Clinical-Community Relationships as a Pathway To Improve Health: Tools for Research and Evaluation

Clinical-Community Relationships as a Pathway To Improve Health: Tools for Research and Evaluation

Event Date: 
Wednesday, August 7, 2013

On August 7, 2013, AHRQ hosted a special Web event that provided an overview of recent efforts focused on the area of clinical−community relationships, including an in-depth look at two new tools designed to support research and evaluation in the field: the Clinical−Community Relationship Measures (CCRM) Atlas and the Clinical−Community Relationships Evaluation Roadmap.



Janice Genevro, PhD, Lead, Primary Care Implementation Team, Center for Primary Care, Prevention, and Clinical Partnerships, Agency for Healthcare Research and Quality (AHRQ)

Dr. Genevro is a psychologist who specializes in the translation of health services research into effective practice. She earned a doctoral degree in Health Psychology from the University of California, San Francisco. As a post-doctoral fellow at the National Institute of Child Health and Human Development, she conducted research at the intersection of child development and health. Dr. Genevro also has served as a faculty member and staff researcher at the Johns Hopkins Bloomberg School of Public Health, working with other faculty and staff to evaluate programs designed to improve primary care pediatrics through the integration of child development services into routine care. As a social worker, she led the social services component of a comprehensive program designed to improve perinatal outcomes in families at increased risk, a community-clinical partnership that was administered through a consortium of a medical school, academic medical center, and 13 community health centers. Dr. Genevro is a past member of the Institutional Review Board of the National Human Genome Research Institute, National Institutes of Health.


Rebecca Etz, PhD, Assistant Professor of Family Medicine, Virginia Commonwealth University, and Co-Director, Ambulatory Care Outcomes Research Network

Rebecca Etz, PhD, is an Assistant Professor in the Department of Family Medicine, Virginia Commonwealth University (VCU) and recognized as a Presidential Faculty Excellence recipient. Dr. Etz is a cultural anthropologist with expertise in qualitative research methods and design. Her research focuses on mental and behavioral health in primary care settings, practice re-design, and the promotion of improved, patient-centered care through innovative uses of health information technologies. Before joining VCU, Dr. Etz worked in the Department of Family Medicine and Community Health at Robert Wood Johnson Medical School in New Jersey, first as a National Research Service Award Fellow and then as an Assistant Professor. Her previous research activities include studies in behavioral health, care coordination, preventive care delivery, cancer screening, organizational change and adaptive use of health information technologies. Dr. Etz collaborates with The Robert Graham Center for Policy Studies in Family Medicine and Primary Care, the American Board of Family Medicine and several universities.

Robert M. Pestronk, MPH, Executive Director, National Association of County and City Health Officials (NACCHO)

As Executive Director for the National Association of County and City Health Officials (NACCHO), Robert M. (Bobby) Pestronk represents our nation’s local health departments and their staff who protect and promote health, prevent disease, and seek to establish the social foundations for wellness in nearly every community across the United States. Prior to his position at NACCHO, he served as Health Officer in Genesee County, Michigan for 22 years. Mr. Pestronk is a member of the Board of Directors for the Ruth Mott Foundation. He is a past Board member of NARSAD, the Mental Health Research Association, the Michigan Health Officers Association, and of the Michigan Association for Local Public Health. He is a Primary Care Policy Fellow through the United States Department of Health and Human Services and trained as a Scholar through the Public Health Leadership Institute. He is Past President of the Primary Care Fellowship Society, the Public Health Leadership Society Council, and the Michigan Health Officers Association.

Additional Information

Panel Slides
Download PowerPoint Presentation Slides (PPT, 3.73 MB). (PowerPoint Viewer )
Slide 1

Clinical-Community Relationships as a Pathway to Improve Health: Tools for Research and Evaluation
August 7, 20131:00-2:00 PM ET

Slide 2

Janice Genevro, PhD, MSW
AHRQ Prevention and Chronic Care Program

Slide 3

AHRQ and Clinical-Community 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?

Slide 4

AHRQ and Clinical-Community 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.

Slide 5

Learning Objectives

  • Understand the concept of clinical-community relationships and the rationale and need for further investigation of measures
  • Learn about the processes used to develop the Clinical-Community Relationships Measures Atlas and Roadmap
  • Hear about the application of these products to research, evaluation, and public health practice

Slide 6

Using the Webcast Console and Submitting Questions
Screen shot of the web-event providing direction of how to submit questions by utilizing the Q&A widget at the bottom of the screen.

Slide 7

Accessing Presentations
Screen shot of the web-event providing direction of how to download slides by utilizing the download slides widget at the bottom of the screen.

Slide 8

Rebecca Etz, PhD
Virginia Commonwealth University
Robert M. Pestronk, MPH
National Association of County and City Health Officials (NACCHO)

Slide 9

Clinical-Community Relationship Measures (CCRM)
Rebecca Etz, PhD
Virginia Commonwealth University
Department of Family Medicine and Population Health

Slide 10

The 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

Slide 11

The 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

Slide 12

The 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

Slide 13

Conceptual 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 rely

1Himmelman 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.
3Etz 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.

