Key Leaders Discuss Primary Care and Public Health Integration at APHA
At the American Public Health Association’s Annual Meeting in Chicago last month, several national leaders in public health and primary care presented a special session organized by APHA titled, “Integrating Prevention in Public Health and Primary Care: Leading Wedge Policies to Create the Healthiest Nation in a Generation.” The session was moderated by Gail Bellamy, PhD, director of the Florida Blue Center for Rural Health Research and Policy and is a professor of behavioral sciences and social medicine at Florida State University College of Medicine.
Sharon Moffat, chief of health promotion at ASTHO, opened the session by highlighting one example of a nationally led collaborative focused on the integration of public health and primary care. The Integration Forum connecting primary care and public health is a partnership of more than 50 organizations and 100 individual partners seeking to inform, align, and support the implementation of integrated efforts that improve population health and lower health costs. This initiative began in July 2012 with a meeting co-hosted by ASTHO and the Institute of Medicine (IOM) that brought together key individuals in primary care and public health to create a strategic map. The map filled the need for a strategic approach to integration in follow-up to the IOM report Primary Care and Public Health: Exploring Integration to Improve Population Health. Since that meeting, the Integration Forum has been bringing people and organizations together with great ideas on integration of the disciplines of primary care and public health. Partners and potential partners engage actively and learn new strategies for engagement through the Integration Forum’s communications channels including: a monthly newsletter, social media outreach, bi-monthly calls focused on one of four areas (Successes and Measures, Sustainability, Workforce, Communications), bi-monthly calls with all participants on relevant hot topics in health systems transformation, and constant outreach to identify new partners that must be part of the process to make this a reality.
Michael Barry, executive director of the American College of Preventive Medicine (ACPM), then described the role of preventive medicine in health systems transformation. Barry introduced the medical specialty of preventive medicine and how physicians who specialize in this area serve as boundary spanners in communities and healthcare institutions, bridging the divide between clinical care and population health. He shared information about the ACPM’s strategic initiatives focused on health systems transformation and how to infuse population health in healthcare systems. He highlighted the unique training of preventive medicine residents and described how the training positions these physicians as leaders in integration efforts and encourages communities to seek out preventive medicine physicians to further integration work that may be under way or under consideration.
Lastly, John Auerbach, associate director for policy at CDC, discussed evidence-based, national initiatives that integrate primary care and public health, particularly clinical and community preventive services. He reviewed the CDC’s Framework for Public Health, which outlines three areas in which the value of public health and its contributions to health systems can be measured:
- Traditional Clinical Approaches – Public health plays a key role in preventive care (e.g., obesity, chronic diseases). Public health can help to increase utilization of preventive services by pointing out that society is not where it should be (sharing data). Public health is also good at mobilizing the public to be aware of the importance of clinical preventive services and in mobilizing clinical practices and insurers to share materials with patients to educate them on preventive services.
- Innovative Patient-Centered Care – Payment reform and value-based contracting provides the opportunity for insurers to pay for certain public health activities that were not previously were no reimbursed (e.g., home-based visits by community health workers to reduce asthma triggers in the home).
- Communitywide Health – Public health focuses on how to create conditions in communities that encourage healthy living and healthy environments enabling the healthcare system to shift resources from sick care to wellness care. . (e.g. Oregon and Vermont are designing community health programs that merge funding from multiple sources so you combine community and clinical approaches; CMS just proposed a hospital quality measure that would incentivize hospitals if the smoking rates go down in the counties where they operate; Affordable Care Act IRS requirement for nonprofit hospitals to work with public health partners for community health needs assessments – check out CDC’s Community Health Improvement Navigator).
Panelists responded to the following questions about primary care and public health integration:
What does primary care need public health to do more of and less of (and vice versa) to sustain the integration of primary care and public health?
- The gap between public health and primary care is like pushing a boulder uphill. It's slow going, but we shouldn’t despair. We are seeing more and more integration now than in the past.
- We need more discussions around transitioning some safety-net services (e.g. STD, TB, immunizations, and reproductive care) provided in free clinics by public health, and whether those settings should be scaled back or eliminated if patients now have insurance to go to primary care settings. This requires a community by community analysis of need and opportunities.
- Both primary care and public health need to work better on reaching out to each other. There are payment barriers that need to be discussed to move us forward. Take the first step and have those crucial conversations.
- Related to data, we have different systems, issues of interoperability, and HIPAA, but patients and the community could benefit tremendously if we address those issues.
- Public health is great at data, but how can we better use data to drive action? How can public health work with primary care in the clinical setting (e.g. using the electronic health record to identify hypertensive patients not in control and connecting them with public health resources)?
- At the clinical practice level, there is a focus on social determinants of health and what is driving the diseases and conditions that bring patients to their clinic. Primary care can go to public health for those answers, and primary care can share their EHR data with public health.
What are some next steps we can all take to promote the integration of primary care and public health?
- We need to keep an eye on and participate in several initiatives happening in different communities. One important example is the CMS State Innovation Model grants. CMS awarded one billion dollars in funding to 34 states, three territories, and the District of Columbia with the goal of bringing all public and private payers to the table to redesign health reimbursement systems. It's a messy process and is different in every state, but it’s important to find out what is happening in your state and try to get at the table. Learn more on ASTHO’s SIM Wikispace.
- The role of advocacy is important. Many organizations have a position or policy statement supporting this work at all levels. There is much opportunity for each of us to advance policies. See AAFP’s positions statement as one example.
For more information on this topic, see these resources:
Courtney Bartlett, MPH, CPH, CHES, is the director for primary care at ASTHO. In this position, she manages ASTHO’s support of the Integration Forum as well as other projects under a cooperative agreement from HRSA including work on community health workers, telehealth, maternal and child health, and access to care issues. Before coming to ASTHO, Courtney interned at the Association for Maternal and Child Health Programs where she supported work related to children and youth with special healthcare needs.