|By the Innovations Exchange Team, based on an interview with Ruta Valaitis RN, PhD, Dorothy C. Hall Chair in Primary Health Care Nursing, Associate Professor, School of Nursing, McMaster University|
Innovations Exchange: What does “linkages” mean in the context of delivering preventive services?
Ruta Valaitis: The Agency for Healthcare Research and Quality (AHRQ) report1 refers to linking or joining clinical organizations and community or public health organizations to improve clinical preventive services. These interorganizational relationships are characterized by their time commitment, trust, resource sharing and exchange, and sharing of risks and responsibilities that improve delivery, access to, and quality of preventive services. Common types of linkages include co-locating services, coordinating services at different sites, and developing a referral mechanism to prevention resources.
What are the benefits of linkages between clinical practices and community organizations?
Patients benefit from these linkages because it increases their access to medical care and comprehensive services. Clients of community organizations who lack regular primary care can be evaluated and treated by clinicians for acute and chronic conditions. Patients of primary care practices benefit from referrals to community organizations, which tend to focus on social determinants of health such as housing, employment, or food needs. Research in Canada has shown that implementing multiple interventions aimed at prevention and health promotion can produce positive outcomes,2 which supports key messages in the AHRQ report and the case studies on the Innovations Exchange Web site.
An ecological model for health promotion has focused attention on both individual and social environmental factors as targets for health promotion interventions.3 Multiple interventions that incorporate more than one level of the ecological model (i.e., intrapersonal, organizational, community, or policy) and more than one sector are more likely to be effective. The Charlotte REACH program is a good example of using multiple interventions effectively by building coalitions (community level), training lay health visitors (organizational level), and providing services (intrapersonal level). Overall, research supports multiple interventions involving community organization and health care services partnerships.
What types of health conditions or diseases can clinical–community linkages prevent?
The AHRQ report1 focused on linkages that enhanced the delivery of preventive services in four areas: tobacco use, obesity, nutrition, and physical activity. Our scoping literature review,4 which included papers from international authors, was broader and covered health promotion, disease prevention, disaster planning and management, as well as health professional capacity building. The issues addressed by the collaborations were biomedical (chronic disease, communicable disease control, and immunizations), behavioral (smoking cessation), and socioenvironmental (disaster response planning, poverty reduction, environmental health). In Canada, effective primary care linkages with local public health agencies have increased primary care prevention efforts. For example, public health nurses provided training to primary care practices to enhance the 18-month well baby visits.5 Also, public health nurses have trained primary care staff in office 'best practices' to control the spread of respiratory infections.6
Many areas are ripe for developing linkages that are not typically considered in prevention efforts. For example, the development of a farmer’s market in the Charlotte REACH program illustrates an innovation aimed at overcoming access to healthy food problems, which is a root cause of poor nutritional intake.
Finally, a seminal 2008 report from the World Health Organization argued for stronger multisectorial cooperation among community-based organizations, public health, and primary care to strengthen the primary health care system.7 Canadian federal and provincial governments are responding to this call through their growing interest in promoting primary care and public health collaboration as well as community-based care.
What are barriers to developing clinical–community linkages?
The AHRQ report indicates that clinicians are often unaware of services and resources that community organizations offer. We have found that clinicians may not fully appreciate or understand the public health approaches used, which are grounded in behavioral, public health, and social sciences. We have also found that the primary care and public health organizations lack a common language, role clarity, and an understanding of each other’s worlds.
The AHRQ report refers to clinicians volunteering their services at health fairs and free clinics in their communities, as well as training community staff to conduct primary care screenings. These activities in addition to interprofessional and intersectoral professional education events, and interdisciplinary undergraduate education programs, would facilitate a common understanding of each other’s roles.
A major organizational barrier to building linkages identified in the AHRQ report was the lack of sufficient funding for program implementation, which included the inability to compensate clinicians and a growth in demand for services that the program intervention could not meet. This problem was highlighted in the Innovation Profile Sisters in Action.
