Community Health

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[edit] Community Health

Loren Leshan

Regardless of ever-changing health care delivery systems and beliefs, the main question guiding our medical practices continues to be ``How do we provide the best care to all of our patients?<sup>[1]</sup> The purpose of this chapter is to point to ways that ``new imperatives in medicine help us realize this oldest and best desire of our profession. Community medicine, which draws on the gold standard of population studies, offers an underutilized source of answers to that question.

Rather than being a buzzword or a fad, community medicine is intrinsically a part of what good doctors do, have always done, and will continue to do. It leads not only to better health for the patient and a stronger medical practice but also to improved satisfaction for the practitioner.^[2] The philosophies and systems approach of community medicine offer ideas for potentially far-reaching public health ventures and also practical methods to improve health care in the community of one's clinical practice.^[3][1] Community health practice, then, is a matter of enlightened patient, community, and self-interest.

This chapter gives the broadest overview of community health in the context of an ``average physician's practice in the United States. Instead of concentrating on providing a template for a formal system or a theoretic framework, it shows some of the ways physicians can use population data, community health principles, clinical guidelines, and evidence-based medicine to improve their everyday practice patterns, as well as to improve community health.

[edit] BACKGROUND

Community health practice is deeply embedded in the traditions of medicine.^[4] One of the basic principles of community medicine is that for primary care physicians to provide effective health care over the long run, they need to view the whole panorama of their patients' lives, not just the isolated disease that brings the patients into medical care. This means integrating into health care an understanding of patients' families and the communities that constitute their physical environment and influence their beliefs, behaviors, and opportunities.

Medical history, lore, and personal experience are rich with stories of physicians making a difference in their communities. Both Aristotle and Maimonides stressed the importance of the environment and family. A more recent role model was William N. Pickles.^[5] Pickles studied the epidemiology of disease in his country practice in the Aysgarth Rural District of England. Like his colleague, Sir James MacKenzie, Pickles was able not only to care for the residents of his communities, but also to study the epidemiology of their illnesses. He understood that the context in which his patients lived, their community, was inseparable from their health concerns.

[edit] Changing Scene

Primary care in the United States has focused on primary patients, and most health care delivery models, although currently in the process of change, have been designed for individual health care, while public health departments have shouldered much of the responsibility for the health of populations. These departments have effectively, efficiently, and at low cost monitored the environment. They have spearheaded efforts to control environmental pollutants such as lead, disease vectors such as contaminated water, and outbreaks of infectious disease such as polio.

The separation of public and private health is artificial, however, and does not always lead to the best health care.^[6] With changing social and financial structures, physicians are learning that by networking with community agencies, they can leverage their own effectiveness in preventing and solving problems for their patients.

[edit] REAL LIFE NEEDS LEAD TO COMMUNITY MEDICINE PRACTICES

Most physicians enter the world of community medicine when they identify a problem that is occurring commonly among patients in their community, and realize that individual treatment plans are not achieving the results they would like. The following composite vignette exemplifies how community health practices can evolve out of a recognized need. Late one Saturday night, Dr. Gomez admitted a very sick asthmatic woman to the intensive care unit (ICU) for possible intubation. On his way home, after spending several harrowing hours with his patient, Dr. Gomez reflected on his many poorly controlled asthmatic patients and his fears for their lives. He wondered why it was so difficult to control their symptoms, prevent exacerbations, and manage their chronic asthma. The next morning at church, a group of parishioners overheard him expressing his concerns to their minister. They became interested and asked if there was anything they could do as a group of volunteers. The minister suggested that the doctor ask his patient what might be helpful. Later, when the patient was recovering, Dr. Gomez talked to her. She told him that the hardest task for her was creating the clean home environment described in the patient care booklet. Vacuuming and dusting in her apartment led to coughing fits and midnight emergency room visits. She was not sure the landlord would let her remove the carpeting.

One of the volunteers, the mother of an asthmatic child, was experienced in ``environmental control. With a group of volunteers, she visited the patient with buckets and mops in hand. They talked to the landlord, who agreed to let them take up the carpeting and paint the floor. The volunteers not only cleaned and ``decluttered the apartment, but also helped find appropriate bedding. After the initial cleaning, a small group of volunteers spent 2 hours a month cleaning for the patient. She compensated them with babysitting, cooking, doing laundry, and other tasks that did not trigger her asthma.

