The importance of coordination between public health (PH) and health care (HC) entities became highly apparent during the COVID-19 pandemic. For most PH jurisdictions, the lack of an integrated epidemic response model impaired the ability of both PH and HC entities to respond in a timely and effective manner to mitigate the high rates of COVID-19 transmission and its subsequent morbidity and mortality. Due in large part to the historical evolution and financing of the two in the United States, the PH and HC sectors lack a structured partnership with one another, which has greatly hindered coordination and innovation around the delivery of shared core functions. While there is abundant literature on the need for and barriers to such partnerships, as well as case studies of integrated models of PH and HC, it is less clear what local, state, and federal policy actions are needed to improve the interface between PH and HC. In support of a planned Delphi Process to develop an actionable policy agenda, Kaiser Permanente commissioned this rapid review of publicly available documents on the integration of PH and HC. Integration is an imprecise term and meant, in this report, to encompass the full continuum of coordination from cooperation to collaboration, to partnership, to merger (i.e., single entity).

We searched Medline ALL via Ovid from 2000 through 18 April 2022 to identify English language published evidence, expert or consensus recommendations, concept papers, and case studies of optimal models on the integration of PH and HC. The search was designed to capture papers on PH integration with HC. The concept of PH was captured with the terms “public health” or “population health” or “community health.” The concept of HC included components of a health systems (e.g., primary care, hospitals, health insurance) and health planning (e.g., delivery of care, health policy trends, practice, or local government). We also included terms to capture settings or instances in which integration or coordination would be necessary (e.g., public health emergencies, disaster planning). We supplemented searches with expert input and reference lists of selected documents.

We communicated in real time with our Office of Community Health liaisons at Kaiser Permanente on refining our inclusion criteria as we reviewed titles and abstracts. We included any document that explicitly focused on the integration or interface between PH and HC. HC included health systems (hospital and ambulatory), health plans, long-term care, pharmacies, laboratory services, inclusive of medical, mental/behavioral, and dental services. We included of countries with different PH and HC infrastructures; however we excluded documents focusing only on low- and middle-income countries. We also conducted targeted searches for white papers or policy documents on PH and HC resilience, data sharing and IT interoperability, and international models of the integration of PH and HC. Targeted searches involved searching keywords in Google, government websites, and the websites of other organizations of interest.

We reviewed titles and abstracts for inclusion. If abstracts were not available, or inclusion could not be determined by title and abstract only, we reviewed the full text for inclusion (Figure 1). After inclusion, we categorized sources into three tiers. Tier 1 consisted of exemplar papers meeting inclusion criteria to be used as our primary source of data (e.g., recent guidance/statements, expert panel or large consensus papers, scoping or systematic reviews, collections of case examples informing broader guidance statements, case studies of multinational efforts). Tier 2 consisted of papers that met inclusion criteria but were single expert or opinion pieces, older publications, and/or individual case studies. Tier 3 consisted of papers that only marginally met our inclusion criteria (i.e., may not have specified collaboration between PH and HC, do not inform policy actions or considerations). Within each tier, we identified two major categories of documents: those generally addressing the integration of PH and HC or primary care and those specific to emergency preparedness and response.

Included articles were not critically appraised for risk of bias. We abstracted main findings focusing on policy actions and considerations from all Tier 1 articles. We then identified shared themes (of actions and considerations) and grouped these themes into general domains. For Tier 1 articles that included an intentional effort to capture a wide representation of case examples (e.g., literature or scoping review), we also recorded when case examples were cited or used to support the policy recommendations. When possible, we added more granularity to policy actions and considerations from these case examples. We then abstracted the main findings from Tier 2 articles and cross-walked these findings with findings from Tier 1 papers to make sure we had achieved saturation of themes. We a priori planned only to abstract Tier 3 articles if saturation of content with Tier 2 articles was not achieved. We did not abstract findings from Tier 3 articles. These themes of potential policy actions and considerations are summarized in two main tables (Supplementary Tables 1, 2). We also abstracted general details from Tier 2 case examples of PH and HC integration, noting if objective measures of success were reported. Published studies reporting objective measures of success are summarized in a separate table (Supplementary Table 3).

A draft of this review underwent external peer review by eight experts in public health, population health, community health, emergency preparedness and response, and laboratory services.

This rapid review identified a large volume of published or public documents that can inform policy actions and considerations to support the integration of PH and HC in general or specific to PH emergencies. Although these documents span over 20 years, the general themes are quite consistent over time. Because the path of least resistance will always be to work unilaterally, a deliberate and concerted effort must be made to effectively integrate PH and HC. Dedicated funding, incentives, and governance in a hospitable financial and legal environment, as well as a concerted effort by leadership across the federal, regional/state, and local levels is essential for successful integration. This integration extends to multiple entities within PH and HC that are less often acknowledged (e.g., laboratories, mental health providers, pharmacies, long-term care facilities) but, as demonstrated by the COVID-19 pandemic, are critical elements to PH and HC. Ultimately, integration of PH and HC will allow for a proactive rather than reactive management of individual and population health, both during ‘peace time’ and during public health emergencies. Addressing population health will necessarily require addressing health equity as well as upstream and social drivers of health.

Integration between PH and HC necessarily evolves over time and represents a continuum from mutual awareness to true partnership (or functioning as a single entity, in some other countries). The eventuality of true partnership in part depends on time, such that the most efficient policies may be those that foster initial phases of integration. Likewise, the most efficient policies may be those that leverage existing collaborations (e.g., healthcare coalitions). Demonstrating return on investment is critical, but it is important to understand that realizing ‘success’ in this endeavor will happen on a time scale different than most health-related innovations and will require development of adequate metrics of success.

In our review, we found that successful PH initiatives with collaborations at the local and regional level were frequently made possible by commensurate funding and policies at the federal level. External events with funding (e.g., state federal tobacco settlement funds, federal emergency preparedness grants and funding) were necessary catalysts for collaboration. Case examples revealed multiple factors influencing successful integration between PH and HC, including government involvement, geographic proximity of partners, shared goal (of population health) with clear roles/responsibilities and shared protocols, aligned leadership, accountability, workforce education and training, and sharing and collaborative use of data and analysis. Since a community is the immediate and ultimate ‘caretaker’ of populations served by PH and HC, communities need to be included in these integrative efforts. While PH and HC may be the core partners, engaging a broad range of private and public community partners (e.g., social services, education, business, faith-based organizations, community-based organizations) will be necessary to respond to public health emergencies and achieve population health goals.

JL obtained funding, served as the lead on the synthesis of findings, and drafted the manuscript. EW assisted with the synthesis of findings and review of manuscript, as well as conducted the identification of and abstraction from included studies. SB and AM conducted the identification of and abstraction from included studies, as well as created tables and figures. MD conducted all database searches and reviews. All authors contributed to the article and approved the submitted version.

Funding for this review was provided by Kaiser Permanente’s Office of Community Health.

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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