Primary Care

In 1996, the IOM Committee on the Future of Primary Care defined primary care as “the provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community” (IOM, 1996, p. 1). The committee emphasized that “primary” means care that is first and fundamental, and declared that primary care is not a specialty or a discipline but an essential function in health care systems. The inclusion of the words “integrated,” “sustained partnership,” and “context of family and community” reflects a prominent population perspective, as well as a responsibility to connect with other actors in the health system.

Also embedded in the 1996 report is the inextricable link between mental health and primary care. A paper commissioned for that report, and included as an appendix, asserts that “a sensible vision of primary health care must have mental health care woven into its fabric” (IOM, 1996, p. 285). Primary care providers address a broad range of health issues to which mental health concerns are integral. Mental, behavioral, and physical health are so closely entwined that they must be considered in conjunction with one another. While the nature and role of primary care have been debated and studied at length, it is generally recognized that primary care has the four key features listed in Box 1-1.

BOX 1-1

Four Key Features of Primary Care. It is person-rather than disease-focused. This focus entails sustained relationships between patients and providers in primary care practices over time, often referred to as continuity. It provides a point of first contact (more...)

The importance of primary care is well known and researched. In their review of the literature, Starfield and colleagues (2005) found that areas with the highest numbers of primary care providers have the best health outcomes; people who consistently receive care from a primary care provider have better health outcomes than those who do not; and the characteristics themselves of primary care are associated with good health. Additionally, primary care was found to be associated with a reduction of health disparities both in the United States and among international populations (Starfield et al., 2005).

Primary care is the foundation of the U.S. health system. In the United States, more individuals receive care in primary care settings than in any other setting of formal health care. On average, primary care settings see 11 percent of the entire population each month, compared with 1.3 percent for emergency departments and 0.07 percent for academic medical center hospitals (Green et al., 2001). Of interest, these proportions have not changed substantially since the 1950s and 1960s despite the stunning progress of medical knowledge, new technology, and expansion of health services (White et al., 1961).

The primary care system in the United States comprises both private providers and those supported by government agencies, such as the Veterans Health Administration and the Health Resources and Services Administration (HRSA). HRSA-supported health centers serve nearly 20 million patients a year (HRSA, 2011) and provide a safety net for society’s most vulnerable populations. Although most primary care is delivered through the private sector, both private and government-supported primary care share common features. For example, in its policy paper on primary care, the National Business Group on Health, which represents more than 300 large employers providing health care coverage for 55 million people, asserts that primary care should be the key to efficiency, effectiveness, and quality improvement in the nation’s health system (National Business Group on Health, 2010). Both sectors also share the same challenges.

As a whole, primary care currently is facing a workforce shortage. The primary care workforce remains a relatively small proportion of the overall workforce compared with other health fields (Bodenheimer et al., 2009; Canadian Labour and Business Centre, 2003; European Observatory on Health Systems and Policies, 2006). During the last decade, the proportion of primary care providers fell from nearly a third to now less than a fourth of the output of the graduate medical education system (COGME, 2010; Phillips et al., 2011; Salsberg et al., 2008). This decline goes beyond physicians to include nurse practitioners and physician assistants as well (HRSA, 2010; Jones, 2007). Primary care also faces a chronic problem of relative shortage due to workforce maldistribution (Zhang et al., 2008). Regional shortages have seen little improvement despite federal and state loan repayment programs and the rapid growth of safety net clinics over the last decade (GAO, 2003).

In addition to workforce shortages, the increase in chronic diseases has posed challenges for primary care and served to motivate its transformation. Chronic diseases are linked to a number of unhealthy behaviors, such as lack of physical activity, poor nutrition, and tobacco use, but primary care often has struggled to address these behaviors adequately. In recognition of the difficulties associated with treating chronic diseases, the Chronic Care Model (Wagner et al., 2001) was implemented. This initiative emphasized a systematic and more efficient means of improving chronic care management for individual patients (Coleman et al., 2009). In its fullest expression, the Chronic Care Model contained six critical elements—community resources and policies, health care organization, self-management support, delivery system design, decision support, and clinical information systems—and effectively bridged patient care across the practice setting, the delivery system, and the broader community (Bodenheimer et al., 2002)

The success of the Chronic Care Model in revitalizing the management of patients with chronic conditions by relying on an interdisciplinary primary care team with aligned objectives and methodology generated interest in redesigning the entire practice of primary care. This interest in reinventing primary care led in turn to interest in the “medical home,” a model first proposed in the 1960s for providing care for children with special needs (Rosenthal, 2008). In the last few years, intensive activity has focused on implementing the “patient-centered medical home,” spurred by funding and research supported by the Centers for Medicare & Medicaid Services (CMS), the Commonwealth Fund, HRSA, and a number of other groups. These efforts are aimed at stimulating new models of care delivery, with primary care teams at the core of the delivery structure.