The patient asked Dr. Gomez if she could help form a support group for asthmatic patients in his office. Dr. Gomez used his billing system to generate a list of his patients with asthma and sent them letters inviting them to the first meeting. With the help of clinic staff, the group created a patient diary to record peak airflows. Most patients had been told to measure their peak flows but few had been told what to do with the information.

Dr. Gomez then realized that he had given very few patients a ``plan of care to help them decide what to do when their peak flows were low. Although the National Institutes of Health (NIH) has disseminated asthma clinical guidelines suggesting the use of asthma ``plans of care, Dr. Gomez had not implemented them. The support group and nursing staff helped Dr. Gomez develop a patient education sheet to give to patients with their individual ``plan of care. The asthma support group was also successful in starting a cleaning cooperative. They helped each other maintain clean environments in exchange for services such as babysitting. Over the next 12 months, Dr. Gomez noticed that the patients in the support group experienced fewer asthma exacerbations and fewer symptoms.

This story illustrates several ways that physicians can work within their practices to build a healthier community of patients, as well as to improve patient care by following clinical guidelines. By focusing on common concerns and using common resources, the asthmatic patients and their physician were able to work together to manage a common condition that impacted all their lives. In time, the support group, physician, and nursing staff shared their asthma control program with others outside the practice through their religious organizations, health department, and schools.

[edit] DEFINITIONS

Populations are groups of people who can be described by epidemiologic or demographic factors such as infant mortality rate, literacy rate, economic level, age, and employment status.^[7] Other important aspects that impact population in geographic communities are environmental factors such as air and water pollution; housing stock; and availability of opportunities for recreation, education, or employment.

A community is a group of individuals who are conscious of a shared unifying trait, such as common geographic boundaries, culture, history, language, age, race, religion, or special needs.

Community health is defined by population data: rates of infant mortality, fertility, and other vital statistics usually collected by the census bureau or health departments. Managed care organizations and other insurers can facilitate both the collection of data and the improvement of these rates. They can supply additional information about hospitalization, immunization rates, physicians' prescribing practices, and use of diagnostic tests.^[7] These data can be used to improve clinical practice patterns and to monitor and improve patient outcomes. This chapter includes some ways this kind of population data can be used to improve physician practice patterns, as well as community health (Box 10-1).

A physician's practice is, in a sense, a special population,^[8] unified by being served by the practice. The population of both patients who have presented for care and those who have not been seen is called the denominator. Numerators include any subsets of the denominator.

A healthy community would be one in which members interact and cooperate in helping each other grow, learn, and succeed. The physical environment would be nontoxic; health statistics and economic conditions would be favorable for all members of the community. Such a community would be considered a desirable place to live. Clearly, physicians can serve important leadership roles in improving the health and well being of the community and its members.

[edit] DEVELOPING COMMUNITY HEALTH CARE

[edit] Community-Oriented Primary Care

During the last 30 years, the World Health Organization (WHO) and the community health center movement have supported broad efforts to improve the health of populations through redesign of health care delivery systems. The method most often suggested for integrating traditional public health with primary care in order to provide more comprehensive and coordinated services on a community level is community-oriented primary care (COPC), also called responsive primary care (Box 10-2).

Although COPC can be used to apply epidemiologic and evidence-based medicine to a specific population in a specific practice, in reality most physicians lack the time, training, and incentive to fully implement the model as originally conceived by Kark.^[9] Fortunately, it is not necessary to implement the entire model to realize benefits in most practices.^[10] Pathman has found that most doctors do incorporate elements of community medicine into their practices. These commonly applied practices include (1) identifying and intervening in the health problems facing communities, (2) responding to the particular health issues of local cultural groups when caring for patients, (3) coordinating local community health resources in the care of patients, and (4) assimilating into the community and its organizations.

Although the first dimension may seem daunting in the press of daily practice, the second and third dimensions, responding to local cultural groups' health needs and coordinating resources for particular patient needs, are common practices. The fourth dimension, assimilating into the community and its organizations, often happens naturally as physicians pursue their personal and family lives.

[edit] Examples and Benefits

[edit] Identifying and Intervening in Health Problems Facing Communities.

