The University of New Mexico, Albuquerque, NM, USA.
Presbyterian Healthcare Services Community Health, Albuquerque, NM, USA.
Health Promot Pract. 2022 Nov;23(1_suppl):153S-163S. doi: 10.1177/15248399221111192.
Linking clinical services to community-based resources is a promising strategy for assisting patients with chronic disease prevention and management. However, there remains a gap in understanding how to effectively develop and implement community-clinical linkages (CCLs), especially in communities of color. The Healthy Here initiative used Stage Theory of organizational change to implement a centralized wellness referral system, linking primary care clinics to community organizations in majority Hispanic/Latinx and Native American communities. Data were collected using a standardized referral form. Facilitators and challenges were identified through semi-structured discussions with partner organizations. Between 2016 and 2021, 43 clinics and 497 health care providers made 7,465 referrals, the majority of which were from the focus populations. The average proportion of patients referred by clinic champions decreased significantly over time, reflecting diffusion of the intervention within clinics. Facilitators to system success included building on existing networked partnerships, utilizing a centralized referral center, leveraging funding, sharing data, addressing challenges collectively, incorporating multilevel leadership, and co-developing and testing a standardized referral form and process with a single clinic and provider before scaling up. Challenges included funding restrictions, decreasing referrals within clinics over time, changing availability of resources and programs, and the COVID-19 pandemic. This innovative initiative demonstrates that CCLs can be developed and implemented to successfully reach Hispanic/Latinx and Native American communities and provides strategies for overcoming challenges.
将临床服务与社区资源联系起来是帮助慢性病患者进行预防和管理的一种有前途的策略。然而，对于如何有效地开发和实施社区-临床联系（CCL），尤其是在有色人种社区，人们仍存在理解上的差距。Healthy Here 计划采用组织变革的阶段理论，实施集中的健康转介系统，将初级保健诊所与西班牙裔/拉丁裔和美国原住民社区的社区组织联系起来。使用标准化的转介表收集数据。通过与合作伙伴组织的半结构化讨论确定促进因素和挑战。在 2016 年至 2021 年间，43 家诊所和 497 名医疗保健提供者进行了 7465 次转介，其中大多数来自重点人群。随着时间的推移，诊所冠军推荐的患者比例平均显著下降，反映出该干预措施在诊所内部的扩散。系统成功的促进因素包括利用现有的网络伙伴关系、利用集中的转介中心、利用资金、共享数据、共同解决挑战、纳入多层次领导以及与单个诊所和提供者共同开发和测试标准化的转介表和流程，然后再扩大规模。挑战包括资金限制、随着时间的推移诊所内转介减少、资源和项目的可用性变化以及 COVID-19 大流行。这项创新计划表明，可以开发和实施 CCL，以成功覆盖西班牙裔/拉丁裔和美国原住民社区，并提供克服挑战的策略。
