555908
research-article2014
JPCXXX10.1177/2150131914555908Journal of Primary Care & Community HealthGofin et al
Commentary
Community-Oriented Primary Care (COPC) and the Affordable Care Act: An Opportunity to Meet the Demands of an Evolving Health Care System
Journal of Primary Care & Community Health 2015, Vol. 6(2) 128–133 © The Author(s) 2014 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/2150131914555908 jpc.sagepub.com
Jaime Gofin1, Rosa Gofin1, and Jim P. Stimpson1
Abstract Community-oriented primary care (COPC) is a model of health care delivery that tightly integrates primary care and public health. This model of care, applied around the globe, could be more widely adopted in the United States as clinical delivery systems respond to the growing demand for population health management, which has been driven largely by various provisions of the Affordable Care Act (ACA). For that purpose, there is need for changes in capacitating health professionals and changes in organizational structures that will address the needs and health priorities of the population, considering individual care management in the context of population health for a defined population. This article presents how the Affordable Care Act is an appropriate framework for COPC to succeed and the way forward to develop COPC through practical alternatives for the delivery of primary care within a population context. Keywords community-oriented primary care (COPC), population health, community health, Affordable Care Act Since its inception, the health care industry has been oriented toward providing sick care to individual patients. This orientation, which has been driven largely by financing mechanisms such as fee-for-service, underscores the growing concern about the future supply and performance of the primary care workforce.1 Health care leaders need to address a shift from sick to wellness care2 and from the individual to the community by preparing the required workforce and infrastructure. The objective of this paper is to describe how implementation of community-oriented primary care (COPC) could be an option for addressing the changes in the health system toward population health management motivated by the health reform law.
What Is Community-Oriented Primary Care? Community-oriented approaches to health services integrating individual with population health care have been in place in the United States 3-8 and other countries9-13 largely because of evidence that primary care delivery with a community orientation is associated with more effective, equitable, and efficient health services.14-16 One of the recognized models, COPC, is focused on providing care to a defined population, based on their assessed needs, to improve health status combining primary care and population health.17 To
achieve this aim, the conceptual framework for COPC is based on 5 principles18: (a) responsibility for comprehensive care of a defined population; (b) care based on health needs and its determinants; (c) prioritization of those needs to implement health programs; (d) programs that integrate promotion, prevention, and treatment; and (e) community participation. The process to develop COPC requires (a) defining (geographically, members registered in a practice or as a sociological construct) and characterizing the community to determine health needs, their determinants and assets; (b) prioritization of identified health problems; (c) detailed assessment of the prioritized condition; (d) development and performance of intervention program; (e) surveillance and evaluation; and (f) reassessment of health needs.10 Since its development by Sidney and Emily Kark9,10 in South Africa and in Jerusalem, COPC has a history of improving community health in the United States and 1
College of Public Health, University of Nebraska Medical Center, Omaha, NE, USA Corresponding Author: Jaime Gofin, College of Public Health, Department of Health Promotion, Social and Behavioral Health, 984365, University of Nebraska Medical Center, Omaha, NE 68198-4365, USA. Email: [email protected]
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Gofin et al around the globe,3-13 COPC practices were developed at the local or regional level, favored by transformational leadership, political will, and in cases by health reform. They succeeded in improving chronic diseases control, perinatal health, and child health and development. In the United States, the pioneering work of Jack Geiger, who established health centers in Mississippi and Boston in the 1960s, is the precursor of federally qualified health centers in the United States.19 By the mid-1980s, the Institute of Medicine (IOM) concluded that the primary barriers to more widespread adoption for COPC were fee-for-service financing and the limitations of quantitative evaluation data.20,21 In 2012, the IOM endorsed COPC as a dynamic, interdisciplinary model that integrates primary care and public health creating significant improvements in primary care delivery.22 Community-oriented primary care is aligned with the Triple Aim Initiative,23 seeking to optimize the performance of health systems by addressing the individual patient experience of care, population health and health care costs. Its application is challenging due to economic forces that incentivize fee-for-service and individualized health care.24
