TODAY’S EVENT MODERATOR

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

2. TODAY’S EVENT MODERATOR Janice Genevro, PhD, MSW AHRQ Prevention and Chronic Care Program

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?

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.

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

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

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

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

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

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

13. Conceptual Framework • Building our framework • Himmelman and relationships1 • 4 levels of linkage, collaboration as our target • Donabedianand 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. 3 Etz R, Cohen D, Woolf S, et al. Bridging primary care practices and communities to promote healthy behaviors. Am J Prev Med. 2008; 35(5S):S390-S397.

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

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

16. Conceptual Framework

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

18. Clinical-Community Relationships Measures Atlas • Published March 2013 • Includes 22 measures • Measurement framework and rationale • Aligns measures to framework • 10 of 56 categories include at least one measure http://www.ahrq.gov/professionals/prevention-chronic-care/resources/clinical-community-relationships-measures-atlas/index.html

19. Clinical-Community Relationships Measures Atlas

20. Existing Measures

21. Existing Measures

22. Existing Measures

23. Existing Measures

24. Clinical-Community Relationships Evaluation Roadmap • Focus on clinical interactions and integrating services • Capture the context of care delivery • Inform research development and design http://www.ahrq.gov/professionals/prevention-chronic-care/resources/clinical-community-relationships-eval-roadmap/index.html#

25. Clinical-Community Relationships Evaluation Roadmap Priority Areas of Study • Influence of element characteristics • Influence of relationships between the elements • Relative importance of elements and relationships in context • Best methods, strategies, and settings for studying and improving clinical-community relationships • Best measures for evaluating effectiveness of clinical-community relationships

26. Clinical-Community Relationships Evaluation Roadmap Seven Recommendations • Use complex systems approaches • Accommodate/tailor for variability in design • Develop standard measures • Conduct rigorous, mixed methods approaches • Report findings more thoroughly in useful formats • Assess feasibility and sustainability of interventions for clinics, patients, and clinical-community relationships • Consider conceptual framework as a starting point

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

28. Clinical-Community Relationships and NACCHO • Recognition of the local health department playing a role in preventive health • Provides framework for understanding relationships among local health departments and practitioners • Provides guidance for young public health services and systems researchers

29. Contributions of the CCRM Project to the Public Health Community • Guidance to local health departments • Understand roles in evolving health care system • Promote connection with primary care practices • Working with various stakeholders • Develop effective relationships • Reduce barriers to encourage relationships

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

31. Public Health Implications of the Evaluation Roadmap • The Roadmap is a “through the looking glass” approach to population/public health: • Greater access to clinical preventive services • More coordinated and team-based care • Potential cost savings • Better health quality • Better health outcomes

32. Key Research Concerns for Public Health • 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?

33. Key Research Concerns for Public Health • How can the cost savings from the practice of community-clinical relationships be reinvested in efforts to improve social equity? • What are the best qualitative and quantitative methods for evaluating clinical-community relationships? • How can we best scale up and adapt what’s working best in some locations so that it working best in all places?

34. Questions? Click me to get Q&A box to appear 34

35. For More Information http://www.ahrq.gov/professionals/prevention-chronic-care/index.html

36. For More Information http://www.innovations.ahrq.gov/linkingClinicalPractices.aspx

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 http://www.ahrq.gov/professionals/prevention-chronic-care/index.html or contact: Janice Genevro, PhD janice.genevro@ahrq.hhs.gov