Historically, public health officials and primary care health professionals have worked largely in isolation from each other. As a result of an increasing emphasis on cost-effective, outcome-based health care, however, all of that is beginning to change. At all levels of health care -- from large governmental organizations to small community clinics -- members of the two disciplines are starting to look at opportunities to work together.
"This is a transformative moment in health care," said Lloyd Michener, M.D., chair of community and family medicine at Duke University in Durham, N.C. There's never been more financial pressure for primary care physicians to build relationships and partnerships with public health departments, he said. Not only are health care providers being challenged to reduce costs, but national organizations, including the CDC, the Healthcare Resources and Services Administration (HRSA), and even third-party payers are looking for opportunities to align public health services with those delivered by primary care health professionals to improve population health.
Michener is the principal investigator for The Practical Playbook for Integrating Public Health and Primary Care, a Web-based resource that will provide clinicians and public health officials with tools and strategies to support a variety of integrated models for improving population health. The Playbook will be developed during the next two years through a partnership that includes Duke University, the CDC and the de Beaumount Foundation. A preliminary version of the website is expected to start taking shape in early April.
- National organizations are looking for opportunities to align public health services with those delivered by primary care health professionals to improve population health.
- The Practical Playbook for Integrating Public Health and Primary Care is a Web-based resource now being developed to provide clinicians and public health officials tools and strategies to support integrated models for improving population health.
- The AAFP has been involved in national discussions about integration and has formed a workgroup to track this trend and what it means for Academy members.
According to a Feb. 20 news release(www.debeaumont.org) from the de Beaumont Foundation, "By increasing collaboration between the public health and primary care sectors, individuals can receive the resources and services they need through effective and engaged community-based systems. The Practical Playbook for Integrating Primary Care and Public Health will offer a comprehensive and practical approach to that goal and promises improvement in population health by transforming the relationship between the public health and primary care sectors."
The project builds on an Institute of Medicine (IOM) report, Primary Care and Public Health: Exploring Integration to Improve Population Health(www.iom.edu), that was released in March 2012.
Although the IOM report, which was requested by the CDC and HRSA, noted that the concept of integrated, community-oriented primary care is not new -- the profession of family medicine is firmly grounded in it -- few communities have succeeded in establishing long-term relationships. Regional factors, including local health challenges, laws and policies, and slim resources, have been barriers to such interfaces.
"The key task now is to focus on the challenge of sustainable implementation of community-based models of primary care and public health integration," the IOM report said, noting there are various levels of integration, from simple awareness of the services each discipline provides to collaboration and partnership in solving community health problems. But to succeed, models of integration should
- share a common goal of improving population health,
- involve the community in defining and addressing needs,
- rely on strong leadership across disciplines, and
- share data and analysis.
Playbook creators are analyzing successful integration programs to determine key elements of effective integration that are able to span different communities and different health challenges, Michener said.
Data-sharing is an especially critical component of integration, according to Michener. De-identified data from patients' electronic health records combined with public health data can be used to pinpoint communities in need of improved health services along with appropriate interventions. Outcomes can be tracked almost in real-time, he added.
The CDC offers several resources on population health management that family physicians may find useful, according to Denise Koo, M.D., M.P.H., director of the agency's scientific education and professional development program office. CDC data on epidemiology and health outcomes can be helpful when doing initial community health assessments, said Koo. Also, the CDC Learning Connection provides free CME related to population health.
Younger family physicians may want to consider enrolling in the Epidemic Intelligence Service, a two-year postgraduate training program in applied epidemiology. Although the program was created to detect biological warfare during the Cold War, the skills trainees learn "are incredibly useful in the health care system today, where we're putting the emphasis on accountability," Koo said.
For example, using data from hospital records and emergency medical services, the Annapolis Community Health Partnership identified a hot spot of area residents who frequent the emergency department, said Patricia Czapp, M.D., chair of clinical integration at Anne Arundel Medical Center in Annapolis, Md.
A single apartment building, home to 184 seniors and disabled adults, originated 220 medical 911 calls in the course of a year. Moreover, in the span of six months, the building's residents visited the local emergency department 175 times, Czapp said. "A lot of people aren't getting primary care in this area," she noted.
As a result, the partnership -- which includes the medical center, the county health department, the county department of aging and disabilities, the local housing authority, and city government -- plans to open a patient-centered primary care medical home on the first floor of the apartment building. The medical home practice will begin serving building residents and others in the community when it opens next summer.
"We could not do this alone," said Czapp, referring to medical center staff. The clinic will depend on partners for mental health resources and smoking cessation and other wellness programs, she explained. The clinic also will rely on the county health department, along with community organizations, to endorse the clinic and refer patients there.
Although the partnership is receiving startup funding and other financial incentives from the state's new Health Enterprise Zone initiative, the practice ultimately aims to be self-sustaining, Czapp said. Practice staff will ensure patients sign up for Medicaid. Overall, the partnership hopes to demonstrate a 30 percent decrease in hospital admissions and 911 calls for apartment residents.
Integrating public health and primary care is "way overdue," according to Denise Koo, M.D., M.P.H., director of the CDC's scientific education and professional development program office. "The current administration supports collaboration," she said.
As a result of the IOM report, HRSA and the CDC have begun meeting on a regular basis to look for opportunities to build synergy and partnerships between the CDC's public health programs, HRSA-funded health clinics and other services. Koo is a key player in the development of the Playbook, and Sarah Linde-Feucht, M.D., acting chief public health officer at HRSA, also will be joining the Playbook's advisory committee.
"I think it's really important for CDC to play a role in the closer alignment of public health and health care. We want to actually have the focus be on health as opposed to delivering pieces of care to individual body parts," said Koo.
The movement to create a strong primary care-public health interface at the national level also has been bolstered by a January report from Trust for America's Health, which calls on the nation's public health system to increase its capabilities, including its programs and funding, to help move the country from providing "sick care" to providing true "health care." Partnerships between public health, health care professionals and community organizations are critical in managing and preventing the chronic diseases that plague the United States, according to A Healthier America 2013: Strategies to Move from Sick Care to Health Care in Four Years(healthyamericans.org).
"Our health care system has historically continued to provide payment for a volume of services rather than the quality of the outcomes," said Robert Moser Jr., secretary of the Kansas Department of Health and Environment and a family physician. "We're not doing a good job of population health management," he said.
As they work to establish patient-centered medical homes, practices have realized their patients need behavioral health services, social services and patient education to be healthy. "It costs to hire patient educators and do health promotion and disease prevention," Moser said. "Public health is already doing that, so I think it's imperative to reach out and look at the benefits of what's currently happening."
Integration is being encouraged in Kansas as a result of the Patient Protection and Affordable Care Act's requirement that nonprofit hospitals demonstrate their benefit to community health, Moser said. Hospitals now are tasked with completing community health assessments and improvement plans, and public health departments also are required to do these assessments. Grants are available for hospitals and public health departments that work jointly on community health assessments, he said.
Assessments bring key players to the table, and Moser hopes they'll find a few small projects where integration can succeed. "I think if they start chipping away at the doable things at that level first, they can expand on that and begin to tackle some of the more complex issues."
The AAFP is involved in the national discussion on integration, said Julie Wood, M.D., AAFP vice president for health of the public and interprofessional activities. A workgroup has been formed to track this trend and provide members with practical approaches to working with their local public health officials.
"Family physicians are on the forefront of this, we just don't know who they all are," Wood said. "Part of the Playbook is to find out who is doing integration and to help each other out."