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2. LITERATURE REVIEW AND ENVIRONMENTAL SCAN


2.1 Methods

To understand linkages between clinical practices and community/public health, AHRQ contracted with RTI to conduct a "scoping" literature review and an environmental scan. A scoping review, unlike a systematic review, broadly surveys the literature but does not evaluate articles for methodological quality (Martin-Misener & Valaitis, 2009). An environmental scan examines unpublished literature and publically available program information. A total of 49 interventions that met the inclusion/exclusion criteria were identified through the literature review and environmental scan.

Using the definition of linkages provided above and the conceptual model depicted in Figure 1-1, RTI and AHRQ developed a list of study questions that we could address with a literature review and environmental scan (see Appendix B for list of study questions). The study questions were vetted with AHRQ and the Steering Committee to identify the questions that were of greatest importance to this effort. We describe our methods for the literature review and environmental scan in Sections 2.1.1 and 2.1.2, respectively.

2.1.1 Literature Review

To initiate this review, RTI and AHRQ generated the following general search parameters:

  • English language,
  • journal articles (not including book reviews, commentaries, editorials),
  • human subjects,
  • 1999 to present,
  • no age group limitations, and
  • U.S. and international.

These parameters were selected to capture programs that might be active beyond the publication date and therefore might be contacted for participation in a case study.

Next, RTI and AHRQ developed search terms by using several strategies. First, we listed keywords for the topics of interest, such as obesity, physical activity, tobacco cessation, and partnership/linkage. Second, RTI asked AHRQ and the Steering Committee to recommend exemplar articles. RTI then selected five exemplars and examined those articles' Medical Subject Headings (MeSH) terms for additional search terms. Finally, RTI asked the Steering Committee to suggest additional keywords or MeSH terms.

After assembling a comprehensive list of relevant MeSH terms and keywords, RTI grouped terms logically into three categories: terms relating to program content, terms dealing with primary care, and terms describing the community health or public health component of the intervention. Table 2-1 presents the search terms and their organization.

Table 2-1. Search Terms for the Literature Review and Environmental Scan
Program Content Primary Care Community Health or Public Health
Exercise Primary health care Community health services
Exercise therapy Medical Home Health promotion
Motor activity   Referral and consultation
Nutrition therapy   Directive counseling
Diet therapy   Insurance, health, reimbursement
Health behavior   Reimbursement mechanisms
Tobacco use cessation   Reimbursement, incentive
Tobacco use disorder   Community-based participatory research
Smoking   Patient education as a topic
Smoking cessation   Delivery of health care, integrated
Obesity   Partnership practice
Diet, reducing   Primary prevention
    Clinical preventive services
    Practice-based public health
    Health department

Using the search terms, RTI searched the following major health services and social science electronic databases:

  • PUBMED (MeSH terms),
  • CINAHL (MeSH terms),
  • ISI Web of Science (author determined keywords), and
  • PsychInfo (author determined keywords).

To facilitate the search, we applied Boolean operators (i.e., AND, OR) between each of the keywords and their categories. Within an article, we wanted to find at least one of the terms within the column; thus, we searched by using "OR" between all of the terms within a column. Because we were interested in the combination of terms across columns, we applied "AND" for terms across columns.

RTI then ran iterative searches and assessed search quality (i.e., presence of the five exemplar articles) and volume (i.e., number of articles returned from the search). To winnow the number of articles, RTI applied MeSH subheadings, which yielded a manageable 745 results after duplications were removed. At the same time, RTI developed inclusion/exclusion criteria to select articles that corresponded to our definition of linkage and the conceptual model:

  • Articles must contain a linkage between a clinical practice and public health or community health organization. Health plans were not included as a clinical practice.
  • Articles must address counseling or other activities to promote healthy diet, exercise, or tobacco cessation. Delivery of clinical preventive services as recommended by the USPSTF was desirable but was not an inclusion criterion.
  • Clinical practices that were primarily increasing their capacity to provide preventive health services through expanding clinic staff and program offerings were excluded.

While assessing the literature, RTI made a number of refinements to the inclusion/exclusion criteria. For instance, articles meeting the inclusion criteria sometimes centered on particular categories of participants (e.g., a smoking cessation program for people with diabetes). These were included as they addressed this effort's core set of clinical preventive services. Research studies and clinical trials were also included despite concerns about limited generalizability. However, RTI opted to exclude articles that described interventions yet to be implemented or a strategic planning process so that the focus could remain on studies of interventions being implemented in the field. RTI also excluded articles in which the community or clinical partner played a nominal role, such as serving on an advisory group or steering committee.

