- Email: [email protected]
Clinic and Community
Clinic and Community The Road to Integration Laurie L. Lachance, PhD, MPH, Amy R. Friedman Milanovich, MPH, Ashley N. Garrity, MPH Introduction: There is growing recognition of the important role that social and environmental conditions play in health, and of the interaction needed between clinical providers and the broader community in which patients live, work, play, and manage their health. Through the Safety Net Enhancement Initiative, the Kresge Foundation funded demonstration projects in eight vulnerable communities to address health inequities and increase integration between clinical and community systems. Methods: In 2014, integration efforts in 2011–2013 were qualitatively analyzed within and between sites to identify common features. The series of steps taken by sites during the 3-year implementation period that were necessary to move toward integration were then analyzed.
Results: Safety Net Enhancement Initiative sites increased capacities within clinics, including policy and practice changes that expanded the way “health” is defined by clinical providers and the implementation of onsite programs/services. Several sites changed clinic policies to support referral to community programs with partner organizations. Several sites also successfully changed local community policies and practices. Moving toward integration, mechanisms were created to link newly developed or identified community resources to the clinical system. Conclusions: As an established system organized around disease treatment, not prevention, certain changes need to be made within the clinical system to prepare for integration. These changes require shifting perspectives, changing behaviors, and developing novel administrative models. Similarly, integration requires changes within and among community systems, including organizations, services, and residents. Ultimately, there is the need to find ways for these two very different environments to interact and coordinate. (Am J Prev Med 2016;51(6):1072–1078) & 2016 American Journal of Preventive Medicine. Published by Elsevier Inc. All rights reserved.
Introduction
T
here is growing recognition of the important role that social and environmental conditions play in individual and community health1–3 and, simultaneously, increasing efforts to enhance patient-centered care.4–7 These priorities have placed a spotlight on the interaction between clinical providers and the broader community in which patients live, work, play, and manage their health. Healthy living and disease prevention rely not only on access to clinical care, but also access to healthy food, safe places for exercise, transportation, employment, From the University of Michigan School of Public Health, Ann Arbor, Michigan Address correspondence to: Laurie L. Lachance, PhD, MPH, University of Michigan School of Public Health, 1415 Washington Heights, Ann Arbor MI 48109-2029. E-mail: [email protected]. 0749-3797/$36.00 http://dx.doi.org/10.1016/j.amepre.2016.09.006
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and social support.8,9 The majority of these resources come not from a physicianʼs office or health clinic, but rather from an individualʼs community. A physician may recommend that a patient increase exercise to treat health conditions and prevent chronic disease. In many communities, especially in vulnerable communities, there is no safe place to exercise, no connection between the physicianʼs office and existing resources, and no system of follow-up to ensure the patient is able to access resources; thus, the physicianʼs recommendation becomes nullified. Looking across successful efforts to integrate primary care and community health, a panel convened by the Institute of Medicine identified a set of core principles and a continuum for integration.10 Integration of primary care and community health is envisioned on a continuum, with movement away from isolation, where the sectors work in separate silos, toward mutual awareness, cooperation, collaboration, and partnership. Included in these principles
& 2016 American Journal of Preventive Medicine. Published by Elsevier Inc. All rights reserved.
Lachance et al / Am J Prev Med 2016;51(6):1072–1078
are the common goals of improving population health and involving the community in defining and addressing its needs. At the end of this continuum are “two sectors working so closely together that, from the individualʼs perspective, there is no separation.”10 This level of integration would require commitment to a shared vision, a secure partnership, and an established process of support and communication. The prevention and chronic care communities have proposed frameworks for how to build such integration.11–21 The well-established Chronic Care Model17 presents a model of quality improvement that recognizes the role of the broader community, healthcare providers, and patients in improving chronic disease management. At the time of its publication, the idea of including the community and patients in a systemic approach was novel.17 Focusing more closely on the systems that link clinical providers and community organizations, Krist et al.12 presented a detailed description of the mechanisms that enable clinical providers and community organizations to develop an integrated approach to engagement, delivery, and follow-up care, focusing particularly on development of “spanning personnel” and “spanning support,” to facilitate integration across and between levels, and provide a system of interaction between the clinical and community systems.12 Critical to building clinical community integration is the importance of accountability for oversight and improvement. The Sickness Prevention Achieved Through Regional Collaboration model18 highlights the importance of having a central coordinating entity that takes on these responsibilities. Examples for development and funding for policy and staff changes from the literature include the Community-Centered Health Home approach,19,20 the Accountable Health Communities Model,21 and successful Medical Legal partnerships.22 These initiatives include local public health agencies, hospitals, social service organizations, advocacy groups, and other community partners.19–22 This paper offers early evidence of capacity changes achieved by eight sites to increase the integration of community health and prevention into communitybased primary care efforts. For those working to integrate clinical and community systems, these early steps are a necessary precursor. From 2011 through 2013, the Kresge Foundation funded demonstration projects to integrate primary clinical care and community health, specifically focused on social determinants of health in order to address health inequities and improve population health within vulnerable communities. A fundamental requirement of the initiative set forward by the Foundation was evidence of a partnership between community health centers December 2016
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(CHCs), local nonprofit clinics providing primary care services to primarily uninsured and underserved individuals, local public health departments, anchor institutions (e.g., established hospitals or universities), and community-based organizations; the role of each organization was determined locally.
Methods Through the Safety Net Enhancement Initiative (SNEI), grantee organizations in eight vulnerable communities were selected to form multisector partnerships and spearhead the development and implementation of demonstration projects to address health inequities as defined and prioritized by their communities. The eight selected sites varied by population density (i.e., urban, rural, frontier), racial and ethnic composition, and physical and social environments; however, each described significant challenges to health, including high rates of poverty and unemployment, poor health outcomes, and barriers to healthy living (Table 1). During a participatory planning process, residents and stakeholders in each community reviewed the communityʼs assets and challenges, prioritized health-related outcomes of particular concern, and defined some of the barriers related to these concerns that were associated with health inequities within their community. Although the health outcomes of interest were similar across several sites, the focus and design of demonstration projects in each site varied to address local assets and challenges, including the physical and social environment and systems of care. Sites designed strategies to address a range of barriers to health, including those related to a lack of: access to care: transportation, culturally appropriate care, and affordable services; physical activity: access to safe, engaging opportunities for movement and exercise; healthy nutrition: access to healthy food, knowledge, and skills for healthy eating; economic development: sustainable employment opportunities for residents; safety: safe places to exercise, garden, and receive care and services; and social cohesion: connection among community residents, and between residents and the available services. In 2014, after the sitesʼ implementation phase, the SNEI crosssite evaluation team “mapped” each SNEI site to consider how SNEI sites addressed integration. The process was used to identify whether and how the relationship of clinical- and community-level efforts to improve population health changed, and then looked across individual site maps to identify common features of integration across sites.