Slide 14

Conceptual Framework
Image of Etz bridge in which the two anchors are primary care and community resources. Between the anchors are connecting strategies including commucincation and patient referrals.
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,

Slide 15

Conceptual Framework
Graphic of the Clinical-Community Relationships Measures Conceptual Framework. A venn-diagram of three circles connecting - patients, clinics/clinicians, and community resources. There is a bridge entitled “measures” connecting the clinic/clinicians and community resources circle. There is also a “phantom” bridge connecting all of the circles.

  • Elements: patients, clinics/clinicians, and community resources
  • Domains: structure, process, outcomes
  • Relationships among them

Slide 16

Conceptual Framework
A graphical depiction of the conceptual framework table in the CCRM Atlas. There are 33 domains on the listed vertically, 3 elements & 3 relationships listed horizontally, and 56 relevant categories.

Slide 17

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

Slide 18

Clinical-Community Relationships Measures Atlas
An image of the Clinical-Community Relationships Measures Atlas Cover.

  • Published March 2013
  • Includes 22 measures
  • Measurement framework and rationale
  • Aligns measures to framework
  • 10 of 56 categories include at least one measure

Slide 19

Clinical-Community Relationships Measures Atlas
An image of the Clinical-Community Relationships Measures Atlas Measure description - Measure 6: Clinical Confidence in ability to instruck patient/family in proper use of local agency referral (Safety Check Practitioner Post-Visit Survey)

Slide 20

Existing Measures
Graphic of the CCRM Atlas Measures Table, with a circle of the clinic-patient relationship measures.

Slide 21

Existing Measures
Graphic of the CCRM Atlas Measures Table, with a circle of the referral process domain measures.

Slide 22

Existing Measures
Graphic of the CCRM Atlas Measures Table, with a circles over clinician experience, knowledge of resource, and proactive and ready clinician domains.

Slide 23

Existing Measures
Graphic of the CCRM Atlas Measures Table, with a circles within the community resource element measures and patient-community resource measures.

Slide 24

Clinical-Community Relationships Evaluation Roadmap
Image of the Clinical-Community Relationships Evaluation Roadmap cover

  • Focus on clinical interactions and integrating services
  • Capture the context of care delivery
  • Inform research development and design

Slide 25

Clinical-Community Relationships Evaluation Roadmap
Priority Areas of Study

  1. Influence of element characteristics
  2. Influence of relationships between the elements
  3. Relative importance of elements and relationships in context
  4. Best methods, strategies, and settings for studying and improving clinical-community relationships
  5. Best measures for evaluating effectiveness of clinical-community relationships

Slide 26

Clinical-Community Relationships Evaluation Roadmap
Seven Recommendations

  1. Use complex systems approaches
  2. Accommodate/tailor for variability in design
  3. Develop standard measures
  4. Conduct rigorous, mixed methods approaches
  5. Report findings more thoroughly in useful formats
  6. Assess feasibility and sustainability of interventions for clinics, patients, and clinical-community relationships
  7. Consider conceptual framework as a starting point

Slide 27

Clinical-Community Relationship Measures (CCRM)
Robert M. (Bobby) Pestronk, MPH
National Association of County and
City Health Officials (NACCHO)

Slide 28

Clinical-Community Relationships and NACCHO
A NACCHO logo for Public Health - Prevent.Promote.Protect

  • 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

Slide 29

Contributions of the CCRM Project to the Public Health Community
A graphic of various local health departments and community services intertwined in a network.

  • 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

Slide 30

Public Health Implications of the Evaluation Roadmap
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

Slide 31

Public Health Implications of the Evaluation Roadmap
An image of various individuals' hands coming together.
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

Slide 32

Key Research Concerns for Public Health
An image of a valley and river.

  • 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?

Slide 33

Key Research Concerns for Public Health
An image of a valley and river.

  • 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?

Slide 34

Graphic of web-event widgets and instructions of where to ask questions.

Slide 35

For More Information
Screenshot of the Agency for healthcare Research and Quality Prevention and Chronic Care web page.

Slide 36

For More Information
A screenshot of the Agency for Healthcare Research and Qualilty Health Care Innovations Exchange's web page - Building Relationships Between Clinical Practices and the Community to Improve Care

Slide 37


This project was funded under contract # HHSA290-2010-000021 from the Agency for Healthcare Research and Quality (AHRQ), U.S. Department of Health and Human Services. The opinions expressed in this presentation are those of the presenters and do not reflect the official position of AHRQ or the U.S. Department of Health and Human Services.
For more information about AHRQ's work in this area, visit
or contact:
Janice Genevro, PhD


Note: The opinions expressed in this presentation are those of the presenters and do not reflect the official position of AHRQ or the U.S. Department of Health and Human Services.

Janice Genevro: Greetings everyone. Welcome to AHRQ's web event on Clinical-Community Relationships as a Pathway to Improve Health. We are so pleased to have you with us today. I am Janice Genevro from the Agency for Healthcare Research and Quality and I'll be moderating the webinar today. I would like to begin by describing the flow of the webinar.

First, I will provide some background information on AHRQ's interest in this area. Next, I will offer a few tips regarding webinar logistics. Then I will turn the presentation over to our two speakers and open the floor after they speak for questions. Last but not least, we hope that you will complete the webinar evaluation form that we will be available at the end of the presentation.

