Curriculum

Community-Oriented Primary Care

Joint project.

Department of Family Medicine, St.Petersburg Academy for Postgraduate Studies

St.Petersburg School of Public Health

Students: family medicine residents and physicians undergoing retraining

Goal: To enhance the knowledge and skills of family physicians regarding a community responsive approach to caring for patients, their families, and their communities, through the process of involvement in an issue of community concern.

Objectives:

Background.

According to the report passed by the St.Petersburg government the population of St.Petersburg continue to shrink. On January 1st, 2002 it was 32 thousand less that in 2001 and 150 thousand less that in the beginning of 1997. This results from high mortality and low birth rate the later is in St.Petersburg the lowest in Russian Federation. The percentage of children in St.Petersburg is also the lowest among all regions of Russian Federation. In 2001 percent of people age 60 and above increased up to 21.1%.

This shows that two important tendencies start to emerge - diseases of old age, CVD being primary example, start to play ever increasing role with stroke outnumbering the coronary heart diseases; and city will became more and more sensitive to decrease in workforce as ratio working / old continue to deteriorate. The later will make city more and more sensitive to workforce loss due to diseases of younger adults. Correspondingly unique demographic situation of St.Petersburg calls for increased attention to diseases of the old age and diseases striking younger adults - especially HIV and other chronic debilitating or fatal infectious diseases. Unfortunately, the health care is frequently looking upon itself as “on-demand” service, where each patient is unconnected to others and exist in separate Universe. The lesions from epidemiology are frequently overlooked as epidemiology and public health are poorly represented in medical school curricula. This goes hand-in-hand with overspecialization of medicine, where each physician is responsible for separate body system, not for patient as a whole and not certainly for the community. The situation could change with emergence of family medicine, a newly recognized medical specialty designed to care for patients with a broad range of common illnesses. Recognizing the value of patient management in the context of family, social, and cultural environments, departments of family medicine are frequently include nonphysicians, particularly behavioral scientists, as faculty integral to the training programs. Family medicine is developing as a comprehensive approach to health care, in which the family physician serves as the coordinator, bridging multiple biopsychosocial systems and factors to affect positively the health of the individual patient. Correspondingly the major approach to the strengthening the role of primary care and raising its effectiveness in the light of planned decentralization of health care the double approach combining Community-Oriented Primary Care (COPC) model and evidence-based medicine (with health technology assessment) in what we call a community-oriented evidence-based primary care (COEBPC) is advisable.

Community-oriented primary care (COPC) is a systematic approach to health care based upon principles derived from epidemiology, primary care, preventive medicine, and health promotion (Longlett et al. 2001). In 1982, the US Institute of Medicine advocated increased COPC training among health professionals (Connor and Mullan 1983). A conference sponsored by the Institute of Medicine (IOM) resulted in an operational definition that included three requirements for implementing COPC.

Definition of community-oriented primary care:

1) A primary care practice providing accessible, comprehensive, coordinated, continuous-over-time, and accountable health care services.

2) A defined community for whose health the practice has assumed responsibility. In this context, community refers to geographic or social communities; groups that form within the workplace, church, or schools; or persons enrolled in a common health plan. Specifically excluded are communities consisting of the active patients in a practice.

3) A process including the following steps:

(a) defining and characterizing the community,

(b) conducting a community diagnosis,

(c) developing and implementing an intervention, and

(d) monitoring the impact of intervention.

An additional step added to this list includes (e) involving the community to carry out the preceding four steps (Rhyne et al. 1998). The fundamental basis of COPC is the community and the ethic of service to drive community health improvement (Gardner et al. 2000).

It is important to realize, that community is not always defined as simple neighborhood. As experience from the US show, despite successful federally funded projects many physicians remained skeptical that COPC methods could be implemented in the private practice environment. This skepticism led to modifications in the definition of COPC. In 1982, Kark and Abramson provided five distinct definitions of community in preferred order:

(1)   a true community in the sociological sense;

(2)   a defined neighborhood;

(3)   workers in a factory or company or students in a defined school;

(4)   persons registered as potential users of a group practice, a health maintenance organization, a neighborhood health center, or other defined service; and

(5)   users of a defined service or repeated users of the service.

That same year, Madison suggested that COPC principles could be more easily implemented if rather than restricting community to naturally occurring social groups or to geographic groupings, its meaning could be broadened to include the population served by a single practice or to the community of patients with a particular disease. For many, COPC is associated with any health care provided in the community.

The students in this course should realize different definition of community and understand that principles of this approach could be used in virtually any environment.

The basic processes of COPC provide an excellent framework for population-based medicine, practice management, and continuous quality improvement strategies. COPC processes require the skills necessary for routinely assessing and defining a problem, designing an intervention for addressing the problem, and evaluating and monitoring outcomes of the intervention.

COPC core competencies for family physicians

(1)   Understand that patients' physical and social environment and their health and well-being are related

(2)   Understand the impact of the community upon the health of the population

(3)   Understand the impact of the community upon a physician's practice

(4)   Understand the epidemiologic techniques to determine health problems in a community

(5)   Determine the health promotion techniques and interventions to address community health problems

(6)   Evaluate outcomes research for validity

(7)   Define COPC and its core content and process

(8)   Define COPC elements in a family practice

(9)   Define and characterize a given population using secondary data

(10)                       Recognize a community health problem using either subjective or objective data

(11)                       Design an intervention to address a recognized community health problem

(12)                       Know which community resources address a recognized problem

(13)                       Contribute to an organized community action group and monitor the group's progress

(14)                       Determine roles of attending and faculty physicians in community action groups

(15)                       Locate local, state, and national databases for common or chronic disease states

(16)                       Exhibit group leadership skills in a multidisciplinary setting

(17)                       Understand the utility of personal computers and electronic medical records in COPC

(18)                       Analyze activities of a community action group in COPC terms

(19)                       Understand the difference between health promotion and disease prevention projects and a COPC practice

Providing training in several fields could strengthen those core competencies:

·        Epidemiology (Clinical epidemiology)

·        Biostatistics (Design and evaluation of outcome studies)

·        Behavioral Science (Leadership and group facilitation skill training)

·        Behavioral Sciences (Team skills, especially with professionals in other disciplines and community members)

·        Behavioral Sciences (Health promotion and disease prevention techniques)

·        Health Informatics (Medical information storage and retrieval systems)

·        Health Economics (Medical cost analysis)

·        Environmental health (Impact of environment on health and diseases)

Core theoretical courses:

Practical Skills courses:

Introduction to COPC.

