the “patient centered medical home”2. the patient-centered medical home as a transitional step...

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W A Y N E C O U N T Y, M I C H I G A N

Department of Health and Human Services

The “Patient Centered

Medical Home”: Where is Public Health?

Mouhanad Hammami, MD

County Health Officer &

Chief of Health Operations

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The “PCMH”

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Patient Centered Medical Home

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Patient Centered Medical Home Recognition Program

• PPC-PCMH Recognition is based on meeting specific elements included in nine standard categories:1. Access and Communication2. Patient Tracking and Registry Functions

3. Care Management4. Patient Self-Management and Support

5. Electronic Prescribing6. Test Tracking7. Referral Tracking

8. Performance Reporting and Improvement9. Advanced Electronic Communication

NCQA Physician Practice Connections®

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Patient-Centered, Physician-Guided Care

Adapted from: Defining Primary Care: An Interim Report, Institute of Medicine 1994

Physician Patient

Practice Family

Team

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PRIMARY CARE

The House on the Hill …

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Primary Care Strengths

• Regular, direct contact with individuals

• Patient’s often change their health behaviors on the advice of their doctor.

• Provides tailored services• Ensures coordination of care.

• Patients who have a long term relationship with a doctor typically have lower hospital admissions and total costs of care, and are more likely to receive preventive services.

• Critical to disease management in chronic diseases.

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Primary Care Weaknesses

• Encourages inefficiencies;

• Fails to provide needed, high-quality services;

• Does not promote disease prevention,

• Opting for expensive care after patients are

already sick.

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Primary Care Weaknesses

• Not safe. – Medical errors are the cause of unnecessary death and injury to tens of

thousands of hospitalized Americans each year.

– Preventable medication errors injure 1.5 million people in hospitals, long-term care, and outpatient settings at costs upward of $4 billion annually. (IOM 2006)

• Not timely. – Delayed screening, diagnosis and treatment for mental disorders, cancers,

and certain acute conditions often lead to unnecessary suffering and even death.

– U.S. fell to last place among 19 industrialized nations related to deaths that might have been prevented with timely and effective care. (Commonwealth Fund, 2008)

• Not efficient. – Various studies estimate that 20 percent to 30 percent of all health care

spending is for unneeded care.

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Percentage of Americans with

Ineffective or Untimely Care

SOURCE: “Public Views on U.S. Health System Organization: A Call for New Directions.” Commonwealth Fund, 2008 and MEPS Survey, 2007.

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Primary Care Shortcomings• Not effective.

– Overuse, underuse, and medical errors all contribute to ineffective care.

– Each year, an estimated 18,000 people die because they do not receive

effective interventions.

– Americans receive just 55 percent of recommended treatments for preventive care, acute care, and chronic care management.

• Not patient-centered.

– Physicians often miss the opportunity to communicate effectively with patients and other Caregivers

• Not equitable.

– The care that racial and ethnic minorities receive often is of lower quality compared to the care received by whites.

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David Lawrence, former CEO of Kaiser Permanente

on the care his 88-year-old mother received in the regular Medicare system after she fell

“ At times, Mom’s care seemed like a pick-up

soccer game in which the participants were

playing together for the first time, didn’t

know each other’s names, and wore earmuffs so

they couldn’t hear one another. Her care seemed

like an ‘ad-hoc-racy’ that involved well-trained

and well-intentioned people, state-of-the-art

facilities, and remarkable technologies—but

was not joined into a coherent whole for the

benefit of her or her family. My mother

ricocheted from place to place like a pinball.

Each contact brought another bill, different

advice, and increased risk that something

could go wrong.”

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Life Expectancy and Health Spending, 2009.

OECD, 2011

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PC challenges

• Encourages inefficiencies;

• Does not promote disease prevention,

• Opting for expensive care after patients are already sick

• Current incentives and payment systems do not necessarily correlate with better health outcomes.

• The financial incentives and payment systems favor specialty care over primary care.

• Shortage of primary care providers.

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Social Justice Challenges

• Unfamiliarity of the institution with social

determinants of health

• Lack of sufficient resources to address SDH.

• Uncomfortable intervening in areas in which

they are neither leaders nor well prepared.

