EPID 600 - Introduction to Public Health Practice - Fall 2017

CMG Buttery MB BS MPH.

Focus on Primary Care - The Interface with PH & Preventive Medicine

Start out by Reviewing Slides on Primary Care in the US - view in note format rather than full-screen to see additional explanatory notes.

Read the definitions of primary care and family practice by the American Academy of Family Physicians, log on the to Institute of Medicine and review the summary of the book: "Primary Care: America's Health in a New Era." (pages 27-51, focus on Box 2-1 page 32)

Then look at the Family Medicine research site. consider the history (link) and types of research being conducted, wether the studies are descriptive or analytic?  Are they current, retrospective or futuristic? Are they quality or quantity based?  Are they policy or practice based?  Can they lead to changes in the health care system?

Follow up with Dr. Buttery's PowerPoint slides on Epidemiology, review the slide so you can see the notes. This web site provides the latest data on the NAMCS and access to its latest surveys, as a supplement to the PowerPoint slides, find the National Ambulatory Medical Care Survey : 2010 Summary Tables then look at table 13 where you will see that the top 20 diagnoses for office visits cover 70% of primary care visits .  Some of you may want to use this data for your research topic to complete your MPH studies. Also look at a punch card I designed for general practice research in 1963 as part of a clinical practice information system-Page 2). In 1963 there were no PCs and as far as I know this was the first published attempt to describe data management and accountability in private practice. Now 50+ years later we are still stumbling on our way to achieve this. Take a look at this discussion of implementing an  EHR, also the following recent article, Transparent Medical Records from the NEJM

The 2010 revision to the US heath care system (The Affordable Care Act) does not address the problem of access to primary care until several years into the program, as millions more people are added to the insured group, but no increase in primary care physicians is likely for 8-10 years (2025 or later). Further, more preventive services will be provided as an option with only a minimal increase in the physicians/nurses available to provide such care reducing  the effect of the 2010 legislation. this is the result of the failure of politicians in the United States to look at the long-term effect of their actions but only focus on the next 24 months until their reelection.

Is there a PCP Crisis (this policy piece from the AAFP takes about a minute to load and you have to bypass the associated Ad).
UK Lessons for Primary Care Why don't we learn from other countries? Remember the first session on Failing to learn from History.
Reports Warn of Primary Care Shortages 
Review this perspective from the NEJM. Feb. 2011, on Medical Schools and Primary Care, can you find out what is happening at VCU?.
Does Having More Physicians Lead to Better Health System Performance? (See page 3)
Access to care in Boston
What about the comparative cost of care in the USA and Europe? (scan the publications, figures, listed in the sidebar on right.)

Review this Commonwealth Fund survey (2011- slide set) of the public's view of the US Health System. Does income have anything to do with it? Also look at this latest review of multinational access to primary care from the Commonwealth Fund. A Lifeline for Primary Care (No significant change in last 5 yrs except the ACA)

Look at this diagram from ASTHO about improved integration of PH & PC.
The Political Economy Of U.S. Primary Care
The World Health Report 2008 - Primary Health Care (Now More Than Ever) Focus on the Director General's comments
What about Prevention in Primary Care Practice Pages 1-2  then scan the first

Is anybody doing anything about quality of primary care? Look at the 2005 report of the UK Health System, pages 10-13. Compare this to the 2006 "Health Report to the American People", pages 6-11. What do you think the UK and US can learn form each other? Where does politics start and science stop? In December 2012  this piece in the New York Times asking where are the primary-care physicians. Then read this 2012 article from Health Affairs discussing of alternative ways to solve the primary-care physician shortage without necessarily opening more medical schools or training additional numbers of doctors which would fit into the medical home concept very nicely. Also from the December issue of Health AffairsFinally take a look at this AHRQ site on prevention quality indicators, focus on the second section on "how are prevention quality indicators used"

Since the advent of the Affordable Care Act of 2010 a number of groups and organizations are reconsidering the structure of the American healthcare system. First look at the
white paper from the Academy of family physicians “primary care for the 21st century” which focuses on the value of a medical home (PCMH) and on its place in the changes to the health system coming from the Affordable Care Act as it relates to our current epidemic of chronic disease. Then scan this 2012 paper from the Commonwealth Fund to obtain an overview of the commonality in primary care among primary physicians from different developed countries. Look at the role of electronic health records in these countries and think about your last visit your personal physician, if you have one. Considers how the barriers to accessing health care differ among the different countries with payment being the prime problem the US and long waits to see their physicians, and most of the other countries.. Also note that in the US access to care after hours is available for most part through the emergency room in the United States while organizational practices in other countries, while not ensuring 100% care 24/7, is far superior. Also consider care coordination in most of the other countries compared to the US and in relation to the white paper from the AAFP on "primary care in the 21st century". When we consider the lack of primary care physicians in the United States it is worth looking at support for primary care in other countries. This short 2013 editorial from Health Affairs in January is worth reading in relation to the AAFP's paper and the Commonwealth fund's slide set. When thinking about physician supply be sure to look at "shortage areas" on the bookmark page in the "Supply" section, also Unravelling Physician Supply Dilemma.

Now we need to look more closely at Medical Homes/ Team Based Care by scanning this report from the IOM and VA regarding development of team practice. Scan the whole article but concentrate on pages 8 to 9.

