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Osborn 1986 TEACHING COMMUNITY-ORIENTED PRIMARY CARE (COPC): A PRACTICAL APPROACH, Traducciones de Medicina

Universidad Antonio Nariño (UAN) - PastoMedicina

Articulo del 1986 para seguimeinto de cuidado comunitario

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Journal of Community Health Vol. 11, No. 3, Fall 1986
TEACHING COMMUNITY-ORIENTED
PRIMARY CARE (COPC):
A PRACTICAL APPROACH
Emilie H.S. Osborn, M.D., M.P.H., Norman Hearst, M.D., M.P.H.,
Joyce C. Lashof, M.D. and W. McFate Smith, M.D., M.P.H.
ABSTRACT: To improve education in community-oriented primary
care (COPC) and to promote its practice in the community, the Univer-
sity of California's School of Public Heahh in Berkeley and School of
Medicine in San Francisco are collaborating in an innovative program
in cooperation with several federally-funded community clinics in the
San Francisco Bay Area. The School of Public Health designed a COPC
track t0r graduate public heahh students from various departments of
the school who wished to work in community heahh care. The track in-
cludes a seminar given in the spring of the students' first year in which
COPC theory is taught and teams of students working with a faculty ad-
visor and a clinic preceptor design COPC projects for tbe primary care
sites. These projects are then implemented in the summer and fall by
students who elect to use this experience to satisfy their fieldwork re-
quirement. This paper is a report of the first year's experience with this
collaborative effort,
INTRODUCTION
Community-oriented primary care (COPC) represents a marriage
of public health and primary care. The term, first coined by Sidney Kark,
is an approach to the primary health care of a community or defined
population using epidemiologic methods to determine the priorities for
health care and designing appropriate interventions that improve the
health of the population.l~ These interventions must be evaluated in of
der to modify programs--as a feedback loop. The skills necessary to im-
plement COPC, in addition to clinical skills, include epidemiology and
Emilie tt.S. Oshorn, M.D., M.P.H. is Assistant Professor, Family and (]ommunity Medi-
cine, University of California at Sail Francisco. Norman ftearst, M.D., M.P.H. is Assistant Clinical
Professor, Clinical Epidemiology and Family and Community Medicine, Universit~ of Calitornia at
San Francisco..]oyce C. Lashof, M.D., is Dean, School of Public tTeahh, University of Calitornia at
Berkeley. W. McFate Smith, M.D., M.P.H. is Director, Preventive Medicine Residency, School ot
Public Health, University of California at Berkeley.
This project has been supported in part with Federal fttnds i'rom the Bureau o[ Heahh
Care Delivery and Assistance, Health Resourtes and Services Administration, U.S. Public ttealth
Service, under contract #240-84-0124. The content of this publication does not necessarilv refle(t
the views or policies of the Department of Heahh and Human Scrvices.
Address reprint requests to: Dr. Emilie Osborn, University of California, SF, Famiiv&
Community Medicine, AC-9, San Francisco, CA 94143.
© 1986 Hutnan Sciences Press l (35
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Journal of Community Health Vol. 11, No. 3, Fall 1986

T E A C H I N G C O M M U N I T Y - O R I E N T E D

PRIMARY CARE (COPC):

A PRACTICAL APPROACH

Emilie H.S. Osborn, M.D., M.P.H., Norman Hearst, M.D., M.P.H., Joyce C. Lashof, M.D. and W. McFate Smith, M.D., M.P.H.

ABSTRACT: To improve education in community-oriented primary care (COPC) and to promote its practice in the community, the Univer- sity of California's School of Public Heahh in Berkeley and School of Medicine in San Francisco are collaborating in an innovative program in cooperation with several federally-funded community clinics in the San Francisco Bay Area. T h e School of Public Health designed a COPC track t0r graduate public heahh students from various departments of the school who wished to work in community heahh care. The track in- cludes a seminar given in the spring of the students' first year in which COPC theory is taught and teams of students working with a faculty ad- visor and a clinic preceptor design COPC projects for tbe primary care sites. These projects are then implemented in the summer and fall by students who elect to use this experience to satisfy their fieldwork re- quirement. This paper is a report of the first year's experience with this collaborative effort,