A fully realized patient-centered medical home encompasses the principle that individual patients are members of a broader community, and that activity within the construct of individual clinical encounters includes links that can be leveraged to generate wellness and prevention beyond the individual patient. A systematic approach to population health, called community-oriented primary care (COPC), is employed in other health systems and has previously been studied by the Institute of Medicine (IOM, 1984). This approach to primary care helped launch the community health center movement in the United States and is still used in some communities. COPC, which is discussed in more detail later in the chapter, offers a model of primary care that more fully embraces public health. There is already some evidence that the foundational relationship between patient and primary care provider can generate dividends for the broader community. Several integrated service delivery networks, such as the Geisinger Health System, Group Health Cooperative of Puget Sound, and HealthPartners, are providing early evidence that accountable care for patient panels and populations can reduce mortality, costs, and unnecessary utilization, and in some cases can improve the fiscal health of hospitals as well (Flottemesch et al., 2011; Grumbach and Grundy, 2010; IOM, 2010).

Primary care is well positioned to work with public health on improving the health of local populations. The research networks of major primary care provider groups could assist in this effort. Some of primary care’s major concerns include factors that are not present in a clinical setting, such as circumstances at the onset of illness, predisposing factors that increase the risk of death and disease, and precipitating factors that lead people to seek care (White, 2000). One of its strengths is that primary care often holds a position of trust in communities and is able to leverage that position in addressing community concerns. This community relationship is exemplified by health centers and other primary care delivery systems, particularly those that use a community-oriented approach. Thus, primary care is working in areas that largely overlap with public health and is strategically placed at the interface of people in communities and the rest of the health care system.

Public Health

Public health is a dynamic field that continues to evolve to meet the needs of society. While the concept of modern public health emerged in response to the conditions that resulted from industrialization and the subsequent rise in infectious diseases (Rosen, 1993), the issues confronting public health look very different today. Although the primary focus of public health has shifted from infectious to chronic diseases, which are more prevalent in today’s society, its emphasis has remained on improving conditions where people spend their lives outside of health care settings. While it is generally recognized that a critical component of public health is the services provided under the legal authority of government through health departments, articulating broadly what public health is and does is no easy task.

A number of key reports published over the last few decades have presented a vision for public health. The 1988 IOM report The Future of Public Health provides two critical definitions. The first is the mission of public health, defined as “fulfilling society’s interest in assuring conditions in which people can be healthy” (IOM, 1988, p. 140). The second is the substance of public health, defined as “organized community efforts aimed at the prevention of disease and promotion of health. It links many disciplines and rests upon the scientific core of epidemiology” (IOM, 1988, p. 41). Although the report emphasizes the importance of government health agencies and argues that strengthening the role of health departments would be crucial in moving public health forward in the future, its overall conception of public health is much broader, involving the private sector, community organizations, public–private partnerships, and others.

In 2002, the IOM released The Future of the Public’s Health in the 21st Century, which reinforces the idea that public health’s broad mission of ensuring healthy communities requires interactions among a number of health-influencing actors, such as communities, businesses, the media, governmental public health, and the health care delivery system (IOM, 2002). The report notes that health departments are not alone in carrying out the essential public health services listed in Box 1-2. Figure 1-1 depicts an interconnected system of sectors that influence a population’s health, with government public health being one of several actors (IOM, 2002).

BOX 1-2

Essential Public Health Services. Monitor health status to identify community health problems. Diagnose and investigate health problems and health hazards in the community.

FIGURE 1-1

The intersectoral public health system. SOURCE: IOM, 2002.

