Community Oriented Primary Care New Directions for Health Services Delivery (1983) / Chapter Skim
Currently Skimming:
The Meaning of Community Oriented Primary Care in the American Context
The Meaning of Community Oriented Primary Care in the American Context
Pages 60-103
The Chapter Skim interface presents what we've algorithmically identified as the most significant single chunk of text within every page in the chapter.
Select key terms on the right to highlight them within pages of the chapter.
From page 60... ...
During my senior year in medical school, in what proved to be the central experience of my undergraduate medical education, I worked and studied for 6 months with Professors Kark, Abramson, and their colleagues in South Africa at the Polela Health Center, serving a rural Zulu tribal reserve, and the Lamontville Health Center, serving an extraordinarily diverse periurban, African and Asian population near Durban.i That experience led definitively, if circuitously, to my own attempts at an approximation of community oriented primary care in rural Mound Bayou, Mississippi, and urban Columbia Point, Boston efforts in which Dr.
|
From page 61... ...
All of us in the field claim to be practicing community medicine, yet some of us assert it is a clinical discipline, while others tend to limit it to administrative and management sciences, policy studies, or epidemiology and behavioral science.5 Some see it as consultative to primary care; others insist it must be immersed in primary care and point to the community health center developments of the last two decades as complete examples of community medicine and even of COPC. Still others, interested in COPC as an expansion and clarification of the scope of community medicine, would argue that most of the community medicine efforts of the 1960s illuminated the
|
From page 62... ...
It is the merger of these public health concerns with the clinical practice of medicine, and their application to the defined and socially coherent groupings we call communities, that creates the discipline of community medicine. By "methodology" I mean in particular the application to organized clinical practice of the methods of epidemiology and the behavioral sciences, particularly sociology, social psychology, and anthropology.
|
From page 63... ...
Each one has interfered with the development of a shared understanding of the nature of the field. It is important to review them before examining the operational meaning of something even more specific: community oriented primary care.
|
From page 64... ...
A practice that carries out such analyses may increase its effectiveness and efficiency, identify unsuspected problems, and review what it is doing about them, but that does not, per se, make it a practice of community medicine or community oriented primary care. It is this willingness tO use the word "community" as a catch-all that has made it the battered child of the literature in social and community medicine, more often abused than respected.
|
From page 65... ...
The fallacy lies in the belief that community orientation and awareness are all or most of what is needed to achieve good community medicine. Community oriented primary care is not just an attitude one holds; it is something one does, a set of actions taken regularly and systematically as part of a strategy for changing the health status of a whole population.
|
From page 66... ...
In Julian Tudor Hart's striking phrase, they wanted to move decisively away from the entrepreneurial physician's role as a"medical shopkeeper," passively responding to customers, treating the sick and discarding the apparently healthy.6 They hoped, instead, to exploit the possibilities latent in everyday practice for the development of community health strategies not just patient care plans longer in time and broader in scope. They came to their work committed to community involvement, to "public health" interventions, and even to social and political activism in relation to health.
|
From page 67... ...
in practicing community oriented primary care were not those described by Mullan,7 or reported earlier by Geiger,8 Gordon,9 and others in discussion of community conflict. They were, rather, the absence or insufficiency of the other elements of COPC, particularly the community-based epidemiology.
|
From page 68... ...
It would be as dangerous to the development of COPC as it has been, on occasion, to the general understanding of"community medicine" if we are overgenerous in defining it. CRITERIA FOR COMMUNITY ORIENTED PRIMARY CARE With these fallacies in mind, let us turn to the recent definitions of COPC.
|
From page 69... ...
There is little new about calls for epidemiologic investigation, for the incorporation of behavioral science knowledge into clinical practice, or about the idea of community-as-laboratory. The initial proposals for neighborhood health centers, among many examples, spoke explicitly of defined populations, epidemiologic surveillance, and the merger of"public health" concerns with those of patient-centered clinical practice.
|
From page 70... ...