Results The mapping helped describe a series of steps taken by sites during the 3-year implementation period that were necessary to move toward integration (Figure 1). Efforts to improve clinical and community capacity required
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Table 1. SNEI Sites, Community-Identified Areas of Interest, and Program Activitiesa Grantee, location, project name
Health-related outcome(s)
Social determinant(s) of health
Program overview/activity examples
North Country HealthCare, Flagstaff, AZ, Hermosa Vida
Childhood overweight and obesity
Barriers to accessing resources for engaging in healthy behaviors
School-based initiatives (e.g., structured recess, walking school bus, Parent Academies); community-based activities (e.g., produce distribution, policy coalition)
Alameda County Public Health Department, Oakland, CA, Food to Families
Overweight and obesity among pregnant women and their families
Local economic and employment opportunities for young adults
Health education; fresh food prescription program at two CHCs (“Produce Rx”); corner store produce distribution system that trained and employed youth
Kokua Kalihi Valley Comprehensive Family Services, Honolulu, HI, Returning to Our Roots
Overall well-being
Social isolation
Community farming and preparation of traditional foods; dialogue with elders about culture and health; expanded access to fresh, healthy foods via clinic café
Whittier Street Health Center Boston, MA, Building Vibrant Communities
Hypertension and depression
Stressors (e.g., unemployment, neighborhood violence, barriers to health care)
Lay health workers used to conduct wellness screenings and help residents navigate services; structured physical activity and nutrition education classes
Voices of Detroit Initiative, Detroit, MI, IMPACT
Diabetes and hypertension
Neighborhood safety
Safe, central location established to house services and activities (e.g., cooking and fitness classes, pharmacist consultations); referrals to/from primary care services
Taos Health Systems, Peñasco, NM, Kids First
Childhood trauma and adverse childhood events
Isolation and lack of community support
Parent education using “Nurturing Parenting” curriculum; expanded service availability in rural community; behavioral health integration into clinics and schools
Cleveland Clinic Foundation, East Cleveland, OH, EC Teen Collaborative
Overall well-being of adolescents
Violence and community connectivity
Youth empowerment approach incorporating health education; utilized health and social service providers as “navigators” working with teen participants; peer education
Beaufort-Jasper-Hampton Comprehensive Health Services, Sheldon Township, SC, Pathways in STEP
Hypertension and related risk factors (e.g., overweight and obesity)
Poverty and economic stressors
Training of community members through Leadership Institute to improve community health; formation of Healthy Churches Consortium
a Source: SNEI Sitesʼ Implementation Proposals and program documents. CHC, community health center; SNEI, Safety Net Enhancement Initiative.
shifting perspectives, changing behaviors, and developing novel administrative models. Creating a shared vision and addressing current and needed leadership emerged as critical steps in creating the authentic partnerships needed for capacity change. Other necessary steps included building resources and capacities within the clinical and community systems individually while simultaneously beginning to develop linkages to support the connection among and between the clinical and community systems. SNEI partnerships needed to develop the building blocks—programs, policies, and relationships—that would lead to integration. Eventually, it is hoped that these new capacities and resources might work toward a more unified system, through which clinical and community organizations would be truly “integrated” so that the processes and policies in each support a shared vision and coordinated system of health improvement.
Improved Clinical Capacity Although the Kresge Foundation required the involvement of CHCs within SNEI partnerships, their role varied significantly across the eight sites, as did the level at which efforts were focused on improving the capacity within the clinical system to address social determinants of health. Though the majority of SNEI efforts were focused on building capacity outside of the clinic walls, at least four sites documented increased capacities within clinics to address social determinants of health, including policy and practice changes that expanded the way “health” is defined by clinical providers and the implementation of on-site programs/services (Table 2). Several of the clinic capacity outcomes also represent linkages to community resources. As the result of SNEI efforts, for example, Hermosa Vida (Flagstaff, AZ) implemented several initiatives within the clinic to provide more culturally appropriate care to patients, including the www.ajpmonline.org
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Improved Community Capacity Similar to changes within the clinical system, SNEI sites increased both programs and policies within the community system to address social determinants of health and integrate systems of care. In fact, all eight of the SNEI sites made significant accomplishments in this arena. As described in Figure 1 and Table 3, sites developed safe, affordable, accessible programs and resources to address community needs, including exercise programs, distribution of fresh fruits and vegetables, and parenting support services. Screening programs were developed to identify individuals in need of services, and individualand community-level education was provided to introduce concepts related to healthy living. In addition to new program development, several sites successfully changed local policies and practices to ensure lasting impact. For example, Hermosa Vida (Flagstaff, AZ) facilitated community organizing, which led to a change in local policies to make parks more accessible to the community, and Returning to Our Roots (Honolulu, HI) installed Electronic Benefit Transfer machines at farmersʼ markets that accept Supplemental Nutrition Assistance Program benefits. These policy changes represent important steps in improving community access to resources that address social determinants of health. Figure 1. Integration of community health and prevention into community-based primary care in the Safety Net Enhancement Initiative.
