Community-Oriented Primary Care (COPC) and the Affordable Care Act

Abstract

Community-oriented primary care (COPC) is a model of health care delivery that tightly integrates primary care and public health. This model of care, applied around the globe, could be more widely adopted in the United States as clinical delivery systems respond to the growing demand for population health management, which has been driven largely by various provisions of the Affordable Care Act (ACA). For that purpose, there is need for changes in capacitating health professionals and changes in organizational structures that will address the needs and health priorities of the population, considering individual care management in the context of population health for a defined population. This article presents how the Affordable Care Act is an appropriate framework for COPC to succeed and the way forward to develop COPC through practical alternatives for the delivery of primary care within a population context.

Since its inception, the health care industry has been oriented toward providing sick care to individual patients. This orientation, which has been driven largely by financing mechanisms such as fee-for-service, underscores the growing concern about the future supply and performance of the primary care workforce. ¹ Health care leaders need to address a shift from sick to wellness care ² and from the individual to the community by preparing the required workforce and infrastructure. The objective of this paper is to describe how implementation of community-oriented primary care (COPC) could be an option for addressing the changes in the health system toward population health management motivated by the health reform law.

What Is Community-Oriented Primary Care?

Community-oriented approaches to health services integrating individual with population health care have been in place in the United States ^3-8 and other countries^9-13 largely because of evidence that primary care delivery with a community orientation is associated with more effective, equitable, and efficient health services.^14-16 One of the recognized models, COPC, is focused on providing care to a defined population, based on their assessed needs, to improve health status combining primary care and population health. ¹⁷ To achieve this aim, the conceptual framework for COPC is based on 5 principles ¹⁸ : (a) responsibility for comprehensive care of a defined population; (b) care based on health needs and its determinants; (c) prioritization of those needs to implement health programs; (d) programs that integrate promotion, prevention, and treatment; and (e) community participation. The process to develop COPC requires (a) defining (geographically, members registered in a practice or as a sociological construct) and characterizing the community to determine health needs, their determinants and assets; (b) prioritization of identified health problems; (c) detailed assessment of the prioritized condition; (d) development and performance of intervention program; (e) surveillance and evaluation; and (f) reassessment of health needs. ¹⁰

Since its development by Sidney and Emily Kark^9,10 in South Africa and in Jerusalem, COPC has a history of improving community health in the United States and around the globe,^3-13 COPC practices were developed at the local or regional level, favored by transformational leadership, political will, and in cases by health reform. They succeeded in improving chronic diseases control, perinatal health, and child health and development. In the United States, the pioneering work of Jack Geiger, who established health centers in Mississippi and Boston in the 1960s, is the precursor of federally qualified health centers in the United States. ¹⁹

By the mid-1980s, the Institute of Medicine (IOM) concluded that the primary barriers to more widespread adoption for COPC were fee-for-service financing and the limitations of quantitative evaluation data.^20,21 In 2012, the IOM endorsed COPC as a dynamic, interdisciplinary model that integrates primary care and public health creating significant improvements in primary care delivery. ²²

Community-oriented primary care is aligned with the Triple Aim Initiative, ²³ seeking to optimize the performance of health systems by addressing the individual patient experience of care, population health and health care costs. Its application is challenging due to economic forces that incentivize fee-for-service and individualized health care. ²⁴

Community-Oriented Primary Care and Workforce Development

The Affordable Care Act (ACA) offers the opportunity to reorient health care to use less specialized care and more primary care.

The transition from individual to community care requires a workforce that has clinical and population health and management skills. There has been progress in health professions schools and residency programs, albeit uneven, in introducing population health–related subjects into the curriculum that can be a basis for learning COPC. ²⁵ The Association of American Medical Colleges and the Centers for Disease Control and Prevention have proposed public health competencies for medical schools ²⁶ and recommendations have been made by the Advisory Committee on Interdisciplinary, Community-Based Linkages, ²⁷ regarding the inclusion of population health in health professions curricula by an interprofessional approach. The IOM has recommended that organizations such as the Health Resources and Service Administration and Centers for Disease Control and Prevention would find regulatory options for medical education funding that would address training in primary care and public health settings, and support programs addressing integration. ²²

A promising initiative, the Service Scholars Pathway Program, at Tufts University School of Medicine, ²⁸ incorporates community medicine during the 4 years of study.

Another urban experience is the Training in Urban Medicine and Public Health (TRIUMPH) program in the University of Wisconsin School of Medicine and Public Health. ²⁹ It emphasizes underserved populations and the social determinants of health. Initial evaluations show graduates’ selection of primary care specialties compared with graduates not in the program. Similarly, a program at the University of Illinois College of Medicine at Rockford Rural Medical Education incorporating a COPC project in rural areas has produced graduates that are more likely to choose professions in primary care and practicing in rural areas than those that did not participate in the program. ³⁰ The Robert Graham Center has developed COPC curriculum for trainees at community health centers. ³¹

Some surveys show the extent of COPC training in residency programs. A survey of 224 randomly selected family practice residency programs found that less than half of the programs included COPC in their curricula. ³² Another survey of 400 physicians and 470 residency directors indicated that almost 40% of the programs teach COPC, but only 7% of the physicians practiced COPC after graduation. ³³ This suggests that there is capacity to grow COPC in residency programs.

