Bringing Together Clinics and Communities

Most of what affects our health happens outside the doctor’s office. Social, environmental and behavioral factors such as adequate housing, food access and the impact of violence all influence individual and community health.¹ 

This means that health care providers are increasingly looking outside their clinics to address these factors, often referred to as the social determinants of health. 

Partnerships between clinical and community organizations, known as clinical-community linkages, can expand health and health care beyond the doctor’s office to improve population health and reduce costs. 

The Colorado Health Institute (CHI), with the Trailhead Institute, is learning firsthand the importance of clinical-community linkages by developing and managing the Colorado Regional Health Connectors (RHCs) program, now in its second year. The RHC workforce reached full strength in April 2017, with a total of 21 RHCs hired across the state. Each RHC is responsible for a distinct geographical region.

Regional Health Connectors

RHCs connect clinics and community groups to advance health and address the social determinants of health. They do this by improving the coordination of services and strengthening ties among health care providers and others outside their offices, whether by forging a relationship between a clinic and the local food bank or connecting a hospital system with community-based chronic disease management programs.

RHCs don’t work directly with patients. Instead, they look for health-related trends across their regions and help organizations work together to address them. In the process, RHCs make sure clinics and local organizations are aware of what’s available in their communities. This helps prevent services from being duplicated unnecessarily or going unused by the people who need them. 

Each RHC works as part of a local host organization to better connect systems that improve health, including primary care, public health, social services, and other community resources. RHCs expand the capacity of these systems to develop and strengthen partnerships to improve health. 

How is Colorado Building Clinical-Community Linkages? 

Clinical-community linkages can help patients gain better access to care, especially for preventive and chronic care services.² They address issues such as poverty and health illiteracy that can create barriers for patients who need help. And they give clinicians ways to support patients outside of the clinic and connect them with community programs.³

These kinds of partnerships are not new nationally or in Colorado. Here are some examples: 

• National Diabetes Prevention Program (DPP): Doctors in Colorado are partnering with 48 organizations across the state offering DPP, a year-long program that aims to prevent Type 2 diabetes.⁴ The initiative connects health care providers, employers, faith-based organizations, government agencies and community organizations. So far, pre-diabetic participants in the program have reduced their risk of diabetes by more than half.5 Many insurers and employers are now paying for DPP participation.^6,7 On January 1, 2018, Medicare started paying for DPP participation nationwide.⁸

• Nurse Family Partnership (NFP): Colorado is one of 42 states implementing this evidence-based home visitation program for low-income, first-time mothers. NFP pairs mothers with registered nurses who provide at-home care from before birth to the baby’s second year.⁹ The home visitation model goes beyond prenatal care, offering referrals for services like job training, education programs and child care to its first-time mothers.¹⁰ To date, 22 agencies have served more than 22,000 Colorado mothers in all 64 counties.¹¹

• Health Worker Programs: The Colorado Department of Public Health and Environment (CDPHE) is supporting health care workers who bring community resources to people with chronic diseases like diabetes or asthma or people who are at risk of developing those conditions.¹² The agency offers professional development for health workers, along with the University of Colorado, and hosts an alliance to share best practices and strengthen linkages made by patient navigators, community health workers and promotores de salud — community health workers providing culturally and linguistically competent health education and prevention for Spanish-speaking Coloradans.^{13, 14}  

Other examples include smoking cessation services, physical activity programs at the YMCA or health clubs, Cooking Matters,¹⁵  Healthy Start,¹⁶  Alcoholics Anonymous, commercial weight loss programs and La Leche League, a community-based breastfeeding promotion program.¹⁷

Regional Health Connectors and Clinical-Community Linkages 

RHCs are a unique new workforce that builds upon this work in a systematic way throughout Colorado. RHCs are dedicated to improving the coordination of services to address the social determinants of health. Supporting and strengthening clinical-community linkages across the state is a major part of their jobs. 

RHCs look for ways to build bridges between clinics and community organizations, avoid duplication and better connect different parts of the health care system. RHCs work closely with practice transformation organizations to coordinate efforts to improve care.  

In each region, an RHC spent the first six months on the job reviewing local data and reports and talking with local community partners, including health care providers, government agencies and community organizations. 

Based on what they learned, the RHC proposed three projects to address the unique goals of their community. In each region, two of the three projects are related to behavioral health and one to cardiovascular disease. 

The projects encompass a broad range of issues. Some projects RHCs have worked on include:

• Organizing stakeholders in the San Luis Valley to help improve access to transportation to behavioral health care.
• Facilitating a referral network in the region around Grand Junction that connects medical practices to behavioral health providers.
• Increasing the availability of naloxone in rural Lake, Chaffee, Fremont and Custer counties.  

