Clinic-community linkages for high-value care.


T increasing emphasis on improving health outcomes and controlling health care costs puts pressure on U.S. health care systems to deliver value. One essential strategy for improving population health is linking the delivery system, the community, and the patient in an integrated effort. Although complex interactions between neighborhood-level determinants of health and individual patient characteristics occur primarily outside the delivery system, they have a profound effect on how patients interact with the system and ultimately on the quality of the care they receive and their health outcomes. The likelihood of hospital readmissions, for example, depends more on characteristics of individual patients and the surrounding community than on features of the discharging hospital.1 A promising approach to achieving this linkage is community-based performance measurement — reporting and acting on clinical performance measures at the community level, rather than at the level of delivery-system units such as hospitals or physicians. Using this measurement approach, a delivery system can gain a better sense of where its patient population clusters within communities and how their environment affects their health outcomes. The strategy for addressing patients’ needs follows from these analyses; it entails identification of patients residing in communities where quality of care and outcomes are notably unsatisfactory, identification of promising approaches for patients in those communities, and integration of these approaches into the care plans of patients from those communities who receive their care in the health system. The first step requires both an operational definition of community and a robust infrastructure for data analysis. Census tracts, small geographic areas of approximately 4000 people, are often used to define “communities” because of their correlation with some known health indicators such as asthma.2 A robust dataanalysis infrastructure, including an advanced electronic health record (EHR), can facilitate measurement of quality of care and outcomes for the delivery system’s patient population according to their community of residence as determined with geocoding techniques. Using the patient population cared for by an integrated physician group practice in eastern Massachusetts, we have measured variation in patient outcomes among communities rather than among clinics and physicians, allowing identification of “hot-spot” communities where clinical performance is low or disease burden is particularly high (see map).3 The second step involves targeting “positive outliers” in these hot-spot communities — patients cared for in the delivery system who have achieved good outcomes, and particularly those with historically poor outcomes who have had recent improvements, such as patients who were obese but have reduced their body-mass index over the previous year. This model can be readily extended to other ambulatory conditions, such as hypertension, or to the targeting of hospital readmissions. Once positive outliers have been identified, strategies can be identified for achieving success. To address obesity, for instance, we recruited positive-outlier patients to collaborate with primary care leaders in a qualitative exploration of community-specific strategies for weight management. Such efforts may involve identifying local community resources (healthy food options or safe, open recreational spaces), outlining strategies for behavior change and goal setting, or identifying ways to obtain peer support. The goal is to create an operational toolkit specific to a given community. The third step is integrating these approaches into patients’ care plans. We are testing a toolkit of success strategies for obesity that will be delivered to primary care pediatricians through an integrated EHR. Pediatricians caring for an obese patient who resides in a targeted community will receive decision support within the EHR, encouraging referrals to population health managers equipped with information on appropriate strategies for addressing obesity in that patient’s community. The resulting care plans are documented in the EHR and approved by the pediatrician. In another such initiative, called the HealtheRx program, student workers map community resources on Chicago’s South Side by walking each street in the neighborhood and cataloguing all available community resources; then “community health infor-

DOI: 10.1056/NEJMp1408457
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@article{Sequist2014CliniccommunityLF, title={Clinic-community linkages for high-value care.}, author={Thomas D. Sequist and E. Taveras}, journal={The New England journal of medicine}, year={2014}, volume={371 23}, pages={2148-50} }