To determine whether an article should be included, abstracts and subsequently full texts were reviewed by members of the research team. When questions arose, a second reviewer would review the abstract and/or full text, and decisions were made by consensus. At the end of the literature review, 19 articles were included, yielding 36 examples of linkages (Figure 2-1). Most commonly, articles were excluded because they addressed issues that were outside of the content areas being examined and/or they did not include an intervention that included both a clinical and a community partner.

Coding Structure and Access Database

Using the conceptual model, linkage definition, and research questions, the RTI team developed a coding structure for extracting data from the selected articles. The coding structure included such topics as program focus (e.g., physical activity, nutrition), participating partners (e.g., hospital, health care system, health department, community-based organization), intervention/innovation, and predisposing conditions. To facilitate analysis, RTI then created an Access database containing these codes and entered all selected articles into it. (The abstraction form is available from RTI upon request.)

Figure 2-1. Literature Review Flow Diagram

aSeveral articles yielded more than one linkage example.

2.1.2 Environmental Scan

For the environmental scan, the project team conducted general and targeted Internet searches. In the general search, we entered various configurations of the search terms into Google; for the targeted search, we examined Web sites recommended by AHRQ, the Steering Committee, and RTI experts. We describe each activity below.

General Search

RTI conducted a thorough search of the practice-based literature in print and electronic formats. In this search, we looked for clinical and public health organizations that highlight or include examples of clinical-community partnerships and linkages through their work. Using a variety of search terms (Table 2-2), the team used the Google search engine to identify examples of linkages between clinicians/health care providers and community prevention programs.

Each set of Google search results was mined for possible examples that met the inclusion/exclusion criteria. The first 20 links were reviewed for possible linkage examples. If a potential example was identified in that set of links, then the next 10 links were reviewed. If another example was identified, then the next 10 links were reviewed until no additional potential examples were identified. Once a set of search terms was exhausted, a different combination of terms was entered into Google and the same process was repeated. Interventions that met the selection criteria were added to the Access database.

Table 2-2. Examples of Search Terms Used in Google and Targeted Web Search
Terms Dealing with Types of Partners Terms Dealing with the Type of Relationship Additional Terms
Clinical Partner (and variants: partnership, partnering) Prevention
Clinicians Linkages (and variants: links, linking) Public health
Providers Relationship Community health
Health providers Referral Community
Health care providers    
Community programs    
Community prevention programs    
Community health center    
Health center    

Targeted Search

In addition to a broader Google search, RTI gathered additional examples of linkages from Steering Committee members and other contacts using a Program Identification Form. Finally, a targeted search of relevant organizational Web sites was conducted to identify any additional examples. A list of organizational Web sites that were included in the search is provided in Table 2-3.

In a process similar to the Google search, reviewers used a variety of search terms when searching these organizational Web sites to identify any relevant examples of linkages. Additional searches of the New York Academy of Medicine Grey Literature Report were conducted to capture supplementary resources not identified through other sites or searches.

Because many sites listed hundreds of activities and interventions, many of which were not relevant to the selection criteria established for this work, conducting an exhaustive search of each site would have been cost-prohibitive. Instead, a qualitative approach was used in which each site was reviewed for up to 1 hour to identify interventions and activities that most closely met the inclusion/exclusion criteria.

Using a record abstraction form that corresponded to the Access database, reviewers captured key descriptive information about each relevant case. This information was then entered into the Access database so that it could be analyzed concurrently with the literature review data. Thirteen additional interventions were included in the final analyses.

Table 2-3. Targeted Web Sites Included in the Scan
Type of Organization Organization
Government agencies
  • AHRQ
  • CDC
    • Division of Diabetes Translation
    • Office on Smoking and Health
    • Division of Nutrition and Physical Activity
    • Division of Heart Disease and Stroke Prevention
    • Racial and Ethnic Approaches to Community Health (REACH)
    • Steps to a HealthierUS
  • Health Resources and Services Administration
Public and private organizations
  • Robert Wood Johnson Foundation
  • W.K. Kellogg Foundation
  • Kaiser Family Foundation
Practitioner and public health-related organizations
  • American Medical Association
  • American Academy of Family Practice
  • American College of Preventive Medicine
  • American Public Health Association
Other prevention partners
  • Association of Prevention Teaching and Research
  • Association of State and Territorial Health Officials (ASTHO)
  • National Association of City and County Health Officials (NACCHO)
Other relevant sites
  • New York Academy of Medicine Grey Literature Report

2.2 Findings

The literature review and environmental scan aimed to address a number of key study questions (Appendix B) that were developed in concert with the conceptual model (Figure 1-1) that guides this project. The key questions of interest are presented in Table 2-4.

