Motherhood, Apple Pie, and COPC

We applaud the Editorial in the March-April issue (1) which promotes discussion on COPC as an approach that is increasingly being considered in the re-orientation of primary care, and we would like to share a few comments on its message.

The principles and methods of the COPC approach are relevant to countries of different socio-economic and cultural backgrounds. The very rich experience in the United States in teaching and evaluation of COPC should be recognized in its own right, but it also poses questions regarding the difficulties about the spread of the model. Considering the universal value and the relevance of the model, the difficulties in its practice might be related more to the specific health care structure and organization of each country rather than to the COPC model itself. Effectiveness of the approach has been demonstrated in the impact on community health. (2,3)

Although resources and financial support are obviously important (necessary but not sufficient), experience shows that "substantial funding" is not always a "sine qua nom" to get the model running. COPC requires expertise in those disciplines in which the model is built, such as epidemiology, social and behavioral sciences and health management. Some primary care teams may have the expertise, and if that is not the case, they may be coordinated with other clinics which do posses that expertise, or could be linked with academic institutions.

The evolving process of COPC in Spain shows that the main force behind its progressive application has been a professional association, the Catalan Society of Family and Community Medicine, through its COPC Working Group. The process which started in 1986, through an extensive training of Family Physicians and Primary Care Teams (4), has evolved into the application of COPC principles in about 25 primary care clinics, and more recently in 8 pilot demonstration centers. This development has been supported by several stakeholders in the region, such as policy makers of the Department of Health, health care managers, academic institutions and active members of the communities.

The assertion that there is need for "an energetic advocate" or "a committed leader" to apply the model, should not be considered as an obstacle or a deterrent but as an important requirement in facilitating the re-orientation of primary care services, as with any new activity in health care. These attitudes of health practitioners may also be needed to avoid a mere technical application of the approach without consideration of its essential elements of social justice.

In addition, the opportunities for the development of COPC are enhanced when is introduced in a teaching environment and when there is process of reform of health services, as in Spain and in the UK (3). Similarly when there is community involvement in health and health care, information technology and initiatives to integrate clinical medicine and public health. (5) Recent declarations of WONCA support an extension of Family Medicine towards COPC.

The development of COPC in any practice, should be based on an adoption of the COPC principles and on the local adaptations of the COPC methods. In that sense the "…unanswered questions that have plagued this model…" (1), could be considered as challenges for the health practitioners, more than an impediment. The creation and developments of instruments and facilities that help the application of COPC, will also depend on a carefully planned re-organization of the usually busy setting, in terms of allocation of time and development of skills.

The gap between the extensive teaching of COPC and the less extensive practice, does not mean that the logic of this model is like the undisputed virtues "of the American apple pie."

1) Williams RL. Motherhood, Apple Pie, and COPC, Editorial - Annals of Family Medicine; 2004;2(2):100-102.

2) Abramson JH. Community-oriented primary care-strategy, approaches and practice: a review. Public Health Reviews 1988;16:35-98.

3) American J Public Health 2002, November issue with eight articles on COPC.

4) Peray JL, Foz G and Gofin J. COPC in Spain, COPaCetic Newsletter, Spring 2001:4-7.

5) Cashman SB, Anderson RJ, Weisbuch JB, Schwartz MD and Fulmer HS. Carrying out the Medicine Public Health Initiative: the roles of preventive medicine and community-responsive care, Acad Med 1999;74(5):473 -483.

Competing interests:   None declared

In the title of his editorial, "Motherhood, Apple Pie, and COPC," Williams chooses a profound metaphor for the paradox of Community-Oriented Primary Care (COPC). Like motherhood COPC is necessary, idealized, and revered yet still grossly undervalued (and, therefore, underfunded) by the current medical marketplace. He questions both the feasibility of and evidence for improved health from implementing COPC in "busy primary care practices" and challenges us to develop the practical methods necessary to assemble that evidence. He lauds the cross-sectional, door-to-door, community-based research of Plescia and Groblewski conducted in Charlotte, NC, which they reported on in the same issue.[1] In coalition with community residents, activists, and agencies they have pursued evidence- and theory-based health promotion and disease prevention strategies, incorporated both qualitative and quantitative methods, and laid the foundation for longitudinal follow-up studies that are still necessary before the effectiveness of their COPC intervention can be ascertained.