INTRODUCTION

Community-oriented primary care (COPC) represents a marriage of public health and primary care. The term, first coined by Sidney Kark, is an approach to the primary health care of a community or defined population using epidemiologic methods to determine the priorities for health care and designing appropriate interventions that improve the health of the population.l~ These interventions must be evaluated in o f der to modify programs--as a feedback loop. The skills necessary to im- plement COPC, in addition to clinical skills, include epidemiology and

Emilie tt.S. Oshorn, M.D., M.P.H. is Assistant Professor, Family and (]ommunity Medi- cine, University of California at Sail Francisco. Norman ftearst, M.D., M.P.H. is Assistant Clinical Professor, Clinical Epidemiology and Family and Community Medicine, Universit~ of Calitornia at San Francisco..]oyce C. Lashof, M.D., is Dean, School of Public tTeahh, University of Calitornia at Berkeley. W. McFate Smith, M.D., M.P.H. is Director, Preventive Medicine Residency, School ot Public Health, University of California at Berkeley. This project has been supported in part with Federal fttnds i'rom the Bureau o[ Heahh Care Delivery and Assistance, Health Resourtes and Services Administration, U.S. Public ttealth Service, under contract #240-84-0124. The content of this publication does not necessarilv refle(t the views or policies of the Department of Heahh and Human Scrvices. Address reprint requests to: Dr. Emilie Osborn, University of California, SF, Famiiv& Community Medicine, AC-9, San Francisco, CA 94143.

© 1986 Hutnan Sciences Press l (

166 JOURNAL OF COMMUNITY HEALTH

survey methodology, program planning, team skills, and community or- ganizing. Schools of public health, which teach all of these skills, offer a natural training environment for health care workers interested in COPC. In the fall of 1984, the Health Resources and Services Adminis- tration (HRSA) contracted with the Berkeley School of Public Health to develop a curriculum in community-oriented primary care carried out jointly with the Division of Family and Community Medicine at Univer- sity of California, San Francisco. This contract was the result of a year- long planning process which included faculty and students from both schools and representatives of federally-funded community clinics in the Bay Area. This paper is the initial report of the first year's experience with this collaborative project. The scope of the workplan approved by HRSA was:

  1. To determine what elements of COPC are possible to implement in various primary health care delivery sites.
  2. To determine what would be required to incorporate COPC into ongoing delivery sites.
  3. To determine what impact specific COPC efforts have on the com- munity and practice.
  4. To develop curricula and training modules for educational pro- grams designed to prepare multidisciplinary health care teams to incorporate COPC in their health care delivery.:'

T H E C O P C C U R R I C U L U M

To meet the educational goals of the School and the specific in- formational needs of the involved community health centers, a curricular track in COPC was developed. This consists of a course during the spring semester, followed by team projects carried out during the following summer and fall. The two-hour weekly lecture--discussion session cov- ers the basic concepts of COPC based upon the model described by the Institute of Medicine? The course was designed to build upon courses students had taken previously or were taking concurrently. It begins with an introduction to the history of COPC, the organization of primary care in the United States, and the community health center movement. Over the next two months, faculty from different departments review the basic methods of COPC: defining the community, needs assessments, survey methodology, selection of appropriate interventions and evaluation pro- cedures. These presentations are designed to show the relevance of epi-

! 68 JOURNAL OF COMMUNITY HEALTH

  1. Esparto-Dixon Regional Rural Health Network, Yolo C o u n t y
  2. South of Market N e i g h b o r h o o d Health Center, San Francisco
  3. Mission N e i g h b o r h o o d Health Center, San Francisco
  4. La Clinica de la Raza, Alameda County

Community Oriented Primary Care Sites

  • Espartn-Dixon Regional Rural Health Network, Yolo Co.
  • La Clinica de la Raza, Alameda Co.
  • South of Market Neighborhood Health Center, San Francisco Co.
  • Mission Neighborhood Health Center, San Francisco Co.

