Clinical-Community Relationships Evaluation Roadmap

Despite abundant evidence of the effectiveness of certain clinical preventive services, many patients do not receive them. The reasons are numerous, including competing demands and limited reimbursement in primary care. A promising approach to enhancing the delivery of preventive services is for clinicians to coordinate, cooperate, and collaborate with external nonclinical organizations such as local health departments and community-based organizations. The Agency for Healthcare Research and Quality (AHRQ) is interested in understanding the ways in which relationships between primary care practices and community organizations may be effective and feasible in improving the delivery of clinical preventive services recommended by the United States Preventive Services Task Force (USPSTF).

Based on a targeted literature review of evidence on the effectiveness of clinical-community resource relationships for delivering select preventive services, we found that the existing body of evidence is sparse and heterogeneous. Similarly, the number of studies using existing measures for research or evaluation of clinical-community resource relationships is sparse. Substantial research is needed to better understand the potential benefit of clinical-community resource relationships for improving preventive care for patients.

This Evaluation Roadmap is designed to be a resource for future research and evaluation, of use to funders, researchers, and program evaluators interested in primary care and understanding effective clinical-community resource relationships. The Roadmap is rooted in a conceptual framework that depicts the interrelationships between several factors that may influence the effectiveness of linkages between primary care clinics and community resources for preventive services. The framework includes three basic elements—the clinic/clinician, the patient, and the community resource—and the three dyadic relationships between these elements. This framework is explained in more detail in Appendix A.

While the Roadmap specifically addresses clinical-community resource relationships for selected clinical preventive services, the principles and questions presented here may also apply to other clinical and non-clinical services. Thus, the Roadmap also may prove useful and applicable to those interested in effective relationships and coordination between clinics and a variety of community organizations, such as schools or providers of social services.

The following priority questions and recommendations for advancing research and developing measures are based on an environmental scan of measures, a targeted literature review of research, an assessment of evidence gaps, and input from an expert panel.

Priority Questions

1. How do the characteristics of primary care clinicians and clinics, patients, and community resources influence the effectiveness of linkages for the delivery of clinical preventive services?
2. How do characteristics of the clinician-patient relationship, the patient-community resource relationship, and the clinical-community resource relationship influence the effectiveness of linkages for the delivery of clinical preventive services?
3. How does the relative importance and influence of clinics and clinicians, patients, and community resources, and their mutual interrelationships, vary in different circumstances or contexts, including the delivery of different clinical preventive services?
4. What are the best methods, strategies, and settings for studying and improving clinical-community resource relationships for the delivery of clinical preventive services?
5. What are the best measures for evaluating the effectiveness of clinical-community resource relationships for the delivery of clinical preventive services?

Recommendations

1. Researchers should use complex systems approaches to best understand the influence of contextual issues on the effectiveness of clinical-community resource relationships for the delivery of clinical preventive services.
2. Research on clinical-community resource relationships should be designed to flexibly accommodate variability in primary care clinic, patient, and community resource characteristics, including the use of tailored or semi-tailored interventions.
3. Researchers and program evaluators should use and develop standard measures of relevant characteristics of the six elements and relationships that influence the effectiveness of linkages for the delivery of clinical preventive services.
4. Research into clinical-community resource relationships for the delivery of clinical preventive services should be relevant and rigorously designed, using deep qualitative methods as well as formal quantitative study designs.
5. Research findings should be reported more thoroughly and in more useful formats.
6. Studies should include assessments of the feasibility and sustainability of interventions to improve clinical-community resource relationships for the delivery of clinical preventive services, including effects on clinics, patients, and community resources.
7. Future research could consider the conceptual framework developed for this project as a starting point that might be further refined.

As a general conceptual guide for future research in a field that is relatively underdeveloped, the Roadmap is meant to provide direction for next steps, rather than a definitive vision of the ultimate research and measurement goals. It is hoped and expected that, as the field advances, more specific and well-defined evidence gaps will become apparent, and with those gaps the associated research and measurement needs will become clearer and more specific.