1. Community and Clinician Partnership for Prevention (C2P2) Alex R. Kemper, MD, MPH, MS Philip Sloane, MD, MPH Rowena Dolor, MD, MHS Tricia L. Trinite’, MSPH, ANP-BC Funding: AHRQ; PBRN Task Order Request #1

2. Background Unhealthy behaviors are common and lead to significant morbidity and mortality –Tobacco use –Poor diet –Lack of physical activity

3. Background Rate of behavioral-based interventions to address unhealthy behaviors by primary care providers is low –Lack of knowledge –Poor self-efficacy –Challenge of delivering interventions in a busy setting with limited capacity

4. Chronic Care Model

5. Objective To evaluate strategies to develop and foster linkages between primary care practices and community resources

6. Setting www.learnnc.org Orange County: Population: 120,000 Black: 13% Hispanic: 6% Durham County: Population 230,000 Black 37% Hispanic 11% Overall, 13% below FPL In North Carolina Tobacco: 25% Overweight: 36% Obese: 27% ≥ 20 minutes physical activity ≥3 days per week: <25% Ready to change: 44% who smoke, 60% with poor nutrition, 68% who lack exercise

7. Participants and Interventions Control Duration of the Intervention: 6 month, starting spring 2008 9 Practices (IM and FP) Passive Intervention Active Intervention R

8. Practices Control –3 family practice clinics Passive Intervention –1 family practice clinic –2 internal medicine clinics Active Intervention –2 family practice clinics (1 with trainees) –1 internal medicine

9. Initial Selection of Community- Based Resources Behavioral-based interventions based on the 5 A’s Must be accessible Interested in new referrals Able to participate in bi-directional communication

10. Initial Community-Based Resources Tobacco Quitline Public Health Department Dietitians YMCA Duke Live-for-Life Program

11. Passive Intervention Brochure and referral material for selected community organizations: Practice kick-off meeting Brief help as requested

12. Practice Brochure

14. Active Intervention Passive Intervention Protocol plus: –Access to the “ACCTION Pack” –More regular contact with a “practice champion”

15. ACCTION Pack

17. Outcome Measures Main Quantitative Measure: –Referral from practices to a community resource Description of the barriers to and facilitators of developing linkages between practices and community resources

18. Tobacco Assessment BaselineMidpointFinal Control41%56% Passive46%53%54% Active80%72%

19. Tobacco Use BaselineMidpointFinal Control9%13%9% Passive6%9%11% Active14%12%13%

20. Tobacco Referral BaselineMidpointFinal Control3% (1)0%2% (1) Passive4% (1)0%7% (4) Active6% (3)11% (6)5% (3) No intervention effect

21. Diet Assessment BaselineMidpointFinal Control15%22%25% Passive10%27%28% Active36%31%38%

22. Diet Needs Modification BaselineMidpointFinal Control8%16%19% Passive7%21%24% Active25%22%31%

23. Diet Needs Referral BaselineMidpointFinal Control3% (1)7% (5)7% (7) Passive14% (4)6% (7)7% (9) Active14% (11)6% (6)6% (10) No intervention effect

24. Physical Activity Assessment BaselineMidpointFinal Control21%27%30% Passive17%32%29% Active41%35%37%

25. Physical Activity Needs Modification BaselineMidpointFinal Control11%15%21% Passive9%21%23% Active21% 30%

26. Physical Activity Referral BaselineMidpointFinal Control1% (2)3% (2)2% (2) Passive2% (1)1% (1) Active8% (6)4% (4)0% (0) No intervention effect

27. What limited the impact of the interventions? Little understanding about how to build collaborations –Physicians were not motivated to form collaborations, even when they were interested in engaging the community –Organizations had significant staff turnover –No method for bi-directional communication Concerns about cost Concerns about treatment No information about outcomes

28. What limited the impact of the interventions? ACCTION Pack –Difficult to use to get to information quickly –Not populated with local resources –Practices wanted handouts –Practices overwhelmed with material

29. Conclusions and Next Steps Forming partnerships between clinicians and community-based organizations is difficult Successful partnerships cannot be developed by bringing materials to practices alone

30. Conclusions and Next Steps Future efforts should –work on bringing together potential partners and allowing them to develop mutually beneficial collaborations –focus on increasing consumer demand and the expectation that primary care providers will refer to such organizations

31. Thank You!