 |
|
Patients and Community Together
A Family Medicine Community-Oriented Primary Care Project in an Urban Private Practice
William H. Bayer, MD;
Kevin Fiscella, MD, MPH
Arch Fam Med. 1999;8:546-549.
ABSTRACT
| |
Background There has been considerable discussion in the literature regarding the value and feasibility of community-oriented primary care (COPC), but relatively few published real-world examples.
Objective To examine the effect of a practice-based COPC project on rates of preventive health interventions within an inner-city family medicine practice.
Methods A newly created community advisory board called Patients and Community Together (PACT) and the medical director of the practice in Rochester, NY, collaborated on all phases of the COPC project. Papanicolaou smear and mammography screening, childhood immunizations, diabetes control, and smoking cessation were targeted for intervention. A practice/community awareness campaign was instituted and individual and group incentives were developed. Progress was monitored through a computerized medical record that included all active patients in the practice.
Results Rates of annual Papanicolaou smears increased from 46% to 71%; annual mammography for women older than age 50 years, from 56% to 86%; completed childhood immunizations when younger than 6 years, from 78% to 97%; and performance of semiannual glycosylated hemoglobin, from 85% to 92%. Rates of patients with glycosylated hemoglobin values under 10% improved from 56% to 77%. There were 5 smokers who successfully quit.
Conclusion This project illustrates how practice-based COPC can be successfully implemented within a private practice setting. It also shows how COPC principles can be used to achieve the goals for Healthy People 2000 within inner-city practices.
INTRODUCTION
COMMUNITY-oriented primary care (COPC) has been widely promoted as a model for improving primary care to populations.1-3 Community-oriented primary care has been defined by the Institute of Medicine (Washington, DC) as
an approach to health care delivery that undertakes responsibility for the health of a defined population which is practiced by combining epidemiologic study and social interventions with clinical care of individual patients, so that the primary care practice itself becomes a community medicine program. Both the individual patient and the community or population are the foci of diagnosis, treatment and ongoing surveillance.4
Despite the endorsement by academic family physicians and the Institute of Medicine, COPC has not been widely adopted by community family physicians.5 Community-oriented primary care has been criticized because it is unproven and its implementation requires skills, time, and resources that are beyond those of most practicing physicians.6 Moreover, many physicians have been discouraged by the prospect of defining a community in a clinically relevant fashion.
However, recent developments in medicine offer promise for addressing many of these practical barriers to implementing COPC. These developments include the growth of managed care, widespread use of electronic information management systems,7-8 and a growing focus on patient involvement in care.9-10 First, in managed care, providers are accountable for the health of all enrolled patients, not simply patients who come in for care. Thus, health providers must shift their attention from an exclusively individual focus to a practice-based, population focus similar to that envisioned by COPC. Second, the advent of computer-based information management systems makes COPC more logistically feasible for community physicians. For example, patients in need of specific services can be quickly identified and progress toward goals can be easily tracked. Last, a growing literature suggests that patient involvement in care promotes better outcomes.10-11 Thus, there is increasing empirical support for the concept of patient and community involvement in the COPC process. These 3 developments formed the basis for a COPC project undertaken within an inner-city, private family medicine practice.
In this practice-based project, key steps in the COPC process12 were effectively implemented. First, the community was defined as all active patients enrolled in the practice. This practice-based definition of community, though more restrictive than others,13-14 is nonetheless consistent with the concept of COPC as defined by the Institute of Medicine and as promulgated by COPC advocates.12, 15 Second, patients and providers jointly identified and prioritized the health care needs of the community. Third, patients and providers designed and implemented a strategy for addressing the identified health care needs. Last, the goals of the project were evaluated using carefully collected data.
PATIENTS AND METHODS
PRACTICE POPULATION
The project was undertaken in a private family medicine practice in Rochester, NY. The census tracts surrounding the practice are characterized by some of the highest rates of poverty, low birth weight, crime, and underimmunization in the state of New York. For the purposes of this project, an active patient was defined as a patient who had previously registered for care and was seen within the last 24 months. The provider staff at the time of the project included a full-time family physician (W.H.B.) and a full-time nurse practitioner.
Role of Patients and Community Together
The patient advisory committee, named Patients and Community Together (PACT), consisted of 11 patients who responded to a flyer placed in the waiting room. The group was representative of the adolescent and adult practice population for age, ethnicity, and sex. Patients and Community Together members identified areas of need within the practice, formulated health objectives, and proposed strategies for reaching those objectives. The PACT advisory board also aided in organizing projects such as a community health fair, publicizing the program, and developing promotional ideas such as poster boards in the waiting room. The meetings were held monthly, and the program outreach worker attended most of the meetings. Interventions were included according to the perceptions of the board as a whole. Two of the board members had diabetes and many other board members had close relatives with diabetes. The board felt there was a large knowledge gap in the area of diabetes and that medical office visits alone would not bridge that gap. The board also felt that the problem of substance abuse was generally well addressed in the community, except for the glaring example of nicotine dependence. Therefore, smoking cessation was included in the list of interventions. Other priority areas identified by the board were Papanicolaou smear screening for women aged 18 to 65 years, mammography screening for women aged 50 years and older, and immunizations for children aged 5 years and younger.
