Clinical-Community Relationships Evaluation Roadmap
1. Introduction and Purpose
Clinical preventive services can reduce morbidity and mortality from various health conditions. The United States Preventive Services Task Force (USPSTF) issues recommendations for the delivery of clinical preventive services based on the findings of systematic evidence reviews (USPSTF, 2010). Even with strong evidence of effectiveness (e.g., USPSTF recommendation levels A and B), many patients do not receive recommended clinical preventive services (McGlynn et al., 2003). The reasons for this are numerous, including competing demands in primary care clinics and limited reimbursement for clinical preventive services (Infante et al., 2007). Another important factor could be the high number of recommended preventive services. One study concluded that it would require 7.4 hours each day for an average primary care clinician to provide all recommended preventive care (Yarnall et al., 2003), which is a practical impossibility.
Certain preventive services may be provided effectively in nonclinical community settings. Examples of such community resources are telephonic smoking cessation counseling services, physical activity programs at the YMCA or health clubs, commercial weight loss programs, Alcoholics Anonymous, or La Leche League. In addition to increasing the availability of preventive services for the community at large, collaborative efforts between primary care practices and community resources, including local health departments, offer the possibility of an effective, efficient, patient-centered approach to address the preventive service needs of some or many of their patients. Examples of several approaches to implementing this type of collaborative clinical-community relationship can be found in Appendix C.
Despite this promise, even when a clinical preventive service could be provided by a non-clinician in the community, and even when such community resources are available, clinicians may be unaware of them, or lack the ability to both make referrals to these external organizations and receive confirmation that appropriate preventive services are delivered. Previous research has indicated that it is possible to establish effective relationships between clinics and community resources, to the benefit of patients, clinicians, and the community resources (Woolf et al., 2006). Certain strategies such as infrastructure support and improved communication systems may facilitate such relationships (Etz et al., 2008).
1.2 Purpose and Scope of the Evaluation Roadmap
This Evaluation Roadmap is intended to serve as a general guide and resource for future research and evaluation into the design and implementation of effective clinical-community resource relationships for the provision of selected clinical preventive services. The complete list and rationale for the selection of services is provided in Appendix B-1. The Roadmap may be of use to funders, researchers, and program evaluators interested in primary care and understanding effective clinical-community resource relationships. AHRQ's goal in developing the Roadmap is to stimulate interest in both implementation and research in this emerging approach to the delivery of selected clinical preventive services. In the Roadmap we present a number of priority questions and recommendations for advancing research and developing measures that are considered to be broadly applicable across multiple preventive services. While the Roadmap specifically addresses clinical-community resource relationships for selected clinical preventive services, the principles and questions presented here may also apply to other clinical services and/or to non-clinical services. As such, the Roadmap may also prove to be useful and applicable to a broader audience, including those interested in effective relationships and coordination between clinics and a variety of community organizations, such as schools or providers of social services. The Roadmap was developed with the input and guidance of a panel of eight national experts, however, the authors are solely responsible for its content. Go to Appendix D for the expert panel membership.
The Roadmap is rooted in a conceptual framework described in detail in Appendix A. The conceptual framework comprises six interrelated components that may influence the effectiveness of a primary care clinic's1 effort to connect a patient with a community resource to successfully receive a clinical preventive service. These six components include three basic elements (clinic/clinician; patient; community resource) and the 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. We distinguish a "clinical-community resource relationship" from a "linkage.". A linkage represents the combined interactive influences of all three basic elements and their three respective dyadic relationships in the connection of a primary care patient with a community resource for delivery of a preventive service. The clinical-community resource relationships of interest here are those that have been established and exist with the intent of facilitating the referral of patients to receive preventive services, or that may have been established for another purpose, but which might nonetheless facilitate the delivery of preventive services. This distinction is more fully described in Appendix A. In the 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 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 Roadmap.
The Roadmap is based on a targeted literature review of the effectiveness of clinical-community resource relationships for delivering eight different clinical preventive services (described in Appendix B-1); an assessment of gaps in that body of evidence; an environmental scan of studies using existing measures to evaluate clinical-community resource relationships (described in Appendix B-2); a Web-based Atlas of measures of clinical-community resource relationships2; and consultations with an expert panel. Consistent with earlier work (Porterfield et al., 2012), we found that the existing body of evidence is sparse and heterogeneous, which precluded our identifying a set of discrete evidence gaps related to specific key research questions. Similarly, the number of studies using existing measures for research or evaluation of clinical-community resource relationships is sparse. Given the current relatively underdeveloped state of research, the Roadmap provides general conceptual guidance for needed next steps with examples of the types of studies that can begin to fill in gaps in the research.
