project designed to assist in the Milwaukee Health Department’s efforts to reduce lead poisoning rates in children by reaching out to an underserved neighborhood. The program employed a team of community outreach workers, led by a nurse-coordinator from the health center. The team conducted home visits, provided blood testing, performed environmen- tal surveys, and reported results to both the health center and the health department for follow-up care and possible intervention. The program resulted in significant decreases in the prevalence of lead poisoning in the area (Schlenker et al., 2001). In some instances, primary care and public health were brought to- gether by a neutral convener, often a nonprofit organization or academic institution. In the SPARC initiative, discussed previously, a nonprofit orga- nization formed a coalition of primary care, public health, and community groups to take a comprehensive approach to expanding the delivery of 1 Personal communication, C. Tran and Parker Small, University of Florida, November 2011. 2 Personal Communication, C. Tran, University of Florida, December 2011.

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68 PRIMARY CARE AND PUBLIC HEALTH Using Electronic Health Records to Support High-Quality Primary Care In line with the Take Care New York agenda, NYC DOHMH has taken aggressive steps to support high-quality health care and the active management of chronic diseases. At the center of this effort is the Primary Care Information Project, which supports physicians in adopting the use of electronic health records to improve population health. The Primary Care Information Project helped initiate the New York City Regional Electronic Adoption Center for Health (REACH) to assist providers in achieving meaningful use of electronic health records, with the capacity to sup- port 4,500 providers. More than 3,500 providers have already enrolled in REACH to meet the meaningful-use criteria and better serve their commu- nities (NYC Reach, 2011). To further its promotion of effective use of information technology, NYC DOHMH launched Health eHearts, a pay-for-performance incentive program that rewards small practices and community health centers for achieving excellent heart health among their patients. Designed to reduce health disparities, Health eHearts uses clinical quality outcomes generated from electronic health records and provides incentives up to $25,000 per quarter to practices showing qualifying improvements in the use of aspirin, blood pressure and cholesterol management, and the promotion of smoking cessation to improve cardiovascular health. By the end of 2010, 42 practices had received an average of $38,000 each for their efforts in these areas (Marcello et al., 2011). Also in 2010, NYC DOHMH launched the Panel Management Program to help primary care providers maintain continuity of care for high-risk patients and those with chronic disease. Using registry features of electronic health records, prevention outreach specialists iden- tify patients who are at risk for diseases associated with hypertension, high cholesterol, smoking, and diabetes, and then contact them with reminders about disease management activities such as making appointments, filling prescriptions, and receiving vaccinations (New York City Department of Health and Mental Hygiene, 2011). Monitoring and Surveillance The Panel Management Program’s capacity for monitoring and evalu- ation is grounded in the Community Health Survey, which regularly sur- veys 10,000 New York City residents to gather data on a variety of health measures. In 2004, a community-level Health and Nutrition Examination Survey was conducted, modeled after the nationwide survey conducted by CDC. The data thus collected resulted in several publications released by NYC DOHMH, including Health Bulletin, which directs its public health messages to city residents (Frieden et al., 2008). In addition, NYC

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69 INTEGRATION DOHMH was one of the first local health departments to implement syn- dromic surveillance—the routine surveillance of health care encounters to detect public health threats—in part to address the threat of a potential bioterrorist attack. NYC DOHMH has partnered with health care facilities to implement systems that provide its staff with nonconfidential data for daily analysis aimed at identifying disease trends and outbreaks by scanning for clustering by symptoms or health care-seeking behavior. NYC DOHMH currently monitors visits to 48 city emergency departments. Every day, hospitals transmit an electronic file to NYC DOHMH containing patients’ chief complaint, age, sex, zip code, and time of visit. The chief complaint is automatically coded as one of four syndromes (respiratory, fever-flu, vomiting, or diarrhea), and standardized analyses are performed 7 days a week by a corps of analysts at NYC DOHMH. Syndromic surveillance has enhanced the ability of public health to monitor community illness in a way that is timelier, though less specific, than traditional surveillance based on laboratory or provider reports (Heffernan et al., 2004). Community Outreach NYC DOHMH actively engages with local communities to promote health education and access to care. It is participating in two home visit- ing programs for new mothers. One of these programs, the Nurse-Family Partnership, aligns nurses with first-time mothers for weekly to biweekly visits until the child is 2 years old (Nurse-Family Partnership, 2011). The second program, the Newborn Home Visiting Program, is localized to Brooklyn, Harlem, and the Bronx. A health worker attempts to visit every new mother to promote health education, breastfeeding, and the reduction of environmental risks in the home. NYC DOHMH also conducts community outreach to promote cancer screening. In 2003, it established the Colonoscopy Patient Navigator Pro- gram to ensure that populations facing greater screening obstacles receive a colonoscopy. The navigators are tasked with helping patients navigate the health system and overcome barriers to screening. By 2007, the Colo- noscopy Patient Navigator Program had assisted more than 25,000 New Yorkers in undergoing colonoscopies. Through this program and other initiatives of Take Care New York, NYC DOHMH has seen remarkable gains in cancer screening, attributable mainly to its ability to partner with local care providers and communities. Overall rates of colon cancer screen- ing have increased substantially since the introduction of Take Care New York—by 43 percent from 2002 to 2006; by 2009, 66 percent of adults over age 50 had been screened for colon cancer within the previous 10 years (Frieden et al., 2008; Marcello et al., 2011).

