Communities of Solution: The Folsom Report Revisited

"The Community as a Learning System: Using Local Data to Improve Local Health," by the National Committee on Vital and Health Statistics (NCVHS), offers further examples of communities of solution.(1) The late- 2011 report, which I wrote with NCVHS members and staff, describes fourteen local initiatives from the Bronx, NY, to South Los Angeles and summarizes the success factors and barriers they have in common. A central premise, as it is of both versions of the Folsom Report, is the need to address the social determinants of individual and community health. The coalitions NCVHS describes are working to improve community health in arenas that include land use, food, child care quality, and more as well as health care access and coordination.

A major question raised for me by the article by Dr. Griswold et al. is what would enable primary care professionals to step outside their institutions into activities that engage citizens in shared work toward broadly defined community health goals. How can providers join their patients and neighbors in identifying common interests and forming communities of solution?

A good place to begin, I believe, is by building connections among community-based networks and initiatives that are already at work in different sectors. As the authors observe, information technology now makes many things possible. For example, in Mendocino County, CA, where I live, our "Healthy Mendocino" Steering Committee is developing an online resource to inform, support, and link activities directed at as many local health determinants as possible. Our community partners bring perspectives encompassing low-cost housing, youth and family resources, food, community development, public safety, and government as well as public health and health care. A near-term priority is to harness the energetic work already under way on local food production and consumption.(2)

Finally, I want to call attention to the resource limitations faced by many communities as they work for local solutions--an issue requiring national attention. A major limitation, especially in rural areas, is the absence of researchers with whom to partner in community-based participatory research. We can hope that these far-sighted reports will engender new approaches and tools that are usable for all communities.

(1) National Committee on Vital and Health Statistics, The Community as a Learning System: Using Local Data to Improve Local Health. U.S. Department of Health and Human Services, December 2011. http://www.ncvhs.hhs.gov/111213chip.pdf

(2) http://www.co.mendocino.ca.us/hhsa/pdf/PR_2009_12_03_food.pdf ; http://gardensproject.org/projects/foodpolicycouncil/

Competing interests:   None declared

Thank you for the opportunity to comment on this inspiring piece. On page 253, the Folsom Group noted that "Addressing social determinants requires linkage between public health, community health, mental health, and primary care; we now have powerful tools necessary to enable that linkage."[1]

Linkages are not enough. Only useable, understandable information truly meets Grand Challenge 13: "Utilize health information technology and emerging data-sharing innovative networks that enable the flow of relevant knowledge (public health, environmental, educational, legal, etc) to the communities of solutions." Linked data can and should inform: (1) Clinic- and system-based quality improvement initiatives; (2) provider-patient interaction during encounters; and (3) healthcare policy. As others have commented, integrating GIS and other forms of data has the potential to draw attention to and inform solutions to reduce healthcare disparities and achieve healthier communities.

However, turning data into useable information is much harder than it sounds. In a local example, we are working closely with healthcare providers, patients and policymakers to figure out how to put linked data into a useable format: the pie charts, bar graphs, and points of comparison (including relevant public health and community data) that help to make sense of the data and inform action. To achieve this, we are building a data learning collaborative in OCHIN, Inc., a health-center controlled network of safety net health centers with a linked electronic health record. What makes it especially interesting (and challenging!) is that participating clinics are each part of different ACOs as well as located in different states, creating natural experiments as the Affordable Care Act is implemented. Participating clinics are also actively engaged in many other initiatives: Testing alternative payment methodologies; implementing patient-centered medical homes; meaningful use, etc.

We look forward to learning more about other communities of solution that are innovating for a healthier community.

1. The Folsom Group (American Board of Family Medicine Young Leaders Advisory Group). Communities of solution: the Folsom Report revisited. Ann Fam Med. 2012 May;10(3):250-260.

Competing interests:   None declared

I remember discussions of the Folsom report when I was a new resident forty years ago. It is nice to see its resurrection but disappointing to see that little has changed. There is a spark of hope now, but time and money will tell the outcome. The current crop of medical students who rotate through my office certainly say they would love to practice rural family medicine, but few do.

The critical point of the community solutions is that only the community can know its solutions. I live and work in Grand County, Colorado.

Competing interests:   None declared

A "Communitarian" is a great way to evoke the team approach called for in the Medical Home; and both the Chronic Care[1] and Expanded Chronic Care[2] Models.