A common current practice involves routinely screening for lead in areas where the homes of most of the physician's patient population were built before 1978. Less common, but eliciting a response in places where the threat is high is recognizing a pattern of cancers common among workers at a local workplace and then identifying exposures to carcinogens. The physician would additionally help in efforts to eliminate the particular carcinogen from the workplace or lead from homes.

[edit] Responding to the Particular Health Issues of Local Cultural Groups When Caring for Patients.

Examples of responsiveness include providing patient education materials that are culturally and linguistically appropriate to the background or educational levels of one's patients, or having evening or Saturday hours to accommodate the work schedules of the patient population. Such efforts build physicians' practices and patient adherence by increasing patient satisfaction.

[edit] Coordinating Local Community Health Resources in the Care of Patients.

Examples of ways in which physicians coordinate resources in the care of patients include referring chemically dependent patients or survivors of domestic violence to appropriate resources.

[edit] Assimilating into the Community and its Organizations.

Such common and rewarding activities as getting involved with the efforts of one's personal religious organization or the school system to address teen sexuality or substance abuse are assimilating activities. Physicians not only find their niche in their own communities through assimilation, they also provide leadership and expertise. The vignette earlier in this chapter also illustrates physician involvement in Pathman's dimensions. Dr. Gomez had joined one of the local community churches. He used that involvement to help coordinate local community health resources, in this case other church members. He responded to the health needs of a special group in his practice (people with asthma) by forming a support group in his community. Asthma was identified as a common health problem in the community. Subsequent intervention included educating children, teachers, and parents in the schools, and assisting in communitywide efforts to monitor and decrease the air pollution.

[edit] COMMUNITY MEDICINE AND QUALITY MANAGEMENT

A systematic methodology for optimizing patient care for common problems in primary care is described by Rivo.^[1] He uses a four-step method (Box 10-3) and employs the principles of continuous quality improvement (CQI) or total quality management (TQM).

The vignette demonstrates the use of these steps. Dr. Gomez chose a common condition and identified patients within the practice with that condition (steps 1 and 2). He used NIH asthma care guidelines to guide the care of patients (step 3). The patient support group helped to define measurable outcomes by developing a patient record and plan of care. Over time patients were given peak flow meters and an individualized plan of care; they seemed to improve and had fewer symptoms and exacerbations. These were measurable outcomes, which could have been used to monitor and improve care (steps 3 and 4).

Congestive heart failure and low back pain are examples of other conditions lending themselves to this approach. This clinical system can also be used to improve the delivery of prevention services such as immunizations or screenings (Box 10-4). By following a systems approach, physicians can lead the ``community of their practice to improve the clinical care of their patients.

[edit] ARENAS OF INVOLVEMENT: WHERE COMMUNITY MEDICINE TAKES PLACE

Reif and others have categorized physician involvement in their communities as levels or arenas of involvement^[11] (Fig. 10-1). The first arena is the examination room. Here, in assessing and planning care, the physician must be aware of population characteristics, patterns of illness, risk, and injury. In getting to know the communities they serve, good physicians are aware of common cultural patterns, occupations, health-seeking behavior, and lifestyle. The good physician uses this awareness in developing diagnoses as well as care plans. Follow-up visits monitor the effectiveness of this approach.

Figure 10-1 Arenas of involvement in community medicine. (Courtesy Christopher Reif, MD, MPH.)

The second arena is the clinic or health center. There, the focus is on the population of patients in the practice, whether they have been in the center for care or not. By following evidenced-based guidelines, physicians can ensure the best care for all the patients in the system. Using CQI and data from billing or insurers or demographic sources, physicians can monitor and improve primary care services within their practice system, much as Dr. Gomez did.

The third arena is the network of agencies and organizations within the neighborhood of the practice used to provide ancillary services such as counseling, home care, drug treatment, day care, domestic violence shelters, and hospice and other patient care needs. By knowing and working with this network, physicians are better able to meet the many needs of their patients. A good working relationship with the agencies within the network means that services are coordinated more efficiently and at lower cost, allowing physicians to leverage their own effectiveness.

