Examples of 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 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 andan e-referral 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 Brandireceive 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 linkagesreduce some of the barriers to adequate health care among tribal communities by coordinating services among programs and organizationsto 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, self-management, 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 thatpatients 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 involveteam-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