Primary Care and Public Health Exploring Integration to Improve Population Health (2012) / Chapter Skim
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2 Integration: A View from the Ground
2 Integration: A View from the Ground
Pages 45-78
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From page 45... ...
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.
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From page 46... ...
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.
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From page 47... ...
They found that most of the partnerships they reviewed addressed one of three issues: increasing access of underserved individuals 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)
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From page 48... ...
Incentives for primary care practices and public health agencies to interact included grant requirements that encouraged collaboration, a mutual benefit from collaboration or a shared goal, and positive experiences in prior professional relationships. The more successful partnerships often developed a shared mission with a formalized structure and clearly defined roles.
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From page 49... ...
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 costeffectiveness 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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From page 50... ...
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.
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From page 51... ...
Limitations The most striking aspect of the committee's literature review was the relatively limited number of articles that described robust examples of primary care and public health integration supported by outcomes. This lack of strong examples may be attributable in part to limitations of the review itself.
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From page 52... ...
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.
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From page 53... ...
. Prevention and health promotion Chapter 1 highlights the importance of prevention and health promotion activities for improving population health.
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From page 54... ...
Successful integration efforts often were tailored to the community's strengths and needs. A number of examples were initiated and led by public health entities, often health departments.
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From page 55... ...
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.
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From page 56... ...
The program sought to improve services in both primary care and public health, as well as to enhance communication and coordination of efforts between the two. The program worked to improve the delivery of preventive care in primary care practices and to assist the public health department in implementing intensive home visits to low-income pregnant women and their infants.
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From page 57... ...
While the committee's statement of task included exploring the possible role of health departments as data hubs, the INPC model demonstrates the advantages of having a third party administrate such a hub. In this example, the data hub not only provides a health information exchange for use in individual patient services but also is used for population health analyses that serve public health functions.
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From page 58... ...
A requirement for the track is a scholarly third year focused on community-engaged research, population studies, or other forms of investigation of health systems and their improvement in collaboration with the Duke Center for Community Research, in partnership with the Durham County Health Department. Nongovernmental Public Health Given the broad nature of public health, a number of organizations, such as academic health centers, research networks, or nonprofit groups,
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From page 59... ...
In areas without a strong governmental public health presence, these organizations can substitute for a health department's role in integration, although they usually are not responsible for the breadth of public health services that a health department typically provides. Some examples from the literature review demonstrate promise for integration but do not fit neatly into the committee's criteria for inclusion; these examples illustrate creative engagement of community resources in addressing community health concerns by working with primary care.
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From page 60... ...
These principles are listed below and then illustrated through the case studies that follow. The committee believes that to better integrate primary care and public health, the following principles must be in place: • a shared goal of population health improvement; • community engagement in defining and addressing population health needs; • aligned leadership that -- bridges disciplines, programs, and jurisdictions to reduce frag mentation and foster continuity, -- clarifies roles and ensures accountability, -- develops and supports appropriate incentives, and -- has the capacity to initiate and manage change; 4 Personal communication, J
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From page 61... ...
The case studies described in this section illustrate how communities across the nation are attempting to bring diverse stakeholders together from the primary care and public health sectors to forge alliances aimed at tackling pressing community health problems and promoting population health. Evaluations of these case studies demonstrate that integration can produce improvements in at least some meaningful measures of system performance and patient-oriented outcomes.
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From page 62... ...
Each of the networks -- including the Durham Community Health Network -- is organized and operated by community physicians, hospitals, health departments, and departments of social services under the auspices of the state Medicaid program and with the support of the state medical, hospital, and public health organizations. The networks are funded by small per capita payments from Medicaid, and are responsible for improving outcomes and achieving net savings.
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From page 63... ...
In 2009, DHI funded 10 planning teams charged with developing new methods for reducing morbidity and mortality from diseases identified by the health department as priorities. The 10 teams of community members and clinicians, working with an oversight committee, co-led by the director of public health, and supported by data from the health department and the clinicians' practices, identified seven common elements that could improve health and health care delivery in Durham: (1)
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From page 64... ...
Current implementation strategies are focusing on two communities identified by the teams and a countywide implementation committee as both ready for change and likely to benefit, and detailed planning for integrated community-based care that connects the residents of these communities to local resources is now under way. Principles of Community Engagement The growing array of programs in Durham involving community groups, the health department, and academic and community physicians led to the establishment of a set of Principles of Community Engagement that includes specific rules for designing and planning such programs, whether clinical, educational, or research oriented (Michener et al., 2005, 2008)
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From page 65... ...
The department of public health also is engaged with other stakeholders in broader efforts to integrate primary care and public health to improve population health. One such effort is the San Francisco Health Improvement Partnerships initiative.
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From page 66... ...
The data warehouse is now being used by the department of public health, local Medicaid managed care health plans, and other collaborating agencies to inform strategies for better coordinating services across the primary care, community care, and social services sectors to care for this population more effectively and efficiently. Hepatitis B Quality Improvement Collaborative San Francisco was one of the first cities in the United States to launch a major public health campaign to promote screening for hepatitis B among populations at high risk for chronic hepatitis B
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From page 67... ...
is a local health department with many of the resources and much of the regulatory authority of a state health administration. Over the past decade, many NYC DOHMH programs have embodied the principles of Take Care New York, New York City's comprehensive health policy, which sets goals for population health improvement, generates targeted programs, and monitors their impact and progress toward success (Frieden, 2004)
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From page 68... ...
. 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.
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. Community Outreach NYC DOHMH actively engages with local communities to promote health education and access to care.
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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 cardiovascular health by providing financial incentives.
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From page 71... ...
Table 2-3 highlights the examples and case studies 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.
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From page 72... ...
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.
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From page 73... ...
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.
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From page 74... ...
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.
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From page 75... ...
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 community and a way in which stakeholders could gauge their performance in meeting community needs.
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From page 76... ...
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 integration activities that are already taking place at the local level. Finally, HRSA and CDC could assist in evaluating local integration efforts.
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From page 77... ...
2005. The Indiana network for patient care: A working local health information infrastructure.
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From page 78... ...
2009. Effective clinical partner ships between primary care medical practices and public health agencies.
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