In addition to working toward long-term objectives such as reducing obesity or improving mental health outcomes in their communities, the RHCs also track intermediate goals. For example, Weld County’s RHC reports on the status of a new community garden designed to improve access to healthy foods as an intermediate goal on the way towards reducing obesity in her region.  

Conclusion

The RHC program has created a statewide network of people working to build connections between clinics and community organizations — a critical step toward improving the health of Coloradans and increasing coordination between systems that work on health. As the RHCs evolve and support clinical-community linkages throughout the state, CHI will continue to share their stories and what we learn. 

Endnotes

¹ Taylor LA, Coyle CE, Ndumele C, Rogan E, Canavan M, Curry L, et al. “Leveraging the Social Determinants of Health: What works?” Blue Cross Blue Shield of Massachusetts Foundation; (June 2015). http://bluecrossfoundation.org/sites/default/files/download/publication/Social_Equity_Report_Final.pdf

² Agency for Healthcare Research and Quality. (December 2016). “Clinical-Community Linkages.” https://www.ahrq.gov/professionals/prevention-chronic-care/improve/community/index.html.

³ Agency for Healthcare Research and Quality. (December 2016). “Clinical-Community Linkages.” https://www.ahrq.gov/professionals/prevention-chronic-care/improve/community/index.html. 

⁴ Centers for Disease Control and Prevention. “What Is the National DPP?” January 14, 2016. https://www.cdc.gov/diabetes/prevention/about/index.html. 

⁵ National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, U.S. Department of Health and Human Services. “Diabetes Prevention Program (DPP).” (October 2008). https://www.niddk.nih.gov/about-niddk/research-areas/diabetes/diabetes-prevention-program-dpp/Documents/DPP_508.pdf. 

⁶ Colorado Department of Public Health & Environment. “Diabetes Prevention Program.” https://www.colorado.gov/pacific/cdphe/diabetes-prevention-program. Accessed July 18, 2017.

⁷ Health & Human Services Press Office. “Independent experts confirm that diabetes prevention model supported by the Affordable Care Act saves money and improves health.” March 23, 2016. https://wayback.archive-it.org/3926/20170127185647/https://www.hhs.gov/about/news/2016/03/23/independent-experts-confirm-diabetes-prevention-model-supported-affordable-care-act-saves-money.html 

⁸ Centers for Medicare & Medicaid Services. “Medicare Diabetes Prevention Program (MDPP) Expanded Model.” November 2, 2016. https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2016-Fact-sheets-items/2016-11-02-2.html.

⁹ Nurse Family Partnership. “Nurse Family Partnership of Colorado.” http://www.nursefamilypartnership.org/locations/Colorado. Accessed July 13, 2017.

¹⁰ Tri-County Health Department. “Nurse Family Partnership.” http://www.tchd.org/352/Nurse-Family-Partnership. Accessed July 13, 2017.

¹¹ Nurse Family Partnership. “State Profile: Nurse Family Partnership in Colorado.” http://www.nursefamilypartnership.org/assets/PDF/Communities/State-Profiles/CO_State_Profile.aspx. Accessed July 13, 2017.

¹² Colorado Department of Public Health & Environment. “Community-clinical Linkages.” https://www.colorado.gov/cdphe/domain-4-community-clinical-linkages. Accessed July 18, 2017.

¹³ Barbare, S. “Colorado works to establish registry for patient navigators.” Colorado Department of Public Health and Environment. https://www.colorado.gov/pacific/cdphe/news/patient-navigator-registry. Accessed July 18, 2017.

¹⁴ Colorado Patient Navigator / Community Health Collaborative. “Welcome to the Colorado Community Health Worker and Patient Navigator Work Group.” https://sites.google.com/site/copnchwcollaborative/home. Accessed July 18, 2017. 

¹⁵ No Kid Hungry, Center for Best Practices. “Fighting Hunger Through Health Care: A Seamless Solution.” (September 1, 2012).
https://bestpractices.nokidhungry.org/sites/default/files/resources/Health%20Care%20Issue%20Brief.pdf. 

¹⁶ The Healthy Start Study. https://healthystartstudy.org/healthy-start-i/. Accessed July 18, 2017. 

¹⁷ CC Relationships Evaluation Roadmap AHRQ July 2013

¹⁸ Shelley, D, Cantrell J. “The effect of linking community health centers to a state-level smoker’s quitline on rates of cessation assistance.” BMC Health Services Research 10 (2010): 25. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2823740/. Accessed April 18, 2018.

¹⁹ Porterfield, D et al. “Linkages Between Clinical Practices and Community Organizations for Prevention: A Literature Review and Environmental Scan.” American Journal of Public Health 102 (June 1, 2012): S375-S382. https://ajph.aphapublications.org/doi/abs/10.2105/AJPH.2012.300692?url_ver=Z39.88-2003&rfr_id=ori%3Arid%3Acrossref.org&rfr_dat=cr_pub%3Dpubmed. Accessed April 18, 2018.