Community-oriented Primary Care Shows Promise in Value-based Era

January 24, 2017 09:07 am Michael Laff

Expanding primary care access does not mean having to brainstorm new ideas, and one existing model, in particular, can help physicians care for patients in a community setting.

In the transition to value-based physician payment models and with the emergence of a new generation of medical students who want to contribute to improving the health of the public, community-oriented primary care (COPC) is again attracting interest as a model of care aimed at improving health outcomes on a population level.

The concept can be traced back to the 1940s when a South African couple, Sidney and Emily Kark, sought a method to treat an ethnically diverse population in a rural impoverished community. They focused on community health needs, as well as acute medical care. The model was brought to the United States in 1957 by a medical student, H. Jack Geiger, who trained with the Karks. After starting in just two U.S. sites, the COPC model has expanded to more than 8,000 federally qualified community health centers.

Winston Liaw, M.D., M.P.H., medical director for the Robert Graham Center for Policy Studies in Family Medicine and Primary Care, wrote a history of COPC that was published as an infographic(journals.lww.com) online Jan. 17 in Academic Medicine.

"It's an older concept that has been rejuvenated because of renewed interest in population health and value-based payments," Liaw told AAFP News.

The authors note that COPC has not gained widespread traction under volume-based payment systems, but with an eye on value-based payment, the Robert Graham Center and the National Association of Community Health Centers have created a COPC curriculum(www.graham-center.org) in which residents learn to address population health principles and engage community health needs outside of clinical care office visits.

A full COPC care team can include a physician, nurse, epidemiologist, dentist, health educator and community health worker who focus on social medicine and population health needs. The first step is defining the population that the team will serve, followed by identification of a specific health problem such as obesity or diabetes.

The practice then locates a community partner -- for example, a YMCA that will offer classes and memberships at a discount for clinic patients. Medical team members then track patient enrollment and participation. The work is as much about patient education and connecting with patients as it is about disease protocols.

"Our health care system is oriented toward volume and not value," Liaw said. "It's not easy to do COPC because the incentives aren't there to do population health, but that's changing now."

For instance, George Washington University and the University of Nebraska offer master's degrees in public health with a concentration in COPC. The programs target both medical and nonmedical professionals, especially individuals who want to work in underserved communities while addressing health disparities. In the two-year programs, residents attend classroom sessions and complete a thesis focused on a population health problem.

The Unity Health Care teaching health center in Washington, D.C., incorporates a COPC curriculum for medical residents from the A.T. Still University School of Osteopathic Medicine. Unity's family medicine residency program also focuses on clinical training among the most vulnerable populations in federally qualified health centers in the Washington area.

"In the push toward value-based payment, if you improve the health of a community, then that aligns the providers with incentives, and then there is a strong incentive to engage in COPC," Liaw said.

CMS is encouraging development of population health and community medicine strategies, and COPC is one method to train future physicians and allied medical professionals that incorporates these strategies, according to Liaw.

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