Community-clinical partnerships need trust, funding, and clear goals

Community-clinical partnerships need credibility if they are going to help patients improve their health, according to two physicians who helped write a National Academies report on the topic. The report, Using Community Partnerships to Inform the Prevention Strategy of the Center for Medicare and Medicaid Innovation, was published this year by the National Academies of Science, Engineering and Medicine after a request from Medicare to review the evidence and consider whether new payment and policy approaches are needed. The report’s authors say accountable care organizations may be a practical place to begin building these relationships, but they are not the only possible model.

Medical Economics spoke with two of the report’s co-authors: Alex H. Krist, M.D., M.P.H., a professor of family medicine at Virginia Commonwealth University, and Andrea A. Anderson, M.D., M.Ed., FAAFP, a family physician and associate professor at George Washington University School of Medicine and Health Sciences. Both continue to practice family medicine. In their view, the basic challenge is not simply connecting a clinician with a community program. It is creating a relationship that patients can trust, that both organizations understand, and that can last long enough to make a difference in chronic disease prevention and management.

Anderson said communication is central to making those partnerships credible. Clinicians need to understand what a community partner is offering, what the clinical organization is trying to accomplish, and how both sides are aligned in what they present to patients. She said that matters when a patient is referred for help with conditions such as diabetes, because the clinician should know what the community partner teaches and how that partner supports the patient. She also said misinformation makes the challenge more urgent. In her view, repeated contact with a trusted community program can reinforce a patient’s long-term goals, whether those goals involve managing diabetes, obesity, or hypertension. But that trust can be lost when funding disappears and a program ends, making it harder to rebuild later.

Krist said that authentic engagement has to come first. In his view, a community-clinical partnership should begin as a real and equitable relationship between organizations, not as a one-way referral system. He said the health care system has often responded to the root causes of poor health by sending patients elsewhere rather than forming true partnerships. He also said current payment models can concentrate most of the money in health systems while leaving community organizations under-resourced. The report is direct about the need for fairness in how resources are distributed, he said. At the same time, he argued that doing partnership work well strengthens trust because it shows that clinical care systems are interested in improving health, not simply generating billing. A warm referral from a physician can also transfer some of that trust to the community partner and reassure the patient that the program is real, vetted, and intended to help.

Anderson described that warm handoff as especially powerful. In her example, a physician can tell a patient to visit a specific program and even name the person to ask for. When the community partner then says the patient was sent by the physician, the connection can build confidence on both sides. Krist said that sort of familiarity is common in successful professional relationships, and the report is meant to show how it could be codified and expanded at scale. The authors said the larger point is that partnerships are not just about one organization referring work to another. They are about building a shared foundation that gives patients repeated, trusted support over time and gives clinicians a way to extend care beyond the exam room.

On the question of which organizations should lead such efforts, Krist said accountable care organizations are a strong starting point. He defined ACOs as provider-led organizations accountable for the quality and cost of care for a defined patient population. In his view, they offer a useful framework because they already have organizational capacity and incentive structures that can align with community partnership work. Since ACOs are intended to improve outcomes and lower costs, they are a logical fit for partnerships that aim to help patients better manage chronic conditions and prevent future illness. He also said CMS is likely to be interested in supporting ACOs in this work. Still, he emphasized that other models could also work, including health systems, clinical practice groups, and community-based approaches built around a geographic region rather than a single institution.

Anderson agreed that community-clinical partnerships can take many forms and should not be limited to one type of patient or one segment of the population. She said virtually everyone manages at least one health issue, and many people can benefit from learning how to manage chronic illness or prevent disease before it starts. That, she said, is part of the broader role of primary care and prevention. The report’s recommendations, she added, are intended to support those goals by showing how community partnerships can help with chronic disease management and prevention in a way that reaches more people.

For primary care physicians reading the report, Krist said the document was designed as a roadmap. It gathers examples and references that can help CMS, clinicians, health systems, and community organizations think about how to move forward. Anderson said the underlying message is that primary care is a team sport. High-quality primary care requires the whole team, including partners outside the walls of the health care center. That means working together, investing financially in community relationships, and also investing at the system level in evaluation so partnerships can be sustained and improved. She said the goal is to build and maintain the kind of collaboration that helps primary care do what it is set up to do: support patients’ health over the long term.

The report’s authors framed that work as a practical next step for Medicare and for the organizations that serve patients in the community. Their message was not that one model will solve every problem, but that durable partnerships, fair funding, and clear communication can help make community-clinical collaboration more credible and more effective. In their telling, the future of these partnerships will depend on whether clinicians, health systems, and community groups can align around shared goals and sustain the relationships needed to support patients beyond a single referral.