Download Tribal Community and Clinical Linkages

Tribal Community and Clinical Linkages
Tribal community and clinical linkages are connections between
tribal patients, families, and caregivers, tribal health care
providers, health care systems, public health organizations, and
other community resources. The goal of these linkages is to
coordinate services to improve patient access to preventive and
chronic care services and to support community-wide
improvement of health behaviors and environments.
Community
Resources Organizations
Clinic Health Care
Provider
Patient Community
Member
Community and clinical linkages may include coordinated
services within one program, referrals between programs, development of guidelines, systems,
and educational resources to fill gaps in community health care needs, and community
activities and events. Effective linkages help each organization or program achieve to its
mission.
The venn diagram above shows the foundation of community and clinical linkages. The Patient
– Community Member circle includes the individual receiving care services and family and other
individuals directly responsible for the Patient’s care. The Clinic – Health Care Provider circle
includes physicians, traditional healing practitioners, nurses, and clinical support staff working
in primary care environments. The Community Resource – Organizations circle includes health
programs, resources, and organizations that provide services to Patients and their families or
caregivers. The patient, family, clinic, and community resources all exist in a broader context
and are influenced by social, organizational, and environmental factors. Community and clinical
linkages occur in the areas of over-lap, and necessitate active, ongoing connection and
communication.
Community and clinical linkages are a natural fit for Tribal communities because they focus on
the health of the patient, family, and community. They depend on sustained relationships and
communication, trust, and collaboration.
Examples of Tribal Community and Clinical Linkages
Elise visits her Primary Care Physician and indicates that she is interested in quitting smoking.
The physician makes an internal referral to the Tribal smoking cessation program and an ereferral to the State Quit Line, who employs a Native American counselor. The tribal smoking
cessation program provides Elise with weekly counseling sessions and nicotine replacement
medications, while the State Quit Line counselor holds an intake session and sends Elise weekly
check-in texts. This community and clinical linkage increases the rate of referrals to smoking
cessation program and improves behaviors such as increasing quit rates among smokers.
Mike visits the Traditional Healing Practitioner and is advised to increase his physical activity by
joining the gym at the Tribal Recreation Facility and participating in the Tribe’s Wellness
Program with weekly personal trainer sessions. Tribal Wellness Program staff are able to
update Mike’s Traditional Healing Practitioner on his progress through the Tribe’s electronic
health records system. This community and clinical linkage improves behaviors with increased
physical activity, better diets, and improved overall wellbeing.
Brandi visits her Primary Care Physician and is assigned a Patient Navigator when she receives
an abnormal finding suspicious of cancer from a pap smear. The Patient Navigator helps Brandi
receive the health care services that she needs from testing, diagnosis, treatment, through
survivorship. The Patient Navigator helps Brandi to access resources including transportation
to treatment, health care coverage and reimbursement, counseling, cancer support groups,
nutrition programs, and survivorship care. This community and clinical linkage improves cancer
outcomes.
Why Community and Clinical Linkages?
AI/AN populations may access healthcare through Tribes, traditional medicine programs, Indian
Health Services, Urban Indian Health Centers, state Medicaid programs, private health systems,
and public health programs. AI/AN populations may also access a wealth of community
resources including fitness groups, exercise facilities, recreation and cultural programs, sporting
events, food and nutrition programs, mental health services, transportation, housing, and other
medical and health services.
Each community’s health care systems have unique strengths and weaknesses. Unfortunately,
gaps exist in the health care services that rural and urban tribal communities access. Tribal
communities experience health disparities across a broad range of chronic diseases. American
Indians and Alaska Natives are diagnosed with more advanced stages of cancer and suffer from
higher rates of cancer mortality than non AI/AN populations (Petereit et al., 2011; )
There are numerous reasons why tribal community members may not be getting the health
care that they need. Community members may encounter challenges in accessing basic
medical and health services due to a variety of issues, including a lack of health care coverage,
lack of transportation to and from clinics or for special medical procedures located in facilities
in distant towns, lack of housing or telephone, and mental health, among others. (Infante et al.,
2007: Guadagnolo et al., 2011; Petereit et al., 2011)
During medical appointments, health care providers may provide important health education to
patients, which patients can use at home to manage their health and reduce their risk factors
for chronic disease. However, there is often only time for brief consultations between
providers and patients in the clinic and, once the patient leaves the clinic, providers may not
support or reinforce the guidance shared.
Community and clinical linkages reduce some of the barriers to adequate health care among
tribal communities by coordinating services among programs and organizations to fill gaps
across the spectrum of health care and to support community-wide health improvement.
There is a need for identifying community needs and resources so that health care providers
can offer make appropriate referrals to services that they cannot provide themselves, and
patients can access the health care resources they need to pursue and manage their own good
health, including prevention, screening, counseling, treatment, and follow-up, selfmanagement, and end-of-life care.
The United States Preventative Services Task Force and the Community Task Force have created
a strong body of evidence based strategies and recommendations for health care services,
including screening, counseling, referral, and preventative medications. These strategies may
reduce the burden of disease if employed; however, studies have found that patients may not
be receiving the recommended preventative clinical services and one study found that only half
of the recommended services were provided (McGlynn et al., 2003).
In community and clinical linkages, community-based organizations and resources are
differentiated from primary care clinics/providers. In a Tribal Health Care Clinic, health care
providers may practice in one area and a Tribal Behavioral Health office may be located down
the hall. While these two entities exist together, the communication and coordination of
services that happens among them is what defines a community and clinical linkage.
SOLUTION:
Community and clinical linkages support and increase community member access to
preventative services, appropriate medical treatment, and community resources that promote
healthy behavior. Improved coordination among health care services and resources reduces
gaps, allowing better health care quality and better health outcomes. Community programs are
better utilized as more community members access program resources.
Effective community-clinical linkages involve team-based health care with patient, family, and
community involvement in preventative and self-management care. Patients get more help
with developing and maintaining healthy behaviors, as well as changing unhealthy behaviors.
Steps toward developing community-clinical linkages:
Identify gaps in needed health services
Identify organizations for partnership and their strengths and weaknesses
Identify and establish pathways to coordinate services and communication
Facilitate access to appropriate services
Maintain communication and coordination among programs and organizations
Resources:
The Agency for Healthcare Research and Quality (AHRQ) has done research, analysis, and
coordinated efforts to support effective community and clinical linkages, or clinical-community
relationships. The AHRQ convened a 2008 Clinical-Community Linkages Summit among health
care providers, institutions and community organizations, and a 2010 summit among federal
agencies and organizations to develop a national strategy for promoting linkages to increase
the delivery of clinical preventative services. The AHRQ published the Clinical-Community
Relationships Measures Atlas in 2013, which collated years of research on the feasibility and
effectiveness of community and clinical linkages in clinical preventative services for the purpose
of continued research and evaluation.
Agency for Healthcare Research and Quality Innovations Exchange
U.S. Preventative Services Task Force
U.S. Centers for Disease Control and Prevention Division of Community Health Programs