Clinical-Community Relationships as a Clinical-Community Relationships as a Pathway to Improve Health: Pathway to Improve Health:

Tools for Research and EvaluationTools for Research and Evaluation

August 7, 2013August 7, 20131:00-2:00 PM ET1:00-2:00 PM ET

TODAY’S EVENT MODERATORTODAY’S EVENT MODERATOR

Janice Genevro, PhD, MSW

AHRQ Prevention and Chronic Care Program

AHRQ and Clinical-AHRQ and Clinical-Community RelationshipsCommunity Relationships

Building the Evidence Base:

What Do We Know? What Do We Need to Know?

How are partnerships among primary care and medical specialty providers, the community, and public health organizations developed, strengthened, and sustained to improve care and meet the needs of patients and families?

AHRQ and Clinical-AHRQ and Clinical-Community RelationshipsCommunity Relationships

The Promise of Clinical-Community Relationships

Form partnerships among clinical, community, and public health organizations to fill gaps in needed services.

Coordinate health care delivery, public health, and community-based activities to promote healthy behavior.

Promote patient, family, and community involvement in preventive health care.

Learning ObjectivesLearning Objectives

Understand the concept of clinical-community Understand the concept of clinical-community relationships and the rationale and need for relationships and the rationale and need for further investigation of measuresfurther investigation of measures

Learn about the processes used to develop the Learn about the processes used to develop the Clinical-Community Relationships Measures Clinical-Community Relationships Measures Atlas and RoadmapAtlas and Roadmap

Hear about the application of these products to Hear about the application of these products to research, evaluation, and public health research, evaluation, and public health practicepractice

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TODAY’S PRESENTERSTODAY’S PRESENTERS

Robert M. Pestronk, MPHRobert M. Pestronk, MPHRebecca Etz, PhDRebecca Etz, PhD

Virginia Commonwealth University

National Association of County and City Health

Officials (NACCHO)

Clinical-Community Relationship Measures (CCRM)Clinical-Community Relationship Measures (CCRM)

Rebecca Etz, PhD

Virginia Commonwealth UniversityDepartment of Family Medicine and Population Health

The CCRM Project - PurposeThe CCRM Project - Purpose What is the purpose of this project?

Focus on clinical-community partnerships Develop measures to assess clinical-community

relationships Improve care and ability to meet patient needs Promote integrated approach to preventive services Overcome persistent obstacles to delivery

Fragmentation experienced by providers Fragmentation experienced by patients Fragmented medical neighborhoods ‘Decentering’ of relationships in medicine

The CCRM Project - MethodsThe CCRM Project - Methods

What did we do?

Literature review to identify state of the art as well as gaps

Conceptual framework to facilitate learning Expert panel to assist with literature findings,

conceptual framework, identification of measures and creation of candidate measures

Set priority questions suggested by framework Develop recommendations for future directions

The CCRM Project - ParametersThe CCRM Project - Parameters

What were the assumptions informing our work?

Prevention that originates in primary care Community resources provide non-clinical services USPSTF recommendations Centering on relationships between clinical settings and

community settings meant that outcomes were not our focus

Conceptual FrameworkConceptual Framework

Building our framework Himmelman and relationships1

4 levels of linkage, collaboration as our target

Donabedian and structure-process-outcome2

Enveloping context, action and engagement

Etz and bridging3

Anchors on which connecting strategies rely1Himmelman A. Collaboration for a change: definitions, decision-making models, roles, and collaboration process guide.

Unpublished work. 2002. Partnership Continuum Inc., Minneapolis (MN).2Donabedian A. Explorations in quality assessment and monitoring: the definition of quality and approaches to its assessment.

Ann Arbor: Health Administration Press; 1980.3 Etz R, Cohen D, Woolf S, et al. Bridging primary care practices and communities to promote healthy behaviors. Am J Prev Med.

2008; 35(5S):S390-S397.

Conceptual FrameworkConceptual Framework

Rebecca S. Etz, Deborah J. Cohen, Steven H. Woolf, Jodi Summers Holtrop, Katrina E. Donahue, Nicole F. Isaacson, Kurt C. Stange, Robert L. Ferrer, Ardis L. Olson, Bridging Primary Care Practices and Communities to Promote Healthy Behaviors, American Journal of Preventive Medicine, Volume 35, Issue 5, Supplement, November 2008, Pages S390-S397, ISSN 0749-3797, http://dx.doi.org/10.1016/j.amepre.2008.08.008.

Conceptual FrameworkConceptual Framework

Elements: patients, Elements: patients, clinics/clinicians, and clinics/clinicians, and community resourcescommunity resources

Domains: structure, Domains: structure, process, outcomesprocess, outcomes

Relationships among themRelationships among them

Conceptual FrameworkConceptual Framework

Expert Panel Expert Panel

• Lynda Anderson, PhD - Centers for Disease Control and Prevention (CDC)

• Cheryl Aspy, MEd, PhD - Oklahoma Physicians Resource/Research Network (OKPRN), University of Oklahoma Health Sciences Center

• Carol Cahill, MLS - Center for Community Health and Evaluation, Group Health Research Institute (GHRI)

• Rebecca Etz, PhD - Ambulatory Care Outcomes Research Network (ACORN), Virginia Commonwealth University

• Russell E. Glasgow, PhD - National Cancer Institute (NCI)

• Cheryl Irmiter, PhD - Easter Seals (formerly AMA)

• Bobby Pestronk, MPH - National Association of County and City Health Officials

• Ruta Valaitis, RN, PhD - McMaster University; City of Hamilton, Public Health Department

Clinical-Community Clinical-Community Relationships Measures Atlas Relationships Measures Atlas