Dr. Ringle's point about Nurse Practitioners is well taken. A systematic review of Advanced Nurse Practice Outcomes[3] assessed quality, access and cost across varied settings, finding that "APRNs provide effective and high-quality patient care". The increased role of Advanced Practice Nurses was seen especially in underserved populations - an observation that resonates highly with my experience. I have worked for many years with FNPs both clinically and in the research arenas, and have been impressed by and grateful for their acumen, knowledge, perspective and colleagueship or "communitarianism". By the way, there is evidence also for the cost effectiveness of NPs.[4]

1. Wagner et al. Quality improvement in chronic illness care: a collaborative approach. J on Quality Improvement 2001; (27)2:63-80.
2. Barr et al. The Expanded Chronic Care Model: An integration of concepts and strategies from population health promotion and the chronic care model. Hosp Quarterly 2003; 7(1).
3. Newhouse RP, Bass EB, Steinwachs DM, et al. Advanced Practice Nurse Outcomes 1990-2008: A Systematic Review. Nursing Economics Sept-Oct 2011; 29(5).
4. Nurse Practitioner Cost Effectiveness. American Academy of Nurse Practitioners; 2010.

Competing interests:   None declared

Half a century ago, the original Folsom Report captured a comprehensive list of grand challenges on the path to integrating community health services. Here, Griswold and colleagues set forth an updated yet equally ambitious agenda. In many respects, I agree with and echo their analysis, though I would underscore three points.

First I would underscore the fundamental importance of integrating the domains of medicine and public health to the resolution of the 13 grand challenges. The triple aim of improving population health, enhancing the quality of healthcare, and controlling costs cannot be achieved without combining the forces of medicine and public health to improve wellness at the community level.

Second, the authors proffer the divergent aims of economic gain and community wellbeing as explanation for the lack of progress towards the grand transformation envisioned in the original report. I believe that a socially conscious, outcomes-focused healthcare system need not be at odds with the healthcare industry, particularly the large segment that is not for profit. The principle of shared value as introduced by Michael Porter maintains that understanding and meeting community needs can be a sustainable business approach. Under this frame, academic health centers and others will need the incentives and resources to shift from a uni- directional, community service model towards a bi-directional community engagement model as many are beginning to do. Financial incentives must be aligned with desired outcomes to lead to major changes--either individual, such as specialty choice and location of practice, or institutional, such as decreasing inpatient volume and moving more care into community settings. However, we can't afford to wait for government and private payer policy to change before we begin to create systems-based solutions. The 50 years which have elapsed since the Folsom Report was issued demonstrate that a more bottom-up approach is needed. This requires some forward-thinking communities to blaze a path, demonstrating successful ways to circumvent the stubborn barriers to realizing better value from our healthcare spending.

Finally, the authors rightly point out that modern technologies mean that local innovations need not be isolated. This cannot be overemphasized. We have the ability like never before to capture, aggregate and comb massive amounts of data, target activities and measure results in real time. Virtual learning communities are a cost effective way to harness technology to spread the knowledge of what works and will undoubtedly play a substantial role in addressing these stubborn problems.

Competing interests:   None declared

Many congratulations to Kim Griswold and the Folsom Group for a very thoughtful and timely article on 'Communities of Solution: the Folsom Report Revisited' published in Ann Fam Med May/June 2012'. Communities of Solution is an exciting proposition - to move forward in such a grounded and positive manner to address the many challenges facing health care and public health in the USA and other countries too. We also absolutely agree with the authors that the current emphasis on engaging community in research is an excellent approach for evaluating Communities of Solutions. Using this approach, community-researcher-policymaker participatory research teams are a natural extension to develop baseline evaluations, community relevant health promotion interventions and follow up evaluations. The publications from the CDC-funded public health centers dedicated to community-based participatory research have many examples of successes using this approach. In addition, the results from our recent realist review of participatory research demonstrate strong partnership synergy between researchers and community members, increased relevance of the research, increased recruitment of participants, increased capacity building of both academic and community members, longevity with many partnerships lasting well into their second decade and many spin off projects impacting health in other areas including health services delivery.

Reference: Jagosh J, Macaulay AC, Pluye P, Salsberg J, Bush P, Henderson J, Sirett E, Wong G, Cargo M, Herbert C, Seifer S, Green LW, Greenhalgh T. Uncovering the Benefits of Participatory Research: Implications of a Realist Review for Health Research and Practice. Milbank Quarterly 2012;90(2):311-346 doi: 10.1111/j.1468-0009.2012.00665.x.

