In Winslow’s classic 1920 definition, public health is the “science and art of preventing disease, prolonging life and promoting physical and mental health and well-being.” (Winslow CEA. The untilled fields of public health. Science. 1920;51(1306):23–33.) Public health efforts enhance the capacity of community and society to maintain and improve personal health. By 1940 the role of public health agencies was clarified to include a minimal set of basic functions: maintaining vital statistics, environmental sanitation (e.g., rodent control, housing inspection), controlling communicable disease (immunization, surveillance), improving maternal and child health (prenatal care, home visiting, school nurses), and health education for personal hygiene and guidance on when to seek medical care.
Primary health care—an individual’s usual source of care for preventive health services, acute care, chronic disease management, specialist referrals—was generally developed outside the operational sphere of local government public health agencies. The major exception was the public health responsibility to provide indigent care. As primary care systems developed in a free market economic context, a dichotomy emerged with public health functions.
The divide between these systems began to break down in the 1960s, a period of increasing focus on social justice including health equity. It was during this time that a new safety net health care system was developed to include indigent care, community health centers. A contemporaneous effort to move primary care outside of medical offices was “community-oriented primary care” (COPC). The COPC model combined public health methods with primary care practice. Instead of only treating individual patients, primary care providers identified community-wide health problems and developed strategies to address them. With COPC, primary care not only would improve individual health but also improve community health and well-being, an essential public health goal. The COPC model proved economically unsustainable but the goal of developing primary care services that contribute to meeting public health goals remained.
Another primary care model with roots in the 1960s is the “medical home.” This begins with ensuring access to care and extends beyond the medical office to include the range of services an individual needs for comprehensive care. With its emphasis on coordinating care from diverse sources including oral health, mental health, and social services, the terms “health home” or “health care home” have been adopted as better reflecting the model. In common with COPC, the health care home addresses health disparities—the disproportionate burden of illness on low-income and minority populations—by high quality prevention, treatment, and management of chronic conditions.
The health care home bridges public health and primary care. Its emphasis on health information technology facilitates communication between primary care practices and public health agencies for disease surveillance and immunization registry. Its focus on access includes the development of primary care practices in community settings such as schools and housing projects. Its emphasis on self-management of chronic conditions helps reduce health disparities and contain costs through prevention and reduction of emergency department visits and hospitalizations.
The Affordable Care Act of 2010 has provisions that support and expand health care homes: funded demonstration projects, development of reimbursement mechanisms to sustain the model, a shift in focus from treating illness to promoting prevention and wellness, and an inclusive definition of primary care providers that supports among others, nurse practitioners and physician assistants. These innovations are accompanied by an emphasis on involving communities in health care planning and research.
While heated debate about health care reform continues in the political sphere, our health care is systematically being reformed through expansion of health care homes. This has already begun to contribute to meeting several of the American Public Health Association’s overarching policy priorities, improving access to care for all and reducing health disparities.