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Ensuring that members of society are healthy and reaching their full po tential requires the prevention of disease and injury; the promotion of health and wellbeing; the assurance of conditions in which people can be healthy; and the provision of timely, effective, and coordinated health care. A wide array of actors across the United Statesincluding those in both primary care1 and public healthcontribute to one or more of these ele ments, but their work is often carried out in relative isolation. Achieving substantial and lasting improvements in population healch will require a concerted effort from all of these entities, aligned with a common goal. The integration of primary care and public health could enhance the ca pacity of both sectors to carry out their respective missions and link with other stakeholders to catalyze a collaborative, intersectoral movement to ward improved population health. In recognition of this potential, the Health Resources and Services Administration (HRSA) and the Centers for Disease Control and Prevention (CDC) requested that the Institute of Medicine (IOM) convene a committee of experts to examine the integration of primary care and public health. The 17member Committee on Integrating Primary Care and Public Health comprises experts in primary health care, state and local public health, serv1ce 1The committee recognizes that mental health is an inextricable part of primary care. When pri mary care is discussed in this report, the committee means it to be inclusive of mental health. 2When discussing the term \"population health,\" the committee chose to adopt Kindig and Stoddart's denition (2003, p. 381): \"the health outcomes of a group of individuals, including the dis tribution of such outcomes within the group.\" integration, health disparities, health information technology, health care nance, health care policy, public health law, workforce education and training, organizational management, and child health. The committee was charged to: Identify the best examples of effective public health and primary care integration and the factors that promote and sustain these efforts. These examples were to illustrate shared accountability; workforce integration; collaborative governance, nancing, and care coordina tion; and the effective use of information technology to promote in tegration and achieve highquality primary care and public health. Examine ways by which HRSA and CDC can use provisions of the Patient Protection and Affordable Care Act (ACA) to promote the in tegration of primary care and public health. 0 Discuss how HRSAsupported primary care systems and state and local public health departments can effectively integrate and coordi nate to improve efforts directed at cardiovascular disease prevention, as well as other issues relevant to health disparities or specic popu lations, such as maternal and child health and colorectal cancer screening, and describe actions HRSA and CDC should take to pro mote these changes. Funding for this study was provided by HRSA, CDC, and the United Health Foundation. In conducting the study, the committee held ve formal meetings, as well as three subgroup meetings, and used a variety of sources: the pub lished literature, discussions with HRSA and CDC, presentations from practitioners, and commissioned papers. In drawing on these sources, the committee developed a list of key principles for the integration of primary care and public health, which are outlined below and discussed in detail in Chapter 2. These principles were used as a guiding framework in present ing examples of successful integration, identifying opportunities for intera gency collaboration, and formulating the recommendations presented in this report. KEY TERMS Primary Care The committee adopted an earlier IOM denition of primary care: \"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\" (10M, 1996, p. 1). Primary care in the United States is delivered through both private providers and those sup ported by government agencies, such as the Veterans Health Administration and HRSA. HRSAsupported health centers serve over 19 million patients a year (HRSA, 2011) and provide a safety net for society's most vulnerable populations. Although most primary care is delivered through the private sector, both private and governmentsupported pri mary care share common features: both are personrather than disease focused, provide a point of first contact for whatever people might con sider a health or health care problem, are comprehensive, and coordinate care (Stareld and Horder, 2007). Public Health The committee adopted a denition of public health that likewise was borrowed from an earlier IOM report: \"fullling society's interest in assur ing conditions in which people can be healthy\" (IOM, 1988, p. 140). To meet this denition, public health has shifted its primary focus from addressing infectious disease to tackling chronic disease. To ensure healthy condi tions, public health encompasses a diverse group of public and private stakeholders (including the health care delivery system) working in a vari ety of ways to contribute to the health of society. Uniquely positioned among these stakeholders is governmental public health. Because health departments are legally tasked with providing essential public health ser vices, they are required to work with all sectors of the community. This al lows them to serve as a catalyst for engaging multiple stakeholders to con front community health problems. In addition, their assessment and assur ance functions put them in close contact with the community and in touch with the community's