Community-Responsive Medicine: A Call for a New Academic Discipline

219 Guest editorial COMMUNITY-RESPONSIVE MEDICINE: A CALL FOR A NEW ACADEMIC DISCIPLINE DAVID R. SMITH, M.D. Medical Director and Chief Executive Officer Community-Oriented Primary Care Parkland Memorial Hospital RON J. ANDERSON, M.D. President and Chief Executive Officer Parkland Memorial Hospital 5201 Harry Hines Boulevard Dallas, Texas 75235 Poor access το health care is one of the primary deficiencies of our modern medical system. Despite the fact that the U.S. Department of Health and Human Services (DHHS) has identified comprehensive health care to the indigent as one of this nation's priority health concerns,1 access to health care has declined in this country in recent years, primarily as a result of the growing number of individuals—an estimated 37 million—without health insurance.2 Equally large numbers of individuals, in particular women of childbearing age and children, are underinsured.3 Another indicator of access, ambulatory care visits, declined by 30 percent between 1982 and 1986Λ5 The underutilization of ambulatory care placed even greater demands on public hospitals and emergency rooms as patients presented for treatment of preventable and episodic health problems. This pattern bypasses the most cost-effective and health-effective services which can be provided in a comprehensive primary care setting. Community-responsive health care minimizes fragmentation by reducing barriers such as transportation and by co-locating related services, such as laboratory; pharmacy; radiology ; health education; Women, Infants, and Children (WIC) services; and immunizations, in one site. This concept of integrated care has been labelled "one-stop shopping."6 Community-responsive medicine can be considered the academic discipline of Community-Oriented Primary Care (COPC).7 COPC is a way of practicing medicine that blends traditional primary care with public health Journal of Health Care for the Poor and Underserved, Vol. 1, No. 2, Fall 1990 220 Community-Responsive Medicine services. Primary care, a structural element of COPC, "can be defined as that array of health services provided by a practitioner to a patient that is accessible and acceptable to the patient, comprehensive in scope, coordinated and continuous over time, and for which the practitioner is accountable for the quality and potential effects of the services."7 Primary care focuses on the individual patient or "user" and does not assume responsiblity for the health status of the community at large. In contrast, COPC is driven by the defined need for health services identified within the target community. By combining obstetrical, gynecological, pediatric, and adult medicine with public health services such as immunization and communicable disease control, COPC pro-actively aims to reduce the incidence of diseases that can lead to costly hospital care. COPC providers are accountable for results and take responsibility for the health status of a defined community. The community is empowered through education and involvement in the process to identify and rank its health problems.7,8 The COPC concept has had successful application in this country. The National Institute of Medicine reviewed seven case studies in a report published in 1983.8 The case studies spanned both urban and rural practice settings as well as programs with academic affiliations. Not all of these systems had every aspect of COPC, but all had defined their target community and were providing directly or indirectly a wide array of related health services such as outreach, mental health, translation services, and immunizations. Two programs, one in Tucson, Arizona, and another in Oregon, prompted the revitalization of their respective departments of community medicine and fostered the expansion of the academic curriculum to include a community-based component. In Dallas, Texas, Parkland Memorial Hospital has implemented a large COPC Program supported in part by county taxes. The program focuses health services to six at-risk communities in Dallas County that were identified in a county-wide needs assessment conducted by Parkland. The program is affiliated with the University of Texas Southwestern Medical School. Physicians working in these health centers are granted faculty status by the university and provide attending coverage on the inpatient units of Parkland Hospital. This arrangement enables the COPC Program to provide continuity of care for the practice and inpatient settings. The Program operates five health centers that handle in excess of 110,000...