Community-Oriented Primary Care and Workforce Development The Affordable Care Act (ACA) offers the opportunity to reorient health care to use less specialized care and more primary care. The transition from individual to community care requires a workforce that has clinical and population health and management skills. There has been progress in health professions schools and residency programs, albeit uneven, in introducing population health–related subjects into the curriculum that can be a basis for learning COPC.25 The Association of American Medical Colleges and the Centers for Disease Control and Prevention have proposed public health competencies for medical schools26 and recommendations have been made by the Advisory Committee on Interdisciplinary, Community-Based Linkages,27 regarding the inclusion of population health in health professions curricula by an interprofessional approach. The IOM has recommended that organizations such as the Health Resources and Service Administration and Centers for Disease Control and Prevention would find regulatory options for medical education funding that would address training in primary care and public health settings, and support programs addressing integration.22 A promising initiative, the Service Scholars Pathway Program, at Tufts University School of Medicine,28 incorporates community medicine during the 4 years of study. Another urban experience is the Training in Urban Medicine and Public Health (TRIUMPH) program in the University of Wisconsin School of Medicine and Public
Health.29 It emphasizes underserved populations and the social determinants of health. Initial evaluations show graduates’ selection of primary care specialties compared with graduates not in the program. Similarly, a program at the University of Illinois College of Medicine at Rockford Rural Medical Education incorporating a COPC project in rural areas has produced graduates that are more likely to choose professions in primary care and practicing in rural areas than those that did not participate in the program.30 The Robert Graham Center has developed COPC curriculum for trainees at community health centers.31 Some surveys show the extent of COPC training in residency programs. A survey of 224 randomly selected family practice residency programs found that less than half of the programs included COPC in their curricula.32 Another survey of 400 physicians and 470 residency directors indicated that almost 40% of the programs teach COPC, but only 7% of the physicians practiced COPC after graduation.33 This suggests that there is capacity to grow COPC in residency programs. Capacity building in COPC can best be realized by interprofessional training. A model of collaboration was developed by Kark in Jerusalem between a Community Health Center providing integrated preventive and curative care to a defined population and a School of Public Health.17,18 An interprofessional team attended to the clinical and community health aspects of the population. This has proven to be an effective and sustainable approach to improve the health of the community while serving as the training ground for health professionals.10,18 Schools of public health that offer COPC-MPH programs are also outlets for academic partnerships for COPC training.34,35
Community-Oriented Primary Care and the Affordable Care Act The ACA will reshape the health care workforce through provisions that transform how medical care is provided in the United States. Several sections of the Act, especially in Title V, aim to increase the size and diversity of the workforce in primary care and public health. For example, Title V funds grants to support programs that promote positive health behaviors and outcomes for medically underserved populations by using community health workers (Sec 5313); training the workforce on primary care in underserved areas (Sec 5403); supporting community-based health workers and the education of primary care providers to improve community health (Sec 5405); and colocating primary and specialty care in community-based mental health settings (Sec 5604). However, the fundamental shift in the US health care system under the ACA occurs through the establishment of accountable care organizations, networks of providers responsible for managing the health of a defined Medicare population (Sec 3022). This section of the Act incentivizes population health management rather than
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individualized patient care. This shift toward population health will require new models of care, many of which will be developed and tested through the newly established Center for Medicare and Medicaid Innovation (Sec. 3021). The ACA provision to develop the Teaching Health Center Graduate Medical Education (THCGME), for primary care residency training in a community based setting36 has potential for increasing the workforce in primary care and introducing innovative curricula in community health. Partnerships with medical schools and teaching hospitals are suggested to further the residents’ clinical training. The ACA provision could alleviate the tension between being a productive practice and providing a residency training program by channeling the resources directly to the THCGME.37
Community-Oriented Primary Care Going Forward The pervasive demand-based system in primary care, the limited time allocated for consultations, and the fragmentation of services requires reorganization to facilitate a continuum of care to a defined population and the management of population health. COPC could provide an expansion and refinement to the patient-centered medical home, to address the need to decrease the use of services and improve quality38and the needs of underserved patients.39 This can be realized through coalition building and partnerships, team development, the use of information technology and new forms of payment.