health needs. While public health dened broadly in this report goes beyond governmental public health, the committee recog nized that health departments play a fundamental role in creating healthy communities and focused on them when possible. Integration While integration can be an imprecise term, integration of primary care and public health was dened for this report as the linkage of programs and activities to promote overall efciency and effectiveness and achieve gains in population health. The committee conceived of integration in terms of multiple variableslevels, partners, actions, and degree. For this report, the agency and local levels are discussed. Partners for the agency level include HRSA, CDC, and other agencies as necessary; partners for the local level M utual Awareness Collaboration Cooperation Partnership FIGURE S-l Degrees of integration. include a primary care entity, a public health entity (with a preference for health departments), the community, and other stakeholders as necessary. The variable of actions required a shared goal of improved population health; a willingness and ability to contribute to that goal; and, ideally, a commitment to an ongoing process and continual dialogue. Finally, the committee conceived of integration as degrees on a continuum ranging from isolation to merger (Figure 8-1) and focused on mutual awareness, co operation, collaboration, and partnership, with a preference for activities moving toward greater integration. CONTEXT FOR INTEGRATION OF PRIMARY CARE AND PUBLIC HEALTH The opportunity currently exists to shift the health system in signicant ways. A number of relatively new developments have converged to create this opportunity. The dramatic rise in health care costs has led many stakeholders to explore innovative ways of reducing costs and improving health. As health research continues to clarify the importance of social and environmental determinants of health and the impact of primary preven tion, there is growing recognition that the current model of investment in the nation's health system is unacceptable. At the same time, an unprece dented wealth of health data is providing new opportunities to understand and address communitylevel health concerns. And most important, the passage of the ACA presents an overarching opportunity to change the way health is approached in the United States. This pivotal time makes it possible to achieve sustainable improvements in population health, a key goal for health system reform. Pursuit of this goal will require a balance of investment and clarity of roles across activi ties that address the broad determinants of health, populationlevel behav iors, and individual health careactivities in which primary care and public health have prominent roles. Primary care and public health presently operate largely independently, but have complementary functions and the common goal of ensuring a healthier population. By working together, primary care and public health can each achieve their own goals and simultaneously have a greater impact on the health of populations than either of them would have working inde V pendently. Each has knowledge, resources, and skills that can be used to assist the other in carrying out its roles. They should be viewed as \"two in teracting and mutually supportive components\" of a health system de signed to improve the health of populations (Welton et al., 1997, p. 262). Among agencies within the Department of Health and Human Services (HHS), HRSA and CDC have especially important roles to play in improving population health. Both have articulated a vision of how their work can im pact the broader determinants of health (Frieden, 2010; HRSA, 2010), and both see themselves as having a public health mission. HRSA plays a strate gic role in helping to ensure access to personal health services for unin sured and vulnerable populations through its support for the provision of primary care and preventive services at health centers, Ryan White clinics, and rural health clinics, as well as training programs for the primary care and public health workforces and maternal and child health programs. And with its focus on health promotion, disease prevention, and preparedness, CDC is recognized as a global leader in public health. The agency works with local and state health departments on a number of efforts, including implementing disease surveillance systems, preventing and controlling in fectious and chronic diseases, reducing injuries, eliminating workplace hazards, and addressing environmental health threats. It is signicant that these agencies have come forward to pursue integration. PRINCIPLES FOR INTEGRATION To gain an understanding of current and recent efforts to integrate pri mary care and public health, the committee reviewed past integration ef forts to identify some of the ways in which primary care and public health can interact, as well as the benets of and barriers to successful collabora tion. The committee gathered examples of integration by searching peer reviewed journal and grey literature databases, querying relevant stake holders, and drawing on its members' own experiences. A thorough review of these examples revealed some prominent themes and lessons and made it possible to select case studies that reect the major components of suc cessful integration. The review informed the development of a set of prin ciples that the committee believes are essential for successful integration of primary care and public health: - a shared goal of population health improvement; - community engagement in dening and addressing population health needs; 0 aligned leadership that bridges disciplines, programs, and