 |
|
Community-Oriented Primary Care
The State of an Art
Arch Fam Med. 1999;8:550-552.
IN APRIL 1998, Sidney Kark, MD, the South African physician who coined the term "community-oriented primary care" (COPC) died in Israel. He and his wife, Emily Kark, MD, began an international movement to bridge and unite the practices of clinical and community medicine. Beginning in the 1940s in a rural practice in Pholela, KwaZulu-Natal, the Karks experimented and refined their progressive concept of COPC, ran afowl of the apartheid regime in South Africa, and then emigrated with their ideas and innovations to the Kiryat Yovel Health Center in Jerusalem, Israel. Through publication of The Practice of Community-Oriented Primary Health Care1 and Epidemiology and Community Medicine,2 mentoring American leaders such as Jack Geiger, MD, Fitzhugh Mullan, MD, and the late Joanne Lukomnik, MD, MPH, and teaching in the United States, Israel, and elsewhere, the Karks have nurtured a movement and built an important intellectual legacy for primary care. They have also told their own story in a book, Promoting Community Health: From Pholela to Jerusalem, which will be published this year.3
The passing of COPC's first generation of leadership through death and retirement gives us an opportunity here to review briefly what the COPC movement has accomplished and where it stands today.
Community-Oriented Primary Care, long a conceptual partner of the War on Poverty's community health center movement, became distinguished on its own in the early 1980s with the convening of conferences, studies, and publications by the Institute of Medicine (IOM)4-5 and Health Resources and Services Administration.6 The IOM report codified Kark's definition of COPC and proposed a 4-step model of COPC that became both a standard and barrier to what qualified as COPC. The IOM process required (1) definition of the practice's community, (2) identification of a health problem, (3) intervention to improve the health problem, and (4) evaluation of the intervention to modify and improve its effect on health. The IOM definition emphasized the importance of the community population denominator, not just patients enrolled in a clinical practice.
However, the definition of COPC itself has evolved since 1983 and now has proponents (myself included) of a 5-element, dynamic process that centers on "engaging and mobilizing the community" but that may not necessarily follow linear, sequential steps, be based in a primary care practice, or be evaluated only quantitatively.7 This dynamic process is illustrated in the figures below, either as a circle or a star within a circle (Figure 1 and Figure 2).
|
|
|
|
Figure 1. According to Rhyne et al,7 experience has shown that the steps of community-oriented primary care may vary in order depending on the community, health problem, or approach taken by the collaborating team.
|
|
|
|
|
|
|
Figure 2. The author's "star in the circle" model of community-oriented primary care.
|
|
|
Employing the IOM definition of COPC, "strict constructionists" would not consider the impressive accomplishments of Bayer and Fiscella8 reported in this issue of the ARCHIVES, as an example of COPC—but would applaud their contributions to continuous quality improvement. By employing the methods of COPC over 30 months—engaging and mobilizing the community—they significantly improved the rates of Papanicolaou smears, mammography, childhood immunization, smoking cessation, and diabetes monitoring in a private practice in inner-city Rochester, NY. Through ongoing collaboration with their patient advisory committee, called Patients and Community Together (PACT), and a part-time outreach worker, Jefferson Family Medicine (with 3000 active patients) identified and prioritized its health promotion targets and organized innovative, community-oriented interventions aimed at improving preventive practices among its patients. And they succeeded! (While their preintervention and postintervention study design employs a historical control and, therefore, subject to the Hawthorne effect, the magnitude of change suggests an "active" ingredient!)
Community-Oriented Primary Care, however, has always sought not only to go beyond the office and hospital into the community, as the IOM emphasized, but also to change what takes place in the examining room and at the bedside and how practice tools such as the electronic medical record are used. Jefferson Family Medicine is not the first example of bringing the community into the practice,9 but it is the first to document such significant improvements.
