Million HeartsŪ Community-Clinical Linkages Toolkit

Updated:Jul 5,2018

Million Hearts

American Heart Association Million Hearts® Collaboration
Community-Clinical Linkages Toolkit 2018

Introduction

The American Heart Association and the Million Hearts® Collaboration developed the Million Hearts® Community-Clinical Linkages Toolkit to complement the Centers for Disease Control and Prevention's Practitioner’s Guide: Community-Clinical Linkages for the Prevention and Control of Chronic Diseases.

Heart disease, stroke and other cardiovascular diseases kill more than 800,000 Americans each year, accounting for one in every three deaths. Cardiovascular disease is the nation’s number one killer among both men and women and the leading cause of health disparities across the population. To address this issue, the U.S. Department of Health and Human Services (HHS) established Million Hearts®, an initiative co-led by the Centers for Disease Control and Prevention (CDC) and the Centers for Medicare & Medicaid Services (CMS) that aims to prevent one million heart attacks, strokes or other cardiovascular events in five years.

The Million Hearts® Initiative coordinates and enhances cardiovascular disease prevention activities across public and private sectors and has been successful in developing tools for many partners. Public health departments play a critical role in addressing cardiovascular health needs by collaborating with community partners and advancing the Million Hearts® mission. Million Hearts® has brought together existing efforts and new programs to improve health across communities through innovative collaboration between public health, primary care, community clinics and community-centered organizations. This collaboration will continue to scale up proven clinical and community strategies to prevent heart attacks and strokes across the nation.

For more information about Million Hearts® and the resources that have been developed by the CDC Million Hearts® team, visit their webpage: https://millionhearts.hhs.gov/index.html.

Definition of Community-Clinical Linkages

Community-Clinical Linkages (CCL) are defined as connections between community and clinical sectors to improve population health. As noted in the Community-Clinical Linkages Practitioner’s Guide, community-clinical linkages are an effective approach to prevent and control chronic diseases. Research has shown Community-Clinical Linkages improve clinical outcomes in heart disease, blood pressure, cholesterol, diabetes and asthma. Community-Clinical Linkages also improve behavioral changes in nutrition, physical activity, diabetes self-management, smoking cessation and medication adherence.

The Community-Clinical Linkages Practitioner’s Guide presents strategies that involve practitioners from the public health sector who are leading efforts to link community and clinical sectors (see Figure 1).



 

 

Purpose and Goals of the Community-Clinical Linkages Toolkit

Key partners of the Million Hearts® initiative are public health departments—they play a critical role in addressing cardiovascular health needs through collaboration with community partners. The Community Clinical-Linkages Toolkit adds to the collection of Million Hearts® tools and is intended to help public health practitioners further the Million Hearts® goal of preventing heart attacks and strokes through the development and strengthening of effective community-clinical linkages.

Building on the experience, expertise, and partnership of the first five years, Million Hearts® 2022 seeks strong and specific commitments to the priorities so that together we can improve cardiovascular health for all. Public health departments are well-positioned to lead the charge to bring together community and clinical stakeholders in collaborative effort to positively impact cardiovascular health.

How Public Health Practitioners Can/Should Use the Community-Clinical Linkages toolkit

The Community-Clinical Linkages Toolkit has been developed to help public health practitioners implement the following seven step-by-step LINKAGES strategies that are highlighted in the Community-Clinical Linkages Practitioner’s Guide’s LINKAGE framework:
  • Learn about community and clinical sectors.
  • Identify and engage key stakeholders from community and clinical sectors.
  • Negotiate and agree on goals and objectives of the linkage.
  • Know which operational structure to implement.
  • Aim to coordinate and manage the linkage.
  • Grow the linkage with sustainability in mind.
  • Evaluate the linkage.

For each of these seven LINKAGE strategies, the Community-Clinical Linkages Toolkit provides resources that were obtained from state- and local-level organizations to help implement each strategy. The resources have links and brief descriptions of their contents. Wherever possible, the originating agency’s description of the entry has been used.

