Community Connections

Linking Primary Care Patients to Local Resources for Better Management of Obesity

Prepared by:

The State Networks of Colorado Ambulatory Practices and Partners (SNOCAP-USA)

Elizabeth E. Stewart, Ph.D., M.B.A., Healthy Living & Sunflower Trails Sunflower Foundation:

   Health Care for Kansans

Neta Taylor-Post, H.B.O.R., B.A., YMCA of Greater Providence

Laura Nichols, M.S., SNOCAP-USA

Elizabeth W. Staton, M.S.T.C., SNOCAP-USA

Andrew Schleuning, B.S., Kansas City University of Medicine & Biosciences


Chapter 1. Introduction



   Goals of Toolkit

Chapter 2. Background: Case for Community Linkages

   Primary Care's Expanding Caseloads and Shrinking Workforce

   Promise of Community Partner

   Origin of Toolkit: Collaboration Among AHRQ, SNOCAP-USA, YMCA

Chapter 3. Linking With a Community Partner

   Step 1: Establish Motivation and Interest of Practice

   Step 2: Find, Connect, and Evaluate a Partner

   Step 3: Identify Patients

   Step 4: Create and Use a Referral Form

   Step 5: Integrate Process Within Patient Paths

   Step 6: Develop a Feedback System

Chapter 4. Linking With the Patient

   Patient Engagement

   Patient Engagement Tools

Chapter 5. Summary



Appendix A. Case Studies

Appendix B. Shared Appointments

Appendix C. What Is a Diabetes Prevention Program?

List of Tools


The State Networks of Colorado Ambulatory Practices and Partners (SNOCAP-USA) and the YMCA are grateful to the primary care practices that participated in the pilot project and freely shared their experiences for the benefit of other practices. Participating in a formal quality improvement project takes time and commitment, and the authors wish to extend their thanks to each practice for its hard work and willingness to participate in the evaluation.

This document is in the public domain and may be used and reprinted without permission.

This toolkit is based on research conducted by SNOCAP-USA under contract to the Agency for Healthcare Research and Quality (AHRQ), Rockville, MD (Contract No. HHSA 290-2007-10008). The findings and conclusions in this document are those of the authors, who are responsible for the content, and do not necessarily represent the views of AHRQ. No statement in this report should be construed as an official position of AHRQ or of the U.S. Department of Health and Human Services.

Page last reviewed March 2014
Internet Citation: Community Connections. March 2014. Agency for Healthcare Research and Quality, Rockville, MD.