EVENT: Community Health Institute & Expo Conference 2024

Authors

Patricia M. Chen, PhD; Nancy Hood, MPH, PhD; Chanza Baytop-Grange, MPH, DrPH 

Abstract 

Introduction

Chronic disease is one of the main causes of death and disability, and a leading driver of health care costs in the United States. Marginalized communities are disproportionately impacted by chronic diseases and often experience barriers to care. Community engaged approaches can be effective for developing community-driven solutions and addressing health disparities. Community-clinical linkages (CCL), connections between the community and clinical sectors, are an evidenced-based approach to chronic disease prevention and management, but little is known about CCL implementation in diverse communities to address social determinants of health (SDOH). CCLs centered on community engagement and partnerships can build trust, leading to sustained service delivery and improved health outcomes.  

See Leveraging Community Partnerships for Community-Clinical Linkage Models

Program Description

The NIH Community Engagement Alliance (CEAL) is a diverse network of researchers and community partners established during the COVID-19 pandemic to build trust in communities disproportionately impacted by COVID. With the end of the COVID-19 public health emergency, CEAL expanded its scope of work to include additional program areas, such as chronic disease management, social determinants of health, and primary care research among other public health topics. CEAL aims to address health disparities by partnering with communities to advance community-driven solutions and strengthen community-engaged research.  

We systematically reviewed proposals and budget narratives from the 21 CEAL Regional Teams and the Network for Community-Engaged Primary Care Research (NCPCR) and abstracted details about interventions, community partners' roles, and engagement strategies to identify teams’ approaches to establish and implement CCLs. We highlight eight teams who leveraged their partnerships to establish CCLs serving historically marginalized and under resourced communities to improve outcomes for chronic disease, maternal health, and SDOH. Examples of community partners include faith-based and community organizations, social service organizations, professional associations, and local health departments. Community partners play various roles in CCLs, including recruitment, implementation, and project governance. Some CCLs identify participants in primary care settings and link them to community partners for screening and referrals to social service organizations, whereas others start in a community-based setting to help participants connect to clinical partners. For example, one team has community ambassadors located in housing developments to identify individuals with hypertension or diabetes needs and connect them to primary care services. Additionally, seven teams use community health workers (CHWs) as part of their linkage model to provide navigation and referrals to services. Five teams have CHWs located in primary care clinics whereas two teams have CHWs based in a community setting.

Lessons Learned

Key lessons learned are that the design and implementation of CCLs in diverse communities to address social needs are dependent on local context and authentic engagement between community and clinical partners to identify and develop community-driven solutions. CEAL teams are uniquely positioned to establish linkages between community and clinical settings because of their partnerships with the community.  CEAL teams used a community-engaged approach to develop CCLs in under resourced communities, relying on the experience and expertise of their community partners. This approach can be replicated. For example, community health centers (CHCs) can use similar community engagement strategies and best practices to advance CCLs in their communities. The variation in CCL models and partner roles reflect the adaption to local context, which make these linkages feasible, acceptable, and responsive to the community priorities. It also highlights bi-directional learning between community and clinical sectors, which can help clinical partners integrate culturally responsive processes into clinic workflows and care delivery. This can support and enhance clinic capacity to improve patient outcomes and overall community health.

Conclusions

Community partnerships are essential for developing CCLs that are feasible, acceptable, and responsive to the communities they serve. The CCL models developed by CEAL teams underscore the importance of community engagement to ensure members of historically marginalized and under resourced communities are connected to services for health and social needs. Others seeking to establish CCLs should consider strategic selection of community partners and their input on the design and implementation. Community connections can foster trust and facilitate access to care for populations often not reached by health care and public health systems.