A Call for Action on Primary Care and
Public Health Integration
Denise Koo, MD, MPH, Kaytura Felix, MD, Irene Dankwa-Mullan, MD, MPH,
Therese Miller, DrPH, Jill Waalen, MD, MPH
an integrated fashion to address the root causes of illness and
prevent additional cases of disease, and to make the default
choice a healthy one.1Effective support of healthy behaviors
primary care clinicians, with public health agencies, schools,
lic health work together to support individuals, families, pa-
the report “Primary Care and Public Health: Exploring In-
tegration to Improve Population Health”3in which the
reviewed promising models of primary care and public
health integration, often with shared accountability for im-
their review of numerous examples, the IOM committee
developed a set of principles that they deem essential for
dently of each other. This is not optimal; our current
1. a shared goal of population health improvement;
2. community engagement in defıning and addressing
population health needs;
3. aligned leadership;
4. sustainability, including shared infrastructure; and
5. sharing and collaborative use of data and analysis.
The IOM report notes that integration can start with any
of these principles and that starting is more important
than waiting until all are in place.
This online-only jointly-published supplement com-
(AHRQ), CDC, Health Resources and Services Adminis-
tration (HRSA), and the National Institute on Minority
Health and Health Disparities (NIMHD) of the NIH—
sponsored this supplement to showcase and support ad-
ditional efforts in this critical area. A guest editor from
each agency worked with editors and reviewers from the
American Journal of Public Health®(AJPH) to select pa-
pers from among more than 125 submitted manuscripts.
The articles included in this supplement—a fırst-time
joint publication by AJPH and AJPM—highlight how
these two sectors intersect and the work ahead to achieve
The time is ripe for such integration. As mentioned in
tary in this issue by DHHS Assistant Secretary for Health
velopments in the reform of health care (e.g., the passage
emergence of Accountable Care Organizations [ACOs]
and the Patient-Centered Medical Home model) offer
the vision of a health system in the U.S.
Results of the semistructured interviews of 13 na-
tional leaders in healthcare reform, reported by
Sweeney et al.,5reinforce an overarching theme of this
issue—as the foundation for an improved healthcare
system, primary care will need to transform into hav-
an expanded primary care team, including partner-
ships with public health.
the case studies of Lebrun et al.6featuring nine commu-
nity health centers recognized as leaders in integrating
public health into the delivery of primary care services.
Development by one such health center and a public
health department of a joint referral system for services
From the Scientifıc Education and Professional Development Program
CDC, Atlanta, Georgia; the Offıce of Research and Evaluation (Felix),
Health Resources and Evaluation, Health Resources and Services Admin-
istration, the Prevention/Care Management Portfolio (Miller), Agency for
Healthcare Research and Quality, Rockville, the Offıce of Innovation and
National Institute on Minority Health and Health Disparities, NIH,
Bethesda, Maryland; the Department of Family and Preventive Medicine
(Waalen), University of California San Diego, La Jolla, California
Address correspondence to: Denise Koo, MD, MPH, Scientifıc Educa-
tion and Professional Development Program Offıce, Centers for Disease
Control and Prevention, 1600 Clifton Road, NE, MS E-92, Atlanta GA
30333. E-mail: firstname.lastname@example.org.
Published by Elsevier Inc. on behalf of American Journal of Preventive Medicine Am J Prev Med 2012;42(6S2):S89–S91
provided exclusively by each party furnishes a striking
to coordination and synergy.
Other examples of direct interaction of public health
departments and primary care clinics include the New
in medically underserved areas as “detailers” to promote
clinical preventive services and chronic disease manage-
ment targeted by the health department.7Kay et al.8re-
port that efforts by the Seattle–King County, Washing-
ton, health department to promote influenza vaccination
by targeting all providers of primary prenatal care—
contributed to higher vaccination rates among pregnant
and postpartum women after the health department’s
ing of electronic medical record data with the Massachu-
setts health department for public health surveillance.
nity engagement by primary care practitioners, as also
cited in the interviews by Sweeney et al.5The article by
Taliaferro and Borowsky,10for example, focuses on pri-
can support “strength-based” youth development. The
al.,11identifying 49 specifıc interventions that linked pri-
mary care and community organizations for the delivery
of preventive services in such areas as tobacco cessation
and obesity prevention, revealed that evidence of the
ods to evaluate these linkages should be standardized.
portunities for integration within the current environment,
health have evolved—particularly since the beginning of the
Primary care and public health have also tended to
operate in relative isolation. For example, the survey by
Parton et al.14revealed that, although the New York City
Department of Health and Mental Hygiene successfu-
lly reaches many physicians—particularly primary care
providers—and that the providers were receptive to en-
gagement with the health department, physicians often
remain unaware of important health department re-
sources (e.g., the universal reporting form). E-learning
(e.g., the module on correct death certifıcate completion
delivered to medical residents by New York City’s health
department described by Hemans-Henry et al.15) is but
sectors. Wells et al.16also provide a useful mapping of
competencies integrating clinical and public health skills
for preventive medicine residents doing rotations in
community health centers. Efforts toward integration
will also benefıt from lessons of past opportunities in the
from work to defıne both the unique and shared roles of
public health practitioners and primary care clinicians.