Community oriented primary care, then, is an approach to medical practice that undertakes responsibility for the health of a defined population, by combining epidemiologic study and social intervention with the clinical care of individual patients, so that the primary care practice itself becomes a community medicine program. Both the individual patient and the community or population are the focus of diagnosis, treatment, and ongoing surveillance.
|
From page 71... ...
Epidemiologists at a health center may study the distribution of respiratory illness in a community in relation to environmental factors in the homes, but that in itself does not assure that there will be a systematic effort on the part of the health center's primary care teams to inquire about those risk factors, nor does it necessarily lead to organized feedback of information tO the community itself in an effort tO reduce or eliminate those at risk. A city health department may conduct an elegant study of the distribution of teenage pregnancies or low-birth-weight infants in a large poverty area; a hospital or health center in that area may use the data in organizing itS outreach, family planning, prenatal care, and pediatric services.
|
From page 72... ...
We have multiple competing providers, selling personal health services to individuals or small groups, not communities. These diverse providers private practitioners, hospital-based or free-standing medical groups, hospital-based outpatient units and emergency rooms, community health centers and the occasional health maintenance organization—are linked loosely, if at all, through referral mechanisms, but not for purposes of data-sharing, program development, surveillance, or risk-factor reduction.
|
From page 73... ...
What is more, a recent study of inequalities in health status in the United Kingdom showed a pattern of persistent and sometimes widening differences in mortality between the social classes.24 The study notes that "despite the creation and the influence of the National Health Service, the health of those in the lower social classes has improved much more slowly than the health of the more affluent." The "lack of improvement and in some respects deterioration" of working class health has been striking over the last 20 years, particularly with regard to the long-term effects of inadequately treated childhood disease; the greatest social class differences are in preventive services and child health. If the mortality rates of the wealthy had
|
From page 74... ...
So long as the practitioner remains in the shopkeeper role, focused on episodic curative activities, the outcomes are not very different: Increased curative medical activity in the United States generates profits and in Britain generates taxes, but in neither case does health status improve. A measureable contribution of clinical practice to improvement in the health status of populations can hardly be expected until there is real regionalization, reward for preventive services, a merger of"public health" and clinical medicine concerns, more community medicine training of physicians and other health workers, and the provision of outreach and epidemiologic resources to practitioners.
|
From page 75... ...
In rural or small-town settings, some are the only providers of care. They include community health centers, singly or in networks; urban and rural health initiative projects; migrant health centers; rural and small-city group practices; and community hospital-based primary care practices.
|
From page 76... ...
. in the cycle of extreme poverty, ill health, unemployment and illiteracy by providing comprehensive health services, based in multidisciplinary community health centers, oriented toward maximum participation of each community in meeting its own health needs and in social and economic changes related to health." The proposed health services were to "include preventive, curative and health education programs in new patterns of medical care organization." They were to "emphasize the formation of community health association .
|
From page 77... ...
More than 30 studies show reduction in admission rates as high as 44 percent and reduction in hospital days per capita ranging from 25 percent to as high as 62 percent.30 One recent analysis, based on surveys in five communities (Atlanta; Boston; Charleston, South Carolina; Kansas City; and East Palo Alto) involving some 20,863 persons, showed that annual days of hospitalization per capita were 50 percent lower for community health center users than for those using outpatient departments and emergency rooms as their primary source of care and 31 percent lower than those who used private physicians as their primary source, holding constant the effects of age, sex, race, education, income, insurance coverage, and health status.3i Another recent study compared Medicaid beneficiaries (AFDC recipients)
|
From page 78... ...
On the contrary, the range of community health center services was usually broader, and repeated audits have shown the quality of health center services to equal those of traditional providers. Perhaps the most important studies, although they are methodologically the most difficult, are those that demonstrate a significant effect of health centers on the health status of their target populations.
|
From page 79... ...
In the other case, a health center accomplished little in the way of continuing community surveillance and epidemiology, but made major efforts at community oriented environmental, health education, and training programs linked to primary care delivery. The East Boston (MA)
|
From page 80... ...
