Community-Oriented Primary Care

256 Brief communication COMMUNITY-ORIENTED PRIMARY CARE TO THE EDITOR: I read with great interest Dr. Xylina Bean's description [Vol. 2, No. 1:147-153] of her group's efforts to address the health care needs of an underserved community in Los Angeles. They employed a method called "ecoprimary care" to improve prenatal care for women living in two local housing projects. Their approach included organizing community providers, defining a target population, conducting a needs assessment, designing and implementing interventions, and evaluating the results of the interventions. We have used a similar approach in an attempt to improve health care for the poor in Orange County, California. Despite the count/s relative affluence, approximately 22 percent of its residents lack any form of health insurance. Moreover, becauseofaburdensome bureaucracy and low reimbursementrates, relatively few providers accept Medi-Cal (California's Medicaid). Making matters worse, the county government's spending for indigent health care is quite low. Orange County ranks at the bottom of the 10 most populous California counties in per capita expenditures from local funds. The county operates no public hospital and administers no comprehensive care clinic for anyone over the age of five. These and other factors have resulted in substantial barriers to access that affect uninsured and low-income residents. We based our approach on community-oriented primary care (COPC), a method from which "ecoprimary care" probably evolved. COPC, developed initially by Kark in South Africa1 and applied subsequently in various localities in the United States2-3, ideally consists of four sequential steps. First, an organization that provides primary care defines and characterizes a community that it intends to serve. Second, through research, the organization identifies community health care needs; this phase of the work comprises a "needs assessment." Third, the organization develops and implements emphasis programs to meet needs or to correct problems revealed in the second stage. Fourth, an evaluation takes place to monitor the impact of emphasis programs accomplished in its catchment area. We were fortunate that a private Catholic hospital decided to develop and implement emphasis programs to improve access to needed services in its catchment area. To identify needs and to rank them, this hospital contracted with our research group to perform a systematic, community-based survey in Journal of Health Care for the Poor and Underserved, Vol. 2, No. 2, Fall 1991 ___________________________________________________________257 the northern part of Orange County. In terms of the four stages of COPC, the contracting hospital first defined the targeted community as all individuals and families within its geographic area whose incomes were below or near the federal poverty level. Second, we conducted a random survey of health care needs of low-income families within the catchment area. We found that prenatal care and preventive services for children were particularly deficient.4 Third, the contracting hospital initiated emphasis programs, including educational materials, a mobile medical van, a child immunization program, and a prenatal care program, that responded to some but not all of the needs that we identified through the survey. As for COPCs fourth step, the hospital elected to evaluate their emphasis programs solely by numbers of patients served, rather than by more extensive and costly evaluative measures. Because of the inadequacy of our county's indigent health care system, advocacy for improved services has been an important component of our work.5 We have used the research results to bolster political and, occasionally, legal activities—actions that can also be considered emphasis programs in the COPC model. The political activities have included publicizing the research findings in local newspapers, meeting with local government officials, and testifying at county budget hearings. To date, legal action has been limited. However, on some occasions, we have encountered medically indigent patients whose treatment by county officials or private providers seemed to fall outside the bounds of the law. Legal professionals have initiated actions for individual patients facing financial barriers to care, and have testified that the county's health programs do not comply with federal and state standards. Dr. Bean and her colleagues should be congratulated for their excellent work. Because of the group's efforts, there is no doubt that residents in the targeted community have received improved...