Table 2-4. Key Literature Review and Environmental Scan Research Questions
Concept in Framework Research Questions of Interest
Building blocks
  • Which organizations are involved?
  • What types of linkages exist?
  • Can the described linkages be categorized according to existing partnership or linkages frameworks?
Interventions/innovations
  • What types of interventions/innovations have been implemented?
    • What are the target populations?
    • Where do interventions take place?
    • How has information technology been incorporated into the interventions?
Outcomes
  • What outcomes are being measured?
  • What data sources are used?
  • What did the linkages accomplish?
  • What were key intervention/linkage facilitators and barriers?

2.2.1 Overview

Using the pre-established selection criteria, the literature review and environmental scan yielded a total of 49 interventions that included a linkage as a part of the intervention or program implementation. See Appendix C for a list of interventions.

Examination of the interventions found that 27 of the 49 interventions identified were a part of large, funded and centrally coordinated public health efforts. These included Prescription for Health (n = 19) and the Building Community Support initiatives (n = 5), both funded by RWJF, and the Health Resources and Services Administration's (HRSA's) Women's and Children's Health Program Healthy Behaviors in Women Effort (n = 3). The remaining 22 interventions varied from large state coordinated efforts to smaller community or individual practice-level interventions. A majority of the interventions identified were located within the United States (n = 44), with a smaller number of interventions (n = 5) located outside of the United States, including the United Kingdom, Sweden, and Spain. Programs located in the United States were implemented in 23 different states.

Funding sources for these efforts varied and included the following:

  • national agencies and organizations (e.g., HRSA, CDC, National Cancer Institute, AHRQ, National Institutes for Health);
  • state agencies and organizations (e.g., Cooperative Extension, State Departments of Public Health);
  • foundations (e.g., Kate B. Reynolds Charitable Trust, RWJF, Allina Health Foundation);
  • health care organizations and systems (e.g., local hospital, academic medical center); and
  • corporate sponsors (e.g., Pepsico, Inc., McDonald's Corporation).

The following sections highlight intervention information obtained from the articles and resources reviewed. It must be noted that in many cases the information may not fully reflect all aspects of the interventions examined because the review was limited to the information contained within the print or electronic resources. Additional data collection from a subset of interventions identified through the literature review and environmental scan will be conducted in the next phase of this work. Preliminary findings from this work indicate that the counts provided within the articles and resources reviewed are underestimates, which indicates that many more partners and activities are implemented through these efforts.

2.2.2 Building Blocks

This section describes the results pertaining to the "building blocks" component of the conceptual framework in Figure 1-1. The following questions are addressed:

  • Which organizations are involved?
  • What types of linkages exist?
  • Can the described linkages be categorized according to existing partnership or linkages frameworks?

Which Organizations Are Involved?

The interventions reviewed engaged a wide variety of clinical and community partners in the implementation of program activities. At a minimum, both a clinical partner and a community partner had to be present to be selected for inclusion in the review. Most often, the organization initiating the intervention or from which the intervention was initially originated was the clinical partner or practice (Table 2-5). "Other" initiating organizations include national associations and academic or educational institutions.

Table 2-5. Organizations Initiating the Intervention
Organization Initiating the Intervention Frequency (%a)
Clinical practices 26 (53%)
Community organizations 11 (22%)
Other 5 (10%)
Not stated/could not be determined 7 (14%)
aThe total percentage exceeds 100% because some interventions involved multiple clinical practice types.

Clinical partners varied widely but included community health centers, hospitals, health care systems, and single provider practices. Frequencies of the types of clinical partners are presented in Table 2-6. The numbers reported in Tables 2-6 and 2-7 are likely undercounts as the data rely on the level of detail provided in the reports or articles reviewed.

Table 2-6. Types of Clinical Partner Organizations
Clinical Practice Type Frequency (%a)
Community health center 7 (14%)
Hospital 4 (8%)
Health care system 7 (14%)
Group practice 1 (2%)
One or more single practices 10 (20%)
Other 5 (10%)
Unspecified clinical partner 22 (45%)
aThe total percentage exceeds 100% because some interventions engaged multiple clinical practice types.

