Community health initiatives are widespread, challenging our sense of civic obligation.

Bob Sigmond's assertion that community coordination is a key missing ingredient in achieving more effective health systems at the local level is worth our full attention. He brings to this issue a wealth of relevant experience in the financing and delivery of health services and as a pioneer in health planning at the community level. Having had a modest exposure to community initiatives through, most recently, a program in Calhoun County, Michigan, I support Sigmond's basic point, although with a few elaborations that I will mention later. Coordination Is on the Move Despite pervasive changes in health systems across the country, from my perspective, the public in general and, specifically, buyers and providers of care in many communities are frustrated with fragmentation of care, rising costs, uneven access, shortages of primary care, inadequate information, and a lack of consumer input or feedback. Whereas there are few successes to point to, many communities are beginning to address these and other issues through community studies and the development of overarching coordination programs. Over 2,000 persons attended a meeting last year in Anaheim to discuss Healthier Communities(1). Greater coordination was a key topic; the pot is beginning to boil, fired by a mixture of social and economic pressures. The theme of coordination is being addressed among national associations as well. Recently, the American Hospital Association, with the Hospital Research and Educational Trust (HRET), has published a vision entitled, Community Care Networks (1994), which called for collaborative networks of hospitals, physicians, other health providers, and social agencies to work in a coordinated fashion for a fixed annual payment--with their success being measured not only by overall costs but by impact on health status. In October 1994, HRET received a $6 million grant from the W. K. Kellogg Foundation to monitor and guide local community initiatives and to coordinate a concept of community benefit standards. It is important to note that the AHA guidelines supplementing the vision stress such key concepts as: childhood immunization, mammograms, and other preventive efforts; the need to promote primary care and improve environmental conditions; and the need to control costs through an attack on root causes--for example, teenage pregnancy, lack of prenatal care, alcoholism, substance abuse, preventable accidents, and poor nutrition. Communities are being urged not only to coordinate health programs but to broaden their definition of health as well. What has prompted establishment of such guidelines among AHA leaders remains speculative, but one suspects that the realization has grown that a broader definition of health that includes new local initiatives is the most effective route to value, and for some, only on such a path can hospitals and allied health institutions lay legitimate claim to being accountable and thus deserving of special tax status. Employers and health plans are also beginning to look at performance indicators from an increasingly broad-based community perspective. The guidelines of the Health Employers Data Information Set (HEDIS) seek to apply preventive and patient satisfaction-oriented performance criteria when comparing health plans. Health plans themselves are becoming increasingly focused on these issues as they seek accreditation through the National Committee on Quality Assurance. The Jury Is Still Out, but the Reasons for Coordination Are Compelling It is true that we have little evidence yet regarding how local initiatives that are built on a concept of coordination have succeeded in improving access, reducing fragmentation, improving quality of care, or moderating cost increases. We appear embarked on a new cycle of social medicine, but the jury is still out. On the other hand, before opting one way or another, we should remind ourselves that a significant amount of medicine is practiced without outcome validation, and some of it seems to do some good. …