What 1966 Can Teach Us About the Future of Primary Care: The Case for Communities of Solution

Primary care

In April 1966, the National Commission on Community Health Services presented President Lyndon Johnson with their report, Health Is a Community Affair.[1] Although the report was highly anticipated and generally well-received in an era of social reform, its impact over time has been limited.

Now, as COVID-19 poses severe challenges to American health care, and primary care struggles to survive, Health Is a Community Affair is a must-read. It offers a blueprint for a more responsive health care system—national in scope, local in focus—and an integrated primary care and public health approach that is essential for the well-being of communities moving forward.

A Personal Care and Community Health Framework

The National Commission on Community Health Services was charged with setting nationwide goals for delivering community health care. Health is a Community Affair includes recommendations on 14 topics deemed vital to health care planning. Perhaps the most innovative and underused recommendation is to organize health care around “communities of solution,” collaborative entities defined not by geography, but by the problems to be solved. A community of solution can cross local, regional, or national boundaries to address health issues through cooperative planning, shared resources, institutional collaborations, public-private partnerships, and team work because, as the report states, “neither communities nor their problems are self-contained.”

But a community of solution is more than a collaboration. It is a framework for improving health and delivering health care based on individual and community needs, with a focus on personal, comprehensive care delivered by multidisciplinary teams, community participation, attention to environmental and public health, and an adequate health workforce.

The community of solution concept got an important update in 2012-2013 by the American Board of Family Medicine’s Folsom Group (named for Marion Folsom, chair of the 1960’s national commission).  They reimagined the original recommendations in a 21st century context, resulting in a series of 13 building blocks[2] for implementing a community-focused, primary care-based system of care. These building blocks include integrated care, community partnerships, health literacy, and technology—all pointing the way to a new model of primary care.

Is a community of solution approach feasible? In a word, yes. The Folsom Group found examples of projects around the country that crossed geographic boundaries, incorporated multiple disciplines, including public health, and focused on or were led by communities. In one example,[3] a community of solution was formed to address poor access and fragmented care in a seven-county region of Texas. Together, civic groups, health care and social service professionals, policymakers, and educational institutions established the Brazos Valley Health Partnership. They quickly developed recommendations, resulting in the development of a rural health resource center that encompassed health care and social services, eventually expanding to four locations in four counties. With the establishment of local resource centers, each county implemented its own community of solution to address local needs, while the work of the regional community of solution continued. Today, they offer medical care, meal programs, transportation, substance abuse treatment, and access to legal aid, sexual assault counseling, youth and family programs, and more.

Other communities of solution[4] have facilitated local data sharing among stakeholders in public health, community health, informatics, and policy; developed a web-based tool to improve local health through an initiative funded by 20 community partners; and addressed chronic disease management in an underserved population through a collaboration among community members, community health workers, a hospital, an academic institution, the local faith community, and food pantries.

Community Health is a Priority

After more than 50 years, America is finally poised for the integrated primary care, public health, community-based approach described in Health is a Community Affair on a national scale. Why now? Because as the pandemic reshapes our world, it is bringing our priorities front and center. It is changing the organization and delivery of health care, underscoring the importance of caring for the nation’s health by caring for its communities.

With the 1966 report and its 2012 update as a framework, we can begin to operationalize a communities of solution system by addressing several fundamentals.

  • New ways of thinking: A health care system that embraces community health and local solutions requires a shift in perspective “from diseases to people, and from developing systems just for the individual to developing systems that serve the interconnected good of the population.”[5]
  • Common ground: Although a comprehensive integrated approach offers the personal and population-level care that communities need, the US health care and public health systems have long maintained separate silos. Widespread implementation of communities of solution will require primary care, public health, mental health, and other partners to find common ground through shared cultural and organizational resources and mutual understanding of the value of their collaboration.
  • Aligning payment: Payment systems must support collaborative community-focused care with “prospectively paid, risk-adjusted per member per month amounts, independent of the specific services delivered” so that clinicians can adapt to the needs of their patients and communities.[6]
  • Aligning education and workforce: Because communities of solution address a range of community needs, they require a broad workforce including clinicians, public health professionals, mental health professionals, community organizers, transformation facilitators, health connectors, and more. As a result, a community-based system of care requires a broad vision of where graduate medical education occurs, who is involved, and what is taught. Primary care clinicians and public health practitioners must learn together, for example, and train with a variety of collaborators within communities of solution.
  • Resources: In developing 21st century communities of solution, “perhaps the most exciting low-hanging opportunity is the potential to utilize technology to integrate individual-level, practice-level, and community-level health measures.”2 This includes community mapping, public health information exchanges, and other information technology linkages. Communities of solution need accurate data, technical support, shared learning, and infrastructure for collaboration.