As with clinical partners, a wide variety of community organizations or partners were also engaged in the implementation of program activities. Generally, these partners were classified as community-based organization, community coalition, governmental public health, or other. In many cases, multiple community partners were engaged in the implementation of program activities. Fourteen programs included unspecified community service organizations (all were Prescription for Health programs described in a single article).

Table 2-7. Types of Community Partner Organizations
Partners Frequency (%a)
Community-based organization 6 (12%)
Community coalition 3 (6%)
Governmental public health 3 (6%)
Community-based organization and community coalition 3 (6%)
Community-based organization and governmental public health 3 (6%)
Educational institutions/universities 9 (18%)
Businesses 2 (5%)
Commercial weight loss programs 3 (6%)
Other, which includes other combinations of more than one community partner 11 (22%)
Unspecified community partner 14 (29%)
aThe total percentage exceeds 100% because some interventions engaged multiple clinical practice types.

What Types of Linkages Exist?

The 49 linkages examined represent a wide variety of program activities and interventions that sought to impact both individual and organizational practices and behaviors as well as larger community-level improvements designed to lead to improved health outcomes. The interventions themselves or subcomponents of the interventions can be classified into several common types or categories: referral process, provision of training and resources to improve medical provider practices, clinical partner referral to health resources, clinical partner volunteers at community program, and other. Some interventions had more than one component; thus, the following categories are not necessarily mutually exclusive.

Referral Process

Referral of patients from clinical practice to community partner: Fourteen interventions involved a system of referral where a clinical practice identified patients who could benefit from assistance to improve their health. The interventions often included programs to help patients quit smoking or improve their diet and exercise. Clinicians were often trained on how to identify at-risk patients, using screening tools, notes in electronic medical records (EMRs), or other note systems, and then provided information on how to refer patients to a particular community program or organization that provided intervention services.

Referral of patients from community partner to clinical practice: Two interventions used a referral process where individuals enrolled in a community health program were referred to clinical partners for medical services. One of these community programs worked with a clinical partner to provide potential program participants with a physical exam and medical clearance prior to enrolling in the program. The second program referred participants with diabetes to clinical partners for ongoing medical care, testing, and treatment.

Six interventions that included a referral from a provider to a community program or from a community program to a provider described a feedback process that included sharing of patient/participant information between the two partners. This information often included enrollment and participation in an intervention as well as participant progress made during, and in some cases after, their participation in the intervention (e.g., weight lost).

Referral of Patients by Clinical Practices to Health Resources

Patient referral to Web site or electronic health resources: Six initiatives involved providers referring patients to electronic health resources or Web sites where they could find a variety of health information on their own. In some cases, the information provided to patients via these Web sites was specific to a particular intervention with which the clinician was involved. In other interventions, the resources included a program partner's Web site and/or more general resources on health and behavior change. In one case, patients were referred to a Web site where they could complete a health history and then would be directed to tailored health promotion resources, information, and programs.

Provision of a community guide describing local health services and resources to clinical practices (in electronic or paper format): Five initiatives included the provision of a community guide that helped patients identify local program resources to assist them with health improvement. Clinicians provided this guide both electronically via the Web and through available hard copies.

Training for Medical Providers by Community Organizations to Improve Medical Provider Practices

Training for medical providers on how to assess patient health status and encourage behavior change: Fifteen initiatives involved an intervention where community partners trained or provided resources to providers to improve their ability to identify issues or behaviors that may affect patient health and to work with patients to address those issues. Health care providers received training on a variety of issues, including

  • referring patients to outside resources, including smoking quitlines, community health and wellness programs, and self-management programs;
  • talking with patients about weight management, diet, exercise, and smoking cessation;
  • using the five As (assess, advise, agree, assist, arrange);
  • motivational interviewing/counseling;
  • patient goal setting and action planning; and
  • patient screening.

Training for medical providers on development and implementation of in-house clinical preventive services: Thirteen initiatives involved clinical practices working with a community partner to offer preventive services within their practice or system. These services often included diabetes self-management classes, hiring of an in-house "health change facilitator"/health educator/health coach, and implementation of a wellness club. Often these programs were combined with other interventions.

