From Foresight, Vol. 6, No. 3
published 1999
The challenge our state and nation confront in health care has not diminished with the dawn of the new millenium. Today, we are being challenged to abandon unproductive approaches, to form new mental models of what health care is, does and produces, to adopt new approaches to continual system improvement, and to rigorously evaluate system outcomes. Rather than another report on the scope of the problem, this article challenges each of us to change our minds about health care. Then we can begin the work of discovering effective strategies for making the changes we agree must be made.
The approaches advocated here are not really new. They are based on the application of the principles of Community-Oriented Primary Care (COPC), a well-known but seldom-used (in this nation) conceptual framework for health care. Perhaps the magnitude of today’s challenge combined with the stimulus of embarking on the 21st century will be sufficient to entice us to examine and revise our current mental model of health care. As we advance our discussion of COPC, please think particularly about two major components: community assessment and program evaluation/performance monitoring.
The nature of the challenge we face is perhaps best illustrated by a story. A young male is admitted to a medical center with fever, chills, and generally severe illness. He has no use of his legs because of a gunshot wound from several years ago. He is known to have chronic infections in his hips and legs as a result of the original wound. An evaluation finds that a reactivation of these infections is the cause of his current situation. His life is in the balance. But therapeutic options are limited and the likelihood of success is not high. Whether he can tolerate surgery, what surgery should be performed, and the effectiveness of antibiotic therapy are all in question.
The staff of this medical center is faced with agonizing choices about how best to save a severely impaired life. While no good choices are left, the health care system played some role in the development of this scenario over the years. Very possibly, it could have prevented such a disastrous outcome with timely attention to any one of a number of social or economic circumstances that may have contributed to this clinical situation. The roots of health crises such as this reach into every part of our culture, notably including our health care “system,” which lacks the perception of responsibility to help rectify and prevent such horrific outcomes. Instead, it focuses on acutely treating gunshot wounds and infections, without assuring continuity of care over time in various settings.
Those of us who are devoted to improving health care delivery and policymaking must ask and answer some serious questions before we can prevent recurrence of scenarios like the one described. What should health care become? Were a new “mental model” adopted, how might our health care system constructively intervene and entertain positive options while they still exist? Moreover, who has an interest in building such a system? We might agree that not all of those who should have an interest actually do. And how can those of us who see the importance of such changes get them done?
Before beginning to address these questions, allow me to clearly state certain assumptions about health care under which I am operating. We all know that our assumptions largely determine our conclusions, so if you disagree with these assumptions, you will likely reach different conclusions.
1. The purpose of health care is to improve the health of individuals and the population.
2. The community is the foundation of health care, and its engagement is required if a health care system is to achieve its purpose.
3. Integrating the continuum of care at the community level is a requirement for an efficient and effective health care system.
4. How we think about health care (our mental model), its purpose, structure, process and outcomes, determines the questions we ask, and the answers we receive.
5. Ethics and values, rather than dollars, must be the basis of discussing health care. (This explains the failure of the reform debate to date.)
6. A good health care system is an important element of community and economic development.
7. The “market” is not the solution, but rather much of the problem.
8. Future gains in quality, access, and cost management will be found in improving the process of care, rather than in “managed care,” as we have come to know it.
9. Continuous learning and improvement, and adoption of best practices, are critical to system improvement.
10. Effective information systems are essential to improve care across the continuum of time, place, and person.
11. Medical care has little to do with the health of the population.
12. Health care is multi- and trans-disciplinary.
13. We won’t resolve most of our health care problems until everyone is included in the system.
14. Healing and prevention are naturally linked.
15. Health care is a national issue, requiring appropriate policy development and resource allocation to achieve consistent solutions in communities everywhere.
16. The process of educating health professionals must change if the health care system is to perform differently.
The vision of the desired future state of health care implied by these assumptions has two parts. First, the system of tomorrow will be community-based and actively involved with all aspects of community life, including business, church, school, government, public safety, sanitation, etc. It will recognize that every aspect of a community’s life affects the health of the population. The system of health care envisioned here would actively educate, advocate, and allocate in a manner that engages all aspects of the community in improving health while facilitating community ownership and control. Thus, the system would help prevent catastrophes like the one in our introduction.
Second, the community-based system envisioned here operates like a finely tuned machine across the continuum of care. Care is obtained from many providers in many locations, and every encounter, whether in a hospital, the health department, the home, a rehabilitation center, or a nurse practitioner’s office, builds on the prior encounter and prepares for the next one. Preserving confidentiality, the information system provides accurate information to the person who needs it at the exact time and place needed. All components of the continuum work collaboratively, and the health department is a highly valued component of that continuum. All citizens of the community have full access to the system and receive the same high quality of care.
What challenges lie ahead in the process of getting from here to this preferred vision of health care? Let us count some of the ways!