Our Prevention and Chronic Care Program has invested in a multiyear, multiphase initiative to explore what's known about Clinical-Community Relationships and their role in improving care and improving health. Our focus of this work has been our interest in understanding what is needed from the perspectives of method, data and process to build an evidence base regarding the effectiveness and efficiency of Clinical-Community Relationships in delivering appropriate clinical preventive services. The current phase of this work, which we will describe today, was led by a project team that included investigators from Westat, Oregon Health & Science University and the Oregon Rural Practice-based Research Network, and also by an expert panel that will be described in detail later in the presentation.

Clinical-Community Relationships hold the promise of improving care and improving health outcomes. AHRQ operationally defines Clinical-Community Relationships as forming partnerships and relationships among clinical, community, and public health organizations to fill gaps in needed services, coordinating healthcare delivery, public health and community-based activities to promote healthy behavior and promoting patient, family, and community involvement in preventive healthcare.

As I mentioned earlier, the current project is part of a larger initiative and our specific focus on the measurement of Clinical-Community Relationships throughout a several stakeholder events, which AHRQ convened to inform the Clinical-Community Relationship research agenda. Participants in this summit held in 20 towns identified strategies that they, as a group, believed to be high priority and actionable. The top priority strategies identified by the stakeholders were to develop metrics related to linkages between clinical practices and community organizations, to identify how linkages contributes to better outcome and to promote research competencies within community-based programs to understand the outcomes of primary care and community linkages.

And now I would like to introduce the specific purposes and processes of today's webinar. As a result of your participation today, it's our intent that you will understand the concept of Clinical-Community Relationships and the rationale and need for further investigation of measures; learn about the processes used to develop the Clinical-Community Relationship Measures Atlas and Roadmap; and hear about the application of these products to research, evaluation and public health practice.

Now, just a few quick points regarding the webinar console. The console can be resized to fit your entire browser window. We are pleased to offer closed captioning on this web seminar. To access the closed captioning, please click on the link called “Closed Captioning” that is on the lower right hand of your screen view. After you click the link, a new window will display the captioning. I would also like to remind you that if you experience any technical problems, you can click on the question mark button at the bottom of the screen to access the help guide or click on the Q&A button at the bottom of the screen to contact us with your questions. Our technical staff will work with you to resolve any issues.

The last 15 minutes of this web event are reserved for discussion based on questions that you submit. Questions may be submitted at any time during the presentation if you click on the Q&A button at the bottom of your screen, then type your question into the box and select Submit. We welcome your questions and comments on the upcoming presentations.

You also have the option to download slides from this console by selecting the download slides button for the PDF version of this presentation.
We are very fortunate today to have as our speakers two members of the expert panel that guided work on this project. Our first speaker will be Dr. Rebecca Etz, who is an Assistant Professor in the Department of Family Medicine at Virginia Commonwealth University and recognized as a Presidential Faculty Excellence recipient. Dr. Etz is a cultural anthropologist with expertise in qualitative research methods and designs. Her research focuses on mental and behavior health in primary care settings, practice redesign and the promotion of improved patient centered care through innovative uses of health information technology.

Our second speaker is Robert, or Bobby, Pestronk. As Executive Director for the National Association of County and City Health Officials or NACCHO, Mr. Pestronk represents our nation's local health departments and their staffs who protect and promote health, prevent disease, and seek to establish the social foundations for wellness in nearly every community across the United States. Prior to his position at NACCHO, he served as Health Officer in Genesee County, Michigan for 22 years. Mr. Pestronk is a member of the Board of Directors for the Ruth Mott Foundation.

Rebecca and Bobby both made very significant contributions to the project as members of the expert panel and I am delighted that they are with us today to describe this work from their perspectives as a researchers and public health practitioners. So Rebecca over to you.

Rebecca Etz: Thanks, Jan. It's important to know I think from the outset that we really wanted to develop a tool that would help researchers interested in Clinical-Community partnerships. We wanted something that would encourage such partnership, something that would help to develop, strengthen and sustain them. So we firmly believed that strong partnerships between the clinical offices and community resources would allow for an enhanced ability among primary care practices to provide care for their patients and to promote the healthier behaviors we know lead to better quality of life and reduce disease burden.

I think it's clear that primary care cannot do it alone. A great deal has been published about the number of hours in a day and per visit required to deliver all preventive services as recommended. So partnering with community resources in meaningful relationships is one way to allow practices to virtually expand their hours and to extend their reach beyond the clinic walls that may limit the services and intensity of care delivery we know can be optimal.

The first four bullets under purpose are ones that I know the full group would agree with. The fifth bullet is part of what motivated me to become involved in this project. There are persistent obstacles to the delivery of care that frustrate many of us, and I think most of us would agree that fragmentation is the biggest offender. Relationships among those involved in care delivery create a natural bridge to mend that fragmentation. Centering on the connection between clinical settings and community resources is one way to build an integrated medical neighborhood able to fulfill the social contract of primary healthcare. In other words, care that takes full advantage of a delivery system that rests in the context of where people live, work, and play.

So, I have organized today's presentation or at least my part it around the things that we did in order to complete this project. From the lit review, to the conceptual framework, and to the involvement of the expert panel, I plan to walk you through how we developed the atlas, the work on which we are building, as well as that which we need to create. Perhaps most importantly, for the researchers in this webinar, I'll end with priority questions and future directions our team generated as a result.

