3. Changing Landscape
• Focus on Population Health Management
– Affordable Care Act (ACA)
– New Care Models – ACO’s
– Patient Centered Medical Home
– MACRA – New Payment Models
4. Changing Landscape
• Delivering on the Triple Aim
– Improving population health
– Improving patient experience
– Reducing Cost
– Improving physician’s
5. Why Now?
• Dramatic rise in health care costs has led
many stakeholders to embrace innovative
• Health research continues to clarify the
importance of social and environmental
determinants of health and the impact of
6. Why Now?
• Unprecedented wealth of health data is
providing new opportunities to understand and
address community-level health concerns
• The ACA and MACRA presents an overarching
opportunity to change the way health is
approached in the United States
7. Estimated Deaths Attributable to Social Factors in
the U.S. - 2000
• Low education: 245,000
• Racial segregation: 176,000
• Low social support: 162,000
• Individual level poverty: 133,000
• Income inequality: 119,000
• Area level poverty: 39,000
• In comparison:
– Acute MI: 192,898
– Cerebrovascular disease 167,661
– Lung cancer: 155,521
Estimated Deaths Attributable to Social Factors in the US. Galea S et.al.
8. Integration of Primary Care and Public Health
• Community-oriented primary care –
supports population health.
• Roles of primary care and public
health overlap and reinforce one
• Become informed about the
• Family medicine, public health, and
other relevant organizations should
collaborate to improve delivery
systems and conditions in which
Overlapping Roles of Primary Care and
9. AAFP’s Call to Action
• Physician Level
– Understand the role of public health
– Awareness of integration efforts between primary care and
• Practice Level
– Redefine population based on a community level
– Recognition and incorporation of the public health
infrastructure into the medical neighborhood
– Collaboration and communication with public health
infrastructure to operate as a continuous unit with a
10. AAFP’s Call to Action – cont’d
• Leadership Level
– Facilitate collaboration and communication amongst
health systems and public health orgs
– Drive change within health systems to partner with
public health orgs
• Educational Level
– Drive change within undergraduate and graduate
medical education to ensure FPs of tomorrow are
prepared for a more integrated system
11. Poverty and Health – The Family Medicine Perspective –
• Move toward prevention and away from
• Enhance communication and trust through
cultural proficiency, coaching, and peer-to-
• Address socioeconomic challenges and
work with patients to develop achievable
• Make a community health resource folder
and help patients access material support.
• Participate in research that develops
evidence for how to address poverty.
• Advocate on behalf of low-income
communities. Reprinted with permission from Glass TA, McAtee MJ. Behavioral science at the crossroads in public
health: extending horizons, envisioning the future. Soc Sci Med. 2006;62(7):1650-1671.
12. Practical Playbook – Roadmap for Integration
Pairs the public health organizational structure with the
patient-centered medical home – wherein a team of health
care professionals provides preventive and medical care in
the context of family and community – and an unstoppable
health care force is created.
13. Practical Playbook(www.practicalplaybook.org)
• AAFP has been integral in promoting the initiative
spearheaded by the CDC; the Department of
Community and Family Medicine at Duke University in
Durham, N.C.; and the de Beaumont Foundation.
• The initiative offers an interactive Web-based resource
designed to help primary care and public health
professionals collaborate to achieve population health
improvement and reduce health care costs through
14. AAFP’s Community Health Resource Navigator
Smoking Bans in the U.S. Farmers Markets and Parks in the Phoenix
Brings information about communities to the family physician’s fingertips.
• Community resources such as food pantries, farmers markets, parks and recreational facilities,
etc. Build and share your virtual resource folder.
• Evidence-based public health laws, such as smoking bans, land use policies, vaccination
exemptions, etc. Learn how to support patients’ health by advocating for healthy public policy
in their communities.
15. Mini-Grants for Tobacco and Nicotine
Prevention and Control
Aims to reduce the harm inflicted on Americans by tobacco
and nicotine products by promoting prevention and
cessation, and eliminating secondhand smoke exposure.
• Systems Thinking: Applicants are asked to consider
what other organizations are doing and to integrate their
activities as appropriate to develop synergy in their
• Innovation: Applicants are asked to help their
organization do something new, but creating or adopting
a new intervention.
16. • A community-based education program designed to teach kids to
• Has reached more than 10 million children worldwide since being
created in 1988.
• Effective in increasing students’ knowledge of and attitudes towards
• Anecdotally, Tar Wars has resulted in family physicians working
alongside a variety of community partners, including public health.
17. Identifying Benefits, Barriers, and Facilitators to Integration of
AFP Chapters and Public Health Organizations – Applied Research
• Collaborative project with The Practical Playbook
• Aim is to understand the motivation behind why AFP chapters do or
do not collaborate with public health organizations. Findings will
inform future work to promote collaboration between AFP chapters
and public health organizations to further the integration of primary
care and public health movement.
• Qualitative design based on interviews with 7 AFP chapter
executives and 7 AFP chapter staff members.
18. Additional Resources
• Integration of Primary Care and Public Health from a Family Medicine Perspective
• Cultural Proficiency - Quality of Care for Diverse Populations Videos http://www.aafp.org/patient-care/social-determinants-of-
• Help Your Patients Manage Racism-Related Health Risks http://www.aafp.org/patient-care/social-determinants-of-health/cultural-
• Early Childhood Literacy - Reach Out and Read Program http://www.aafp.org/patient-care/social-determinants-of-health/child-
• Community Health Resource Navigator (CHRN) - an interactive mapping tool http://www.aafp.org/patient-care/social-determinants-of-
• Poverty and Health - Family Medicine Perspective http://www.aafp.org/about/policies/all/policy-povertyhealth.html
• Social Determinants of Health http://www.aafp.org/about/policies/all/social-determinants.html
• Health Literacy http://www.aafp.org/about/policies/all/health-literacy.html
• Population Health http://www.aafp.org/about/policies/all/population-health.html