Skip Navigation
Service Delivery Innovation Profile

Automated Clinician Prompts and Referrals Facilitate Access to Counseling Services, Leading to Positive Behavior Changes Among Patients

Tab for The Profile Tab for Expert Comments
Clinician–Community Collaborations: A "Win-Win" Scenario

By Steven H. Woolf, MD, MPH
Director, Center for Human Needs
Virginia Commonwealth University

Clinicians play a key role in helping patients to adopt healthy behaviors, but they also face challenges in offering intensive assistance, such as lack of time, skills, and reimbursement. Patients often need extended help because lifestyle change is so difficult.

Systematic reviews demonstrate a correlation between behavior change and the intensity of counseling that patients receive.1 Although some practices have adopted in-practice solutions such as group visits or delegating behavioral counseling to nonphysician staff educators, the majority of primary care practices in the United States cannot reconfigure themselves to offer intensive behavioral counseling as a regular service.

The innovations presented here offer a promising new model for assisting patients that involves a partnership between health systems and community resources.2,3 Each example demonstrates an effort to build relationships between clinicians and community programs to facilitate a coordinated approach that helped patients obtain intensive assistance in modifying unhealthy behaviors. In the Community Health Educator Referral Liaisons (CHERL) model, a liaison worked with the practices to make these arrangements. The Virginia Ambulatory Care Outcomes Research Network (ACORN) eLinkS project established relationships with community programs but used the electronic medical record as a tool to facilitate referrals. The Steps to Health King County project featured a countywide approach grounded in Wagner’s Chronic Care Model.4

Such collaborations offer a "win-win" scenario for clinicians, community programs, and, most importantly, for patients. Patients obtain more intensive assistance, clinicians obtain help in offering services to patients that they cannot provide, and community programs receive clients for which their services were designed. If the approach proves to be more effective than the ordinary counseling offered by clinicians—and early evidence suggests that it might5—financing the model may prove to be more efficient and economical for health plans and employers to address tobacco use, obesity, and other risk factors.

Such collaborations do not occur in a vacuum. Substantial legwork and preparation are required to cultivate relationships between clinicians and community programs, which often know little about each other, and to build an infrastructure and functional operating procedures that make it fast and easy to refer patients. Busy primary care practices, community programs, and public health departments typically lack the time, resources, and energy for this legwork. Providing contact information for each other is often the best they can do on their own. Building a more robust and effective collaboration often requires the involvement of a third party. In each of the innovations discussed here, a project team funded by outside sources was the energizing force in establishing the collaboration.

The promise of taking these successful models to scale on a national level therefore requires policy solutions that address financing and resources to support a third party, available in communities across the country, to help link local clinicians with relevant community resources. Collaboration requires other ingredients, such as new models of reimbursement in which payers would recognize the cost-effectiveness of reimbursing counseling provided under these arrangements. It also requires a culture shift, breaking down a century-old schism between medicine and public health and rediscovering their shared interest in promoting good health and reducing the prevalence of unhealthy behaviors.


1Whitlock EP, Orleans CT, Pender N, et al. Evaluating primary care behavioral counseling interventions: an evidence-based approach. Am J Prev Med. 2002;22(4):267-84. [PubMed]

2Woolf SH, Krist AH, Rothemich SF. Joining Hands: The Rationale for Partnerships Between Physicians and the Community in the Delivery of Preventive Care. Washington, DC: Center for American Progress; 2006.

3Etz RS, Cohen DJ, Woolf SH, et al. Bridging primary care practices and communities to promote healthy behaviors. Am J Prev Med. 2008;35(5 Suppl):S390-7. [PubMed]

4Glasgow RE, Orleans CT, Wagner EH. Does the chronic care model serve also as a template for improving prevention? Milbank Q. 2001;79(4):579-612. [PubMed]

5Krist AH, Woolf SH, Frazier CO, et al. An electronic linkage system for health behavior counseling: effect on delivery of the “5 As.” Am J Prev Med. 2008;35(5 Suppl):S350-8. [PubMed]

Disclosure Statement: Dr. Woolf has not indicated whether he has financial interests or business/professional affiliations relevant to the work described in this article.

Original publication: December 08, 2008.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: July 16, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: February 25, 2014.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.