Linking Clinical Practices and Community Organizations to Improve Care | AHRQ Innovations Exchange

Linking Clinical Practices and Community Organizations to Improve Care | AHRQ Innovations Exchange



Building Relationships Between Clinical Practices and the Community to Improve Care

Introduction

As part of its mission to improve health care, from primary prevention to chronic care management, the Agency for Healthcare Research and Quality (AHRQ) is exploring how to develop, strengthen, and sustain relationships among primary care practices, the community, and public health organizations in order to meet the needs of patients and families.

Measuring Clinical-Community RelationshipsIn 2008 and 2010, AHRQ convened two summits that focused on how linkages between clinical practices and community resources (such as local health departments and community organizations) can enhance the delivery of clinical preventive services. At the 2010 Summit, stakeholders identified strategies to support local efforts to develop such linkages, and recommended the development of metrics to support related research. In 2011, AHRQ launched the Clinical-Community Relationships Measures (CCRM) project, a collaborative effort to explore how to define, measure, and evaluate programs that support the delivery of clinical preventive services through clinical-community relationships.

Experts with knowledge of primary care, community-based organizations, preventive services, and research methods collaborated to develop a CCRM Atlas, CCRM Atlas Supplement and aClinical-Community Relationships Evaluation Roadmap. The tools are intended for researchers studying clinical-community relationships, individuals seeking to evaluate related interventions or demonstration projects, and primary care clinicians and community organizations that provide preventive services.

"Researchers assessing links between primary care and community resources have struggled with a lack of information about how to design the evaluation process. The CCRM Atlas offers researchers a conceptual framework they can use to select measures that accurately reflect changes brought about through clinical-community relationships."

—Cheryl Aspy, MEd, PhD, Professor and Associate Director of the Research Division, Family and Preventive Medicine, University of Oklahoma College of Medicine

"Clinical-community partnerships play a critical role in delivering preventive services and population-based support for improved health behaviors. The CCRM Atlas is a novel and much-needed resource that helps researchers gain clarity about how to evaluate clinical-community relationships and design projects that target areas in need of growth."

—Rebecca Etz, PhD, Assistant Professor of Family Medicine, Virginia Commonwealth University, and Co-Director, Ambulatory Care Outcomes Research Network

Innovation Profiles

• Multistakeholder, Community-Wide Collaborative Prevents Disease and Promotes Health
• Automated Clinician Prompts and Referrals Facilitate Access to Counseling Services, Leading to Positive Behavior Changes Among Patients
• Community Partnership Uses Lay Health Advisers to Reduce Chronic Disease Risk Factors, Leading to Improvements in Lifestyle and Health in Low-Income African Americans
• Community Referral Liaisons Help Patients Reduce Risky Health Behaviors, Leading to Improvements in Health Status
• Community Coalition Connects Medical Practices to Community Resources, Leading to Improved Asthma and Diabetes Outcomes in At-Risk Populations
• Health Clinics and Community Organizations Coordinate Outreach Workers to Educate and Support Farm Workers, Leading to Healthier Behaviors and Higher Satisfaction

QualityTools

• Clinical-Community Relationships Measures Atlas
• Potential Measures for Clinical-Community Relationships: A Supplement to the
  Clinical-Community Relationships Measures Atlas
• Clinical-Community Relationships Evaluation Roadmap
• Map My Community
• MD Link: Partnering Physicians with Community Organizations: A Toolkit for Physician Champions
• Multi-stakeholder Community Inventory Modules

Additional Resources

• Web Event: Clinical-Community Relationships as a Pathway to Improve Health: Tools for Research and Evaluation
• 2012 IOM Report: Primary Care and Public Health: Exploring Integration to Improve Population Health
• 2010 Summit Report: Linkages Between Clinical Practices and Community Organizations for Prevention
• View 2010 Summit Page
• 2008 Summit Report: Summit on Linking Clinical Practice and the Community for Health Promotion
• View 2008 Summit Page
• Integrating Evidence-Based Clinical and Community Strategies To Improve Health
• AHRQ's Prevention and Chronic Care Program Clinical-Community Linkages Page