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Public Health – Primary Care Linkages

Public Health – Primary Care Linkages. Kurt C. Stange, MD, PhD Professor of Family Medicine & Community Health, Epidemiology & Biostatistics, Oncology & Sociology Gertrude Donnelly Hess, MD Professor of Oncology Research Director, Residency in Preventive Medicine & Public Health

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Public Health – Primary Care Linkages

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  1. Public Health – Primary Care Linkages Kurt C. Stange, MD, PhD Professor of Family Medicine & Community Health, Epidemiology & Biostatistics, Oncology & Sociology Gertrude Donnelly Hess, MD Professor of Oncology Research Director, Residency in Preventive Medicine & Public Health Case Western Reserve University American Cancer Society Clinical Research Professor Editor, Annals of Family Medicine www.AnnFamMed.org Promoting Health Across Boundaries www.PHAB.us DCCPS through the Intergovernmental Personal Act

  2. Primary Care Underfunded Misaligned mission & incentives Misunderstood Broad scope, fragmented approach Increasingly about chronic illness Mission more about promoting health than delivering commodities About partnerships Public Health Underfunded Misaligned mission & incentives Misunderstood Broad scope, fragmented approach Increasingly about chronic illness Mission more about promoting health than delivering commodities About partnerships Primary Care & Public Health- Very Different

  3. Primary Care More funding Different funding More information support Greater integration within Greater integration across sectors More targeting and incentives Greater focus on population health Public Health More funding Different funding More information support Greater integration within Greater integration across sectors More targeting and incentives Greater focus on population health Efforts to Reform Primary Care & Public Health - Very Similar AAFP, AAP, ACP, AOA. Joint principles of the PCMH. 2007; www.medicalhomeinfo.org/Joint%20Statement.pdf . IOM.For the Public’s Health: Investing in a Healthier Future. Washington: National Academies Press, 2012.

  4. 1000 persons 800 report symptoms 327 consider seeking medical care 217 visit a physician’s office (113 visit a primary care physician’s office) 65 visit a complementary or alternative medical care provider 21 visit a hospital outpatient clinic 14 receive home health care 13 visit an emergency dept 8 are hospitalized <1 is hospitalized in an academic medical center Fig. Results of a reanalysis of the monthly prevalence of illness in the community and the roles of various sources of health care. (Green LA et al., N Engl J Med 2001, 344:2021-2024)

  5. Primary Care • Large majority of needs (comprehensive) • Sustained partnership (personalized) • Context of family & community • Integrated (considers parts and the whole) • Accessible Donaldson MS, Yordy KD, Lohr KN, Vanselow NA, eds. Primary Care: America's Health in a New Era. Washington D.C.: National Academy Press; 1996.

  6. Primary Care • Countries with strong primary care • Have lower overall costs • Generally have healthier populations • Within countries • Areas with higher primary care physician availability (but not specialist availability) have healthier populations • Greater primary care physician availability reduces the adverse effects of social inequality Starfield B. New paradigms for quality in primary care. Br J Gen Pract 51:303-309, 2001. Macinko J, Starfield B, Shi L. Quantifying the health benefits of primary care physician supply in the United States. Int J Health Serv. 2007;37:111-26. Starfield B, Shi LY, Macinko J. Contribution of primary care to health systems and health. Milbank Q. 2005;83(3):457-502

  7. Community-Oriented Primary Care • Takes responsibility for the health of a defined population • Steps • Define the population. • Assess the defined population's health needs. • Organize an effective intervention strategy. • Evaluate the success of the intervention. Mullan F, Epstein L. Community-oriented primary care: new relevance in a changing world. Am. J. Public Health. 2002;92(11):1748-1755. Tollman S. Community oriented primary care: origins, evolution, applications. Soc. Sci. Med. 1991;32(6):633 - 642. Nutting PA. Community-Oriented Primary Care: From Principle to Practice. Washington, DC: U.S. Government Printing Office;1987. DHHS Publication No. HRS-A-PE 86-1 (Now available from the University of New Mexico Press).