The user will find resource lists, white papers, case studies, examples of referral forms and clinic check-off lists. Strategies that demonstrate how to incorporate community health workers, community pharmacy programs, primary care and community outreach are also included. Additional resources address the use of electronic health records (EHR) and data to identify areas of need and activate funding sources.

Acknowledgements

Million Hearts® Collaboration Community-Clinical Linkages Workgroup:

  • American Heart Association (AHA)
  • Association of Public Health Nurses (APHN)
  • Association of State and Territorial Health Officials (ASTHO)
  • Centers for Disease Control and Prevention (CDC)
  • National Association of Chronic Disease Directors (NACDD)
  • National Association of County and City Health Officials (NACCHO)
  • National Forum for Heart Disease and Stroke Prevention
  • The Ohio State University (OSU)
  • Preventive Cardiovascular Nurses Association (PCNA)

Community-Clinical Linkages Resources

Learn

LEARN about community and clinical sectors-
Examples of assessments, such as community needs assessments by nonprofit hospitals; state or local assessment, such as an environmental scan or survey; criteria to determine which organizations of interest have the capacity and readiness to support the linkage.
TitleDescription of Resource/how it pertains to the letterType of resource (issue brief, case study, checklist, assessment)
Developing Community-Clinical Linkages for WISEWOMEN Programs (PDF)This brief provides guidance and resources for managers of CDC-funded WISEWOMAN programs to support community-clinical linkages for delivering a coordinated portfolio of services to WISEWOMAN participants.Brief
Health Equity Resource Toolkit for State Practitioners Addressing Obesity DisparitiesThe CDC toolkit and website will assist public health practitioners with a systematic approach to program planning using a health equity lens. The purpose of the Health Equity Toolkit is to increase the capacity of state health departments and their partners to work with and through communities to implement effective responses to obesity in populations that are facing health disparities.  The Toolkit provides a six-step process for planning, implementing, and evaluating a program to address obesity disparities.Toolkit- introduction with link to toolkit but also has tabs for the Purpose of the Site, Audience and How to Use this Site. Toolkit is an 83-page PDF.
Engaging Partners for Million Hearts® Success: Million Hearts® Stakeholder Workshops (PDF)This NACDD Million Hearts® Stakeholders Workshops summary document has case studies and a "how to implement a million hearts stakeholders workshop" checklist. This type of workshop brings partners together to focus on one or two aspects of Million Hearts® related issues, to scan the landscape of current activities in the state, to learn about successful approaches others have used, to identify assets and opportunities, and to develop a set of strategies and priorities and the beginning of an action plan. Case Study, Checklist
Measuring Undiagnosed Hypertension in New YorkThis case study highlights New York's collaboration with a regional health information organization (RHIO) to measure undiagnosed hypertension and presents the development, implementation and successes of 2 pilot programs. The two pilots enabled the DOH to evaluate the quality and completeness of the RHIO’s health information exchange (HIE) data and draw conclusions that will guide its data analysis for quality improvement activities related to hypertension and support continuing work with HIEs.Case Study; NACDD Success Story
Community Reports from the Cleveland ClinicThe Cleveland Clinic provides examples of Community Health Needs Assessment Reports, Community Benefit report, and an Economic Impact Report. Assessment; report
Tools for Healthcare Providers from the Preventative Cardiovascular Nurses AssociationThis website houses resources such as the Multiple Cutting-Edge Cardiac Risk Guidelines, Assessment Tools and Clinical Resources from PCNA-The Preventative Cardiovascular Nurses Association.Website with resources, multiple printable patient education resources

