Work to join public health, primary care moves ahead: Breaking down silos
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* Kim Krisberg

Public health workers and primary care physicians may work toward the same goal — healthier people — but bringing the two fields together is not a simple task. Just ask Catherine McLaughlin.

McLaughlin, PhD, a member of the Institute of Medicine Committee on Integrating Primary Care and Public Health, witnessed the divide firsthand as she spoke to both public health and primary care audiences about a 2012 IOM report that called for better integration between the two fields. While both sides were facing similar health improvement challenges, they often seemed stuck within their respective silos, unaware of the strengths each discipline brought to the table, McLaughlin said.

“It was interesting to see the dichotomy play out,” said McLaughlin, a senior fellow at Mathematica Policy Research and professor emerita at the University of Michigan School of Public Health. “They were exactly the issues we tussled with in the (IOM) committee in trying to figure out how we get these two sides integrated...But they have to be in this together. There’s diminishing returns for both sides when they work in isolation.”

With chronic diseases such as heart disease, obesity and diabetes affecting millions of Americans and driving health care costs increasingly skyward, advocates in both fields are calling for better collaboration and recognizing that neither side can effectively tackle today’s health problems on their own. Fortunately, in the two years since IOM released “Primary Care and Public Health: Exploring Integration to Improve Population Health,” work is moving forward. Like many community health endeavors, there is no one-size-fits-all approach to bringing together public health and primary care. Instead, successful integration will begin with local action — “it’s about going back to good old grassroots community organizing,” said APHA member Brian Castrucci, MA, chief program and strategy officer at the de Beaumont Foundation.

In March, the de Beaumont Foundation, along with the Centers for Disease Control and Prevention and Duke Community and Family Medicine, debuted the “Practical Playbook: Public Health and Primary Care Together” initiative, which provides tools to help local stakeholders jumpstart collaborations in their communities. As of late April, the Practical Playbook website had already welcomed about 8,500 visitors, reported Castrucci, who said that the time is ripe for integration.

“There’s great recognition that the link between personal health and community health is indelible,” he told *The Nation’s Health.* “Today’s disease threats have social and environmental origins that go far beyond the clinical walls. There’s not a vaccine or a treatment or a pill that can solve not having access to fresh fruits and vegetables.”

Obesity is just one example of why integration is so beneficial, Castrucci said. While local health departments did not always have obesity data at the census-tract level, the historical progression of the obesity epidemic is documented in medical records. If local public health practitioners had been privy to such data, they could have advocated for policies that create healthy eating and physical activity opportunities at a much earlier stage in the epidemic, Castrucci said. On the flip side, integrating public health data on neighborhood-specific outbreaks and disease trends into electronic medical records could help primary care physicians more efficiently diagnose and treat their patients.

“You can do this within the hospital — you can hire epidemiologists and community health workers and make a pseudo public health department in a hospital, but it divides the community because each hospital will do it their own way,” Castrucci said. “(Public health) is a structure ready to partner, ready to help. The question is are we going to break down the silos or have silo expansion?”

Garth Graham, MD, MPH, president of the Aetna Foundation, said integration will take a change in philosophy and vision within both fields. Within the primary care field, Graham said physicians typically learned how to treat the disease and not the patient with the disease. For example, he said he once visited a patient at her house and only then realized that her chaotic home life was making it extremely difficult to sustain a medication regimen.

“Just prescribing medicine wasn’t enough,” Graham told *The Nation’s Health.* “You have to be able to train people to see both the micro and the macro. It really means patient-centered, community-centered care.”

An example of the foundation’s population health work is its partnership with the Camden Coalition of Healthcare Providers in New Jersey. The foundation is funding the coalition to develop a fellowship program that will train primary care physicians in “hotspotting” techniques, which will help physicians pinpoint areas with high health care needs and more efficiently deploy primary care resources.

“It really does come down to the individual patient and the consumer and how do you manage that person in a better way and allow them to make better choices,” Graham said.

Part of the integration process is simply each side getting to know each other better — “it really is a cross-cultural experience,” said APHA member Paul Jarris, MD, MBA, executive director of the Association of State and Territorial Health Officials. In the wake of the 2012 IOM report, ASTHO convened the Primary Care and Public Health Collaborative, a group of diverse stakeholders that eventually developed a strategic map toward integration. Recently, collaborative members met in May to begin updating the strategic map, which was originally released in July 2012. Jarris said full integration will ultimately require aligning health care dollars toward prevention. For example, he pointed to federal waivers to allow Medicaid to pay for home visiting programs or environmental asthma abatement.

“Rather than health care becoming a public health agency, they need to learn to partner with public health and vice versa,” Jarris said. “The system has to recognize that investing in public health and impacting social determinants is critical to improving health and lowering costs.”

In Greene County, Ohio, public health workers and representatives from the local hospital system have been meeting regularly to discuss community health needs and how they can better work together. Just 10 years ago, such a conversation probably would not have happened, said Melissa Howell, MPH, MS, MBA, RN, RS, health commissioner with the Greene County Combined Health District. But today, hospital representatives are more aware of public health’s role in prevention and in keeping residents out of the emergency department — and the process is slowly moving from mutual awareness to better cooperation, Howell said.

“We need all hands on deck,” she said. “It takes much more than a single treatment. We’re talking about treating an entire community.”

For more information on public health and primary care integration, visit [www.practicalplaybook.org](http://www.practicalplaybook.org) and [www.astho.org/Programs/Access/Primary-Care-and-Public-Health-Integration](http://www.astho.org/Programs/Access/Primary-Care-and-Public-Health-Integration).

*   Copyright The Nation’s Health, American Public Health Association