• Discomfort with community anger

• Conflict between strengths and community

needs

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Primary Care Potential Fixes

• Changing the way care is delivered, aligning payments, and promoting health and wellness can result in a healthier population and drive value in the health care system.

• A number of opportunities exist for improving primary care through these channels:– Payment reform as a driver for quality;– Expanding the primary care workforce to ensure access; and

– Expanding primary care provider capabilities in ways that support access, efficiency and equity.

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Good Time for Change …

• The dramatic rise in health care costs has led many stakeholders to explore innovative ways of reducing costs and improving health

• Growing recognition that the current model of investment in the nation’s health system is unacceptable

• Unprecedented wealth of health data is providing new opportunities to understand and address community-level health concerns

• The Passage of the ACA

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Key Themes That Emerged in Interviews With National Policy

Key Informants About the Value and Changing Role of Primary

Care in the Context of Emerging Political Opportunities

1. affirmation of primary care as the foundation of a more effective health care system,

2. the patient-centered medical home as a transitional step to foster practice innovation and payment reform,

3. the urgent need for an increased focus on community and population health in primary care, and

4. the ongoing need for advocacy and research efforts to keep primary care on public and policy agendas

Sweeney et al, American Journal of Public Health, 2012

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PUBLIC HEALTH

Little House on the Prairies …

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The 10 Essential Public Health Services 1. Monitor health status to identify community health

problems.

2. Diagnose and investigate health problems and health

hazards in the community.

3. Inform, educate, and empower people about health

issues.

4. Mobilize community partnerships to identify and solve

health problems.

5. Develop policies and plans that support individual and

community health efforts.

6. Enforce laws and regulations that protect health and

ensure safety.

7. Link people to needed personal health services

and assure the provision of health care when

otherwise unavailable.

8. Assure a competent public health and personal

healthcare workforce.

9. Evaluate effectiveness, accessibility, and quality

of personal and population-based health services.

10. Research for new insights and innovative

solutions to health problems.

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Public Health Strengths

• Access to a wide range of data providing the most accurate picture of the local population;

• Expertise in identifying and assessing critical health issues affecting local communities through the use of epidemiologic science and analytical techniques;

• Skillful evaluation and quality improvement tools for personal and population-based health services;

• Efforts grounded in research and evidence-based practices;

• Extensive experience in care coordination for high-risk populations; and

• Professionals skilled and knowledgeable in providing community outreach and education.

SEMHA Strategic Planning Final Report, 2013

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Local Health Departments� Monitor health status and understand health issues facing the

community;

� Protect people from health problems and health hazards;

� Give people information they need to make healthy choices;

� Engage the community to identify and solve health problems;

� Develop public health policies and plans;

� Enforce public health laws and regulations;

� Help people receive health services;

� Maintain a competent public health workforce; and

� Evaluate and improve programs and interventions.

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Public Health Resources that Support Primary Care

Practices

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NACCHO, 2010

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NACCHO, 2010

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NACCHO, 2010

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NACCHO, 2010

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NACCHO, 2010

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NACCHO, 2010

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Public Health Weaknesses

• Limited Funding

• Limited health services that are offered based on

availability of funds/grants

• Lack of data and disconnect with other health

providers Funding based services

• Lack of human resources such as grant writers or dedicated people to conduct research

• Under publicized and under appreciated

SEMHA Strategic Planning, 2013

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NACCHO, 2010

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NACCHO, 2010

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NACCHO, 2010

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NACCHO, 2010

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Department of Health and Human Servicesfamily and community”

“the provision of integrated, accessible

health care services by clinicians who are

accountable for addressing a large

majority of personal health care needs,

developing a sustained partnership with

patients, and practicing in the context of

family and community” IOM, 1996

“fulfilling society’s interest in assuring

conditions in which people can be

healthy” IOM, 1988

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“Chargoggaggoggmanchaugagoggchaubunagungamaugg”

"You fish on your side… I fish on my side …

and nobody fish in the middle”

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Why Integrate?

