Clinical-Community Partnerships for Better Health: Observations from New York City's Partnerships for Early Childhood Development Initiative

Read the related press release.

There is increasing awareness that social determinants of health affect physical and mental health outcomes. This is especially true in early childhood. Social determinants, particularly those that lead to toxic stress, can stunt a young child's brain development and thereby impact their life-long health. In March 2017 the United Hospital Fund, in collaboration with the Altman Foundation and The New York Community Trust, launched a learning collaborative and grant initiative called Partnerships for Early Childhood Development (PECD), which supports clinical-community partnerships to address social needs of children ages 0-5 and their families. Even in its first year, PECD has resulted in a number of observations and lessons that may be helpful to others seeking to begin these kinds of partnerships themselves.

A report recounting these observations may be downloaded on this page. Click here for the related press release.

About PECD
In its first year PECD provided $700,000 to 11 New York City hospital-based primary care practices to build partnerships with one or more of 17 community-based organizations. Under the initiative, each of the 11 clinical-community partnership teams designed and implemented its own social determinants of health project to screen families for social needs, refer families to community partners, and close the referral loop to ensure timely and effective feedback and follow-up. A learning collaborative brought all participants together to share best practices and learn from each other's experiences.

PECD by the Numbers

11 primary care practices
17 CBO partners

Aggregate Results
5,534 families screened
1,890 positive screens
634 families referred
395 families used CBO services
78 times feedback loop was closed

Most Common Needs (% positive screen rate)
36% adult education needs
31% child behavioral and developmental needs
21% quality child care needs
18% food support needs

Project Results
Over 5,500 families were screened in the first year, and nearly 1,900 of these families were identified as having one or more social need. The most common social needs were related to adult education, child care, and food insecurity. In addition, large numbers of children were identified as having behavioral, developmental, or emotional challenges. Referral rates were reasonably high, frequently above 50 percent, but rates of service use and referral feedback to the initiating provider were much lower. This was due to barriers teams faced in tracking referrals and sharing information, as well as the various social hurdles that kept some families from seeking services. Closing the feedback loop and strengthening approaches to help families connect to community services will be an important focus in the second year of PECD.

Common Challenges
Teams faced several challenges implementing their projects. Workflow inefficiencies, technology limitations, and workforce issues were among the most common and significant challenges. Most workflows relied on paper screens, since more efficient alternatives – such as tablets that sync with electronic health records (EHRs) – were not universally available to teams. This created paper management issues, including the hassle of manually entering screening results into databases. Teams also struggled with tracking referrals and sharing information between or across sites because of technology limitations. Teams' EHR systems were not helpful for either of these purposes because they did not contain a data field for tracking referrals and because their community partners did not have access to these systems. As workarounds, most teams used RedCAP or Excel databases to track referrals, which usually meant that to close the feedback loop teams would have to manually reconcile databases with their community partners. Legal issues surrounding patient privacy were another challenge in sharing information between and across sites.

In terms of workforce challenges, some teams found it hard to get buy-in from clinicians. Teams observed that building and training their workforces, in general, required considerable amounts of time, energy, and planning. Ensuring families understood the purpose of screening, and were comfortable with it, was another challenge. Nearly all teams reported immigrant families as being particularly hesitant to complete screenings or seek community services due to fear of reprisal. Finally, the teams with multiple partners and the teams screening for multiple needs faced the added challenge of having to create (and refine) more complex systems of care and referral pathways.

Promising Practices
Teams used a number of practices to work through and around some of the challenges described, many of which are ongoing. To get buy-in from clinicians, teams invited their community partners to come into the clinic and present about the services they offered. Several practices also began rotating their medical residents through their community partner site, which increased enthusiasm for social determinants of health screening and referrals. Sharing stories of families whose needs were addressed through referrals also helped with clinician buy-in. As a strategy for getting families to complete screens at higher rates, teams trained staff on how to explain the purpose of the screens in a culturally sensitive manner. Teams also trained staff on immigrants' rights so they would be prepared to speak knowledgably about the subject if a family wanted to discuss it. Using bilingual staff and staff that reflected the patients' demographics were also helpful for increasing screen completion rates.

As a strategy for ensuring better linkages between the clinic site and the community partner, one team jointly hired, and now co-manages, a community health worker. Risk stratification methods were also employed to better match care management approaches and supportive services to the level of family need. Lacking EHR systems that could track referrals and share information with community partners, teams used RedCAP and Excel databases for those purposes. To improve efficiency in these areas, some teams plan on using technologies like NowPow and Epic Community Connect in the second year of PECD. Lastly, although paper screens are inherently inefficient, one team improved its workflow by placing checkpoints around the clinic to remind staff on how to handle completed screens.

Tips for Forming Partnerships
Building strong clinical and community organization partnerships requires effort on both sides, including setting aside face-to-face meeting time early on. Such meeting time was enormously helpful for PECD teams in that it allowed partners to understand each other's service capacities and delivery processes, work through organizational cultural differences, and create shared goals for the near term and the long run. The collective understanding developed during this meeting time is especially important for partnerships seeking to address multiple social needs. In addition, the experience of PECD teams suggests that strong clinical-community partnerships require budgeting for the participation of community partners. One third of all PECD funds was passed onto community partners as compensation for their participation. This distribution of grant funds was essential to the success of these organizations in partnering with health systems.

PECD Moving Forward
Building on the progress made in its first year, the second year of PECD is scheduled to begin in July 2018. Eight grantees and their community partners will continue into this second year, with a focus on streamlining teams' workflows, expanding their screening programs, and improving their processes for closing the feedback loop and connecting families to services.