permanent hire of a translator and development and adoption of more culturally appropriate language for clinic staff. Similarly, SNEI staff of Kids First (Peñasco, NM) successfully changed clinic policies to incorporate mental health screening and referral processes for all patients in order to identify individuals in need of behavioral health services. Several sites changed clinic policies to support referral to community programs with partner organizations. Two sites adopted the use of prescriptions for healthy food or community support programs as a means to formalize recommendations and referrals. These policy changes represent long-term, sustainable changes in the way clinical systems address social determinants of health. In addition to changing clinical processes, three sites introduced onsite services to address social determinants of health. Two sites made changes to the physical infrastructure of the clinic to promote access to healthy food (i.e., onsite healthy food café and community garden). One site developed health education classes to teach patients how to prepare healthier meals using local produce. December 2016
Building Linkages The fundamental concept of SNEI was to join primary care services with community health services to address health disparities and improve population health. Several sites developed mechanisms for linking clinic and community efforts through bidirectional information sharing. The community organizer within the Hermosa Vida (Flagstaff, AZ) neighborhood, for example, spearheaded efforts within the clinic to make the clinic more responsive to community needs by conducting a patient provider assessment to identify communication issues and developing clinic policies and training related to appropriate language use and communication. Through Kids First (Peñasco, NM), a social worker hired jointly by the health system and a social service agency provided a formal linkage between the institutions. In both cases, the clinical system created a permanent job position to ensure sustainability of these efforts. Through its initial program design, the East Cleveland Teen Collaborative created a formal infrastructure to support information exchange across and within multiple clinic and community organizations. Health Navigators designated by individual organizations met regularly to jointly develop and implement a leadership program for community youth. In six of eight SNEI sites, project managers, who were either hired by or existing staff of CHCs, held primary
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Table 2. Improve Clinical Capacity Type of change Policies/procedures: implementation of formal rules, guidelines, or practices
Capacity built within clinics Implemented process for clinicians to write prescriptions for healthy food
and program participationa
Established systems within the clinic to refer patients to community
support systemsa Implemented formal screening process for identifying families in need of additional services Hiring of permanent staff to implement new/improved policies/ procedures: o Hired a translator to ensure that patients were able to more effectively communicate with clinical staff o Added a social worker to their permanent staff model to screen and refer patientsa Programs: addition of or changes to activities or physical infrastructure
Classes in the clinic educated patients on healthy food and healthy cooking Café in the clinic increased access to healthy food for clinic personnel,
patients, and community
Implementation of community garden on clinic site Dedication of space for a community program a
Indicates changes that represent both capacity built within the clinical system and a linkage to the community.
responsibility for developing and implementing SNEI efforts and effectively served as the linkage between the clinic and the community systems being developed. As employees of the clinic, they were internal representatives of this effort and increased the visibility of community resources within the clinic. They also supported ongoing communication among and between programs, and sometimes became the “face” of the clinic within the community. These project managers often served as a mechanism to link systems to each other.
Discussion The SNEI was implemented as a demonstration project to support the development of models to integrate community health and prevention with primary care for vulnerable populations. During the relatively short timeframe of the initiative (3-year implementation period), sites increased the potential of their community and clinical systems to focus on social determinants of health, primarily by building capacity and readiness. As an established system organized around disease treatment, not prevention, changes need to be made within the clinical system to prepare for integration. These changes require shifting perspectives, changing behaviors, and developing novel administrative models. Similarly, integration requires changes within and among community systems, which include a number of elements that naturally ebb and flow in response to community needs. Ultimately, there is the need to find ways for these two very different environments to interact and coordinate—a significant challenge. A critical step in this preparation for integration is the development of a shared vision among key leaders and
stakeholders. A belief in the notion that improving population health requires not just accessible, quality clinical care, but also a safe, healthy community environment that supports opportunities for health, including access to healthy food, safe places for exercise, economic opportunities, and social support and connection. The Kresge Foundation wisely required that sites demonstrate the development of a partnership among clinical providers, local public health agencies, and communitybased organizations in the design and implementation of SNEI efforts. This opportunity created a starting point for leaders to develop and demonstrate a commitment to the work. In many situations, leaders are eager to come to the table for a grant proposal when much-needed funds are available. It is more difficult to engage those leaders in maintaining that vision over the long haul. The extent to which key SNEI stakeholders followed through on their initial commitment is unclear and varied by site and institution. In all sites, community representatives appeared eager and engaged, despite historic hesitancies from communities wary of “another project” that provides short-term efforts and then fades away. With the exception of the one site in which the local public health agency was the grant recipient, the engagement of local public health agencies was less consistent, likely reflecting the overall challenges public health agencies have experienced in recent years in which their mission was significantly questioned and funding reduced. Of critical importance in an effort to integrate community health into primary care was the role of clinical leaders and, in particular, the key leaders of the CHCs involved in this effort. In six sites, CHCs were the lead agencies for SNEI and played a critical role by housing and supporting initiative staff, providing administrative support, and www.ajpmonline.org
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Table 3. Improved Community Capacity Type of change Policies/procedures: implementation of formal rules, guidelines, or practices
Capacity built within communities Policies to reduce fees for community organizations to use
local parks
Acceptance of SNAP benefits at farmerʼs markets Dedication of spaces within community buildings for safe exercise
and services
Programs: addition of or changes to activities or physical infrastructure
Development of community-centered (located) programs for safe
accessible physical activity
Development of community-centered (located) programs to increase
access to healthy food, e.g., CSA distribution, community gardens, corner store produce distribution Implementation of efforts to screen community members for unidentified needs Community education to increase knowledge and awareness of issues related to social determinants of health Individual capacity: increased capacity of individual community members to improve health in their communities
Leadership training for community leaders to implement health
programs
Engagement in advocacy for policy change CSA, community-supported agriculture; SNAP, Supplemental Nutrition Assistance Program.
lending their credibility to initiate partnerships and secure the grant. The extent to which these leaders embraced a deep commitment to the initiativeʼs vision is a more significant question. Truly integrating prevention into primary care requires a fundamental shift in the concept of “health” and a willingness to change existing practice. This shift is happening, albeit slowly, throughout the country, and part of the intention of SNEI was to develop early models for how this might be replicated as this movement takes root. The Foundation made an effort to identify sites that were “ready” for this initiative and had evidence of clinical engagement. At least one siteʼs clinic leaders have surfaced as “thought leaders,” providing support and nurturing not only locally but other communities and national efforts. In many SNEI sites, however, the degree to which clinical leaders embraced this notion is unclear, and it appears that their support amounted to “business as usual,” as they were happy to support staff and programs but were not proactive in incorporating the efforts into the clinical systems. This likely reflects the overall status of the country, in which there are pressures to change but limited incentive and capacities to support this change. In some sites, it is also possible that local staff could have focused more effort on the internal clinical environment to support this engagement. These are important lessons to note for future initiatives. For communities wishing to address social determinants of health, it is critical to focus on separating work and activities that are program based, and will most likely disappear when funding subsides, from efforts that are aimed at changing structures and policies that will continue over time. Through local leadership, new programs were developed and implemented in clinics and community settings. December 2016
It is unclear whether these newly developed programs will be sustained into the future; whether the Zumba classes will continue; whether the community garden will be maintained; or whether camps and activities for kids will endure. There are clearly some SNEI efforts that will have lasting and enduring impact. Clinic and community members are more aware of the importance of social determinants of health. Policies have been established to hire permanent staff and accept payment vouchers at farmerʼs markets. Community members are more aware of, and have greater skills for, healthy eating and increased access to parks and walking paths. These are important changes that were designed to be sustained beyond the Kresge funding and they will have a sustained impact on the way health and health care are approached in these communities. As with many short-term initiatives, there is always the risk that programs and activities will fade with the end of the grant. The SNEI efforts that have endured beyond the funding period are a reminder of the importance of addressing sustainability early and often in the course of an initiative.