• A wide array of public and private actors across the nation contribute to the health of populations

• Achieving substantial and lasting improvements in population health will require a concerted effort aligned under a common goal

• Integration of primary care and public health could enhance the capacity of both sectors to carry out their missions and link with other stakeholders to catalyze a collaborative, intersectoral movement toward improved population health

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The Folsom

Report, 1967

“the planning, organization,and delivery of community

health services by both official

and voluntary agencies must be based on the concept of a

‘community of solution.’”

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Community Oriented Primary Care

• Sidney and Emily Kark, 1942

• Pholela Health Center, South Africa, late 1950s

• Expanded medical work to include improving housing, sanitation, and access to food

• Practicality (ccordinationof care)

• Principle (community participation)

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Indian Health Services

• Late 1950s,

• Indian Health Service had reorganized its program and established “service units” that combined primary care and public health services to address unique needs of the Native American communities.

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What Care Coordination Should Look Like

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PUBLIC HEALTH

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The Chronic Care Model

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The Expanded Chronic Care Model

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Linkages between clinical practices and community organizations: a proposed model

Porterfield et al.

AJPH, 2012

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FQHC

Your Neighborhood Convenience Health Center …

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Federally Qualified Health Center

• FQHCs serve as the health care home for 20

million people nationally through over 7,500 service delivery sites.

• It is estimated that

FQHCs save the national health care system up to $24 billion a year.

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Essential Public Health Services Carried Out by FQHCs

Public Health Services Examples of Health Center Activities

1. Monitor health status to identify

community health problems

•Work with state department of health to

coordinate an interface that will send

immunization data from health center’s

electronic health record system to state

immunization registry, to increase the

electronic exchange of records and aid

providers in tracking immunization rates.

•Conduct annual community needs assessments in partnership with local

health department and a state health task

force.

•Utilize community- and citywide data

provided by local and state public health

departments to determine areas of focus

for health and social needs.

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2. Diagnose and investigate health

problems and health hazards in the

community

Collaborate with state, city, and private

agencies to identify and address health

problems resulting from infectious diseases

among homeless populations.

Test for blood lead levels among patients

and refer families to deleading programs or

new housing.


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3. Inform, educate, and empower people

about health issues

Culturally appropriate case management

Address disparities

Participate in community outreach

Provide education and health promotion

in homeless shelters and at community

events, on a variety of public health

concerns, such as nutrition, exercise,

smoking cessation, health insurance,

advanced directives, early prenatal care,

child passenger safety seats, and domestic

violence


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4. Mobilize community partnerships to

identify and solve health problems

Encourage healthy behaviors such as

physical activity, and promote the economy

through job creation; partners may be

environmental organizations, government

agencies, researchers, business owners,

and other community organizations.

Partner with local community

organizations, educational and research

institutions, and health advocacy groups to

engage in policy advocacy, research, and

community outreach and education.

Collaborate with local farmers and

growers to organize a farmers’ market to

make fresh produce accessible to consumers

and to promote healthy eating.


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5. Develop policies and plans that

support individual and community health

efforts

Coordinate care with the local health

department to ensure that there is no

duplication of services;

Colocate/lease space in the health

department’s facilities and provide family

practice, oral health, and behavioral health

services on-site.

Formal agreements and policies clarify

which services will be provided by each

entity to maximize services to residents.


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6. Educate on laws and regulations that

protect health; advocate for, review, and

evaluate legislation; facilitate compliance

Provide testimony, advocacy, and

education on legislation related to

mandatory prevention measures


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7. Link people to needed personal health

services and ensure the provision of

health care when otherwise unavailable.

Work with local and state health

departments to promote and provide

vaccinations in nonclinical settings

(e.g., WIC clinics, day care centers, fire

stations, elementary and middle schools).

Partner with other health care providers to

create a coordinated safety net system

providing comprehensive health care to

low-income, uninsured county residents.

Primary care, specialty care, medication

assistance, laboratory and diagnostic

services, inpatient and outpatient hospital

services, case management, and health

coaching are provided at no or low cost to

members.

Enabling services to ensure access to

care include transportation and translation

services.


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8. Ensure a competent public health and

personal health care workforce

Work with state leaders to develop a

certification program for CHWs and to

facilitate a billing mechanism for CHW

services;

Organize health workforce summits,

manage student and resident rotations,

and implement health workforce

recruitment activities in local schools.