Volunteer Work by Clinical Partners at Community Organizations

Two programs described a linkage that involved clinical partners volunteering their time at a community organization/intervention site to provide services to program participants. In both of these interventions, these community partners provided services to medically underserved populations. One example also consisted of medical students implementing a health promotion initiative at a community center. This effort served a dual role of providing medically underserved families with resources and tools to improve their health and wellness and training medical students on how to work with community partners to provide health services.

Other

Other types of program activities include

  • community partners making presentations to schools about diabetes awareness
  • (n = 1);
  • clinical partners making presentations to schools about nutrition, fitness, and well-being (n = 1); and
  • coordinated community-wide change initiative that entailed interventions across multiple community partners and organizations; linkages between community and clinical partners was just one aspect of the community-wide effort to improve the health of an entire community (n = 1).

Can the Described Linkages Be Categorized According to Existing Partnership or Linkages Frameworks?

Each of the 49 linkages was categorized using Himmelman's (2002) model of collaboration. This model organizes collaboration into four levels: networking, coordinating, cooperating, and collaborating. Table 1-1 provides an overview of this framework. Using this framework for collaboration, the linkages were found to fall most commonly within the coordinating category (n = 11), followed by networking (n = 6), cooperating (n = 6), and collaborating (n = 4). Because most of the papers reviewed were not solely focused on describing the linkage, but rather the intervention, it was not possible to characterize the type of collaboration between the clinical and community partners using this framework in almost half (n = 22) of the programs.

2.2.3 Interventions/Innovations

This section describes the results pertaining to the intervention component of the conceptual framework in Figure 1-1. The following questions are addressed:

  • What types of interventions/innovations have been implemented?
  • What are the target populations?
  • Where do interventions take place?
  • How has information technology been incorporated into the interventions?

What Types of Interventions/Innovations Have Been Implemented?

The selection criteria limited this review to interventions that focused on a relatively small number of health behaviors and conditions: nutrition, physical activity, obesity, tobacco avoidance, and tobacco cessation. The majority of interventions addressed a combination of these health behaviors and conditions, rather than just one. Table 2-8 summarizes the health focus of the interventions reviewed.

Table 2-8. Health Behavior and Conditions Addressed by the Linkages
Health Behavior/Condition Frequency (%)
Nutrition, physical activity, and obesity 8 (16%)
Nutrition, physical activity, and tobacco cessation 8 (16%)
Nutrition and physical activity 7 (14%)
Physical activity 6 (12%)
Nutrition, physical activity, tobacco avoidance, and tobacco cessation 4 (8%)
Obesity 2 (4%)
Tobacco cessation 3 (6%)
Nutrition 2 (4%)
Other 9 (18%)

What Are the Target Populations?

The interventions reviewed targeted a wide range of ages. A majority of the linkages sought to impact the behaviors and services provided to adults over the age of 18 (59%) or served all ages (8%), and a small number served people under the age of 18 (10%) (Table 2-9).

Table 2-9. Age Groups Served
Age Groups Served Frequency (%)
All ages 4 (8%)
Youth (<18 years of age) 5 (10%)
Adults (>18 years of age) 29 (59%)
Missing/not explicitly stated 11 (22%)

Less commonly, interventions focused on meeting the needs of specific racial and/or ethnic groups. These groups include African Americans (five interventions), American Indians (three interventions), Hispanics/Latinos (two interventions) and Asians (one intervention).

Where Do Interventions Take Place?

Services were often administered in a wide variety of community settings, including clinics, primary care offices, schools, worksites, and a variety of other community organization offices/facilities (Table 2-10).

Table 2-10. Intervention Setting
Intervention Setting Frequency (%)
Clinical care office (clinic, primary care office, hospital) 16 (33%)
Community organization office/facility or meeting place in the community 19 (39%)
School 3 (6%)
Worksite 1 (2%)
Not stated 18 (34%)

How Has Information Technology Been Incorporated into the Interventions?

Use of information technology for the administration of these efforts was examined in the reports of all 49 interventions. In 15 of 49 interventions (31%), some form of information technology was used in the administration of their interventions, including e-mail, phone, Internet/Web, EMRs, and handheld devices.

2.2.4 Outcomes

This section presents results pertaining to the evaluation of the interventions, what the interventions accomplished, and how this was measured. The following questions are addressed:

  • What outcomes are being measured?
  • What data sources are used?
  • What did the linkages accomplish?
  • What were key facilitators and barriers?
  • Are these linkages sustained?

