|By the Innovations Exchange Team|
The Agency for Healthcare Research and Quality (AHRQ) developed the Clinical-Community Relationship Evaluation Roadmap to offer suggestions for future research and evaluation efforts, and methods to study these relationships. The Roadmap is grounded in a conceptual framework that shows how interrelationships among several factors may influence the effectiveness of linkages between primary care clinics and community resources for the delivery of preventive services such as alcohol misuse counseling, tobacco use counseling, and obesity counseling. The framework describes three basic elements—the clinic/clinician, the patient, and the community resource—and focuses on the relationships among these elements.
The Innovations Exchange: How will the Roadmap enhance research in the field of clinical-community relationships?
Jodi Summers Holtrop, PhD, MCHES: The Roadmap can stimulate thought and generate interest in how to successfully link clinical practices and community resources to obtain the best outcomes for patients. The document is a valuable resource because it draws attention to the lack of knowledge in this area, and outlines the key research questions that need to be answered. As a researcher, it can be affirming to see that a research question I am considering is also of interest to a broader scientific community. The Roadmap also provides a conceptual model, which can help researchers think through how to design a study to answer questions about why an intervention is or isn’t working.
The Roadmap emphasizes the importance of context in studying clinical-community relationships, a consideration that has been underemphasized in the past. We found that context was important when we created and studied a new role called the Community Health Educator Referral Liaison (CHERL) in three communities in Michigan. The goal was to connect primary care practices with community resources to improve patient health behaviors. Some communities had more resources than others, so there was variation in what was available to patients. Patients and providers responded differently to the CHERL intervention, with some practices using the CHERL more than others. Although the CHERLs had similar training and backgrounds, the context of the intervention affected both their experiences and the results.
What gaps exist in studies of clinical-community relationships?
There is a dearth of specific tools and overall methods to study how these relationships work to provide access to clinical preventive services. Written surveys can be problematic if they don’t address research questions of interest, if participants interpret the questions differently, or if participants don’t respond in adequate numbers. The results also may be difficult to compare across studies. For example, the field is struggling to identify a valid and reliable measure for primary care practice culture that can be used to assess intervention outcomes.
I am pleased that the Roadmap recommends the use of qualitative, quantitative, and mixed methods. Many researchers don’t use mixed methods, yet qualitative and quantitative methods are both important and inform each other. Quantitative results tend to address direct outcomes of the implementation of certain interventions, such as whether patients with diabetes improved their hemoglobin A1c levels. In contrast, qualitative methods facilitate learning about the “how” and “why” of an intervention’s impact.
What challenges do researchers face in conducting studies of clinical-community resource relationships?
It’s challenging to find researchers to study linkages between primary care practices and public health organizations because few such relationships exist to study. These groups generally have not collaborated historically, and they have little financial incentive to change, because primary care physicians are paid for spending time with patients rather than engaging with public health organizations.
Also, it is challenging to measure the impact of these complex relationships. In our CHERL innovation, there were three geographic communities, with three to six participating practices in each community. Each CHERL worked on connecting the practices with a myriad of public health and community resources. From a research administration perspective, we had to capture a lot of data to understand the relationships among all of them.
How can the Roadmap be used by practice-based research networks?
The document provides guidance to practice-based research networks (PBRNs) about which areas need more research. The Roadmap serves as an impetus to get more researchers involved in conducting studies about clinical-community resource relationships. A PBRN is particularly useful for studying interventions in primary care practices that involve practice change, including methods for linking the practices with community resources.
How important is it for researchers to assess the sustainability of clinical-community interventions?
I believe that when people write research proposals, they should address the sustainability of an intervention. The way most research is funded, it is difficult to examine sustainability. Research is needed that provides answers about how a new innovation works under ideal circumstances as well as its effectiveness in “real-world” circumstances. Studying long-term sustainability can be challenging because of the short-term nature of many grants. Fortunately, the field of dissemination and implementation research has grown, providing the opportunity to study the translation of innovations as they are implemented in actual practice, without research constraints.
About Jodi Summers Holtrop, PhD, MCHES:
Dr. Holtrop is an Associate Professor in the Department of Family Medicine at the University of Colorado Denver School of Medicine. She has a doctorate in health promotion and is a master certified health education specialist. As a health educator for more than 20 years, she has extensive experience in developing and testing health behavior change interventions in community and primary care settings. Dr. Holtrop is codirector of the State Network of Colorado Ambulatory Practices & Partners (Colorado’s consortium of PBRNs) and a former codirector of the Great Lakes Research into Practice Network (Michigan’s PBRN). She focuses on qualitative and mixed methods research with an emphasis on implementation and translational research.
Disclosure Statement: Dr. Holtrop reported that she received payment from AHRQ to serve as a scientific reviewer for various AHRQ study sections and received an honorarium for serving as an expert panel member at a 2012 AHRQ forum on clinical-community relationships. Michigan State University received grants from AHRQ and the National Institutes of Health for Dr. Holtrop to serve as a principal investigator for research on chronic disease management.