  8. Public Health – Primary CareIntegration is “IN”

  9. Institute of Medicine of the National Academy of Sciences • “The interactions between the two sectors are so varied that it is not possible to prescribe a specific model or template for how integration should look.” • General principles IOM. Integrating Primary Care and Public Health. www.iom.edu/Activities/PublicHealth/PrimaryCarePublicHealth.aspx

  10. Principles of Integration • Shared goal of population health improvement • Community engagement in defining and addressing population health needs • Aligned leadership • Bridges disciplines, programs, and jurisdictions • Clarifies roles and ensures accountability, • Develops and supports appropriate incentives • Has the capacity to manage change • Shared infrastructure • Collaborative use of data & analysis IOM Committee on Integrating Primary Care and Public Health. Exploring Integration to Improve Population Health. Washington: National Academies Press, 2012.

  11. Affordable Care Act Opportunities • Community Transformation Grants • Community Health Needs Assessments • Medicaid Preventive Services • Community Health Centers • National Prevention, Health Promotion & Public Health Council & the National Prevention Strategy • CMS Innovation Center • Accountable Care Organizations • Patient-Centered Medical Homes • Primary Care Extension Program • National Health Service Corps • Teaching Health Centers IOM Committee on Integrating Primary Care and Public Health. Exploring Integration to Improve Population Health. Washington: National Academies Press, 2012.

  12. Communities of Solution • Emerging young family medicine leaders • Updated 1967 Folsom Report • 13 grand challenges • Organizing community & personal health services The Folsom Group.Communities of Solution: The Folsom Report Revisited. Ann Fam Med. 2012; 10(3):250-260. www.annfammed.org/content/10/3/250.full

  13. 2012 CDC National Cancer ConferenceTom Frieden • Public health & clinical medicine can work synergistically • Public education, outreach • Care coordination • Service provision • Quality assurance, surveillance & monitoring • Organized systems

  14. 2012 CDC National Cancer ConferenceRich Wender • Barriers to PC – PH collaboration • Incentives not aligned • Under-funded • Operate at edge of viability • Few resources for innovative partnerships • Different cultures • It is hard work • To make it work • High functioning PC & PH • Central staffing for population work • Local staffing for personal work • Get in the same room with stakeholders focused on a community problem

  15. 2012 AHRQ Expert Panel on Clinical-Community Relationships Measures • Creating measures atlas • Evaluation roadmap

  16. Re-emerging Political Space for Linking Person and Community Through Primary Health Care 4 themes from national policy key informants: • Affirmation of primary care as the foundation of a more effective healthcare system • Patient-centered medical home is a transitional step to foster practice innovation & payment reform • Urgent need for an increased focus on community and population health in primary care • Ongoing need for advocacy and research efforts to keep primary care & public health on policy agenda Sweeney SA, Bazemore A, Phillips Jr. RL, Etz RS, Stange KC. A re-emerging political space for linking person and community through primary health care. Am J Prev Med, 2012; 42(6S2): S184-S190.

  17. Public Health – Primary CareCollaboration/Integration is “IN” • Its about how to get it done. • Your examples and mine

  18. Two Current Cleveland Initiatives www.betterhealthcleveland.org/ www.hipcuyahoga.org/

  19. Activating Resources for Community Health Promotion (ARCH) • Intervention • Database of community programs • Health behavior prescription pad • Results • In- • Significant increase in community program use and healthy behaviors Flocke SA, Gordon LE, Pomiecko GL. Evaluation of a community health promotion resource for primary care practices. Am. J. Prev. Med. 2006;30(3):243-251.

  20. Evidence Integration Triangle (EIT) Intervention Program/Policy(Prevention or Treatment) (e.g., key components; principles; guidebook; internal & external validity) Feedback Feedback Evidence Stakeholders Practical Progress Measures (e.g., actionable & longitudinal measures) Participatory Implementation Process (e.g., stakeholder engagement; CBPR; team-based science; patient centered) Feedback Glasgow RE, Green LW, Taylor MV, Stange KC. Am J Prev Med 2012, 42: 646-654.

  21. Public Health – Primary CarePartnership • Great potential • Great challenges • Synergy in each doing what we’re good at • Questions • What are you good at? • Who do you have access to, and when? • What data do you have / need? • What work is value-congruent? • How can we come to the table around mutual need? • How can we partner for complementary effect?

