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Overview and Summary Eileen Condor In March 1982 the Institute of Medicine sponsored an invitational Con- ference on Community Oriented Primary Care (COPC). Over the course of 3 days, 120 conference participants from six countries took part in plenary sessions and small group workshops. During the plenary sessions papers were presented and responded to by discussants. Both the major papers and the discussant papers dealt primarily with the theoretical issues of COPC. The workshops provided an opportunity for the participants to listen to case reports by people currently engaged in COPC, to discuss the problems of applying theory to practice, and to suggest creative ways these problems could be solved. Time constraints made plenary discussion im- possible but ample opportunity for discussion was provided in the work- shops. The success of the conference is evidenced by the richness of these proceedings. The contents of this volume reflect the organization and main themes of the March conference. Part I, "Theoretical Issues," covers the meaning and scope of COPC in an historical context, an international perspective on COPC, the problems and opportunities presented by COPC in the current economic and political climate, the role of health workers in COPC, and the education and training of providers of COPC. Part II presents summaries of 16 case reports illustrating the application of COPC principles to medical education and health services delivery in a variety of settingsurban, rural, public, and private. The discussion, conclusions, and suggestions that emerged from the small group workshops are summarized in Part III. COPC is defined at the outset by Sidney Kark and Joseph Abramson. 1

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2 Overview and Summary Their work expands the definition of primary care formulated by the In- stitute of Medicine in 1977, which listed five attributes essential to primary care: accessibility, comprehensiveness, coordination, continuity, and ac- countability. To these attributes COPC adds a community focus and the application of epidemiologic methods to the clinical care of individual pa- tients. COPC is both a general approach to the delivery of services and a specific methodology for defining and intervening in specific health care problems. COPC is not a revolutionary concept. Elements or specific features of the Kark/Abramson model have been present in a variety of programs and practices in the United States and abroad over the past 50 years. Generally lacking, however, has been a synthesis of the elements of community ori- entation, demographic and epidemiologic investigation, personal medical services, environmental intervention, community organization, and health education in a single practice or by a small number of practices and health agencies working as a single system. Several notable exceptions, wherein a synthesis has been approximated, include the Many Farms Project with the Navajo Indians, the CHAD project at Kiryat Hovel in western Jerusalem, Glyncorrwg Health Center in Wales, the East Boston (MA) Neighborhood Health Center, the Beersheva experience in Israel, and the Su Clinica Familiar in Harlingen, Texas. (Glyncorrwg, Beersheva, and Su Clinica Fa- miliar are described in the case reports in Part II.) Where COPC has existed in its "pure" form and/or where significant elements of it seem to have been present and tested, there appears to be an improvement in the health of the populations served. There is some evidence of reduction in infant mortality rates, in prevalence of conditions (hypertension, cigarette smoking, and overweight) shown to be highly cor- related with severe, debilitating diseases, and in costs of hospitalization resulting from preventable diseases. With COPC, as with any effort to grapple with the complexities of primary care delivery, there are both opportunities and constraints that present themselves. In the current economic climate, the targeted and effective use of resources encouraged by COPC is a particularly appealing feature. Moreover, the worldwide commitment to a broad definition of primary care expressed formally at a 1978 World Health Organization conference on primary care in Alma-Ata, U.S.S.R., serves to reinforce and underscore the relevance of COPC. The increase in the number and distribution of physicians and health professionals that has occurred in the last decade and that appears to be continuing has the potential for creating an atmosphere conducive to COPC. As the supply of physicians and health professionals increases there may