T H E T E A M S

T h e preceptors were a Family Practitioner clinic director, and three clinic administrators: two with M.P.H.'s in P r o g r a m Planning and Administration and one with an M.S.W. T h e clinics were all paid f r o m the project b u d g e t for the preceptor's release time and for transportation expenses so that the preceptors could attend the seminar. A t t e n d a n c e was excellent. T h e y participated in the class and met regularly with the

Emilie H.S. Osborn et al. 169

faculty and students to develop projects and function as team leaders. Students were assigned to teams after the first month of class. Assign- ments were made on the basis of the students' preferences for fieldwork placement and their d e p a r t m e n t major to assure a mixture of skills (e.g. a planner, epidemiologist, and health educator). Students and preceptors met weekly to develop a project for each site. Project proposals were pre- sented to the class in the last two weeks, in lieu of a final examination. Students who elected to do fieldwork in COPC were matched with proj- ects for the s u m m e r internship.

T H E F I E L D W O R K P R O J E C T S

T h e COPC model as described in the IOM report consists of four components: 1) defining the community, 2) identifying specific health problems, 3) modifying the health care program to address problems, and 4) monitoring and evaluating the intervention.' Although it was ini- tially hoped that the clinics would have a clear picture of their community and that the projects would be directed toward identification of health problems and designing interventions, this proved not to be the case. All teams chose to concentrate on identifying and characterizing the users and non-users of the clinics and assessing the barriers to providing health care to underserved segments of the population. Although all four projects dealt with characterizing the clinics' pa- tient population and identifying community health needs, the projects differed from each other in important ways. In the rural site of Esparto, the students conducted a door-to-door community survey. Due to their persistence and hard work, they were able to achieve an impressive 80% response rate a m o n g 200 households randomly selected from the entire clinic service area based on a cluster sampling technique. Since no accu- rate list of residents or dwellings was available in this rural area, a great deal of time was spent updating United States Geological Survey maps to produce a usable sampling frame. Data collection took ahnost the entire project period, leaving little time to analyze the results and prepare rec- o m m e n d a t i o n s for the clinic. However, the survey produced important information for the clinic including the finding that only 13% of the pop- ulation of the service area consider the clinic to be their main source of medical care. Groups of potential users who are not currently patients of the clinic were identified. T h e students dew)ted additional time beyond the course to present their results to community leaders and clinic per- sonnel. T h e students at the South of Market Health (;enter in downtown San Francisco combined both qualitative and quantitative methods to ob-

E m i l i e H.S. O s b o r n et al. l 71

CONCLUSIONS

T h e major result of this first year of a COPC track has been the involvement of the clinics in the process of community-oriented primary care. T h r o u g h the tremendous amount of work and the enthusiasm gen- erated by the students, clinics that often feel on the edge of survival were given the opportunity to apply an innovative approach to serving their communities. This would not have been possible without the cooperation and active involvement of clinic administrators and staff. By including a high-level representative from each clinic in the COPC seminar, and reimbursing the clinics fi)r release time to attend the course and work with the student teams, the School of Public Health has done what needs to be done more often in our health care system: it has joined with the community to help solve problems of health care delivery. T h e next phase of the project will be crucial. Needs assessments are only the first step in COPC. From these surveys and reports, projects need to be developed to implement specific interventions in response to the identified needs. Although it is too early to fully evaluate the impact of this effort on the clinics and the School, a few observations are in or- der. T h e clinic directors and preceptors are enthusiastic and are anxious to continue the relationship. T h e students inw)lved in the fieldwork all feel they have learned a great deal by working in teams and by being in- volved in the community and all [eel they have an investment in seeing the results of their work utilized. For the School, it has increased our visi- bility in the community and has helped increase interaction among dif- ferent programs at the School of Public Health and with the Division of Family and Community Medicine at UCSF. We view this as.just a begin- ning in developing an academic base fi)r COPC: one upon which we hope to build.

REFERENCES

  1. Kark SL, Community-Oriented Primary, Health Care. New York: Appleton-Century-Crofts, 1981.
  2. Madison DL, T h e case fbr community-oriented primary care. JAMA 249: 1279-1282, 1983.
  3. A Program to Advance the Concept and Practice of Community-Oriented Primary (;are. COB: GMH RFP HrFA 240-BHCDA-173(4), 1984.
  4. Instilute of Medicine: Community-oriented Primary Care: A Practical A.~.~essment, Vol. 1, The Commit- tee Report, Washington, D.C.: National Academy Press, 1984.