More recently, the IOM published two in a series of reports called For the Public’s Health, looking at public health in the context of measurement and law (IOM, 2011a,b). A third report, on financing, was published in 2012 (IOM, 2012). These reports provide an opportunity to revisit public health in light of changes in health status in the United States since the IOM’s 1988 report was published. For example, obesity tripled among children and doubled among adults between 1980 and 2008 (CDC, 2011). Recognizing the complex nature of health challenges facing society today, the IOM committee responsible for the report on measurement noted that it is the “complex interactions of multiple sectors that contribute to the production and maintenance of the health of Americans” (IOM, 2011b, p. 21). The prevention of disease, which is a pillar of public health’s work, requires the engagement of all segments of a community. For instance, combating the rise in obesity requires encouraging individuals to improve their diet and increase physical activity. These efforts require multiple partners, such as schools, employers, urban planners, and policy makers. These various stakeholders may provide one or more of the essential public health services. For example, a community-based organization may implement a health outreach campaign to educate people about health issues, or a public–private partnership may be engaged to mobilize the community to solve a particular health problem.

Traditionally, public health has worked with systems, policy, and the environment to reduce the burden of infectious disease. Improvements in sanitation, food preparation, and water treatment are successful examples of this work. To address more current concerns, public health has turned its attention to fighting chronic disease. Community-based interventions undertaken by public health for the prevention of chronic diseases have proven to be effective (The New York Academy of Medicine, 2009). In addition, some research suggests that making system, policy, and environmental changes may be effective; for example, French and colleagues (2004) found that an intervention aimed at the school environment resulted in students purchasing healthier foods. In general, the field would benefit from additional efforts to evaluate the effectiveness of these interventions in terms of implementation and outcomes.

Public health faces a number of challenges, including insufficient funding to fulfill its mission, a shrinking workforce, and inadequate investments in health information technology (HIT). In its report on public health funding, the Trust for America’s Health found that public health funding had been reduced at the federal, state, and local levels (ASTHO, 2011; NACCHO, 2011; Trust for America’s Health, 2011). Not surprisingly, a reduction in the public health workforce has also been documented (ASTHO, 2011; NACCHO, 2011; Trust for America’s Health, 2011). Another concern for public health is the lack of investment, relative to the health delivery system, in HIT. This disparity is exemplified by the distribution of HIT funding in the American Recovery and Reinvestment Act of 2009, which designated $17.2 billon of the total $19.2 billion appropriated for HIT for incentives to be paid to physicians and hospitals to promote the use of electronic health records (Steinbrook, 2009). This lack of investment could pose challenges for public health in managing population-level data.

Despite these challenges, public health today continues to meet the changing needs of communities. It encompasses a diverse group of public and private stakeholders (including the health care delivery system) working in a variety of ways to contribute to the health of society. Uniquely positioned among these stakeholders is governmental public health. Because health departments are legally tasked with providing the essential public health services, they are required to work with all sectors of the community. This allows them to serve as a catalyst for engaging multiple stakeholders to confront community health problems. In addition, their assessment and assurance functions put them in close contact with the community and in touch with its health needs. Public health defined broadly is much more than governmental public health, yet health departments play a fundamental role in creating healthy communities.

Integration

Integration is an imprecise term that encompasses a wide variety of definitions. Accordingly, the committee decided it would be too limiting and not helpful to use a narrow definition. For this report, integration of primary care and public health is defined as the linkage of programs and activities to promote overall efficiency and effectiveness and achieve gains in population health. Because integration can take many forms, the committee chose to think conceptually about the variables that influence integration, which include the level at which it takes place, the partners involved, the actions entailed, and the degree to which integration occurs.

Benefits of Integration

As mentioned above, there have been few formal analyses of the efficacy of primary care and public health integration. However, evidence indicates that some advantages can be realized through integration.

A recent literature review of primary care and public health collaborations conducted in Canada found that these efforts resulted in improved health outcomes, improved workforce outcomes, and benefits at the patient and population levels (Martin-Misener et al., 2009), but that these examples are not widespread. Lasker and the Committee on Medicine and Public Health (1997) conducted a review of more than 400 instances of medicine and public health collaboration and noted a number of benefits that arose from such endeavors. Specifically, the authors found that collaboration benefited clinicians by providing population-based information relevant to their practices, enhancing their capacity to address behaviors and the underlying causes of illness, and generating better quality assurance standards and performance measures. Public health entities received support for their role in carrying out population-based strategies, including the collection of individual-level data for surveillance purposes, the dissemination of health education and key health promotion messages, and cooperation for the assurance of quality medical care for all members of a community.

