Community-oriented primary care: critical assessment and implications for resident education

BACKGROUND: Community-oriented primary care (COPC) is a systematic approach to health care based on principles derived from epidemiology, primary care, preventive medicine, and health promotion that has been shown to have positive health benefits for communities in the United States and worldwide. METHODS: MEDLINE was searched using the key phrase "community-oriented primary care." Other sources of information were books and other documents. RESULTS AND CONCLUSIONS: Because of lack of predictable reimbursement for COPC services and difficulties encountered incorporating COPC in medical and residency curricula, widespread application of COPC has not occurred. Recent trends in public health initiatives, managed health care, and information technology provide an environment ripe for application of COPC in medical practice. Also, recent recommendations made by the Strategic Planning Working Group of the Academic Family Medicine Organizations and the Association of Family Practice Residency Directors regarding specific community competencies for residency training have direct bearing on COPC and family medicine educators. These trends and recommendations, properly configured, will produce a medical training and practice environment conducive to COPC.     

Family medicine in Cuba: community-oriented primary care and complementary and alternative medicine

Family physicians in Cuba and the United States operate within very different health systems. Cuba's health system is notable for achieving developed country health outcomes despite a developing country economy. The authors of this study traveled to Cuba and reviewed the literature to investigate which practices of Cuban family physicians might be applicable for US family physicians wishing to learn from the Cuban experience. We found that community-oriented primary care (COPC) and complementary and alternative medicine (CAM) are well developed within the Cuban medical system. Because COPC and CAM are already recommended by US family medicine professional bodies, US family physicians may want to learn from the Cuban experience and perhaps incorporate elements into their individual practices.     

Training and application of community-oriented primary care (COPC) through family medicine in Catalonia, Spain

The community-oriented primary care (COPC) approach, implemented in various countries by family physicians, general practitioners, and other primary care workers, integrates clinical medicine with aspects of public health. A process of 20 years of training health professionals (40-hour workshop) by the professional association of family physicians (Catalan Society of Family and Community Medicine), training family medicine residents and giving support to health teams in Catalonia, Spain, generated a present group of 30 primary care teams involved in community health projects. This paper describes and analyzes factors related to changes in the health system, the role of family medicine in Spain, and to features of the COPC approach and its training methods as elements that narrow the gap between training and practice.     

The Jerusalem experience: three decades of service,research, and training in community-oriented primary care

Community-oriented primary care (COPC) developed and was tested over nearly 3 decades in the Hadassah Community Health Center in Jerusalem, Israel. Integration of public health responsibility with individual-based clinical management of patients formed the cornerstone of the COPC approach. A family medicine practice and a mother and child preventive service provided the frameworks for this development. The health needs of the community were assessed, priorities determined, and intervention programs developed and implemented on the basis of detailed analysis of the factors responsible for defined health states. Ongoing health surveillance facilitated evaluation, and the effectiveness of interventions in different population groups was illustrated. The center's international COPC involvement has had effects on primary health care policy worldwide.     

Caring for Southeast Asian refugee patients in the USA

This paper concerns care of refugees from Southeast Asia who speak little English and are relatively unfamiliar with the formal health care system in the United States. It aims to demystify the behaviors of refugee patients and to support health practitioners who are attempting to care for them. Western medicine is discussed in terms of the expectations that refugees tend to hold of it, and of the conflicts with Southeast Asian beliefs and practices which it presents. Despite language differences, health care agents can increase the effectiveness of their communication with persons from Southeast Asia, primarily by allowing for their viewpoints. Topics discussed are: the first encounter with a refugee patient; use of interpreters; obtaining informed consent; "the passive obedient" patient; the "non-compliant" patient; body image; sources of social support for healing; use of medications; traditional self-care practices; and death and depression.     