What Outcomes Are Being Measured?

A wide variety of outcomes were measured across the interventions examined. Evaluation focused on a mix of process, impact, and outcome indicators, as presented in Table 2-11. Organizational outcomes were examined by a very small number of programs and were not clearly defined. For that reason, they are not included in the table.

What Data Sources Are Used?

Evaluation methods and findings were described by 18 of 49 linkages. However, 19 of the interventions without a description of their evaluation efforts were a part of larger national initiatives, namely Prescription for Health and Building Community Support. So while evaluation of specific efforts may not have been described in the articles reviewed, evaluations of both individual programs and the overall coordinated efforts were likely conducted. For articles that did describe evaluation efforts, a wide variety of evaluation methods, indicators, and outcomes were described. Data collection tools and methods were not as well described as the outcomes being measured.

The evaluation methods used varied significantly from relatively simple process evaluations of program implementation to more complex measurement of program impacts and outcomes. Impact and outcome evaluation strategies included self-report data from program participants and pre-post intervention studies. A small number of interventions included more complex evaluation studies that included randomized control group comparisons. Several evaluations included some form of post-intervention follow-up, which varied from immediately following the intervention through 1 to 2 years post-intervention.

Primary data collection methods include

  • surveys of participants via written survey instrument or via e-mail,
  • interviews with participants conducted in person or over the phone, and
  • review of EMRs or patient medical charts.

Evaluation appears to have been conducted by some program staff; however, in a large number of interventions, a formal evaluation partner, most commonly a university partner, was responsible for evaluation design and implementation.

Table 2-11. Evaluation Outcomes Measured
Type of Evaluation Outcomes Measured
Process
  • Characteristics related to program implementation
  • Enrollment
  • Referrals
  • Attendance at intervention activities
  • Ongoing engagement beyond program period
  • Participant satisfaction
  • Visits to health care provider
  • Participation in health screenings
  • Program implementation/fidelity to intervention protocol
  • Intervention costs
Impact
  • Individual psychological measures
  • Stage of change, motivation to change, readiness to change
  • Perception of health/physical condition/self-worth
  • Well-being
  • Self-efficacy
  • Attitudes
  • Behavioral outcomes
  • Level/frequency/duration/intensity of physical activity
  • Changes in diet
  • Changes in alcohol/tobacco use
  • Changes in self-management behavior
    Outcome
    • Clinical health outcomes
    • Health-related quality of life
    • Health events
    • Diabetic control
    • Cholesterol levels (LDL, HDL)
    • Blood pressure
    • Blood sugar levels (glycosylated hemoglobin, HbA1c)
    • Body mass index (BMI)
    • Weight loss

    What Did the Linkages Accomplish?

    Eighteen interventions described evaluation outcomes and methodology, and a subset of these reported impact or outcome results that extended beyond general process measures of involvement, enrollment, or attendance. Three interventions that used a comparison group design found significant differences between intervention and control groups in impact or outcome measures. Outcomes reported by the first two studies included significant improvements in perception of physical condition, physical self-worth, and physical health (Taylor & Fox, 2005) and significant improvements in tobacco use abstinence rates among self-reported smokers (Hollis et al., 2005). A third study, the MONICA Project/Norsjo Intervention Programme, which implemented a long-term community-wide intervention that included linkages between community and clinical partners, found significant changes in total cholesterol levels and systolic blood pressure between the intervention and reference population and a 36% reduction in predicted coronary heart disease mortality (using the North Karelia risk equation) after adjustment for age and education, compared with 1% in the comparison community (Weinehall, Hellsten, Boman, & Hallmans, 2001).

    Six studies reported some changes in participant behaviors and characteristics when pre-post intervention comparisons were made. Behavior changes include

    Six studies reported some improvement in clinical health outcomes. Study designs varied across the interventions but consisted primarily of pre-post intervention. One project collected data 6 months post-intervention and one collected data 12 months post-intervention. One study included pre-post intervention comparisons with a matched comparison community (Weinehall et al., 2001). Improvements in the following clinical health outcomes were reported:

    Finally, two interventions that sought to change clinical provider behaviors to improve delivery of clinical preventive services noted improvements in related behaviors by providers, although these changes did not necessarily translate into changes in patient health behaviors. These outcomes include the following:

    • Improvement in clinician referral of patients to community programs for health behavior change and improvements in rates of discussion of diet, exercise, and weight management (Flocke, Gordon, & Pomiecko, 2006): Data were collected by conducting follow-up calls with patients to inquire if their provider had discussed health education topics or provided health education materials. While the evaluation noted increased rates of provider discussions in these key areas, the evaluation also noted that there was no difference in patient motivation to modify behavior 8 weeks after the clinical visit was made, when compared to motivation before seeing the doctor.
    • Improvement in clinician behaviors to measure BMI, provide healthy messages, and follow up with patients (Pomietto et al., 2009): Data were collected primarily by clinical teams that conducted monthly chart audits at participating sites.

