Integrating Primary Care Practices and Community-based Resources to Manage Obesity

Quick Start Guide

Much has been written about the need for practice transformation and improved connections between primary care and community resources following the Institute of Medicine's Crossing the Quality Chasm report.2 This toolkit is designed to help you cross a "chasm" in your own community by building bi-directional linkages (a bridge) between your primary care clinic and community-based resources that can help your patients maintain or achieve a healthy weight.

This toolkit describes a series of process steps and provides tools (resources) that will allow you to accomplish the following five tasks.


Task Chapter
  • Obtain buy-in from practice clinicians and staff to improve the care you provide to overweight and obese patients.
Chapter 1. Attaining Zoning and Building Permits for the Bridge
  • Measure and assess your clinic's current performance in obtaining an accurate height, weight, and Body Mass Index from patients.
Chapter 2. Building and Assessing the Clinic Foundation
  • Provide brief interventional counseling to patients to determine and enhance their level of readiness to change.
Chapter 3. Getting Patients Excited About Crossing the Bridge
  • Identify and build relationships with community-based resources to support patient referral.
Chapter 4. Building the Community Foundation
  • Create a systematic mechanism to refer patients to community-based resources that provides appropriate feedback.
Chapter 5. Crossing the Bridge and Returning


We found that when these five tasks are accomplished, a "bridge" will exist between your practice and community-based resources for obesity management and health behavior change. This bridge can help you improve the quality of care and enhance the services your patients receive.

Your clinic may have already accomplished some of these tasks. If so, review the chapter briefly for pointers or skip the chapter and move to a section your clinic is ready to tackle.


Like a real bridge, linkages between your clinic and community resources will require continued investments in time and resources once established.

This toolkit will help you meet that challenge!

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Page last reviewed May 2014
Page originally created May 2014
Internet Citation: Quick Start Guide. Content last reviewed May 2014. Agency for Healthcare Research and Quality, Rockville, MD.