Primary Care and Population Health: Third in a Five-Part Series

Robert Wood Johnson Foundation Human Capital Blog, January 31, 2013

Nicholas Stine, MD, and Dave Chokshi, MD, MSc, writing on behalf of the New York Academy of Medicine Primary Care and Population Health Working Group.

The New York Academy of Medicine is the National Program Office for the Robert Wood Johnson Foundation Health & Society Scholars program, which works to reduce population health disparities and improve the health of all Americans. The New York Academy recently conducted a survey of 17 thought leaders in primary care and population health. In the third of five blog posts, we share a synthesis of what those leaders had to say. All quotes are printed with permission.

Local and State Health Department Collaboration: Most discussants agreed that clinical systems and health departments use different notions of ‘population’—and historically are not well integrated. As David Stevens, MD, noted, “There’s capacity that needs to be built on a common language on how to work together that isn’t there because they've been separated so long.”

There was, however, a prevailing notion that this dynamic is changing in important ways. Many cited the convergence of IRS Community Health Needs Assessment (CHNA) requirements and new public health accreditation standards as a potential blueprint for future collaborations. Clinical delivery systems, generally well-resourced but with limited community assessment and intervention skills, are now responsible for conducting a CHNA every three years while developing and implementing an action plan to address identified needs.

Health departments, meanwhile, offer skills and expertise in this area but are generally starved for funds to execute such functions. Health department accreditation, by requiring a similar community assessment, creates a common agenda as well as a process to demonstrate accountability. “We almost don't care what they choose to invest in,” remarked Seattle/King County Health Officer David Fleming, MD. “The primary goal is to create the climate of collaboration.”

Downstream from these initial collaborative forays, many discussants articulated a vision of health departments as an “integrator” of clinical and non-clinical services to improve population health. Through maintaining a broad, geographic, population-based perspective, health departments may serve the role of convener and mobilizer, even though they may not have the resources or expertise to deliver interventions. In addition to their own surveillance and epidemiologic capacities, health departments may serve as aggregators and organizers of practice-based data to identify targets for population health improvement.

Steve Teutsch, MD, MPH, described some of the challenges and opportunities from the health department perspective.  “Engagement with the broader clinical community is a tremendous struggle.” One major hurdle is fragmentation of provider systems: in Los Angeles County, the health department works with academic medical centers and with Kaiser Permanente, but the rest of the clinical delivery system is “terribly decentralized.”

On the public health side, the main challenge is scale. “To get 10 million people to do something all at once—it is a difficult job.” Teutsch described a phased approach whereby communities that are interested in a particular public health intervention—e.g., a smoking ban, bike lanes, or banning toys in fast food meals—are supported as “early adopters.”  These pilots are used to demonstrate efficacy and then build momentum for broader adoption.

Visit the RWJF Human Capital Blog next week for Part Four in this series, which will look at the role of primary care and clinical incentives. See all the posts in the series here.

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