  22. Extra (Optional) Slides

  23. Evidence Integration Triangle (EIT) - A Patient-Centered Care Example Intervention Program/PolicyEvidence-based decision aids to provide feedback to both patients and health care teams for action planning and health behavior counseling Evidence: US Preventive Services Task Force recs. for health behavior change counseling; evidence on goal setting & shared decision making Feedback Feedback Stakeholders: Primary care (PC) staff, patients and consumer groups; PC associations; groups involved in meaningful use of EHRs, EHR vendors Practical Progress Measures Brief, standard patient reported data items on health behaviors & psychosocial issues -- actionable and administered longitudinally to assess progress Participatory Implementation Process Iterative, wiki activities to engage stakeholder community, measurement experts and diverse perspectives Feedback

  24. IOM Case Studies of Integration • San Francisco, CA • Healthy SF focused on access • Health Improvement Partnerships • New York, NY • EHR support • Community organization partnerships • Durham, NC • CCNC, a statewide network to coordinate & improve care • Diverse participants • Collaborative financing structure IOM Committee on Integrating Primary Care and Public Health. Exploring Integration to Improve Population Health. Washington: National Academies Press, 2012.

  25. The Generalist Approach • Recognizing systems connectedness (belonging & participation in community & Kosmos) • Being - open, humble, connected • Knowing – iterates between whole & particulars • Perceiving – scanning & prioritizing • Thinking/doing – most important parts in context, lower level tasks enable higher Stange KC. The generalist approach. Ann Fam Med. 2009;7(3):198-203.

  26. Principles of Primary Care Accesibility as 1st contact with health care Accountability for large majority of healthcare needs (comprehensiveness) Coordination & integration of care across settings, acute & chronic illnesses, mental health & prevention Sustained partnership – relationships over time in a family & community context Starfield B. Primary Care. Balancing Health Needs, Services and Technology. New York: Oxford University Press, 1998. Donaldson MS, Yordy KD, Lohr KN, Vanselow NA, eds. Primary Care: America's Health in a New Era. Washington D.C.: National Academy Press; 1996. Stange KC, Nutting PA, Miller WL, et al. Defining and measuring the Patient-Centered Medical Home. J Gen Intern Med. 2010; 25(6): 601-612. 28

  27. Paradox of Primary Care • Poor quality of care by disease-specific process of care measures • Better quality at population level • Similar whole-person functional health • Better population health • Lower resource use and cost Stange KC, Ferrer RL. The paradox of primary care. Ann. Fam. Med. 2009;7(4):100-103.

  28. Global Typology of Primary Care Organisational Developments Organisational Structure and Value Base Service Focus Location Endpoint Type Process (examples) Extended Simple Normative Registered Health Patient general practice partnership patient list centre Managed care Complex, Calculative Target groups Physicians User enterprise stakeholder group Reformed Coalition, Commercial Medical Multi- Client polyclinic divisional conditions specialist clinic District health Hierarchic, Executive Public health General Populations system administrative improvement hospital Community Association, Affiliative Local Health Citizen development network populations stations agency Franchised Quasi- Remunerative Payers Private, Customer outreach institutional, hospital virtual premises Meads G (2006) Primary Care in the Twenty-First Century: An international perspective. Oxford: Radcliffe Publishing.

  29. Crossing the Quality Chasm Recommended health care focus Reduce illness burden, injury, disability Improve health and function of people Health care should be Safe Effective Patient-centered Timely Efficient Equitable Institute of Medicine. Crossing the quality chasm: A new health system for the 21st century. Washington, DC: National Academy Press; 2001. 31

  30. Crossing the Quality Chasm

  31. http://www.improvingchroniccare.org www.improvingchroniccare.org

  32. Expanded Chronic Care Model Barr VJ, Robinson S, Marin-Link B, Underhill L, Dotts A, Ravensdale D, Salivaras S. The expanded Chronic Care Model: an integration of concepts and strategies from population health promotion and the Chronic Care Model. Hosp. Q. 2003;7:73-82.