As part of discussion of a medical home which focuses on a carefully developed team to deliver comprehensive care it is worth looking at what Nurse Case Management discussion say about case management say about the services provided by public health nurses, that exemplified each of the following attributes of case management?  Remember that the range of services differs between health departments.  The concept you should take with you, is that the underlying framework of case management, provided by PHNs, MSWs, and Health Educators happens in all health departments. From the King's Fund- What is Case Management. In the December 2015 HA is this article on Home Based primary care. Case management addresses a wide variety of health care issues and needs. As a result, it is often implemented for multiple reasons, including:

1. Case management focuses on the full spectrum of needs presented by clients and their families; it is client-focused. Client and family satisfaction within case- managed systems is generally high.
2. A strong component of case management is an outcome orientation to care. The goal is to move with the client/ family toward optimal care outcomes.
3. Case management facilitates and promotes coordination of client care, minimizing fragmentation.
4. Case management promotes cost-effective care by minimizing fragmentation, maximizing coordination, and facilitating client/family movement through the health care
5. Case management maximizes and coordinates the contributions of all disciplines within the health care team.
6. Case management responds to the needs of insurers and other third-party payers, specifically those related to out-come-based, cost-effective care.
7. The needs of clients, providers, and payers all receive attention within a case management system. Case management represents a merger of clinical and financial interests, systems, and outcomes.
8. Case management can be included in the marketing strategies of hospitals and other institutions to target clients/ families, insurers, and employers.

From the King's Fund scan case management and review integrated care key points and this latest review from the IOM (review pages 22-36).In thinking about team-based care it is worth looking this editorial from the BMJ in relation to nurse practitioners, physicians assistants, and medical social workers in the US model. Primary Care & Nurse Practitioners. Also look at this comment from the Kaiser Family Health Foundation followed by this editorial from JAMA. Think about how PH and Community Services can be linked in the US, by scanning this brief from Torbay, England as a model. Also look at this short video from the UK and scan this summary of future plans for the NHS and think about potential for application in the US, and this blog from the Kings Fund. Do you think' 'Concierge' care can improve care or just make it unaffordable for more people?

Take a look at this 7.5 min. video on patient/care linkage from the IOM, and this comment from the Kings Fund on the "Future of Primary Care"
Take a look at transforming Primary Care in Brazil
Does the Affordable Care Act look at improving Primary Care

A recent article from Kaiser health News shows the value of community health workers as part of the medical team. We tend to forget them as they often work outside the primary care practice and are monitored by staffs of social work and voluntary agencies. In the UK they are part of the practice team found in each primary care practice. We need to think about them as part of the team in the United States.

A couple of other views on the Medical Home part of a community of care/team based practice can be seen in:

Primary Care: and its linkages with Public Health & Preventive Medicine

Recommended readings to supplement the Primary Care Discussion .   Students are encouraged (but not required) to read the summaries of these articles, even if they do not read the entire article, using the Journal search page at the TM library

The June 2012 Supplement on Primary Care and Public Health practice integration  American Journal of Public Health, 2012; Volume 6(Suppl 3)

How many and what types of physicians do you think are needed to manage the health needs of the US Population?  Do you think we have produced either too many, the wrong types, or used the wrong incentives to encourage distribution?

Benchmarking the US Physician Workforce. An alternative to needs-based or Demand-Based Planning. JAMA Dec. 11, 1996, Vol. 276 No 22 P 1811'*Public Health and Primary Care: A Framework for Proposed Linkages. AJPH. Oct. 1996, Vol. 86 No 10. P 1365.

An Uncertain Future: Physician Jobs in the Balance. JAMA Jan 1, 1997, Vol. 277 No 1 P 68

Once we have determined how many physicians/providers, of what type, we need, how do we obtain them and does more physicians mean better quality of care?

Retraining Physicians for Primary Care. A Study of Physician Perspectives & Program Development. JAMA May 21, 1997, Vol. 277 No 19 P 1569

Family Physician Workforce Reform. AAFP Recommendations (Medicine & Society.) AFP Jan 1996 Page 65

Problem of Quality of Life Medicine. JAMA July 2, 1997, Vol. 278 No I P 47

We hear everyday now about health system reform.  What are we trying to reform?  Access? Payment? Types of Physicians trained? Distribution? Quality? Incentives to promote prevention of disease and optimal Health?    Medical Care? Are these different questions interrelated? How?

Also you will find these journal articles (use TML library) useful, even if they are a little old:

New Prevention Guidelines called 'State of the Art'. JAMA Feb. 21, 1996, Vol. 275 No 7 P 505
Health System Reform (Special Communication.) JAMA Au 14, 1996, Vol. 276 No 6 P 505
Medicine & Public Health - Pursuing a common destiny. JAMA Nov 6, 1996, Vol. 27 No 17 P 1429
Swapping Health Care Systems. Whose Grass is Really Greener?. JAMA Dec 25, 1996, Vol. 276 No 24 P 1996
Health Reform for the 21`t Century? It May have to Wait until the 2Ist Century. JAMA Jan 25, 1997, Vol. 277 No 3 P 193
Managed Care. A product of Market Dynamics. JAMA Feb. 19, 1997, Vol. 277 No 7 P 560

This blog from the King's Fund discusses integration of primary care and the community