METHODS
Data Collection
Computerized medical records have been used since the practice opened in 1992. Each examination room is equipped with a computer terminal and patient notes are entered by keyboard. In 1994, a quality assurance component was added that allowed tracking of all health procedures. Office procedures such as immunizations and Papanicolaou smears are automatically recorded as they are billed. Out-of-office procedures such as mammograms are entered separately by the office nurse.
Intervention
An outreach worker from the community was hired half-time to follow up on the program objectives, establish individual incentives, develop community awareness, and track progress. She contacted patients (usually by telephone or through friends or family) who required follow-up. She organized the PACT meetings, health fairs, and health conferences. For immunization goals, the theme "Twelve by Two," which signified that children needed 11 immunizations and at least 1 lead test by age 2 years, was established. On achieving this goal, children were awarded with an "I'm a Jefferson Family Medicine Hot Shot" T-shirt. Patients who completed their Papanicolaou smear or mammograms were eligible for special PACT T-shirts, designed and produced by a local high school T-shirt company that was recommended by a PACT member. Three smoking cessation programs were also conducted; quitters of any addicting substance received PACT sweatshirts, as did diabetics who met their goals.
Several methods to increase community awareness of the importance of our program were used. First, a community fund was established. Achievement of a preventive health activity would lead to PACT contributions to the fund. Each mammogram, Papanicolaou smear, and immunization brought a $5 contribution, and each person who successfully quit a substance or each diabetic who achieved a glycosolated hemoglobin level under 0.1 generated $100 for the community fund. Posters that charted progress toward the goals were displayed throughout the office. At a local elementary school, a contest was held for the best poster that demonstrated the need for immunizations and healthy lifestyles. Five 10-speed bicycles were awarded to winners. Finally, the outreach worker and the patient advisory board organized a PACT banquet and health fair that was attended by over 600 people. Individual awards were presented at the banquet and $5000 from the PACT community fund was awarded to 5 different local nonprofit organizations.
The outreach worker was responsible for monitoring and ensuring progress toward program goals. A quality assurance tracking system based on the computerized record system (The Specialist; CMI Medical Systems, Rochester, NY) generated progress reports on our various goals, and the outreach worker contacted persons who needed to come in for shots, examinations, or screening tests.
Statistical Analysis
Data were dichotomized based on whether the patient had received the intervention according to schedule. For childhood immunizations, compliance was defined as receipt of all immunizations within 6 months of the interval recommended by the American Academy of Pediatrics for children younger than 6 years. For Papanicolaou smear screening, compliance was defined as having had a Papanicolaou smear within 1 year of the audit for women aged 18 to 65 years who had an intact uterus. For mammography screening, compliance meant documentation by mammogram report of performance within 1 year of the audit for all women aged 50 years and older. For diabetic testing, compliance was defined as having a glycosylated hemoglobin level test within 6 months of the audit. For diabetic control, compliance was defined as a glycosylated hemoglobin level lower than 0.1. Preintervention data were collected at the start of the project in June 1994. These data were compared with data collected at follow-up in December 1996. Statistical significance was assessed using a series of McNemar tests. Statistical analyses were performed using SAS software.16
RESULTS
At the start of the project in June 1994, there were approximately 3000 active patients. The patients were reflective of the surrounding community: predominantly female, young, African American, and impoverished (Table 1). At baseline, 22% of all children younger than 6 years in the practice were more than 6 months behind in their immunizations (Table 2). Less than half of eligible women had a Papanicolaou smear and only slightly more than half had a mammogram performed within the preceding year. Fifteen percent of diabetic patients had not had a glycosylated hemoglobin level test performed within 6 months. Among those who had a glycosylated hemoglobin level test, only 56% had levels that were lower than 0.1.
|
|
|
|
Table 1. Description of Active Patients at the Start of the Project
|
|
|
|
|
|
|
Table 2. Comparison of Preventive Health Interventions Before and After the Community-Oriented Primary Care Project
|
|
|
At follow-up, there were statistically significant increases in compliance for each of these health interventions (Table 2). Specifically, 97% of all children had timely immunizations, 71% of eligible women had a Papanicolaou smear performed within the year, and 86% of women over 50 had a mammogram performed. Furthermore, 92% of all diabetic patients had glycosylated hemoglobin level tests performed within 6 months; of these, 77% had glycosylated hemoglobin levels that were lower than 0.1. Five smokers quit during the project period. Most of these goals met or exceeded the standards set forth by the Health Employer Data Information Set17 and by the National Health Promotion and Disease Prevention Objectives in Healthy People 2000.18
COMMENT
This COPC project undertaken at an inner-city, private family medicine practice with patient and community collaboration demonstrated statistically significant and clinically relevant improvements in compliance with preventive health interventions and 1 clinical outcome measure. Rates of childhood immunizations, Papanicolaou smears, mammography screening, and control of diabetes all improved during the COPC project.