Coalition Building and Partnerships Community collaboratives have been built to use common resources more effectively to improve care and access to care. For example, the Camden Coalition of Health Care providers in New Jersey40 was developed to improve care for a complex population consuming multiple fragmented and uncoordinated services, while decreasing costs. The collaborative concept could be expanded to include those at risk and the healthy to promote their health, forming Accountable Care Organizations. Community collaboratives in several cities in Texas, New York, Hawaii, and others could be a model of how to use their common resources more effectively to improve access to care, health and behaviors; impact their environment and promoting economic development.41 The Folsom report42 recommends a “community of solutions” to address health problems in cooperation with other agencies. The trend of hospital mergers and acquisitions could be a catalyzer in an integrated system of care. While there is concern this will lead to increasing costs and fewer choices, strategies have been suggested to counteract this trend such as limiting providers networks, supporting formation of physician organizations, reference pricing for services and
procedures, and providing opportunities for government regulation.43 An organizational decision to use the merged services to serve a defined population (“the community”) to perform a needs assessment (already mandated) and develop programs for priority conditions could assist the development of COPC services. Collaboration with health departments can contribute to this endeavor.44
Team Development The ACA is increasing the number of patients accessing primary care. The inclusion of prevention and promotion activities and the identification of the sick not under care and those who have not accessed the service will require reorganization of teams and the development of new skills. COPC is in line with recent guidance on alleviating the primary care workforce shortage such as practices pooling physicians, expanding the role of allied health professionals, and enabling continuity of care by using electronic records,45 or providing innovative solutions to primary care.46 However, it was found that most primary care innovations provided additional resources to address specific diseases rather than changing practice organization.47 In the implementation of a COPC practice, the physician will be redefined as a leader of a high-performing primary care team.48 This transformation would help alleviate the primary care physician shortage,45,49 or demand–capacity mismatch.50
Information Technology The growing trend in the use of electronic health records51 that was enabled by the ACA could be a tool to enable population health management.52 Electronic health records can assist medical teams in incorporating COPC activities such as defining the population under care, establishing the denominator population; performing health assessments; health surveillance and evaluation of care; and assessing quality improvement. The use of integrated medical records53 could help teams to deliver more efficient care for chronic diseases and preventive care by improving communication about the patient.54
Payment Several initiatives are being proposed and tested to reform the current fee-for-service. One of those is transition to a physician payment system that rewards quality and valuebased care.55 Studies on the effectiveness of Pay-forPerformance, which addresses improving quality, efficiency, and overall value of health care, has shown conflicting results. There is also concern that this system of payment may exacerbate health disparities, if disadvantaged populations, which are likely to decrease the providers’ performance scores, are avoided.56
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Gofin et al New models of financing care tested through the Center for Medicare & Medicaid Services Innovation Center,57 such as capitated payments and value-based care, will enable new delivery models that will be community-based and seek to keep the population healthy rather than waiting for the sick to come into the clinic. Accountable Care Organizations are one model of care that is being tested and early results suggest this delivery and financing model is shifting clinical organizations toward population health management, medical homes, and team-based care.58 A financing system that supports population health, proactive care, and prevention would contribute to the delivery of COPC.
Conclusions Amid the challenges of the Health Care Reform, the ACA offers a window of opportunity to change the health care system. COPC has the potential to pushing health care away from mainly sick care and toward prevention of disease and promotion of health, integrating individual care and population health. As a result of the ACA, the current policy climate provides an opportunity to test the COPC approach in terms of management, efficiency, and sustainability. Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The author(s) received no financial support for the research, authorship, and/or publication of this article.
References 1. Dill MJ, Salsberg ES. The complexities of physician supply and demand: projections through 2025. Center for Workforce Studies. Association of American Medical Colleges. November 2008. https://members.aamc.org/eweb/upload/ The%20Complexities%20of%20Physician%20Supply.pdf. Accessed March 11, 2014. 2. National Prevention Council, National Prevention Strategy, Washington, DC: US Department of Health and Human Services, Office of the Surgeon General, 2011. http://www. surgeongeneral.gov/initiatives/prevention/strategy/report. pdf. Accessed March 11, 2014. 3. Pickens S, Boumbulian P, Anderson RJ, Ross S, Phillips S. Community-oriented primary care in action: a Dallas story. Am J Public Health. 2002;92:1728-1732. 4. Deuschle KW. Community-oriented primary care: lessons learned in three decades. J Community Health. 1982;8: 13-22. 5. Geiger JH. Community-oriented primary care: a path to community development. Am J Public Health. 2002;92: 1713-1716.
