Overview

With the national focus on primary care, we felt it appropriate to devote a chapter in this manual to discussing Community Oriented Primary Care (COPC) and how the NHSC initiative to encourage development, expansion and improvement of primary care sites fits into the larger public health vision. These initiatives encourage community leaders to:

get beyond medical to quality of life . . . assume greater responsibility for overall community health status.

Included in Chapter 2 is a discussion of how the Healthy People 2010 initiative and Community Oriented Primary Care (COPC) relate to the site development process.

The emphasis is on how communities can:

work collaboratively with the healthcare sector- physicians, public health officials, insurers and providers to develop cooperative strategies that promote health. (Healthcare Forum, 1994)

Also included in this chapter is a discussion of health care delivery models and details on the wide variety of practitioners for consideration as you develop plans for your site development.

HEALTHY PEOPLE

Healthy People is the prevention agenda for the Nation. It is a statement of national opportunities - a strategic management tool that identifies the most significant preventable threats to health and focuses public and private sector efforts to address those threats. Healthy People offers a simple but powerful idea: provide the information and knowledge about how to improve health in a format that enables diverse groups to combine their efforts and work as a team. It is a road map to better health for all, which can be used by many different people, states and communities, professional organizations, and groups whose concern is a particular threat to health, or a particular population group. Healthy People is based on scientific knowledge and is used for decision making and for action.

The Healthy People 2010 framework builds on initiatives pursued over the past two decades. A 1979 Surgeon General's Report, Healthy People, provided targets to reduce premature mortality in four age groups in the 1980s and was supported by objectives with 1990 endpoints. Healthy People 2000: National Health Promotion and Disease Prevention Objectives was released in 1990; it is a comprehensive agenda organized into 22 priority areas, with 319 supporting objectives. Its three overarching goals are to increase years of healthy life, reduce disparities in health among different population groups, and achieve access to preventive health services. Like its predecessors, Healthy People 2010 is being developed through a broad consultation process, characterized by intersectoral collaboration and community participation. Healthy People 2010 is the United States' contribution to the World Health Organization's (WHO) "Health for All" strategy.

OVERARCHING GOALS

Healthy People 2010 is designed to achieve two overarching goals:

• The first goal of Healthy People 2010 is to help individuals of all ages increase life expectancy and improve their quality of life.
• The second goal of Healthy People 2010 is to eliminate health disparities among different segments of the population.

FOCUS AREAS

Healthy People 2010 contains 28 Focus Areas as follows:

1. Access to Quality Health Services
2. Arthritis, Osteoporosis, and Chronic Back Conditions
3. Cancer
4. Chronic Kidney Disease
5. Diabetes
6. Disability and Secondary Conditions
7. Educational and Community-Based Programs
8. Environmental Health
9. Family Planning
10. Food Safety
11. Health Communication
12. Heart Disease and Stroke
13. HIV
14. Immunization and Infectious Diseases
15. Injury and Violence Prevention
16. Maternal, Infant, and Child Health
17. Medical Product Safety
18. Mental Health and Mental Disorders
19. Nutrition and Overweight
20. Occupational Safety and Health
21. Oral Health
22. Physical Activity and Fitness
23. Public Health Infrastructure
24. Respiratory Diseases
25. Sexually Transmitted Diseases
26. Substance Abuse
27. Tobacco Use
28. Vision and Hearing

GOALS

Each of the 28 focus area chapters also contains a concise goal statement. This statement frames the overall purpose of the focus area.

Examples of focus area goals are:

• 3. Cancer:
  Reduce the number of new cancer cases as well as the illness, disability, and death caused by cancer.
• 6. Disability and Secondary Conditions:
  Promote the health of people with disabilities, prevent secondary conditions, and eliminate disparities between people with and without disabilities in the U.S. population.

STATE STRATEGY

Most States have built on national objectives, but virtually all have tailored them to their specific needs. A 1993 National Association of County and City Health Officials survey showed that 70 percent of local health departments used Healthy People 2000 objectives. The State Healthy People Action Contracts, working with community coalitions, are now framing their own versions of Healthy People 2010. (See the Healthy People Web site [http://www.healthypeople.gov] for names of your State contacts or to link with State Action Plan Web sites.)