A major part of the funding for the census, the surveys, and epidemiologic analyses comes from research grants rather than from the medical services budget drawn from federal health center grants and third-party reimbursement. The center's publications do not describe in detail the ways in which the community oriented feedback loop is closed: the incorporation of practice data into the epidemiologic work, the transfer of epidemiologic information to center practice, the routines of risk factor surveillance in providing primary care to patients, or the linkage of all of these to community organi
|
From page 81... ...
The major effort, aside from the direct provision of personal health services tO individuals and families, went into other programs. These included: Clinical Services Nutrition Services Family Practice Medicine, Pediatrics, Ob-Gyn, Emergency Services, Minor Surgery, Community Health Nursing and Nurse-Midwifery, Home Health Services, Homemaker Services, Mental Health Services (individual and group counseling, diagnostic psychological, and educational testing)
|
From page 82... ...
Visits to the health center for personal health services in any time period were usually exceeded by individual participation in local community health association activities or by community development, health education, housing repair, and other environmental programs. One study showed that, on the average, some 3,000 individuals each month had contact outside the health center, in the community, with field staff.
|
From page 83... ...
East Boston and Mound Bayou, perhaps, represent the extremes of divergent approaches to COPC in the community health center movement. One is an epidemiologic model and the other a community development model, though both are organized around the provision of primary care clinical services to defined communities.
|
From page 84... ...
study with a residency year or years. The importance of academic links to community oriented practices has already been mentioned.
|
From page 85... ...
the American Academy of Family Practice, the American College of Preventive Medicine, the Association of American Medical Colleges, the Institute of Medicine, and most important- representatives of the Rural Practice Network, the National Association of Community Health Centers, and the various professional societies focused on ambulatory/primary care.
|
From page 86... ...
Software is now available to interface dissimilar computer systems in a single network. Microcomputers have already been used to create automated problem-oriented records for a primary care clinic in Israel4i and for recording and analyzing patient data in prenatal care in Great Britain.42 Microcomputer technology may make possible, at low cost, an extension of the kind of cooperative efforts made by the Mayo Clinic, the-chief provider of primary care services to Rochester, Minnesota, and Olmsted County, and virtually all the other primary care providers serving the area's population, to create a pooled diagnostic register for the area.43 The Mayo Clinic makes 885,000 diagnoses per year, of which about 20 percent pertain to local residents; to these are added the diagnoses made by almost all the physicians in the county.
|
From page 87... ...
The consequences of reduced access to care (whether it is called a procompetition strategy or simply openly presented as budget-cutting of the kind that threatened in 1981 to remove 1.2 million people from access to the services of community health centers) may be heightened by the reappearance of malnutrition and increased environmental hazards for some segments of the population.
|
From page 88... ...
, Neighborhood Health Centers. Lexington: D.C.
|
From page 89... ...
Report presented at the 1981 American Health Planning Association and National Association of Community Health Centers Sympos
|
From page 90... ...
(1981) The Responsiveness and Impacts of Public Health Policy: The Case of Community Health Centers.
|
From page 91... ...
He makes the critical point that it is the synthesis of primary care practice and community epidemiology that forms this unique concept of community oriented primary care. I will not spend my time commenting on the exciting potentials that this concept anticipates, not the least of which is the opportunity for the rejuvenation of professional idealism at the grass roots level, which seems so scarce in these times.
|
From page 92... ...
In those rare institutions that were open to such concerns, there was precious little experience or expertise in primary medical practice or community outreach and sensitivity so that first moves, even though well intentioned, were often not successful. The situation is different today, with departments of family medicine and community or social medicine established in most academic centers and certain institutions having distinguished themselves as leaders in the establishment of neighborhood health centers, area health education centers, and primary care medical and interdisciplinary education.
|
From page 93... ...
If I were responsible for recommending institutional arrangements for maximum secure growth of community oriented primary care practices, I would first pick small delivery sites such as model family practice clinics, health maintenance organizations, and neighborhood health centers, who see such concepts as a clear part of the basic mission but who are also affiliated with academic centers for backup and consultation and support. The small-to-medium HMO is a most promising opportunity for such developments at this time because of their focus on a defined population and because the epidemiology has the potential for increasing cost-effectiveness as well as quality.
|
From page 94... ...
