In the context of this CCRM Atlas, a clinical-community relationship exists when a primary care clinician makes a connection with a community resource to provide certain preventive services such as tobacco screening and counseling and, when the clinical practice and the community resource engage in at least one of Himmelman's strategies for working together—networking, coordinating, cooperating, and collaborating (Himmelman, 2002). These strategies are distinguished by the formality of the relationships, key characteristics (e.g., time commitments, levels of trust, access to resources), and levels of resource sharing.
2.1 Examples of Clinical-Community Relationships
The AHRQ Health Care Innovations Exchange contains several examples of clinical-community relationships. These examples, while varying by the community resources used, the communities served, and the preventive services provided, all demonstrate effective use of clinical-community relationships as a strategy for the provision of preventive services.
Example 1: In Richmond, Virginia, a group of medical practices incorporated a system called Electronic Linkage System (eLinkS) into its daily workflow (AHRQ, 2008a). eLinkS prompted clinicians to offer behavior counseling and then referred patients to community resources to help provide those services. The community resources provided services such as group counseling for alcohol and smoking behavior as well as telephone counseling for weight loss. Another component of this clinical-community relationship was a community resource's ability to update patient records through a Web site that automatically sent information regarding a patient's progress back to the patient's clinician. This clinical-community relationship resulted in a high rate of referrals for counseling services as well as improved behaviors such as high quit rates among smokers.
Example 2: The Community Health Educator Referral Liaisons (CHERL) project in Michigan used liaisons, also known as health navigators, to help reduce patients' risky health behaviors (e.g., drinking, smoking, physical inactivity) (AHRQ, 2008c). After receiving the referral from a clinician, the CHERL provided ongoing counseling to the patient and referred the patient to appropriate community resources. The CHERL updated clinicians on the patients' goals and intervention plans as well as patients' progress in meeting goals. Patients who participated in the program reported better diets, more physical activity, and less smoking and drinking.
Example 3: The King County Steps to Health project used community health workers as liaisons among clinic/clinicians, patients, and community resources (AHRQ, 2008b). The clinical-community relationships formed in this project fostered referrals to community resources for various health promotion services. The project provided evidence of patients' improved healthy behaviors such as increased physical activity, and better outcomes for asthma and diabetes patients.
2.2 Difference Between Care Coordination and Clinical-Community Relationships
There is a distinction between care coordination and clinical-community relationships as defined here. The Agency for Healthcare Research and Quality's Care Coordination Measures Atlas defines care coordination as, "the deliberate organization of patient care activities between two or more participants (including the patient) involved in a patient's care to facilitate the appropriate delivery of health services" (McDonald et al., 2010, p. 4). Organizing care involves the marshaling of personnel and other resources needed to carry out all required patient care activities and is often managed by the exchange of information among participants responsible for different aspects of care. Clinical-community relationships would fit under this definition of care coordination. However, most activities typically measured under "care coordination" are between groups commonly thought of as health care organizations. Care coordination is often employed to address the needs of a specific population of patients including those with multiple co-morbidities and consumers of high levels of health resources. Measuring care coordination is essential in improving the quality of primary care services. The CCRM Atlas focuses on a subset of care coordination between clinics and community-based resources that are not typically considered health care organizations.
2.3 The Role of Public Health in Clinical-Community Relationships
AHRQ recognizes that the specific activities and collaborative relationships involving local public health departments vary depending on the needs of local delivery systems. In some localities the public health department may fill the role of the primary care clinic or clinician as we have defined it, in other localities it may fill the role of a community resource (e.g., providing services in a nonclinical setting), and in some places it may serve in both roles. In any of these situations, the measurement framework for clinical-community relationships presented in this Atlas still applies as the elements of communication highlighted in the framework are still needed. This is equally true whether the relationship is between a public health primary care site and a private community resource, a private primary care site and a public health community resource, or a public health primary care site and a public health community resource. Even in this third situation it is important to measure and track the structure and functioning of the relationship to ensure that it is meeting the needs of the community for delivery of the relevant clinical preventive services. This CCRM Atlas is intended to provide a common framework to help understand and evaluate clinical-community relationships.