Competing interests:   None declared

When I entered medical school in the early '70's healthcare consumed 6% of the Gross National Product, the highest percentage of the largest economy in the world. As my mates and I experienced firsthand the inefficiency, inequity and sometimes downright abuse perpetrated on the population by the healthcare non-system, we agreed things couldn't get much worse. And, of course, they have gotten much worse over the almost forty years that I've been a doctor, with the health care sector currently accounting for 17% of the GNP.

It comes down to economics and politics. As the Folsom Group says so well, "The US health care system is now a stunningly successful mechanism for wealth generation....Money flows toward sickness care and profits."

With this being an especially ugly time regarding the influence of money on politics and policy, as evidenced by current political campaigns, how can we hope that doing what needs to be done to reform health care in our country will be done, when meaningful reform will necessarily slow the flow of money toward sickness care and profits?

The authors do present good reasons to hope for positive change. For one, the Affordable Care Act, even if all or part of it is voided by the Supreme Court, has gotten the reform camel's nose under the tent. And there is huge pressure for change building as the result of the unaffordability of health care to the middle class and to the employers that still pay for a large share of that care, many of them large, powerful, moneyed businesses. This time, really, really, really, things have to change.

Should family physicians lead the change? Can we? I don't think so. We can be co-participants, perhaps even conveners of communities of solution. Notwithstanding our usual proximity to the communities we serve, we FPs are still mere members, albeit important members, of those communities. Our agenda, like everybody else's, is sometimes too self- serving to put ourselves at the very center of health care communities of solution.

Which brings me to the ax I wish to grind. Everybody, including the Folsom Group, agrees that an adequate supply of primary care providers is an essential element in constructing a functional health care system. The deficit of providers is already dire. We need everybody we can get.

And yet, The Association of Family Medicine Residency Directors, reflecting positions taken by our American Academy of Family Physicians, published an editorial in this same issue calling for restricting independent practice by nurse practitioners, under the rubric (and editorial title) "Education Gaps Between Family Physicians and Licensed Nurse Practitioners" (Ann Fam Med May/June 2012 vol. 10 no. 3 270-271). In this case it's the teachers of our future family doctors who are giving a very un-communitarian message, putting private interest in family doctors' turf ahead of community need.

We FPs have waged turf battles with our non-generalist colleagues just about from the day we were born as a specialty. Repeatedly, we point to outcome studies that show our results to be at least as good as our antagonists', whether it's intensive care, vaginal delivery, Cesarean section, or endoscopy. We've never pretended that we can do all the same things as an intensivist, obstetrician or gastroenterologist. Rather, when we do choose to perform a medical service we do it just as well as those who have considered that work their exclusive domain.

The same goes for nurse practitioners. Study after study has shown that, for the services they do provide, supervised by a doctor or not, patient outcomes are at least as good as physicians'. And their documentation is generally better.

I am disappointed but not surprised when organized family medicine, now over 40 years old, occasionally shows this sort of narrow mindedness and stodginess. I go back for inspiration to a seminal article by Gayle Stevens "Family Medicine as Counterculture" (Family Medicine March/April 1989 vol. 21 no. 2 103-109).

The Folsom Report shows that the family medicine counterculture is alive and well. I am especially heartened by the fact that a group called the "Young Leaders Advisory Group" has taken the lead in updating this very important perspective and the set of ideas it supports. We just need to have it pointed out to us now and then when we are speaking like self- serving doctors rather than as the compassionate team players we strive to be.

Competing interests:   None declared

The Folsom Report Revisited in the May/June 2012 issue of the Annals of Family Medicine notes that the community-oriented care (COPC) movement grew out of the 1967 Folsom Report. The operational definition of COPC is based on three components: a primary care practice, an involved and definable community, and a set of activities that systematically address the major health issues of the community.1 The Folsom Report Revisited describes the importance of family physician leaders engaging communities to take charge of their local health care environment. In addition to being health care opinion leaders, physicians are presented with opportunities to be followers when the community is ready to lead. Whereas the individual family physician has a time-limited impact on the local community, the community will be here tomorrow. Family physicians have an opportunity and a responsibility to encourage and develop the capacity of their community to have a high quality, sustained health system.

