Million Hearts Tools for Change Resources

Community-Clinical Linkages

Referral Systems and Protocols from Clinical Sites to Community Resources*

*NOTE: Community resources may include community-based care coordination services, community team-based care, and/or self-management resources

Community Team-Based Care for Hypertension Management Implementation Protocol (Arkansas)
This document outlines the implementation protocol for a community team-based care model being tested by an Arkansas Department of Health Local Health Unit and a private community physician to provide community team-based care for patients with uncontrolled hypertension.

Clinician Referral and Order Form to Nurse Care Coordinators (Arkansas)
This referral form was developed by the Community Team-Based Care Program for Chronic Disease Management for use by physicians for recommending patients in need of care to Arkansas Department of Health Nurse Care Coordinators.

Patient Workflow for Check. Change. Control. Program (Kent County, Maryland)
Detailing the relationship between the Clinical-community Linkage Coordinator and the Health Mentor within the Check. Change. Control. Hypertension initiative, this workflow identifies all of the stages of patient engagement for program completion.

Referral Form for Chronic Disease Self-Management Program (St. Mary’s County, Maryland) 
Utilizing the “Living Well: Take Charge of Your Health” evidence-based program for chronic health conditions, this referral form allows clinicians to refer patients who are at-risk or high-risk for chronic disease to the chronic disease self-management program.

ASTHO Million Hearts Success Story: NY Develops Clinical Pathway to Identify and Manage Adult Hypertension
Through the ASTHO Million Hearts State Learning Collaborative, one local clinic in New York is working with the New York State Department of Health (NYSDOH) and other state and local partners to develop and implement a standardized clinical pathway to identify and manage patients with uncontrolled and undiagnosed hypertension.

Provider Referral Form (Ohio) 
Summit County, Ohio provides email/fax referral form for clinical providers to use to refer patients to the Summit County Public Health Care Coordination Unit.

Check it. Change it. Control it. Public Health-Community Partnership Development (Ohio) [recording]
On a peer group call for ASTHO's learning collaborative in April 2014, Summit County presented about how their local health department offers residents free community services connections, and assist them through the process of getting the help they need (view the slide deck).

Creating Community-Clinical Linkages to Address & Prevent Chronic Disease [webinar]
In June 2015, NACCHO hosted a webinar featuring Summit County Public Health’s (Summit County, Ohio) robust referral networks linking primary care providers with public health and community resources. During this webinar, Summit County Public Health describe their experiences working with local and state partners to build bi-directional referral networks between public health and primary care physicians. Access recording and slides.

Oklahoma Million Hearts Patient Process Flow 
The Oklahoma State Department of Health led a team of state and local partners to develop a protocol for identifying and referring individuals with hypertension into a public health nurse-driven care coordination system. This flow chart depicts the protocol for this “Heartland OK” referral system.

Provider Referral Form (Oklahoma) 
Pittsburg County, Oklahoma provides fax referral form for clinical providers to use to refer patients to the Pittsburg County Health Department for care coordination services.

Heartland OK Patient Progress Report (Oklahoma)
This progress report form supports the “Heartland OK” referral system. The public health nurse care coordinator sends the completed form monthly to each participating individual’s provider. The form includes a summary of referrals made to community-based resources and the patient’s progress in achieving their clinical management plan.

ASTHO Case Study: Oklahoma Million Hearts Learning Collaborative
Through the ASTHO Million Hearts Learning Collaborative, Oklahoma is improving hypertension identification and control by establishing clinical referral and follow-up protocols, linking individuals with hypertension to clinical care and public health nurse care coordination resources, and exploring innovative payment models.

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