OTHER PARTICIPANTS

Individuals, groups, and organizations are also encouraged to integrate Healthy People 2010 into current programs, special events, publications, and meetings. Businesses can use the framework, for example, to guide worksite health promotion activities as well as community-based initiatives. Schools, colleges, and civic and faith-based organizations can undertake activities to further the health of all members of their community. Health care providers can encourage their patients to pursue healthier lifestyles and to participate in community-based programs. By selecting from among the national objectives, individuals and organizations can build an agenda for community health improvement and can monitor results over time.

Primary care centers, NHSC sites, and other health professionals are particularly encouraged to promote the Healthy People 2010 initiative by providing information about health promotion, protection, and prevention to their patients and encouraging the integration of healthy practices into the daily lives of individuals, families, and communities.

Other Healthy People 2010 Resources

In addition to the two-volume Healthy People 2010 document itself, there are various other resources which are linked to the goals, objectives, and outcome measures in the main reference. Two such resources are highlighted below.

The first resource is the Healthy People 2010 Toolkit published by the Public Health Foundation. The Toolkit provides guidance, technical tools, and resources to help states, territories, and tribes develop and promote successful state-specific Healthy People 2010 plans. It can also serve as a resource for communities and other entities embarking on similar health planning endeavors.

This Toolkit is organized around seven major "action areas," which were derived from national and state Healthy People initiatives. With the assistance and guidance of the Office of Disease Prevention and Health Promotion, U.S. Department of Health and Human Services (HHS), the Public Health Foundation reviewed both year 2000 and year 2010 initiatives and identified these seven areas as common elements of most health planning and improvement efforts. The seven action areas are:

• Building the Foundation: Leadership and Structure
• Identifying and Securing Resources
• Identifying and Engaging Community Partners
• Setting Health Priorities and Establishing Objectives
• Obtaining Baseline Measures, Setting Targets, and Measuring Progress
• Managing and Sustaining the Process
• Communicating Health Goals and Objectives

Each action area includes:

• A brief explanation and rationale
• A checklist of major activities, which are taken from the comprehensive planning checklist
• tool in "Managing and Sustaining the Process"
• Tips for success
• National and state examples to illustrate Healthy People processes in action
• Recommended "hot picks" of resources for further information, designated by a star
• Planning tools that can be easily adapted to state or local needs, designated by a tool

The suggested processes, tools, and resources in the seven action areas can help states build on past successes and round out their approaches to planning and developing year 2010 objectives. An effective planning initiative should reflect the state's unique needs, resources, and buy-in from a broad constituency.

A Web-based version of the Toolkit offers users enhanced access, navigation, and search capabilities and is available at: http://www.health.gov/healthypeople/state/toolkit. The Web version contains direct links to state Healthy People Web pages, up-to-date listings of state Healthy People action contacts, Healthy People 2010 lead agency content experts, and HHS Regional Health Administrators. Because this Toolkit is in the public domain, you are encouraged to copy the Toolkit to share with your state and local partners.

The second resource is entitled Healthy People in Healthy Communities: A Community Planning Guide Using Healthy People 2010, published by the Office of Disease Prevention and Health Promotion, Office of Public Health and Science, HHS. The Web site reference for this publication is http://www.healthypeople.gov/Publications. To begin to achieve the goal of improving health, a community must develop a strategy. That strategy, to be successful, must be supported by many individuals who are working together. In much the same way you might map out a trip to a new place, you can use the Planning Guide's MAP-IT technique to "map out" the path toward the change you want to see in your community.

The process of creating a healthy community will take time, much effort, and many steps. This guide recommends that you MAP-IT - that is, Mobilize, Assess, Plan, Implement, and Track. This MAP-IT approach will help you understand and remember the specific steps you will need to take and the order in which you should take them. Keep in mind, though, that there is no one way to do this, and many of these steps will need to be taken again and again.

• Mobilize individuals and organizations that care about the health of your community into a coalition.
• Assess the areas of greatest need in your community, as well as the resources and other strengths that you can tap into to address those areas.
• Plan your approach: start with a vision of where you want to be as a community; then add strategies and action steps to help you achieve that vision.
• Implement your plan using concrete action steps that can be monitored and will make a difference.
• Track your progress over time.