Beyond the benefits to providers and public health entities, it stands to reason that society gains from integration as well. Integration can improve the efficiencies and harness the capabilities of primary care and public health and their respective workforces to focus on common problems. By joining forces, primary care and public health are better able to meet the nation’s goal of improved population health. Unfortunately, however, integration is no easy task.

Challenges of Integration

Aligning primary care and public health to work together and with other partners in pursuit of the shared goal of improved population health is challenging. A number of trends reinforce the fragmented nature of the current health system, including a history of segregation between primary care and public health, a lack of financial resources and incentives, and an inflexible regulatory system (Baker et al., 2005; IOM, 1988, 2002, 2003, 2011b).

In the early 20th century, despite years spent as related and overlapping areas (Brandt and Gardner, 2000; Duffy, 1979), public health began to establish itself as a profession independent of medicine. This fissure can be traced to a number of factors, most notably the decision to create public health schools separate from medical schools and the rise of the biomedical model.

In 1915, the Welch-Rose Report, authored by William Welch and Wycliffe Rose of the Johns Hopkins School of Medicine, described a research-focused approach to public health education. Based on this report, the Rockefeller Foundation, with which Welch was affiliated, began to focus its philanthropic efforts on public health, and in 1916, the Johns Hopkins School of Hygiene and Public Health was established with financial support from the foundation. By 1947, 10 schools of public health had been established, separating public health education from the more narrowly focused and uniform medical curriculum. As public health professionals and educators argued for more independence from medicine in universities and government, public health became viewed by medical professionals as an economic competitor that was largely encroaching on matters believed to be best resolved through the care and treatment provided by medical professionals to individual patients (Brandt and Gardner, 2000).

In addition to this separation, the biomedical model of disease emerged from a greater understanding of germ theory and bacteriology. This model conceived of disease as something separate from any social causes. As the objective biomedical model gained prominence, a natural consequence was the uncoupling of medical care from public health, which was viewed as being marred by politics and social matters. This view led to a decline in spending on and attention to public health relative to medical care that persists today (Brandt and Gardner, 2000).

After decades of separation, both primary care and public health have hard-won identities, achievements, and cultures that they prize. Revising these identities and adapting to each other’s cultures in order to integrate their efforts can be experienced as a loss. Both sectors tend to view themselves as neglected and underappreciated. Both primary care and public health are fragmented within themselves, sometimes struggling to coordinate and align efforts internally, much less with each other. Both have dedicated advocacy groups that stake out territory and defend it against encroachment by alternative interests.

This historical divide is further cemented by a lack of financial investment in both primary care and public health. In this environment, the creation of financial incentives and supporting linkages between primary care and public health is not easy to accomplish or sustain. Payment structures within the delivery system reward disease treatment rather than prevention, pay for volume rather than value, and incentivize specialty care and procedural interventions over primary care. Moreover, primary care and public health both receive a relatively small proportion of the expenditures devoted to health in the United States (as discussed in more detail in Chapter 4). Frequently, they find themselves competing with each other for resources insufficient for either, much less both. Primary care and public health at their best result in nonevents, often at moments distant in time, for individuals and populations, making success somewhat invisible to others. This invisibility often hinders both sectors from attracting funders willing to invest in improvement efforts.

Furthermore, both primary care and public health operate under inflexible regulatory policies and funding restrictions that may preclude or hamper shared action. Neither is accountable to the other, and there is no shared space where primary care and public health come together routinely and automatically to identify problems and opportunities, plan together, coordinate their work, and undertake joint efforts. In terms of informatics and data collection, primary care and public health often lack interoperable information systems both within the delivery system and between the delivery and public health systems. This internal fragmentation and external siloing often means that even when entities are willing to integrate, they lack the infrastructure to do so.

These challenges notwithstanding, the committee believes that the potential benefits of greater integration of primary care and public health are sufficiently promising to merit action now, taking these challenges into account. The call to better integrate primary care and public health is not new. The National Commission on Community Health Services, in a report known as “The Folsom Report” (1966), raised this issue half a century ago by calling for a more comprehensive model of health including both primary care and public health elements; Kerr White’s Healing the Schism revisited this idea in 1991 (White, 1991). While examples of long-term, successful models of integration are not abundant, there appears to be an interest in communities in bringing primary care and public health together to improve population health (see Box 1-3 and Chapter 2). However, the sustainability and scalability of models of integration have been lacking. The key task now is to focus on the challenge of sustainable implementation of community-based models of primary care and public health integration. Critical elements for this task are providing sustained resources and incentives for these models and supporting the infrastructure necessary to weave together the diverse stakeholders across multiple sectors that must participate in their implementation.

