Core Concepts in Community Based Care

Community primary care

Dr B. and several nurse practitioners take care of the health needs of a group of small villages in a rural, arid region. About ten years ago the health team began to see sporadic cases of a disfiguring rash that appeared on exposed skin areas, composed of single or multiple oozing, erythematous ulcerations. These wounds showed up spontaneously and went through cycles of crusting and re-ulceration over the course of several months, until they finally healed, generally with significant scaring. Through biopsy they were diagnosed as cutaneous leishmaniasis, a protozoan infection spread by small, biting, sand flies of the genus Phlebotomus. As the years progressed, more and more cases occurred in all the villages, commonly on the faces of children, often leaving unsightful scars.
In response to community pressure, the public health office in the area began to spray houses with pesticide, attempting to kill the sand flies. Much to the consternation of residents, not only did more cases occur, but also the pesticide turned out to be DDT, a harmful and largely outlawed pesticide that lasts in the soil for decades. Several individuals formed an ad hoc committee, coordinated with the medical and nursing staff. After a joint public meeting, it was decided to take local action.
A national authority on the disease and its vectors was invited to an open seminar. He described the epidemiology, pattern of infection, and natural history of the disease. As it turned out, the reservoir for the sand fly carriers were rodents that lived in a specific type of reed-like bush that had recently increased in prevalence as irrigation had increased. More effective and less ecologically toxic solutions than spraying the houses with pesticides were suggested. These measures included changing community behaviours, such as sitting on the lawns near sunset when the sand flies' activity level was highest, using insect repellents, fixing screens, and removing the habitats of the rodents close to the communities.
Through further planning and collaboration between the medical staff and the community group, a system of tracking new cases was set up. In addition, a grant was written, and funds were received from the local council for removing rodent habitats. Individuals were trained for the job of identification and elimination. A public education campaign, spearheaded by the medical staff, informed the communities about what could be done. Pesticide use dropped by 80 per cent, and within a year the number of cases diminished by 40 per cent.

Primary care and the community
As this anecdote vividly points out, the aetiology, diagnosis, and management of health and disease are often not limited to the office or hospital setting. Medical science and its practitioners, however, tend to follow a linear, cause and effect model—pursuing single biological determinants generally within the body of the patient, and then isolating and attacking the offending agent. This approach tends to lead in turn to an exclusive focus on the individual within the office or hospital setting as the centre of attention. Thus, for example, strategies for preventing cardiovascular disease among primary care physicians emphasize reducing cholesterol levels with diet or medication, rather than changing the composition of locally consumed foodstuffs or organizing community walking groups. Low back pain is treated with analgesics and muscle relaxants rather than redesigning work environments.
When the issue is examined closely, it is apparent that most conditions are the result of complex interactions among a host of factors. Success with treating diseases requires that we begin to think of health and illness, and our roles in treating ill health, as extending from the practice into the community and society. Tuberculosis may be caused by a single pathogen, but poverty and crowding are just as important when considering its impact and spread. AIDS may be a result of infection with HIV, but socio-economic and behavioural considerations largely determine who becomes infected and how the disease progresses. Indeed, behavioural, community-based, and societal factors play key roles in much of human disease and have increasingly assumed dominant roles in determining health and illness around the world. Without an integrated approach at all levels of disease causation—the individual, family, community, and society—it is unlikely that significant progress in improving health can be made.
The primary care clinician is ideally situated to adopt and act on this broader perspective. Functioning at the interface between the individual and the health care system, the primary care provider is also best positioned to see the relationships between the person, the disease and the community. The first and perhaps most significant step in the process is to begin to ‘think big’—to look beyond the patient sitting across from you. This demands a change in frame from the usual focus on the individual patient or family to the larger community and social ecosystem. Such a shift may seem more natural when one realizes that only a small proportion of persons in the community with symptoms actually reach the primary care practitioner,(1) and that many epidemiological risk factors (e.g. exposure to pollution, vectors of disease, exercise or eating habits, etc.) are shared among members of a community.
There are other reasons for the primary care practitioner to include the community in efforts to improve the health of individuals. Treating multiple persons with the same problem is inefficient and unsatisfying when critical causes outside of the office walls are not addressed. Extending preventive services from the practice to the community can reach people not otherwise receiving care. By extending the reach of preventive care, the overall costs of care for a community are ultimately reduced. Many would argue as well that apart from these pragmatic reasons, there is a moral argument for a community to be included in the planning and delivery of its health care.
What is ‘community’?
While the word ‘community’ may seem as if it needs no explanation, when viewed from the primary care practice, community can have several meanings. Traditionally, it has meant the geographic area from which a practice's patients come. Many practices, though, serve a community that is better defined by its cultural or socio-economic characteristics (ethnic group, low-income, etc.), and that may or may not also have geographic definitions. Still other ‘communities’ may be defined by their common source of employment, or by shared values or religious beliefs. Future ‘virtual’ communities, some of which exist today, may be defined by their interconnection on the Internet or their use of similar transportation or communication. Occasionally, it may be difficult to describe the community with which a practice is affiliated, and an alternative is to define a practice's ‘community’ as its active and inactive patients together.(2)
Regardless of the way in which a practice defines its community, it is important to remain aware that a community is not a single, homogeneous entity. It is a dynamic composite of groupings that are constantly shifting. One segment of the community may be most concerned with the health effects of substance abuse, and later come to focus on domestic violence as a priority, while another portion may be more impacted by cardiovascular disease. Community leaders, both informal and formal, may differ in their views not only among themselves, but also with portions of the community most affected by particular health problems. For the primary care clinician, recognition of the fluid nature of communities is key to successfully working outside of the office setting.

