Acknowledging the role of prevention in curbing the growing costs of health care and reducing morbidity and mortality in the United States, the 2010 Patient Protection and Affordable Care Act mandates that insurers provide coverage for specific preventive services without imposing cost-sharing requirements (U.S. Congress, 2010). Covered services include:1
- Recommendations of the United States Preventive Services Task Force (USPSTF).
- Recommendations of the Advisory Committee On Immunization Practices (ACIP) that have been adopted by the Director of the Centers for Disease Control and Prevention (CDC).
- Guidelines supported by Health Resources and Services Administration's (HRSA's) Bright Futures Project and Uniform Panel of the Secretary's Advisory Committee on Heritable Disorders in Newborns and Children.
- Recommendations of the Institutes of Medicine (IOM) for HRSA's Women's Preventive Services.
Of particular interest in this project are services that are recommended by the U.S. Preventive Services Task Force (USPSTF) as Grade A and B recommendations (USPSTF, 2010). An "A" or "B" letter grade indicates that the panel recommends a service because there is at least a moderate net benefit for performing the service. The USPSTF recommendations include a broad range of clinical preventive health care services such as screenings, counseling, referrals, and preventive medications. Despite the existence of the USPSTF recommendations, a 2003 study found that patients receive only half of the recommended clinical preventive services overall, and less than 20 percent of recommended counseling or education services (McGlynn et al., 2003). There are many constraints and barriers that can limit delivery of these services in primary care settings, including time constraints, lack of appropriate staffing, and reimbursement issues (Infante et al., 2007). A promising approach to enhancing the delivery of preventive services in clinical settings is for providers to coordinate, cooperate, and collaborate with external nonclinical organizations such as local health departments and community-based organizations that share an interest in improving health and preventing disease and that can deliver these services.
The Agency for Healthcare Research and Quality (AHRQ) refers to this collaborative approach to the delivery of preventive services as clinical-community relationships. AHRQ has set a long-term goal of understanding whether fostering relationships between clinical practices and community organizations is an effective and feasible way to enhance the delivery of specific clinical preventive services. This work is integral to the mission of AHRQ's Prevention and Care Management Portfolio to improve the quality, safety, efficiency, and effectiveness of evidence-based preventive and chronic-care management services in primary care settings. AHRQ has funded a series of projects in an effort to better understand and support these relationships.
AHRQ implemented a series of activities from 2008 to 2010 that included:
- Convening a Clinical-Community Linkages Summit in 2008 to encourage collaboration, coordination, and integration among health care clinicians, institutions, and community organizations.
- Conducting a literature review and environmental scan of linkages between clinical practices and community organizations.
- Developing case studies of promising linkages.
- Convening a 2010 summit of representatives from Federal agencies and other stakeholder organizations to develop a national strategy for promoting linkages to increase the delivery of clinical preventive services.
Stakeholders participating in the 2010 summit identified strategies to support local efforts to develop clinical-community linkages. One key strategy recommended was to develop metrics related to linkages between clinical practices and community organizations. In response, AHRQ launched a research project with the following aim:
- To develop an atlas to help evaluators identify appropriate measures for clinical-community relationships2 interventions in research studies and demonstration projects, particularly those measures focusing on USPSTF A and B preventive services, which are feasible in community settings.
In developing this Clinical-Community Relationships Measures Atlas (CCRM Atlas), we investigated existing clinical-community relationships measurement approaches based on results from a targeted environmental scan and input from expert stakeholders.
The CCRM Atlas includes structure, process, and outcome measures related to clinical-community relationships. The measures are organized according to a measurement framework that focuses on the characteristics and activities of clinicians, patients, and community organizations, as well as their interactions and relationships. This framework for describing and organizing the measures reflects the important aspects of establishing and operating clinical-community relationships in practice.
1.1 Purpose
The CCRM Atlas aims to support the field of clinical-community relationships measurement by:
- Providing a framework for understanding the measurement of clinical-community relationships.
- Providing a list of existing measures of clinical-community relationships.
- Aligning the existing measures within a clinical-community relationships measurement framework.
- Providing further details regarding the existing measures, including contextual information such as the preventive service(s) addressed in the setting(s) where the measure was used.
1.2 Intended Audience
The CCRM Atlas is designed with the following key audiences in mind:
- Researchers studying clinical-community relationships.
- Evaluators of interventions or demonstration projects that aim to improve clinical-community relationships.
- Primary care clinicians and community organizations/programs utilizing clinical-community relationships to provide prevention services to patients.
1.3 Scope
The measures within the CCRM Atlas focus on the structures, processes, and outcomes that are fundamental to clinical-community relationships. AHRQ's focus on clinical-community relationships seeks to explore how partnerships among primary care settings and community resources are developed, strengthened, and sustained to provide quality preventive care to patients and families. The framework and measures highlighted in the CCRM Atlas are based on the following assumptions:
- The prevention strategy originates in the primary care setting. The role of a primary care practice encompasses providing for and recognizing the need for preventive health services, including arranging for the delivery of services not provided in the primary care setting (i.e., providing referrals to community resources). Some of the measures listed in the Atlas may not have been applied in a primary care setting, but were deemed to be applicable in a primary care setting.
- There is differentiation between clinics/clinicians and community-based resources. Primary care clinics/clinicians and community-based resources are defined as separate entities. Some organizations, such as public health departments, may include both clinical and nonclinical resources; however, the aspects of communication and coordination highlighted in the framework are relevant to relationships within these organizations as well.
- The prevention strategies are focused on counseling and screening services provided in nonclinical community resource settings. While prevention strategies may vary from practice to practice and community to community, the Atlas selected a set of clinical preventive services focused on counseling and screenings that could be provided in community settings. A listing of these services is provided in Appendix A. For example, a family physician could refer a patient to a community-based organization that provides tobacco cessation counseling.
- Prevention is focused on primary and secondary strategies. The selected counseling and screening services in the Atlas exclude tertiary prevention services such as a clinic's/clinician's referral to a community resource to provide counseling for a patient diagnosed with cancer.
- Patient health outcome measures are excluded. The Atlas contains measures of the functioning of relationships among clinics/clinicians, patients, and community-based resources. Since evidence exists on patient health outcomes from preventive services delivery and patient health outcome measures are well-defined, patient health outcome measures are not within the scope of this Atlas.
- Measures are accessible. Only measures that users can access without a fee were included in this CCRM Atlas.
1.4 An Emerging Field
The idea of measuring clinical-community relationships is relatively new, and as the field of clinical-community relationships develops, the measurement domains discussed in the CCRM Atlas may change; definitions for domains may alter and/or domains may be added or removed. New models for delivering preventive services as well as evolving policies related to health care delivery may affect the applicability or relevance of the domains within the Atlas.
Further, there are some domains referenced in this Atlas for which no measures currently exist, or the measures that do exist might require additional evidence to establish their effectiveness in evaluating clinical-community relationships. The Atlas is being established, in part, to investigate potential measures for evaluating clinical-community relationships. We envision that, as measures for this field are developed and tested, new measures will be added to the Atlas.
The framework discussed in the CCRM Atlas is intended to be specific enough so that readers can understand the key components of a clinical-community relationship. However, it is also intended to be flexible enough to accommodate this emerging field of study.
1. U.S. Department of Health & Human Services Recommended Preventive Services http://www.healthcare.gov/law/resources/regulations/prevention/recommendations.html.
2. At the time of the summit, AHRQ referred to clinical-community relationships as clinical-community linkages.
