Clinical-Community Linkages

Creating sustainable, effective linkages between the clinical and community settings can improve patients' access to preventive and chronic care services by developing partnerships between organizations that share a common goal of improving the health of people and the communities in which they live. These linkages connect clinical providers, community organizations, and public health agencies.

The goals of clinical-community linkages include:

• Coordinating health care delivery, public health, and community-based activities to promote healthy behavior.
• Forming partnerships and relationships among clinical, community, and public health organizations to fill gaps in needed services.
• Promoting patient, family, and community involvement in strategic planning and improvement activities.

Types of clinical-community linkages include coordinating services at one location, coordinating services between different locations, and developing ways to refer patients to resources.

Why Are Clinical-Community Linkages Important?

Strategies that improve access to clinical preventive services (such as screening and counseling), community-level activities, and appropriate medical treatment have been shown to reduce and prevent disease in communities. Collaborations between clinical, community, and public health organizations offer a win-win scenario for participating organizations, clinical teams, and patients.

What do effective clinical-community linkages offer?

• Patients get more help in changing unhealthy behaviors.
• Clinicians get help in offering services to patients that they cannot provide themselves.
• Community programs get help in connecting with clients for whom their services were designed.

How Can Clinical-Community Linkages Be Put Into Action?

It may seem obvious to link organizations that share similar goals for groups of patients. However, primary care clinicians, public health agencies, and community groups often provide services with little interaction with each other. To build and improve linkages across private and public health organizations within communities, it is important to identify gaps in needed health services and to fill those gaps by using the strengths and abilities of the participating organizations.

AHRQ's Innovations Exchange features examples of successful clinical-community collaborations and more resources for linking clinical practices and community organizations. These resources include:

• Automated Clinician Prompts and Referrals Facilitate Access to Counseling Services, Leading to Positive Behavior Changes Among Patients.
• Linking Clinical Practices and Community Organizations for Prevention.
• Integrating Evidence-Based Clinical and Community Strategies to Improve Health.
• Linkages Between Clinical Practices and Community Organizations for Prevention: Final Report.

Tools for making clinical-community linkages can also be found in the AHRQ Health Literacy Universal Precautions Toolkit:

• Link Patients to Non-Medical Support: Tool #18
• Direct Patients to Medicine Resources: Tool #19
• Connect Patients with Literacy and Math Resources: Tool #20
• Make Referrals Easy: Tool #21

Resources for Research on Community-Clinical Linkages

• Clinical-Community Relationships Evaluation Roadmap.
• Clinical-Community Relationships Measures (CCRM) Atlas.
• Community Connections: Linking Primary Care Patients to Local Resources for Better Management of Obesity.
• Integrating Primary Care Practices and Community-based Resources to Manage Obesity: A Bridge-building Toolkit for Rural Primary Care Practices.
• Potential Measures for Clinical-Community Relationships—A Supplement to the Clinical Community Relationships Measures Atlas.

Conference Presentations

The following AHRQ Annual Conference presentations on clinical-community linkages are also available:

Strategies to Put Patients at the Center of Primary Care: Partnering for Health – 2011

• SHARP Partnering With Patients (  Microsoft PowerPoint version - 5.48 MB )
  Samer Assaf and Ross Adams, Rees-Stealy Medical Group
• Linking Practice and Community Through a Focus on Capability (  Microsoft PowerPoint version - 4.23 MB )
  Robert Lewis Ferrer, University of Texas Health Science Center at San Antonio