  33. Safety Net Providers’ Strategic Alliance • Practice-Based Research Network • Cleveland Safety Net Practices • Mission to generate new knowledge to • Improve patient care • Advocate to close holes in the safety net AHRQ PBRNs: http://pbrn.ahrq.gov/ Cleveland CTSC: www.case.edu/med/pbrn/PBRN%20Networks.html Madden MH, Tomsik P, Terchek J, Navracruz L, Reichsman A, Clark TC, Cella P, Weirich SA, Munson MR, Werner JJ. Keys to successful diabetes self-management for uninsured patients: social support, observational learning, and turning points: a safety net providers' strategic alliance study. J Natl Med Assoc. 2011;103(3):257-64. Reichsman A, Werner J, Cella P, Bobiak S, Stange KC; SNPSA Diabetes Study Working Group. Opportunities for improved diabetes care among patients of safety net practices: a safety net providers' strategic alliance study. J Natl Med Assoc. 2009 Jan;101(1):4-11.

  34. Visits by Diabetic Patients in a CHC • Mean of 25 problems (range 13 to 32) • Multiple acute & chronic illnesses, prevention • Variety of issues • Biomedical • Behavioral • Social • System • Environmental health Bolen SD, Sage P, Perzynski AT, Stange KC. No Moment Wasted: The Primary Care Visit for Adults with Diabetes (under review), 2012.

  35. The PHAB Initiative inPromoting Health Across Boundaries www.PHAB.us Supported by: Case Western Reserve University Forward Thinking Interdisciplinary Alliance Innovation Pilot Investment Grant Research Professorship from the American Cancer Society Grant from the Patient-Centered Outcomes Research Institute (PCORI) Intergovernmental Personnel Act (IPA) from the National Cancer Institute

  36. PHAB Promoting Health Across Boundaries Problem A view of health too narrowly focused on disease and health care has resulted in unhealthy people, families, communities, environments, and fragmented, unsustainable health care systems.

  37. PHAB Promoting Health Across Boundaries Mission The mission of the PHAB initiative is to advance the knowledge and practice of boundary-spanning activities that enable health.

  38. Person & Family Healthy Environments Personalized Health Care Public Health & Community Primary Health Care Health Responsible, Evolvable Organizations Healing Environments Health Care System

  39. Promoting Health Across Boundaries www.PHAB.us

  40. Cohen D, McDaniel RR, Crabtree BF, et al. A practice change model for quality improvement in primary care practice. J Healthc Manag, 2004; 49:155-170.

  41. What is Health? Among these definitions, a concept is emerging of health as a resource to support meaningful work and connection.

  42. “Paper or plastic?”

  43. Problem of Fragmentation

  44. US Health Care • “Fundamentally flawed” * • Most expensive in the world** • 37th in the health of our people** • More integrated systems provide greater value*** * Institute of Medicine. Crossing the quality chasm: A new health system for the 21st century. Washington, DC: National Academy Press; 2001. ** WHO. Press Release WHO/44: World Health Organization assesses the world's health systems. World Health Organization, Geneva Switzerland. http://www.who.int/inf-pr-2000/en/pr2000-44.html. *** Starfield B, Shi LY, Macinko J. Contribution of primary care to health systems and health. Milbank Quarterly. 2005;83(3):457-502.

  45. Fragmentation • Focusing on the parts without appreciating their relation to the whole • Limited understanding of how the components of health and disease processes and health care work together • Leads to • Uncontextualized investigation • Fragmentation of care • Devaluing of health care’s higher order functions and possibilities. Engel, GL. The need for a new medical model. Science 1977;196:129–136. Stange KC. The paradox of the parts and the whole in understanding and improving general practice. Int J Qual Health Care, 2002; 14(4):267-268. Stange KC. The problem of fragmentation and the need for integrative solutions. Ann. Fam. Med. 2009;7(3):100-103.

  46. Robert May, President of the Royal Society “Application of the physical and biological sciences has made today arguably the best of times… But the unintended consequences of these well-intentioned actions…could well make tomorrow the worst of times. The significant breakthrough we really need is better understanding of human institutions, particularly of the impediments to collective, cooperative activity in which all individuals pay small costs to reap large group benefits. Darwin recognised the evolution of cooperative behaviour as one of the most important unsolved problems of his day. We have made relatively little progress since then. Perhaps the social scientists of 2056 will have succeeded in combining the rigour of the "hard" (that is, easy) sciences with the thoughtful introspection of the humanities to solve this problem. I certainly hope so.” 18 November 2006, NewScientist.com news service.

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