Clinical-Community Relationships Evaluation Roadmap

Appendix C: Examples of Current State of Practice

In addition to evidence regarding measures and effectiveness of clinical-community resource relationships for the delivery of clinical preventive services, the project team identified several examples of relevant current practices reported on the AHRQ Innovations Exchange (, a Web-based repository of new and better ways to deliver health care. An earlier AHRQ-funded project (Porterfield et al., 2012) included in-depth case study assessments of five clinical-community resource relationships. Using mostly qualitative descriptive data, the investigators examined how clinical-community resource relationships for preventive services were implemented, including an analysis of predisposing, enabling, and reinforcing factors. It was not within the scope of this project to identify a comprehensive list of current practices or to conduct in-depth assessments; however, a few examples illustrate some existing approaches to fostering clinical-community resource relationships for delivery of preventive services.

  • One group of medical practices adopted an electronic system that prompts clinicians to initiate behavioral counseling for diet, exercise, smoking, and alcohol consumption at the point of care; and then electronically sends referrals to community-based counseling organizations, which contact patients for continued counseling services (go to
  • Another program, adopted by fifteen primary care practices in three different communities, used four Health Educator Referral Liaisons to link patients with community resources for counseling to reduce smoking, alcohol consumption, and physical inactivity. The liaisons also provided feedback to the referring clinicians (go to
  • In a third program to promote weight loss and physical activity, clinicians write “prescriptions” for specified recreational activities and exercise programs that community organizations have agreed to offer free of charge to patients who present these prescriptions (go to

Each of these programs reported successful linkages of patients with community resources and/or improvements in targeted behaviors.

Page last reviewed July 2013
Internet Citation: Clinical-Community Relationships Evaluation Roadmap: Appendix C: Examples of Current State of Practice. July 2013. Agency for Healthcare Research and Quality, Rockville, MD.