jurisdictions to reduce frag mentation and foster continuity, claries roles and ensures accountability, develops and supports appropriate incentives, and has the capacity to manage change; - sustainability, key to which is the establishment of a shared infra structure and building for enduring value and impact; and - the sharing and collaborative use of data and analysis. While the committee believes that all of these principles are ultimately necessary for integration, it also believes that integration can start with any of these principles and that starting is more important than waiting until all are in place. EXAMPLES OF INTEGRATION From the literature review, the committee identied a number of exam ples of successful integration efforts. These examples appear in a diverse array of communities and help demonstrate the breadth of possibilities for primary care and public health interactions. Drawing on these experiences, the committee derived some lessons about the composition and focus of recent efforts to integrate primary care and public health: - In many of the examples, integration was driven by a specic health issue that was identied as a community area of concern, such as chronic disease, prevention, or the health needs of a specic population. - Participants in integration initiatives varied widely, including an array of primary care and public health entities and other contributors, such as community organizations, academic institutions, businesses, and hospitals. - Key opportunities for integration included the sharing and use of data and the development of a workforce capable of functioning in an integrated environment. Through its review of the literature, the committee sought examples to use as case studies that would demonstrate welldeveloped relationships between public health and primary care. With these examples, the com mittee wished to highlight ongoing linkages between primary care and public health entities that extend beyond a single project, demonstrate a 1 .- I- I . 11 1- . 1- 1 commitment to an ongoing relationship between the two disciplines, and reflect the above principles for integration. The committee selected three communi ties to showcase: - Durham, North Carolina; San Francisco, California; and 0 New York, New York. AREAS IN WHICH HRSA AND CDC CAN STRENGTHEN INTEGRATION To explore the potential for interagency collaboration to foster the in tegration of primary care and public health, the committee examined how HRSAsupported primary care systems and public health departments could integrate efforts in three specic areas: maternal and child health (specically the Maternal, Infant, and Early Childhood Home Visiting Program), cardiovascular disease prevention, and colorectal cancer screen ing. These areas were selected because they lend themselves to a life course perspective, include elements of mental and behavioral health, and touch on issues relevant to health disparities. They also represent a miX of programs led by HRSA and CDC. In its review of these three areas (discussed in Chapter 3), the commit tee was struck by two things. First is the vastly different organizational SLI'UCLUI'CS ()1 HKDA 'dIlu LUL, WIllCIl CI'C'dLE lUngLlCdl DaI'I'ICI'S LU L116 lOI'IIl'd tion of partnerships. These structural differences mean there often is no natural link between the agencies. This situation is not necessarily nega tive. In fact, like puzzle pieces that t into place, these structural differ ences can actually assist in promoting better coordination. In the short run, however, the differences can mean that staff from one agency do not always have a natural counterpart in the other. Second, despite these bar riers, there is a genuine willingness among the two agencies to work together. The committee's examination of the above three areas revealed some key ways in which integration can be encouraged. They include the value of using community health workers, the opportunities provided by data shar ing, and the possibility of a third party to foster integration. The committee encourages HRSA and CDC to explore these possibilities in the three areas examined by the committee, as well as others. POLICY AND FUNDING OPPORTUNITIES Federal policy and funding are the greatest levers available to HRSA and CDC for encouraging the integration of primary care and public health on the ground. As the most ambitious health policy in a generation, the ACA provides an unusual opportunity to work toward that goal. While the ACA does not explicitly address the integration of primary care and public health, it provides a menu of initiatives that agencies and communities can \f\f\fdiseases. Community Health Centers (ACA 5601) The provision pands funding health centers. EX for L116 llllplClllCllL'dLlUIl Ul BLdLC UCIIIUIISLIHLIUIIS, particularly in outreach to community providers to enlist them as active participants in such demonstrations, training and techni cal support to state Medicaid agencies, out reach to public health departments and health centers in demonstration states, and collaboration with CMS on the development of outcome standards and scalability criteria. An imperative for HRSA is to preserve and strengthen the role of health centers as core safety net providers of clinical care and pre vention in the communities they serve. Incentives could be built into funding for these centers to promote activities and link ages with local public health departments and encourage community engagement and partnerships for communitybased prevention. Outreach campaigns to promote clinical pre ventive services in underserved communities, as well as initiatives aimed at improving the quality of primary care for populations with serious and chronic health conditions, could focus on how to improve the performance of health centers. \f\f\fTeaching Health - HRSA could work with teaching health cen Centers ters to adopt the patientcentered medical (ACA 5508) home curriculum and ensure that any cur The provision autho riculum used to train residents includes rizes and funds the strong community and public health compo establishment of and nentsideally with residents working on ongoing operational prOJects that concretely promote primary carepublic health integration. 