Integration of Primary Care and Public Health (Position Paper)

Integration of Primary Care and Public Health (Position Paper)

Introduction

No one can discount the fragmented, broken US healthcare system, plagued with titles such as having the highest per capita investment in health care of any nation in the world1 yet ranking consistently low in quality measures compared to other industrialized nations.2 Efforts at reinvigorating the system have been focused on integrated, high-value health care that places Family Medicine within the Primary Care specialties as an important solution to the health care crisis.3-5 For it is “one of the first objectives for family physicians to understand the living conditions patients face when they leave our office or when they leave the hospital.”6 This is paralleled with a growing awareness of the social,7 environmental,8 and community9 determinants of health.  However, for successful broad system change, Family Medicine within the Primary Care specialties must co-align with the public health sector, two fields with a common interest yet functioning independently for the last century.

The focus on population health management further touted within the Affordable Care Act (ACA),10 the development of new care models such as accountable care organizations (ACOs), and the patient-centered medical home (PCMH) recognize that individual health is inseparable from the health of the larger community which, working up the ladder, ultimately determines the overall health of the nation.11 To better align these individual and community forces, primary care and public health needs to reconnect.  Ongoing efforts at integration with the IOM’s Primary Care: America’s Health in a New Era12 and The Future of the Public’s Health in the 21st Century13 developed momentum that led to the most recent release of the IOM’s Primary Care and Public Health: Exploring Integration to Improve Population Health,14 demonstrating successful models of integration and the accountability looked for in ensuring quality patient care.

Many local, state-level, and national efforts and collaboratives have been developed to facilitate mechanisms for this integration to occur at all levels.  Despite the call of the Folsom Report for community health service delivery to occur in 1967,15 primary care, as the foundation for an improved health care system, needs further transformation to deliver community health in the concept of an expanded primary care team which includes public health.16,17 This position paper discusses the need for integration, a call to action for members, a review of the changing landscape of health care delivery and payment structure as well as educational reforms needed to provide for this new type of physician, and provides academy members with critical resources to learn more and pave the way to integration.

Call to Action

The AAFP urges its members to become informed about the importance, the value, and the movement for integration of primary care and public health.  The AAFP has developed a Workgroup within the Commission on Health of the Public and Science which has been monitoring and been seminally involved with the national efforts taking place on this front.  Family physicians play a critical role in integration and can continue to contribute through inclusion of local, regional, state, and national public health partners within the medical neighborhood. 

The AAFP also urges all national, state, federal, and private sector institutions to partner with primary care and public health partners to ensure a more integrated delivery system is provided to improve population health.  Bold initiatives throughout the health sector and not simply from within primary care and public health are necessary for this integration to be successful. 

Family physicians play a crucial role in these efforts.  In order to meet these needs, the AAFP calls for action in the following areas:

  • Physician Level
    -   Understand the role public health has to play for you, your patients,
        and the community you serve
    -   Demonstrate awareness of integration efforts between primary care
        and public health
  • Practice Level
    -   redefining population based on the public health definition as
        geographic as opposed to a practice patient panel
    -   recognition and incorporation of the public health infrastructure into the
        medical neighborhood
    -   continuous collaboration and communication to with the public health
        infrastructure to operate as a continuous unit with a common goal
  • Leadership Level
    -   Facilitate collaboration and communication amongst health systems and
        public health organizations
    -   Drive change within hospitals or health systems to partner with public
        health organizations
  • Educational Level
    -   Drive change within undergraduate and graduate medical education to
        ensure physicians of tomorrow are prepared for a more integrated
        system

Through these and other actions, the AAFP, its constituent chapters, and its individual members will be the bold champions of integration and meet the overall goals of promoting population health which translates itself to improving the health of the nation.

The Changing Landscape

The changing landscape of healthcare is such that two major reforms are concurrently ongoing.  One of which is occurring on a larger scale both nationally and at the state level with mechanisms to deliver on the triple aim of improving quality and access while reducing costs.  Some of this is being done through payment and insurance reform models and other ways through expansion of medical insurance coverage to simply get people into care.  The other major reform that is occurring is possibly a byproduct of or a contributor to the larger scale change and is occurring at the practice level.  Both are seeking similar aims and certainly many of the local/grassroots efforts are already demonstrating the integration of primary care and public health at these levels; however, for the integration effort to be successful, it must transcend all levels.

Population Health

“Population health” is a term frequently used in both healthcare and public health.  It has been used to mean different things, depending on context and perspective.  In order to assist AAFP members to understand population health, this definition defines population health from the perspective of the family physician.

Population health is “the health outcomes of a group of individuals, including the distribution of such outcomes within the group”18.  The population being considered may vary based on an individual’s perspective and goals.  For the family physician, the most obvious “group of individuals” is their patient panel.  This is where most AAFP members focus their energies and where they often have the greatest impact.  Population health also includes the health status and outcomes of the larger communities to which the physician and patient belong.  It is essential when caring for their patients that family physicians consider the factors beyond the walls of their practice that influence their patients’ health.  The family physician must consider the social and physical environments in which their patients live and work in order to effectively improve health outcomes.