Capacity building in COPC can best be realized by interprofessional training. A model of collaboration was developed by Kark in Jerusalem between a Community Health Center providing integrated preventive and curative care to a defined population and a School of Public Health.^17,18 An interprofessional team attended to the clinical and community health aspects of the population. This has proven to be an effective and sustainable approach to improve the health of the community while serving as the training ground for health professionals.^10,18 Schools of public health that offer COPC-MPH programs are also outlets for academic partnerships for COPC training.^34,35

Community-Oriented Primary Care and the Affordable Care Act

The ACA will reshape the health care workforce through provisions that transform how medical care is provided in the United States. Several sections of the Act, especially in Title V, aim to increase the size and diversity of the workforce in primary care and public health. For example, Title V funds grants to support programs that promote positive health behaviors and outcomes for medically underserved populations by using community health workers (Sec 5313); training the workforce on primary care in underserved areas (Sec 5403); supporting community-based health workers and the education of primary care providers to improve community health (Sec 5405); and colocating primary and specialty care in community-based mental health settings (Sec 5604). However, the fundamental shift in the US health care system under the ACA occurs through the establishment of accountable care organizations, networks of providers responsible for managing the health of a defined Medicare population (Sec 3022). This section of the Act incentivizes population health management rather than individualized patient care. This shift toward population health will require new models of care, many of which will be developed and tested through the newly established Center for Medicare and Medicaid Innovation (Sec. 3021). The ACA provision to develop the Teaching Health Center Graduate Medical Education (THCGME), for primary care residency training in a community based setting ³⁶ has potential for increasing the workforce in primary care and introducing innovative curricula in community health. Partnerships with medical schools and teaching hospitals are suggested to further the residents’ clinical training. The ACA provision could alleviate the tension between being a productive practice and providing a residency training program by channeling the resources directly to the THCGME. ³⁷

Community-Oriented Primary Care Going Forward

The pervasive demand-based system in primary care, the limited time allocated for consultations, and the fragmentation of services requires reorganization to facilitate a continuum of care to a defined population and the management of population health. COPC could provide an expansion and refinement to the patient-centered medical home, to address the need to decrease the use of services and improve quality ³⁸ and the needs of underserved patients. ³⁹ This can be realized through coalition building and partnerships, team development, the use of information technology and new forms of payment.

Coalition Building and Partnerships

Community collaboratives have been built to use common resources more effectively to improve care and access to care. For example, the Camden Coalition of Health Care providers in New Jersey ⁴⁰ was developed to improve care for a complex population consuming multiple fragmented and uncoordinated services, while decreasing costs. The collaborative concept could be expanded to include those at risk and the healthy to promote their health, forming Accountable Care Organizations. Community collaboratives in several cities in Texas, New York, Hawaii, and others could be a model of how to use their common resources more effectively to improve access to care, health and behaviors; impact their environment and promoting economic development. ⁴¹ The Folsom report ⁴² recommends a “community of solutions” to address health problems in cooperation with other agencies.

The trend of hospital mergers and acquisitions could be a catalyzer in an integrated system of care. While there is concern this will lead to increasing costs and fewer choices, strategies have been suggested to counteract this trend such as limiting providers networks, supporting formation of physician organizations, reference pricing for services and procedures, and providing opportunities for government regulation. ⁴³ An organizational decision to use the merged services to serve a defined population (“the community”) to perform a needs assessment (already mandated) and develop programs for priority conditions could assist the development of COPC services. Collaboration with health departments can contribute to this endeavor. ⁴⁴

Team Development

The ACA is increasing the number of patients accessing primary care. The inclusion of prevention and promotion activities and the identification of the sick not under care and those who have not accessed the service will require reorganization of teams and the development of new skills. COPC is in line with recent guidance on alleviating the primary care workforce shortage such as practices pooling physicians, expanding the role of allied health professionals, and enabling continuity of care by using electronic records, ⁴⁵ or providing innovative solutions to primary care. ⁴⁶ However, it was found that most primary care innovations provided additional resources to address specific diseases rather than changing practice organization. ⁴⁷ In the implementation of a COPC practice, the physician will be redefined as a leader of a high-performing primary care team. ⁴⁸ This transformation would help alleviate the primary care physician shortage,^45,49 or demand–capacity mismatch. ⁵⁰

Information Technology

The growing trend in the use of electronic health records ⁵¹ that was enabled by the ACA could be a tool to enable population health management. ⁵² Electronic health records can assist medical teams in incorporating COPC activities such as defining the population under care, establishing the denominator population; performing health assessments; health surveillance and evaluation of care; and assessing quality improvement. The use of integrated medical records ⁵³ could help teams to deliver more efficient care for chronic diseases and preventive care by improving communication about the patient. ⁵⁴

Payment

Several initiatives are being proposed and tested to reform the current fee-for-service. One of those is transition to a physician payment system that rewards quality and value-based care. ⁵⁵ Studies on the effectiveness of Pay-for-Performance, which addresses improving quality, efficiency, and overall value of health care, has shown conflicting results. There is also concern that this system of payment may exacerbate health disparities, if disadvantaged populations, which are likely to decrease the providers’ performance scores, are avoided. ⁵⁶

New models of financing care tested through the Center for Medicare & Medicaid Services Innovation Center, ⁵⁷ such as capitated payments and value-based care, will enable new delivery models that will be community-based and seek to keep the population healthy rather than waiting for the sick to come into the clinic. Accountable Care Organizations are one model of care that is being tested and early results suggest this delivery and financing model is shifting clinical organizations toward population health management, medical homes, and team-based care. ⁵⁸

A financing system that supports population health, proactive care, and prevention would contribute to the delivery of COPC.

Conclusions

Amid the challenges of the Health Care Reform, the ACA offers a window of opportunity to change the health care system. COPC has the potential to pushing health care away from mainly sick care and toward prevention of disease and promotion of health, integrating individual care and population health. As a result of the ACA, the current policy climate provides an opportunity to test the COPC approach in terms of management, efficiency, and sustainability.