A Practical Playbook to help primary care and public health team up

Brian Castrucci, who’s worked in city and state health departments and is now Chief Program and Strategy Director at the de Beaumont Foundation, likes to ask people two questions: Do you know who your primary care provider is? And, Do you know who’s head of your local public health department? The fact that many people can answer the first question but not the second, he says, demonstrates why public health needs to partner with health care.

“US medical providers are giving people some of the best medical care in the world, but if they’re returning patients to communities and environments that are antagonistic to good health, patients will still fare poorly,” Castrucci explains. “Public health can help create environments that are supportive of the medical interventions people are getting from the healthcare system.” For instance, doctors might recommend that patients with diabetes and high blood pressure engage in regular physical activity, but it’s hard for people to follow those recommendations if they live in communities with few safe opportunities for exercise. Public health departments can play a role in identifying such communities and working to make them more supportive of healthy lifestyles.

With a new tool called the Practical Playbook, the de Beaumont Foundation, Duke Community and Family Medicine, and the Centers for Disease Control and Prevention aim to help local and state public health professionals and local, state, and regional primary-care groups collaborate with one another to improve their communities’ health and reduce healthcare costs. It offers tips and resources for partners working through each stage of the integration process: organize and prepare; plan and prioritize; implement; monitor and evaluation; and celebrate and share. The Practical Playbook site also contains a wealth of success stories, including the following:

Indiana’s Asthma Emergency Department Call Back Program conducts outreach to asthma patients seen in the emergency department of Parkview Health emergency rooms in northeast Indiana to help patients improve their asthma management. With support from the Indiana Department of Health, the not-for-profit Parkview Health system has a trained community health nurse or respiratory specialist contact patients soon after an emergency department visit for asthma to assess patients’ needs and offer assistance. Patients who cannot afford medication to control their asthma are enrolled in Parkview’s Medication Assistance Program, and those without a medical home are referred to a Parkview physician, community health center, or free clinic. The program also works with the Fort Wayne-Allen County Department of Health and local school districts to provide families with resources to help manage asthma and avoid future hospital visits. A survey of program participants found that 59% reported missing zero days of school or work since joining. Program resources available on the Practical Playbook website include contact forms that Parkview Health uses for the initial contact with asthma patients following their emergency department visit and six months after the initial contact. A program evaluation found 38 fewer asthma-related emergency room visits and nine fewer hospitalizations after the program’s first year, for an estimated savings of more than $600,000.

Massachusetts’ Mass in Motion program helps 33 communities support healthy eating and active living. In response to an alarming ride in statewide obesity rates, especially among African-Americans and Latinos, the Massachusetts Department of Health partnered with local organizations and healthcare teams (Massachusetts Department of Public Health, the Harvard Pilgrim Health Care Foundation, The Boston Foundation, Blue Cross Blue Shield, Tufts Health Plan Foundation, MetroWest Health Foundation) to provide technical assistance and support for 11 pilot sites to build capacity and establish multi-sector partnerships to increase active living and healthy eating, with an emphasis on health equity. With a federal Community Transformation Grant and funding from Partners HealthCare, the program was able to scale up. Communities are participating in Healthy Corner Store, Adopt-a-Park, Farm to School, and Safe Routes to School Programs; improving sidewalks and roads to encourage walking and biking; and launching community gardens and mobile veggie markets. In an early analysis of body mass index (BMI) levels, five Mass in Motion communities saw a 2.4% decrease in BMI levels classified as overweight or obese, while other communities experienced only a 0.4% decrease. Mass in Motion’s Practical Playbook page links to the program’s annual highlights and information on Community Transformation Grants.

Michigan’s Healthy Futures program is a partnership between Munson Medical Center and local health departments to assure pregnant women and new mothers have the healthcare and resources they need. The partners launched the program in response to findings that many women were not able to get necessary prenatal care and that families had complex health needs that could not be addressed within the scope of doctor’s visit. Now, expectant mothers participating in Healthy Futures get support from a registered nurse during pregnancy and during the first two years of their children’s lives. They also receive newsletters covering topics such as immunizations, safety, and nutrition. Research has found that among enrollees, breastfeeding rates and immunization rates for two-year-olds are higher than national, regional, and state averages. The program’s Practical Playbook page includes links to the Healthy Futures newsletters that go to women at various stages of pregnancy and to parents throughout their children’s first two years of life.

The Practical Playbook doesn’t just aim to lengthen the list of success stories, though; it’s part of a larger effort to build a system that integrates primary care and public health in order to address the chronic illnesses that account for a growing share of the US disease burden. In 2012, the Institute of Medicine released the report Primary Care and Public Health: Exploring Integration to Improve Population Health. It recommended bringing the two sectors together and identified a set of core principles for integration efforts. Dr. J. Lloyd Michener, who chairs the Department of Community and Family Medicine at Duke University Medical Center and served on the IOM committee that produced the report, recalls, “In putting the IOM report together, we noticed that there were lots of examples of successful primary care-public health integration, but people didn’t know about them.”

Michener, who also worked on the Practical Playbook, stresses that he and his colleagues are working to “build on local strengths and expertise.” He points out that with the Affordable Care Act starting to reward healthcare providers for prevention (with initiatives such as accountable care organizations and shared-savings models), primary-care practices have new incentives to invest in improving the health of the populations they serve. But they don’t always know that public health can be a key partner. “We’re trying to help public health departments and primary-care providers take advantage of the tools the ACA provides, as well as the knowledge and experience that clinicians and public-health practitioners can share with one another,” he says.

The jump in rates of heart disease, diabetes, and other chronic diseases has also made the integration necessary. “We’ve gone from a time when disease was primarily caused by microbes to a time when it’s originating in social and environmental conditions – but our healthcare system hasn’t necessarily made the switch,” says Castrucci. “We need to allow public health to address some of the upstream concerns – and public health has 300 year old infrastructure and experience to do it.”


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