Guided by AHRQ, Westat, and colleagues from the Oregon Health & Science University, there were parameters to our work that are important to understand. I think it will help everybody to create clear expectations here regarding both what the Atlas is and what it isn't. We all know we've done this work before that it's sometimes hard to accept study constraints. I know I typically try to resist them, but they are often necessary and they are an important part of containing and advancing what it is usually a complex conversation. You will see some of these return when we discuss the priority questions and recommendations further on. The list of assumptions I review here is abbreviated from what you will find in the Atlas posted online.

First, we began with prevention as it originates in primary care and is directed outward, and yes, this is clearly a point of struggle. The conversation around prevention is far more dynamic than that and we both realize it and support the idea of prevention that originates in other areas. This is only one vantage point to the conversation but it is an important one and a critical step for improving primary care delivery. We were struck by the difficulty and the need for organizations, community organizations and area residents to have equal roles as agents in that conversation. But having the limit of going from primary care outward allowed us to ground our discussion, the potential otherwise for it to grow in abstraction and become less useful, as a result, was pretty real.

Second in our list of assumptions, we are in such a movement of growth right now in research and care delivery that some of our most basic terms are used in incredibly expansive ways. It can make them unwieldy and so we found a real need to define some of our most basic terms. Perhaps most important for this webinar are the definitions of community resource and clinician; community resources as places that do not provide clinical preventive services. Here we were really trying to limit our scope in useful ways that would allow us to purposefully exclude specialty care and lab settings from our discussion of community resources. Second, it's important to note that we talk about clinicians and not providers or physicians. Clinicians here really we intend to include such categories as nurse practitioners and other clinicians that you might commonly find in a primary care practice.

Third, it was important that the services identified could be feasibly delivered in non-clinical settings. This was another place in which we struggled. It limited our ability to develop an atlas of measures that embrace the importance of contacts and the really great prevention work that focuses on the impact of the social determinants of health. I think that poll is probably a natural outcome of the movement when primary care and public health are becoming more and more integrated, and we are looking for a new language that will facilitate that process. Since we are not there yet, we took our guidance here from the US Preventive Services Task Force and limited ourselves to the non-clinical preventive services that received A and B level recommendation. These included counseling relative to alcohol misuse, tobacco use, breastfeeding, healthy diets, obesity and obesity screening, and counseling related to sexually transmitted infection.

In the end, I think that this is okay. If we believe in the concept of whole-a-archies, in which each system with which we work is both complete in itself and nested in a larger system then it's meaningful to focus our efforts on one system in isolation. So long as we are cognizant of the impact and interaction that it has with those larger or neighboring system, we really see this atlas as a first step on which others will be built. Naturally, they will be able to encapsulate and expand on this foundation that we are establishing.

The fourth assumption within our framework relates to patient outcomes. By grounding our inquiry within the clinical-community relationships that improve care delivery and are responsive to patient needs, specific attention to patient outcomes are excluded from our framework. If you look at the atlas, you will see a fuller set and description of the assumptions we identify but I believe these are likely the most important for understanding our work while listening and watching this webinar. That atlas represents new formulations and new ground but it's also necessarily grounded and inspired by work that's been done before. Our team started our work with a targeted lit review that went 10 years deep and covered four databases based on a diverse set of search terms. What came out of that process was a large set of relevant articles and a critical subset that became the foundation of both our conceptual framework and the measures that we later identified.

For the framework, we were informed by the work of three people in particular. We thought about Arthur Himmelman's model for understanding the ways in which people work together. It was clear to our team that the fourth level he described, that in which people share information, alter their activities as a result of what they learn, share their resources and become invested in an enhancing the capacity of each other with the way we wanted to go. That was the core of clinical-community relationships, sharing information, altering activities, sharing resources and being invested in enhancing the capacity of each other. It's not likely a surprise that Donabedian's model is one on which we would rely as it seems to be a mainstay but I think it's important that we be explicit about how we applied his model. For us the structure in his model and question was the concept of care delivery, process for us was the action of providing preventive services and the outcome of interest was the engagement of clinical and community partners.

From the bridging model we were drawing on two things. First, that certain characteristics need to exist within community resources and within primary care settings in order to enable successful partnerships, and second, that we orient our vision to allow for documenting and assessing the strategies used for creating successful dynamic connection. What you see here on your screen is the bridging model and I realize that this may be hard to read for some of those attending this webinar. It's listed right out of the American Journal of Preventive Medicine, if you are interested the citation's there on the screen. While creating this model, one of our biggest drawbacks was a lack of access to information about patients. The data informing this model were generated from the evaluation of Prescription for Health, a national study involving over 300 primary care practices. As the evaluation team on which I serve, we only had access to information as reported by participants. Call it the missing link, but a bridge without traffic or patients really does fall apart. So this project adds the much needed detail of the patient element, looking at the overlap of patients, clinical settings and community settings.

Through the Atlas, we created a model that includes patients and therefore allow us to develop measures that best enable our understanding of the dynamic relationships that inform delivery of non-clinical preventive services. Our model as illustrated is based on three elements, intersecting domains among those elements and the dynamic relationships in the middle that keep this bridge a living connection. For our purposes, the domains are organized around Donabedian's model while the elements represent an enhancement of the anchors found in the bridging model.