Finally, integration is hampered by the fact that both
public health and primary care have limited resources
(e.g., funding and time), which can make integration an
additional burden rather than an opportunity. Many au-
tives and adequate infrastructure for integration.
Current work within our own agencies is targeted to-
ward some of these challenges and to addressing the
principles laid out in the recent IOM report.3HRSA, as
with the three other collaborating agencies, aims to im-
prove the integration of primary care and public health.
One such visible effort, as described in the commentary
by Linde-Feucht and Coulouris,17is the Healthy Weight
Collaborative, a quality-improvement project to prevent
draws on the assets of multiple sectors and highlights the
importance of bringing together primary care and public
health to effect meaningful change.
The CDC continues to work at the intersection of public
enue Service to develop guidance for charitable hospitals in
their implementing and reporting on the new community
health needs assessment and ongoing community benefıt re-
initiative, a DHHS effort to prevent one million heart attacks
and strokes during the next 5 years.19CDC also has long-
standing relationships to support the integration of public
demic organizations as the Association of American Medical
Colleges,20the Association for Prevention Teaching and Re-
search, and the Association of Schools of Public Health. The
tive efforts embodied by the CDC Community Transforma-
continue to engage in collaborative approaches to promot-
Koo et al / Am J Prev Med 2012;42(6S2):S89–S91
settings. Efforts include supporting community-based par- Download full-text
ticipatory research that enhances primary prevention care
obesity prevention. In addition, NIMHD continues to en-
gage in the coordination of primary care and prevention
linkages among primary care practices, public health or-
ganizations, and community services is an effective, effı-
cient, and feasible method of improving clinical preven-
tive service delivery. AHRQ is funding practice-based
research networks to demonstrate how primary care
practices can work with public health and community-
based organizations to improve obesity management.
ment activities and developing an evaluation plan to
stimulate research regarding a better understanding of
clinical–community linkages processes and outcomes to
improve the delivery of clinical preventive services.
Now is the time to heal the schism between medicine
and public health.21Only by working together to create
an integrated health system that leverages the comple-
truly be able to do our best job of caring for our commu-
nities and the U.S. population.
Publication of this article was supported by the U.S. DHHS
NIH National Institute on Minority Health and Health
The fındings and conclusions in this paper are those of the
author(s) and do not necessarily represent the offıcial position
of the DHHS.
No fınancial disclosures were reported by the authors of this
1. Frieden TR. A framework for public health action: the health
impact pyramid. Am J Public Health 2010;100(4):590–5.
2. Fineberg HV. Shattuck Lecture. A successful and sustainable
health system—how to get there from here. N Engl J Med
improve population health. Washington DC: The National
Academies Press, 2012.
community for a healthier America. Am J Prev Med 2012;
5. Sweeney SA, Bazemore A, Phillips RL Jr, Etz RS, Stange KC. A
re-emerging political space for linking person and community
through primary health care. Am J Prev Med 2012;42(6S2):
ers, and lessons learned. Am J Prev Med 2012;42(6S2):S191–S202,
primary care providers: New York City’s experience, 2003–2010.
Am J Prev Med 2012;42(6S2):S122–S134, dx.doi.org/10.1016/j.
8. Kay MK, Koelemay KG, Kwan-Gett TS, Cadwell BL, Du-
chin JS. 2009 pandemic influenza A vaccination of pregnant
women—King County, Washington State, 2009–2010. Am J
9. Klompas M, McVetta J, Lazarus R, et al. Integrating clinical
practice and public health surveillance using electronic medi-
cal record systems. Am J Prev Med 2012;42(6S2):S154–S162,
youth development in primary care. Am J Prev Med 2012;42(6S2):
zations for prevention: a literature review and environmental
12. Scutchfıeld FD, Michener JL, Thacker SB. Are we there yet?
Seizing the moment to integrate medicine and public health.
Am J Prev Med 2012;42(6S2):S97–S102, dx.doi.org/10.1016/
13. Gourevitch MN, Cannell T, Boufford JI, Summers C. The
the context of accountable care. Am J Prev Med 2012;42(6S2):
health into practice: a model for assessing the relationship be-
tween local health departments and practicing physicians. Am J
Prev Med 2012;42(6S2):S135–S153, dx.doi.org/10.1016/j.amepre.
15. Hemans-Henry C, Greene CM, Koppaka R. Integrating
public health–oriented e-learning into graduate medical
education. Am J Prev Med 2012;42(6S2):S103–S106, dx.doi.org/
16. Wells EV, Sarigiannis AN, Boulton ML. Assessing integration
of clinical and public health skills in preventive medicine res-
idencies: the effect of competency mapping. Am J Prev Med
17. Linde-Feucht S, Coulouris N. Integrating primary care and
public health: a strategic priority. Am J Prev Med 2012;
18. CDC. Winnable Battles. Atlanta, GA: DHHS, CDC; 2012.
19. DHHS. Million Hearts. millionhearts.hhs.gov/index.html.
20. Maeshiro R, Koo D, Keck W. Patients and populations: public
health in medical education. Am J Prev Med 2011;41(4S3):
21. White KL. Healing the schism: epidemiology, medicine, and
the public’s health. New York NY: Springer-Verlag, 1991.
Koo et al / Am J Prev Med 2012;42(6S2):S89–S91