In the early 1990s our department embarked on a similar course to demonstrate the effectiveness of COPC with foundation rather than CDC funding. Our quasi-experimental, controlled research design planned to establish a community baseline using door-to-door household surveys and then measure the health status change after five years follow-up, comparing a COPC-model health center vs. traditional primary care practice vs. no organized primary care surveys in three Bronx neighborhoods. Like Plescia and Groblewski, my colleagues published the baseline findings,[2] but the foundations lost interest in COPC in favor of studying managed care and defunded the study. May the CDC be more steadfast and patient with the research process!

Building the bridge between primary care and public health has been problematic because traditional departments of public health have not embraced COPC or partnerships with office- or health center-based physicians. There are hopeful signs that this is changing as the challenges of preventing and managing our epidemics of chronic disease (e.g., asthma, cancer, diabetes, obesity, substance abuse, and even HIV/AIDS) move public health professionals towards COPC-like collaborations. First, with funding from the Robert Wood Johnson Foundation, the American Public Health Association (APHA) and American Medical Association created a Committee on Medicine and Public Health and published two monographs on collaboration;[3,4] then APHA published a book on COPC[5] and then devoted most of its November 2002 issue of the American Journal of Public Health to COPC.

Most recently, the New York City Department of Public Health and Mental Hygiene initiated an ambitious campaign called "Take Care New York," which begins with "have a regular doctor or other health care provider" and makes nine other recommendations, all but one of which involve primary care physicians (e.g., "be tobacco-free," "keep your heart healthy," "know your HIV status," etc.). The Department has also created three District Public Health Offices to focus its efforts in collaboration with those communities with the greatest health disparities, published Community Health Profiles on all of the city’s 42 neighborhoods; and begun "academic detailing" in physicians’ offices to promote campaigns for adult immunizations, colorectal cancer screening, and tobacco cessation. This is the first time in memory that the Department has reached out to practicing physicians by actually visiting them in their offices. All of these initiatives are evidence-based and data-driven and provide hope that the costs and evaluation of COPC in the not-so-distant-future will not have to be totally born by primary care champions and grantsmanship. Rather, communities, primary care physicians, and departments of public health will learn to the "power of collaboration" and share Mom’s apple pie!

A.H. Strelnick, M.D. Department of Family & Social Medicine Albert Einstein College of Medicine Bronx, NY

1. Plescia M, Groblewski M. A community-oriented primary care demonstration project: refining interventions for cardiovascular disease and diabetes. Ann Fam Med 2004;2:103-9.
2. Taylor BR, Haley D. The use of household surveys in community-oriented primary care health needs assessment. Fam Med 1998;28:415-21.
3. Lasker RD and the Committee on Medicine and Public Health. Medicine & Public Health: The Power of Collaboration. New York, NY: New York Academy of Medicine, 1997.
4. Lasker RD, Abramson DM, Freedman GR. Pocket Guide to Cases of Medicine & Public Health Collaboration. New York, NY: New York Academy of Medicine, 1998.
5. Rhyne R, Bogue R, Kukula G, Fulmer J, eds. Community-Oriented Primary Care: Health Care for the 21st Century. Washington, DC: American Public Health Association, 1998.

__________

Competing interests:   None declared

When All Else Fails

By David R. Smith, M.D. Chancellor, Texas Tech University System

Community Oriented Primary Care (COPC) can serve both as a framework for transforming a “medical model” of care to a “health model” and as a template for a constructive debate to reform existing US health policy. COPC is a dynamic interface between primary care and population-based pubic health. In mathematical, or epidemiological terms COPC focuses on the numerator and the denominator – the patient seated before you and the dynamic community in which they live.

