Reflecting on the Past and Future of Community-Oriented Primary Care

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Louise Cohen
Louise Cohen

As I look forward to the opportunities that lie ahead for primary care and our extraordinary organization, the Primary Care Development Corporation (PCDC), we remember and honor the PCDC founders and their great foresight in the early 1990s.  Because of the efforts of PCDC staff, board, sponsors, friends and especially our founding CEO, Ronda Kotelchuck, it is a significant source of pride to say “I’m part of PCDC.”

A history of community-oriented primary care
When I consider what I hope to accomplish at PCDC, I think about “community-oriented primary care,” the concept upon which the organization was founded.

Community-oriented primary care as a concept was first introduced by Emily and Sidney Kark in 1942 in Pholela, South Africa. The Karks set about the task of community-wide access to high-quality primary healthcare. Their first step was counting everyone who lived in the community and assessing their health needs. Then they brought in and trained health providers and created health centers.

But they went further; they dug wells, built houses, tilled the land, improved sanitation and created jobs because they recognized the role that clean water, food, housing and employment played in the overall health of the region. Their innovative approach inspired and helped shape the first community health centers in the United States.

This global idea moved locally when in the early-1990s, New York City Mayor David N. Dinkins declared “health is a basic right of every New Yorker,” and asked his administration to strengthen the primary care system.  This resulted in the unique public-private partnership that became PCDC.  In the original strategic plan, written in 1993, the new organization was to: enable every New Yorker to have a primary care doctor, promote a higher quality of healthcare and do so at a lower cost.

This should sound familiar to the primary care community, as the key elements of the triple aim:  better care, smarter spending and healthier people.

Fast forward to today
Today, primary care is in transition, moving from a reliance on the one-on-one doctor-patient relationship, to team-based care, often outside of traditional settings. It is supported by best practice guidelines, compiled from years of work and evidence from providers, epidemiologists and researchers to address the factors that cause the most morbidity and mortality in our lives: smoking, hypertension, diabetes and obesity, depression, substance abuse, HIV/AIDS and maternal mortality.  Reaching outside the walls of the health center, primary care must address and work to change the social conditions in which people live, and which have a significant impact on their health, in the twenty-first century version of community-oriented primary care.

Consider the nearly 1,300 community health centers providing quality care to nearly 23 million people, 92% of whom are below 200% of the poverty level, which have been providing community-oriented primary care since the 1960s.

Consider that women’s health centers are primary care. In 2010, roughly 8,400 family planning centers provided services to nearly 9 million women. Of the women who obtain care at these centers, six in ten consider it their usual source of medical care. For them, this is an entry point into the healthcare system, and for many young women aged 16-24, may be their only contact with the healthcare system.

Consider that 19 percent of the U.S. population lives in rural communities, and that rural healthcare networks and migrant health centers provide care for as many as 3 million migrant workers working in the United States.  Add to that the possibilities afforded by telemedicine to support effective healthcare in communities without sufficient healthcare providers, or in rural areas.

Consider the 2,000 school-based health centers that provide physical and mental healthcare for millions of children and young people.

Consider the 2.2 million people incarcerated in our country’s jails and prisons, and their extraordinary healthcare needs during their imprisonment and upon release.

And finally, consider the new adjuncts to primary care, such as urgent care and retail clinics, which combine to treat millions of patients annually in the United States,  and often at night or on weekends when primary providers are not available, but which remain to be connected with the rest of the health care system through health information technology.

Looking at today’s healthcare landscape, with value-based purchasing, delivery system and payment transformation, health information technology, care coordination and care management and integrated behavioral health and primary care, it may seem that we are a far distance from that early concept of community-oriented primary care.

But I would argue that the work PCDC supports today is virtually the same as what Sidney and Emily Kark first proposed in the 1940s and what Mayor Dinkins, Ronda Kotelchuck and the PCDC founders undertook in 1993: to develop, promote, improve, support and adequately finance community-oriented primary care in all of its facets, in order to create and sustain healthy communities and families.

I am honored to be the CEO of PCDC, and to be part of this wonderful organization and the future of primary care.