Health Policy Journal Club, October 2020

Integrating Primary Care, Public Health, and Social Services

The health policy journal club is an interdisciplinary, interprofessional group convened monthly by the Farley Health Policy Center to discuss timely topics in health policy. A curated selection of high yield articles provides the basis for discussion. Past topics have included income inequality and health, professionalism in medicine, patients as consumers, and adjusting payment for measures of social risk. This page presents the reading list from the most recent journal club along with key takeaways from the articles and discussion. 

Key takeaways from the readings:

• Healthcare alone is insufficient to make people healthy.
• There is a long and rich history of efforts to integrate primary care with public health and social services stemming from the work of Will Pickles in the 1920s and 30s in rural English villages to Sydney Kark at Pholela Health Center in South Africa in the 1940s to the creation of federally-qualified health centers in the US in the 1960s. These efforts, coined community-oriented primary care (COPC), were the focus of a 1982 Institute of Medicine (IOM) conference and subsequent report. 
• The 1982 IOM conference concluded that COPC requires:
  • Primary care practices providing accessible, comprehensive, coordinated, continuous, and accountable care.
  • A defined community whose health the practice takes responsibility for (not simply the patients who show up in a practice).
  • A 4-step process:
    • Define and characterize the community.
    • Describe community health problems.
    • Modify health care programs to address high priority health needs.
    • Monitor effectiveness of modifications.
• There is a tension between defining community more loosely for feasibility and remaining true to the original definition of a socially and/or geographically defined group.
• COPC has a strong positive impact on the health of communities.
• The Robert Wood Johnson Foundation has made the integration of primary care, public health, and social services an area of focus for its philanthropic efforts. As part of those efforts, a framework has been developed that centers around the three sectors sharing a common purpose, data, financing, and governance. As a fourth component, a strong community role and engagement is critical.
• Comparing states in the US, a higher ratio of social service and public health spending to healthcare spending is associated with better health outcomes including lower rates of obesity and asthma, decreased mortality from heart attacks and lung cancer, and fewer reports of unhealthy mental health or activity limited days.  
• States do not make overall budget and policy decisions to optimize the health of populations in the state. Driving this are competing priorities, misaligned incentives, and a lack of consensus on who is responsible for health.
• Separate budgets, responsibilities, metrics, and personnel mean that delivery of the various health and social services is siloed, rather than being holistically integrated around the needs of a person or family.
• Policy principles to drive improvements in population health include multisector involvement and engagement, gaining political will, flexibility in tailoring programs, commitment to payment reform to align incentives with broader health goals, and using evidence to initiate and sustain programs.
• Accountable Communities for Health is a model that strives to address population health from a community rather than healthcare perspective (in contrast to traditional Accountable Care Organizations). Hennepin Health in Minnesota is one example of such a program that used aligned financing and data to drive down emergency department utilization and hospital admissions and improve quality of care.

In the discussion, participants highlighted:

• Motives are not enough to drive cross-sector partnerships; incentives, particularly financial incentives, move motivation to action.  
• The multiple payers (in the healthcare sector) and multiple agencies (in the social services sector) in the US do not create incentives for public health change or a long-term view of return on investment (ROI). There is not a single agency or entity responsible for the overall health and wellbeing of families or communities. There is seldom funding for the direct costs of collaboration and integration.
• Different levels of government control different social programs (e.g., state-level control of Medicaid vs local control of school districts).
• ROI is not thought about as broadly as it should; the integration of primary care, public health, and social services can have far-reaching impacts across sectors.  For example, decreased costs in correctional facilities and decreased productivity losses from presenteeism and absenteeism in the workplace are rarely examined but likely impacted.
• For further reading, a 2019 report from the National Academies of Medicine examines integrating health with social services in detail (citation provided below).

Readings

Background

1. A theory of change for aligning health care, public health, and social services in the time of COVID-19. Landers GM, Minyard KJ, Landford D, Heishman H Am J Public Health. 2020;110(S2):S178-180. 
2. Community-oriented primary care: historical perspective. Longlett SK, Kruse JE, Wesley RM. J Am Board Fam Pract. 2001;14:54-63. 

Barriers and solutions  

1. Variation in health outcomes: The role of spending on social services, public health, and health care, 2000-2009. Bradley EH, Canavan M, Rogan E, et al. Health Aff. 2016;35(5):760-768.
2. Investing in social services for states' health: identifying and overcoming the barriers. Rogan E, Bradley E. Milbank Memorial Fund. May 2016.
3. Integrating Social Needs into the Delivery of Healthcare to Improve the Nation’s Health. National Academies Press. 2019. https://www.nationalacademies.org/our-work/integrating-social-needs-care-into-the-delivery-of-health-care-to-improve-the-nations-health

Accountable Communities for Health

1. Accountable communities for health: moving from providing accountable care to creating health. Tipirneni R, Vickery KD, Ehlinger EP. Ann Fam Med. 2015;13:367-369.
2. Elements of accountable communities for health: a review of the literature. Mongeon M, Levi J, Heinrich J. NAM Discussion Paper. November 6, 2017. 

Contact the Farley Health Policy Center with questions or if you are interested in joining the journal club listserv.