QI Tips: How to Help Your Patients Connect with Community Resources

If you are a healthcare practitioner, you know many things outside of a doctor’s office can negatively affect a patient’s health. Patient health can be impeded by issues such as struggles with housing and bills, lack of support for breastfeeding or exercise, or confusion about how to navigate the healthcare system. Building relationships with community organizations can be a huge boon to healthcare practices and their patients.

More and more, practices are striving to move toward a patient-centered medical home — a healthcare model where complex and disparate healthcare needs are integrated, coordinated and tailored to the patient. Success requires that practices build knowledge of and partnerships with relevant community resources.

Examples of the benefits of partnering with communities abound in quality improvement work. In obesity prevention work, connecting across sectors (public health, primary care and community) is vital to promoting and supporting healthy weight. For example, healthcare practices in the Mass in Motion Kids project partner with their local YMCAs and other programs to offer patients discounts and programs for maintaining healthy weight. Community partnerships also support patients in breastfeeding by, for example, referring to appropriate lactation consultants and family support groups, or providing education for faith-based organizations to share with their members.

Below are some tips from several teams and NICHQ partners on how to develop community resources to recommend to patients:

Ask families what resources they currently use.
A good place to start is asking families within your own practice what community resources they have used in the past or are currently using. Many families will have connections to community resources and can give feedback on how helpful particular organizations are.

Attend professional or family-geared, health-related resource fairs.
Finding one to attend (even if it’s family-focused) or helping a larger hospital organize a resource fair can be extremely helpful to families and practitioners. At a resource fair, you will be exposed to a variety of active and hopefully efficient groups. By talking and networking with the presenters and table managers, you will find resources that might be helpful to your patients. Make sure to get specific names and phone numbers for contacts.

Network with other professionals.
Other medical professionals in your area can be a great source of information. At local conferences or other events, ask other healthcare practitioners if they refer to particular community organizations frequently.

Cast the net wide and be open to unusual community supports.
Consider hyper-local, atypical sources. Elementary and secondary schools may have a host of afterschool programs or their own list of resources to share. And some healthcare practitioners are finding that faith-based organizations can be a support for patient and family health. These organizations can offer informational literature or free programs to help promote particular health efforts.

Seek out parent-to-parent or patient support groups for particular conditions.
Particularly with a new diagnosis of a complex health condition — such as autism, hearing loss, sickle cell or a mental health disorder — professional support groups can be invaluable to an overwhelmed parent or patient. Some are informal (e.g., church-based support groups) and others are more systematic (e.g., Hands & Voices).

Use online resources to start your search.
The Maternal and Child Health Library Community Locator is one resource practices can use to begin: http://www.mchlibrary.info/KnowledgePaths/kp_community.html

Provide patients with a contact name, number and reason that they should contact this resource.
Having a specific contact and stating explicitly what the patient should ask for from this resource will improve the chances of a successful connection.

Vet and refine your community resource list.
Be sure to make note in a patient record or electronic medical record to follow up with the patient about a recommended resource at the next visit. This will help you vet and refine your list of community resources for others.

Offer additional support for families who have intensive needs.
If your practice can manage it, patient navigators can be a good point of contact for patients who need more support. Patient navigators are specially trained staff that strengthen community connections and help guide patients through obstacles that adversely affect their health, for example, finding housing or food assistance (See “Patient ‘Navigators’ Help Manage Care and Overcome Social Obstacles for Patients with Sickle Cell Disease”).

Many thanks to Bonnie Thompson, family resource specialist and CHIPRA family leader of the Mass Family Voices at the Federation for Children with Special Needs, for providing information for this story.

Published: 2013

QI Tips: Help Patients Connect