The Patient Centered Medical Home : Where is Public Health?

Transcription

1 The Patient Centered Medical Home : Where is Public Health? Mouhanad Hammami, MD County Health Officer & Chief of Health Operations 1

2 The PCMH 2

3 Patient Centered Medical Home 3

4 Patient Centered Medical Home Recognition Program PPC-PCMH Recognition is based on meeting specific elements included in nine standard categories: 1. Access and Communication 2. Patient Tracking and Registry Functions 3. Care Management 4. Patient Self-Management and Support 5. Electronic Prescribing 6. Test Tracking 7. Referral Tracking 8. Performance Reporting and Improvement 9. Advanced Electronic Communication NCQA Physician Practice Connections 4

5 Patient-Centered, Physician-Guided Care Practice Team Physician Patient Family Adapted from: Defining Primary Care: An Interim Report, Institute of Medicine

6 The House on the Hill PRIMARY CARE 6

7 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. 7

8 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. 8

9 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, longterm 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. 9

10 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,

11 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. 11

12 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. David Lawrence, former CEO of Kaiser Permanente on the care his 88-year-old mother received in the regular Medicare system after she fell 12

13 Life Expectancy and Health Spending, OECD,

14 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. 14

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16 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 16

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18 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. 18

19 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 19

20 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,

21 Little House on the Prairies PUBLIC HEALTH 21

22 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. 22

23 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,

24 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. 24

25 Public Health Resources that Support Primary Care Practices 25

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27 NACCHO,

28 NACCHO,

29 NACCHO,

30 NACCHO,

31 NACCHO,

32 NACCHO,

33 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,

34 NACCHO,

35 NACCHO,

36 NACCHO,

37 NACCHO,

38 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 Department of Health and Human IOM, Services 1996 fulfilling society s interest in assuring conditions in which people can be healthy IOM,

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40 Chargoggaggoggmanchaugagoggchaubunagungamaugg "You fish on your side I fish on my side and nobody fish in the middle 40

41 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 41

42 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. 42

43 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 (ccordination of care) Principle (community participation) 43

44 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. 44

45 What Care Coordination Should Look Like 45

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47 PUBLIC HEALTH 47

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49 The Chronic Care Model 49

50 The Expanded Chronic Care Model 50

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52 Linkages between clinical practices and community organizations: a proposed model Porterfield et al. AJPH,

53 Your Neighborhood Convenience Health Center FQHC 53

54 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. 54

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57 Essential Public Health Services Carried Out by FQHCs Public Health Services 1. Monitor health status to identify community health problems Examples of Health Center Activities 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. 57

58 Essential Public Health Services Carried Out by FQHCs Public Health Services 2. Diagnose and investigate health problems and health hazards in the community Examples of Health Center Activities 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. 58

59 Essential Public Health Services Carried Out by FQHCs Public Health Services 3. Inform, educate, and empower people about health issues Examples of Health Center Activities 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 59

60 Essential Public Health Services Carried Out by FQHCs Public Health Services 4. Mobilize community partnerships to identify and solve health problems Examples of Health Center Activities 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. 60

61 Essential Public Health Services Carried Out by FQHCs Public Health Services 5. Develop policies and plans that support individual and community health efforts Examples of Health Center Activities 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. 61

62 Essential Public Health Services Carried Out by FQHCs Public Health Services 6. Educate on laws and regulations that protect health; advocate for, review, and evaluate legislation; facilitate compliance Examples of Health Center Activities Provide testimony, advocacy, and education on legislation related to mandatory prevention measures 62

63 Essential Public Health Services Carried Out by FQHCs Public Health Services 7. Link people to needed personal health services and ensure the provision of health care when otherwise unavailable. Examples of Health Center Activities 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. 63

64 Essential Public Health Services Carried Out by FQHCs Public Health Services 8. Ensure a competent public health and personal health care workforce Examples of Health Center Activities 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. 64

65 Essential Public Health Services Carried Out by FQHCs Public Health Services 9. Evaluate effectiveness, accessibility, and quality of personal and population-based health services Examples of Health Center Activities 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. 65

66 Essential Public Health Services Carried Out by FQHCs Public Health Services 10. Research for new insights and innovative solutions to health problems Examples of Health Center Activities Foster strong relationship with local university to perform research and program evaluation. Research initiatives take a communitybased participatory research approach. 66

67 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. 67

68 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. 68

69 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

70 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. 70

71 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) 71

72 Removing the Walls INTEGRATION 72

73 Timing The ACA presents an overarching opportunity to change the way health is approached in the United States 73

74 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 74

75 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 75

76 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). 76

77 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) 77

78 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 78

79 Degrees of Primary Care and Public Health Integration 79

80 Synergies of Medicine and Public Health Collaboration Synergy Improving health care by coordinating services for individuals Improving access to care by establishing frameworks to provide care for the uninsured Improving the quality and costeffectiveness of care by applying a population perspective to medical practice Using clinical practice to identify and address community health problems Strengthening health promotion and health protection by mobilizing community campaigns Examples Bring new personnel and services to existing practice sites Establish one-stop centers Coordinate services provided at different sites Establish free clinics Establish referral networks Enhance clinical staffing at public health facilities Shift indigent patients to mainstream medical settings 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 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 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 Influence health system policy health system by collaborating around Engage in cross-sector education and training policy, training, and research Conduct cross-sector research SOURCE: Lasker and Committee on Medicine and Public Health,

81 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,

82 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 82

83 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. 83

84 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 84

85 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.,

86 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,

87 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. 87

88 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. 88

89 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 89

90 Facilitators of and Barriers to Primary Care and Public Health Collaboration Systems Level Organizational Level Facilitators 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 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 Barriers 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 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 90

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92 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. 92

93 Current Funding Streams Health Centers Kaiser Family Foundation, 2010 Local Health Department NACCHO,

94 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. 94

95 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 95

96 The IOM Report RECOMMENDATIONS 96

97 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. 97

98 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 practices related 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. 98

99 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. 99

100 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 pilots that 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 research advances 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 communitylevel 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. 100

101 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. 101

102 You guys have been great THANK YOU 102