1. The greatest and most resistant roadblock to change is the mental model of health care that each of us holds in the United States. In order to build a new system of care, we must individually and collectively change our ways of thinking about health care. In our current operational mental model for health care, population health is eclipsed by illness care. But if we are serious about improving the health of citizens, rather than conceptualizing health care as a response to illness, we must recognize illness care as a mere component of a larger system. To develop this new mental model, we must conceptualize it thoroughly, articulate it clearly, communicate it effectively, and incentivize others to adopt it, which requires that the change be perceived as being in the best economic interest of the person being asked to change. This revised and shared mental model of health care pervades all the other challenges.
2. Information technology companies will not produce capabilities for which there is no market. Capabilities for true integration across the continuum of care presently do not exist at the level and scale required to implement COPC. Cost, technology, mental model, and confidentiality are all issues.
3. Many federal and state regulations, policies and proscriptions hamper population health improvement. Illness and procedure focus, compartmentalization, lack of coordination, political constituency influence, and resource constraints must all respond to a new mental model before we can apply available resources to improving the health of the population.
4. Professional groups stake out their turf and function as special interests with little demonstrable focus on improving population health. As a physician, let me assert that physician groups (specialty groups, state and national associations) must place contributing to population health improvement on at least an equal footing with the economic ascendancy of their members. Physicians must adopt a mental model encompassing population health, best practices, continuous improvement, service, and the community. Being a physician has to be far more than running a business that involves a pricey commodity.
5. The entire reimbursement situation mitigates against population health improvement. Illness, procedure, and special class of individual are today’s criteria for reimbursement (along with “discouragers” to avoid payment). Universal inclusion in health improvement is a real mental model shift for payors!
6. Trade groups (hospital associations, e.g.) and industries (pharmaceuticals, e.g.), tend to advocate their economic interests without placing sufficient emphasis on population health. Our challenge is to find a way to bring these powerful entities to view improving population health as one of their responsibilities, if meaningful resources are to be dedicated to COPC.
7. Health care systems—executives, boards—must change their mental models of their responsibilities, their vision, and ultimately their resource allocation to become partners with communities in health improvement. This represents a reversion to an older not-for-profit mental model, away from today’s hard scrabble battle for financial survival.
8. The local continuum of care components must adopt a collaborative good-for-one, good-for-all mentality. The problem of competition and turf in the community is largely the result of reimbursement constraints and perverse economic incentives, and requires serious commitment and altruism to collaborate for improving community health.
9. Communities must become highly collaborative, as resources can be shared and services often should extend to multiple communities. Local leadership and local government can greatly enhance such improvement if the community places a priority on such collaboration.
10. Citizens can promote the adoption of a new mental model by changing their expectations. The population must demand collaboration to improve the health of the community and inclusion in the improvement process. We need to educate the population about the vision of improving their health status.
11. We have not sufficiently recognized the economic value of a good health care system, which is owned and used by the people. This is particularly applicable in rural communities and can be a major incentive to form a community coalition. Propagation of the new mental model will be infinitely easier if we demonstrate the economic benefit of an effective, inclusive community health care system.
12. Finally, a virtually limitless number of political, social and economic barriers resists an inclusive, effective community-based health care system. Remember, however, it all has to do with our mental model—our vision of how things ought to be, and our resulting allocation of resources. A new mental model will help convert today’s barriers into escalators, reaching new levels of population health improvement performance.
Here we focus on COPC as the approach most likely to convert the vision into reality. It is a gigantic concept, which must spring from the pages of books, journals and websites into the lives of people in communities across the nation if we are to improve the health care system and the health status of our communities. COPC is a profoundly simple, simply profound concept, much akin to common sense. It is a comprehensive approach to converting acute illness treatment capacity into population health improvement programs. It is a way of continuously improving system capabilities. Every component of health care ultimately relates to a COPC; it is part of the total continuum, from lay community health care worker to the ultimate scientific sophistication. COPC starts with defining the community for whom care is to be provided. It then assesses the health status of the community, identifying needs and establishing priorities. Next it develops programs to resolve high-priority needs with clear goals and evaluation criteria, and finally evaluates performance of the program and feeds back into the operation to improve performance. This constitutes ongoing assessment, which perpetually renews the COPC cycle, thereby continuously improving the system.
While care for the ill is an integral part of this model, it does not root out the primary commitment to improve the health of the entire community population. Obviously, the public health sector is an integral part of COPC. Core public health functions must be revitalized, reversing the current dangerous decline. All components of the continuum interlock; they are synergistic and are required for full capability in health improvement.
Defining the community to be served by a specific COPC can be done in many different ways. The most common is geographic, though special-needs populations or other specific groups could be identified as the community to be served.
Community assessment deserves extensive attention. Both qualitative and quantitative approaches are essential. Obtaining community awareness and buy-in must occur in this phase. A community profile can be developed describing sociodemographic characteristics, health status, risk factors, health care resources, patterns of use, and assessment of perceived functional status and quality of life. Quantitative information is obtained from existing sources such as census data, behavioral risk survey data, and the state health department. Community-specific data are difficult to collect, contributing to the “denominator problem” of precisely identifying the population and its specific issues. Qualitative information is obtained from surveys, key informants, focus groups, and town meetings. Community Initiated Decision-Making (CIDM) is a process successfully applied in obtaining qualitative information and gaining community ownership of the process. It is a two-way learning process with an effective community health care council, or coalition. The development of a community coalition to prioritize health improvement initiatives is critical in the assessment phase. This coalition is the leadership nucleus, including representatives of the continuum of care, broad community leadership, and “consumers” of health care services. This community engagement can create the energy to sustain COPC, align interests and create collaboration across the continuum. Several responses are required of the provider community to enable this assessment process to succeed and generate ongoing community engagement in the health care system.