Were you to visit the Atlas, you would find a metrics using the same terms and looking something like this. You see the demands expanded along the y-axis on the left, while the elements and relationships appear on the x-axis on the top. Making Donabedian's model functional within our framework yielded 33 domains. You will notice when you see them that they are informed by two models, particularly the socio-ecological model, or how an individual is situated within a system, and the expanded chronic care model, in which functional areas that enhance team-based care delivery are highlighted. Though these metrics could yield a possible 186 measures, we determined only 56 categories made sense.

As part of the literature review I mentioned, we were able to identify 22 validated instruments previously published and have included them in the Atlas. But more on that in a moment, as this is the point at which the expert panel became a critical element to our collaborative project. You can see the expert panel listed here. It was comprised of a fairly diverse group of people, all of whom, I am glad to say, had a great sense of humor while they did their work. They held in common, a real boots on the ground kind of experience and exposure to a wide range of primary healthcare delivery systems. Their multidisciplinary conversation wasn't always easy, but it was purposeful and managed to add greater coherence to what we found in a fairly disparate literature. This was a nice moment of luxury in which we were able to stand back and reflect on a body of literature as a whole, and that's time we really don't often get to spend.

I am really glad that this can advantage other people. The result of our work was published by AHRQ this past March and can now be found online. It includes all the things I have discussed so far, the logic of our framework, the measures we were able to find and how those align with the framework rationale.

When a measure is available for a particular category you will find a hyperlink in the Atlas that connects to an information page about that measure. What you see here is one such information page. It includes important background information about the measures, so that you can easily assess if it will fit the needs of your work or project. And if it does, there is a hyperlink available that connects you directly to the validated instrument with permission of the author. I really think that this is one of the coolest features we created in the Atlas.

Now what I have here is a modified version of the matrix that you see in the Atlas. On the left, I list the 10 domains for which we were able to find existing measures. In the body of the matrix, the yellow boxes show under which element or relationship that measure exists, along with the number to indicate how many measures we found. Notice the heavy focus here on clinical-patient relationship, on the referral process and on the knowledge base of the clinician, the relative lack of information regarding patient and community resources. None of these concentrations or gap should be surprising, given the focus of past research and funding opportunities available to primary care. Fortunately, that picture is beginning to shift.

Now for those of you out here who are doing the math with 56 possible categories to fill and only 10 existing measures, the next step for our team was to begin the process of filling in the remaining categories with candidate measures. The Evaluation Roadmap is now posted as of July and can be available on AHRQ's website as well. It is our intention that both of these products, the Atlas of Clinical-Community Relationship Measures and the Evaluation Roadmap, help researchers within primary care, among community organizations and among those involved in stakeholder engagement work to advance their work in ways that begin to heal the fragmentation that plagues our system. The framework of the Atlas is particularly instructive in the ways it orients research design and potential points of data collections such that the impact and value of clinical-community relationships is both tangible and measurable.

As I mentioned in the beginning, our work on the second deliverable of this project, the Evaluation Roadmap, concluded with the identification of five priority questions. You have them on your screen, but I think it's worth reading through them. How did the characteristics of each of the elements in our framework–primary care, clinicians and clinics, patients and community resources–influence the effectiveness of linkages for the delivery of non-clinical preventive services? Likewise, how do the characteristics of the relationships among those framework elements influence the effectiveness of those same linkages? How does the relative importance influence both elements and relationship as described in our framework vary based on different circumstances in different contexts or in differing delivery systems? What are the best methods, strategies, and setting to conduct and improve these relationships? And what are the best measures for evaluating the effectiveness of those relationships in particular?

Also, from the Evaluation Roadmap are seven recommendations for future research. Highlighted here is the complexity of the dynamic we hope to inform, the necessity for flexible research designs and really the need to develop standardized measures in this area and to disseminate our findings in new ways. I would like to reiterate that this is a – this framework is intended as a starting point to facilitate new kinds of conversations and we hope that it will foster such work.

I really thank you for your time today and would like to now turn this presentation over to Bobby Pestronk.

Robert Pestronk: Thanks, Rebecca and Jan. As the Executive Director of NACCHO, I was pleased to be a member of the expert panel, because NACCHO's long range vision is health, equity and security for all people and their communities, and our mission is to be a leader, partner, catalyst, and voice for local health departments. Thought leaders in the public health domain, that is those who are thinking about ways to create an improved health system making use of the assets, tools, and resources within communities, have spoken of the need to better integrate the practice with primary care with the work of local health departments. So the Atlas and Roadmap are important to the National Association of County and City Health Officials for a number of reasons. Among them, they give us tools to share with our members. These tools can help us and our members conceptualize an evolving public health and clinical care system, recognizing ways in which community practitioners, like local health departments, clinical practitioners, community organizations, and researchers, can understand the progress of that evolution and also formulate, characterize, and document their roles as that evolution proceeds.

The Atlas and Roadmap will help advance an understanding of these important yet evolving relationships, which are now hypothesized to make health easier. We know well the importance of relationships as a channel to stimulate change and to maintain the status quo. We also know that relationships form, sustain, fail to develop or perish, and we need to know more about why this is. The Roadmap and Atlas are designed to promote conversation. Conversation builds relationships, and these will help NACCHO work with other national associations, those representing clinicians, clinical care, and community organizations, and with our own members, as they work in their communities, to better understand and lower barriers that impede more effective communication and relationships.