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70 PRIMARY CARE AND PUBLIC HEALTH Principles of Integration Embedded in the Case Studies The case studies described here illustrate the principles, presented ear- lier, that form the foundation for integrating primary care and public health. Each of these case studies exemplifies a shared goal of population health improvement. This goal was realized in different ways in different locations. In New York, for example, the department of public health took the initiative, but only through joint efforts with primary care providers were improved outcomes possible. In San Francisco, collaborative efforts built on the success of Healthy San Francisco as a health access innovation, and then evolved to embrace a broader vision of population health. The case studies have been presented within the context of their local communities because one unifying theme is the local variability seen in sustainable examples of integration. Community engagement is required throughout the process. In San Francisco, the community was engaged in diverse ways—not only through the traditional primary care and public health sectors but also through community-based social service organiza- tions, political leaders, and academic researchers. Community Care of North Carolina offers a statewide organizational structure, but provides for flexibility for each of the 14 local networks to take action based on lo- cal strengths and needs. In Durham, for example, community engagement guided integration efforts using an approach that recognizes and draws on the strengths of the local community. The third principle, aligned leadership, is embodied in each of these case studies. Aligned leadership involves more than directing a program. It reflects the ability to bridge disciplines, programs, and jurisdictions, as in the case of Durham’s Just for Us, a partnership among a community health center, county social and mental health agencies, an academic health center, and a city housing authority. Aligned leadership also entails the ability to clarify roles and ensure accountability. Community Care of North Caro- lina reflects the development of incentives to encourage integration. The networks created through this partnership are funded by small per capita payments based on the achievement of improved outcomes and net savings. Primary care practices receive additional per capita payments to support their population health activities. Similarly, the public health department in New York City works with primary care providers to promote cardiovas- cular health by providing financial incentives. Developing and supporting appropriate incentives is another aspect of leadership. The final element of aligned leadership is the capacity to initiate and manage change. In mov- ing from the status quo to an innovative approach, each of these examples reflects this element. Making a commitment to sustainability is the fourth principle. This commitment to sustainability is illustrated by San Francisco, where re-

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71 INTEGRATION sources were pooled, and by Community Care of North Carolina, where dedicated funding streams ensure that the program will have an enduring value and an enduring impact. Finally, integration requires that data and analyses be shared and used collaboratively. Integration of data has been central to the work in San Francisco, from linking data sets on high users of multiple services, to agreeing on uniform hepatitis B quality metrics, to identifying existing data sources with which to track progress on physical activity and healthy eating. While the committee believes that all these principles are ultimately necessary to integrate and sustain integration efforts, it also believes that integration can start with any of these principles and that starting is more important than waiting until all the elements are in place. HOW THE EXAMPLES AND CASE STUDIES ILLUSTRATE EFFECTIVE PRIMARY CARE AND PUBLIC HEALTH INTEGRATION The committee’s statement of task included identifying examples for a number of aspects of effective primary care and public health integration. Rather than identify a separate programmatic example for each aspect, however, the committee approached this task by looking for programs that illustrate multiple aspects. Table 2-3 highlights the examples and case stud- ies that relate to each aspect identified in the statement of task. LESSONS LEARNED The literature review provided many valuable lessons about the state of primary care and public health integration. First, it highlighted that there are a wide variety of such activities taking place in communities throughout the United States. These activities embody many different approaches to integration, reflecting the needs of the local community, the available local resources, and the local partners that are willing and able to come together. This emphasis on local differences means there is no generalizable solution to integration that the committee can propose. However, the many impres- sive local efforts can influence action at the federal level. The importance and difficulty of achieving sustainability is another les- son. Many of the partnerships described in the literature were short term, funded by grants and either decreasing in scope or disappearing altogether when the source of external funding dried up. Embedding integration activi- ties in existing structures to ensure that they continue after external funding has stopped is key to sustaining these activities. Sustainability continues to challenge local partners and has limited the impact of successful primary care and public health integration efforts in the past.

