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Electronic letters published:
![[Read Comment]](/icons/misc/sectionDOWN.gif){kind=icon}
Improving community-based care: opportunities for leadership
Response to Dr. Frey
A "side" benefit of CCNC that may be more important than the primary one
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Mark J. DeHaven, Dallas, USA Professor, UT Southwestern Medical Center
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The article by Steiner, et al. is welcome reading for many reasons. First, amidst the growing body of literature calling for health care reform, reducing health disparities, and preventing disease, the author’s describe an actual primary care system of care that is addressing all of these concerns (1). Second, for those who value the Declaration of Alma- Ata, the CCNC appears as a unique American adaptation incorporating the Declaration’s two overarching goals of fairness in access to care and efficiency in service delivery (2). Finally, the program’s emphasis on integrating primary care with community organization in a way that reduces costs and improves quality, serves as an important lesson to national policy makers. Perhaps United States’ policy makers can discover what others have found in parts of the world where health care resources are substantially more limited – that successful and innovative heath care approaches are possible, but only when the political will exists among those in positions of authority (3). However, in addition to these reasons the CCNC may be especially significant for the opportunity it presents for family medicine, in the context of the growing national emphasis on clinical and translational research. The authors specifically note that the CCNC was developed as a collaborative effort among concerned physicians, community leaders, and policy makers, and not through the efforts of health services researchers. However, the type of approach they describe – community leadership in network development and care coordination founded on primary care principles – is precisely how a community medicine research approach can work. The CCNC emphasis on improving quality, reducing costs, and preventing and managing disease, provides a research agenda for the nation and for those involved in academic community medicine. In community-based participatory research (CBPR) – and as done in the present case – the community can take the lead in defining priorities and the investigators can be one participant among many, contributing to improving the community’s health while sharing research expertise when appropriate. Community medicine has long existed in the specialty of family medicine, but without having a well-defined role or mission (4). More than three decades ago Kurt Deutschle at the Mt. Sinai Medical Center, envisioned a medical school with three types of faculty – basic science faculty would improve understanding of disease, clinical faculty would translate this knowledge into treating individual patients, and community medicine faculty would integrate this knowledge into the community while identifying new health problems (5). The vision articulated by Deutschle still awaits expression. At this critical time in the evolution of medicine and medical care delivery, innovative approaches such as the CCNC suggest that there is an opportunity for family medicine to provide leadership in developing both alternative models of care delivery and collaborative community-based approaches to research. References 1. Schroeder, S. We can do better – improving the health of the American people. NEJM. 2007; 357:1221-1228. 2. Chan, M. Return to Alma-Ata. The Lancet. 2008; 372: 865 – 866. 3. Birn, AE. Federalist flirtations: The politics and execution of health services decentralization for the uninsured population in Mexico, 1985 – 1995. J Pub Health Pol. 1999; 20 (1): 81 – 108. 4. DeHaven, MJ and Gimpel N. Reaching out to those in need: the case for community health science. JABFM. 2007; 20: 527-532. Journal of the American Board of Family Medicine. 5. Silver, AL and Rose, DN. Kurt W. Deuschle and community medicine: clinical care, statistical compassion, community empowerment. Mount Sinai J of Med. 1992; 59(6): 439-443. Competing interests: None declared |
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Beat Steiner, Chapel Hill NC family physician
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Dr Frey highlights one of the most enjoyable aspects of being a medical director in one of the Community Care networks. Working collaboratively with other community physicians to improve the care of Medicaid patients has been a real joy. I work clinically in a Community Health Center and prior to my work with CCNC had few opportunities to interact with my colleagues in private practice. I now know most of the primary care physicians practicing in our four county network, have visited them in their practices and have shared ideas with them at our meetings. Given the state of our health care system and the current economic realities, competitive tensions remain between practices but I agree with Dr Frey that CCNC has raised the social capital in our communities. Competing interests: None declared |
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John Frey, Madison, Wisconsin USA University of Wisconsin School of Medicine and Public Health
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Congratulations to Steiner et. al both for leading the effort to pull practices together to promote quality and for getting it into print for others to consider and apply to our own local and regional environments. The process they used may be as important to the health of the citizens of North Carolina as the improved economic and chronic care outcomes they describe. Family doctors still practice in this country primarily in small groups or single handed practices. That trend may be changing, but not radically, and will continue to be the norm particularly in smaller towns and rural communities such as many in their study. With the erosion in primary care careers, it is even more essential that the qualities which compel physicians to practice in small groups be understood and supported. The process CCNC used to get sometime rivals in communities to talk with each other, find common ground, bring resources that can be used by the networks and the individual practices to meet patient needs undoubtedly created a sense of interdependence and collective action which reinforced the control, autonomy, and service that are essential for physician satisfaction. If the work of Steiner and colleagues leads to physicians who not only improve their practices and earn more in the process but increase the social capital in their communities through collaboration and cooperation, then they will have increased the likelihood that those physicians will stay in community practice. 1 In an era of looming primary care collapse, that may be the biggest success of CCNC in the long run. 1. Cutchin M. Physician retention in rural communities: the perspective of experiential place integration. Health Place. 1997 Mar;3(1):25-41 Competing interests: None declared |
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