Research published in 1998 by Pathman et al10 at the University of North Carolina, Chapel Hill, provides a long absent empirical framework for COPC. Drawing upon a national, randomized sample of primary care internists, pediatricians, and family physicians, Pathman et al identified 4 domains of community skills and knowledge employed by practicing physicians: (1) familiarity with community resources and services, (2) attention to sociocultural aspects of patient care, (3) participation in and assimilation into the community as citizens, and (4) participation in health activities of the community, such as COPC. They also found that specific components of undergraduate medical education and residency training influenced the involvement, confidence, and sense of competency that practicing physicians reported in each of the 4 domains.11
The year 1998 also marked the publication of the first major text on COPC in a decade. Edited by Robert Rhyne, MD, Richard Bogue, PhD, Gary Kukulka, PhD, and Hugh Fulmer, MD, Community-Oriented Primary Care: Health Care for the 21st Century12 is a comprehensive, state-of-the-art review and practical guide to the specific skills and techniques that support COPC. These 4 editors have assembled 30 authors, many affiliated with the W. K. Kellogg Foundation's (Battle Creek, Mich) 13-site Community-Oriented Primary Care National Rural Demonstration Project, Kansas City, Mo (1988-1991), which was cosponsored by the American Hospital Association's Research and Educational Trust, or W. K. Kellogg Foundation's Urban COPC Demonstration Project, Boston, Mass (1988-1993). Their work reflects the COPC experience of clinicians and administrators during the 1990s.
The book makes 2 very important contributions to the COPC literature: (1) It recognizes that any clinical site (eg, health maintenance organization, public health clinic, hospital, etc), and not just primary care physicians, may bridge individually oriented and family-oriented clinical practice with community-oriented and population-oriented public health and engage in COPC. (2) It modifies the IOM's sequential 4-step model of COPC by adding a fifth central component that involves the community, thereby challenging the sequential notion of the COPC steps, suggesting rather that they are dynamic and interactive (Figure 1). Publications by the American Public Health Association, Washington, DC, also recognize COPC as not only the domain of primary care but also the domain of public health clinicians, necessary partners that were too long absent from the COPC movement. The American Public Health Association also published Planning for Community-Oriented Health Systems,13 which does not cite a single reference from the COPC literature and demonstrates how isolated planning and public health were from clinical discourse even in the mid 1990s.
During the 1990s, other institutions joined the the W. K. Kellogg Foundation in supporting COPC. Beginning in 1993, the Bureau of Health Professions Title VII grants to residency programs in family practice encouraged and funded the development of programs and curricula in COPC. Residency programs as diverse as Maine Medical Center (Portland), Brown University (Pawtucket, RI), Sinai Samaritan Hospital (Milwaukee, Wis), Henry Ford Health System (Detroit, Mich), White Memorial Hospital (Los Angeles, Calif) and Thomas Jefferson University (Philadelphia, Pa) developed COPC curricula. In 1994, the Department of Family Medicine at Case Western Reserve University, Cleveland, Ohio, began publishing a COPC newsletter, COPaCetic, sponsored by the Robert Wood Johnson Foundation (Princeton, NJ). Boston hosts both the Carney Hospital's COPC Fellowship Program and the Center for Community Responsive Care, while George Washington University, Washington, DC, sponsors COPC fellowship training in General Academic Pediatrics at Children's National Medical Center and an international COPC certificate program with Hebrew University, Jerusalem. Parkland Hospital and Health System, Dallas, Tex, has developed its community clinic network based on COPC principles and bears the title of COPC Network.
The collaborations between clinical practice and public health and between health professionals and members of the communities they serve are the heart of COPC. Also with Robert Wood Johnson Foundation support, the American Medical Association, Chicago, Ill (then led by family physician Nancy Dickey, MD) and the American Public Health Association came together with many other professional organizations and federal agencies to re-examine the relationship between medicine and public health. The Committee on Medicine and Public Health has led to 2 valuable publications, Medicine and Public Health: The Power of Collaboration14 and Pocket Guide to Cases of Medicine and Public Health Collaboration.15 Like the earlier sequence published on COPC by the IOM, these 2 monographs explore the theory of collaboration and examine specific case studies (N=414), respectively. Community-oriented primary care is prominently included in this broader movement. The Center for the Advancement of Collaborative Strategies in Health continues the work of the Committee on Medicine and Public Health, based at the New York Academy of Medicine, New York, NY. Their current program, Cooperative Actions for Health, operates in 18 states and is headquartered in Washington, DC. It is coordinated by the American Public Health Association in partnership with the American Medical Association; their credo is "Working Together to Improve the Health of the Public." Robert Wood Johnson Foundation provides funding support.
