1. 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. Integrating Linkages Between Primary Care Practices and Community Resources to Promote Healthy Behaviors Deborah J. Cohen, PhD 1 ; Rebecca S. Etz, PhD 1 ; Maribel Cifuentes, RN, BSN 2 ; Larry A. Green, MD 2; Linda J. Niebauer 2 1 University of Medicine and Dentistry of New Jersey, Robert Wood Johnson Medical School, Somerset, NJ, 2 University of Colorado Denver, School of Medicine, Denver, CO Analysis of Change Strategies Strategies for Change Lessons Learned and Key Messages 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 Project Strategies for Change 1 ACORN Richmond, VA 5As-based intervention using Electronic Health Record (EHR) prompts to counsel and refer at-risk patients to four pre-identified resources: web-based counseling, telephone counseling, and group counseling through Weight Watchers TM. 2 OKPRN Oklahoma City, OK Practice enhancement assistants provide training, monthly performance feedback, and change facilitation. Practices participate in local Quality Improvement (QI) collaborative. EHR-based health risk assessment (HRA) as part of vital signs process. Clinician counseling and referral to community resources for at-risk patients. 3 NYCRING Bronx, NY Reframe 2 year-old well child visit to focus on obesity risk and behavior change. Used new screening tool for HRA, brief clinician counseling and referral to lifestyle coach for intensive counseling and further referral to community resources. 4 AAFP Leawood, KS Integration of proven interactive telephone voice response system (IVR) into practice. Clinicians provide brief messages, educational materials, and referral to IVR. Patients interact with IVR for weekly counseling and evaluation. 5 PRENSA San Antonio, TX Extended role of medical assistants to identify patients at-risk for unhealthy behaviors, provide brief counseling, and referral to pre-identified health system and community resources. Use of existing electronic HRA system. 6 CECH Hanover, NH PDA-based electronic health screener to identify at-risk adolescent patients and to enhance communication and brief counseling offered by physicians. Resource card and referral to community resources for at-risk patients. Listserv made available to share best practices among participating offices. 7 NCFMRN Chapel Hill, NC Participation in prevention collaborative to promote screening, counseling, and use of electronic and community resources through joint planning and collaborative meetings with local and state agencies. Designated liaison to link practices and community resources. Self-administered patient HRA using tablet PC, prevention registry, brief physician counseling and referral for at-risk patients. 8 GRIN East Lansing, MI Community Health Referral Liaison role (CHERL) established as adjunct referral mechanism for at-risk patients identified by the practice. CHERL received faxed referral and provided phone counseling and referral to community resources using a guide created pre-intervention. CHERL monitors progress and provides feedback to practices. 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 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 at http://www.prescriptionforhealth.orghttp://www.prescriptionforhealth.org Eight Prescription for Health projects tested various tools and strategies to identify, counsel, and provide referrals to a diverse population of at-risk patients. Effects of Changes Availability of Resource Affordability of Resource Accessibility of Resource Perceived as Value Added Anchor–Community Resources Capacity for Risk Assessment Ability for Brief Counseling Capacity and Ability to Refer Awareness of Community Resources Anchor–Primary Care Opportunity to activate Opportunity to encourage Connecting Strategies Pre-Identifying Community Resources known services and expectations Developing Referral Guides paper or electronic databases Engaging External Intermediaries single-point access to resources Patient Referral Availability of Resource Affordability of Resource Accessibility of Resource Perceived as Value Added Anchor–Community Resources Capacity for Risk Assessment Ability for Brief Counseling Capacity and Ability to Refer Awareness of Community Resources Anchor–Primary Care Opportunity to activate Opportunity to encourage Connecting Strategies Pre-Identifying Community Resources known services and expectations Developing Referral Guides paper or electronic databases Engaging External Intermediaries single-point access to resources Patient Referral 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. 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. 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 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.