Community Connections

Chapter 2. Background: Case for Community Linkages

Primary Care's Expanding Caseloads and Shrinking Workforce

Linking primary care practices with community resources makes sense in light of the increasing demands on primary care providers. In particular, increasing rates of overweight and obesity in the United States will increasingly tax primary care providers, making it unlikely they can handle their patients' needs alone. Consider the following statistics:

  • According to the Centers for Disease Control and Prevention's (CDC) National Center for Health Statistics, more than one-third (35.7%) of U.S. adults are obese.
  • CDC estimates that 17% (or 12.5 million) of children and adolescents aged 2 through 19 years are obese.
  • The U.S. Surgeon General reports that obesity accounts for nearly 300,000 deaths in the U.S. each year. Studies show that obesity is associated with more chronic health problems than smoking, heavy drinking, and poverty and is a major risk factor for developing prediabetes and type 2 diabetes.
  • The CDC also estimates that 79 million people—1 of every 3 Americans—currently have prediabetes.
  • Compared with normal-weight adults, overweight adults report the following more frequently: fair or poor health, limitations in daily activities, and more health care visits.1
  • The average primary care physician oversees a panel of about 2,500 patients.2,3 At the same time, the country faces a shortage of primary care physicians, especially in rural areas.4
  • One analysis5 suggests that in order to fully satisfy all  U.S. Preventive Services Task Force recommendations, a physician must spend 7.4 hours per working day just on those activities—this does not include other activities, such as acute care, procedures, administrative tasks, quality improvement projects, and so forth.

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The Promise of the Community Partner

Primary care practices are struggling to care for their patients with obesity and associated chronic conditions such as prediabetes. The Chronic Care Model, a framework developed in the late 1990s to help providers care for patients with chronic conditions, includes connecting patients to community resources as a major component.6,7 Many resources exist to provide accessible, affordable services to those in need and often are funded with incoming caseloads. Furthermore, many community resources rely on a peer or trained layperson model of support that lends itself to the problem-solving and self-management tools that patients seem to crave, but few medical offices have time to adequately provide. While the concept is promising, the devil is in the details. Even among practices that have implemented innovative programs targeting tobacco use, risky drinking, unhealthy dietary patterns, and physical inactivity, referral to community resources is low.7 This toolkit is intended to untangle those details so that a promising idea can translate into a reality.

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Origin of This Toolkit: Collaboration Among AHRQ, SNOCAP-USA, and the YMCA

In 2010, AHRQ issued a national call for practice-based research networks to develop a practical, sustainable system to link primary care practices and community partners. In response, SNOCAP-USA partnered with the YMCA of the USA to build a referral and feedback system between primary care practices and the obesity and diabetes prevention programs offered by the YMCA, specifically, the YMCA's Diabetes Prevention Program (YDPP).

Under the recommendation of the YMCA of the USA, SNOCAP-USA joined forces with the YMCA of Greater Providence in Rhode Island. SNOCAP-USA worked with a trained YMCA health facilitator to help increase awareness among primary care practices about available community resources, to develop a bidirectional referral and linkage system, and to assess the project through process evaluation and patient outcomes. Specifically, the bidirectional system was developed to link patients at risk for diabetes to the YMCA's Diabetes Prevention Program.

The strategies and suggestions in this toolkit come directly from the experiences and observations of the practices that participated in the pilot project, along with the health facilitator at the YMCA who worked with them for 15 months. Information was gathered through an ongoing series of site visits, interviews, learning collaboratives, and constant communication. The participating practices were given the opportunity to review drafts of the toolkit and provide feedback for improvement. The toolkit also incorporates the accumulated knowledge of SNOCAP-USA after 12 years of assisting practices in quality improvement projects and evaluation methods.

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Page last reviewed March 2014
Page originally created March 2014
Internet Citation: Chapter 2. Background: Case for Community Linkages. Content last reviewed March 2014. Agency for Healthcare Research and Quality, Rockville, MD.