Conclusions Significant literature has explored theoretic models for integrating community efforts to support prevention and chronic health management into clinical care. SNEI represents a case study of how eight sites attempting to integrate community health and prevention into primary care laid a foundation for integration by building local capacities within and between the clinical and community systems. In the end, integration requires systemic change. This real-world case study highlights the complexities and
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challenges, and time involved in changing established systems. These are not quick fixes; they require changes to perspectives, behaviors, and protocols. In their efforts to integrate community health and prevention into community-based primary care efforts, SNEI sites made significant movement in building local capacity—in both clinical and community systems—because that was what was needed to move toward integration. Sites developed programs or linked community members with existing programs, and established links between clinical and community systems. Although it is too early to know the extent to which the programs nurtured through SNEI are sustainable, documented changes to perspectives and policies provide significant opportunities for lasting change. In the world of short-term initiatives, these are substantial successes and represent building blocks on which SNEI communities can build ongoing efforts. The authors would like to acknowledge and express appreciation for the work of the Safety Net Enhancement Initiative projects and communities: Hermosa Vida (Flagstaff, AZ), Food to Families (Oakland, CA), Returning to Our Roots (Honolulu, HI), Building Vibrant Communities (Boston, MA), IMPACT (Detroit, MI), Kids First (Peñasco, NM), EC Teen Collaborative (East Cleveland, OH), and Pathways in STEP (Sheldon Township, SC); and for the support of the Kresge Foundation. Additional information about this project can be found at the University of Michigan Center for Managing Chronic Disease website (http://cmcd.sph.umich.edu/research-program-areas/ safety-net-enhancement-initiative-evaluation/). All authors contributed to the content, design, analysis, interpretation, and preparation of the manuscript. No financial disclosures were reported by the authors of this paper.
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References 1. Marmot MG, Smith GD, Stansfeld S, et al. Health inequalities among British civil servants: the Whitehall II study. Lancet. 1991;337(8754): 1387–1393. http://dx.doi.org/10.1016/0140-6736(91)93068-K. 2. Link BG, Phelan J. Social conditions as fundamental causes of disease. J Health Soc Behav. 1995;Spec No:80–94. http://dx.doi.org/10.2307/ 2626958. 3. Diez Roux AV, Mair C. Neighborhoods and health. Ann N Y Acad Sci. 2010;1186:125–145. http://dx.doi.org/10.1111/j.1749-6632.2009.05333.x. 4. Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academies Press; 2001; http://dx.doi.org/10.17226/10027. 5. Agency for Healthcare Research and Quality. Expanding PatientCentered Care to Empower Patients and Assist Providers. AHRQ Research
19.
20.
21. 22.
in Action, No. 5 (AHRQ Publication No. 02-0024). Washington, DC: Agency for Healthcare Research and Quality; 2002. Davis K, Abrams M, Stremikis K. How the Affordable Care Act will strengthen the nationʼs primary care foundation. J Gen Intern Med. 2011;26(10):1201–1203. http://dx.doi.org/10.1007/s11606-011-1720-y. Epstein RM, Street Jr. The values and value of patient-centered care. Ann Fam Med. 2011;9(2):100–103. http://dx.doi.org/10.1370/ afm.1239. Wilkinson R, Marmot M, eds. Social Determinants of Health: The Solid Facts. 2nd ed. Geneva: WHO; 2003. www.euro.who.int/__data/ assets/pdf_file/0005/98438/e81384.pdf Accessed September 1, 2016. Yen IH, Syme SL. The social environment and health: a discussion of the epidemiologic literature. Annu Rev Public Health. 1999;20: 287–308. http://dx.doi.org/10.1146/annurev.publhealth.20.1.287. Institute of Medicine. Primary Care and Public Health: Exploring Integration to Improve Population Health (Report Brief). Washington, DC: National Academy of Sciences; http://dx.doi.org/10.17226/13381. Ackermann RT. Description of an integrated framework for building linkages among primary care clinics and community organizations for the prevention of type 2 diabetes: emerging themes from the CC-Link study. Chronic Illn. 2010;6(2):89–100. http://dx.doi.org/10.1177/ 1742395310364857. Krist AH, Shenson D, Woolf SH, et al. Clinical and community delivery systems for preventive care: an integration framework. Am J Prev Med. 2013;45(4):508–516. http://dx.doi.org/10.1016/j.amepre. 2013.06.008. Plumb J, Weinstein LC, Brawer R, Scott K. Community-based partnerships for improving chronic disease management. Prim Care. 2012;39 (2):433–447. http://dx.doi.org/10.1016/j.pop.2012.03.011. Chin MH, Goddu AP, Ferguson MJ, Peek ME. Expanding and sustaining integrated health care-community efforts to reduce diabetes disparities. Health Promot Pract. 2014;15(2 suppl):29s–39s. http://dx. doi.org/10.1177/1524839914532649. Peek ME, Ferguson M, Bergeron N, Maltby D, Chin MH. Integrated community-healthcare diabetes interventions to reduce disparities. Curr Diab Rep. 2014;14(3):467. http://dx.doi.org/10.1007/s11892-013-0467-8. Porterfield DS, Hinnant LW, Kane H, Horne J, McAleer K, Roussel A. Linkages between clinical practices and community organizations for prevention: a literature review and environmental scan. Am J Prev Med. 2012;42(6 suppl 2):S163–S171. http://dx.doi.org/10.1016/j.amepre. 2012.03.018. Wagner EH, Davis C, Schaefer J, Von Korff M, Austin B. A survey of leading chronic disease management programs: are they consistent with the literature? Manag Care Q. 1999;7(3):56–66. Shenson D, Benson W, Harris AC. Expanding the delivery of clinical preventive services through community collaboration: the SPARC model. Prev Chronic Dis. 2008;5(1):1–8. Plumb JD, Weinstein L, McCurdy M. The Stephen Klein Wellness Center—a community centered health home—a partnership between Jefferson and Project HOME. Popul Health Matters. 2015; 28(3):2–3. Valdovinos E, Srikantharajah J, Pañares R, Mikkelsen L, Cohen L, Cantor J. Community-centered health homes: bridging the gap between health services and community prevention. www.preventio ninstitute.org/component/jlibrary/article/id-298/127.html. Published 2011. Accessed June 16, 2016. Accountable Health Communities Model. https://innovation.cms.gov/ initiatives/AHCM. Accessed June 16, 2016. National Center for Medical-Legal Partnership. http://medical-legal partnership.org/. Accessed June 16, 2016.