Published March 2013Published March 2013 Includes 22 measuresIncludes 22 measures Measurement framework Measurement framework

and rationaleand rationale Aligns measures to Aligns measures to

frameworkframework 10 of 56 categories 10 of 56 categories

include at least one include at least one measuremeasure

http://www.ahrq.gov/professionals/prevention-chronic-care/resources/clinical-community-relationships-measures-atlas/index.html

Clinical-Community Relationships Clinical-Community Relationships Measures Atlas Measures Atlas

Existing MeasuresExisting Measures

Existing MeasuresExisting Measures

Existing MeasuresExisting Measures

Existing MeasuresExisting Measures

Clinical-Community Relationships Clinical-Community Relationships Evaluation RoadmapEvaluation Roadmap

Focus on clinical Focus on clinical interactions and interactions and integrating servicesintegrating services

Capture the context Capture the context of care deliveryof care delivery

Inform research Inform research development and development and designdesign

http://www.ahrq.gov/professionals/prevention-chronic-care/resources/clinical-community-relationships-eval-roadmap/index.html#

Clinical-Community Relationships Clinical-Community Relationships Evaluation RoadmapEvaluation Roadmap

Priority Areas of Study1.1.Influence of element characteristicsInfluence of element characteristics

2.2.Influence of relationships between the elementsInfluence of relationships between the elements

3.3.Relative importance of elements and relationships Relative importance of elements and relationships in contextin context

4.4.Best methods, strategies, and settings for studying and Best methods, strategies, and settings for studying and improving clinical-community relationshipsimproving clinical-community relationships

5.5.Best measures for evaluating effectiveness of Best measures for evaluating effectiveness of clinical-community relationships clinical-community relationships

Clinical-Community Relationships Clinical-Community Relationships Evaluation RoadmapEvaluation Roadmap

Seven Recommendations1.1.Use complex systems approachesUse complex systems approaches

2.2.Accommodate/tailor for variability in designAccommodate/tailor for variability in design

3.3.Develop standard measuresDevelop standard measures

4.4.Conduct rigorous, mixed methods approachesConduct rigorous, mixed methods approaches

5.5.Report findings more thoroughly in useful formatsReport findings more thoroughly in useful formats

6.6.Assess feasibility and sustainability of interventions Assess feasibility and sustainability of interventions for clinics, patients, and clinical-community for clinics, patients, and clinical-community relationshipsrelationships

7.7.Consider conceptual Consider conceptual framework as a starting pointframework as a starting point

Clinical-Community Relationship Measures (CCRM)Clinical-Community Relationship Measures (CCRM)

Robert M. (Bobby) Pestronk, MPHNational Association of County and

City Health Officials (NACCHO)

Clinical-Community Clinical-Community Relationships and NACCHORelationships and NACCHO

Recognition of the local health department playing a role in preventive health

Provides framework for understanding relationships among local health departments and practitioners

Provides guidance for young public health services and systems researchers

Contributions of the CCRM Project to Contributions of the CCRM Project to the Public Health Communitythe Public Health Community

Guidance to local health departments Understand roles in

evolving health care system

Promote connection with primary care practices

Working with various stakeholders Develop effective

relationships Reduce barriers to

encourage relationships

MCOs

Parks

Mass TransitNursing Homes

Mental HealthDrug

Treatment

Civic GroupsCHCs

Laboratory Facilities

Hospitals

EMS

Health Department

Elected Officials

Tribal Health

Schools

Police

Fire

Jails

Environmental Health

ChurchesHome Health

Economic DevelopmentEmployers

PhilanthropistDoctors

Community Centers

Evaluation Roadmap provides a “context” for delivery of clinical preventive services: Outside of traditional primary care setting Clinicians and clinical practices are embedded

in a larger health care system

Public Health Implications of the Evaluation Roadmap

Public Health Implications of the Evaluation Roadmap

The Roadmap is a “through the looking glass” approach to population/public health: Greater access to

clinical preventive services

More coordinated and team-based care

Potential cost savings Better health quality Better health outcomes

How to use the power of public health tools and clinical prevention services to make life and health easier and less risky for everyone?

What mix of financial incentives, technology, stories, politics, and training are necessary to achieve those goals?

Key Research Concerns for Key Research Concerns for Public HealthPublic Health

How can the cost savings from the practice of community-clinical relationships be reinvested in efforts to improve social equity?

What are the best qualitative and quantitative methods for evaluating clinical-community relationships?

How can we best scale up and adapt what’s working best in some locations so that it working best in all places?

Key Research Concerns for Key Research Concerns for Public HealthPublic Health

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For More InformationFor More Informationhttp://www.ahrq.gov/professionals/prevention-chronic-care/index.html

For More InformationFor More Informationhttp://www.innovations.ahrq.gov/linkingClinicalPractices.aspx

This project was funded under contract # HHSA290-2010-This project was funded under contract # HHSA290-2010-000021 from the Agency for Healthcare Research and Quality 000021 from the Agency for Healthcare Research and Quality (AHRQ), U.S. Department of Health and Human Services. The (AHRQ), U.S. Department of Health and Human Services. The opinions expressed in this presentation are those of the opinions expressed in this presentation are those of the presenters and do not reflect the official position of AHRQ or the presenters and do not reflect the official position of AHRQ or the U.S. Department of Health and Human Services.U.S. Department of Health and Human Services.

For more information about AHRQ’s work in this area, visit For more information about AHRQ’s work in this area, visit http://www.ahrq.gov/professionals/prevention-chronic-http://www.ahrq.gov/professionals/prevention-chronic-care/index.htmlcare/index.html

or contact:or contact:

Janice Genevro, PhDJanice Genevro, PhD

janice.genevro@ahrq.hhs.govjanice.genevro@ahrq.hhs.gov