Community-oriented primary care: a public health model in primary care]

The community-oriented primary care (COPC) model strives to efficiently distribute, organize, and systematize existing health care resources. In addition to promoting healthy lifestyles within the community, the COPC model enables the health care team and the community to cooperate in identifying and prioritizing health issues. Together they develop and implement prevention and treatment plans for those priority areas. With COPC, the health services assume responsibility for the health of a defined population. The health services not only treat diseases but also develop programs for health promotion, protection, and maintenance. Taking this approach, COPC integrates individual and family clinical care with public health, reflecting the spirit of the International Conference on Primary Health Care held in Alma-Ata in 1978. COPC is a systematic process, with flexible principles and methodologies that can be modified to meet the specific challenges of any health care team and community. An analysis of various countries' experiences with COPC shows that applying the model appropriately can improve the general health status of the community and its members.     

Community-oriented primary care in action: a Dallas story

Dallas County, Texas, is the site of the largest urban application of the community-oriented primary care (COPC) model in the United States. We summarize the development and implementation of Dallas's Parkland Health & Hospital System COPC program. The complexities of implementing and managing this comprehensive community-based program are delineated in terms of Dallas County's political environment and the components of COPC (assessment, prioritization, community collaboration, health care system, evaluation, and financing). Steps to be taken to ensure the future growth and development of the Dallas program are also considered. The COPC model, as implemented by Parkland, is replicable in other urban areas.     

Community-oriented primary care: new relevance in a changing world

Since its inception in rural, pre-apartheid South Africa, community-oriented primary care (COPC) has intrigued and informed public health and primary care leaders worldwide. COPC has influenced such programs as the US community health center movement, the general practice movement in the United Kingdom, and recent reforms in the public health system of South Africa. We provide a global overview of COPC, tracing its conceptual roots, reviewing its many manifestations, and exploring its future prospects as an organizational paradigm for the democratic organization of community health services. We examine the pitfalls and paradoxes of COPC and suggest its future utility. COPC has important values and methods to offer disparate but powerful movements in public health worldwide.     

Health care in the Netherlands

This article analyzes Dutch experiences of health care reform--in particular in primary care--with emphasis on lessons for current United States health care reforms. Recent major innovations were the introduction of private insurance based on the principles of primary care-led health care and including all citizens irrespective of their financial, employment, or health status; introduction of primary care collaboratives for out-of-hour services and chronic disease management; and primary care team building, including practice nurses. These innovations were introduced on top of a strong primary care tradition of family practices with defined populations based on patient panels, practice-based research, evidence-based medicine, large-scale computerization, and strong primary care health informatics. Dutch health reform redirected payment to support introduction of innovative health plans and strengthening of primary care to respond to public health objectives. Five recommendations for US primary care follow from this Dutch experience: (1) a private insurance model is compatible with thriving primary care, but it must include all people, especially the most vulnerable in society, and espouse a primary care-led health care system; (2) patient panels or practice lists strengthen continuity of care and community orientation to focus on and respond to local needs; (3) reward collaboration within primary care and between primary care, hospital care, and public health; (4) stimulate primary care professionals to exert their passion and expertise through participation in primary care research and development; and (5) health informatics should be primary care based, preferably adopting the International Classification of Primary Care. With these recommendations, it will be possible for the United States to obtain better population health for its population.     

Integrating primary care and public health: learning from the community-oriented primary care model.

Community-oriented primary care (COPC), a 50-year-old widely applied innovative approach to primary care development, seems to be the same combination of public health and general practice perspectives currently sought in the formation of primary care trusts in Britain's NHS. The article reviews the experience of implementing COPC methods, the outcomes, and the applicability to and implications for primary care policy, taking the current British reforms as an example. The COPC model has been developed mainly in underserved populations to integrate public health objectives and primary care through interdisciplinary approaches, with active involvement of the target population. COPC methods are time consuming, can create problems with professional boundaries, and are vulnerable to socioeconomic changes. They can also deliver complex packages of care for target populations, particularly in poor areas underserved by traditional medical services. British primary care reforms may be seen as an unplanned, uncontrolled, nationwide experiment in applying COPC methods. They differ from COPC as applied elsewhere because change has been introduced from above rather than below, into a well-developed primary care system rather than underserved communities. International experience suggests the need for attention to factors promoting and impeding success and to reliable outcome measures. If this experiment succeeds, COPC methodology may facilitate similar changes in other health care systems.     