The Roadmap complements and is consistent with other recent initiatives to improve the quality of health care and foster the integration of clinics/clinicians and community organizations that provide health services. These include the "Triple Aim" of the Institute for Healthcare Improvement (http://www.ihi.org/offerings/initiatives/TripleAim ) and the National Strategy for Quality Improvement in Health Care (the National Quality Strategy) (http://www.ahrq.gov/workingforquality/nqs/nqs2012annlrpt.htm). The Triple Aim includes improved patient experience of care, improved health of populations/communities, and reduced cost of care. The National Quality Strategy provides direction for achieving these aims, by promoting quality health care in which the needs of patients, families, and communities guide the actions of all those who deliver and pay for care. Six priority areas have been identified in the National Quality Strategy, including the promotion of effective communication and coordination of care, the promotion of the most effective prevention practices for leading causes of mortality, and working with communities to promote wide use of best practices to enable healthy living. Developing clinical-community resource relationships for the provision of select USPSTF-recommended preventive services—the focus of this Roadmap—contributes directly to achieving the triple aim as it can increase the delivery of effective preventive services, thereby improving population health and averting preventable illnesses.
1.3 The Importance of Context
The expert panel emphasized the importance of considering and accounting for the specific contexts in which clinical-community resource relationships for the delivery of preventive services occur. Primary care and communities are complex and interrelated systems, which exist within broader socioeconomic and health care system frameworks. Clinical-community resource relationships must be evaluated with the potential effects of broader socioeconomic and health care system factors in mind. Communities differ in population size, wealth, educational attainment, cultural diversity, and their approach to addressing local challenges. Primary care clinics exist within a larger health care system that rewards certain behaviors based on payment mechanisms, regulations, and public reporting. The specific health care and other community resources available and accessible in each community are unique and may logically influence the effectiveness of linkages for delivery of preventive services. Furthermore, primary care clinics/clinicians, patients, and community resources vary in numerous particular characteristics that can affect the relevance and effectiveness of different approaches for establishing, managing, and maintaining successful clinical-community resource relationships for delivering preventive services. These are described below.
Primary care clinics/clinicians may vary in their: (a) training and capacity to deliver preventive services, related to clinic size, staffing, and workload; (b) information technology infrastructure, including electronic health records, and clinical decision support systems; (c) delivery system design, related to the services of social workers or mental health professionals, as well as staffing patterns and roles within a clinic; (d) organizational infrastructure, related to ownership (e.g., health system or hospitals, public or private), profit/nonprofit status, single specialty or multi-specialty; and (e) knowledge of and familiarity with community resources.
Patients may vary in their: (a) health literacy; (b) capacity for self-management related to personal resources, such as financial status, transportation availability, and family support; (c) accessibility to primary care related to insurance coverage and ability to take time off from work; (d) knowledge of and familiarity with community resources; (e) access to the community resource, including ability to pay for a service; and (f) readiness for behavior change.
Community resources may vary in: (a) capacity to provide services, related to size, staffing, and training; (b) information technology infrastructure, including the ability to identify patients due for preventive services, provide automated reminders, and track services delivery; (c) delivery system design, including the scope of professional services and how those services are provided; (d) organizational infrastructure, related to profit/nonprofit status, board composition, and governance structures; and (e) marketing or communication on the availability of services.
For any given clinic in a particular community, the nature of these three elements (clinic/clinician; patient; community resource) and the relationships among them determine the nature and scope of viable clinical-community resource relationships for successfully providing patients with preventive services. In addition, the relevance and influence of different factors will vary according to the particular clinical preventive service in question. A recent report on improving the integration of primary care clinics and public health organizations noted "that the types of interactions between the two sectors are so varied and dependent on local circumstances, such as the availability of resources and differences in health challenges, that it is not possible to prescribe a specific model or template for how integration should look" (Institute of Medicine, 2012, Report Brief, pp. 1-2).
In recognition of wide local variations in myriad influential factors, the expert panel strongly emphasized the importance of considering and accounting for the context in which research, quality improvement, and evaluation initiatives occur. The relevance and effectiveness of particular interventions depend on each community's unique needs, values, priorities, customs, resources, and preferences. Hence, it is critical that contextual factors are considered in the design, implementation, and evaluation of research into clinical-community resource relationships for delivery of clinical preventive services. Interventions should be flexibly tailored when indicated to accommodate local circumstances. And, given the rich complexity of the interrelated systems involved, it is especially important to conduct rich qualitative research that elucidates the nature and influence of the contextual factors themselves.
2. Dymek C, Johnson M Jr, McGinnis P, Buckley DI, Fagnan LJ, Mardon R, Hassell S, Carpenter D. Clinical-Community Relationships Measures Atlas. (Prepared by Westat under Contract No. HHSA 290-2010-00021.) AHRQ Publication No. 13-0034-EF. Rockville, MD: Agency for Healthcare Research and Quality. March 2013. http://www.ahrq.gov/professionals/prevention-chronic-care/resources/clinical-community-relationships-measures-atlas/index.html.)