Contemporary Public Health: Principles, Practice, and Policy

4. The Role of Community-Oriented Primary Care in Improving Health Care

4 The Role of Community-Oriented Primary Care in Improving Health Care Samuel C. Matheny Over the last few decades, there has been a growing interest in the relationship of primary care to the health of communities. Several factors have contributed to this movement. First, there is increasing awareness that although the United States spends a greater proportion of its national budget on health care than any other country, Americans’ health lags significantly behind that of residents of other developed countries in many areas. Second, there is new and convincing evidence that the presence of a robust primary care system is strongly connected to positive health outcomes. This is complicated by a third factor—that is, the significant shortage of primary care providers in the country. This factor may challenge the successful adaptation to changes in the organization and financing of health care. Last, there has been an increased emphasis on community participation in decision making, which has also influenced health care delivery. It is important to examine the principles of primary care and community health more completely to understand how they are interactive and mutually dependent. Addressing the health care of a community along with the care of individual patients is an essential function of the community-oriented primary care (COPC) concept. Three of the individuals who had key roles in the leadership and development of both primary care and community health were William Willard, Nicholas Pisacano, and Kurt Deuschle. Willard, the founding dean of the University of Kentucky College of Medicine, was the chief author of a report from the American Medical Association entitled Meeting the Challenge of Family Practice.1 The Willard report, along with the Millis report (published the same 86   Samuel C. Matheny year),2 was a major incentive for the creation of a new primary care discipline called family practice. Pisacano, a professor of general practice at the same college , was one of the first individuals to consider the academic training needs for this new discipline and was responsible for the foundation of the American Board of Family Practice, now the American Board of Family Medicine. In 1960 Willard selected Deuschle to head the first Department of Community Medicine in the United States. The integration of these two movements— primary care and community medicine—began a decade later when the educational principles of family practice were solidified, and training programs in family practice and other primary care disciplines embraced many of the concepts of community medicine. Defining Primary Care The term primary care has been used for many years, but its current meaning was established in the middle of the twentieth century, most notably in the Millis report,2 which led to the creation of the discipline of family practice . The definition was updated in 1996 by an Institute of Medicine (IOM) report, which stated: “Primary care is the provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community.”3 This expanded the IOM’s original 1978 definition of primary care to include the following concepts: (1) the inclusion of the patient and the family, (2) the role of the community, and (3) the integrated health care system, which the IOM thought would be an influential factor in health care delivery in the future (figure 4.1). The IOM identified five categories to describe primary care : (1) the care provided by certain individuals, such as family physicians, general internists, pediatricians, physicians’ assistants, and nurse practitioners; (2) a set of activities whose functions determine the boundaries of primary care; (3) an entry point in the system, which focuses on the first provider of care but includes care in hospitals or other settings defined as secondary or tertiary care; (4) a set of attributes as outlined in the 1978 definition, including care that is accessible , comprehensive, coordinated, continuous, and accountable; or (5) a strategy for organizing the health care system that includes the principles of COPC (reviewed later). In a statement issued prior to the IOM report, the chair of the Committee on the Future of Primary Care commented: “Exemplary primary care requires an understanding of the community, defined by the committee as the population served, whether patients or not. This implies an understanding The Role of Community-Oriented Primary Care   87 of what is happening in...