I believe that here in the United States, probably contrary tO some other countries, "community" has been divided into two groups, those who can pay and those who cannot pay. Therefore, we have developed two systems of health services: one, which is based on a private practice model, and another one, which has evolved with some of the community oriented aspects in it and which has taken the form of community health centers and migrant health centers throughout the United States.
|
From page 95... ...
Community health centers and migrant health centers have probably been some of the forerunners in developing or working in the team concept. The economic structure has forced them to actually use a combination of physician, dentist, outreach workers, family health workers, and all supplemental services that back them up.
|
From page 96... ...
Federally funded community health centers and migrant health centers have been forced into some of that epidemiology by reporting requirements. These centers must collect certain data, produce statistics on numbers of people immunized and those who are not, and report on follow-up.
|
From page 97... ...
Abramson's paper and that will give these centers the kind of support in the form of expertise that they need. The funding should also provide for involvement with medical schools both in terms of faculty and students, particularly students that have an obligation to satisfy and have chosen to go to one of the migrant or community health centers.
|
From page 98... ...
The neighborhood health center, close to and responsive to community residents—an idea that has emerged periodically in American history proved particularly attractive to those skeptical about the ability of traditional structures to respond to these new mandates. Less than 3 percent of total public spending went to these programs, while billions of Medicare and Medicaid dollars flowed through the traditional channels of hospital, outpatient clinics' and physicians' offices, and into a new type of provider soon to be named the "Medicaid Mill." Nevertheless,
|
From page 99... ...
These views, which some have described as the counterculture of American medicine, have had a substantial impact on medical education and concepts of medical practice, particularly primary care, family medicine, and the role of new types of health professionals, and, while the vision of a network of a thousand neighborhood health centers spanning the nation never materialized, few hospital outpatient departments, emergency rooms, and even physicians' offices remained untouched by the criticism of crowded waiting rooms, long queues, lack of privacy, and impersonal and sometimes indifferent care. But by the 1970s, with constantly rising medical expenditures, a stagnant economy, and mounting federal and state budget deficits, attention that had been concentrated on access and quality turned to efforts tO curb rising health care expenditures and the search for incentives that would reduce what we now see as excessive use of services and unproductive investment of resources.
|
From page 100... ...
Don Madison, in his paper for this conference, describes the difficulty experienced by a rural neighborhood health center today in maintaining a stable constituency in a community where there are now many competing providers and where those providers now advertise their wares. This presents a very different picture from our earlier view of the rural community health center as a rare and exotic plant, flowering in a landscape empty of health manpower and health care resources.
|
From page 101... ...
But these immediate pressures guarantee that there will continue to be a search for ways to organize and deliver health care that will max~nize the return on resources and anticipate and plan to meet the new demands on these resources that must be expected from changes in the demography of the population and the pattern of health and illness. In these circumstances the concept of community oriented primary care and the additional dimension of its essential relation to an epidemiologic data base become an effective and essential tool for addressing health policy issues in both conceptual and very practical ways.
|
From page 102... ...
For the first time there will be the opportunity to test out on a large scale whether these ways of providing care can work for the Medicaid population. Moving from Massachusetts to the South, and from the initiative of a group of hospitals to the leadership of a state department of health, planning is under way in Tennessee to establish a primary care network of community health centers working in cooperation with public and private institutional providers.
|
From page 103... ...
Montefiore Medical Center in the Bronx is providing the leadership to develop a prepaid health care network designed to offer comprehensive health care services tO Medicaid and other low-income residents of the Bronx. Under this plan, a coalition of community health centers for primary care services would be linked with specialty and inpatient services furnished by participating hospitals, with enrolled Medicaid and lowincome patients covered by a negotiated Medicaid capitation rate.
|
Key Terms
This material may be derived from roughly machine-read images, and so is provided only to facilitate research.
More
information on Chapter Skim is available.