6. Connor E, & Mullan F, eds. Community Oriented Primary Care: New Directions for Health Services Delivery. Washington, DC: National Academies Press; 1983. 7. Nutting P, ed. Community Oriented Primary Care: From Principle to Practice (HRSA publication No. HRS-A_PE 86-1). Washington, DC: US Department of Health and Human Services; 1987. 8. Rhyne RL, Bogue R, Kukulka A, & Fulmer H, eds. Community Oriented Primary Care: Health Care for the 21st Century. Washington, DC: American Public Health Association; 1998. 9. Kark SL, Kark E. Promoting Community Health—From Pholela to Jerusalem. Johannesburg, South Africa: Witwatersrand University Press; 1999. 10. Epstein L, Gofin J, Gofin R, Neumark Y. The Jerusalem experience: three decades of service, research, and training in community-oriented primary care. Am J Public Health. 2002;92:1717-1721. 11. Mullan F, Epstein L. Community-oriented primary care: new relevance in a changing world. Am J Public Health. 2002;92:1748-1755. 12. Gofin J, Foz G. Training and application of community oriented primary care (COPC) through family medicine in Catalonia, Spain. Fam Med. 2008;40:196-202. 13. Iliffe S, Lenihan P, Wallace P, Drennan V, Blanchard M, Harris A. Applying community-oriented primary care methods in British general practice: a case study. Br J Gen Pract. 2002;52:646-651. 14. Starfield B. Refocusing the system. N Engl J Med. 2008;359:2087-2091. 15. Starfield B, Shi L, Macinko J. Contribution of primary care to health systems and health. Milbank Q. 2005;83:457-502. 16. Macinko J, Starfield B, Shi L. The contribution of primary care systems to health outcomes within Organization for Economic Cooperation and Development (OECD) countries, 1970-1998. Health Serv Res. 2003;38:831-865. 17. Kark SL. The Practice of Community-Oriented Primary Health Care. New York, NY: Appleton-Century-Crofts; 1981. 18. Gofin J, Gofin R. Essentials of Global Community Health. Sudbury, MA: Jones & Bartlett Learning; 2011. 19. National Association of Community Health Centers. Press kit. http://www.nachc.com/press-kit.cfm. Accessed July 6, 2014. 20. Nutting PA, Connor EM. Community-oriented primary care: an examination of the US experience. Am J Public Health. 1986;76:279-281. 21. Nutting PA, Wood M, Connor EM. Community oriented primary care in the United States. JAMA. 1985;253:1763-1766. 22. Institute of Medicine. Primary Care and Public Health— Exploring Integration to Improve Population Health. Washington, DC: National Academies Press; 2012. 23. Berwick DM, Nolan TW, Whittington J. The triple aim: care, health and cost. Health Aff (Millwood). 2008;27:759-769. 24. McCarthy D, Klein S. The triple aim journey: improving population health and patient’s experience of care while reducing costs. Commonwealth Fund pub.1421.48:1-11. http:// www.commonwealthfund.org/~/media/Files/Publications/ Case%20Study/2010/Jul/Triple%20Aim%20v2/1421_ McCarthy_triple_aim_overview_v2.pdf. Accessed March 11, 2014.
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25. Gourevitch MC. Population health and the academic medical center: the time is right. Acad Med. 2014;89:1-6. 26. Mahoney JF, Fox MD, Chheda SG. Overcoming challenges to integrating public and population health into medical curricula. Am J Prev Med. 2011;41(4 suppl 3):S170-S175. 27. Redesign health professions education and practice to prepare the interprofessional team to care for populations. Twelfth annual report to the Secretary of the United States Department of Health Human Services and the Congress of the United States, August 2013. http://www.hrsa.gov/advisorycommittees/bhpradvisory/acicbl/Reports/twelfthreport_. pdf. Accessed March 11, 2014. 28. New Tufts University Program Prepares Medical Students for Careers in Underserved Communities. Tufts Now. http://now. tufts.edu. Accessed March 11, 2014. 29. Haq C, Stearns M, Brill J, et al. Training in Urban Medicine and Public Health: TRIUMPH. Acad Med. 2013;88:352-363. 30. MacDowell M, Glasser M, Hunsaker M. A decade of rural physician workforce outcomes for the Rockford Rural Medical Education (RMED) Program, University of Illinois. Acad Med. 2013;88:1941-1947. 31. COPC curriculum, The Robert Graham Center. http://www. graham-center.org/online/graham/home/tools-resources/ copc/copc-resources.htm. Accessed July 6, 2014. 32. Plescia M, Konen JC, Lincourt A. The state of community medicine training in family practice residency programs. Fam Med. 2002;34:177-182. 33. Longlett SK, Phillips DM, Wesley RM. Prevalence of community-oriented primary care knowledge, training, and practice. Fam Med. 2002;34:183-189. 34. MPH-COPC. George Washington University. School of Public Health and Health Services. http://sphhs.gwu.edu/programs/community-oriented-primary-care. Accessed March 11, 2014. 35. MPH-COPC. University of Nebraska Medical Center College of Public Health. http://unmc.edu/publichealth/mph_prog. htm#CommunityOrientedPrimaryCare. Accessed March 11, 2014. 36. Chen C, Chen F, Mullan F. Teaching health centers: a new paradigm in graduate medical education. Acad Med. 2012;87:1752-1756. 37. Reynolds PP. The teaching community health center: an idea whose time has come. Acad Med. 2012;87:1648-1650. 38. Friedberg MW, Schneider EC, Rosenthal MB, Volpp KG, Werner RM. Association between participation in a multipayer medical home intervention and changes in quality, utilization, and costs of care. JAMA. 2014;311:815-825. 39. Mead H, Andres E, Regenstein M. Underserved patients’ perspectives on patient-centered primary care: does the patientcentered medical home model meet their needs? Med Care Res Rev. 2014;71:61-84. 40. The Camden Coalition of Health Care Providers. http://www. camdenhealth.org/programs/care-management-program. Accessed, March 11, 2014. 41. Institute for Alternative Futures. Community health centers leveraging the social determinants of health. Alexandria, VA. March 2012. http://kresge.org/sites/default/files/IAFCHCsLeveragingSDH.pdf. Accessed, March 11, 2014.