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Results: Safety Net Enhancement Initiative sites increased capacities within clinics, including policy and practice changes that expanded the way “health” is defined by clinical providers and the implementation of onsite programs/services. Several sites changed clinic policies to support referral to community programs with partner organizations. Several sites also successfully changed local community policies and practices. Moving toward integration, mechanisms were created to link newly developed or identified community resources to the clinical system. Conclusions: As an established system organized around disease treatment, not prevention, certain changes need to be made within the clinical system to prepare for integration. These changes require shifting perspectives, changing behaviors, and developing novel administrative models. Similarly, integration requires changes within and among community systems, including organizations, services, and residents. Ultimately, there is the need to find ways for these two very different environments to interact and coordinate. (Am J Prev Med 2016;51(6):1072–1078) & 2016 American Journal of Preventive Medicine. Published by Elsevier Inc. All rights reserved.
Introduction
T
here is growing recognition of the important role that social and environmental conditions play in individual and community health1–3 and, simultaneously, increasing efforts to enhance patient-centered care.4–7 These priorities have placed a spotlight on the interaction between clinical providers and the broader community in which patients live, work, play, and manage their health. Healthy living and disease prevention rely not only on access to clinical care, but also access to healthy food, safe places for exercise, transportation, employment, From the University of Michigan School of Public Health, Ann Arbor, Michigan Address correspondence to: Laurie L. Lachance, PhD, MPH, University of Michigan School of Public Health, 1415 Washington Heights, Ann Arbor MI 48109-2029. E-mail: [email protected]. 0749-3797/$36.00 http://dx.doi.org/10.1016/j.amepre.2016.09.006
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and social support.8,9 The majority of these resources come not from a physicianʼs office or health clinic, but rather from an individualʼs community. A physician may recommend that a patient increase exercise to treat health conditions and prevent chronic disease. In many communities, especially in vulnerable communities, there is no safe place to exercise, no connection between the physicianʼs office and existing resources, and no system of follow-up to ensure the patient is able to access resources; thus, the physicianʼs recommendation becomes nullified. Looking across successful efforts to integrate primary care and community health, a panel convened by the Institute of Medicine identified a set of core principles and a continuum for integration.10 Integration of primary care and community health is envisioned on a continuum, with movement away from isolation, where the sectors work in separate silos, toward mutual awareness, cooperation, collaboration, and partnership. Included in these principles
& 2016 American Journal of Preventive Medicine. Published by Elsevier Inc. All rights reserved.
Lachance et al / Am J Prev Med 2016;51(6):1072–1078
are the common goals of improving population health and involving the community in defining and addressing its needs. At the end of this continuum are “two sectors working so closely together that, from the individualʼs perspective, there is no separation.”10 This level of integration would require commitment to a shared vision, a secure partnership, and an established process of support and communication. The prevention and chronic care communities have proposed frameworks for how to build such integration.11–21 The well-established Chronic Care Model17 presents a model of quality improvement that recognizes the role of the broader community, healthcare providers, and patients in improving chronic disease management. At the time of its publication, the idea of including the community and patients in a systemic approach was novel.17 Focusing more closely on the systems that link clinical providers and community organizations, Krist et al.12 presented a detailed description of the mechanisms that enable clinical providers and community organizations to develop an integrated approach to engagement, delivery, and follow-up care, focusing particularly on development of “spanning personnel” and “spanning support,” to facilitate integration across and between levels, and provide a system of interaction between the clinical and community systems.12 Critical to building clinical community integration is the importance of accountability for oversight and improvement. The Sickness Prevention Achieved Through Regional Collaboration model18 highlights the importance of having a central coordinating entity that takes on these responsibilities. Examples for development and funding for policy and staff changes from the literature include the Community-Centered Health Home approach,19,20 the Accountable Health Communities Model,21 and successful Medical Legal partnerships.22 These initiatives include local public health agencies, hospitals, social service organizations, advocacy groups, and other community partners.19–22 This paper offers early evidence of capacity changes achieved by eight sites to increase the integration of community health and prevention into communitybased primary care efforts. For those working to integrate clinical and community systems, these early steps are a necessary precursor. From 2011 through 2013, the Kresge Foundation funded demonstration projects to integrate primary clinical care and community health, specifically focused on social determinants of health in order to address health inequities and improve population health within vulnerable communities. A fundamental requirement of the initiative set forward by the Foundation was evidence of a partnership between community health centers December 2016
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(CHCs), local nonprofit clinics providing primary care services to primarily uninsured and underserved individuals, local public health departments, anchor institutions (e.g., established hospitals or universities), and community-based organizations; the role of each organization was determined locally.
Methods Through the Safety Net Enhancement Initiative (SNEI), grantee organizations in eight vulnerable communities were selected to form multisector partnerships and spearhead the development and implementation of demonstration projects to address health inequities as defined and prioritized by their communities. The eight selected sites varied by population density (i.e., urban, rural, frontier), racial and ethnic composition, and physical and social environments; however, each described significant challenges to health, including high rates of poverty and unemployment, poor health outcomes, and barriers to healthy living (Table 1). During a participatory planning process, residents and stakeholders in each community reviewed the communityʼs assets and challenges, prioritized health-related outcomes of particular concern, and defined some of the barriers related to these concerns that were associated with health inequities within their community. Although the health outcomes of interest were similar across several sites, the focus and design of demonstration projects in each site varied to address local assets and challenges, including the physical and social environment and systems of care. Sites designed strategies to address a range of barriers to health, including those related to a lack of: access to care: transportation, culturally appropriate care, and affordable services; physical activity: access to safe, engaging opportunities for movement and exercise; healthy nutrition: access to healthy food, knowledge, and skills for healthy eating; economic development: sustainable employment opportunities for residents; safety: safe places to exercise, garden, and receive care and services; and social cohesion: connection among community residents, and between residents and the available services. In 2014, after the sitesʼ implementation phase, the SNEI crosssite evaluation team “mapped” each SNEI site to consider how SNEI sites addressed integration. The process was used to identify whether and how the relationship of clinical- and community-level efforts to improve population health changed, and then looked across individual site maps to identify common features of integration across sites.
