Clinical-Community Linkages: A Step towards Better Health

Anand Parekh | November 21, 2013

As a practicing physician, I often counsel patients on the importance of healthy behaviors such as eating a nutritious diet, being physically active, and not smoking or abusing other substances. However, health education in the clinical setting is usually brief and of limited effectiveness – we have little means to reinforce our guidance in the patient’s day-to-day life.

Enter Community Rx, an innovative program that links the doctor’s office or clinic with community health resources. Funded through the Affordable Care Act by an award from the Center for Medicare & Medicaid Innovation and supported by the Centers for Disease Control & Prevention, Community Rx creates patient-centered e-prescriptions for community services (Health-eRx), generated through an interface between the patient’s electronic health record and a comprehensive community resource database. The Chicago Health Information Technology Regional Extension Center, funded by the Office of the National Coordinator for Health Information Technology (ONC), is one of CommunityRx’s technology partners.

With Community Rx, when patients leave their doctors’ appointments, they receive an e-prescription with a customized map and list of health and social resources in their community. Also, the patient is linked with a local community health worker (community health information expert) who acts as a bridge between the clinic and community-based services.

I recently had a chance to visit the Komed Holman Health Center in Chicago, one site that has implemented Community Rx. Drs. Stacy Lindau and Tim Long, pioneers in the development and deployment of Community Rx, walked me through the process of creating a Health-eRx. Essentially a patient’s diagnoses and address are used to generate a list of local places and programs that are matched to specific health needs. The Health-eRx is created within the workflow of the office visit; upon printing a summary of the visit for the patient, a Health-eRx is also provided. A sample Health-eRx created during my visit generated a list of community resources for fitness and exercise; food and nutrition; medical and health services; transportation; housing; mental health services; and programs to help patients with smoking or substance abuse problems.

Why are clinical-community linkages important? Most patients only see their doctor once every few months. If education on healthy behaviors is not reinforced or social service needs are not supported between clinic visits, it’s very difficult to change the underlying risk factors that lead to chronic diseases and poor health. Nearly 8,000 Health-eRx have been provided as of August 2013.  We hope to see improved outcomes and reduced costs where patients are supported by Community Rx.

It’s also worth noting that Community Rx supports local businesses and organizations by developing programming for specific health needs in communities. In addition, the mapping of community health resources is done by MAPSCorps, which trains and employs local high school students to map a community’s health assets. This offers meaningful STEM (Science, Technology, Engineering, and Mathematics) work experiences for the students and others who are employed by this project. Since 2009, MAPSCorps has created 276 active jobs for youth and back-to-work adults, mapped 24 neighborhoods spanning 11 Chicago ZIP codes, and identified over 9,000 community resources.

Community Rx reminds us that optimal health status and quality of life for individuals depend on a team of professionals in both clinical and community settings.  Through collaboration with the Office of the National Coordinator for Health IT, successes like Community Rx can be turned into scalable solutions that work across provider communities.  ONC, through initiatives such as the Standards and Interoperability Framework, develops national standards to allow programs like Community Rx to propagate across the country and work with all Electronic Health Record (EHR) sytems. Through clinical-community linkages, we can better support patients in preventing and managing chronic disease.  Innovations such as Community Rx will help accelerate this country’s health transformation efforts.