Missing pieces in Clinical-Community Linkages

In the world of public and community health, there are services and opportunities galore. But often, these services are siloed. Clinical services like behavioral health treatment and primary care stand separate from social services like Medicaid enrollment and job coaching assistance. Strengthening public health requires connecting all of these resources in intentional and relevant ways. One strategy to do this is Clinical-Community Linkages. The Centers for Disease Control and Prevention defines CCLs as “connections between community and clinical sectors to improve population health.” The CDC CCL model is shown below.

CDC CCL model, n.d.

While the CDC’s model provides a solid foundation for CCLs, there are a few missing pieces that we’ve encountered at Everyday Life Consulting. First, the CCL doesn’t include the individual level, which is essential for entering both community and clinical sectors. Second, Community Health Workers (CHWs) must be involved in the CCL implementation in order for it to be effective. Third, there are opportunities to further break down the community sector to include additional sectors, such as housing, food, and education sectors. While the CCL focuses on connecting the general community sector to the clinical one, we recognize that sectors within the community must also be linked. Below, we examine each of these missing pieces in more detail.

Including the Individual Level

The socioecological model begins with the individual. The CCL should, too. Connecting community sector services with clinical sector services will only serve the individuals involved in one or both sectors. But individuals may not be using either, and that leaves out those who need integrated care from both community and clinical services most. Additionally, as sectors are linked, some individuals may only be comfortable with the sector they’ve traditionally been connected to. For example, a woman who relies on a local food pantry for meals may not feel comfortable using other services to secure Medicaid and then visit a primary care provider.

Involving CHWs

CHWs are employed in all three sectors identified by the CCL. CHWs can provide invaluable insights and bring resident voices to efforts associated with linking services. CHWs understand where the clients are, how they access services, what hesitation they may feel, and strategies to address those feelings. And ultimately, it is CHWs who will implement the actual linking of services. Because CHWs refer individuals to services across all sectors, they will use EHRs, referral systems, and other tools to effectively link sectors.

Restructuring the CCL

The current model of CCLs remains siloed; each sector is separate from the others but connected by public health. To truly connect clinical and community services, Everyday Life Consulting uses an enhanced model of the CCL. Our model combines the structure of the socioecological model, which demonstrates how every sector and factor will impact the individual and vice versa, with the sectors of the CCL. Our model begins with the individual/family, then the organization/agency/provider, followed by the community sector which is broken down by specific social determinants of health. The last aspect of our model is community collective action.

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