    Although a few interventions conducted evaluations and reported evaluation findings, a far greater number either did not conduct evaluations of their interventions or did not describe evaluation findings in the articles and materials reviewed. A key question in this field is whether provision of clinical preventive services through linkages is a more effective approach when compared to service delivery solely through a clinician's office. Unfortunately, none of the evaluations conducted sought to understand or measure whether there is an added benefit to patients or providers when a linkage is in place.

    What Were Key Facilitators and Barriers?

    Facilitators

    Although not well detailed in the publications reviewed, a number of program facilitators were cited that are worth noting.

    Implementation
    • Funding for the development of a program Web site was important; although Web sites are initially expensive to develop, once developed they are a relatively economical tool to maintain and provide information and services to patients (Woolf et al., 2006b).
    • A common EMR system facilitated the ease with which staff across practices used an electronic behavioral counseling system (Krist et al., 2008).
    • Inclusion of community advocates in program planning helped to facilitate linkages and involvement of other key community partners who were influential in program implementation (Plescia & Groblewski, 2004).
    • Utilization of a well-known community liaison was influential in improving community awareness of program efforts and community member participation in program efforts (New York State Community Health Partnership and Milbank Memorial Fund, 1999).
    • Offering incentives such as transportation, childcare, discounted gym memberships, and permission to continue using services after program completion was valuable in encouraging and maintaining participant involvement (across several cases).
    Policy
    • National and local public health policies and recommendations in Spain and England resulted in the development and implementation of successful programs to improve provision of primary care services through linkages with new and existing community health programs (Gine-Garriga et al., 2009; McQuigg et al., 2005).
    • Recommendations by the accrediting organization, The Joint Commission, facilitated commitment by health plans in Massachusetts to collaborate with the Massachusetts Department of Public Health to develop and fund a service to help patients quit smoking (Massachusetts Tobacco Cessation and Prevention Program, 2009).
    Sustainability
    • Selection of program models that are designed to be self-sustaining and can be integrated into other initiatives or organizational structures helped facilitate program sustainability and dissemination beyond original funding (ASTHO, 2007; Pomietto et al., 2009).

    Barriers

    The primary barrier cited by programs examined was lack of sufficient funding for program implementation. This manifested in several ways, including being unable to compensate clinical care providers for their time and effort and creating demand for services that the intervention was unable to meet.

    Are these Linkages Sustained?

    To better understand if the linkages identified through the literature review and case study have been sustained since the publication about their intervention, the RTI team developed a process to follow up on each of the 49 examples identified. This follow-up included a multimethod approach that included search of the Internet and key organization Web sites, e-mails to the primary point of contact for each article, utilization of information gathered during the case study site visits and/or calls (as described in Section 3 of this report), contacts to project officers, and, if needed, phone calls to the primary point of contact for each article.

    From this process, we sought to classify each linkage example as one of the following:

    • Active: The intervention identified through the literature search/environmental scan is currently ongoing as the same intervention.
    • Complete: The intervention identified through the literature search/environmental scan is complete, and there is no evidence that the intervention continues under a different name or through an alternative funding source.
    • Active but altered from original: The intervention as identified through the literature search/environmental scan is complete, but some aspects of the intervention are continuing with one or more of the following changes:
      • funder and/or amount of funding,
      • partnering organizations,
      • components/subcomponents of the intervention being implemented (not implementing the entire program), or
      • target population.
    • Unable to determine: The intervention identified through the literature search/environmental scan cannot be found through any means, and we are unable to determine its status.
    Table 2-12. Sustainability of Linkages by Method of Follow-up
    Sustainability Status Case study case E-mail Web site Phone Prescription for Health Total
    Active 1 9 2 12
    Complete 3 4 4 1 3 15
    Active but altered from original 1 3 4 8
    Unable to determine 2 2 10 14
    Total 5 9 13 5 17 49