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

Appendix A. Case Studies

Practice A

Practice A is a federally qualified health center, caring for low-income patients. When they began working with their community partner, the local YMCA's Diabetes Prevention Program, they were operating in a crowded, run-down clinic. Staff morale was low and both the staff and providers seemed uninspired.

Their community partner overloaded them with information in an attempt to help them adopt a healthy workplace, while simultaneously teaching them about which patients could be referred to the community program. The community partner also was recruiting for two separate YMCA programs, which turned out to be confusing as to which patients were appropriate for which program. The result was low conversion rates of referral enrollment.

Midway through the partnership, the practice moved to a new location and brought in new clinicians who provided a fresh outlook. The executive director made clear his support, and then delegated the work to a nurse manager who took on the project. New energy, combined with bigger space, resulted in improved staff morale.

At the same time, the community partner began to focus on helping the practice recruit patients to a single YMCA program with straightforward patient eligibility. They stripped away the efforts to create a healthy office within the practice and kept working toward the goal of more patient referrals. The community partner began spending a lot of time onsite, but quickly learned that being there every week was not a good use of time and her presence resulted in a low number of referrals. She now visits the practice once a month and meets with a group of patients who have been referred. She does a group registration during this time, and then meets individually with providers and the staff. The result is better staff understanding of the goals and process, higher referral rates from clinicians, and an easier registration process for patients.

Lessons learned:

  • Do not provide the practice with too much information.
  • Focus on a single program to refer patients to.
  • Get buy-in from the medical assistants.
  • Demonstrate the community resource's value.
  • Obtain support from high-level leaders, but find a member of the practice who can be active and focus on the partnership.

Practice B

Practice B is a group practice that is part of the primary care independent practice association. Practice B has a high National Committee for Quality Assurance medical home rating. The practice was the first in its state to be certified. The practice champion is a nurse care manager who is open to learning and improving her skills. She has a relationship with the patients and knows them well. She meets and communicates with the community partner often. When the community partner provides tools, the nurse is open to using them. She also prioritizes her staff's skill improvement. She asked the community partner to work with a medical assistant at the practice to build the medical assistant's motivational interviewing skills. The nurse case manager refers fewer people than some practices, but the people are ready to enroll in the program.

Lessons learned:

  • One motivated, informed practice champion can make all the difference.
  • Identifying patients who are really ready for the community program means a high rate of follow-through on the referrals, even if the overall number of referrals is low.

Practice C

Practice C is a group practice owned by a community hospital; the practice serves several rural communities. The physician champion is good at motivational interviewing. He cares about his patients, and he has made his own lifestyle changes, so he is personally attached to the concept. Of the patients he and his medical assistant refer, a large percent enroll. However, the remaining staff and clinicians in the practice are not engaged in the program and do not have a good sense of why the community partner is involved.

Lessons learned:

  • Even in the absence of practice-wide buy-in, one motivated and committed provider can successfully engage with a community partner.

Practice D

Practice D, a private practice with three physicians and two nurse practitioners, operates efficiently and effectively. The high volume practice works through lunch, so they can see 100 patients a day. They are engaged in a number of chronic care quality improvement projects and diabetes studies. For interacting with their community partner, they rely heavily on the champion for the practice, so when that person went on leave, the connection with the community partner suffered significantly. The physicians understand the community partnership and refer regularly; however, the rate of patient enrollment is not high. Even so, the clinicians don't seem interested in improving their process and are not willing to try new methods of trying to get referrals.

Lessons learned:

  • Busy, well-functioning practices may prioritize existing relationships and projects above new ones.
  • Relying heavily on a single point of contact can jeopardize the partnership if that person leaves.

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Page last reviewed March 2014
Page originally created March 2014
Internet Citation: Appendix A. Case Studies. Content last reviewed March 2014. Agency for Healthcare Research and Quality, Rockville, MD.