The Community of Solution described in the Folsom Report brings me full circle from my first practice on the Oregon coast to my current role as the director of a rural practice-based research network. Following my internship, three years in Alaska with the Indian Health Service (IHS) and a two year family medicine residency, I started my first family medicine practice in 1977. My IHS experience grounded me in the importance of community groups. As a result of this community orientation I applied for and received a four-year grant from the Robert Wood Johnson Foundation's Rural Practice Project (RPP). As a requirement of the grant I established a 501C non-profit corporation and became an employee of a community board. The RWJ grant funds allowed the practice to incorporate dental, mental and health education services. The program had a goal of establishing 25 model rural practices and ended up funding thirteen. The practices in this program demonstrated that rural communities were able to successfully sponsor and make decisions about their primary care practice.2

Thirty five years later, I find myself again looking to the community as leading local healthcare transformation. The Oregon Rural Practice- based Research Network, with a full time director of community health and four rural-based practice enhancement/research coordinators (PERCs), devotes almost half of our network activity linking primary care practices and community groups to work on projects related to the social determinants of health. The ORPRN experience is not unusual as other practice-based research networks (PBRNs) have recognized the population- based responsibility of primary care practices. Williams described the broader agenda of PBRNs to engage communities and health systems to improve health.3

Oregon recently received approval from the U.S. Department of Health and Human Services to transform the way care is delivered in Oregon's Medicaid program with a Coordinated Care Organization (CCO) model. The requirements of becoming a CCO include local control, community health workers and patient-centered primary care homes. In response to a rapidly changing healthcare landscape, ORPRN held a Rural Health Care Transformation Conference in early May 2012. The key rural health stakeholder leaders were in the same room representing the hospitals, primary care practices, family medicine organizations, the Area Health Education Consortium, the state workforce institute, the state health authority, and community groups. Two community stories captured the Community of Solution spirit. The first was Rimrock Alliance, a central Oregon non-profit organization in a community of 9,800 people. Rimrock has taken charge of deciding what they want their health workforce to look like and over the past two years they have led the recruitment of three family physicians, a general surgeon, a psychologist, a pharmacist, an emergency room physician, a chiropractor, and two physician assistants. The community group reviews the applicants, decides who to sponsor for a visit, arranges the interviews, and provides key input into deciding who will fit and making the ultimate hiring decision.

The second community story addressed healthcare equity. This story was told by a rural family physician who led the development of a community collaborative which received funding to study the use of the emergency department as an indicator of strengths and gaps in local health care. The private practices and the federally quality health center were members of the collaborative.

Our Rural Healthcare Transformation Conference represented the Community of Solution concept in action. A challenge for family medicine practices will be how best to harness the community energy and vision. The current trend in practice ownership is the shift from physician-owned practices to health system-owned practices.4 Family physicians may be moving farther from their community roots with the health system model. From my perspective returning family medicine practice ownership to the community as the RWJ Foundation's Rural Practice Project did 35 years ago is an alternative model, consistent with the Community of Solution concept. Many thanks to The Folsom Group for the community of solution update.

1. Community-Oriented Primary Care: A Practical Assessment. Vol. 1: Report of a study (1984). Copyright 1984, 2000, The National Academy of Sciences.
2. Moscovice IS and Rosenblatt RA. Rural Health Care Delivery Amidst Federal Retrenchment: Lessons from the Robert Wood Johnson Foundation's Rural Practice Project. AJPH December 1982, Vol. 72, No. 12
3. Willams RL and Rhyne RL. No Longer Simply a Practice-based Research Network (PBRN) Health Improvement Networks. JABFM. September 2011.Vol.24, No.5
4. Kocher R and Sahni NR. Hospitals' Race to Employ Physicians--The Logic behind a Money-Losing Proposition. N Engl J Med 2011;364:1790-1793

Competing interests:   None declared

The San Antonio Texas "Community of Solution" is an excellent example of what the Folsom Report and our "re-visit" highlight: taking on the complexities involved in population health, and welcoming the most vulnerable patients into primary care. The integration of mapping techniques and utilizing geographical boundaries to be part of the solution seems key to these neighborhoods involved. The project seems to embrace elements of each of the proposed Grand Challenges in the Folsom Report Revisited.

I found the definition of the Bexar County Hospital District very interesting as a "political subdivision"; and how complexity science is helping the systems of University and political district to work together.

Will definitely stay tuned in to this one!

Competing interests:   None declared

This is a wonderful article bringing Community Health into a modern context. With today's information systems, we are able to provide for population health like never before. Community health has long been a value of family medicine, but seeing one patient at a time gave us limited value in providing full community care. Now, with information technology and teams providing care, we can be strategically proactive in addressing community needs. My compliments and thanks to this team for providing this seminal article to serve as a guide.

Competing interests:   None declared