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Clinical and Community Delivery Systems for Preventive Care: An Integration Framework

https://doi.org/10.1016/j.amepre.2013.06.008Get rights and content

Abstract

Although clinical preventive services (CPS)—screening tests, immunizations, health behavior counseling, and preventive medications—can save lives, Americans receive only half of recommended services. This "prevention gap," if closed, could substantially reduce morbidity and mortality. Opportunities to improve delivery of CPS exist in both clinical and community settings, but these activities are rarely coordinated across these settings, resulting in inefficiencies and attenuated benefits. Through a literature review, semi-structured interviews with 50 national experts, field observations of 53 successful programs, and a national stakeholder meeting, a framework to fully integrate CPS delivery across clinical and community care delivery systems was developed. The framework identifies the necessary participants, their role in care delivery, and the infrastructure, support, and policies necessary to ensure success.

Essential stakeholders in integration include clinicians; community members and organizations; spanning personnel and infrastructure; national, state, and local leadership; and funders and purchasers. Spanning personnel and infrastructure are essential to bring clinicians and communities together and to help patients navigate across care settings. The specifics of clinical–community integrations vary depending on the services addressed and the local context. Although broad establishment of effective clinical–community integrations will require substantial changes, existing clinical and community models provide an important starting point. The key policies and elements of the framework are often already in place or easily identified. The larger challenge is for stakeholders to recognize how integration serves their mutual interests and how it can be financed and sustained over time.

Introduction

Despite widespread agreement about the benefits and economic value of effective clinical preventive services (CPS),1, 2, 3, 4 Americans receive only half of recommended care.5, 6 For example, as recently as 2010, large proportions of Americans were overdue for colorectal cancer screening (47%); influenza (28%) and pneumococcal (33%) vaccinations; and screening mammography (22%).7 From 1999 to 2004, only 25% of adults aged 50–64 years were up to date on all indicated high-priority services.8, 9 This gap in preventive care is more pronounced among low-income Americans, racial and ethnic minorities, and older adults.10

Decades of interventions and policies focused on improving CPS delivery in the clinical setting have achieved modest success. Efforts have included reminder systems, removal of patient financial barriers, patient and clinician education, first-dollar coverage of preventive services, and practice and health system redesign.11, 12, 13 Another strategy to enhance CPS delivery is to shift delivery into the community, reaching people where they live, work, learn, and play.14

Community engagement in CPS is neither new nor unevaluated.15, 16 For decades, media campaigns initiated by public health agencies and community organizations have raised awareness about critical services such as cervical, colorectal, and breast cancer screening. Access to colorectal and breast cancer screening has been made available at community flu-shot clinics, and vaccinations have been administered in pharmacies, churches, and polling places.3, 17, 18, 19, 20 State health departments have operated smoking-cessation quitlines.18 Lay health workers based in the community have also promoted CPS.21, 22 Yet the community, acting alone, cannot be effective in improving delivery of clinical preventive services without the collaboration of the medical community.

Delivery of CPS might be more effective if the efforts of clinical and community systems are coordinated to promote their use. Such a partnership is a logical extension of shared interest in prevention and population health. Better outcomes have been documented when clinicians initiate care, and community programs provide intensive assistance and follow-up, than when clinicians and communities address CPS in silos.23, 24

Such collaboration is useful to promote screening tests and immunizations, but moving outside the clinic is essential to meaningfully address lifestyle issues. The socioecologic model of health, and the behavioral science literature, demonstrates that personal choices are heavily influenced by broader social, economic, cultural, health, and environmental conditions.25, 26, 27, 28 Clinician counseling to change lifestyle cannot realistically be effective without being coordinated with efforts in the community to create living conditions that support healthier choices. The medical community is part of a larger community ecosystem involving multiple sectors that, by working together, can achieve “citizen-centered” approaches to such conditions as tobacco use, obesity, and other modifiable risk factors.29

Streamlining parallel delivery systems would also be expected to increase efficiency and thereby contribute to the “triple aim” of controlling costs along with improving the patient care experience and population health.30 The inherent logic of this argument was recognized 2 decades ago, notably by the leaders of the Medicine and Public Health Initiative31 and subsequent calls for action,32 and recent years have brought increasing calls to integrate clinical and community care systems.33, 34 However, the field can point to only a handful of working models of such integrations with published evidence of improved quality of care or health outcomes.35

Many blue-ribbon panels are arguing that now is the time to broadly establish clinical–community integrations.36, 37 The Patient Protection and Affordable Care Act (ACA) called for reorienting health systems toward increased integration through the formation of accountable care organizations,13 but commentators note the need for integration with the community to successfully improve population health.38, 39 Primary care specialties have embraced the concept of the patient-centered medical home, or what was once called community-oriented primary care.12

The Health Information Technology for Economic and Clinical Health (HITECH) Act invested in an electronic architecture that can link information systems across clinical and community care settings.40 This concept of broadly integrating public health and primary care was advocated in a recent IOM report.13, 36 Integration also provides an architecture to build on the growing movement in active stakeholder engagement—of patients as engaged partners in shaping their care experience and of the community as partners in improving public health—and provides a vehicle for bringing these threads together.41, 42, 43, 44, 45 Payment reforms to shift traditional fee-for-service reimbursements to global risk-based payments for improved outcomes offer a potential financial model for clinical–community integrations.

What is the next step? How might everyday clinical and community organizations establish and sustain a local model for integrating care and apply it to prevention?46, 47 Multiple national organizations and thought leaders are currently developing a strategic plan to provide the answers. The current paper describes a conceptual framework that suggests how clinicians and community organizations might integrate care on a national scale and apply it to prevention.

Section snippets

Methods

The CDC’s Healthy Aging Program issued two major reports identifying a substantial deficiency in CPS uptake among older Americans.43, 44 Under the auspices of the National Association of Chronic Disease Directors, guided discussions with 25 national experts on prevention were conducted to understand the opportunities and challenges to increase the use of CPS among adults age 50 and older. A recurrent theme that emerged from the interviews was the need for integrating the extant clinical and

Outlining the Stages of Preventive Services Delivery

Clinical preventive services are often defined as screening tests, immunizations, health behavior counseling, and preventive medications.1 But prevention is more than simply ordering a test, administering an immunization, counseling a patient, or prescribing a medication. Effective delivery requires much more, including (1) engaging individuals in need of services; (2) administering the CPS; and (3) following up (Figure 1).52

Engagement encompasses all that is necessary before administration,

What Will It Take to Implement Clinical Community Integrations?

Although creating an effective integrated clinical–community care system will require substantial changes, it is possible to build on existing clinical and community platforms to augment delivery of preventive care without undermining the role of clinicians or existing programs. There is substantial national interest and a palpable momentum to create clinical–community integrations. Policies and other elements of the framework are already in place, but the field is now turning to specific next

Conclusion

Just as U.S. society is committed to caring for acute and chronic illnesses, a similar commitment for prevention is important. Greater success in preventing disease through collaboration may not only save lives but may also reduce disease burden and thereby help curb the rising costs of health care. There may be challenges in operationalizing a model that proposes to engage clinicians and community organizations, spanning personnel, national and state leaders, local leadership, and funders,

Acknowledgements

This publication was supported by Grant/Cooperative Agreement Number U58DP002759-01 from the CDC to National Association of Chronic Disease Directors (NACDD) and Michigan Public Health Institute (MPHI). Work was also supported by the CTSA Grant Number ULTR00058 from the National Center for Advancing Translational Sciences (NCATS). Its contents are solely the responsibility of the authors and do not necessarily reflect the views of the CDC, NACDD, MPHI, or NCATS. The authors specially

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