LEARN about community and clinical sectors-
Examples of assessments, such as community needs assessments by nonprofit hospitals; state or local assessment, such as an environmental scan or survey; criteria to determine which organizations of interest have the capacity and readiness to support the linkage.
TitleDescription of Resource/how it pertains to the letterType of resource (issue brief, case study, checklist, assessment)
Developing Community-Clinical Linkages for WISEWOMEN Programs (PDF)This brief provides guidance and resources for managers of CDC-funded WISEWOMAN programs to support community-clinical linkages for delivering a coordinated portfolio of services to WISEWOMAN participants.Brief
Health Equity Resource Toolkit for State Practitioners Addressing Obesity DisparitiesThe CDC toolkit and website will assist public health practitioners with a systematic approach to program planning using a health equity lens. The purpose of the Health Equity Toolkit is to increase the capacity of state health departments and their partners to work with and through communities to implement effective responses to obesity in populations that are facing health disparities.  The Toolkit provides a six-step process for planning, implementing, and evaluating a program to address obesity disparities.Toolkit- introduction with link to toolkit but also has tabs for the Purpose of the Site, Audience and How to Use this Site. Toolkit is an 83-page PDF.
Engaging Partners for Million Hearts® Success: Million Hearts® Stakeholder Workshops (PDF)This NACDD Million Hearts® Stakeholders Workshops summary document has case studies and a "how to implement a million hearts stakeholders workshop" checklist. This type of workshop brings partners together to focus on one or two aspects of Million Hearts® related issues, to scan the landscape of current activities in the state, to learn about successful approaches others have used, to identify assets and opportunities, and to develop a set of strategies and priorities and the beginning of an action plan. Case Study, Checklist
Measuring Undiagnosed Hypertension in New YorkThis case study highlights New York's collaboration with a regional health information organization (RHIO) to measure undiagnosed hypertension and presents the development, implementation and successes of 2 pilot programs. The two pilots enabled the DOH to evaluate the quality and completeness of the RHIO’s health information exchange (HIE) data and draw conclusions that will guide its data analysis for quality improvement activities related to hypertension and support continuing work with HIEs.Case Study; NACDD Success Story
Community Reports from the Cleveland ClinicThe Cleveland Clinic provides examples of Community Health Needs Assessment Reports, Community Benefit report, and an Economic Impact Report. Assessment; report
Tools for Healthcare Providers from the Preventative Cardiovascular Nurses AssociationThis website houses resources such as the Multiple Cutting-Edge Cardiac Risk Guidelines, Assessment Tools and Clinical Resources from PCNA-The Preventative Cardiovascular Nurses Association.Website with resources, multiple printable patient education resources

IDENTIFY and engage key stakeholders from community and clinical sectors.
Examples of how to identify key stakeholders from organizations; determining messages or themes that might resonate with them, and why they would be interested in participating in your community-clinical linkage; how to identify champions within each organization in community and clinical sectors; how to inform community-clinical linkage by conducting an educational campaign and outreach services; establishing a state or local advisory committee.
TitleDescription of Resource/how it pertains to the letterType of resource (issue brief, case study, checklist, assessment)
Creating Community-Clinical Linkages Between Community Pharmacists and Physicians (PDF)This CDC guide serves as a supplement to Community-Clinical Linkages for the Prevention and Control of Chronic Diseases: A Practitioner’s Guide, and focuses on creating community-clinical linkages between community pharmacists and physicians.  The guide provides a framework for how community pharmacists and physicians might develop a link, illustrates examples for existing linkages, and discusses common barriers.Guide
Partnering with Pharmacists in the Prevention and Control of Chronic Diseases (PDF)This CDC guide provides information to public health on partnering with pharmacists including: evidence to support maximizing pharmacists’ engagement in team-based health care; a description of how chronic diseases are addressed in community pharmacies; examples of medication therapy management from state health departments; and strategies for working with pharmacistsGuide
Engaging Partners for Million Hearts® Success: Million Hearts® Stakeholder Workshops (PDF)This NACDD Million Hearts® Stakeholders Workshops summary document has case studies and a "how to implement a million hearts stakeholders workshop" checklist. This type of workshop brings partners together to focus on one or two aspects of Million Hearts® related issues, to scan the landscape of current activities in the state, to learn about successful approaches others have used, to identify assets and opportunities, and to develop a set of strategies and priorities and the beginning of an action plan.Case Study, Checklist
Public Health Agency Payer Collaboration to Address Hypertension (PDF)Partnerships between state health agencies and public and private payers are critical to effective statewide efforts to improve hypertension identification and control. This white paper describes opportunities, strategies, and example partnerships identified through the ASTHO Million Hearts®  Learning Collaborative.White paper
Measuring Undiagnosed Hypertension in New YorkThis case study highlights New York's collaboration with a regional health information organization (RHIO) to measure undiagnosed hypertension and presents the development, implementation and successes of 2 pilot programs. The two pilots enabled the DOH to evaluate the quality and completeness of the RHIO’s health information exchange (HIE) data and draw conclusions that will guide its data analysis for quality improvement activities related to hypertension and support continuing work with HIEs.Case Study
Nevada Stakeholder Workshop for Heart Disease and StrokeThis case study describes the Nevada Million Hearts®  Stakeholder Workshop, which aims to re-engaging stakeholders, aligning goals and strategic plan for heart disease and stroke prevention in the state.Case Study
ASTHO Community-Clinical Linkages Change Package ToolkitASTHO Community-Clinical Linkages Change Package Toolkit to help states identify potential strategies in improving hypertension control by streamlining protocols for patients from the community to the clinical setting. This toolkit is meant to offer a comprehensive array and consideration of a variety of evidence-based strategies and implementation steps.Toolkit
NACCHO's Engaging Partners and Community MembersThis resource from NACCHO includes trainings and webinar for identifying and engaging stakeholders.Trainings; webinars
Increasing Adoption of EHRs and Advancing the role of CHWsTo prepare the Heart Disease and Stroke Prevention Unit at the Michigan Department of Community Health (MDCH) and its partners for the implementation of a coordinated chronic disease program and integrated work plan, MDCH hosted a Million Hearts® stakeholder workshop in May 2014 focused on increasing adoption of EHRs and advancing the role of CHWs. 

