Individual clinicians and clinic support staff operating in clinical settings in which primary care is delivered. This element encompasses two entities—the primary care clinic and the individual primary care clinician. For the purpose of this framework, the primary care clinic/clinician element serves as the initiation point for clinical-community relationships (i.e., where referrals for preventive services originate).
A range of organizations and programs that provide services to patients, including USPSTF-recommended clinical preventive services. A community resource needs to maintain staffing and other resources to provide its range of services and programs.
The individual who receives primary care services, including preventive care and illness care; this definition includes family members and/or others directly responsible for the care of the individual. The patient is the subject of a referral and there are factors specific to a patient outside of the patient’s relationship with either the clinician or the community resource that may affect whether or not a clinician’s referral to a community resource has the desired result.
The interaction between the clinic/clinician and community resource, in which two organizations must be aware of each other, find some common benefit that can be derived from the connection, and then establish routine systems of maintaining that connection in a manner that produces a positive cost-benefit ratio or increased perceived value. To the extent that communication and coordination between organizations appears to be seamless from the patient’s perspective, there will likely be more effective service delivery.
The interaction between the clinic/clinician and patient. There must be a level of trust between the clinician and the patient for the clinical-community relationship to work. These parties must be cognizant of each other’s expectations, needs and situation; the better the communication between the clinician and patient, the more likely a clinical-community relationship will be effective.
The interaction between the patient and the community resource. The level of patient trust in a relationship with a community resource and the community resource’s ability to engage the patient can affect the community resource’s success in providing appropriate preventive services.
The physical and organizational properties of a setting in which care is provided. Some structure domains in the framework relate to information technology infrastructure, capacity to provide particular health services, and patient access to health care services.
The treatment or service being provided to a patient. The process domains in the framework relate to care planning and referrals. Process factors in this context may also be broadened to include any activity or service that would facilitate providing preventive services by a community resource.
Results of the treatment or service. Outcome domains relate to the patient’s receipt of services and clinician and patient experiences of care. Domains related to patient health outcomes are not included.
What is the Clinical-Community Relationships Measures (CCRM) Database and what does it do?
Relationships among patients, primary care clinics/clinicians, and community resources can be measured. In the context of the CCRM Database, a clinical-community relationship exists when a primary care clinician makes a connection with a community resource to provide certain preventive services such as tobacco screening and counseling. The clinical practice and the community resource may engage by networking, coordinating, cooperating, or collaborating. The Clinical-Community Relationships Measures (CCRM) Database provides a framework for understanding the measurement of clinical-community relationships and provides information about existing measures.
The CCRM Database, based on AHRQ's Clinical-Community Relationships Measures Atlas, is intended to assist researchers and evaluators interested in clinical-community relationships measurement and primary care clinicians and community organizations using clinical-community relationships to provide prevention services to patients. Users of the Database can identify and compare validated tools for clinical-community relationships measurement to find those that are most appropriate for their needs.
For more information about how the CCRM Database was developed, please refer to the Background page. To learn more about implementing clinical-community relationships, please consult the related resources below.
Related Resources and Content
How to use the Database
Users can conduct a search of measurement tools by either:
- Selecting elements of the framework (patients, clinicians/clinics, and community resources) and the interactions between each
- Selecting a type of measure, such as structure, process, or outcome
Search results provide users with a list of measurement tools that fit the selected criteria. Summary pages are available that can help users learn more about the background, validation, and content of each measurement tool.
Begin using the Database now by proceeding to the Search page and making selections in the left sidebar.