While much progress has been achieved at the cellular and sub- cellular level of medicine, macro-medicine, or a population-based focus to health, has languished in archaic reimbursement policy and the historically fractured bonds of medicine and public health. A brief historical review may add some perspective to the argument. Post 1920 Flexnerian philosophy established firmly the scientific basis for modern medical education, however the same report did little to enhance the bonds between medicine and public health. While medical education became rooted in a nurturing academic environment, public health remained entrenched in pre-civil war public policy with often minimal public financial support. Reimbursement strategies evolved to reward curative care through health insurance and governmental entitlement programs such as Medicaid and Medicare, while public health depended on a category of funding often defined as discretionary.

If one allows this author some poetic license with Greek history, one can metaphorically see this dichotomy originating in ancient Greece. Aesculapius the father of medicine had two daughters Hygeia and Panacea. Panacea, under this illustrative metaphorical analogy was the daughter of curative care and Hygeia was the daughter of population-based care. While one thrived in an environment of vibrant research, technologic innovations and relatively better reimbursement, the other, Hygeia the daughter of public health languished in the world of politics, plagues and divisive public policy.

COPC can trace remnants of its ancient roots in the history of health care. With its focus on measurable outcomes and responsive to the documented needs of a community, COPC has a built in framework of accountability. The caregivers of the 5th Century B.C. in China, the Madarins, were an early model of accountability tied to incentives and were only paid if the patient got well.

The article by Plescia and Groblewski in the March/April edition of the Annals of Family Medicine, and the subsequent commentary by Williams, bridges the chasm between the possible and reality. COPC remains an effective framework for health policy reform and an accountable community- based health care delivery system. As the population of this country ages and the burden of chronic illness increases the opportunity to effectively understand population trends and evaluate preventive and therapeutic interventions will be paramount. The champions for this comprehensive approach to care may well shift to the business community struggling to maintain a healthy labor force. Demographic shifts in race and ethnicity (to include a minority non-hispanic white population) will alter our methods to respond effectively to a variety of disease trends such as long term surges in type II diabetes.

As a delivery model COPC’s implementation has been sporadic. The banner bearers have largely been the public health community and some strong advocates within the ranks of primary care. While significant, this support has not been able to thrust COPC into the mainstream health policy discussion. Critical elements of COPC, to include the gathering of health information from primary data sources (patients and communities), remain relatively expensive and perceived as academic, the journey to implement the philosophy of COPC must be seen in terms of a marathon not a sprint and evolutionary in nature.

Incrementalism may continue to define US health policy, but inflationary costs of curative care and the burden of chronic disease and aging may alter the dynamics for reform. Progress must be made to incorporate the tenets of COPC into the curriculum of health professionals and bring about change in funding and reimbursement to reward population based interventions at the community level. (1) Coordination of the public health community and private medical delivery system is paramount. If nothing else COPC can serve as a realistic platform for a more rational (not rationed) approach to care for a nation struggling for any answer. If all else falls some wise person once said, do what is right. At least begin the journey even if the full maturation of the model may require fundamental reform of this nations curative care system.

1. DR Smith, RJ Anderson, PJ Boumbulian: Community Responsive Medicine, Defining an Academic Discipline, American Journal of the Medical Sciences, 302(5):313-8, 1991

Competing interests:   None declared

Dr. Williams has provided us with a succinct, relevant, and pithy commentary about the past, present, and future of COPC. There have indeed been periodic studies over the years both in the United States and abroad that have demonstrated the value of COPC in integrating clinical and public health praxis. Unfortunately, these COPC efforts have not generally proven to be sustainable. The question is WHY, and Dr. Williams correctly provides us with a number of the reasons including the need for leadership and advocacy, the lack of ongoing financial support, the complexity of busy primary care practice settings, and inadequate empirical evidence that there is an improvement in personal, family, and community health outcomes.