NEGOTIATE and agree on goals and objectives of the linkage.
Models or diagrams that depict the details of the linkage, such as a logic model. Examples of: Providing funding; contributing products or services, such as transportation, home medical supplies, and incentives, for patients; or providing training. Examples of how to align goals and objectives build on assets of the organizations in community and clinical sectors, such as working with the patient centered medical home (PCMH) model.
Title Description of Resource/how it pertains to the letterType of resource (issue brief, case study, checklist, assessment)
Community Health Worker Success and Opportunities for StatesThis issue brief gives a broad overview of how state public health departments can utilize CHWs to improve community health outcomes and generate cost-savings with examples from Texas, Connecticut, Michigan, and Wisconsin.Issue Brief
Public Health Agency Payer Collaboration to Address Hypertension White PaperPartnerships between state health agencies and public and private payers are critical to effective statewide efforts to improve hypertension identification and control. This white paper describes opportunities, strategies, and example partnerships identified through the ASTHO Million Hearts Learning Collaborative.White Paper
ASTHO Community-Clinical Linkages Change PackageASTHO's Community-Clinical Linkages Change Package Toolkit helps states identify potential strategies in improving hypertension control by streamlining protocols for patients from the community to the clinical setting.Toolkit
Provider and Pharmacist Collaboration to Improve Blood Pressure and Diabetes Control; Team Guide and Resources
The Community Preventive Services Task Force
The Community Guide recommends team-based care to improve blood pressure control based on strong evidence of effectiveness in improving the proportion of patients with controlled blood pressure and the economic evidence indicates that team-based care is cost-effective.Systematic review
National Prevention Strategy Clinical and Community Preventive Services (PDF)This factsheet contains action items for government and community partners in the delivery of preventive services. Preventive services are traditionally delivered in clinical settings, some can be delivered within communities, work sites, schools, residential treatment centers, or homes. Clinical preventive services can be supported and reinforced by community-based prevention, policies, and programs.Factsheet
Foundations in Privacy ToolkitThis toolkit developed in partnership by the Gray Plant Mooty law firm and the MN Department of Health helps health care providers exchange patient information from both a legal and operational perspective. It has resources to develop privacy policies and procedures and train their workforce on these complex rules.Toolkit
Meritus Health Parish Nursing Network Logic Model (PDF)This logic model graphic depicts Inputs, Activities, Outputs and Outcomes from Washington County, Maryland which formed a collaboration between the local health department, health system and faith
community nurse network to address the undiagnosed and uncontrolled hypertension in the county.
Logic Model
Metrics for Healthy CommunitiesThis example logic model provides a menu of typical inputs, activities, outputs, and outcomes for community development and health organizations that work in the Community Health Center field.Logic Model