The funding barrier has also been felt in Canada. Funding was made available for special short-term projects such as through the Federal Primary Health Transition Fund, but many could not be sustained without a long-term investment. Since the majority of Canadian funding models in primary care do not support or provide funds or financial incentives for time, staff resources, or skills required to develop and maintain community linkages, such partnerships are very difficult to actualize. Workloads and time pressures can become insurmountable obstacles.
However, the Community Health Centre (CHC) model, with its long history in Canada, is a notable exception.8 Professionals in this model are salaried and centers are mandated to work in partnership with the communities they serve. So it is not surprising that CHCs have reported on a variety of community development projects in collaboration with their local communities.9
In addition, public health agencies are generally mandated to work with community partners10 and key Canadian public health core competencies are directly related to partnerships, collaboration, and advocacy development.11 Therefore, the public health sector in Canada has a high readiness for building and sustaining linkages and may be the natural leaders to develop them.
What factors facilitate developing clinical–community linkages?
Our research has identified factors that support collaboration that were similar to those identified in the AHRQ report. From an organizational perspective, relationships between clinical and community organizations are fostered when there is strong and effective communication between partners as well as a shared mission, vision, and purpose to their work. These factors are well aligned with the results from our scoping literature review and our more recent analysis of more than 70 primary care and public health key informants located across Canada.12 Communication that supports cross-sectorial planning, coordination, and decisionmaking is a critical factor to support collaborations. Holding ongoing meetings and even quarterly dinners was a key activity identified in the Wayne Action Team for Community Health and other Innovation Profiles.
Trust is also a key factor for successful linkages. Valuing the work of each sector was found to be important to building trust and positive attitudes in collaborations both in the scoping literature review and key informant interviews. Trust was a critical factor both at the organizational as well as interpersonal level. In addition, the existence of tools such as codeveloped clinical protocols, formal agreements, and electronic sharing of information, such as electronic health records (EHRs), to exchange communication and information have also facilitated collaborations. ARHQ’s research found that collaborative work skills of individuals were important facilitators for linkages.
Similarly we found that personal skills needed for building linkages included leadership and change management and working within teams. Having a history of working together in previous collaborations was identified as a facilitator of collaboration in three of the four Innovation Profiles from the 2010 summit and in our key informant interviews. Demonstrating personal initiative regarding working in collaborations was also identified in our research, as was being patient, because working within collaborations takes time and outcomes are not readily evident. Physicians who have traditionally worked in solo practices may need to learn to work in a different way when working in collaborative partnerships where leadership styles need to be nonauthoritative. Having evidence of the benefits of collaboration also contributes to building a strong belief in collaboration, both at the provider and organizational level. Interventions that demonstrate small successes may help.
What are some examples of promising practices involving linkages?
There is little evidence of promising practices regarding linkages with primary care and community organizations in Canada. However, we are currently working on the development of a paper that reports on the nature of collaborations based on more than 70 key informant interviews, which will identify promising practices. The AHRQ report identifies at least five categories of linkages including referral processes, provision of trainings to practitioners to improve medical practices, clinical partner referrals to health resources, and clinical volunteering in community programs. For each type of linkage, the promising practices will likely differ. For example, co-location has been identified in the literature and our key informant interviews as a key facilitator for some partnerships. Further research into promising practices by category of linkage would be useful.
What would move evaluation research forward for clinical and community linkages?
Our research supports AHRQ’s conclusion that there is an overall “lack of evaluation and variation in types of outcomes measured.” Many of the Canadian key informants we interviewed indicated that partners should conduct evaluations of their collaborations because this evidence is lacking and is needed for system and organizational buy-in to support future collaborative work. Collaborations are not static—they evolve over time and as contexts change. Thus, evaluations can provide valuable direction for the next phase in collaborative work and can support quality improvement practices. The development of indicators of successful collaborations is a key next step.
In addition, the Canadian Institute of Health Services and Research Policy has listed primary care and community-based health care research among its priority areas for research funding. This provides Canadian researchers with opportunities to submit research proposals that engage in creating indicators of successful collaborations. Similar opportunities in the United States would assist in the effective development of robust indicators.
What dissemination strategies would help advance clinical–community linkages?