Types of community involvement
Primary care practitioners can become involved in their communities in a number of ways. Pathman et al. have provided a convenient categorization of some of those ways.(3) They describe four types of involvement: (a) co-ordinating community health resources on behalf of patients; (b) providing culturally relevant health care; (c) assimilating into the community and its organizations; and (d) identifying and intervening in a community's health problems.(3) Each type of involvement along this spectrum is important, but it is the final category for which generalists, more than other clinicians, are particularly well suited. This final category might also be initiated by members of the community itself.

History of generalist involvement in community health
Generalist physicians have long played a key role in recognizing and acting on community patterns of disease. Pickles, a British generalist using observations from his country practice in the early 1900s, was able to elucidate key aspects of the epidemiology of hepatitis A through his experiences in his community.(4) Halley Stott, a generalist practicing in a Zulu area of South Africa, recognized the critical role of nutritional deficits among his patients, and began a community gardening programme and established a non-governmental organization dedicated to improving the nutritional status and health of local residents.(5) Also in South Africa in the 1940s, Sidney and Emily Kark and associates developed primary care practices that integrated community- and practice-based interventions on high-priority health problems using a model that later came to be known as community-oriented primary care (COPC).(6) Key members of this group later established similar models in Israel, and influenced the development of the community health centres initiative in the United States of America.(7) Elsewhere in the United States of America, primary care of Native Americans has often been based on similar linkages.(8)

Community-oriented primary care
With increasing realization that many of the causes of ill-health have roots in individuals' behaviour, community, and society, there has been a growth of interest in extending primary care to impact all levels of causation of ill-health. Community-oriented primary care, as an example of such an approach, has drawn particular interest.(9,10) Community-oriented primary care is best thought of as a process for integrating primary care practices with their communities. As depicted in Fig. 1, COPC begins with an assessment of community health needs and resources by a community and a primary care practice. Interventions both in the community and in the practice are developed for priority health needs, and the effects of the interventions are then evaluated.

Fig. 1 Diagram of the community-oriented primary care process.