 KNOW which operational structure to implement.
Examples of referral and feedback between two organizations at different sites or facilities; and at the same site or facility. Examples of formal agreements such as a Memorandum of Agreement, an action plan, and a contract.
TitleDescription of Resource/how it pertains to the letterType of resource (issue brief, case study, checklist, assessment)
CDC Science in BriefsCDC Science in Briefs provide concise and user- friendly on hypertension, cardiovascular disease, community health workers, pharmacists and other relevant areas.Brief
Automated Clinician Prompts and Referrals from AHRQA case study from the Agency for Healthcare Research and Quality (AHRQ) looks at a group of medical practices that incorporated a system into its daily workflow that prompt clinicians to offer behavior counseling and then refer patients to community services that could help them improve preventable health risks.Case Studies
Enhancing the Continuum of Care: Integrating Behavioral Health and Primary Care through Affiliations with FQHCs (PDF)From the National Council for Community Behavioral Healthcare, this checklist contains steps and considerations for developing affiliation agreements with Federally Qualified Health Centers.Checklist
How community-based organizations can support value-driven health care.This article in Health Affairs provides an overview of ways that community-based organizations can add value to providers and healthcare.Brief
Overview of Preparing Community-Based Organizations for Successful Health Care Partnerships. (PDF)This brief from the SCAN Foundation offers a discussion of strategic planning and leadership competencies when developing linkages, as well as the sometimes-different motivators among community-based organizations and clinical leadership.Brief
Clinical Referral and Order FormAn example of a referral form from nurses to care coordinators in a community-based care program for chronic disease management.Provider and Community-based care collaboration
Referral Tracking and Follow Up (PDF)This tool provides an overview of tracking and follow-up on patient referrals within a community-based care coordination program, identifies key connection points and relationships, and includes some additional tools to manage patient referrals.Action Plan
A synopsis of “The Hypertension Team: The Role of the Pharmacist, Nurse, and Teamwork in Hypertension Therapy” (PDF)This Science-in-Brief promotes the adoption of team-based care, and expanding the use of personal technology, which has the potential to improve self-monitoring and communication between patients and healthcare teams.Brief

AIM to coordinate and manage the linkage.
Examples of engaging communities at the grassroots level to build public will; sharing local best practices and outcomes to engage and educate decision makers; coordinating funds from diverse sources to support shared goals and strategies.
TitleDescription of Resource/how it pertains to the letterType of resource (issue brief, case study, checklist, assessment)
South Carolina Addresses Health DisparitiesOverview of South Carolina's Department of Health and Environmental Control's (DHEC) approach to addressing health disparities using cultural competency training as the model for spreading the message. Brief
Integrating Primary Care Practices and Community based Resources to Manage Obesity: A Bridge-building Toolkit for Rural Primary Care Practices (PDF)Toolkit from the Agency for Healthcare Research and Quality helps health care decision-makers – patients and clinicians, health system leaders, and policy makers – make more informed decisions and improve the quality of health care services. Toolkit
Medical Reserve Corps Million Hearts® GuideThe Virginia Department of Health Developed an example of a scripted interaction for community health worker following up with patients for and coaching and care coordination. Guidelines