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9. Evaluate effectiveness, accessibility, and

quality of personal and population-based

health services

Conduct annual patient satisfaction

surveys to evaluate health care services and

identify areas of improvement.

Establish a Quality Improvement

Committee tasked with improving access,

quality, and effectiveness of care, with

monthly committee meetings to identify

areas of improvement, development and

testing of improvement plans, and program

evaluation.

Report monthly outcomes related to

clinical quality indicators and standards of

care for primary care, eye care, oral health,

behavioral health, and chronic disease

management.


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10. Research for new insights and

innovative solutions to health problems

Foster strong relationship with local

university to perform research and

program evaluation.

Research initiatives take a community-

based participatory research approach.


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LHDs can help FQHCs address critical elements of ensuring service delivery and expansion

� Contributing infrastructure support;

� Helping FQHCs connect with their community;

� Collecting, providing, and coordinating community data;

� Providing a population-based perspective on local issues to inform FQHC communications;

� Convening community members, with local boards that include FQHC representatives;

� Collaborating on FQHC applications for funding;

� Identifying appropriate populations, geographic areas, and partners for

collaboration;

� Using regulatory authority to address identified public health threats; and

� Enforcing public health laws and regulations.

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Sharing Population-Based Information

� Immunizations;

� Screenings;

� Disease management;

� Surveillance;

� Patient self-management;

� Measurement of clinical performance;

� Measurement of service performance;

� Measurement of patient access and communication;

� Population/community health assessments; and

� Contextual information such as indicators of the determinants of

health.

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Integration of Primary Care and Public Health in

Federally Funded Health Centers

Facilitators• Strong, stable leadership in health center

and partner organizations

• High staff retention, buy-in, and

institutional knowledge

• Diverse coalitions built on trust among

public, private, nonprofit sector entities,

each with clear roles and responsibilities

• Diverse funding sources to initiate

projects

• Incorporation of activities into service

delivery to ensure sustainability

• Ongoing data collection and analysis,

community needs assessments, use of

surveillance data, and program evaluation

• Position in a larger context that is conducive

to public health initiatives

Inhibitors• Lack of a champion or leadership changes in

partner organizations

• Staff turnover in health center and partner

organizations

• Bureaucratic delays and funding opportunities

that impede collaborations and progress

• Competition between partner organizations for

limited funding streams

• Inability to sustain project beyond grant

period because of lack of reimbursement for

public health activities

• Limited integration and interoperability of

data sources, within health centers as well as

between health centers and partner

organizations

• Social and political factors at the local levels

Lebrun et al, AJPH 2012

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Successful Partnerships

� Currently, FQHCs and LHDs successfully partner to address a variety of public health and primary care priorities, including but

not limited to the following:

� HIV prevention and testing;

� STD testing, care and treatment;

� Dental health;

� Behavioral health;

� Chronic disease prevention;

� Maternal and child health; and

� Emergency preparedness.

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Key Partnership Models

A. One organization refers its patients to the other organization for services (i.e., a Referral Arrangement)

B. One organization co-locates to the other organization’s facility (i.e., a Co-Location Arrangement)

C. FQHC purchases services and/or capacity from the LHD (i.e., a Purchase of Services Arrangement)

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INTEGRATION

Removing the Walls …

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Timing …

• The ACA presents

an overarching

opportunity to change the way

health is

approached in the

United States

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Opportunities Presented by the ACA

• Community Transformation Grants

• Community Health Needs Assessments

• Medicaid Preventive Services

• Community Health Centers

• National Prevention, Health Promotion and Public Health Council and the National Prevention Strategy

• CMS Innovation Center

• Accountable Care Organizations

• Patient-Centered Medical Homes

• Primary Care Extension Program

• National Health Service Corps

• Teaching Health Centers

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The Intersection: A System for Health

� A true health system (not just health care system)

� System focused on improving and maintaining health

� Public health and health care systems integrated together

� Seamless system that leverages resources in

community

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Attributes of an ideal health care delivery system

1. Patients’ clinically relevant information is available to all providers at the point

of care and to patients through electronic health record systems.

