Community Connections: Linking Primary Care Patients to Local Resources for Better Management of Obesity

Chapter 1. Introduction

The Scenario

Phones are ringing nonstop in the background, and someone in the waiting room is crying. The recently "upgraded" electronic health record (EHR) system is frozen. As a practice manager, you're trying to keep everything under control.

A physician comes out of the exam room 20 minutes behind and frustrated. "Where do we keep those forms on the Food Pyramid?" she almost shouts.

"I think they're in that drawer in Room 3, but that room is occupied."

A medical assistant passing by adds, "Plus I think those are the old ones, not that the new pyramid we're supposed to use."

"Forget it," the physician says, deflated. "My patient is 100 pounds overweight and a food pyramid is not going to help. Besides, I'm too far behind to start anything."

As you watch her walk away, defeated, you think—there has got to be a better way-–a better way to help our patients who struggle with excess weight, a better way to provide assistance in such a time-crunched environment, a better way to, overall, tackle the lifestyle issues we see daily even at 10 a.m. on a Monday morning.

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The Solution

In a perfect world, the next step would be as simple as writing a referral to an inexpensive and credible community resource—a resource specifically designed to assist and support patients in their efforts to make healthy lifestyle changes—and providing feedback to the physician about the patient's progress. In a perfect world, the referral process would occur seamlessly as part of the patient flow, and the physician and care team would feel good knowing their patients were receiving the kind of focused time and attention the current medical model does not promote within the exam room. In a perfect world, the patient-centered medical home would have a valuable partner beyond its walls. We're not in that perfect world yet, but this toolkit is intended to get us closer.

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The Goals of This Toolkit

Every primary care practice is different, which is part of why the work can be very stimulating and fulfilling. However, the very differences that make each practice unique also make it challenging to issue blanket guidelines for quality improvement (QI) projects that will work for every practice. This toolkit is intended to offer broad ideas based in actual practice experience with the understanding that every practice will need to customize concepts for their own specific needs. Ideally, clinicians and staff at every level of a practice should review the toolkit, as each member contributes to patient care.

When we created this toolkit, we intended to: 

  • Help primary care practices determine and evaluate what accessible and affordable resources exist in your community for patients struggling with obesity and/or prediabetes.
  • Help primary care practices establish a productive relationship with community partners so that each party benefits, as well as the patients.
  • Help primary care practices work with community partners to develop a bidirectional referral process that integrates directly into your existing patient flow. A bidirectional process considers both the information leaving the practice and the information flowing back in.
  • Help primary care practices enhance engagement strategies with patients so that the referral process becomes a meaningful conversation with increased potential for patient activation. 

A recently completed pilot project, funded by the Agency for Healthcare Research and Quality, followed the experience of seven primary care practices working closely with a well-known community resource, the YMCA, and the YMCA's Diabetes Prevention Program. This toolkit is the product of their experiences. The tool is intended to help the reader examine his or her practice, reach out to community resources, develop sustainable links, and exercise new strategies and tools to increase patent engagement. Although the YMCA, as a key partner in this project, played a critical role in developing the toolkit, the lessons and examples are intended to be translatable to any community resource and any practice willing to take the extra step to make it happen.

This toolkit will not:

  • Suggest ways to connect patients to expensive hospital-based programs. While those programs can help improve the health of some patients, they are not the right fit for every patient.
  • Suggest ways to integrate a cadre of additional health care professionals into your practice; e.g., a registered dietician, psychologist, or exercise physiologist. While such a scenario is ideal, many practices are not financially structured to support such additional staff.
  • Suggest ways to fundamentally change the structure or design of your practice, or put resources into developing a new patient program. The goal is to develop links to existing programs with a referral/engagement process that assimilates within your existing workflow.

Definitions of Clinical Roles in This Toolkit 

Clinician—physician (M.D., D.O.), nurse practitioner (N.P.), physician assistant (P.A.)

Practice manager—person who manages nonclinical aspects of the practice

Care team—everyone involved in patient care

(Clinical) care team—medical assistants, nurses (R.N., L.P.N.), others that assist in clinical care

(Administrative) care team—front desk staff, referral staff, billing staff

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Page last reviewed March 2014
Page originally created March 2014
Internet Citation: Chapter 1. Introduction. Content last reviewed March 2014. Agency for Healthcare Research and Quality, Rockville, MD.