42. The Folsom group. American Board of Family Medicine Young Leaders Advisory Group. Communities of Solution: The Folsom Report Revisited. Ann Fam Med. 2012;10: 250-260. 43. Ginsburg PB, Pawlson G. Seeking lower prices where providers are consolidated: an examination of market and policy strategies. Health Affairs Web First, published online May 19, 2014. http://content.healthaffairs.org/content/early/ 2014/05/13/hlthaff.2013.0810. Accessed July 20, 2014. 44. Shaw FE, Asomugha CN, Conway PH, Rein AS. The patient protection and Affordable Care Act: opportunities for prevention and public health. Lancet. 2014;384:75-82. 45. Green LV, Savin S, Lu Y. Primary care physician shortages could be eliminated through use of teams, non-physicians and electronic communication. Health Aff (MIllwood). 2013;32:11-19. 46. Chen PG, Mehrotra A, Auerbach DI. Do we really need more physicians? Responses to predicted primary care physician shortages. Med Care. 2014;52:95-96. 47. Friedman A, Hahn KA, Etz R, et al. A typology of primary care workforce innovations in the United States since 2000. Med Care. 2014;52:101-111. 48. Margolius D, Bodenheimer T. Transforming primary care: from past practice to the practice of the future. Health Aff (Millwood). 2010;29:779-784. 49. Kirch DG, Henderson MK, Dill MJ. Physician workforce projections in an era of health care reform. Annu Rev Med. 2012;63:435-445. 50. Bodenheimer TS, Smith MD. Primary care: proposed solutions to the physician shortage without training more physicians. Health Aff (Millwood). 2013;32:1881-1886. 51. Hsiao C-J, Hing E, Ashman J. Trends in electronic health record system use among office-based physicians: United States, 2007-2012. Natl Health Stat Report. 2014;(75): 1-18. 52. Green L, Lischko A, Bernstein T. Realizing the potential of All-payer Claims Databases. January 2014. http://www.rwjf. org/content/dam/farm/reports/issue_briefs/2014/rwjf409989. Accessed March 11, 2014. 53. DesReches CM, Painter MW, & Jha AK, eds. Health information technologies in the United States: better information systems for better care, 2013. Robert Wood Johnson Foundation. http://www.rwjf.org/content/dam/farm/reports/reports/2013/ rwjf406758. Accessed March 11, 2014. 54. Davis K, Stremikis K, Squires D, Schoen C. 2014 update. Mirror, mirror on the wall. How the performance of the U.S. health care system compares internationally. http://www. commonwealthfund.org/publications/fund-reports/2014/jun/ mirror-mirror. Accessed July 6, 2014. 55. The National Commission on Physicians Payment Reform. March 2013. http://physicianpaymentcommission.org/report/. Accessed July 6, 2014. 56. Fleming C. Health Policy Brief: “Pay-for-Performance”. Health Aff (Millwood). October 11, 2012. http://health-affairs. org/blog/2012/10/11/health-policy-brief-pay-for-performance/. Accessed October 3, 2014. 57. Center for Medicare & Medicaid Services. Innovation Center. http://innovation.cms.gov. Accessed March 11, 2014.
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Gofin et al 58. DeVore S, Champion RW. Driving population health through accountable care organizations. Health Aff (Millwood). 2011;30:41-50.
Author Biographies Jaime Gofin, MD, MPH, is Professor of Public Health and Director of the COPC MPH Program at the College of Public Health of the University of Nebraska Medical Center. Former Director of the Community Health Center in Jerusalem where COPC was developed and taught, and of the COPC MPH Program at GWU in Washington DC. Dr. J. Gofin has developed and conducted COPC capacity building programs in different countries.