As the healthcare system works to integrate primary care and public health, family physicians and the patient centered medical home will have more opportunities to partner with community resources and advocate for policies and interventions in these communities aimed at influencing social determinants of health and improving health outcomes. 

As noted, some of the push for integration of primary care and public health arises from the realignment in care design to focus on population health.  Population health, as currently described throughout the literature, is defined as health outcomes of a group of individuals, including the distribution of outcomes within the defined group.18,19 Some question, however, whether this definition represents what we mean when we focus on population health and some of the confusion arises due to the disjointed definitions of what we mean by a population. 

Public health agencies define populations based on residential location, stratified by demographic factors such as race, ethnicity, gender, age, language, disability, or disease status.18 When considering the appropriate delivery of community-oriented primary care and delivering the promise of community of solution, this definition stands out as most reasonable given the social, environmental, and community determinants of health are based on geographic neighborhoods.20 A shift to such a definition requires a large professional culture framework shift21 from the current medical definition of population as an aggregate of individuals for whom an individual health care entity has provided care to over a period of time.  This definition has guided the medical profession to its current thinking which aligns with many of the quality standards (National Council on Quality Assurance’s Healthcare Effectiveness Data and Information Set (HEDIS), Center for Medicare/Medicaid Services, Accountable Care Organization (ACOs), etc.). 

This distinction in definition and the difficulty with which to make this leap to the public health sector’s definition is shadowed by the change of delivering a service within medicine to delivering a commodity.  Delivering a commodity within the context of a series of buyers and sellers defines a specific group of individuals with “haves” and “have nots” that have led to health inequities.  With large scale changes in insurance coverage and changes in access, it will be that much more important to define geographically where the population sits and provides for much greater opportunities to align with public health on initiatives. Public health competencies and tools are crucial for this realignment that facilitate a better understanding of the needs of the population, prioritizing activities according to epidemiological, organizational, and economic trends.22 Furthermore, like nephrons each contributing to a piece of renal function, each medical home unit with its medical neighborhood within the same community can lead to improved health and wellness regionally and so on up to a national level.  However, until our definition of population aligns, we will never align the individual and community forces that can best foster health for all.

Patient-Centered Medical Home (PCMH)

PCMH by its very definition23 provides care that is patient-centered, comprehensive, team based, coordinated, accessible, and focused on quality.  Models such as the PCMH that promote the team approach to care are essential to a changing health landscape as they ensure whole person orientation, follow evidence-based guidelines, and are dedicated to continuous quality improvement (CQI).  While the primary care unit serves as the foundation of the medical home, it is critical to acknowledge the countless individuals within the medical neighborhood that contribute to the patient and his/her family’s care.  These can include specialist physicians, allied health workers, community resources, behavioral health workers and organizations, schools, educational organizations, volunteer organizations, governmental organization, and notably public health organizations. 

The inclusion of public health in the medical neighborhood is an essential component of integration.  However, it is critical that it be viewed as a seamless unit in care delivery and not an entity fully outside of the medical home unit as this continues the legacy of silos of care delivery that has been ongoing. For it was this line of thought and concern about “turf” that led to the schism of the two fields at the turn of the 20th century. This also further perpetuates the importance of aligning population definitions amongst primary care and public health to ensure our goals are congruous. To deliver the promise of a “community of solution”16 and commitment of delivering community care, we must emphasize community-oriented primary care (COPC) which is based on the principles of epidemiology, primary care, preventive medicine, and health promotion that sustains the goal of integration as well as the goal of population health.24-26

Medical Education Reform

As the system and delivery models change with an emphasis on population health with primary care and public health integration, pipeline and workforce issues must also be adapted. This includes both changes to undergraduate and graduate medical curriculum as well as faculty development programs to ensure faculty of medical schools and residency programs are able to provide students with the tools needed. Despite integration of public health into medicine largely focusing on primary care and public health integration, the tools for population health are those needed by all physicians across specialties and therefore it is essential both at the undergraduate and graduate medical education level.

Traditional undergraduate medical education occurs in large, tertiary care academic institutions with the majority of rotations and experiences being hospital-based. Many schools are evaluating and uprooting this model, recognizing that teaching chronic care, preventive medicine, and including features of interdisciplinary education and demonstrating team-based care at the undergraduate medical education level does not occur best in the inpatient setting. Increased ambulatory experiences either through block or longitudinal experiences with students as patient advocates or care navigators are being developed.27-29 There are no current best-practices for models in the undergraduate level for what prepares students best for practice with population health focus other than those from Canada and Europe whose medical education systems differ from our own.30

As medical schools seek to review and evaluate current curricula, departments of Family Medicine are poised as leaders within the effort and are charged to play a critical role in this process. Many academic Family Medicine departments have implemented COPC curricula, population health teaching, preventive care programs, and community outreach within Family Medicine and Ambulatory clerkships that are likely to be the foundation for such educational transformation.  