The Roadmap and Atlas also provide a framework for researchers and practitioners together, which can help form and test hypotheses about the effective relationships among public health departments, other community organizations and primary care practitioners. Because the Atlas and Roadmap are sourced by AHRQ, I hope they will encourage in increasing recognition within the clinical and research domains of the importance of the work, position, and roles of community organizations like local health departments in the successful universal delivery of clinical preventive services.

And the Atlas and the Roadmap are now present as well to guide the formation of research agendas by young public health and clinical services and systems researchers. Health can and should be easier. If international data are a benchmark, health can be less expensive too, or greater value can be returned from current expenditure and effort. Tighter integration between community and clinical practice can help focus efforts to make health easier. The Atlas and Roadmap are specifically concerned with the successful delivery of clinical preventive services. Successful and universal delivery of these services is consistent with the goals of public health practice to prevent disease, promote health, and keep people safe.

Clinical preventive services are delivered now within a community setting, yet our nation's communities are adverse in demographic, economic, social and political form. Each community is complex with respect to the constellation of assets available to deliver clinical preventive services. It's easy to picture the vast differences and assets between the most rural areas of our nation and the most urban. The Atlas and Roadmap ask us to understand this diversity, this complexity and variation. Community as referenced in the Atlas and Roadmap is a general term standing for numerous types of individuals as well as public, non-profit, and private sector organizations, as the figure on the right illustrates. Many of these organizations and individuals can influence decision making about and delivery of clinical preventive services. Primary care practice too, a major clinical locus for delivery of clinical preventive services, is also complex and access differently from community-to-community through, for example, community health centers, independent practices, and organized groups of physicians operating collectively or under the aegis of a larger health hospital or insurer organization. Shared metrics from the Atlas may help us understand how relationships vary by form of practice.

Local health departments themselves have a jurisdictional presence within every community nationwide. They have a legal responsibility to keep people safe and make health easier, to the general roles of assessment, policy development, and assurance. Their foundation rests on the use of science and politics to understand the cause of disease and the poor quality of life and with that understanding to take the steps necessary to prevent disease and improve quality of life.

The Atlas and Roadmap provide one framework for understanding these roles, providing an initial conceptual framework for documenting the relationships between clinicians and communities and for measuring the relationships and characteristics of those relationships. As the Affordable Care Act introduces experiments designed to reduce cost, improve the quality of care, and increase access to care nationwide, it is at the same time through the clinical lens giving attention and credence to prevention. It's placing financial incentives to operationalize the idea that health should be profitable and illness in many cases is preventable. The result of our individual decision making is influenced by the setting in which those decisions are prejudiced and made, and as a consequence, result in a large burden of unnecessary cost to us as individuals, to the places we live, work, play and pray, and to government, whether local, state, or national. It recognizes in its own way the social conditions which make health difficult and seeks to remedy that situation.

Over the last five years, as the recession eroded approximately a quarter of the jobs in state and local governmental health departments nationwide, local health departments and other community organizations have had to reconsider the allocation and use of their scarce resources. Some local health departments have maintained, some are looking to expand and even some have expanded their delivery of clinical and clinical preventive services. Others have increasingly divested themselves of these services, recognizing the capacity and responsibility for other practitioners to provide them. The use and the subsequent evolution of the Atlas and Roadmap over time can help us understand this evolution of practice nationwide and community-by-community.

The Roadmap offers guidance for how the tools of science can generate information needed for a better public health and clinical practice. It provides a context that may be essential to understand how to increase the likelihood that clinical preventive services will be delivered successfully to all who should receive them. The Roadmap reinforces the idea that clinical preventive services can be delivered and reciprocally referred among the formal clinical and community settings, that service providers outside the clinical setting can both influence the use of clinical preventive services through information and referral and by the direct delivery of those services. The Roadmap recognizes that clinicians and clinical practice are embedded in a larger system of rules, regulations, organizations, and partnerships. The Roadmap and Atlas offer guidance on and ways to measure the nature of collaboration, suggests the use of metrics to incentivize movement towards recognition and use of partnerships and of the need to establish relationships, so that clinical preventive services can be more universally accessed and delivered. Its use by clinicians can help orient them to life outside the office, which influences the health of their patients and the likelihood of compliance with advice and recommendations in profound ways.

The Roadmap recognizes the important meeting place among three very different practice cultures–that of public health, primary care, and research–and encourages greater shared practice and learning among them. One can see in it, the place where ideas of population, health and clinical care overlap, a through the looking glass approach where more successful delivery and receipt of clinical preventive services on a person-to-person basis contributes to improving population health by informing and augmenting through relationship building, shared information, assessment and community improvement processes work to change the social determinants of health, which themselves influence population health by making decisions about health and the receipt of clinical preventive services either more or less likely, easier or more difficult, by design and therefore default.

The more people who gain access to clinical preventive services, particularly but not exclusively those associated with primary prevention, the greater the likelihood of preventing bad health and its associated costs from happening, or of identifying bad outcomes in their early stages. The more illness identified early, the less need for complex and expensive care later on. The Roadmap suggests a means to improve quality that is to improve the likelihood of clinical preventive services being offered by encouraging effective relationships across domains. They reinforce the idea that organizations and personnel in the public health and clinical domains should play together better than they do now with salubrious results.

For sure, learning how to make the delivery and receipt of clinical preventive services more prevalent from various perspectives, clinical, personnel, and organizational practice within a larger policy, community, state or federal context is important. So too is determining what financial resources are necessary to establish and sustain clinical-community relationships, especially from my perspective those involving local health departments.