Results The mapping helped describe a series of steps taken by sites during the 3-year implementation period that were necessary to move toward integration (Figure 1). Efforts to improve clinical and community capacity required
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Table 1. SNEI Sites, Community-Identified Areas of Interest, and Program Activitiesa Grantee, location, project name
Health-related outcome(s)
Social determinant(s) of health
Program overview/activity examples
North Country HealthCare, Flagstaff, AZ, Hermosa Vida
Childhood overweight and obesity
Barriers to accessing resources for engaging in healthy behaviors
School-based initiatives (e.g., structured recess, walking school bus, Parent Academies); community-based activities (e.g., produce distribution, policy coalition)
Alameda County Public Health Department, Oakland, CA, Food to Families
Overweight and obesity among pregnant women and their families
Local economic and employment opportunities for young adults
Health education; fresh food prescription program at two CHCs (“Produce Rx”); corner store produce distribution system that trained and employed youth
Kokua Kalihi Valley Comprehensive Family Services, Honolulu, HI, Returning to Our Roots
Overall well-being
Social isolation
Community farming and preparation of traditional foods; dialogue with elders about culture and health; expanded access to fresh, healthy foods via clinic café
Whittier Street Health Center Boston, MA, Building Vibrant Communities
Hypertension and depression
Stressors (e.g., unemployment, neighborhood violence, barriers to health care)
Lay health workers used to conduct wellness screenings and help residents navigate services; structured physical activity and nutrition education classes
Voices of Detroit Initiative, Detroit, MI, IMPACT
Diabetes and hypertension
Neighborhood safety
Safe, central location established to house services and activities (e.g., cooking and fitness classes, pharmacist consultations); referrals to/from primary care services
Taos Health Systems, Peñasco, NM, Kids First
Childhood trauma and adverse childhood events
Isolation and lack of community support
Parent education using “Nurturing Parenting” curriculum; expanded service availability in rural community; behavioral health integration into clinics and schools
Cleveland Clinic Foundation, East Cleveland, OH, EC Teen Collaborative
Overall well-being of adolescents
Violence and community connectivity
Youth empowerment approach incorporating health education; utilized health and social service providers as “navigators” working with teen participants; peer education
Beaufort-Jasper-Hampton Comprehensive Health Services, Sheldon Township, SC, Pathways in STEP
Hypertension and related risk factors (e.g., overweight and obesity)
Poverty and economic stressors
Training of community members through Leadership Institute to improve community health; formation of Healthy Churches Consortium
a Source: SNEI Sitesʼ Implementation Proposals and program documents. CHC, community health center; SNEI, Safety Net Enhancement Initiative.
shifting perspectives, changing behaviors, and developing novel administrative models. Creating a shared vision and addressing current and needed leadership emerged as critical steps in creating the authentic partnerships needed for capacity change. Other necessary steps included building resources and capacities within the clinical and community systems individually while simultaneously beginning to develop linkages to support the connection among and between the clinical and community systems. SNEI partnerships needed to develop the building blocks—programs, policies, and relationships—that would lead to integration. Eventually, it is hoped that these new capacities and resources might work toward a more unified system, through which clinical and community organizations would be truly “integrated” so that the processes and policies in each support a shared vision and coordinated system of health improvement.
Improved Clinical Capacity Although the Kresge Foundation required the involvement of CHCs within SNEI partnerships, their role varied significantly across the eight sites, as did the level at which efforts were focused on improving the capacity within the clinical system to address social determinants of health. Though the majority of SNEI efforts were focused on building capacity outside of the clinic walls, at least four sites documented increased capacities within clinics to address social determinants of health, including policy and practice changes that expanded the way “health” is defined by clinical providers and the implementation of on-site programs/services (Table 2). Several of the clinic capacity outcomes also represent linkages to community resources. As the result of SNEI efforts, for example, Hermosa Vida (Flagstaff, AZ) implemented several initiatives within the clinic to provide more culturally appropriate care to patients, including the www.ajpmonline.org
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Improved Community Capacity Similar to changes within the clinical system, SNEI sites increased both programs and policies within the community system to address social determinants of health and integrate systems of care. In fact, all eight of the SNEI sites made significant accomplishments in this arena. As described in Figure 1 and Table 3, sites developed safe, affordable, accessible programs and resources to address community needs, including exercise programs, distribution of fresh fruits and vegetables, and parenting support services. Screening programs were developed to identify individuals in need of services, and individualand community-level education was provided to introduce concepts related to healthy living. In addition to new program development, several sites successfully changed local policies and practices to ensure lasting impact. For example, Hermosa Vida (Flagstaff, AZ) facilitated community organizing, which led to a change in local policies to make parks more accessible to the community, and Returning to Our Roots (Honolulu, HI) installed Electronic Benefit Transfer machines at farmersʼ markets that accept Supplemental Nutrition Assistance Program benefits. These policy changes represent important steps in improving community access to resources that address social determinants of health. Figure 1. Integration of community health and prevention into community-based primary care in the Safety Net Enhancement Initiative.
permanent hire of a translator and development and adoption of more culturally appropriate language for clinic staff. Similarly, SNEI staff of Kids First (Peñasco, NM) successfully changed clinic policies to incorporate mental health screening and referral processes for all patients in order to identify individuals in need of behavioral health services. Several sites changed clinic policies to support referral to community programs with partner organizations. Two sites adopted the use of prescriptions for healthy food or community support programs as a means to formalize recommendations and referrals. These policy changes represent long-term, sustainable changes in the way clinical systems address social determinants of health. In addition to changing clinical processes, three sites introduced onsite services to address social determinants of health. Two sites made changes to the physical infrastructure of the clinic to promote access to healthy food (i.e., onsite healthy food café and community garden). One site developed health education classes to teach patients how to prepare healthier meals using local produce. December 2016
Building Linkages The fundamental concept of SNEI was to join primary care services with community health services to address health disparities and improve population health. Several sites developed mechanisms for linking clinic and community efforts through bidirectional information sharing. The community organizer within the Hermosa Vida (Flagstaff, AZ) neighborhood, for example, spearheaded efforts within the clinic to make the clinic more responsive to community needs by conducting a patient provider assessment to identify communication issues and developing clinic policies and training related to appropriate language use and communication. Through Kids First (Peñasco, NM), a social worker hired jointly by the health system and a social service agency provided a formal linkage between the institutions. In both cases, the clinical system created a permanent job position to ensure sustainability of these efforts. Through its initial program design, the East Cleveland Teen Collaborative created a formal infrastructure to support information exchange across and within multiple clinic and community organizations. Health Navigators designated by individual organizations met regularly to jointly develop and implement a leadership program for community youth. In six of eight SNEI sites, project managers, who were either hired by or existing staff of CHCs, held primary
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Table 2. Improve Clinical Capacity Type of change Policies/procedures: implementation of formal rules, guidelines, or practices
Capacity built within clinics Implemented process for clinicians to write prescriptions for healthy food
and program participationa
Established systems within the clinic to refer patients to community
support systemsa Implemented formal screening process for identifying families in need of additional services Hiring of permanent staff to implement new/improved policies/ procedures: o Hired a translator to ensure that patients were able to more effectively communicate with clinical staff o Added a social worker to their permanent staff model to screen and refer patientsa Programs: addition of or changes to activities or physical infrastructure
Classes in the clinic educated patients on healthy food and healthy cooking Café in the clinic increased access to healthy food for clinic personnel,
patients, and community
Implementation of community garden on clinic site Dedication of space for a community program a
Indicates changes that represent both capacity built within the clinical system and a linkage to the community.