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72 PRIMARY CARE AND PUBLIC HEALTH TABLE 2-3 Aspects of Primary Care and Public Health Integration Illustrated by the Examples and Case Studies Aspect Examples Demonstrated, shared Evident in all of the examples, this aspect is especially illustrated by the Community Care North Carolina accountability for population health improvement networks. These networks are led by local physicians, public health officials, and other stakeholders who meet to discuss local health trends and establish statewide priorities for health. Once established, these priorities are taken back to the local community, where local workers determine how the desired result in a given priority area will be achieved. The George Washington University School of Public Optimizing the integration of the Health and Health Services provides its master of public health and primary care workforce public health students with a primary care perspective through its community-oriented primary care (COPC) program. As part of the required practicum, COPC students are expected to work 120 hours in a community setting that offers health services to gain experience in integrating public health initiatives and practices into primary care. To this end, students have participated in practicum experiences covering a wide variety of topics, including hospice care, childhood obesity, community-based rehabilitation, and medication coverage for the elderly. The San Francisco Health Improvement Partnerships Collaborative governance highlight the effectiveness of collaborative governance. The Coordinating Council for the partnerships includes leaders from the primary care and public health sectors, along with many community stakeholders. The diversity of participants in the decision-making process allows for a more comprehensive evaluation of community health challenges and innovative solutions. Embedded in Community Care North Carolina is a Collaborative financing collaborative financing structure in which primary care payments from Medicaid are used in conjunction with public health funding streams to support joint community-level activities, including the coordination of care.

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73 INTEGRATION TABLE 2-3 Continued Aspect Examples Community Care North Carolina has a focus on Collaborative care coordination models the coordination of care and services through its locally managed networks, drawing on the patient- centered medical home and chronic care models. One example is the Just for Us program in Durham, which highlights coordinated primary care and care management for older adults and adults with disabilities in Durham’s public and subsidized housing facilities and group homes. The Indiana Network for Patient Care (INPC) is an Effective use of health information technology, including example of the effective use of health information technology. The system collects data from hospitals, clinics, laboratories, and physicians within the network and uses these data to populate and maintain patient records, to notify local and state departments of public health of laboratory results, and to provide a wealth of epidemiologic data to researchers and public health officials. INPC’s automated notifications system is an example • eporting of notifiable R conditions of the use of health information technology to report the occurrence of notifiable conditions. This system has greatly improved surveillance and reporting of such conditions in Indiana. New York City provides a valuable example of • oordination on care C and follow-up to improve using health information technology to coordinate outcomes care and follow-up to improve outcomes. The Panel Management Program uses prevention outreach specialists to identify patients at high risk of diabetes, high cholesterol, hypertension, and smoking by means of electronic health records and contacts these patients to encourage positive behaviors such as filling prescriptions, making and keeping follow-up appointments, and receiving vaccinations. continued

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74 PRIMARY CARE AND PUBLIC HEALTH TABLE 2-3 Continued Aspect Examples The New York City Department of Health and • rimary care systems P Mental Hygiene provides an example of innovative and public health departments as data collection and analysis performed within a public health department. INPC, on the other potential hubs hand, illustrates a centralized, stakeholder-governed data storage and analysis system that operates independently of primary care and public health systems. The data are controlled by their providers, who are members of the primary care and public health communities; under contract with INPC, they allow some data to be isolated and aggregated with data gathered from other members to create a clearer image of population health. These aggregate data can be accessed by INPC members at the discretion of the owners for the purposes of clinical evaluation, population surveillance, or clinical research. New York City uses a syndromic sentinel surveillance • entinel surveillance S systems system as an early warning system for disease outbreaks. This system requires electronic reporting from emergency departments and ambulance services within 24 hours for encounters involving certain flu- like and gastrointestinal symptoms. It also requires pharmacies to report sales of relevant over-the-counter and prescription medications to public health officials. INPC shows excellent progress on the standardization • rogress on exchanging P electronic health record and dissemination of the information collected from generated information network members. These data are available to provide comprehensive individual health records to network physicians and public health officials, as well as population-based data for epidemiological research. Related to sustainability is the difficulty of achieving scalability. In- tegration activities in local communities rarely are able to move beyond their initial start-up site. There are some exceptions, including SPARC and the case studies. Overall, however, scalability is a challenge in promoting integration. One of the positive lessons is that sharing data and a workforce ap- pears to be a natural way in which primary care and public health can work together. In all of the case studies and many of the examples, sharing data to address community health concerns was foundational for integration efforts. Similarly, the possibility of sharing staff as a way to bring primary care and public health together was a frequent theme in the literature.