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Overview and Summary 3 be a greater emphasis on establishing a stable client population. Market conditions may serve to encourage providers to turn to COPC. Moreover, increased supply may also result in smaller patient loads allowing time for the provision of services essential to COPC, such as health education, counseling, and community involvement. Furthermore, an ever increasing number of health problems are com- munity-related. Health problems rooted in environmental hazards, job- related stress, and/or life-styles occur in individuals but are community- based and require a community orientation for resolution. In addition, the changing demographic profile of the U.S. population suggests that the significant health problems of the next few decades will put a premium on chronic care of an elderly population and will require an approach that considers and takes account of the community being served. COPC affords that approach. Several other factors also represent opportunities for COPC. The ad- vances in microcomputers, which make handling of data both relatively simple and inexpensive, facilitate the aggregation of demographic and ep- idemiologic data that is a basic feature in COPC. Additionally, the current tightening of federal funding, which will force state and local agencies once again to assume responsibility for such functions as health care, may provide the necessary climate for COPC to flourish. Factors that tend to inhibit the development of COPC are not negligible and should be thoroughly considered. These factors were noted by many conference participants. One factor explicitly mentioned by several partic- ipants and that can be inferred from a number of the presentations is the historical association of COPC with underserved populations. In the recent past, programs in this country that have most closely resembled the COPC model have been those programs designed to meet the needs of the un- derserved inner-city minorities, rural populations, and migrant workers, to name a few. As a result of this association, COPC tends to be thought of as a way to organize services for the disadvantaged rather than as a general approach to primary care delivery for a broad base of the population. The presumed limited applicability of COPC can serve to constrain and limit its wider adoption. The variety of perspectives represented and ex- pressed at the conference helped to dispel this notion. Perhaps the greatest impediment to COPC in the United States today is the current reimbursement system which encourages a one-on-one, fee- for-services orientation and a proliferation of discontinuous, high-technol- ogy procedures to treat diseases of individual patients without addressing the concerns of disease prevention and health promotion. Under our current medical care system, a style of medical practice, such as COPC, that em-

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4 Overview and Shimmy phasizes education, social and emotional support of the ill, and identification of those at risk as essential modalities, tends to be superseded by practices and programs that value technological modalities of care. Practices and programs emphasized in COPC are generally not dependent on high technology and therefore do not have the immediate visibility and drama that many medical specialities enjoy today. The preventive, low- technology, common sense approach that characterizes COPC (as well as family and community medicine) has not fared well in competition for prestige and power in academic medical centers. The status factor, therefore, is a real problem in the training and maintenance of practitioners for COPC. Two other factors, perhaps even more fundamental, also serve to inhibit the growth and expansion of COPC: the general unpopularity of the pre- ventive elements of COPC and the cultural belief that responsibility for health should be left in the hands of individuals and that any who would meddle with this responsibility, even when it occurs in the name of health promotion, should be viewed with suspicion. Educating people about the health hazards of certain kinds of behavior is relatively simple and straight- forward; getting these same people to alter their life-style or change their behavior is extremely difficult, and likely to be viewed as self-righteous and intrusive. The importance of these obstacles to the advancement of COPC should not be overlooked. Given that COPC represents a synthesis of a number of disciplines and approaches, the practice of COPC involves the commingling of people with a variety of backgrounds and expertise. Traditional providers of health care- physicians, nurses, and social workers must link up and work closely with epidemiologists, social scientists, and administrators. All of these must look to the community for guidance and advice when diagnosing the com- munity problems, designing and implementing treatment modalities, and evaluating its worth. The community itself must, in some fashion, assume a leadership role in the multidisciplinary health team. The feasibility and effectiveness of such a team and consequently of COPC depends on the cooperative abilities of all the participants. This kind of multidisciplinary team approach, with direction coming from a variety of sources rather than from the physician alone, requires a basic reorien- tation of everyone involved including the patient or consumer of health services. Roles must be clearly defined and educational programs created at all levels in order to produce a cadre of people capable of providing COPC. Strategies for moving in this direction include: . developing COPC role models both in faculties and in practices; expanding practice opportunities for students (medical, nursing, public health, social work, etc.) and residents;

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Overview and Summary 5 . modifying traditional curricula to include elements of COPC such as epidemiology, biostatistics, and management sciences; and . understanding and influencing societal value orientations toward health. The work has begun. Programs such as the Primary Care Curriculum at the University of New Mexico, the Family Practice Program at Case West- ern Reserve University, and the Upper Peninsula Program at Michigan State University (all three are described in Part II) represent valuable at- tempts to implement these strategies. The papers and workshop summaries that constitute this volume give testimony to the success of the conference. They represent the most current thinking on COPC and they reflect the various ideological divisions that tend to characterize any attempt tO blend or synthesize ideas, disciplines, and programs. The collective efforts of all the participants have provided the basis for a new definition of primary care practice that has important implications for the future of health service delivery in the United States. Not satisfied with the state of the art, however, the conference participants made two major suggestions for future COPC activity. First, it was suggested that a COPC data base be developed by compiling the major research data and case reports from community-based, primary care practice experiences around the world. This data base should be pub- lished along with a research agenda that speaks to future needs in the field. Second, the participants suggested that a network of primary care practices affiliated with academic medical centers doing research and training in COPC should be established. This network would function as the basis for collab- orative studies and cooperative training programs to further develop COPC principles and produce COPC practitioners. This volume is intended to provide a firm base upon which tO build these suggested activities. Every effort will be taken to see that they are accom- plished.