Common challenges across projects included:

1. Connecting Strategies Connecting Strategies Pre Pre - - Identifying Community Resources Identifying Community Resources known services and expectations known services and expectations Developing Referral Guides Developing Referral Guides paper or electronic databases paper or electronic databases Engaging External Intermediaries Engaging External Intermediaries single single - - point access to resources point access to resources Opportunity Opportunity Opportunity Opportunity Patient Referral Patient Referral to activate to activate to encourage to encourage Availability of Resource Availability of Resource Capacity for Risk Assessment Capacity for Risk Assessment Affordability of Resource Affordability of Resource Ability for Brief Counseling Ability for Brief Counseling Accessibility of Resource Accessibility of Resource Capacity and Ability to Refer Capacity and Ability to Refer Perceived as Value Added Perceived as Value Added Awareness of Community Resources Awareness of Community Resources Anchor Anchor – – Community Resources Community Resources Anchor Anchor – – Primary Care Primary Care Integrating Linkages Between Primary Care Practices and Community Resources to Promote Healthy Behaviors Deborah J. Cohen, PhD1; Rebecca S. Etz, PhD1; Maribel Cifuentes, RN, BSN2; Larry A. Green, MD2; Linda J. Niebauer2 1University of Medicine and Dentistry of New Jersey, Robert Wood Johnson Medical School, Somerset, NJ, 2University of Colorado Denver, School of Medicine, Denver, CO Context and Problem • The health behavior choices people make are lived out not in a doctor’s office, but in communities. • Primary care practices are key settings for identifying unhealthy behaviors (50% of all U.S. office visits annually). • Prescription for Health’s mission was to identify, test, and evaluate practical tools and strategies to address: • Smoking • Unhealthy Diet • Lack of Physical Activity • Risky Drinking • Integration of health behavior change strategies into existing systems of care is problematic. • Key challenges: • fragmented nature of U.S. healthcare system • lack of connectivity between practices and services in the community that are needed to enable behavior change • lack of adequate reimbursement • lack of appropriate training for practice teams • lack of resources necessary to build new care processes and capacities • Need to reach beyond practice walls to establish integrated linkages with existing informational and community resources. Strategies for Change Eight Prescription for Health projects tested various tools and strategies to identify, counsel, and provide referrals to a diverse population of at-risk patients. Analysis of Change Strategies • Mixed methods evaluation of the Prescription for Health initiative conducted by independent team • Data analyzed included grant applications, site visit field notes and reports, key informant interviews, and diary data • Online diaries kept by each project via bi-weekly entries made over two-year period • Diary data used to understand projects’ implementation experience • Data entered into ATLAs.ti TM database • Codes and emergent themes identified through series of immersion/crystallization cycles • Emergent theme of “linking” and a general model for linking unfolded • Model for linking included practice and community resource characteristics that influenced ability to initiate, facilitate or prevent connections Effects of Changes The projects built a bridge between practices and community resources by using one or more of the following:1) Pre-identified resource options, 2) Referral guides, 3) External intermediaries. The bridge is anchored on one end by practice characteristics and the other end by community resource characteristics. Lessons Learned and Key Messages Common challenges across projects included: 1) need to monitor change in community resources and update contacts 2) re-training and buy-in related to staff turn-over 3) general practice interruptions resulting from new or modified EHRs Primary care practices and community resources are committed to promoting healthy behaviors but struggle with broken, fragile, and often completely lacking infrastructure to link their efforts. The projects’ experience appear to support sociologist Ronald Burt’s hypothesis that “people who stand near holes in the social structure are at higher risk for having good ideas.” A paradigm shift is necessary. Practices should think of their patients as populations and public health officials should think of practices as key partners in reaching the populations they serve. Brokers and boundary spanners can play an important role in fostering integrated, systematic solutions for practices and communities. Prescription for Health is a national program of the Robert Wood Johnson Foundation in collaboration with the Agency for Healthcare Research and Quality Visit us athttp://www.prescriptionforhealth.org