2. Patient care is coordinated among multiple providers, and transitions across

care settings are actively managed.

3. Providers (including nurses and other members of care teams) both within and across settings have accountability to each other, review each other’s work,

and collaborate to reliably deliver high-quality, high-value care.

4. Patients have easy access to appropriate care and information, including after

hours; there are multiple points of entry to the system; and providers are

culturally competent and responsive to patients’ needs.

5. There is clear accountability for the total care of patients.

6. The system is continuously innovating and learning in order to improve the

quality, value, and patient experience of health care delivery.

Commonwealth Fund, Organizing the Health Care Delivery System for High Performance (2008).

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Key Principles of this Health System

� Defines and measures impact on health of community

� Recognizes that communities are different and efforts must be

community-driven

� Driven by community health needs and priorities for action

� Leverages resources in the community

� Involves health department and community partners

� Involves coalitions of non-traditional partners (e.g., business, education)

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Key Principles of this Health System (2)

� Leverages data and technology for population health

� Values critical thinking, accountability

� Identifies best practices

� Researches how to improve health

� Implements changes based on results

� Considers influences on health as a systems issue

� Documents value of this integrated approach both for health care and public health

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Degrees of Primary Care and Public Health Integration

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Synergies of Medicine and Public Health Collaboration

Synergy Examples

Improving health care by coordinating services for individuals

• Bring new personnel and services to existing practice sites• Establish “one-stop” centers

• Coordinate services provided at different sites

Improving access to care by establishing frameworks to provide care for the

uninsured

• Establish free clinics• Establish referral networks

• Enhance clinical staffing at public health facilities• Shift indigent patients to mainstream medical settings

Improving the quality and costeffectiveness of care by applying a

population perspective to medical practice

• Use population-based information to enhance clinical decision making• Use population-based strategies to “funnel” patients to medical care

• Use population-based analytic tools to enhance practice management

Using clinical practice to identify and address community health problems

• Use clinical encounters to build community-wide databases• Use clinical opportunities to identify and address underlying causes of health

problems• Collaborate to achieve clinically oriented community health objectives

Strengthening health promotion and health protection by mobilizing

community campaigns

• Conduct community health assessments• Mount health education campaigns

• Advocate health-related laws and regulations• Engage in community-wide campaigns to achieve health promotion objectives

Shaping the future direction of the health system by collaborating around

policy, training, and research

• Influence health system policy• Engage in cross-sector education and training

• Conduct cross-sector research

SOURCE: Lasker and Committee on Medicine and Public Health, 1997

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Principles for Successful Integration

• a shared goal of population health improvement;

• community engagement in defining and addressing population health needs;

• aligned leadership that– bridges disciplines, programs, and jurisdictions to reduce fragmentation

and foster continuity,

– clarifies roles and ensures accountability,

– develops and supports appropriate incentives, and– has the capacity to manage change;

• sustainability, key to which is the establishment of a shared infrastructure and building for enduring value and impact; and

• the sharing and collaborative use of data and analysis.

Committee on Integrating Primary Care and Public Health; Board on Population Health and Public Health Practice; Institute of Medicine, 2012.

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Opportunities for Integration

• Data– primary care generates data that can be used to create population data useful to public health in conducting surveillance or community assessments.

– Public health assessment data can in turn be tailored to provide valuable information on the health needs and risks of the community served by a particular primary care entity, as well as to allow providers to gauge their clinical performance

• Workforce– community health workers– Community trained physicians

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Existing opportunities for Integration

• Using community health teams; a group of

multi-disciplinary professionals helping a patient

population engage with preventive health practices and improve health outcomes.

• Building coalitions;

• Promoting self management programs; and

• Using health information technology to

accelerate linkages.

