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Community Oriented Primary Care
COPC
Social Medicine in Action
Jaime Gofin, MD, MPH, Rosa Gofin, MD, MPH
Department of Health Promotion, Social and Behavioral Health
College of Public Health
University of Nebraska Medical Center
August 2014
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Purpose: to describe and analyze…
• The Practice of Social Medicine
• Development of COPC
• Current status of COPC
• Social Medicine
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Social Medicine is… a field of medicine
1. Study the impact of the collective behavior of
organized society… on individuals McGraw-Hill Dictionary of Modern Medicine
2. Concentrating on the social, cultural, and
economic impact …of medical phenomena
Farlex Partner Medical Dictionary
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Social Medicine is… a field of medicine
3. Prevention & treatment of disease based on
the study of human heredity, environment,
social structures, cultural values
Mosby’s Medical Dictionary
4. Organized investigation of social, genetic and
environmental factors influencing human
disease and disability & promotion
prevention…individuals & community Webster Dictionary
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Social Medicine is…
“…a practice of medicine concerned with health
and disease as a function of group living”
SL Kark, A Practice of Social Medicine, E&S Livingstone Ltd,1962
“…the social in medicine”
SL Kark, Lectures International MPH Program Hebrew University, 1972-3
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“
“…if the major determinants of health are social, so must be the remedies”
M. Marmot, Lancet 2005;365:1099-1104
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Primary Care (PC) in U.S.*
“Health is better in US regions with more PC
physicians”
“When there are more PC providers relative to
specialist care, costs are lower”
* Acad Med, May 2008
Med Educ Future Study, July 2008
New Eng J Med, 13th November 2008
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Primary Care…*
In countries with a strong Primary Care infrastructure, there are lower rates of:
- premature deaths
- deaths from treatable conditions
More appropriate use of services
Lower costs
Increased patient satisfaction
* based on an international studies, B. Starfield et al (2005-8)
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Primary
Care
Primary
Care
Levels of health care Financing of health care
Other levels
of care
Other levels
of care
J.Gofin
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Medicine in the Community
Community Medicine
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1000 Population
250 consulted
750 felt ill
1 Teaching Hospital
9 hospitalized
Source: K. White, 1961, N
Eng J Med; Green 2001,
NEJM
University of Nebraska Medical Center
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Population
Teaching Hospital
University of Nebraska Medical Center
J. Gofin & R. Gofin. Essentials of Global
Community Health. Jones & Bartlett
Learning,2011.
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Teaching Hospital
Population
Primary Care
University of Nebraska Medical Center
J. Gofin & R. Gofin. Essentials
of Global Community Health.
Jones & Bartlett Learning,2011
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Innovations in Primary Care ?
A study (literature review) about changes in PC
innovations since 2000, on 330 cases:
changes were
additional resources
rather than changes in the organization of
clinical practice*
*Friedman et al. Medical Care, 2014;52(2):101-11
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Community
Oriented
Primary
Care
COPC
University of Nebraska Medical Center
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COPC is…
Integration of
clinical individual care
and
public health actions
in a defined total COMMUNITY
J.Gofin
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COPC: Origin & Development
ORIGIN: by S.L. Kark & E. Kark while providing
primary health care in the rural areas of South
Africa (1940’s)
DEVELOPMENT: at the Hadassah Community
Health Center of School of Public Health &
Community Medicine – Jerusalem
CURRENT STATUS: COPC is one of the
approaches suggested worldwide for the
provision of an integrated care model of
MEDICINE and PUBLIC HEALTH
University of Nebraska Medical Center
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COPC: Origin & Development
ORIGIN: by two family physicians SL Kark & E Kark while providing primary health care in the rural areas of South Africa (1940’s)…
Delivery of health care that they called…as “Social Medicine”
in a Community Health Center
Book: “A practice of Social Medicine” Chapter 1 (1962) re-published in www.socialmedicine.info (Vol1- #2)
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Social Medicine by Kark in the 40’s and 50’s
Community as a whole
Behavioral, cultural and social characteristics were crucial components of assessment of health and of planning of care
Provision of health care by a team
Epidemiology as a tool for the assessment of health determinants and evaluation of care
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Social Medicine by Kark in the 40’s and 50’s
Based on social medicine principles, and
according to health needs of the community
identified by epidemiologic methods,
Kark created & defined a
“COMMUNITY SYNDROME” of
- Malnutrition
- Communicable diseases
- Psycho-social problems
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Pholela Community Health Center
• Reduction of IMR and of infectious
diseases; improvement of health status
of total community
• Decision by Government for another 200
Community Health Centers
• Forty four (44) were established
• Apartheid and closure of all Centers
• Emigration of the Team
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The Social Medicine in Pholela has been…
…considered as “precursor” of the
Primary Health Care (PHC) movement
initiated with the WHO Alma Ata Conference
in 1978, (that changed substantially the PC
landscape worldwide)
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COPC role in the origin of the Alma Ata
Conference on PHC
• Connor EM, Inst of Medicine, 1983
• Susser M, Bull World Health Org,1999
• Crampton P, Soc Sci Med, 2001
• Litsios S, Amer J Pub Health, 2004
• Gofin J & R, Amer J Pub Health 2005
• Sanders D, Univ Western Cape, 2009
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Family Practice
Mother and Child
Elderly Home Care
Hadassah Community Health Center Kiryat HaYovel, Jerusalem:
COPC Service, Teaching & Research
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Activities of the Community Health Center as
part of the Department of Social Medicine:
Total community in a geographic defined area.