Rosa Gofin, MD, MPH, is Professor of Public Health at the College of Public Health of the University of Nebraska Medical Center. She has practiced, taught and researched COPC in the Community Health Center in Jerusalem in the area of Maternal of Child Health; Dr. Gofin has developed COPC capacity building programs for health professionals and students and served as advisor on community health in diverse countries. Jim P. Stimpson, PhD, is the founding Director of the Center for Health Policy, Senior Policy Analyst for Government Affairs, and Associate Professor of Public Health at the University of Nebraska Medical Center. Dr. Stimpson’s research and teaching interests are health policy and the social determinants of population health.
Downloaded from jpc.sagepub.com at University of Sussex Library on July 26, 2015
research-article2014
JPCXXX10.1177/2150131914555908Journal of Primary Care & Community HealthGofin et al
Commentary
Community-Oriented Primary Care (COPC) and the Affordable Care Act: An Opportunity to Meet the Demands of an Evolving Health Care System
Journal of Primary Care & Community Health 2015, Vol. 6(2) 128–133 © The Author(s) 2014 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/2150131914555908 jpc.sagepub.com
Jaime Gofin1, Rosa Gofin1, and Jim P. Stimpson1
Abstract Community-oriented primary care (COPC) is a model of health care delivery that tightly integrates primary care and public health. This model of care, applied around the globe, could be more widely adopted in the United States as clinical delivery systems respond to the growing demand for population health management, which has been driven largely by various provisions of the Affordable Care Act (ACA). For that purpose, there is need for changes in capacitating health professionals and changes in organizational structures that will address the needs and health priorities of the population, considering individual care management in the context of population health for a defined population. This article presents how the Affordable Care Act is an appropriate framework for COPC to succeed and the way forward to develop COPC through practical alternatives for the delivery of primary care within a population context. Keywords community-oriented primary care (COPC), population health, community health, Affordable Care Act Since its inception, the health care industry has been oriented toward providing sick care to individual patients. This orientation, which has been driven largely by financing mechanisms such as fee-for-service, underscores the growing concern about the future supply and performance of the primary care workforce.1 Health care leaders need to address a shift from sick to wellness care2 and from the individual to the community by preparing the required workforce and infrastructure. The objective of this paper is to describe how implementation of community-oriented primary care (COPC) could be an option for addressing the changes in the health system toward population health management motivated by the health reform law.
What Is Community-Oriented Primary Care? Community-oriented approaches to health services integrating individual with population health care have been in place in the United States 3-8 and other countries9-13 largely because of evidence that primary care delivery with a community orientation is associated with more effective, equitable, and efficient health services.14-16 One of the recognized models, COPC, is focused on providing care to a defined population, based on their assessed needs, to improve health status combining primary care and population health.17 To
achieve this aim, the conceptual framework for COPC is based on 5 principles18: (a) responsibility for comprehensive care of a defined population; (b) care based on health needs and its determinants; (c) prioritization of those needs to implement health programs; (d) programs that integrate promotion, prevention, and treatment; and (e) community participation. The process to develop COPC requires (a) defining (geographically, members registered in a practice or as a sociological construct) and characterizing the community to determine health needs, their determinants and assets; (b) prioritization of identified health problems; (c) detailed assessment of the prioritized condition; (d) development and performance of intervention program; (e) surveillance and evaluation; and (f) reassessment of health needs.10 Since its development by Sidney and Emily Kark9,10 in South Africa and in Jerusalem, COPC has a history of improving community health in the United States and 1
College of Public Health, University of Nebraska Medical Center, Omaha, NE, USA Corresponding Author: Jaime Gofin, College of Public Health, Department of Health Promotion, Social and Behavioral Health, 984365, University of Nebraska Medical Center, Omaha, NE 68198-4365, USA. Email: [email protected]
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Gofin et al around the globe,3-13 COPC practices were developed at the local or regional level, favored by transformational leadership, political will, and in cases by health reform. They succeeded in improving chronic diseases control, perinatal health, and child health and development. In the United States, the pioneering work of Jack Geiger, who established health centers in Mississippi and Boston in the 1960s, is the precursor of federally qualified health centers in the United States.19 By the mid-1980s, the Institute of Medicine (IOM) concluded that the primary barriers to more widespread adoption for COPC were fee-for-service financing and the limitations of quantitative evaluation data.20,21 In 2012, the IOM endorsed COPC as a dynamic, interdisciplinary model that integrates primary care and public health creating significant improvements in primary care delivery.22 Community-oriented primary care is aligned with the Triple Aim Initiative,23 seeking to optimize the performance of health systems by addressing the individual patient experience of care, population health and health care costs. Its application is challenging due to economic forces that incentivize fee-for-service and individualized health care.24