Continued Below

Many examples of steps of the COPC process have been published. One of
the more complete examples of the entire COPC process was described by
Bayer and Fiscella.(11) In an inner-city community and associated
family practice in Rochester, New York, understanding about diabetes,
tobacco addiction, and cervical and breast cancer screening were
determined to be priority health needs by a patient advisory committee
working with the practice staff. Combined practice and community-based
actions targeting each of these areas of concern led to significant
improvements in the markers for each condition.
Examples such as this and others published from around the world have spurred interest in expanding the application of the COPC model. By extending prevention and education from the practice into the community, COPC offers the opportunity to bridge the gap between public health and primary care, while increasing the role of community members in decisions about their health care. In moving beyond the office setting, COPC can reach persons not otherwise being seen in primary care. Finally, by targeting efforts at priority needs, COPC also offers the promise of efficient
utilization of scarce resources.
Despite its very attractive potential, COPC has not yet been widely adopted. A key problem has been financing. Despite the potential for long-term cost savings, most health care systems have not provided adequate compensation for essential activities of the process, such as the community needs assessment. Furthermore, a number of examples of COPC in the literature have described a labour- and resource-intensive process that has seemed unachievable to many busy primary care practitioners. Coupled with the fact that many clinicians feel ill-prepared to carry out some of the activities of the process, and that most examples have been driven almost entirely by energetic clinicians, COPC has seemed unapproachable to many.
Recent developments may make COPC more practical, however. Trends in financing of health care are beginning to create incentives for improving the health of populations as well as that of individuals.
Implementing COPC as a teamwork effort in which not only the primary care clinician but also other professionals and non-professionals throughout the community take part makes it less dependent on a single person to drive the process. Such strategies make it more realistic for primary care clinicians to engage and succeed in COPC.
Toolsfor COPC
Another key element for putting COPC within reach of more primary care
clinicians is availability of feasible methods to carry out COPC in busy primary care practices. Conducting a community needs and resources
assessment is at the heart of the COPC process, yet until recent years
this process could be quite time consuming and expensive. Substantial
progress has been made in recent years in this area.
To fully understand the needs and resources of a community requires both
objective health data about the community as well as perspectives of
community members; put another way, it requires both quantitative and
qualitative data about the community. These methods should be seen as
complementary, allowing a richer understanding of health needs and resources. On the quantitative side, it is important to know how well the health problems seen in the practice reflect those that are present in the broader community. Are there problems in the community that are not being seen in the practice, suggesting the need to modify the practice in some way? It is also important to understand the
distribution of health problems through the community. Are there portions of the community at higher risk for certain health conditions or in greater need for particular services, suggesting the possibility of targeting outreach and intervention efforts to that segment of the community?
Rapid developments in health information technology are reducing both the time and cost of quantitative community assessment. A particularly dramatic advance has been the linking of health indicator data with geographic location. When this is available, geographic information system software can now produce maps that clearly depict the distribution of these indicators in a local area. With this capability, primary care practitioners can compare practice and community patterns of health and disease as part of the process of community assessment. As more of these community data become available to local users through the Internet, the feasibility of using it as part of a COPC community assessment improves.
On the qualitative side of the assessment, it is often important to understand community member perspectives on why particular patterns of disease or utilization exist, how much importance is attributed to specific
problems, or on how to best resolve identified health problems. These
qualitative data can often produce unexpected insights. Community
members are often aware of or able to mobilize resources to assist with a problem in which the clinician may not be. Several methods of systematically, yet rapidly, gathering information from community
members have been developed. These approaches include focus groups,
mail and telephone surveys, participant observation, and key informants. Each of these approaches has particular strengths and weaknesses; they are most effective when matched to informational need and community type.(12) Various rapid appraisal/assessment techniques have also been developed that provide quick preliminary understandings of a situation.(13,14 and 15)
Getting started
The essential first step is to begin to think of the problems that are being seen in one's daily practice in their broader context. How is this patient's illness related to the community and how can action at the community level
improve the situation? Look for patterns in the problems being seen, and for potential opportunities to link preventive care in the practice to action in the community. Examine the practice population, its demographic characteristics, and the common or unusual problems seen in the practice. Speak to patients about the community and its health concerns.
In looking beyond the practice, it is important to be realistic about one's goals at the community level, considering the time and resources available. Although the steps in conducting COPC may be similar in theory regardless of location, much of the process of linking the practice and the community is highly dependent on local circumstances. Identify partners to work with who bring interest, resources, or expertise to the effort. Examine what health-related data about the community are readily available and relevant. In many locations, census data may be the most readily available and can
provide key information with which to profile the practice. In other areas, a broader range of health data may be available, such as specific disease rates, data on hospitalized patients, or on public health interventions. Target your search and use of community data to specific questions, and spend time developing mapping capabilities only if they will provide essential information.
The process of gathering views of community members should be guided by the type of information needed and the portion of the community for which the information is most relevant. To enhance the validity of the information obtained, more than one approach to gathering the data should be used where possible. However, it is important to balance efforts to obtain valid,
unbiased qualitative data with the need for practicality in collecting
that data.

