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The Agency for Healthcare Research and Quality Develops New Resources on Clinical-Community Relationships to Promote Research | AHRQ Innovations Exchange

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The Agency for Healthcare Research and Quality Develops New Resources on Clinical-Community Relationships to Promote Research | AHRQ Innovations Exchange

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AHRQ Develops New Resources on Clinical–Community Relationships To Promote Research
Carol Cahill, MLS, Research Associate and Program Manager, Center for Community Health and Evaluation, Group Health Research Institute
Clarissa Hsu, PhD, Research Associate, Center for Community Health and Evaluation, Group Health Research Institute










The Agency for Healthcare Research and Quality Develops New Resources on Clinical-Community Relationships to Promote Research

By the Innovations Exchange Team

The Agency for Healthcare Research and Quality (AHRQ) has developed two new resources on clinical-community relationships with input from an expert panel representing academic, public health, and health care settings. The Clinical-Community Relationships Measures Atlas identifies ways to further define, measure, and evaluate programs based on clinical-community relationships to deliver clinical preventive services. The Atlas also provides a measurement framework and lists existing measures of clinical-community relationships. The Clinical-Community Relationships Evaluation Roadmap offers suggestions for future research and evaluation efforts, and methods to study relationships among clinical care settings, community resources, and patients. The Innovations Exchange discussed these topics with Carol Cahill, MLS, and Clarissa Hsu, PhD, both of whom are research associates with the Group Health Research Institute (GHRI). Ms. Cahill serves as a member of the expert panel involved in developing AHRQ resources on clinical-community relationships.

Innovations Exchange: What is the purpose of the Roadmap?

Carol Cahill, MLS:
The Roadmap provides a framework for efforts to assess clinical-community relationships—including their strength, patient and provider readiness for change, and the context in which services are provided—and to evaluate and improve those relationships and services to ensure that the connections happen. This process includes an evaluation of referrals between the provider and the patient, the experience of the patient and the community resource, and communication between the community resource and the clinical care practice among other measurement concepts.

What was the impetus for developing the Roadmap?

Cahill: Based on my own work in establishing and measuring clinical-community resource relationships, I know there is a need for validated and useful measures. Studies have indicated that certain clinical preventive services, particularly education and counseling, are unlikely to be delivered in clinical settings, but could be provided effectively in community settings such as the YMCA or the local health department. Given AHRQ’s previous work examining care coordination and clinical practice-community relationships, developing the Atlas and Roadmap was a natural next step.

Can you explain the conceptual framework of the Roadmap?

Cahill: The framework looks at three elements—clinical practices, patients, and community resources—and the characteristics of the relationships among them. Specific measures for these elements were considered across three domains (structure, process, and outcomes), based on a model developed by Avedis Donabedian at the University of Michigan.1 Parallel measures exist within some domains; for example, in the process domain, readiness for change is defined as a clinical practice that is ready to refer patients to a community resource, a patient who is ready to make a behavior change and use that community resource, and a community resource that is ready to participate in a referral relationship with a clinical practice. An interesting question is whether something can be measured at the intersection of all three elements, such as the combined interactive influences of the basic elements and their relationships.

How were the clinical preventive services selected for inclusion in the Roadmap?

Cahill: The services were selected because they are recommended by the United States Preventive Services Task Force, and they are suitable to be initiated by clinicians and delivered in community settings. The clinical preventive services included counseling for breastfeeding, smoking cessation, healthy diet, and physical activity in obese patients. However, the Roadmap is intended to have broader application for assessing and improving referrals for other types of services that are available at a wide range of community settings.

Are clinicians interested in developing relationships with community resources?

Cahill: Many clinicians think these relationships are important and are aware of the social determinants of health. In a 2011 Robert Wood Johnson survey2 of primary care physicians, 85 percent said they believe that social services are just as important to address as clinical services, but there are barriers to referring patients for these services. The barriers include a lack of payment incentives for time spent connecting patients to social services, a lack of knowledge about the resources that are available, and challenges talking with patients about sensitive topics.