Community-Oriented Primary Care and Workforce Development The Affordable Care Act (ACA) offers the opportunity to reorient health care to use less specialized care and more primary care. The transition from individual to community care requires a workforce that has clinical and population health and management skills. There has been progress in health professions schools and residency programs, albeit uneven, in introducing population health–related subjects into the curriculum that can be a basis for learning COPC.25 The Association of American Medical Colleges and the Centers for Disease Control and Prevention have proposed public health competencies for medical schools26 and recommendations have been made by the Advisory Committee on Interdisciplinary, Community-Based Linkages,27 regarding the inclusion of population health in health professions curricula by an interprofessional approach. The IOM has recommended that organizations such as the Health Resources and Service Administration and Centers for Disease Control and Prevention would find regulatory options for medical education funding that would address training in primary care and public health settings, and support programs addressing integration.22 A promising initiative, the Service Scholars Pathway Program, at Tufts University School of Medicine,28 incorporates community medicine during the 4 years of study. Another urban experience is the Training in Urban Medicine and Public Health (TRIUMPH) program in the University of Wisconsin School of Medicine and Public
Health.29 It emphasizes underserved populations and the social determinants of health. Initial evaluations show graduates’ selection of primary care specialties compared with graduates not in the program. Similarly, a program at the University of Illinois College of Medicine at Rockford Rural Medical Education incorporating a COPC project in rural areas has produced graduates that are more likely to choose professions in primary care and practicing in rural areas than those that did not participate in the program.30 The Robert Graham Center has developed COPC curriculum for trainees at community health centers.31 Some surveys show the extent of COPC training in residency programs. A survey of 224 randomly selected family practice residency programs found that less than half of the programs included COPC in their curricula.32 Another survey of 400 physicians and 470 residency directors indicated that almost 40% of the programs teach COPC, but only 7% of the physicians practiced COPC after graduation.33 This suggests that there is capacity to grow COPC in residency programs. Capacity building in COPC can best be realized by interprofessional training. A model of collaboration was developed by Kark in Jerusalem between a Community Health Center providing integrated preventive and curative care to a defined population and a School of Public Health.17,18 An interprofessional team attended to the clinical and community health aspects of the population. This has proven to be an effective and sustainable approach to improve the health of the community while serving as the training ground for health professionals.10,18 Schools of public health that offer COPC-MPH programs are also outlets for academic partnerships for COPC training.34,35
Community-Oriented Primary Care and the Affordable Care Act The ACA will reshape the health care workforce through provisions that transform how medical care is provided in the United States. Several sections of the Act, especially in Title V, aim to increase the size and diversity of the workforce in primary care and public health. For example, Title V funds grants to support programs that promote positive health behaviors and outcomes for medically underserved populations by using community health workers (Sec 5313); training the workforce on primary care in underserved areas (Sec 5403); supporting community-based health workers and the education of primary care providers to improve community health (Sec 5405); and colocating primary and specialty care in community-based mental health settings (Sec 5604). However, the fundamental shift in the US health care system under the ACA occurs through the establishment of accountable care organizations, networks of providers responsible for managing the health of a defined Medicare population (Sec 3022). This section of the Act incentivizes population health management rather than
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individualized patient care. This shift toward population health will require new models of care, many of which will be developed and tested through the newly established Center for Medicare and Medicaid Innovation (Sec. 3021). The ACA provision to develop the Teaching Health Center Graduate Medical Education (THCGME), for primary care residency training in a community based setting36 has potential for increasing the workforce in primary care and introducing innovative curricula in community health. Partnerships with medical schools and teaching hospitals are suggested to further the residents’ clinical training. The ACA provision could alleviate the tension between being a productive practice and providing a residency training program by channeling the resources directly to the THCGME.37
Community-Oriented Primary Care Going Forward The pervasive demand-based system in primary care, the limited time allocated for consultations, and the fragmentation of services requires reorganization to facilitate a continuum of care to a defined population and the management of population health. COPC could provide an expansion and refinement to the patient-centered medical home, to address the need to decrease the use of services and improve quality38and the needs of underserved patients.39 This can be realized through coalition building and partnerships, team development, the use of information technology and new forms of payment.