Discovering and applying the best deep qualitative methods and formal quantitative designs to understand clinical-community relationships will continue to be important. Through translational research, distributing and making more prevalent the culture of best practices will also be critical. We will have to bring together practice-based research networks in clinical care and public health and help them play well together using community-based research principles, which have been so well articulated and with which I have my own successful experience. Like this picture, time and friction will be needed to create beauty and the path will be filled with twists and bends.

Community-clinical relationships nest in a larger network of activity necessary to make lives and health easier and more productive for us as individuals and a nation. Community-clinical relationships at their micro-level can affect the social determinants of health, which have increasingly and regularly been demonstrated to be powerful levers to change life outcomes. This will require more clinicians to use their special status in society and weigh in on those aspects of life that make and keep people sick. Social determinants, such as economic stability, education, civic participation, discrimination, neighborhood culture, housing, public safety, and the built environment generally, predispose, experience, incentives, behavior and health or illness are recognizing the importance of community for the successful delivery of clinical preventive services. Our Roadmap and Atlas raise the visibility and importance of these social determinants within the clinical and public health domains. Social determinants make either equity or inequity possible. The social determinants of health are under our control over the long-term. Inequity, a consequence of both personal decision making and social determinants, makes health less likely, life riskier, and quality of life poorer than it should be for a nation as wealthy as ours. Inequity also inflates medical care costs and it medicalizes social problems unnecessarily.

Successful efforts to form and reap the benefits of community-clinical relationships are one step in the right direction. The Roadmap and Atlas will help us practice difficult tasks and give us the courage to work on even more challenging issues and to use the relationships that form to address difficult issues. As research proceeds, it may become clear that health inequity, our present state of affairs, is of our own making through both intentional design and default. Science and further research are necessary, but will be needed in the service of better outcomes. Through research, intention, and continuous improvement, we can achieve better outcomes. A study of our own nation's history reaffirms this faith.

Thanks, Jan. Let me turn it back to you now.

Janice Genevro: Well, thank you Bobby and thank you also Rebecca. And now as we turn to questions from the participants in the webinar, I would also like to remind folks that the information here is not an official policy statement from the Agency for Healthcare Research and Quality or from the Department of Health and Human Services. So the questions that you hear, the answers that you hear, the statements that are being made, are the opinions of the individuals making those statements. So as our first question that I have for Rebecca and Bobby is do the speakers have any suggestions about how primary care researchers and public health researchers can collaborate on clinical community research question? What's the first step in building a research partnership? And Rebecca, I will toss this one to you first.

Rebecca Etz: Thanks, Jan. It's a good question. It's a hard one to answer. But I think the starting point for any such collaboration has to be the people from the organization and the clinic getting together and listening to what the mission is and what the needs and motivations are for bringing the other person to the table. So you want to find out from the person or organization with whom you want to partner, what it is that they are most invested in and why it is that they have come to you for help? And usually you have a joint interest in improving population health of some kind, but the missions can differ. So if you understand clearly what a person's mission is as well as what their history of trying to address that mission might be, you can start your working together by building on the assets that you both bring to the table rather than starting with problems or things that aren't yet there. And I think building on assets is one of the best ways to start that kind of relationship.

Robert Pestronk: Maybe if I could add to that, I think that that using body parts and technology is important and what I mean by that is to walk over and talk with someone from another culture or from the other side. Use the telephone, if one still uses that, to call up somebody who is from another culture and express interest in their culture and set up a meeting to talk with them, or use the range of electronics that are available.

One of the most interesting experiences I had as a local health official in Genesee County, Michigan was walking out of our clinic one day, and–which was up in the Northern part of Flint–and standing in the parking lot chatting with another one of my staff people and looking across a field and noticing that there was an elementary school across the field. And I asked the staff persons with me whether anyone from the clinic had ever gone over and talked with anybody from the elementary school. There we were providing a range of clinical services, maternal and child health services. It turned out that nobody had ever walked over there to chat with the principal or talk with the community liaison person. I think that story is relevant to the development of increasing interactions between the public health researchers and primary care and clinical researchers. Most of the people who are involved in that work are very interesting people with interesting agendas, interesting stories to tell, interesting collections of assets, as Rebecca has mentioned, and sitting down to simply have a conversation and talk about what we might be doing together, I think is the most important first step. I think you will have a good time. I think you will be challenged and I think you will find the people that you are talking with very interesting.

Janice Genevro: Great. Thanks, Bobby. And here is a question that I think is a follow on to that, which is how can state health departments collaborate with health care systems to support or identify these connections?

Robert Pestronk: This is Bobby. I think that the same response is important here. It's interesting. I think that both state health departments and the clinical organizations both need each other, because of the way the current health care system is evolving. There are both formal, structured meetings that are taking place around a whole range of issues, whether those are policy issues related to the Affordable Care Act and the changes that that's forcing in the systems, or in regulatory areas that the state health department maybe engaged in, and setting up time, reaching out from one direction or another, from one organization to another, simply requires somebody to think that that's important to do and then to reach out and make the call.

Janice Genevro: Great. Thank you. And now a question for each of you. Could you describe one example of a successful community public health-clinical partnership? Rebecca, why don't we turn to you for this? Let's start with you.