Community-Oriented Primary Care in the United States was born out of the powerful effect that the Reagan admininstration had on the federally funded community health centers in the early 1980s, when one quarter of all community health centers closed. Community-Oriented Primary Care sought the legitimacy of epidemiological methods linked to clinical practice, but it was not embraced by the larger public health community. As a new century begins, necessity has become a virtue: collaborations between medicine and public health and partnerhips between health professionals and communities are encouraging a more seasoned practice of COPC that moves beyond the mere process and tangibly improves measurable health outcomes. In this issue of the ARCHIVES, Bayer and Fiscella have begun to demonstrate the power of COPC.
AUTHOR INFORMATION
Corresponding author: A. H. Strelnick, MD, Department of Family Medicine and Community Health, Montefiore Medical Center, Institute for Community and Collaborative Health, Albert Einstein College of Medicine, 3544 Jerome Ave, Bronx, NY 10467.
A. H. Strelnick, MD
Bronx, NY
REFERENCES
|
1. Kark SL. The Practice of Community-Oriented Primary Health Care. New York, NY: Appleton-Century-Crofts; 1981.
2. Kark SL. Epidemiology and Community Medicine. New York, NY: Appleton; 1974.
3. Kark SL, Kark E. Promoting Community Health: From Pholela to Jerusalem. Johannesburg, South Africa: Witwatersrand University Press; 1999.
4. Connor E, Mullan F. Community Oriented Primary Care: New Directions for Health Service Delivery. Washington, DC: National Academy Press; 1983.
5. Nutting PA, Connor EM. Community-Oriented Primary Care: A Practical Assessment. Washington, DC: National Academy Press; 1984.
6. Nutting PA. Community-Oriented Primary Care: From Principle to Practice. Washington, DC: US Dept of Health and Human Services; Health Resources and Services Administration, 1987.
7. Rhyne R, Cashman S, Kantrowitz M. An Introduction to Community-Oriented Primary Care (COPC). In: Rhyne R, Bogue R, Kukulka G, Fulmer H, eds. Community-Oriented Primary Care: Health Care for the 21st Century. Washington, DC: American Public Health Association, 1998.
8. Bayer WH, Fiscella K. Patients and community together: a family medicine community-oriented primary care project in an urban private practice. Arch Fam Med. 1999;8:546-549.
FREE FULL TEXT
9. Seifert MH. The Patient Advisory Council Concept. In: Connor E, Mullan F, eds. Community Oriented Primary Care: New Directions for Health Services Delivery. Washington, DC: National Academy Press; 1983.
10. Pathman DE, Steiner BD, Williams ES, Riggins T. The four community dimensions of primary care practice. J Fam Pract. 1998;46:293-303.
ISI
| PUBMED
11. Steiner BD, Pathman DE, Jones B, Williams ES, Riggins T. Primary care physicians' training and their community involvement. Family Med. 1999;31:257-262.
PUBMED
12. Rhyne R, Bogue R, Kukulka G, Fulmer H. Community-Oriented Primary Care: Health Care for the 21st Century. Washington, DC: American Public Health Association; 1998.
13. Rohrer JE. Planning for Community-Oriented Health Systems. Washington, DC: American Public Health Association; 1996.
14. Lasker RD and the Committee on Medicine and Public Health. Medicine and Public Health: The Power of Collaboration. New York, NY: New York Academy of Medicine; 1997.
15. Lasker RD, Abramson DM, Freedman GR. Pocket Guide to Cases of Medicine and Public Health Collaboration. New York, NY: New York Academy of Medicine; 1998.
RELATED ARTICLE
Patients and Community Together: A Family Medicine Community-Oriented Primary Care Project in an Urban Private Practice
William H. Bayer and Kevin Fiscella
Arch Fam Med. 1999;8(6):546-549.
ABSTRACT
| FULL TEXT
THIS ARTICLE HAS BEEN CITED BY OTHER ARTICLES
2006 Job Lewis Smith Award Acceptance Address: Is There an OWA (Other Weird Arrangement) in Your Future?
Fisch
Pediatrics 2007;120:149-154.
FULL TEXT
Motherhood, Apple Pie, and COPC
Williams
Ann Fam Med 2004;2:100-102.
FULL TEXT
"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: New Relevance in a Changing World
Mullan and Epstein
AJPH 2002;92:1748-1755.
ABSTRACT
| FULL TEXT
|
