Principles of Community Medicine/Community Health July 25, 2007Vanessa S. Wong, MD

Objectives Describe the 4 dimensions of community medicine Understand the curricular requirements for community medicine Discuss the UH DFMCH community medicine curriculum

What is community medicine?

Community Medicine Providing medical services in the community Understanding community resources Health promotion and disease prevention Occupational health Knowledge of communities Care of populations Community participation in health care activities

4 Dimensions of Community Medicine Paying attention to sociocultural aspects of patient care Coordinating a community’s health resources in the care of patients Identifying and intervening in a community’s health problem Assimilating into a community and participating in its organizations

What is community?

Definition of community A true community in the sociological sense (shared community sentiment, social institutions) A defined neighborhood Workers/students in a defined company/school Persons registered as potential users of a group practice/HMO/health center Users of a defined service or repeated users of the service

Declaration of Alma Ata International Conference on Primary Health Care, 1978 Health is a fundamental human right

Community Oriented Primary Care (COPC) Primary care practice Defined community Process –Defining and characterizing the community –Describing community health problem –Modifying health care program to address high-priority health needs –Monitoring effectiveness of program modifications

COPC Competencies Define and characterize a given population using secondary data Recognize a community health problem using either subjective or objective data Design an intervention to address a recognized community health problem Know which community resources address a recognized problem

COPC Competencies Contribute to an organized community action group and monitor the group’s progress Determine roles of attending and faculty physicians in community action groups Locate local, state and national databases for common or chronic disease states Exhibit group leadership skills in a multidisciplinary setting

COPC Competencies Understand the utility of personal computers and EHRs in COPC Analyze activities of a community action group in COPC terms Understand the difference between health promotion and disease prevention projects and a COPC practice

COPC Curricular Topics Clinical epidemiology Design and evaluation of outcome studies Leadership and group facilitation skill training Team skills Medical information storage and retrieval systems Medical cost analysis Health promotion and disease prevention techniques Family physician’s role in the community’s health Population-based medicine

Community Medicine Curriculum 2002 Study in Family Medicine –89% have formal community medicine curriculum –86% required rotation –76% at least 1 month devoted exclusively –49% at least 2 months –10% at least 10 months

ACGME Requirements Each residency must have a structured curriculum in community medicine, including didactic and some experiential components. There must be a process to evaluate this curriculum and to document appropriate resident skill attainment in this area.

ACGME Community Medicine Curriculum (1) assessment of risks for abuse, neglect, and family and community violence (2) reportable communicable disease (3) population epidemiology, and the interpretation of public health statistical information (4) environmental illness and injury (5) school health (6) disease prevention through immunization strategies (7) disaster responsiveness (8) community-based disease screening, prevention, health promotion (9) factors associated with differential health status among subpopulations, including racial, geographic, or socioeconomic health disparities, and the role of family physicians in reducing such gaps

ACGME Community Medicine Curriculum (10) experience in using community resources appropriately for individual patients who have unmet medical or social support needs (11) structured interaction with the public health system (12) occupational medicine including disability determination, employee health and job-related illness and injury (13) experience in community health assessment (14) experience in developing programs to address community health priorities (15) community-based health education of children and adults

Curricular Methods/Training Experiences Experiential site visits DOH clinical experience Direct experience w/minority communities Home visits Meetings/lectures w/dept staff Community Tour Prepared readings Use of community resource manual Cultural sensitivity training Participation in longitudinal community medicine project Meetings w/community leaders/activitists Instruction in the COPC model Community assessment activities Formal presentation of experiences Team-building skills Review and use of secondary data Collection of primary data Research/evaluation of community interventions Working w/the media Conflict resolution

Curricular Methods Predictive of Perceived Competency Experiential site visits DOH clinical experiences Home visits Cultural sensitivity training Participation in longitudinal community medicine project Meetings w/community leaders/activitists Instruction in the COPC model

UH DFMCH Community Health Goals Family Practice residents will have an understanding of community medicine by the time of graduation Family Practice residents will participate in community health during their residency

UH DFMCH Community Health Curricular Content 1. Definition of community health 2. Disease prevention and health promotion 3. Occupational medicine 4. Principles of Primary Health Care (PHC) and Community-Oriented Primary Care (COPC)

UH DFMCH Community Health Curricular Objectives 1. Given a particular health program in a particular community, residents will be able to recognize the manner in which its activities fulfill the principles of PHC according to the Declaration of Alma Ata or COPC according to principles outlined by Sidney Kark. 2. Demonstrate knowledge of community health resources in patient care plans to preceptors.

UH DFMCH Community Health Instructional Methods 1. Individual study: Selected readings on the fundamentals of community health. 2. Lectures and discussions: Faculty members and invited speakers will give talks during Wednesday afternoon conferences on their experiences with the process of community health as they have experienced it personally. 3. Individual projects or joining an ongoing project.

UH DFMCH Community Health Evaluations 1. Quarterly meetings with faculty community health director and selected community health advisor(s). 2. Yearly presentation of progress and any findings during a Wednesday afternoon conference. 3. Faculty and fellow residents will critique the methodology and findings of the residents projects.

UH DFMCH Community Health Lectures/Discussions (integrated with the Research and Cross-Cultural Curriculum)

UH DFMCH Community Medicine Activities – Past and Present Wilikina COPC project Ka Nupepa articles School career days School physicals School talks –Family planning –Tar Wars Community clean-up HOME Clinics Medical tent volunteers Church donations Home visits Cross-cultural curricular activities

Group Interaction 4 groups Each group discuss 1 of the dimensions of community medicine Discuss the dimension – what does it mean, why is it important Brainstorm – how would the dimension look like in a formal community medicine rotation/curriculum

Participation in health activities in the community Identifying and intervening in the community’s health problems

Sociocultural awareness in the care of patients Responding to the particular health issues of local cultural groups when caring for patients

Understanding and appropriate use of the community’s health resources in the care of patients Coordinating local community health resources in the care of patients

Community participation and assimilation Assimilating into the community and its organizations

The highest reward for a person's toil is not what they get for it, but what they become by it.... John Ruskin