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75 INTEGRATION ROLE OF HRSA AND CDC The examples and case studies provide some glimpses of HRSA and CDC involvement: the Community Transformation Grant awarded to San Francisco; health centers involved in various communities; and HRSA’s provision of funding to Regenstrief Institute, Indiana State Department of Health, and the Public Health Informatics Institute to develop guidance for better management of child health (Grannis et al., 2010). However, the agencies were not the genesis of the integration; the integration was already happening at the local level. As mentioned above, the committee believes there are some ways in which HRSA and CDC could make a greater con- tribution to these processes. At a minimum, recognition of the overlapping contributions of the two agencies would be helpful. Whether it be prenatal care; childhood immunization campaigns; prevention, tracking, and treatment of sexually transmitted diseases; cardiovascular disease; or cancer, the work of the two agencies is bound together at the level of the community. But separate project requirements, data systems, and administrative structures compli- cate the coordination of needed services. Coordinated planning between the agencies would assist communities in linking their programs to serve their clientele better and more efficiently. Coordination would assist in reducing the tensions that can exist with respect to which community agency “owns” an issue or program. Which agency or group is leading locally depends on local history and relation- ships. Allowing variation in structure while requiring the achievement of common goals would permit building on local strengths and successes and reduce unnecessary tensions. More broadly, coordination between the agencies could create a space in which others could participate. Improving population health is a task requiring both agencies, but is larger than both combined. Private and aca- demic medical practices, hospitals, schools, social services, mental health agencies, parks and recreation, and community groups all have perspec- tives, strengths, and resources to contribute. Several of the examples and case studies described in this chapter demonstrate the value of an initial primary care–public health partnership that expands to include others. Similarly, the coordination of data collection and tracking would assist local efforts. If health departments and HRSA-supported health centers were tracking the same data and if these data were available locally, the data would provide a common understanding of opportunities for the com- munity and a way in which stakeholders could gauge their performance in meeting community needs. Another point that emerges from the literature is the need to develop the human capital required for integration. Bridging disciplines is not easy

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76 PRIMARY CARE AND PUBLIC HEALTH in the best of times and is much more challenging when there are major stressors and uneven talent and skills. Fundamental shifts are necessary in the training of both primary care and public health practitioners so they can work together effectively in meeting the needs of their communities. The examples and case studies also demonstrate that what is needed is less support for initial integration, although that is still helpful, and more the removal of barriers that impede the development and expansion of in- tegration activities that are already taking place at the local level. Finally, HRSA and CDC could assist in evaluating local integration ef- forts. This would help create a more robust evidence base with associated health and process outcomes. This evidence base, in turn, could illuminate potential benefits and best practices or methods for integration. REFERENCES Bailey, M. B., R. Shiau, J. Zola, S. E. Fernyak, T. Fang, S. K. S. So, and E. T. Chang. 2010. San Francisco Hep B Free: A grassroots community coalition to prevent hepatitis B and liver cancer. Journal of Community Health 36(4):538-551. Barnes-Boyd, C., K. Fordham Norr, and K. W. Nacion. 2001. Promoting infant health through home visiting by a nurse-managed community worker team. Public Health Nursing 18(4):225-235. Bender, B. G., P. Dickinson, A. Rankin, F. S. Wamboldt, L. Zittleman, and J. M. Westfall. 2011. The Colorado asthma toolkit program: A practice coaching intervention from the High Plains Research Network. The Journal of the American Board of Family Medicine 24(3):240-248. Constance, A., K. Crawford, J. Hare, S. Parker, A. Scott, A. Stys, and G. May-Aldrich. 2002. MDON: A network of community partnerships. Family & Community Health 25(3):52-60. Cook, J., J. L. Michener, M. Lyn, D. Lobach, and F. Johnson. 2010. Community collaboration to improve care and reduce health disparities. Health Affairs 29(5):956-958. Duke Center for Community Research. 2010. Durham health innovations. https://www.dtmi. duke.edu/about-us/organization/duke-center-for-community-research/durham-health- innovations (accessed November 15, 2011). Duke University School of Medicine. 2012. Duke primary care leadership track. http://duke- med.duke.edu/modules/ooa_myedu/index.php?id=35 (accessed January 23, 2012). Frieden, T. 2004. Take Care New York: A focused health policy. Journal of Urban Health 81(3):314-316. Frieden, T. R., M. T. Bassett, L. E. Thorpe, and T. A. Farley. 2008. Public health in New York City, 2002-2007: Confronting epidemics of the modern era. International Journal of Epidemiology 37(5):966-977. Gawande, A. 2011. Hot spotters. The New Yorker, January 24. George Washington University School of Public Health and Health Services. No Date. Com- munity-oriented primary care. http://www.gwu.edu/learn/graduateprofessional/finda graduateprogram/fulllistofprograms/communityorientedprimarycare (accessed January 23, 2012). Grannis, S., B. Dixon, and B. Brand. 2010. Leveraging immunization data in the e-health era: Exploring the value, tradeoffs, and future directions of immunization data exchange. Indianapolis, IN: Public Health Informatics Institute and Regenstrief Institute.

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