responsibility for developing and implementing SNEI efforts and effectively served as the linkage between the clinic and the community systems being developed. As employees of the clinic, they were internal representatives of this effort and increased the visibility of community resources within the clinic. They also supported ongoing communication among and between programs, and sometimes became the “face” of the clinic within the community. These project managers often served as a mechanism to link systems to each other.
Discussion The SNEI was implemented as a demonstration project to support the development of models to integrate community health and prevention with primary care for vulnerable populations. During the relatively short timeframe of the initiative (3-year implementation period), sites increased the potential of their community and clinical systems to focus on social determinants of health, primarily by building capacity and readiness. As an established system organized around disease treatment, not prevention, changes need to be made within the clinical system to prepare for integration. These changes require shifting perspectives, changing behaviors, and developing novel administrative models. Similarly, integration requires changes within and among community systems, which include a number of elements that naturally ebb and flow in response to community needs. Ultimately, there is the need to find ways for these two very different environments to interact and coordinate—a significant challenge. A critical step in this preparation for integration is the development of a shared vision among key leaders and
stakeholders. A belief in the notion that improving population health requires not just accessible, quality clinical care, but also a safe, healthy community environment that supports opportunities for health, including access to healthy food, safe places for exercise, economic opportunities, and social support and connection. The Kresge Foundation wisely required that sites demonstrate the development of a partnership among clinical providers, local public health agencies, and communitybased organizations in the design and implementation of SNEI efforts. This opportunity created a starting point for leaders to develop and demonstrate a commitment to the work. In many situations, leaders are eager to come to the table for a grant proposal when much-needed funds are available. It is more difficult to engage those leaders in maintaining that vision over the long haul. The extent to which key SNEI stakeholders followed through on their initial commitment is unclear and varied by site and institution. In all sites, community representatives appeared eager and engaged, despite historic hesitancies from communities wary of “another project” that provides short-term efforts and then fades away. With the exception of the one site in which the local public health agency was the grant recipient, the engagement of local public health agencies was less consistent, likely reflecting the overall challenges public health agencies have experienced in recent years in which their mission was significantly questioned and funding reduced. Of critical importance in an effort to integrate community health into primary care was the role of clinical leaders and, in particular, the key leaders of the CHCs involved in this effort. In six sites, CHCs were the lead agencies for SNEI and played a critical role by housing and supporting initiative staff, providing administrative support, and www.ajpmonline.org
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Table 3. Improved Community Capacity Type of change Policies/procedures: implementation of formal rules, guidelines, or practices
Capacity built within communities Policies to reduce fees for community organizations to use
local parks
Acceptance of SNAP benefits at farmerʼs markets Dedication of spaces within community buildings for safe exercise
and services
Programs: addition of or changes to activities or physical infrastructure
Development of community-centered (located) programs for safe
accessible physical activity
Development of community-centered (located) programs to increase
access to healthy food, e.g., CSA distribution, community gardens, corner store produce distribution Implementation of efforts to screen community members for unidentified needs Community education to increase knowledge and awareness of issues related to social determinants of health Individual capacity: increased capacity of individual community members to improve health in their communities
Leadership training for community leaders to implement health
programs
Engagement in advocacy for policy change CSA, community-supported agriculture; SNAP, Supplemental Nutrition Assistance Program.
lending their credibility to initiate partnerships and secure the grant. The extent to which these leaders embraced a deep commitment to the initiativeʼs vision is a more significant question. Truly integrating prevention into primary care requires a fundamental shift in the concept of “health” and a willingness to change existing practice. This shift is happening, albeit slowly, throughout the country, and part of the intention of SNEI was to develop early models for how this might be replicated as this movement takes root. The Foundation made an effort to identify sites that were “ready” for this initiative and had evidence of clinical engagement. At least one siteʼs clinic leaders have surfaced as “thought leaders,” providing support and nurturing not only locally but other communities and national efforts. In many SNEI sites, however, the degree to which clinical leaders embraced this notion is unclear, and it appears that their support amounted to “business as usual,” as they were happy to support staff and programs but were not proactive in incorporating the efforts into the clinical systems. This likely reflects the overall status of the country, in which there are pressures to change but limited incentive and capacities to support this change. In some sites, it is also possible that local staff could have focused more effort on the internal clinical environment to support this engagement. These are important lessons to note for future initiatives. For communities wishing to address social determinants of health, it is critical to focus on separating work and activities that are program based, and will most likely disappear when funding subsides, from efforts that are aimed at changing structures and policies that will continue over time. Through local leadership, new programs were developed and implemented in clinics and community settings. December 2016
It is unclear whether these newly developed programs will be sustained into the future; whether the Zumba classes will continue; whether the community garden will be maintained; or whether camps and activities for kids will endure. There are clearly some SNEI efforts that will have lasting and enduring impact. Clinic and community members are more aware of the importance of social determinants of health. Policies have been established to hire permanent staff and accept payment vouchers at farmerʼs markets. Community members are more aware of, and have greater skills for, healthy eating and increased access to parks and walking paths. These are important changes that were designed to be sustained beyond the Kresge funding and they will have a sustained impact on the way health and health care are approached in these communities. As with many short-term initiatives, there is always the risk that programs and activities will fade with the end of the grant. The SNEI efforts that have endured beyond the funding period are a reminder of the importance of addressing sustainability early and often in the course of an initiative.