Rebecca Etz: Sure. Hi, thanks. Sure. There is a really interesting collaboration that I think is going on in the University of Wisconsin in Milwaukee. The School of Nursing there, which has many nursing centers where they offer primary care, actually opens up their primary care centers within public health offices. So that as people come in for various needs, their motto is they trip over a nurse when they get here. So it's staffed with nurse practitioners and they are able to work with public health because they are located in the same building, really understand each other's needs, and they constantly refer back and forth, which for them is really up and down the hallway.

A result of this connection though is that they have gotten a lot of goodwill and support, not just between each other, but also with the people who live in the area, and one thing that they were able to do as a result of their connection was they actually submitted a grant to the EPA based on concerns that both sides, public health and primary care, were hearing from residents about the really high rates of asthma in their community. And they actually got the grant, they determined that there were toxins in the public housing material that people were living in and they were successful in creating new housing. So it was the really interesting example of the primary care setting being able to extend beyond their walls and work with public health and with patients who were actually, you know, just people interested in their health to advance a community health concern.

Janice Genevro: Great. Thank you. And, Bobby, any example that you think of?

Robert Pestronk: I would actually like to reference work which is beginning and perhaps under way in many communities across the country and that's again stimulated by a particular language in the Affordable Care Act, which is requiring non-profit hospitals to work with the community and the local health departments or public health practitioners in the community, to better define what community benefit status looks like. And it's requiring clinical and public health people to get together to do community health assessment, to determine collectively, what the major issues are – major health issues and public health issues are in a community. And then to follow that with the developments of the community health improvement plan, which will be, if it's done well, I think, a bucket of resources that are contributed not only by the hospital but by other organizations in the community to specifically address what the community and the hospital and public health people in the community think are – is or are the most important issues in that community.

But what a successful clinical-community partnership will look like here then is the development of not only the relationships across these three cultures, because I think that those who will be putting these – doing these assessments and creating these improvement plans will also want researchers to be involved to help document what's going on and to discover what's working well and what's not. But these processes will also engage the larger community in the process of determining priorities and seeing that the public and private and non-profit systems that should and can work more effectively for better health in their community are actually using their assets for that purpose. One can see a very beautiful virtuous cycle beginning as these processes are undertaken and are repeated in communities to build a constituency for better health, to one-by-one remove the barriers for better health in a community, and to build back the trust between people and organizations in a community, which is so essential for longer term better health.

Janice Genevro: Thank you. And we have time for one last question. In this work in the Atlas and also in the Evaluation Roadmap the focus has been on a specific subset of clinical preventive services. And this question asks what types of services perhaps in general or beyond clinical preventive services are best delivered through clinical-community relationships? Bobby, would you like to take that one first?

Robert Pestronk: I don't think that there is a health outcome or a desired health outcome for a community as defined by any community that wouldn't and won't benefit from improved community-clinical partnerships. I think that in addition to the assets and the expertise that the clinical and community organizations and researchers can bring, as I mentioned, the identification of specific services that are important to people in communities can be identified as well. So I think that that the clinical-community relationships around primary care are an entry point for more difficult challenges and for other challenges that are identified by the evolving partnership.

Janice Genevro: Great. Thank you. And, Rebecca, any thoughts on that question?

Rebecca Etz: I think Bobby answered it pretty well actually. The only thing that I would add is that, you know, if we are going to be real, everything is really based on context. So if your interest is in what kinds of services might be best, the one of the first things you want to do is look at the community that you are trying to help and see what services it is that they may need. So each community based on whatever the social determinants are around them, housing needs, accessibility needs, whether there are resources or not, is going to determine what kind of strategy is going to be required to fill those needs. So you can find, if you are in a clinic, you can identify the needs that seem to be most prevalent among the people you see. If you are in an organization, you can identify the same thing. You can find the partner with whom you want to work on these things and together you assess what is it that the community has that might be able to address those.

Janice Genevro: Great. Thank you very much. And I would like to thank all of our participants for your questions, and Bobby and Rebecca, thank you, again, for your presentations and your answers.

As we conclude our web event, I would like to bring a couple of additional items to your attention. For additional information on clinical-community relationships, there is information available to you at the following websites. The first is AHRQ's Prevention and Chronic Care Program, which works to improve the delivery of primary care services in order to meet the needs of the American population for high quality, safe, effective and efficient clinical preventive and chronic disease care. And there are number of resources available on that website related to improving primary care in addition to clinical-community relationships work.

In addition, I would like to draw your attention to AHRQ's Health Care Innovations Exchange. And the Agency for Healthcare Research and Quality created the Innovations Exchange to speed implementation of new and better ways of delivering health care and reducing disparities. The Innovations Exchange has a page entitled Building Relationships Between Clinical Practices and the Community to Improve Care and this page is dedicated to understanding how partnerships among primary care and medical specialty providers, the community and public health organizations are developed, strengthened, and sustained to improve care and meet the needs of patient's families and communities. A link to the archived content from this web event will be located on this page next week. The page also features relevant innovation, perspectives from experts in the field, reports, a practical resource guide for building community relationships, and tools including the CCRM, Atlas, and Evaluation Roadmap, that you heard about today in this webinar.

So finally, I just want to say thank you. We really appreciate your participation. It was great to have you with us and we hope that you will complete the evaluation form that's available now to you – through this page on the web event. So, thanks again. Bye.

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