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Broader Opportunities for Integration

• Patient-centered medical home - care coordination facilitated by increased data sharing, as well as the role of the patient’s family and community, it provides a clear-cut opportunity for integrating primary care and public health

• Accountable care organizations (ACOs) -partnering with health departments would broaden the range of services available to the patient panel

• Employer groups –• Place-based initiatives

• The National Prevention Strategy

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Areas of Activity in Primary Care and

Public Health Collaborations

• Community activities

• Professional education

• Health services • Social marketing and communication

• Information systems

• Steering and advisory functions• Quality assurance and evaluation

• Evidence-based practice

• Prevention • Health promotion and education

• Teamwork and management

• Needs assessment and planning

SOURCE: Martin-Misener et al., 2009

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Types of Organizations Involved in Medicine

and Public Health Collaborations• Medical practices

• Academic institutions

• Community-based clinics

• Professional associations

• Laboratories and pharmacies

• Voluntary health organizations

• Hospitals

• Community groups

• Managed care organizations

• The media

• Foundations

SOURCE: Lasker and Committee on Medicine and Public Health, 1997.

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Locally: FQHCs and LHDs

1. Secure community support and leadership to implement the

partnership.

2. Establish measures to evaluate the partnership and its impact on the

community.

3. Evaluate community needs.

4. Clearly define their goals and objectives for entering into a partnership,

with careful consideration of the Patient Protection and Affordable

Care Act, regulations for Meaningful Use of Health Information

Technology, and the standards of the patient-centered medical home.

5. Carefully consider and determine the appropriate partnership to achieve

the FQHC’s and LHD’s identified goals and objectives.

6. Ensure that the partnership is financially feasible and beneficial.

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States

• The three actions that states can take to improve the interaction of primary care and public health

with delivery systems reform are:

– Enhancing primary care access through payment reform

and workforce development;

– Supporting public health programs that improve care outcomes; and

– Integrating primary care with public health through

community health teams, self-management training, coalition building, and health information technology.

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Interagency Collaboration

• Different organizational structures of HRSA and

CDC present logistical barriers to collaborative

efforts.

• Some key ways integration can be encouraged

include:

– The use of community health workers

– Effectively sharing data

– The involvement of third-parties to bring the two agencies together

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Facilitators of and Barriers to Primary Care and Public Health Collaboration

Facilitators Barriers

Systems Level • Government endorsement of the value of collaboration

• Sustained government funding• Resources available through pooling and

sharing

• Professional education emphasizing a system wide approach to working

collaboratively

• Lack of stable funding for collaborative projects• Lack of adequate funding for evaluation of

collaboration innovations• Separate, entrenched bureaucracies for medical

services and public health

• Lack of an adequate information structure

Organizational

Level

• Multi-professional involvement• Joint planning by primary care, public

health, and the community• Clear lines of accountability

• Use of a standardized, shared system for

collecting data and disseminating

• Lack of a common agenda or vision• A focus on individuals and short term results

• Resource limitations• Lack of capacity to coordinate and manage disparate,

diverse, and large teams

• Limited understanding of the needs of communities

Interactional

Level

• Clear roles and responsibilities for all partners

• Trust, tolerance, and respect for partners• Effective communication

• Resistance to change• Competing priorities and agendas

• Poor rapport between primary car and public health, as well as with the community

• Inadequate understanding of specific roles and

interdisciplinary teamwork

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Challenges

• Current funding system for primary care and public health is not well positioned to promote integration

• Competing funding streams have the effect of creating silos at the local level rather than

encouraging cooperation across entities.

• Similarly, most funding streams from HRSA and

CDC are inflexible, limiting what local entities can do with the funds and how they could be used for

integration.

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Current Funding Streams

Health CentersKaiser Family Foundation, 2010

Local Health DepartmentNACCHO, 2011

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Interagency Collaboration

• These structural differences mean there often is no natural link between the agencies.

• This situation is not necessarily negative. In fact, like puzzle pieces that fit into place, these structural differences can actually assist in promoting better coordination.

• In the short run, however, the differences can mean that staff from one agency do not always have a natural counterpart in the other.