Will the Roadmap appeal to providers of nonclinical services such as social services?

Cahill: Yes, community resources such as the YMCA may be able to use the Roadmap and conceptual framework to develop evaluation questions for program improvement. For example, an evaluation could be conducted about the effectiveness of an outreach program encouraging physicians to give postcards to patients to mail to the YMCA, whose staff would then follow up and schedule an appointment. There are also some communities receiving large Federal grants with a significant evaluation component (such as the Centers for Disease Control and Prevention Community Transformation Grants), and those programs can include strategies involving connections among patients, clinical practices, and community resources.

How will your research project enhance clinical-community resource relationships?

Dr. Clarissa Hsu: A team at GHRI received an award recently from the Patient-Centered Outcomes Research Institute to directly involve patients at several GHRI primary care clinics in the design of an intervention that will link patients with community resources. The innovation involves patients designing a community liaison role to develop and enhance clinical-community relationships. The research project will be piloted in several clinics in Washington.

How have you used the Atlas?

Hsu: Looking at the Atlas was helpful to start thinking through how to measure linkages from the perspective of the patient, clinic, and community resource. To ensure that relationships are developed, structures, processes, and outcomes need to be established. The conceptual framework’s description of these three domains and measurement questions helped us consider how to measure the outcomes of our project from different perspectives. It also enabled us to identify what resources and tools were available for measuring the clinical-community linkages.

What gaps in research would you like to see addressed?

It would be very helpful to have more measures to choose from. The Atlas identifies many areas to measure, but the measures simply don't exist yet. From a research perspective, the framework is a good starting point; however, I look forward to the field fleshing it out with clearer methods and measures, including survey or interview questions that would address some of the complex issues. For example, the measure-mapping table identifies the importance of measuring how much patients know about the community resources available to them, but shows that no measurement resources exist for this domain.

When do you expect to have preliminary findings from your research project?

Hsu: We are in the startup phase of the 3-year grant. The intervention will be designed early next year by a patient and provider design team. After the team figures how to build clinic-community linkages into the clinical practice, we can evaluate how well it works. Because this intervention will be implemented at a clinic, it will be a dynamic process to figure out how these linkages happen in real life. We expect to have preliminary findings once the intervention has been implemented in the clinic for 1 year.

About Carol Cahill, MLS:

Ms. Cahill is a research associate at the GHRI’s Center for Community Health and Evaluation (CCHE). She has a background in information science and community health planning, as well as expertise in geographic information systems and visualization of data. Ms. Cahill has been involved in the design and implementation of a Web-based tool to help primary care providers link patients with community resources for physical activity, healthful eating, and chronic disease management. She has participated in numerous CCHE evaluation projects, including conducting community health needs assessments for Group Health and a national evaluation of health impact assessments for the Robert Wood Johnson Foundation.

About Clarissa Hsu, PhD:

Dr. Hsu is a medical anthropologist who holds a doctorate in sociocultural anthropology. As a research associate and member of the GHRI faculty, she specializes in qualitative methods, research design, and participatory evaluation. Clarissa’s research contributes to improving health by investigating clinical quality improvement measures, the effectiveness of community-based health improvement programs and health promotion policy, patient-centered care and healing, and complementary and alternative medicine.

Disclosure Statements:

Ms. Cahill reported she received payment from AHRQ for her services as a consultant for AHRQ's Clinical-Community Relationships Measures project, including participation in an expert panel that helped develop the Clinical-Community Relationships Measures Atlas and the Clinical-Community Relationships Evaluation Roadmap.

Dr. Hsu reported having no financial interests or business/professional affiliations relevant to the work described in this article.

1 Donabedian A. Explorations in quality assessment and monitoring: the definition of quality and approaches to its assessment. Ann Arbor: Health Administration Press; 1980.
2 Robert Wood Johnson Foundation. Health care’s blind side: the overlooked connection between social needs and good health. Princeton, NJ: Robert Wood Johnson Foundation; 2011. Available at: Link.

Last updated: August 14, 2013.

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