Although these findings are based on a single family medicine practice that serves a single community, we believe that they can be replicated elsewhere. The computer system, including a central processing terminal, data entry terminal, and printers in each room, software, and cabling expense, amounted to approximately $14,000. Office staff were paid $1 per medical record ($3200 total cost) for entering preventive health data into the computer system at the start of the project. Subsequently, data were entered routinely during the course of the visit with the exception of mammograms, which were entered by the nurse on receipt of the report. The single largest expense was the outreach worker who was paid $8 an hour for 20 hours per week on the project. The T-shirts cost approximately $3000 to purchase, design, and print. Additionally, $5000 was devoted to 5 community programs that were funded when various practice targets were met. Finally, the 5 bicycles awarded to the children who won a healthy choices poster contest cost $100 each. The entire project was jointly funded by a local Medicaid health maintenance organization and by a New York State Department of Health Primary Care Initiative grant.
Given the study design, it is difficult to determine which elements were most critical to the project's success. Was it primarily due to the Hawthorne effect, to patient and community involvement, patient incentives, outreach, a computerized management system, or provider commitment? We suspect that each of these factors played an important role. In particular, the project relied on key elements necessary to maximize patient and provider compliance with preventive health.19-20 First, there was strong leadership and commitment on the part of the medical director. Second, the practice developed a series of clearly stated protocols for prevention services. Third, the project relied on a management information system that allowed for the identification of patients who had not undergone the recommended procedure. For example, immunization records were available with one keystroke at the time visit notes were entered into the computerized medical record. Fourth, progress toward each goal was reported monthly to PACT. Fifth, the project established a system for contacting patients and encouraging them to schedule an appointment (community outreach). Last, the project empowered and motivated patients through PACT, community promotions, and incentives to schedule appointments for recommended services.
We consider our results notable in several respects. First, they demonstrate that COPC projects can be feasibly implemented within the context of a busy private family medicine practice with modest external funding. Electronic medical records of patients who have not yet received appropriate preventive health services are flagged using computerized information management systems. Provider reminders are easily generated.21-22 Computerized data management systems can also be used to evaluate the effect of interventions designed to improve compliance.21 Thus, computerized management systems allow providers to implement their own in-house quality improvement systems.23
Second, the findings from this project underscore the role of patient and community involvement in COPC.24 In this project, patient involvement was critical in targeting problems, mobilizing support, and designing the appropriate interventions. It seems improbable that the project would have been nearly as successful without such involvement.
Last, the results show that high rates of preventive health care are achievable in inner-city practices. Although minority communities receive lower rates of preventive health interventions,25 this inequity may be related to limited access to appropriate care26 and to the attitudes of health care providers.27 This project clearly shows that a collaborative effort between providers, patients, community, and an outreach worker can produce rates of preventive health interventions among indigent and minority patients that exceed national goals.
AUTHOR INFORMATION
Accepted for publication January 4, 1999.
This study was supported by grants from the Monroe Plan of Finger Lakes Blue Cross and Blue Shield, Rochester, NY, and the New York State Department of Health, Albany.
Corresponding author: Kevin Fiscella, MD, MPH, Family Medicine Center, 885 South Ave, Rochester, NY 14620 (e-mail: Kevin_Fiscella{at}urmc.rochester.edu).
From the Departments of Family Medicine (Drs Bayer and Fiscella) and Community and Preventive Medicine (Dr Fiscella), University of Rochester School of Medicine and Dentistry, Rochester, NY.
REFERENCES
| |
1. Nutting PA. Community-oriented primary care: an integrated model for practice, research, and education. Am J Prev Med. 1986;2:140-147.
PUBMED
2. Nutting PA. Community-Oriented Primary Care: From Principle to Practice. Albuquerque: University of New Mexico Press; 1987.
3. Frame PS. Is community-oriented primary care a viable concept in actual practice? an affirmative view. J Fam Pract. 1989;28:203-206.
ISI
| PUBMED
4. Institute of Medicine. Community-Oriented Primary Care: A Practical Assessment. Washington, DC: National Academy Press; 1984.
5. Williams R, Foldy SL. The state of community-oriented primary care: physician and residency program surveys. Fam Med. 1994;26:232-237.
