Clinical-Community Relationships Evaluation Roadmap
Appendix A: Conceptual Framework
The Evaluation Roadmap is based on an understanding of clinical-community resource relationships rooted in a previously developed conceptual framework. This conceptual framework is premised on clinical-community resource relationships in which patient referrals originate from the clinic toward the community resource, although reciprocity within the relationship is also considered. The conceptual framework describes six interrelated components that may influence the effectiveness of a clinic's effort to connect a patient with a community resource to successfully receive a clinical preventive service. These six components include:
Three basic elements:
- Community resource.
Three dyadic relationships between these three basic elements:
- Clinician-patient relationship.
- Clinical-community resource relationship.
- Patient-community resource relationship.
The clinical-community resource relationship, which is the central emphasis of the Roadmap, is one of the basic interrelated components of the conceptual framework.
The conceptual framework is represented in Figure A-1. The three interconnected circles of this Venn diagram represent the three basic elements of the framework—the primary care clinic/clinician, the patient, and the community resource.
- The clinic/clinician element includes individual clinicians and clinic support staff operating in clinical primary care settings. Examples of clinic/clinician characteristics that might influence the effectiveness of efforts to connect patients with community resources for clinical preventive services include: awareness of community resources, capacity and training to deliver particular clinical preventive services, organizational infrastructure, openness for change, and information technology infrastructure.
- The patient element is defined as the individual who receives primary care services, including preventive care and illness care. Examples of patient characteristics that might influence the effectiveness of a clinic's effort to connect the patient with a community resource include: stage of readiness for change, health literacy, capacity for self-management, and accessibility to the community resource.
- The community resource element encompasses a range of organizations and programs that provide services to patients, including USPSTF-recommended clinical preventive services. Examples of community resource characteristics that might influence the effectiveness of efforts to connect patients with the community resource include: capacity to deliver the services, organizational infrastructure, and information technology infrastructure.
Figure A-1. Conceptual framework of linkages between clinics and community resources for delivering clinical preventive services
The areas of intersection of the three circles represent relationships between the three basic elements. The three dyadic relationships between the three basic elements are fundamental aspects of the conceptual framework.
- Examples of characteristics of the clinic/clinician-patient relationship that might influence the effectiveness of efforts to connect the patient with a community resource for preventive services include: trust between the clinician and patient, shared decisionmaking, and mechanisms for mutual support of patient self-management.
- Examples of characteristics of the clinic/clinician-community resource relationship that might influence the effectiveness of efforts to connect patients between the two include: level of interrelationship along Himmelman's continuum for collaborative processes (Himmelman, 2002), formal mechanisms for referrals, and effective mechanisms for feedback from community resource to clinic.
- Examples of characteristics of the patient-community resource relationship that might influence the effectiveness of clinics' efforts to connect patients with the community resources include: patients' perception and trust of the community resource, formal mechanisms for referrals, and effective communication between patient and community resource.
In the Atlas (Clinical-Community Relationships Measures Atlas [Dymek et al., 2013]), we pair the six basic factors of the conceptual framework with Donabedian's structure-outcome-process model (Donabedian, 1980) to organize various domains of measurement that might be used to evaluate clinics' efforts to connect patients with community resources for preventive services. This framework for thinking about the elements and relationships is also useful for considering high-priority research and evaluation needs, and we have used it as an important guide in developing this Evaluation Roadmap.
Our conceptual framework expands on the idea of a bridge between primary care practices and community resources as described by Etz et al. (Etz et al., 2008). The larger bridge imposed over the Venn diagram in Figure A-1 represents this connection between the clinic/clinician and the community resource. The Etz bridge includes foundational ("anchor") characteristics of the clinic/clinician and the community resource, as well as the relationship between the two. Our conceptual framework adds the critical element of the patient to this bridge. Given that the real-world function of connections between clinics and community resources to actually deliver preventive services cannot occur without patients, including patient-related factors is essential. By including the patient element in the framework, we consider the potential influence of patient characteristics and the relationships of patients with clinics/clinicians and with community resources.
Defining "Linkage". Including the patient element with the clinic/clinician and community resource elements produces the central area of the Venn diagram above, where all three circles intersect. This area at the center of the diagram is of particular interest, as it represents the combined interactive influences of all three basic elements and their three respective dyadic relationships. The larger bridge in the diagram can represent relationships that are established with the intent of facilitating the referral of patients to receive preventive services, or existing relationships between clinics and community resources that are not specific to the delivery of clinical preventive services, but which might nonetheless facilitate the delivery of those services. The smaller bridge at the center of the diagram represents the process of placing actual patients on that existing bridge to connect them with community resources to receive needed preventive services. We refer to the former concept, represented by the larger bridge, as "clinical-community resource relationships", which is one of the six basic interrelated components of the conceptual framework. We refer to the latter concept, represented by the smaller bridge at the center of the diagram, as a "linkage". A linkage, therefore, represents the combined influence of all six basic factors in the actual realization (or not) of a primary care patient being connected with a community resource for delivery of a preventive service.
It is important to note that the symmetry of the diagram does not imply that each of the basic six factors necessarily exerts an equal influence in making a linkage for the delivery of a clinical preventive service. In fact, the relative influence of factors is generally expected to vary according to the particular preventive service and the specific circumstances of individual clinics, clinicians, patients, community resources, and communities. The relevance of situational variability in the influence of different factors, including the clinical-community resource relationship, is discussed in more detail in Section 1-3, "The Importance of Context."