Using this MAP-IT approach, your coalition can devise a step-by-step, structured plan that is tailored to your community's needs.

PRIMARY CARE SYSTEM DEFINED

The Institute of Medicine has defined primary care in terms of the following five components:

• accessibility
• comprehensiveness
• coordination
• continuity
• accountability

Furthermore, the Institute has suggested that a primary care system should cover at least 90 percent "of the problems arising in a population," by providing primary and secondary prevention, hospital care, home visits, self-care, and services such as school health, sports medicine, and emergency services. This definition has been used in this document as a basis for developing, improving, and expanding sites dedicated to providing primary care in underserved areas.

COMMUNITY ORIENTED PRIMARY CARE

Community Oriented Primary Care (COPC) has emerged in the United States as a method for developing comprehensive services at the community rather than the agency or individual level. It has been described as "the provision of primary care services to a defined community, coupled with systematic efforts to identify and address the major health problems of that community through effective modifications both of primary care services and other appropriate community health programs" (National Academy of Sciences, 1984).

COPC PRINCIPLES

COPC provides the link between defining the community health care needs and site development. The model embodies three principles that guide its implementation and serve to unite the community:

• collaboration and involvement - both the community and the health agency work together to plan and implement community health objectives;
• prevention and treatment - both are considered to be equally important in the improvement of the community's health status; and
• problem-oriented approach - the improvement of community health will not occur until planning and program development are focused on alleviating a specific health problem.

These principles are not intended to replace the essential components of primary care - accessibility, comprehensiveness, coordination, continuity, and accountability. Rather, they are intended to build upon the existing primary care system by adding a population-based approach to identifying and addressing community health problems. Exhibit 2-1 shows how traditional primary care, when combined with a community approach, becomes community oriented primary care - a more effective, comprehensive model for care delivery.

Operationally, COPC consists of four elements which when taken together, serve as the foundation for a dynamic process through which continual monitoring of the effectiveness and appropriateness of services is possible.

• Definition and characterization of the community;
• Identification of the community's health problems;
• Modification of the health care program in response to the identified community health needs; and
• Monitoring of the impact of program modifications.

COPC Staging Criteria

Staging criteria have been developed for each of these elements (see Exhibit 2-2) to enable an organization to measure the degree to which it already employs the COPC model. Progress is measured against five stages where Stage 0 indicates no COPC activity and Stage IV indicates the most advanced level. In addition to measuring current status, the stages can assist an organization move towards the achievement of the model as well as plan operational goals to be achieved with the site development.

Importance of COPC Model

There are several reasons why the COPC model is being outlined in this manual:

• First, the COPC model is the NHSC's model of choice in the delivery of primary care services and, as such, it should be used to guide the development, expansion and improvement of primary health care delivery services.
• Second, use of the COPC model will enable sites to create an environment where culturally-competent and community-responsive care can be provided by NHSC or other health care providers - critical elements of the NHSC mission. Exhibit 2-3 provides a good example of an assessment tool that helps to identify the cross cultural training needs of staff/practitioners. This assessment tool was developed by the University of California at Berkeley, School of Public Health under contract with BPHC to advance the concept and practice of COPC.
• Third, the COPC model uses four elements that parallel the traditional planning process. Collectively they offer an objective step-by-step method for identifying and addressing community health needs.
• Fourth, the COPC model offers a simple evaluation methodology. Through the use of the staging criteria, an organization can evaluate the extent to which it employs the COPC model. Based on the findings, strategies for improvement can be developed.

Planning Approaches

Our intention in presenting Healthy People 2010 in this manual is to make you aware of the goals and objectives for the nation and to help you understand their relevance as you set out to develop and/or improve your primary care delivery system. Likewise, the discussion of Community Oriented Primary Care is to make you aware of an approach that has been promoted by NHSC that could prove relevant during your planning process. Exhibit 2-4 presents a comparison of the planning approaches showing the similarities for community health and site development as presented in The Guide To Implementing Model Standards and Community Oriented Primary Care In Action.