Perhaps, however, there are even deeper issues at play that challenge the basic paradigm of COPC, and call for a more ecological approach that is informed by complexity science and the study of small world networks.(1) In particular, the emergence of the Syndemics Prevention Network at the Centers for Disease Control (http://www.cdc.gov/syndemics) offers a new way of understanding and addressing multiple health disparities and inequities in an increasingly interconnected world.

A syndemic is “a set of linked health problems involving two or more afflictions, interacting synergistically, and contributing to excess burden of disease in a population. Syndemics occur when health-related problems cluster by person, place, or time …. To prevent a syndemic, one must prevent or control not only each affliction but also the forces that tie those afflictions together.” (http://www.medterms.com/script/main/art.asp?articlekey=22591)

Syndemics Prevention Research is by its nature transdisciplinary and multimethod, and also concerned with issues of advocacy and social justice. Questions employed in a syndemic orientation include the following:

• Who is sick (with which diseases)? • Why those people? • Why those diseases? • What can be done to create (or restore) the conditions for optimal health? • Under what circumstances do interventions contribute to improvements in health status and health equity? (http://www.cdc/gov/syndemics/overview-principles.htm)

Annals of Family Medicine readers are encouraged to visit the CDC Syndemics website for more information, but an important question in need of additional discussion is how COPC and Syndemics Prevention Research can/will/should be interfaced with the ten major recommendations presented in the recently published Future of Family Medicine Report (http://www.annfammed.org/cgi/content/full/2/suppl_1/S3).

In particular, what are the boundaries (if any) of practice-based research, how permeable should these boundaries be, who should define (or co-define) the research questions, and whose interests will be served by the findings of the research?

Finally, in a world of increasing commercialization and commodification, will our future research be that of COPC vs. POPC vs. MOPC (i.e., “community-oriented primary care” vs. “population-oriented primary care” vs. “market-oriented primary care”), or some amalgam of the three? It will be important to demonstrate the ROI (“return on investment”) of our family medicine/community-based research efforts. These issues certainly reach far beyond “motherhood and apple pie!”

References

1. Watts DJ. Six Degrees: The Science of a Connected Age. New York and London: W.W. Norton and Company, 2003.

Submitted by: Robert C. Like, MD, MS, Associate Professor and Director, Center for Healthy Families and Cultural Diversity, Department of Family Medicine, UMDNJ-Robert Wood Johnson Medical School

Competing interests:   None declared

Dr. Williams' editorial on the fine article by Plescia and Groblowski cites barriers to the broad adoption of COPC as a strategy to raise the level of community health. I would like to focus on one unrealized opportunity to promote COPC--a partnership between primary care and public health. While primary care traditionally focuses on the health of individuals, it has grown to include "community" as part of its mission. While public health traditionally focuses on the health of populations, in reality, much of its activities involve categorical services to individuals (e.g. TB, STDs, childhood immunizations). Dr. Williams rightly notes the frustration of primary care providers so overwhelmed with practice volume they are unable to fulfill a community health role. Yet that burden would be lightened if primary care and public health were true partners, each contributing their complementary strengths in the service of priority community health problems.

While each system of care needs the other to fulfill its mission, historical divides leave each practicing parallel play. Fears of encroaching on each others' turf, stereotyped views of each others' professional roles, and a reluctance to share resources all reinforce this separation. In fact, in many communities, primary care and public health are physically located in the same facility and even provide the same services but neither communicate professionally, share data nor plan community health efforts together.

In New Mexico, different communities have begun to bridge these divides, stirred by HRSA "Community Access Program" and W.K. Kellogg "Community Voices" funding and prodded by community pressure to use scarce public resources more efficiently. A "health commons" approach has been devised in rural and urban communities to address intractable community health problems such as access to affordable care for undocumented workers, or oral and behavioral health needs in rural communities without dentists or mental health professionals. This approach recognized that these problems cannot be addressed by any single health profession or even by the entire health sector alone, but requires an unprecedented collaboration between different community stakeholders representing different sectors of society. In such an environment, primary care and public health have collaborated to a level not seen in the past, even integrating their clinical space and planning community services together. In such an environment, COPC will find more fertile ground.

Competing interests:   None declared