At the graduate medical education level with initiation of the Milestones requirements,31 the Center for Disease Control (CDC) has taken the lead at developing academic partnerships with organizations to facilitate integration as well as developing population health milestones to evaluate the feasibility and direction to incorporating these elements into residency education.32 With the integration of public health partnerships into the medical neighborhood and Family Medicine residencies’ inclusion of PCMH training, it should naturally follow that these elements will be portrayed in a curriculum to prepare our residents for practice settings with full integration. Furthermore, a standardized Milestones-based competency evaluation tool will ensure that residents are receiving comparable training across different residencies.

Role of the Family Physician

The current role of Family Physicians within the healthcare system inherently holds many of the characteristics needed for public health-primary care interface.  While primary care activities such as preventive clinical practices, screening and early preventive intervention, early diagnosis and intervention, quality driven and evidence-based care, health promotion and health advocacy reinforce public health activities, public health activities such as population surveillance, disease control, health promotion and action based on determinants of health, injury prevention, and policy generation facilitate primary care’s ability to function within the system.  Indeed, despite operating independently for decades, the overlap and contribution of each with a common goal of both individual and population health is great.

As is already the case, many Family Physicians are working with their local, regional, and state health departments and public health offices. While the care of the individual, the importance of the relationship, and the personal connection remains a central focus for the Family Physician, the practice transformation that follows core principles of the Patient-Centered Medical Home, the promise of delivering community-oriented primary care, and payment models based on targets and meaningful use are already altering the way we approach care for patient panels and more importantly communities. Some of the challenge for physicians and practices is limited resources for health educators, community health workers, and outreach services. With the public health sector already doing many of these things, it is imperative that practices connect to ensure they can dedicate personal resources to alternate areas and not duplicate this work that is already being done.

The role of the Family Physician in integration will be a large one as Family Medicine is poised to be the leadership specialty of the new culture of medicine.  Health systems as well as educational institutions, tasked with providing and promoting community health will undoubtedly be looking to their primary care specialties for advice.  These leadership roles must start, however, at the individual physician level and move up to the practice level.  Each physician has a part to play at a personal level and being informed about integration, its importance, the value, and the successes is the first step.  The comprehensive role of the Family Physician with integration occurs at the previously defined 4 levels within the system.

Prepared by the AAFP Integration of Primary Care and Public Health Work Group:
David T. O'Gurek, MD - Chair
Patricia Czapp, MD
Lucius Lampton, MD, FAAFP
Michelle Quiogue, MD, FAAFP
Ada Stewart, MD, FAAFP, AAHIVS

Special thanks to the AAFP Staff:
Julie Wood, MD, FAAFP
Jennifer Frost, MD
Bellinda Schoof
Melanie Bird, PhD
Kevin Kovach

And to the the members of the 2014 AAFP Commission on Health of the Public and Science:
Steven Brown, MD, FAAFP - Chair
Robert "Chuck" Rich, MD, FAAFP

Resources

American Academy of Family Physicians Patient Care Resource
http://www.aafp.org/patient-care.html

    An up to date repository of public health related information including
    clinical recommendations, immunizations, and public health issues within
    different areas of patient care and the scope of Family Medicine.

A Practical Playbook: Public Health. Primary Care. Together
https://practicalplaybook.org/(practicalplaybook.org)

    A collaborative effort from the de Beaumont Foundation, Duke University,
    and the CDC that provides an overview of the principles of integration, the
    value of integration, stages and strategies for integration, and success
    stories and examples of clinical and community settings where integration
    efforts are already occurring.

Association of State and Territorial Health Officials (ASTHO)- Supported Primary Care and Public Health Collaborative
http://www.astho.org/Programs/Access/Primary-Care-and-Public-Health-Integration/(www.astho.org)

    A national collaborative whose work is directed as advancing the Strategic
    Map for Integration of Primary Care and Public Health which was generated
    through the work of ASTHO, the IOM, and the CDC.  Efforts have been
    focused on successes, value proposition, resources, measurements,
    communications, and workforce issues.

Center for Disease Control’s Primary Care Public Health Initiative
http://www.cdc.gov/primarycare/(www.cdc.gov)

    Information regarding the CDC’s work in integration with educational
    resources as well as information on the CDC’s Milestones project for
    population health education.

Health Resources and Services Administration (HRSA) Primary Care Public Health Initiative
http://www.hrsa.gov/publichealth/(www.hrsa.gov)

    Information regarding HRSA’s work in integration with information on
    integration of oral and behavioral health issues into the effort.

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(2014 December Board)