COPC Summary

Readers who may prefer a more concise and graphic summary of COPC definitions, concepts, principles, and characteristics are invited to review Exhibit 2-5. The seven pages within this exhibit are intended to bring together the essential substance of COPC in a format that may be better adapted for visual recognition.

Practice Models

Today, more than ever, there are a variety of different service delivery models from which to choose, including the following:

• Solo practice has dominated the health field for some time; however, it is increasingly being abandoned now in favor of other models. The practitioner who chooses this model needs to be adept in the business as well as the clinical aspect of practice. S/he also needs to consider the availability of coverage and some of the other issues of working alone.
• Partnerships between two or more practitioners address some .of the challenges of working alone in that this model allows for the sharing of costs and workloads, coverage and the camaraderie of other colleagues.
• Group practices range from three practitioners to hundreds. Group practices can be organized as entities on a fee-for-service basis, a capitation basis or a combination of the two. They can be family practice groups, primary care groups, or multi- specialty groups.
• A clinic network where there is an administrative umbrella for groups of clinics provides the many advantages of group practice. Individual clinics are often managed by teams of practitioners and/or administrators where a central management structure frees practitioners of extensive business and management tasks. The central structure often provides computerized systems for accounting, billing and personnel management.
• Managed care includes organizations such as Health Maintenance Organizations (HMOs) or Individual Practice Associations (IPAs). This model tends to be more prevalent in areas with a larger population base such as inner cities, suburban centers and some large rural centers. For a more detailed discussion about managed care, see Chapter 14.
• Community Health Center (CHC) is a comprehensive primary health program governed by a Board of Directors consisting of community representatives. The CHCs were originally designed to provide quality health services to people who lack access, due to absence of providers, geographic distances to other facilities, or financial, cultural, and other barriers to primary care. Many CHCs are also involved in managed care networks.
• Migrant Health Projects provide medical, dental and mental health services to migrant and seasonal farm workers and their families.
• Indian Health Service Clinics provide comprehensive health services to Native Americans and Alaskan natives. The service models range dramatically from hospital and ambulatory clinics to health centers and satellite clinics.
• Hospital Affiliated Primary Care Practice is often provided as part of a diversification program with services being provided onsite at the hospital or in hospital-sponsored satellite clinics located in inner city or rural communities.

The point in raising the discussion about practice models is to underscore the range and diversity of practice models. No one model is appropriate for all communities and, therefore, it is important to explore a range of options before deciding on the model best suited to your needs. Let the needs and resources of the community be the guide to selecting an appropriate and acceptable practice model.

The Primary Care Professional Team

The use of interdisciplinary teams of practitioners is stressed throughout this manual. Depending upon the particular need of a site/community, consideration should be given to how best to structure a primary care team that suits your particular situation. It can include recruiting a team of practitioners to work at the site, recruiting one or more practitioners who are linked with other providers and/or using telecommunication hookups with major medical centers for specialty services.

This section of the manual is devoted to increasing the reader's knowledge and understanding of the different types of primary care practitioners, including:

• A definition of each practice group;
• Common functions performed;
• Their professional preparation; and
• Professional organizations that can provide in-depth information about a particular practice group.

The choice of your primary care team will depend on a number of elements that are unique to each situation. Examples of elements to consider include the following:

• State and local practice regulations - some states require dental hygienists to be directly supervised by a dentist, while other states allow independent practice.
• Population characteristics - if your service area encompasses a sizable geographic area with a large child-bearing female population, a certified nurse-midwife will be an important member of your professional team.
• Specialty services - sites planning to offer mental health and substance abuse programs will need to assemble a team of counselors, social workers and psychiatric clinical nurses.

Exhibit 2-6 presents descriptions for each of the following types of providers on the professional team:

• Physicians
• Physician Assistants
• Nurse Practitioners
• Certified Nurse-Midwives
• Dentists
• Dental Hygienists
• Psychiatrists
• Health Service Psychologists
• Clinical Social Workers
• Licensed Professional Counselors
• Marriage and Family Therapists
• Psychiatric Nurse Specialists

For detailed descriptions, contact the NHSC at 1-800-221-9393 for information on the Licensure/Scope of Practice Directory.