Definition of COPC. History of COPC. South African experience. Development of COPC in Israel. COPC in US: tale of different systems. Alma-Ata Conference, primary care, Soviet system and its relevance to COPC. Roots of COPC: epidemiology and other public health specialties, its relevance to COPC process. Definition of community. Changes of definition and its impact on physicians involvement. Benefits and risks of broad definition. Family medicine and COPC. Work with community. Coalition-building. Working with mass-media.

Introductory Epidemiology with Clinical Epidemiology

Definition of epidemiology. Role of epidemiology in COPC. Epidemiological thinking. Time, Person, Place. Patient, community, population. Measuring diseases. Sources of epidemiological data. Outbreak investigation. Clinical epidemiology. Theory of diagnosis. Definition of normality. Screening. Studying health benefits.

Basic Epidemiology (DE)

Measurement instruments and methods in epidemiology. Medical Surveillance. Types of epidemiological studies: ecological, case-control, cohort studies. Investigation of risk factors. Clinical Trials. Disease mapping. Genetic Epidemiology. Social Epidemiology.

Introductory Biostatics

Variability and Random error. Data presentation: tables and graphs. Distribution. Population and Sample. Central Limit Theorem. Hypothesis test for a mean. Confidence Intervals. Estimating and Testing Proportions. Comparing two groups. Rates and Risks. Odds Ratios. Confounding and Adjusted Odds Ratios

Basics of biostatistics with outcome studies evaluation and design (DE)

Introduction to health outcomes research. Concepts and variables. Internal and external validity. Sources of error. Random error and bias. Types of extraneous variables. Design of experiment. Pre-experimental design. Quasi-experimental design. True experimental design. Statistical design. Randomization and its role in research. Randomized clinical trials. Evaluation of health care research. Critical assessment of treatment research. Critical assessment of diagnostic research. Critical assessment of etiology studies. Systematic review and meta-analysis.

Introductory Health Informatics

Introduction to computers for  physicians. Basic Concepts in informatics. Models. Information. Information Systems. Informatics skills. Communicating. Structuring, Questioning, Searching, Making Decisions. Information systems in health care. The Internet. The Internet and World Wide Web. Decision Support Systems.

Basic Health Informatics (DE)

Introduction to databases. Flat databases. Relational databases. Use of databases. Health data sources. Registers. Morbidity and Mortality Data. Risk Factor Information Systems. Informatics of Toxicology and Environmental Public Health. Data warehouses. Analysis of incomplete and poorly standardized data. Data mining. The Internet and the Web. Search for information (MEDLINE and other bibliographical databases).

Behavioral Sciences.

Determinants of human behavior. Psychological and Sociological perspective. Personality. Cognition, cognitive styles and its relevance to health behavior. Leadership and group facilitation skill training. Team skills. Health promotion and disease prevention techniques. Health behavior and health believes. Risk groups and population approaches to disease prevention. Learning theory. Theory of change. Peer learning and group learning. Effectiveness of different learning approaches. Training “helping people change”. Some examples of behavior-determined diseases: Addiction, STD, CVD. Role of behavior in spread of infectious diseases. Community behavior, community norms and health risks.

Basic Health Economics (DE)

Introduction to economical thinking. Supply and demand. Market. Perfect and imperfect markets. Monopoly, oligopoly, monopsony and its influence of market. Welfare economics. Health care costs. Demand and price elasticity. Health care financing: fee-for service, insurance-based, social insurance and tax-based. Interplay between elasticity, health cost and schedule of cost reimbursement. Economical analysis in health care: cost-minimization, cost-utility, cost-effectiveness, cost-benefit. Supplier-induced demand.

Environmental health

Environment and human health. Risk assessment. Water and health. Water as a source of infectious agents. Water as a source of toxic agents. Air pollution. History of air pollution studies in urban areas. Influence of urbanization on pattern of disease. Air as source of toxic agents. Soil. Toxic and infectious agents in soil. Health care system as an environmental hazard. Health system wastes. Radiation due to health care. Biological hazards. Hospital-acquired infection. Artificial hazards: bioterrorism and chemical terrorism.

Organization of the training

Core theoretical courses (144 hours, during 2-year residency):

Core courses: 4-semesters 2-credit hours

PLUS

DE courses:

Basic Biostatstics (36 FTHE)

Basic Health Economics (36 FTHE)

Basic Epidemiology (36 FTHE)

Basic Health Informatics (36 FTHE)

AND

At least one DE-course

Prevention: Social and biological factors in prevention of STI/HIV

Health Economics: Health Economics and Health Care Prioritization

Epidemiology: Mathematical Epidemiology in Health Care Planning (module 1ý)

Prevention: Development of Preventive Programs (MMA course, adapted)

OR

Two modules:

Agent Biology and Epidemics + Women’s Health:Contraception

Practical Skills courses:

FTHE – Full-Time Hours Equivalent