Conclusions Significant literature has explored theoretic models for integrating community efforts to support prevention and chronic health management into clinical care. SNEI represents a case study of how eight sites attempting to integrate community health and prevention into primary care laid a foundation for integration by building local capacities within and between the clinical and community systems. In the end, integration requires systemic change. This real-world case study highlights the complexities and
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challenges, and time involved in changing established systems. These are not quick fixes; they require changes to perspectives, behaviors, and protocols. In their efforts to integrate community health and prevention into community-based primary care efforts, SNEI sites made significant movement in building local capacity—in both clinical and community systems—because that was what was needed to move toward integration. Sites developed programs or linked community members with existing programs, and established links between clinical and community systems. Although it is too early to know the extent to which the programs nurtured through SNEI are sustainable, documented changes to perspectives and policies provide significant opportunities for lasting change. In the world of short-term initiatives, these are substantial successes and represent building blocks on which SNEI communities can build ongoing efforts. The authors would like to acknowledge and express appreciation for the work of the Safety Net Enhancement Initiative projects and communities: Hermosa Vida (Flagstaff, AZ), Food to Families (Oakland, CA), Returning to Our Roots (Honolulu, HI), Building Vibrant Communities (Boston, MA), IMPACT (Detroit, MI), Kids First (Peñasco, NM), EC Teen Collaborative (East Cleveland, OH), and Pathways in STEP (Sheldon Township, SC); and for the support of the Kresge Foundation. Additional information about this project can be found at the University of Michigan Center for Managing Chronic Disease website (http://cmcd.sph.umich.edu/research-program-areas/ safety-net-enhancement-initiative-evaluation/). All authors contributed to the content, design, analysis, interpretation, and preparation of the manuscript. No financial disclosures were reported by the authors of this paper.
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References 1. Marmot MG, Smith GD, Stansfeld S, et al. Health inequalities among British civil servants: the Whitehall II study. Lancet. 1991;337(8754): 1387–1393. http://dx.doi.org/10.1016/0140-6736(91)93068-K. 2. Link BG, Phelan J. Social conditions as fundamental causes of disease. J Health Soc Behav. 1995;Spec No:80–94. http://dx.doi.org/10.2307/ 2626958. 3. Diez Roux AV, Mair C. Neighborhoods and health. Ann N Y Acad Sci. 2010;1186:125–145. http://dx.doi.org/10.1111/j.1749-6632.2009.05333.x. 4. Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academies Press; 2001; http://dx.doi.org/10.17226/10027. 5. Agency for Healthcare Research and Quality. Expanding PatientCentered Care to Empower Patients and Assist Providers. AHRQ Research
19.
20.
21. 22.
in Action, No. 5 (AHRQ Publication No. 02-0024). Washington, DC: Agency for Healthcare Research and Quality; 2002. Davis K, Abrams M, Stremikis K. How the Affordable Care Act will strengthen the nationʼs primary care foundation. J Gen Intern Med. 2011;26(10):1201–1203. http://dx.doi.org/10.1007/s11606-011-1720-y. Epstein RM, Street Jr. The values and value of patient-centered care. Ann Fam Med. 2011;9(2):100–103. http://dx.doi.org/10.1370/ afm.1239. Wilkinson R, Marmot M, eds. Social Determinants of Health: The Solid Facts. 2nd ed. Geneva: WHO; 2003. www.euro.who.int/__data/ assets/pdf_file/0005/98438/e81384.pdf Accessed September 1, 2016. Yen IH, Syme SL. The social environment and health: a discussion of the epidemiologic literature. Annu Rev Public Health. 1999;20: 287–308. http://dx.doi.org/10.1146/annurev.publhealth.20.1.287. Institute of Medicine. Primary Care and Public Health: Exploring Integration to Improve Population Health (Report Brief). Washington, DC: National Academy of Sciences; http://dx.doi.org/10.17226/13381. Ackermann RT. Description of an integrated framework for building linkages among primary care clinics and community organizations for the prevention of type 2 diabetes: emerging themes from the CC-Link study. Chronic Illn. 2010;6(2):89–100. http://dx.doi.org/10.1177/ 1742395310364857. Krist AH, Shenson D, Woolf SH, et al. Clinical and community delivery systems for preventive care: an integration framework. Am J Prev Med. 2013;45(4):508–516. http://dx.doi.org/10.1016/j.amepre. 2013.06.008. Plumb J, Weinstein LC, Brawer R, Scott K. Community-based partnerships for improving chronic disease management. Prim Care. 2012;39 (2):433–447. http://dx.doi.org/10.1016/j.pop.2012.03.011. Chin MH, Goddu AP, Ferguson MJ, Peek ME. Expanding and sustaining integrated health care-community efforts to reduce diabetes disparities. Health Promot Pract. 2014;15(2 suppl):29s–39s. http://dx. doi.org/10.1177/1524839914532649. Peek ME, Ferguson M, Bergeron N, Maltby D, Chin MH. Integrated community-healthcare diabetes interventions to reduce disparities. Curr Diab Rep. 2014;14(3):467. http://dx.doi.org/10.1007/s11892-013-0467-8. Porterfield DS, Hinnant LW, Kane H, Horne J, McAleer K, Roussel A. Linkages between clinical practices and community organizations for prevention: a literature review and environmental scan. Am J Prev Med. 2012;42(6 suppl 2):S163–S171. http://dx.doi.org/10.1016/j.amepre. 2012.03.018. Wagner EH, Davis C, Schaefer J, Von Korff M, Austin B. A survey of leading chronic disease management programs: are they consistent with the literature? Manag Care Q. 1999;7(3):56–66. Shenson D, Benson W, Harris AC. Expanding the delivery of clinical preventive services through community collaboration: the SPARC model. Prev Chronic Dis. 2008;5(1):1–8. Plumb JD, Weinstein L, McCurdy M. The Stephen Klein Wellness Center—a community centered health home—a partnership between Jefferson and Project HOME. Popul Health Matters. 2015; 28(3):2–3. Valdovinos E, Srikantharajah J, Pañares R, Mikkelsen L, Cohen L, Cantor J. Community-centered health homes: bridging the gap between health services and community prevention. www.preventio ninstitute.org/component/jlibrary/article/id-298/127.html. Published 2011. Accessed June 16, 2016. Accountable Health Communities Model. https://innovation.cms.gov/ initiatives/AHCM. Accessed June 16, 2016. National Center for Medical-Legal Partnership. http://medical-legal partnership.org/. Accessed June 16, 2016.
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