Community-oriented primary care: an integrated model for practice, research, and education

Community-oriented primary care (COPC) has been widely discussed as an approach by which a primary care program may modify and more specifically address the health care needs of its service population. However, efforts to achieve COPC have been inconsistent and based on an incomplete operational model. This paper presents an operational definition of COPC that identifies discrete steps that may be taken by any primary care practice or program as it attempts to more fully develop a community-oriented approach to primary care. The model provides a conceptual basis for further progress in research, education, and the practice of COPC.     

Health and poverty among elderly persons: a community-oriented primary care survey

Providing health care for independent-living elderly persons is important, yet family physicians often lack accurate information about needs and access to care. The Community-Oriented Primary Care (COPC) approach and health status models from health services research provide a framework for assessing need and access to care. Personal interviews were conducted with 990 noninstitutionalized elderly persons in Youngstown, Ohio. Results showed that poverty, gender, and race were not strongly related to health status as measured by numbers of symptoms, functional status, or subjective health status. In addition, elderly persons had fewer health care needs and greater access to care than expected. Simple models of health status, need, and access do not seem to apply. The study shows the usefulness of COPC in planning health services; however, more effort is needed to refine measures of health status, need, and access.     

Recent developments in primary care in the United Kingdom: from competition to community-oriented primary care

In 1990, changes to the National Health Service (NHS) in the United Kingdom introduced a form of US-style competition that broadened the role of general practitioners (GPs). However, the changes (called GP fundholding) produced greater inequality between practices and reduced the capacity of the NHS to plan strategically. Alternative models have been developed that retain the increased influence of primary care, promote community-oriented primary care (COPC), and facilitate strategic planning. A recent proposal from the government turns away from the competition model of 1990 to encourage GP commissioning. It offers the opportunity to create an NHS that is led by a primary care agenda, including better links with the community, and a focus on public health and social services with the goal of improving the health of populations.     

The Curious Case of Cuba

As health professionals in the United States consider how to focus health care and coverage to ensure better, more equitable patient and population health outcomes, the experience of Cuba’s National Health System over the last 5 decades may provide useful insights. Although mutual awareness has been limited by long-term political hostilities between the United States and Cuban governments, the history and details of the Cuban health system indicate that their health system merits attention as an example of a national integrated approach resulting in improved health status. More extensive analysis of the principles, practices, and outcomes in Cuba is warranted to inform health system transformation in the United States, despite differences in political-social systems and available resources.There is a growing awareness in the United States that major changes in health care’s conceptualization, organization, and delivery are needed if the country is to bring soaring medical costs under control and create a population health status commensurate with current evidence and technology.1 The realities that 25 years of the approximate 30-year gain in life span in the 20th century are because of public health actions rather than clinical care2; that risk factors for chronic disease such as tobacco use, inappropriate diet, lack of exercise, and drug misuse are not easily addressed in clinical settings3,4; that many societal influences not traditionally included in medicine’s purview can profoundly affect population health5,6; and that the United States is lagging behind other industrialized nations in population health outcomes6 strongly suggest that a different approach is warranted.Efforts in this direction have begun. A major impetus is the Patient Protection and Affordable Care Act (PPACA), which became law in March 2010. It includes significant funding for public health over the next decade, emphasis on prevention and wellness strategies, and incentives to develop partnerships among clinical and public health entities, governmental and nongovernmental alike, to improve health.7 We suggest that lessons for maximizing the potential of the ACA and other significant efforts to improve our population’s health status can be found in the experience of Cuba, despite differences in our political-social systems and available resources.More than 50 years of political enmity separating Cuba and the United States, complicated by a United States embargo prohibiting normal trade in food, medicines and medical equipment, and official programs aiming at regime change on the island, have made it difficult for Cuba’s National Health System (NHS) and its outcomes to be thoughtfully considered by the United States media, the public, or policymakers. During the same decades, however, strategies were developed in Cuba that have resulted in consistent improvement in the population’s health status, to the extent that today the country’s health indicators resemble those of industrialized nations. In the words of Cooper et al.:

In virtually every critical area of public health and medicine facing poor countries Cuba has achieved undeniable success; these include most prominently – creating a high quality primary care network and an unequaled public health system, educating a skilled work force, sustaining a local biomedical research infrastructure, controlling infectious diseases, achieving a decline in non-communicable diseases, and meeting the emergency health needs of less developed countries.8^(p818)

In this article, we do not advocate the United States adopt the Cuban system: the cultural, political, and socioeconomic differences are too great, and clearly each nation must find its own path to health. However, we may draw from the principles and practices in Cuba to good end, and in particular we suggest the Accountable Care Community (ACC) concept as a viable model to apply such insights in our capitalist context.9 In this light, we describe Cuba’s health care conceptualization, delivery, and associated outcomes, and analyze how Cuban approaches to health might be tailored to our environment to improve both health care effectiveness and population health status.     

Application of epidemiology in community oriented primary care

Community oriented primary care (COPC) is the integrated practice of primary health care and community medicine, bringing together the care of individuals and the care of the community and its subgroups. Epidemiology plays an indispensable role in COPC. The specific features of epidemiology as it is applied in COPC include its pragmatic purpose, its locale, its content, its scale, its specific relevance to the community health programs of the practice, and its clinical setting. The functions of epidemiology in the phases of program development are in the appraisal of needs and priorities, in community diagnosis and health surveillance, in the formulation of objectives and targets, in the choice of strategies and the identification of target groups, and in the implementation, monitoring, and evaluation of programs--as well as in the stimulation of community involvement and as an aid to the clinical management of individual patients. Teaching the epidemiologic skills that are required for COPC necessitates exposure to an epidemiology curriculum which deals with these features and to a COPC practice. An urgent need exists to develop units that will practice, teach, and demonstrate COPC--units in which practitioners, teachers, and students can gain experience and develop, test, and evaluate approaches to the provision of COPC.     

Patients and community together. A family medicine community-oriented primary care project in an urban private practice

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.     

Integrating population health into a family medicine clerkship: 7 years of evolution

A population health curriculum using methodologies from community-oriented primary care (COPC) was developed in 1994 as part of a required third-year family medicine clerkship at the University of New Mexico. The curriculum integrates population health/community medicine projects and problem-based tutorials into a community-based, ambulatory clinical experience. By combining a required population health experience with relevant clinical training, student careers have the opportunity to be influenced during the critical third year. Results over a 7-year period describe a three-phase evolution of the curriculum, within the context of changes in medical education and in health care delivery systems in that same period of time. Early evaluation revealed that students viewed the curricular experience as time consuming and peripheral to their training. Later comments on the revised curriculum showed a higher regard for the experience that was described as important for student learning.     

The community-oriented primary care experience in the United kingdom

The UK National Health Service has long delivered public health programs through primary care. However, attempts to promote Sidney Kark's model of community-oriented primary care (COPC), based on general practice populations, have made only limited headway. Recent policy developments give COPC new resonance. Currently, primary care trusts are assuming responsibility for improving the health of the populations they serve, and personal medical service pilots are tailoring primary care to local needs under local contracts. COPC has yielded training packages and frameworks that can assist these new organizations in developing public health skills and understanding among a wide range of primary care professionals.     

Geographic retrofitting: a method of community definition in community-oriented primary care practices

Community definition is an important aspect of community health work in general and community-oriented primary care (COPC) in particular. Yet, community definitions are often nonspecific, relying on geopolitical boundaries or local presumptions about patient populations. Such definitions are an impediment to the precise application of sociodemographic or health status data to community health problems or to targeted community organizing. This paper describes a technique called "geographic retrofitting" that has proved useful in establishing a rigorous definition of a practice's community based on current patterns of health care by the community. It also demonstrates how this approach, used in conjunction with geographic information systems software, facilitates more-powerful capabilities in community characterization and intervention.