Assessment of health needs.
Community Health Programs (children, adults).
All programs were evaluated, taught, published.
Amer J Pub Health, 2002, November;1717-1721.
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COPC is…(S.L. Kark)
“ … a way of practicing medicine and nursing or of
providing primary care… care of the individual who
is well or sick, or at risk for illness or disease, also
promoting the health of the community as a
whole…” (1983)
University of Nebraska Medical Center
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COPC is…
“… an integration of community medicine with
the primary health care of individuals”
(Institute of Medicine-IOM, 1984)
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COPC Principles Responsibility for the health of a defined
population
Care is based on the identified health needs at the population level
Prioritization
Program of intervention covering all the stages of the health-illness continuum of the selected condition (health promotion, prevention, treatment, rehabilitation – physical, social, mental)
Community involvement
University of Nebraska Medical Center
J. Gofin & R. Gofin. Essentials
of Global Community Health.
Jones & BartlettLearning,
2011
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Canada Health Services Research Foundation
Study: “Collaboration between PHC and PH”* Review of 114 articles (out of 6125)
“The majority of papers didn’t identify use of any
theory, with the notable exceptions of papers
using COPC model,
teambuilding theory, and theoretical
framework for collaboration between Medicine
and PH by Lasker”
*Martin-Misener R & Valaitis R, 2008
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Community definition & characterization
The COPC Process / Cycle
Evaluation
Reassessment
Detailed problem
assessment
Intervention
planning &
implementation
Prioritization
J. Gofin & R. Gofin. Essentials of Global
Community Health. Jones & Bartlett
Learning,2011
University of Nebraska Medical Center
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Community definition & characterization
The COPC Process / Cycle
Evaluation
Reassessment
Detailed problem
assessment
Intervention
planning &
implementation
Prioritization
J. Gofin & R. Gofin. Essentials of Global
Community Health. Jones & Bartlett
Learning, 2011
University of Nebraska Medical Center
- Responsibility
- Identify Health Needs
- Prioritization
- Care Nat. History
Disease
- Community
Participation
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Other characteristics of the approach
Accessibility
Pro-active
Outreach
Multidisciplinary team
Inter-sectorial cooperation
University of Nebraska Medical Center
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COPC in the US
1957 J Geiger in Pholela:
”…walls of examining rooms were lined with charts and graphs of community demography, IMR, other morbidity and mortality rates and their changes over time. It was almost impossible not to be aware of denominators when seeing an individual patient” (IOM,1981)
Health Centers Boston, Mississippi
Development of the Comm. H. Centers
Today there are 1,200 CHCs/20 millions
University of Nebraska Medical Center
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COPC at Rochester, NY*
Patients and Community Together-PACT
- A private family practice - 3.000 population
- Definition: All active patients enrolled in last 2yrs
- PACT & Team identified, prioritized health needs
- Intervention addressing those needs
Evaluation:
- Childhood immunizations, 78% - 97%;
- Papanicolau: 46% to 71%;
- Glycosylated Hb level <0.1: 56% to 77%
* Arch Fam Med 1999;8:546-9
University of Nebraska Medical Center
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Parkland’s COPC Program – Dallas
“largest application of COPC in the US”
- 26 primary care settings, annual assessments
- Priorities: Infant Mortality, DM, CVD, accidents
- “Community conversations”
- Provision of primary health care
- EVALUATION: fewer hospitalizations in COPC
clinics; decrease pre-term births, Hb.A1c
dropped; lower medical costs
AJPH, Nov 2002
University of Nebraska Medical Center
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Hadassah Community Health Center - Jerusalem:
COPC Service, Teaching & Research
Family Medicine
Workshop
Jerusalem
Family Medicine
Spain
G.P. Teams
U.K.
COPC WORKSHOP – International MPH 100 hours
G.W.U.
U.S.
800 graduates from 90 countries
South Africa Latin America Turkey
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COPC teaching and practice in Spain
• COPC Workshops 500 Fam Drs/Nurses (1987…
• COPC Working Group Society Fam Physicians
• COPC in Residency Program Fam Med (2000)
• 8 COPC Pilot Centers for F&CM Residency
• 34 Primary Care Teams applying COPC
• 72 Health Centers in a Network of Community
Oriented Health Centers (2013)
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How did this happen in Spain?
