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www.cpsi.ahrq.gov/ncepcr/tools/workforce-financing/white-paper.html
July 01, 2019 - For example, in Learning to Integrate Neighborhoods and Clinical Care (LINCC), Group Health patients … co-designed a community resource specialist role for primary care. 28 Patients designed the community … health liaison job description and activities, served on a community oversight board to link neighborhood … So it follows that different types of staff and providers make up the care team in different communities … Creating a Clinic-Community Liaison Role in Primary Care: Engaging Patients and Community in Health Care
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www.cpsi.ahrq.gov/funding/policies/nofoguidance/index.html
January 01, 2024 - Priorities include:
Research to engage people and communities in care
Strategies to engage and empower … Models of community involvement, for example, co-design or community-based participatory research to … Priorities include:
Patient, practice, community, and health system level interventions, including … address social determinants of health (SDoH) and optimize health outcomes among high-risk individuals, communities … priorities:
Co-design of interventions and co-creating evidence in partnership with patients, caregivers, communities
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www.cpsi.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/primary-care/tpc/impact-profile-nm.pdf
April 01, 2015 - New Mexico’s IMPaCT grant drew on existing community-based
efforts to address social determinants of … Health extension coordinators (also called “HEROs”) were
chosen by the communities in which they serve … university employees with backgrounds
in health fields and are aware of the resources
available in their communities … The IMPaCT project also helped spur a growing community health worker program serving high-
risk … enrollees while helping New Mexico implement Medicaid Managed Care certification for its
community
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www.cpsi.ahrq.gov/innovations/index.html
August 01, 2021 - Downloadable Databases
Connecting Those at Risk to Care: Quick Start Guide
Pathways Community … Innovations Exchange previously offered a range of learning and networking opportunities including learning communities … Connecting Those at Risk to Care: The Quick Start Guide to Developing Community Care Coordination Pathways … Pathways Community HUB Manual: A Guide to Identify and Address Risk Factors, Reduce Costs, and Improve
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www.cpsi.ahrq.gov/ncepcr/tools/obesity/obpcp-support.html
May 01, 2014 - Studies
Health Assessments
Obesity Management
Obesity Toolkit
Research Communities … Other Publications
Funding Opportunities
Integrating Primary Care Practices and Community-based … Previous Page Next Page
Table of Contents
Integrating Primary Care Practices and Community-based … Foundation
Chapter 3: Getting Patients Excited About Crossing the Bridge
Chapter 4: Building the Community … Sample Community Inventory Form
Tool 9. Sample Prescription Pad
Tool 10.
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www.cpsi.ahrq.gov/ncepcr/tools/obesity/obpcp-tool6.html
May 01, 2014 - Studies
Health Assessments
Obesity Management
Obesity Toolkit
Research Communities … Other Publications
Funding Opportunities
Integrating Primary Care Practices and Community-based … Previous Page Next Page
Table of Contents
Integrating Primary Care Practices and Community-based … Foundation
Chapter 3: Getting Patients Excited About Crossing the Bridge
Chapter 4: Building the Community … Sample Community Inventory Form
Tool 9. Sample Prescription Pad
Tool 10.
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www.cpsi.ahrq.gov/ncepcr/communities/pbrn/registry/clinical-directors-network-inc.html
January 01, 2012 - National Center
Research Initiatives
Data Resources
Tools and Resources
Research Communities … Network Founded:
January 1, 1985
Network Mission Statement:
We are a network that supports community-based … A community-based health care center is one that is committed to improving the overall health of individuals … , families and communities by focusing on their primary medical, dental and/or behavioral well-being.
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www.cpsi.ahrq.gov/ncepcr/research-transform-primary-care/transform/impactgrants/impact-profile-ok.html
April 01, 2015 - Care Research
Research Initiatives
Data Resources
Tools and Resources
Research Communities … The story of this program's success lies in the power of working at the community level and developing … relationships to sustain local community health organizations. … The team was able to connect practice managers to community resources, so that each practice now has … Although the hospital and Community Health Centers are using electronic health records, they are not
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www.cpsi.ahrq.gov/research/findings/studies/index.html
January 01, 2024 - Infections
(59)
Community-Based Practice
(150)
Community Partnerships
(18)
Comparative Effectiveness … Exposure was ZIP code-level Child Opportunity Index (COI), a composite measure of neighborhood resources … Decreasing neighborhood opportunity was associated with increasing hospitalization rates among children … Association of neighborhood opportunity and pediatric hospitalization rates in the United States. … ED, and 60,725 from a rural community ED.
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www.cpsi.ahrq.gov/patient-safety/settings/hospital/resource/guide/web5.html
December 01, 2017 - Describe the important position that hospitals are in to lead delivery system transformation in their communities … Community Resource Guide.
Cross Continuum Collaboration.
ED Care Plan Examples. … Community Health Centers.
Behavioral Health Homes.
Resident Physician Clinics. … Slide 12: Community Resource Guide (Tool 11)
Image: The first page of the Community Resource Guide … The natural first choice was the large community behavioral health center.