Rewriting our Imaginations

A science fiction writer recently explained that “the [corona]virus is rewriting our imaginations. What felt impossible has become thinkable.”[7] If it was hard to see community-based health care as a policy priority just a few months ago, it is now clear. Health is truly a community affair, and it is crucial that we start imagining what the next chapter in American health care will look like.

Shortly after the original report was presented to President Johnson more than 50 years ago, an editorial proclaimed that its recommendations “are far-reaching indeed; it is up to us to do what is necessary.”[8] We must not miss our chance to do what is necessary. Let’s start by stepping up and looking back to 1966.

 

References

[1]. National Commission on Community Health Services. Health is a Community Affair. Cambridge, MA: Harvard University Press; 1966.

[2]. The Folsom Group. Communities of solution: the Folsom Report revisited. Ann Fam Med. 2012;10:250-260. doi:10.1370/afm.1350

[3]. Garney WR, Drake K, Wendel ML, McLeroy K, Clark HR, Ryder B. Increasing access to care for Brazos Valley, Texas: a rural community of solution. J Am Board Fam Med. 2013;26(3):246-253. doi: 10.3122/ jabfm.2013.03.120242

[4]. Griswold KS, Lesko SE, Westfall JM, for the Folsom Group. Communities of solution: partnerships for population health. J Am Board Fam Med. 2013;26:232–238.

[5]. Stange, KC. Power to advocate for health. Ann Fam Med. 2010, 8:100-107. doi: 10.1370/afm.1099

[6]. Gold SB, Green LA, Westfall JM. How payment reform could enable primary care to respond to COVID-19. The Milbank Memorial Fund. https://www.milbank.org/publications/how-payment-reform-could-enable-primary-care-to-respond-to-covid-19/. Published April 2020. Accessed June 10, 2020.

[7]. Robinson, KS. The Coronavirus Is Rewriting Our Imaginations. The New Yorker. May 1, 2020. https://www.newyorker.com/culture/annals-of-inquiry/the-coronavirus-and-our-future. Accessed May 10, 2020.

[8]. The National Commission Reports [editorial].  J Public Health. 1966;56(6):865-867.


Citation:
Gotler RS, Green LA, Etz RS. What 1966 Can Teach Us About the Future of Primary Care: The Case for Communities of Solution. Milbank Quarterly Opinion. June 10, 2020. https://doi.org/10.1599/mqop.2020.0610.


About the Authors

Robin S. Gotler, MA, is a program director and medical historian in the Center for Community Health Integration at Case Western Reserve University and a team member in the Larry A. Green Center, which works to reclaim and reconstitute the intellectual foundations of primary care, advance the science of medicine within social frameworks of meaning, and support better health and improved health care through a synergistic focus on humanism and healing. She is Reflections editor of the Annals of Family Medicine and editor of the book, “The Wonder and the Mystery: 10 Years of Reflections from the Annals of Family Medicine.”

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Larry A. Green, MD, is distinguished professor of family medicine and the Epperson-Zorn Chair for Innovation in Family Medicine and Primary Care at the University of Colorado and senior advisor to the Eugene S. Farley Jr. Health Policy Center. He is an academic family physician who has served in various roles including medical practice in rural and urban settings, residency director, investigator, teacher, and department chair. He directed Prescription for Health, funded by the Robert Wood Johnson Foundation focused on addressing unhealthy behaviors in primary care practice and Advancing Care Together funded by the Colorado Health Foundation, aiming to change a broad spectrum of practices to provide integrated care. He served as the founding director of the Robert Graham Center for Policy Studies in Family Medicine and Primary Care in Washington, DC, and is a member of the National Academy of Medicine. His current work emphasizes redesigning how clinical practice, health professions education, and clinical research are done. Dr. Green completed medical school at Baylor College of Medicine and family medicine residency at the University of Rochester. April 2020

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Rebecca S. Etz, PhD, is codirector of the Larry A. Green Center and a cultural anthropologist at Virginia Commonwealth University with expertise in qualitative research methods and design, primary care measures, practice transformation, and engaging stakeholders. She has spent the last ten years dedicated to learning the heart and soul of primary care. Her career has been shaped by iterative research cycles that expose and reflect on the tacit norms and principles of primary care in which clinicians, thought leaders, and patients are equally invested. Her work has three main lines of inquiry: 1) bridging the gap between the business of medicine and the lived experience of the human condition, 2) making visible the principles and mechanisms upon which the unique strength of primary care is based, and 3) exposing the unintended, often damaging consequences of policy and transformation efforts applied to primary care but not informed by primary care concepts

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