0 HRSA and CDC could work with the centers on training programs that would be aimed at support for teaching health centers, which must be community based. producing competency to work in commu nity health teams, given the emphasis placed on teams under the ACA. NOTE: ACA = Patient Protection and Affordable Care Act. Despite these opportunities, the current funding system for primary care and public health is not well positioned to promote integration. For example, competing funding streams have the effect of creating silos at the local level rather than encouraging cooperation across entities. Similarly, most funding streams from HRSA and CDC are inexible, limiting what 10 cal entities can do with the funds and how they could be used for integra tion. Finally, it should be noted that the funds available to HRSA and CDC for supporting and integrating primary care and public health are quite small relative to the funds available to the Centers for Medicare & Medicaid Services (CMS). By joining forces, the three agencies could create much greater momentum toward integration. RECOMMENDATIONS 1n the commlttee's View, the pr1nc1ples tor integration outlined above serve as a framework for action. The committee developed ve recommen dationsaimed at the agency and department levelswhose implementa tion would assist the leadership of CDC, HRSA, and HHS in creating an en vironment that would support the broader application of these principles. Agency Level Recommendation 1. To link staff, funds, and data at the regional, state, and local levels, HRSA and CDC should: identify opportunities to coordinate funding streams in selected programs and convene joint staff groups to develop grants, re- quests for proposals, and metrics for evaluation; ' create opportunities for staff to build relationships with each other and local stakeholders by taking full advantage of opportunities to work through the 10 regional HHS ofces, state primary care of ces and association organizations, state and local health depart ments, and other mechanisms; - join efforts to undertake an inventory of existing health and health care databases and identify new data sets, creating from these a consolidated platform for sharing and displaying local population health data that could be used by communities; and - recognize the need for and commit to developing a trained work- force that can create information systems and make them efcient for the end user. Recommendation 2. To create common research and learning net works to foster and support the integration of primary care and pub lic health to improve population health, HRSA and CDC should: - support the evaluation of existing and the development of new 10- cal and regional models of primary care and public health integra- tion, including by working with the CMS Innovation Center (CMMI) on joint evaluations of integration involving Medicare and Medicaid beneciaries; - work with the Agency for Healthcare and Research Quality's (AHRQ's) Action Networks on the diffusion of best practices related to the integration of primary care and public health; and - convene stakeholders at the national and regional levels to share best practices in the integration of primary care and public health. Recommendation 3. To develop the workforce needed to support the integration of primary care and public health: - HRSA and CDC should work with CMS to identify regulatory op- tions for graduate medical education funding that give priority to provider training in primary care and public health settings and specically support programs that integrate primary care practice with public health. - HRSA and CDC should explore whether the training component of the Epidemic Intelligence Service (EIS) and the strategic placement of assignees in state and local health departments offer additional opportunities to contribute to the integration of primary care and \f- CMMI to use its focus on improving community health to support pilots that better integrate primary care and public health and pro- grams in other sectors affecting the broader determinants of health; - the National Institutes of Health to use the Clinical and Translational Science Awards to encourage the development and diffusion of research advances to applications in the community through primary care and public health; 0 the National Committee on Vita] and Health Statistics to advise the secretary on integrating policy and incentives for the capture of data that would promote the integration of clinical and public health information; 0 the Ofce of the National Coordinator to consider the development of population measures that would support the integration of com- munity-level clinical and public health data; and - AHRQ to encourage its Primary Care Extension Program to create linkages between primary care providers and their local health departments. Recommendation 5. The secretary of HHS should work with all agen cies within the department as a rst step in the development of a na tional strategy and investment plan for the creation of a primary care and public health infrastructure strong enough and appropriately \f