Coalition Building and Partnerships Community collaboratives have been built to use common resources more effectively to improve care and access to care. For example, the Camden Coalition of Health Care providers in New Jersey40 was developed to improve care for a complex population consuming multiple fragmented and uncoordinated services, while decreasing costs. The collaborative concept could be expanded to include those at risk and the healthy to promote their health, forming Accountable Care Organizations. Community collaboratives in several cities in Texas, New York, Hawaii, and others could be a model of how to use their common resources more effectively to improve access to care, health and behaviors; impact their environment and promoting economic development.41 The Folsom report42 recommends a “community of solutions” to address health problems in cooperation with other agencies. The trend of hospital mergers and acquisitions could be a catalyzer in an integrated system of care. While there is concern this will lead to increasing costs and fewer choices, strategies have been suggested to counteract this trend such as limiting providers networks, supporting formation of physician organizations, reference pricing for services and
procedures, and providing opportunities for government regulation.43 An organizational decision to use the merged services to serve a defined population (“the community”) to perform a needs assessment (already mandated) and develop programs for priority conditions could assist the development of COPC services. Collaboration with health departments can contribute to this endeavor.44
Team Development The ACA is increasing the number of patients accessing primary care. The inclusion of prevention and promotion activities and the identification of the sick not under care and those who have not accessed the service will require reorganization of teams and the development of new skills. COPC is in line with recent guidance on alleviating the primary care workforce shortage such as practices pooling physicians, expanding the role of allied health professionals, and enabling continuity of care by using electronic records,45 or providing innovative solutions to primary care.46 However, it was found that most primary care innovations provided additional resources to address specific diseases rather than changing practice organization.47 In the implementation of a COPC practice, the physician will be redefined as a leader of a high-performing primary care team.48 This transformation would help alleviate the primary care physician shortage,45,49 or demand–capacity mismatch.50
Information Technology The growing trend in the use of electronic health records51 that was enabled by the ACA could be a tool to enable population health management.52 Electronic health records can assist medical teams in incorporating COPC activities such as defining the population under care, establishing the denominator population; performing health assessments; health surveillance and evaluation of care; and assessing quality improvement. The use of integrated medical records53 could help teams to deliver more efficient care for chronic diseases and preventive care by improving communication about the patient.54
Payment Several initiatives are being proposed and tested to reform the current fee-for-service. One of those is transition to a physician payment system that rewards quality and valuebased care.55 Studies on the effectiveness of Pay-forPerformance, which addresses improving quality, efficiency, and overall value of health care, has shown conflicting results. There is also concern that this system of payment may exacerbate health disparities, if disadvantaged populations, which are likely to decrease the providers’ performance scores, are avoided.56
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Gofin et al New models of financing care tested through the Center for Medicare & Medicaid Services Innovation Center,57 such as capitated payments and value-based care, will enable new delivery models that will be community-based and seek to keep the population healthy rather than waiting for the sick to come into the clinic. Accountable Care Organizations are one model of care that is being tested and early results suggest this delivery and financing model is shifting clinical organizations toward population health management, medical homes, and team-based care.58 A financing system that supports population health, proactive care, and prevention would contribute to the delivery of COPC.
Conclusions Amid the challenges of the Health Care Reform, the ACA offers a window of opportunity to change the health care system. COPC has the potential to pushing health care away from mainly sick care and toward prevention of disease and promotion of health, integrating individual care and population health. As a result of the ACA, the current policy climate provides an opportunity to test the COPC approach in terms of management, efficiency, and sustainability. Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The author(s) received no financial support for the research, authorship, and/or publication of this article.
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Author Biographies Jaime Gofin, MD, MPH, is Professor of Public Health and Director of the COPC MPH Program at the College of Public Health of the University of Nebraska Medical Center. Former Director of the Community Health Center in Jerusalem where COPC was developed and taught, and of the COPC MPH Program at GWU in Washington DC. Dr. J. Gofin has developed and conducted COPC capacity building programs in different countries.
Rosa Gofin, MD, MPH, is Professor of Public Health at the College of Public Health of the University of Nebraska Medical Center. She has practiced, taught and researched COPC in the Community Health Center in Jerusalem in the area of Maternal of Child Health; Dr. Gofin has developed COPC capacity building programs for health professionals and students and served as advisor on community health in diverse countries. Jim P. Stimpson, PhD, is the founding Director of the Center for Health Policy, Senior Policy Analyst for Government Affairs, and Associate Professor of Public Health at the University of Nebraska Medical Center. Dr. Stimpson’s research and teaching interests are health policy and the social determinants of population health.
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