First, providers must lend guidance without trying to control the process. CIDM must be by, for and of the specific community. Physicians and hospitals, public health and medical staff, and others must work together by focusing on the best interests of the community. Further, the concept of health care must be expanded to include police, chambers of commerce, churches, small businesses (especially grocery stores!), schools, etc.
Second, the system must adopt a customer focus, assuring that it pleases those it serves. Dialogue must be established and maintained to address resources, quality, utilization, and economics, to make good decisions and to provide services that are used.
Third, providers must seriously address integration of the continuum of care. Care does not occur in a vacuum. Each encounter must build on the prior one and prepare for the next one. It must address time, location and all providers. It must be supported by an effective information system. Fourth, the provider community must be responsive. The degree to which the providers meet their responsibilities of improving health and responding to community priorities will determine whether the community sustains its engagement. Beyond responsiveness, providers must be pro-active. Community coalition members will appreciate the special knowledge, current information, and leadership of experts in population health in the provider community. In fact, public health would do well to take the responsibility of assuring the existence of a community-based health improvement process in every community.
Specific, reliable, measurable indicators must be established to monitor the performance of programs established to solve identified problems. Structure (the capacity to perform), process (activities) and outcomes (what happens) can be monitored. Note that some outcomes such as reductions in cancer rates may be significantly delayed. Modification of risk factors would represent an outcome measure with a shorter and more useful time frame. Clear objectives, rigorous evaluation, and program modification are required to develop and sustain an effective health care system.
A shared vision, which constitutes a new mental model of health care, must continue to evolve. We must conceptualize this vision of our desired future in which illness care is a function within and subsidiary to population health improvement. When this new mental model is adopted by policymakers, funding agencies, and health care payors, we can begin to meaningfully incentivize behaviors that improve population and public health, such as developing a COPC in every community in the nation.
Reactive policymaking can become proactive when this vision of the desired future state, this new mental model of the purpose, structure, function and outcomes of health care, is adopted by policymakers. Until we can “sell” the shared vision, it will be a formidable challenge to produce policies that help!
Resource allocation at every functional level of health care must reflect the new mental model. Resources must be applied to make the vision real, rather than attempting to satisfy special interests, ultimately satisfying no one. Resources must be allocated in a highly purposeful manner. Program effectiveness must be vigorously evaluated to guide resource allocation.
Solutions are and must be local. Centralized policy, funding, and academic entities must advocate, facilitate, and incentivize. But they may not otherwise insert themselves into the process or attempt to take ownership of assets, process or outcomes. Health care infrastructure, behavior and outcomes must be an integral part of the community. The people must know that they can influence system behavior in the interest of the community (i.e., service, health improvement, economic benefit and enhancement of social capital).
COPC and CIDM constitute a means of advancing toward the desired future state. But this health system will never be a finished product. There will be continuing information exchange at all levels, environmental and technological changes, continuous learning, and continuous modification of the system based on performance monitoring. This is as it should be—a dynamic, living system, which symbiotically nourishes the community of which it is a part. This health care system is of the community, used by the community, and a source of pride for the community.
In conclusion, let’s review another story of health care in a real community. It begins in 1995. Assessment of the current state at that time revealed a dilapidated hospital facility with large out migration for medical services. It was failing financially; utilization was low and dropping. The multi-specialty group of physicians was short on quality improvement, customer focus, and trust from the community. There was essentially no working relationship with the health department.
Enter CIDM, under the leadership of a talented, dynamic, committed person who was determined to make things better. Interim activities included: multiple grants; a community health care council or coalition; subsidiary task forces to address prevention, community health care workers, community participation in recruitment of health care professionals, EMS and emergency transportation, emergency room service, and after hours clinic services; and a joint health department-hospital prenatal clinic.
The results: utilization rose dramatically and continues to increase, with facilities and schedules bursting at the seams; the hospital received a top-100 hospital designation and a Governor’s Service Award went to the Coalition; new construction is in advanced planning stages. A “funds flow” study was undertaken in conjunction with a university and a private foundation to determine the magnitude and location of health care spending with the intent of ultimately negotiating a community-managed blending of dollars to achieve universal inclusion. The coalition desires to truly address the health care needs of the entire community.
The point is simply this: with leadership, vision, and community engagement, wonderful things can happen. Communities can become more healthy and build social capital in the process. COPC is a conceptual framework for community engagement and continuing improvement to bring about true fundamental change in the mental model and the outcomes of health care resource application. Let’s show the nation how to do it right!
* Dr. Calico is a physician, the former president of a hospital system, and a member of the Center’s Board of Directors. Return to text.
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