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New Ways to Redirect Funds to Community

Prevention

• Wellness Trusts– A Wellness Trust, at its most basic level, is a funding pool raised and set aside

specifically to support prevention and wellness interventions to improve health outcomes of targeted populations. While funds to support the Trust can come from many sources, one key option is to levy a small tax on insurers and hospitals

• Social Impact Bonds/Health Impact Bonds– Health impact bonds (HIBs) provide a market-based approach to pay for

“evidence-based interventions that reduce health care costs by improving social, environmental and economic conditions essential to health.” raising capital from private investors to invest in prevention interventions, capturing the healthcare cost-savings that result from the interventions, and then returning a portion of those savingto the investors as profit

• Community Benefits from Non-Profit Hospitals– The “community benefit” requirements imposed on nonprofit hospitals and

health plans may represent a significant and sustainable source of funds for community-prevention initiatives

• Accountable Care Organizations – tying reimbursements to quality metrics that demonstrate improved outcome

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RECOMMENDATIONS

The IOM Report …

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Recommendation 1

• To link staff, funds, and data at the regional, state, and local levels, HRSA and CDC should: – identify opportunities to coordinate funding streams in selected programs and convene joint staff groups to develop grants, requests for proposals, and metrics for evaluation;

– create opportunities for staff to build relationships with each other and local stakeholders by taking full advantage of opportunities to work through the 10 regional HHS offices, state primary care offices and association organizations, state and local health departments, and other mechanisms;

– join efforts to undertake an inventory of existing health and health care databases and identify new data sets, creating from these a consolidated platform for sharing and displaying local population health data that could be used by communities; and

– recognize the need for and commit to developing a trained workforce that can create information systems and make them efficient for the end user.

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Recommendation 2 • To create common research and learning networks to foster and support the integration of primary care and public health to improve population health, HRSA and CDC should: – support the evaluation of existing and the development of new local and regional models of primary care and public health integration, including by working with the CMS Innovation Center (CMMI) on joint evaluations of integration involving Medicare and Medicaid beneficiaries;

– work with the Agency for Healthcare and Research Quality’s (AHRQ’s) Action Networks on the diffusion of best practicesrelated to the integration of primary care and public health; and

– convene stakeholders at the national and regional levels to share best practices in the integration of primary care and public health.

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Recommendation 3 • To develop the workforce needed to support the integration of primary care

and public health:

– HRSA and CDC should work with CMS to identify regulatory options for graduate medical

education funding that give priority to provider training in primary care and public health

settings and specifically support programs that integrate primary care practice with public

health.

– HRSA and CDC should explore whether the training component of the Epidemic Intelligence

Service (EIS) and the strategic placement of assignees in state and local health departments offer

additional opportunities to contribute to the integration of primary care and public health by

assisting community health programs supported by HRSA in the use of data for improving

community health. Any opportunities identified should be utilized.

– HRSA should create specific Title VII and VIII criteria or preferences related to curriculum

development and clinical experiences that favor the integration of primary care and public

health.

– HRSA and CDC should create all possible linkages among HRSA’s primary care training

programs (Title VII and VIII), its public health and preventive medicine training programs, and

CDC’s public health workforce programs (EIS).

– HRSA and CDC should work together to develop training grants and teaching tools that can

prepare the next generation of health professionals for more integrated clinical and public health

functions in practice. These tools, which should include a focus on cultural outreach, health

education, and nutrition, can be used in the training programs supported by HRSA and CDC, as

well as distributed more broadly.

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Recommendation 4

• To improve the integration of primary care and public health through existing HHS programs, as well as newly legislated initiatives, the Secretary of HHS should direct: – CMMI to use its focus on improving community health to support pilotsthat better integrate primary care and public health and programs in other sectors affecting the broader determinants of health;

– the National Institutes of Health to use the Clinical and Translational Science Awards to encourage the development and diffusion of researchadvances to applications in the community through primary care and public health;

– the National Committee on Vital and Health Statistics to advise the Secretary on integrating policy and incentives for the capture of data that would promote the integration of clinical and public health information;

– the Office of the National Coordinator to consider the development of population measures that would support the integration of community-level clinical and public health data; and

– AHRQ to encourage its Primary Care Extension Program to create linkages between primary care providers and their local health departments.

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Recommendation 5

• The Secretary of HHS should work with all agencies within the department as a first step in the development of a national strategy and investment plan for the creation of a primary care and public health infrastructure strong enough and appropriately integrated to enable the agencies to play their appropriate roles in furthering the nation’s population health goals.

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THANK YOU

You guys have been great …