The answer depends on the audiences and key messages that need to be disseminated. Our Strengthening Primary Health Care through Primary Care and Public Health Collaboration team recently explored a strategy for dissemination that involved the development of one-page fact sheets targeted for three audiences: policy makers, senior and middle managers, and frontline practitioners. We asked each group in a face-to-face symposium to identify key messages from the research that were meaningful to them. From these messages, we created three fact sheets tailored to each group.13
However, multiple strategies are needed to disseminate research beyond such traditional venues as conference presentations and peer-reviewed publications, which are likely to be irrelevant for many community organizations. It is also critical for groups to consider costs to support the dissemination of research and evaluation when developing budgets for evaluation and research on linkages.
The use of the Internet to disseminate research is another strategy. A promising approach to dissemination is the AHRQ Innovations Exchange Web site, which allows health care professionals to submit their innovative programs subject to the inclusion criteria, and supports them in exchanging information with others.
What can AHRQ do to move a national policy agenda forward?
Among the recommendations that were drawn primarily from the 2010 AHRQ Summit was “convening a joint meeting among the Centers for Medicare and Medicaid Services, state governments, and employers to discuss reimbursement issues for providers participating in linkage interventions.” This is critical, because funding drives action. In Canada, the move to expand interdisciplinary primary care team models, where salaried professionals are supported by provincial governments, appear to have the best opportunity to promote collaborative activities. Fee-for-service payment models are not set up to support collaborative work and can be a disincentive. In addition, incentives for physicians have been used in Canada to promote preventative care practices, but not to promote collaboration. Although paying physician incentives to collaborate may make sense at first glance, this approach needs close examination, because negative consequences for teams may result. For example, in Canada the provision of financial incentives to physicians for prevention activities (e.g., increased rates of mammography screening), but not to other professionals such as nurse practitioners, creates an imbalanced and inequitable funding model. A review of reimbursements needs to consider the point of view of all partners regardless of discipline or sector.
The second recommendation was to “promote systems and tools that allow patient information exchange between clinical and community partners and ensure that community provider resource information is incorporated or can be incorporated into health IT systems.” This direction appears to be very relevant based on the fact that our scoping literature review and key informant interviews supported the need for integrated IT systems to support bidirectional data exchange between primary care and public health. Such shared systems can also support general communication and surveillance activities.
Another AHRQ recommendation was to develop organizational policy that “promotes linkages internally and in collaboration with other agencies (e.g., by including requirements for establishing linkages in funding announcements and opportunities).” In addition to this, there would likely be significant value in expanding requirements to include community engagement in planning, decisionmaking and evaluation of linkages. Community engagement can help ensure that local needs are met in a way that is accessible, equitable, and acceptable to recipients of care and the population.
Finally, continuing to support summits with broad stakeholder groups, such as the one held in 2010 at AHRQ's headquarters, are important because such events can provide the fuel to keep up the momentum that ARHQ has begun. There is much more work to be done to ensure that community organizations and primary care linkages can be effectively built and sustained to improve the health of its nation’s citizens.
About Ruta Valaitis, RN, PhD
Ruta Valaitis is the Dorothy C. Hall Chair in Primary Health Care Nursing and Associate Professor at McMaster University in Toronto, Canada. She joined McMaster University in 1987 as a part-time Lecturer in the School of Nursing. She is presently an Associate Professor in the School of Nursing and the Dorothy C. Hall Chair in Primary Health Care Nursing.
Dr. Valaitis has a Bachelor of Arts in Psychology and a Bachelor of Science in Nursing from the University of Windsor, a Master of Health Science from McMaster University, and a Doctor of Philosophy from the University of Toronto.
Her primary research interests are in primary health care nursing, public health nursing, e-health and e-learning. Currently, she is a principal investigator for a multisite research project funded by the Canadian Health Services Research Foundation exploring collaborations between primary care and public health.
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4 Martin-Misener R, Valaitis R. (Sept. 2008). A Scoping Literature Review of Collaboration between Primary Care and Public Health. A Report to the Canadian Health Services Research Foundation. McMaster University September 2008 (Revised April 21, 2009)