In creating a picture of the community's health needs and resources
through these processes, it is also important to recognize the limits of the data. Quantitative data about small geographic areas are subject to random variation, and patterns of distribution of health indicators may be more apparent than real. Qualitative data are prone to selection bias since not all community members will be represented. Nevertheless, keeping these limitations in mind, this information can still give the primary care clinician valuable direction.

Generally, a sense of priority will become apparent as a result of assessing the needs of a community, or the interests of the clinician will drive further work aimed at a specific need. However, it is important that members of the community be involved in prioritization, planning, and implementing of
an intervention. A teamwork approach will not only enhance the feasibility of extending efforts of the practice into the community, but will also assure that the plans are well fitted to the community.

The steps of getting involved in the community's health can be summarized with the acronym CAP-IT:

• Collect information.
  
• Assess the problem, its aetiology, impact, and consequences.
  
• Provide interventions in a systems manner.
  
• Involve the community in every step.
  
• Tight follow-up.
  

The process starts with collecting information—keeping your ‘ear to the
ground’ for diseases, risk factors, or threats that concern you, your
staff, and the community you treat. These hints may come in the form of
sudden insights, as the shaping of a pattern from seemingly random
occurrences. Assessing the problem involves taking a wide overview of the aetiology, impact, and consequences. Searching for interconnections is critical, both between individual, family, and community factors, and between types of risk factors. For example, reducing the community
burden of asthma may involve examining the prevalence of smoking,
adherence to medical regimens, access to services, and even sources of
air pollution.

The practitioner must also think on a systems level in regard to interventions. The community should be involved in every aspect of the plan, from identifying problems, setting priorities, choosing interventions, executing plans, and carrying out follow-up.
Follow-up is critical since outcomes are the ultimate measure of success and rarely can problems be solved with a single ‘magic pill’ or one-time intervention. Evaluating the process and impacts of interventions can lead to modifications in the approaches taken, to enhanced efficacy of the intervention, and to identification of opportunities for additional interventions.



Population-based care


The role of the community throughout the process described above is a key
distinction between COPC and what has been termed population-based care. While the latter, in common with COPC, aims to link the care of the individual with the health of the larger community, or population, in population-based care, the community plays a more passive role. Prioritization, planning, and interventions are predominantly in the control of health care providers. As a concept that has risen with managed care, population-based care has its roots in efforts to use incentives to achieve desired health outcomes.



Related developments


Recent developments in the United Kingdom have served to strengthen the link between primary care and the community it serves. Traditionally, the
work of general practitioners was focused on a small geographical catchment area, within which relationships with social, housing, and
education services were often patchy and erratic. In an attempt to integrate these services with primary care, Primary Care Trusts are being set up in the United Kingdom, based on population units of around 100 000, in which the administrative geography of medical and social care are co-terminous, facilitating communication and interaction between agencies. Patient participation in service appraisal and planning will be important within Primary Care Trusts, which, for the first time, will have a commitment to providing integrated primary and secondary care services for a substantial, defined population.(16,17)

Beyond the United Kingdom, the World Health Organization in 1999 began its ‘Toward Unity For Health’ initiative. This worldwide programme is
aimed at promoting models of health care that integrate primary care
with community-based and relevant initiatives.



Summary

A new paradigm is slowly emerging in health care. Behavioural, community,
and societal factors are becoming predominant influences in human health and disease at the same time as increasing scrutiny is being given to how health care resources are being used. Together, these trends are leading to a rethinking of the long-standing split between primary care and public health. Health and health care are increasingly recognized as a continuum running from the molecular to the societal levels. By adopting this new perspective and by applying simple tools for action at the community level, primary care practitioners can have a greater impact on the health of the people they serve.