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www.cpsi.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/primary-care/tpc/final-impact-synthesis-report.pdf
July 22, 2015 - Expand existing programs to allow primary care practices and communities to benefit
now
3. … HEROs are
chosen by the communities in which they serve and live, ensuring that they are locally
responsive … with
backgrounds in health fields, and therefore are aware of both the resources available in their
communities … transformation efforts by connecting work being
done in the Adirondacks, Hudson Valley, and Beacon communities … Community Care of North Carolina. The Community Care of North Carolina Toolkit.
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www.cpsi.ahrq.gov/news/blog/ahrqviews/achieve-health-equity.html
August 01, 2021 - These communities are most likely to experience interruptions of work and income. … Immigrants and people in communities of color often work in jobs deemed essential, such as the food services … But as we have learned, it was not just patients lacking access, but also providers working in community … health clinics that serve poor communities, where appropriate technology and resources were inadequate … When we examine this crisis and apply lessons to improve the health of vulnerable communities, we must
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www.cpsi.ahrq.gov/news/blog/ahrqviews/ahrq-pcori-collaborate.html
February 01, 2023 - Support partnerships with community organizations, healthcare systems, and other stakeholders. … Insights from community organizations about the root causes of local and regional health challenges are … meaningful engagement by calling for partnerships between health systems, academic institutions, and community … spread knowledge, advance health system performance, and improve outcomes that matter to patients and communities … diverse research workforce that is representative of the breadth of backgrounds and cultures of the communities
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www.cpsi.ahrq.gov/ncepcr/research-transform-primary-care/transform/synthesis-report/appa.html
October 01, 2015 - Care Research
Research Initiatives
Data Resources
Tools and Resources
Research Communities … between 4 and 8 primary care clinicians (although some included large sites)
Medically underserved communities … Health Centers
Southeast Pennsylvania (including inner-city, suburban, almost-rural, and underserved communities … Neil Calman, MD; A Study of the PCMH: Lessons From a New York State Community Health Center Network … Practices strengthened their linkages with community resources and partners and implemented strategies
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www.cpsi.ahrq.gov/ncepcr/reports/grants-transform/key-characteristics.html
March 01, 2017 - National Center
Research Initiatives
Data Resources
Tools and Resources
Research Communities … between 4 and 8 primary care clinicians (although some included large sites)
Medically underserved communities … Health Centers
Southeast Pennsylvania (including inner-city, suburban, almost-rural, and underserved communities … Neil Calman, MD; A Study of the PCMH: Lessons From a New York State Community Health Center Network … Practices strengthened their linkages with community resources and partners and implemented strategies
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www.cpsi.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/medicaidreadmitguide/mcaidread_tool9_trans_care.docx
July 28, 2016 - for more information on implementing a reliable, whole-person transitional care process, and Tool 11: Community … Resource Guide for community resource information that can be used to populate the right side of the … Best practice is to share this assessment with “receiving” providers in the community. … behavioral health services
· Link to community health worker or navigator programs
· Link to housing … services agency
· Link to food program
· Link to county health department provided services
· Link to community
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www.cpsi.ahrq.gov/data/qualityindicators/index.html
November 01, 2020 - these indicators are based on hospital inpatient data, they provide insight into the health of the community … and the community-based healthcare system. … to identify and investigate communities that may need interventions. … In addition, they provide a quick check on primary care access or outpatient services in a community … and help organizations identify unmet needs in their communities.
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www.cpsi.ahrq.gov/ncepcr/care/coordination/atlas/chapter6m.html
June 01, 2014 - National Center
Research Initiatives
Data Resources
Tools and Resources
Research Communities … follow up, and respond to change
Support self-management goals
■
Link to community … follow up, and respond to change
□
Support self-management goals
□
Link to community … VA Community-Based Outpatient Clinics: Performance measures based on patient perceptions of care. … Format/Data Source: 49-item questionnaire covering 4 key domains: (1) information exchange (community
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www.cpsi.ahrq.gov/evidencenow/projects/heart-health/research-results/results/publications.html
June 01, 2023 - Multi-party agreements involved the JF Maddox foundation, a local community college, local community … The University has since exported this model to other rural communities in the State. … describes how the Healthy Hearts for Oklahoma Cooperative partnered with public health agencies and communities … Findings indicate that this technique yielded messages and materials tailored to different communities … HEROs, based in communities across the state, link priority community health needs with university resources
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www.cpsi.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/medicaidreadmitguide/aspire_webinar3/aspire_webinar3.pptx
December 01, 2014 - Understand the utility of leveraging and coordinating all existing resources – in the hospital and the community … Services for High-Risk Patients
List of Tools
Data Analysis
Readmission Review
Hospital Inventory
Community … “You don’t understand, there are just no resources in the community”
Inventory Community Efforts … & Resources
Post-acute and community providers may offer services and supports hospital staff are unaware … and behavioral health care clinical information
Continue to innovate to meet need of patients
Community