PUBMED
6. O'Connor PJ. Is community-oriented primary care a viable concept in actual practice? an opposing view. J Fam Pract. 1989;28:206-208.
ISI
| PUBMED
7. Ornstein SM, Garr DR, Jenkins RG, Musham C, Hamadeh G, Lancaster C. Implementation and evaluation of a computer-based preventive services system. Fam Med. 1995;27:260-266.
PUBMED
8. Balas EA, Austin SM, Mitchell JA, Ewigman BG, Bopp KD, Brown GD. The clinical value of computerized information services: a review of 98 randomized clinical trials. Arch Fam Med. 1996;5:271-278.
FREE FULL TEXT
9. Anderson JM. Empowering patients: issues and strategies. Soc Sci Med. 1996;43:697-705.
10. Greenfield S, Kaplan S, Ware JE Jr. Expanding patient involvement in care: effects on patient outcomes. Ann Intern Med. 1985;102:520-528.
11. Greenfield S, Kaplan SH, Ware JE Jr, Yano EM, Frank HJ. Patients' participation in medical care: effects on blood sugar control and quality of life in diabetes. J Gen Intern Med. 1988;3:448-457.
ISI
| PUBMED
12. Nevin JE, Gohel MM. Community-oriented primary care. Prim Care. 1996;23:1-15.
PUBMED
13. Gold MR, Franks P. A community-oriented primary care project in a rural population: reducing cardiovascular risk. J Fam Pract. 1990;30:639-644.
PUBMED
14. Taylor BR, Haley D. The use of household surveys in community-oriented primary care health needs assessments. Fam Med. 1996;28:415-421.
PUBMED
15. Nutting PA. Defining a practice community: an approach to COPC for Family Medicine. In: Nutting PA, ed. Community-Oriented Primary Care. Albuquerque: University of New Mexico Press; 1987:45-47.
16. SAS Institute Inc. SAS Procedures Guide, Release 6.03. Cary, NC: SAS Institute Inc; 1988.
17. Sennett C. An introduction to HEDIS. Hosp Pract (Off Ed). 1996;31:147-148.
18. Healthy People 2000: National Health Promotion and Disease Prevention Objectives. Washington, DC: Public Health Service, US Dept of Health and Human Services; 1990.
19. Solberg LI, Kottke TE, Brekke ML, Calomeni CA, Conn SA, Davidson G. Using continuous quality improvement to increase preventive services in clinical practice: going beyond guidelines. Prev Med. 1996;25:259-267.
FULL TEXT
|
ISI
| PUBMED
20. Sifri R, Wender RC. Preventive care: steps toward implementation. Prim Care. 1996;23:127-140.
PUBMED
21. Ornstein SM, Garr DR, Jenkins RG, Rust PF, Arnon A. Computer-generated physician and patient reminders: tools to improve population adherence to selected preventive services. J Fam Pract. 1991;32:82-90.
ISI
| PUBMED
22. McPhee SJ, Bird JA, Fordham D, Rodnick JE, Osborn EH. Promoting cancer prevention activities by primary care physicians: results of a randomized, controlled trial. JAMA. 1991;266:538-544.
FREE FULL TEXT
23. O'Connor PJ, Rush WA, Peterson J, et al. Continuous quality improvement can improve glycemic control for HMO patients with diabetes. Arch Fam Med. 1996;5:502-506.
FREE FULL TEXT
24. Sheps CG. Patient and Community Involvement. In: Nutting PA, ed. Community-Oriented Primary Care: From Principle to Practice. Albuquerque: University of New Mexico Press; 1987:402-406.
25. Witcher PR, Fulton JP, Beauchene N, Harvey E, Bessette B. Chronic disease prevention among minority groups: problems and possibilities. Med Health R I. 1996;79:270-274.
PUBMED
26. Hubbell FA, Waitzkin H, Mishra SI, Dombrink J. Evaluating health-care needs of the poor: a community-oriented approach. Am J Med. 1989;87:127-131.
ISI
| PUBMED
27. Gemson DH, Elinson J, Messeri P. Differences in physician prevention practice patterns for white and minority patients. J Community Health. 1988;13:53-64.
FULL TEXT
| PUBMED
RELATED ARTICLE
Community-Oriented Primary Care: The State of an Art
A. H. Strelnick
Arch Fam Med. 1999;8(6):550-552.
FULL TEXT
THIS ARTICLE HAS BEEN CITED BY OTHER ARTICLES
"Palliatives Will No Longer Do": The Deep Roots and Continuing Dynamic of Community-Oriented Primary Care
Brown and Fee
AJPH 2002;92:1711-1712.
FULL TEXT
Community-Oriented Primary Care: The State of an Art
Strelnick
Arch Fam Med 1999;8:550-552.
FULL TEXT
|
