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Table 3 Synergy 3 – Identifying and addressing community health problems

From: A population-based approach to integrated healthcare delivery: a scoping review of clinical care and public health collaboration

Intervention Key features
A. Conduct community health assessments 1. Facilitates planning and development of health programs and services (for both PC and PH):
2. Ensures that health programs and services offered by PC and PH are responsive to local community needs
3. Allows efficient allocation of limited health resources
4. Community health assessments are more robust if they aggregate data from multiple sources: quantitative data from EHRs, administrative databases or surveys, and qualitative information from community meetings, interviews, and focus groups (and if the data is analyzed from multiple perspectives)
B. Use clinical encounters and share data to build community-wide databases 1. Collaborations can draw on a broad range of data systems including electronic health records, vital records such as electronic birth certificates, surveillance systems targeted at communicable diseases, antibiotic resistance, or behavioral risk factors, and disease-specific registries centered around as cancer, trauma, asthma, tuberculosis, immunization etc.
2. Input from public health practitioners is valuable in elucidating how the information in the system would be used to monitor health outcomes, to determine where clinical services are being delivered, or to target outreach efforts and media campaigns
3. Public health data can be utilized to produce reports on health and disease status of patients at the primary care practice level. This helps to understand needs of practice population and identify specific actions to address local health needs
4. Practice lists can be utilized to design health interventions, track health outcomes, and target specific high-risk patient populations
5. Standardized demographic data in health care settings that can identify gaps and point toward best practices for eliminating disparities
C. Use clinical opportunities to identify and address underlying causes of health problems 1. Collaborations focus on health problems with prominent environmental, social and behavioral risk factors such as lead toxicity, tobacco use, and domestic violence
2. Patients are be provided with targeted counselling and educational materials about personal behaviors such as smoking, sedentary lifestyle or heavy drinking, and referred to appropriate community programs
3. Connections can be made to patients’ social or physical environment in order to test a disease contact or assess potentially toxic worksites/homes