BOX 1-3

Interest in Collaboration. A willingness to collaborate is evident among diverse health disciplines. In 2011, the National Committee on Vital and Health Statistics focused on communities as learning health systems and explored a convenience sample of (more...)

Efforts in the United States

Some prior initiatives have focused on bridging the gap between primary care and public health and the community. For example, efforts have been made in some areas within the United States to adopt COPC models. COPC has been defined as a continual process by which primary health care teams provide care to a defined community on the basis of its assessed health needs through the integration in practice of primary care and public health (IOM, 1984). It is a dynamic, interdisciplinary model for planning, implementing, and evaluating primary care, health promotion, and disease prevention in the community that generally has appealed to practitioners working in underresourced areas with limited access to health care services. The application of COPC in the United States has not been widespread. A recent systematic review found that most articles about COPC did not adhere strictly to the model as originally described (Thomas, 2008). Even with modified models, however, a number of COPC initiatives have been found to generate notable improvements in the delivery of primary care (Merzel and D’Afflitti, 2003; Pickens et al., 2002). COPC models have been implemented internationally as well, with some success (Epstein et al., 2002; Iliffe and Lenihan, 2003).

In 1994 the American Medical Association and the American Public Health Association created the Medicine and Public Health Initiative. This effort began with a task force that met for 2 years and outlined shared agendas in several areas. The task force developed seven major recommendations for collaboration between primary care and public health: (1) engaging the community, (2) changing the education process, (3) creating joint research efforts, (4) devising a shared view of health and illness, (5) working together in health care provision, (6) jointly developing health care assessment measures, and (7) translating initiative ideas into action (Beitsch et al., 2005, p. 150). Other activities of note included a national congress in 1996, the development of a grant program funded by the Robert Wood Johnson Foundation (Cooperative Actions for Health Program, 2001), and a monograph of examples of collaboration (Lasker and the Committee on Medicine and Public Health, 1997).While the initiative was successful in promoting and showcasing efforts at the local level, commitment at the state and national levels ultimately faltered (Beitsch et al., 2005).

Since the Medicine and Public Health Initiative, other, more limited efforts to catalogue and analyze integration initiatives on the ground have been undertaken in the United States. These include a review of public–private partnerships that brought together service delivery networks and coalitions of stakeholders focused on public health and community planning (Bazzoli, 1997), an examination of how organizational characteristics and market conditions contribute to collaborations between either community hospitals or community health centers and public health agencies (Halverson et al., 2000), and the American Medical Association’s analysis of effective clinical partnerships between primary care practices and public health agencies (Sloane et al., 2009). While these initiatives point to an enduring interest in integration, they were not part of a sustained effort to promote integration, and none alleviated a steady and persistent relative neglect of both primary care and public health.

International Efforts

There has been some international recognition of the need to coordinate primary care and public health efforts. In 2003, at a primary care strategic planning meeting held to assess the status of health improvement since the Declaration of Alma Ata (WHO, 1978), the World Health Organization noted that “the emphasis placed on community participation and intersectoral collaboration is especially appropriate now, when so many health issues … cannot be effectively addressed by health systems working in isolation” (WHO, 2003, p. 16). The ensuing report on that meeting recommended the strengthening of public health functions in primary health care settings. Likewise, a number of countries have made efforts to implement the integration of primary care and public health. A restructuring of the National Health Service in England placed public health professionals in Primary Care Trusts in an attempt to change the way primary care operates (The NHS Confederation, 2004). In 2000, New Zealand announced changes to its health care system that established District Health Boards with responsibility for both primary care and public health (New Zealand Ministry of Health, 2000). Attempts to reform public health currently are under way in Canada, where a 2005 workshop called for the Public Health Agency of Canada to develop stronger collaboration between primary care and public health (Rachlis, 2009). In addition, McMaster University in Ontario initiated a research program to explore the potential for collaboration between primary care and public health and the extent to which such collaborative partnerships currently exist (StrengthenPHC, 2011).