GROW the linkage with sustainability in mind.
Examples of implementing small-scale community-clinical linkage activities; how to increase or maintain resources, such as funding, staffing, and electronic health records; using performance monitoring or evaluation results to make necessary changes along the way; and developing a sustainability plan.   
TitleDescription of Resource/how it pertains to the letterType of resource (issue brief, case study, checklist, assessment)
Public Health Agency Collaboration to Address HTN White PaperThis white paper from ASTHO describes partnerships between state health agencies, and public and private payers to support effective statewide efforts to improve hypertension identification and control.White Paper
Million Hearts® Student and Community Training Modules from OSUTwo educational modules designed to assist health care professionals with setting up cardiovascular screenings to screen and educate communities on cardiovascular health and Million Hearts®  screenings. Provides patient and provider information and resources.Educational module and cardiovascular screenings process (requires login).
Data Governance and Data Sharing Agreements for Community-Wide Health Information ExchangeThis case study shares lessons learned based on the experiences of six federally funded communities participating in the Beacon Community Cooperative Agreement Program, and offers guidance for navigating data governance issues and developing data sharing agreements to facilitate community-wide health information exchange. Case Study
Communications and Marketing Plan This communications and marketing plan from the Virginia Department of Health tracks the numbers of people accessing marketing and educational material and social media for their Million Hearts® Learning Collaborative.Communication plan
Good Health and Wellness in Indian Country: Community-Clinical Linkages (PDF)From the California Tribal Epidemiology Center, this resource explains the linkages between the community and clinical sectors aimed at improving population health in a tribal setting.Tips and guides
Agency for Healthcare Research and Quality. Linkages Between Clinical Practices and Community Organizations for Prevention (PDF)AHRQ recommendations on enhancing research efforts, sharing promising models, and promoting policy change to improve preventive service delivery through clinical and community linkages.Literature Review and Case Studies
AMA Business Association Agreement (PDF)This contract provides an example of a business association agreement for practices to share their data with other partners.Contract
The effect of a faith community nurse network and public health collaboration on hypertension prevention and control. (PDF)Overview and results of a faith community - public health nurse collaboration to improve hypertension prevention and control through patient self-management.Article (source APHN)

 EVALUATE the linkage.
Examples of evaluation tools; how to develop a data sharing agreement; links to AHRQ resources: Clinical-Community Relationships Evaluation Roadmap; Clinical-Community Relationships Measures Atlas; Potential Measures for Clinical-Community Relationships: A Supplement to the Clinical-Community Relationships Measures Atlas. Links to the RWJF Diabetes Initiative released a series of checklists that are tied to the Framework for Building Clinic-Community Partnerships to Support Chronic Disease Control and Prevention.
TitleDescription of Resource/how it pertains to the letterType of resource (issue brief, case study, checklist, assessment)
Community Health Worker ToolkitToolkit that compiles evidence-based research supporting the effectiveness of CHWs, information that state health departments can use to train and build capacity for CHWs in their communities, and resources that CHWs can use within their communities.Toolkit- website with links to PDFs organized by Policy Resources, Implementation and Evaluation, Training and Educational, Science in Brief, and Peer-Reviewed Literature. Section IV -Program monitoring and evaluation.
Evaluating Community-Clinical Engagement to Address Childhood Obesity (PDF)

This brief from the National Collaborative on Childhood Obesity Research is a summary of a workshop entitled "Evaluating Clinical-Community Engagement Models: What Works and What Doesn’t." It includes examples of partnerships and engagement between communities and clinical settings, an evaluation of those efforts, and recommendations to promote evaluation strategies and metrics for these engagement models.

Brief
Clinical-Community Relationships Evaluation RoadmapThis roadmap from the Agency for Healthcare Research and Quality addresses clinical-community relationships for selected clinical preventive services and is applicable to those interested in effective relationships and coordination between clinics and community organizations, such as schools or providers of social services.Framework
Clinical-Community Relationships Measures Atlas (PDF)The Clinical-Community Relationships Measures (CCRM) Atlas is designed to provide users with a measurement framework and listing of existing measures for clinical-community relationships; intended to help facilitate research, quality improvement projects, and other interventions investigating clinical-community relationships that have been formed for the purposes of improving the delivery of clinical preventive services; and intended to be used by researchers studying clinical-community relationships as well as evaluators of these relationships.Framework
Building Relationships Between Clinical Practices and the Community to Improve CareA comprehensive AHRQ website with links to Clinical-Community Relationships Measures (CCRM) evaluation resources and quality tools.Guides
What Is Health EquityThis RWJF report defines health equity and identifies crucial elements to guide effective action to reduce disparities in health status. 
CDC Framework for Program EvaluationGuides public health professionals in their use of program evaluation. It is a practical, nonprescriptive tool, designed to summarize and organize essential elements of program evaluation.