Integrating Primary Care and Public Health: A Strategic Priority

Why is the integration of primary care and public health important and timely? Several landmark reports, including the Institute of Medicine (IOM) Primary Care: America's Health in a New Era¹ and The Future of the Public's Health in the 21st Century² clearly identified the need to bridge the chasm between primary care and public health. Furthermore, the Affordable Care Act has redefined the national conversation on health. The Affordable Care Act is premised upon the principle that “the health of the individual is almost inseparable from the health of the larger community. And the health of each community and territory determines the overall health status of the Nation.”³ The significant investments the Affordable Care Act makes in both primary care and public health signal the opportunity to transform our health system into one that integrates the two fields, from system design to community practice.

At the Health Resources and Services Administration (HRSA), our concept of effective system integration is consistent with IOM’s, namely:

Public health and primary care should function as one system … two groups as part of a single system and members of a collaborative team with common objectives—improving population and community health, sharing the same information systems, and serving the same patients and populations at the same time.^1(p357)

Unfortunately, primary care and public health are often seen as separate identities and directly compete for scarce resources. However, we envision integration of primary care and public health as a continuum—from the basic level of program referral, to colocation of health care services, to fully integrated systems involving seamless data and administrative systems, to a collective community approach through joint community health assessment and putting health improvement plans in action.

The Health Resources and Services Administration (HRSA) makes that vision a reality by our work to improve health and achieve health equity through access to quality services, a skilled health workforce, and innovative programs. Integrating primary care and public health is one of our strategic priorities, and this commentary highlights some of the great work being done at the agency with our partners and by our over 80 grant programs. Partnering with the Centers for Disease Control and Prevention (CDC), National Institutes of Health (NIH), Agency for Healthcare Research and Quality (AHRQ), American Journal of Preventive Medicine (AJPM), and American Journal of Public Health (AJPH) on this special themed issue that showcases some of the tremendous efforts and thinking in science, education, practice and policy is but one example of integration in action.

Both a primary care and a public health agency, HRSA has taken important steps toward integrated health care services in the context of communities. Many know HRSA as the “access” agency within the US Department of Health and Human Services because our health center program supports primary and preventive care for 19 million patients nationwide. These centers also provide “enabling” services, such as transportation, translation, and outreach, which help bridge primary care and public health. HRSA funds the Ryan White Program, which provides care, support services, and medication to approximately half of Americans living with HIV/AIDS. In addition, 34 million women, infants, children, and adolescents in the United States are served through partnerships between our Maternal and Child Health Bureau and state and local governments. The Healthy Start Program is a signature example of integration of primary care and public health. The National Health Service Corps supports about 10 000 health care professionals to work in medically underserved communities. HRSA also supports academic institutions to develop a diverse, culturally competent health workforce in medicine, dentistry, nursing, and public health. The Office of Rural Health Policy works to make health care more accessible for the 60 million residents of rural America. HRSA also administers a drug discount program (340B); oversees all organ, tissue, and blood cell donations; and funds poison control centers.

Upon her arrival as administrator, Mary Wakefield, RN, PhD, outlined a clear priority of reinvigorating HRSA’s public health agenda and created a new position for a Chief Public Health Officer to lead this work. A Public Health Steering Committee was mobilized and, with stakeholder input, developed five public health priorities:

1. achieving health equity and improving health outcomes;

2. linking or integrating public health and primary care;

3. strengthening research and evaluation, assuring availability of data, and supporting health information exchange;

4. assuring a strong public health and primary care workforce; and

5. increasing collaboration and alignment within HRSA and among our partners.

These priorities are realized through HRSA’s programs, which, as highlighted above, focus on achieving equity and integrating primary care and public health. The Affordable Care Act creates unique opportunities to do even more: from unprecedented investments in the expansion of community health centers, enumeration of the public health workforce, and health information exchange infrastructure to the models of the patient-centered medical home, accountable care organizations, electronic health records and meaningful use, community health teams, and home visiting programs.

As another example of HRSA’s support for primary care and public health integration, through the Affordable Care Act Prevention and Public Health Fund, HRSA is funding the Healthy Weight Collaborative, a quality improvement project in which 50 teams of primary care, public health, and community representatives apply evidence-based interventions to prevent and treat obesity in children and families. The multisector approach used in this collaborative highlights the importance of bringing together primary care and public health to effect meaningful change in a community, whether through science, education, policy, or practice.

As a final example, building on the aforementioned IOM reports, HRSA and CDC cofunded a new IOM report, Primary Care and Public Health: Exploring Integration to Improve Population Health.⁴ The study addresses the overarching question: How do we improve population health and reduce health disparities through effective integration and coordination of public health and primary care? The report presents recommendations that CDC, HRSA, relevant agencies, and partners can undertake to integrate these spheres.

HRSA is pleased to partner with CDC, NIH, AHRQ, AJPM, and AJPH in the development of this special online Journal Supplement, which offers insight on how to advance primary care and public health “in the field” and throughout communities across the nation. The initiatives described in this supplement help inform HRSA’s efforts to improve population health and promote health equity through the effective integration of primary care and public health, especially in the areas of science, education, practice, and policy. With passage of the Affordable Care Act, the opportunity to meaningfully advance the collective power of primary care and public health is at hand. This supplement, and the examples provided within, showcases the great work, expert thinking, and promising road that lies ahead.