Reform of Health Services
Motivated Family
Physicians
Attributes of the approach
R E L E V A N C E TO THE
SPANISH HEALTH CARE
SYSTEM
On-going collaboration
with academic institution
Family & Community Medicine
Specialty search for own identity
J.Gofin
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COPC is…
“…the practice of Primary Care with population responsibility, oriented to the health improvement of a defined community served by the health service, with the progressive participation of the community and in coordination with all services involved with the health of the community or its determinants”
Foz G, Gofin J, Montaner I. Atencion Primaria Orientada a la Comunidad (APOC):
Una vision actual. In: Atencion Primaria, Martin Zurro (eds) Barcelona, 2008
University of Nebraska Medical Center
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Uruguay
Consultancy Community Medicine (PAHO) 1994
COPC Workshop 18 Health Directors 1997
New Government with a new Political
Platform: National Integrated Health
Services
2005
COPC Capacity Building Program for 37
Regional Directors of PC
2006
Ten Health Care Clinics of second largest
province are involved in the practice of
COPC- MOH Support
2007-14
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COPC: from capacity building to practice
• Spain: 34 Primary Care Centers
• UK: applied in Family Practice
• GWU: COPC Team “beyond teaching”
(Technical assistance to PAHO, HRSA,
Hospitals, Community Coalitions)
• Uruguay: National Integrated Health
Service (priority: primary care)
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COPC – International Health
Organizations
PAHO
WHO
WONCA
Network Towards Unity for Health
Family Physicians in Africa
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Family Practice in Africa*
“Family Medicine practice should always be
community-oriented and context-specific. The
starting point is a defined community. Family
physicians’ care …[with] their community
orientation, with their community role arising out of
their clinical role. Community-oriented primary care
is one tool that family physicians can use to make
the link between individual and community care.”
*2nd African Regional WONCA (World Organization of Family Doctors) Conference, Rustenberg, South Africa, 2010
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Effectiveness:
different programs and countries Decrease prevalence of infectious and chronic
diseases
Decrease hospitalizations
Changes in behavioral factors
Promotion of growth and development
Improve health team work
Organize medical care
Costs?
University of Nebraska Medical Center
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Community Oriented Primary Care-COPC
considered/referred in (12) publications
in the last 3 years in…
• World Health Organization
• Institute of Medicine (IOM) & HRSA
• JAMA, Ann Int Medicine
• Ann Fam Medicine
• Amer J Prev Medicine
• Amer J Pub Health
• Academic Medicine
• Two books
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COPC considered in the publications as…
• an Integration of PH and Medicine
• a cornerstone in Primary Care (PC)
• services working with the community
• based on the epidemiology of community’s
health
• as health care outside the medical offices
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CHALLENGES: Health professionals
attitude towards…
• Reimbursement system
• Lack of incentives and rewards
• More time/efforts for additional new
functions
• Requires to learn methodological skills
on COPC
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The Affordable Care Act (ACA)
- Increasing size/diversity of workforce in
Primary Care & Public Health
- Supporting education of PC providers to
improve community health
- Establishing Accountable Care
Organizations, that
incentivize population health rather than
individual care, through new models of care
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Opportunities to develop COPC
Reform health services environment
Information technology
Community involvement in health
Initiatives on integration of clinical
medicine and public health
Stronger primary care infrastructure
University of Nebraska Medical Center
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Teaching Hospital
Population
Primary Care
University of Nebraska Medical Center
J. Gofin & R. Gofin.
Essentials of Global
Community Health. Jones
& Bartlett Learning,2011
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Teaching Hospital
Population
Community Oriented Primary Care - COPC
University of Nebraska Medical Center
J. Gofin & R. Gofin.
Essentials of Global
Community Health. Jones &
Bartlett Learning, 2011.
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The essence of the COPC process *
”Taking responsibility of the community’s
identified needs and intervention in the
Natural History of a prioritized problem in
which community has an active ,
participative role,
are the essence of the COPC process”
* Gofin J & Gofin R. “Essentials of Global Community Health”, Jones and Bartlett Learning, 2011
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Elements of COPC, as an approach aiming to reach
social justice and social accountability,
e.g.: social medicine
a) Care for a total population considering the
socio-economic-cultural determinants
b) Community involvement and inter-sectorial
coordination
c) Without barriers to access
d) Working WITH the community and not only
IN the community
University of Nebraska Medical Center
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Jaime Gofin & Rosa Gofin
The School of Public Health
and Community Medicine.
Hebrew University &
Hadassah
The George
Washington
University
*Jones and Bartlett Learning, 2011
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Community Health*
Is the collective expression of the health of individuals and groups in a defined community. It is determined by the interaction of personal and family characteristics, the social, cultural, and physical environments, as well as health services, and the influence of societal, political and globalization factors
:
*Gofin J & Gofin R. Essentials of Global Community Health. Jones and Bartlett Learning. Sudbury MA,
2011