An example of this might be managing the survivor of domestic violence identified at a patient visit. The physician usually does not have sufficient time in a busy day to do more than to identify a survivor of domestic violence. However, by knowing the network of agencies serving the needs of this population, the physician can refer the patient to further sources of help. Obviously, this does not mean the physician is handing the patient off, but rather that he or she is referring patients to other experts, while continuing the supportive, ongoing physician-patient relationship. This network works best if all providers work together to evaluate and improve their services.

On a community level, physicians can respond to the public health concerns by engaging in strategic planning and health campaigns with officials and community leadership. The impact of these efforts is measured by epidemiologic data. Decreasing teenage pregnancy or new human immunodeficiency virus (HIV) infections through community education campaigns is an example. The effectiveness of such efforts can be measured by monitoring the rates of teenage pregnancy and new HIV cases, which may be done by the local board of health. In broader arenas, physicians can help develop and support policies that improve the health of the state or nation, or even the world. In times of increasing health care costs, physicians can use community medicine principles to help ensure appropriate distribution of diminishing resources based on epidemiology and effectiveness.

[edit] COST-EFFECTIVENESS and ETHICS

[edit] Maintaining Ethical Balances When Needs Compete

Increasing value and efficiency are not the only challenges arising from economic conditions. As health care has shifted from fee-for-service toward capitated delivery systems, physicians are increasingly being expected to maintain an ethical balance between the needs and resources of patients and families and those of communities. This mandate is still informal, and the means to accomplish it are unclear. Furthermore, most physicians have not been trained to provide health care based on community needs and outcomes.^[12] However, changes in the financial structure of the health care delivery system have once again underscored the importance of the community and family context, which shapes our patients' lives and their illnesses.

[edit] Championing Cost-Effective Health Promotion

The shift to integrated health delivery systems and managed care has also shed light on the use of community health principles to help guide the practice of medicine. A notable example is the use of technology. The rapid development of medicine from technology to pharmaceuticals has given physicians a wide and confusing array of choices for diagnosis and treatment. It is often unclear which choice will lead to the best outcomes for individual patients, let alone society. By basing the use of technology, pharmaceuticals, and treatments or interventions on their proven effectiveness in and across populations of people, physicians should be better able to control costs while maintaining or improving quality.^[1]

In fact, randomized clinical control trials, the gold standard for evaluating technology and pharmacology, are population studies. Although the study population is usually adult men, physicians can apply their knowledge of their practice population's characteristics in deciding which tests or treatments are most useful in individual patients. For instance, the use of screening tests such as mammograms and cholesterol is based on the incidence of these cancers in the age and ethnic group of the particular patient. Another example is deciding when and whether to screen for diabetes. The increased prevalence of type 2 diabetes in African-Americans, Native Americans, and Mexican-Americans argues for screening patients in those populations.

By learning community characteristics, physicians can develop outcomes-oriented medical practices to enhance health and health care in both the short and long run. Although managed care organizations and insurers sometimes focus on short-term profits, ultimately it is cheaper to prevent disease and promote health, both of which are most successfully accomplished in a context of community health. However, viewing patients as members of a population has not always been the priority of physician or insurer. People currently shift in and out of different health maintenance organizations and physicians' practices, giving an apparent disincentive to consider prevention and population needs. Yet the changing groups continue to be drawn from the same geographic areas and community subsets in those areas, and overall population characteristics do not change as rapidly as the individual names do. By applying their understanding of the demographics and other characteristics of the populations they serve, physicians can improve the health of those communities. By documenting the outcomes of their efforts, they may also lead payers to realize the lower long-term costs and, perhaps, greater profits as patients benefit from prevention, care of chronic conditions, rehabilitation, and health maintenance.

[edit] Filling Gaps in the Safety Net

Finally, as the existing social support network for the poor and uninsured is revised, we look increasingly to public-private alliances to coordinate systems to provide health and social services more efficiently and effectively. Because prevention, diagnosis, and management of illness and health are enhanced by the functional interconnectedness of strong communities, physicians can work with others to coordinate services and resources and to build stronger and healthier communities for the benefit of all.

[edit] SUMMARY

This chapter gives a brief overview of community health. It does not intend to provide a template for action or a theoretic framework. Instead, it points to ways a ``new imperative in medicine helps realize and lead us to the oldest and best desires of our profession: giving each and all of our patients the best health care possible. Hopefully, these ideas will be useful to physicians in improving health delivery systems and the health of communities.

[edit] REFERENCES