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Module 6: Introduction to Linking with Your Community

"We have to look at community resources because our families are living in the community full time," explains Paula Duncan, M.D., a pediatrician at the University of Vermont and one of the participants of the Healthy Development Collaborative. "We see them in the office once every two to three months initially—and eventually only once a year." But finding effective partners in your community is an ongoing, evolving process. It can be daunting to identify all of the community resources that your practice might want to refer patients to and to set up systems to support coordination with those resources. Lack of time, knowledge, and staff resources are among the challenges that might limit practices' use of community resources.

To avoid having the task seem insurmountable, narrow your focus initially to one or two services your patients need most frequently and one or two strategies for linking to those services. "We may need to partner with early intervention specialists, for example, who have expertise that we don't have about development and learning," explains Duncan. "Most clinicians welcome the help and the expertise that other professionals in the community can provide." Learn as much as you can about community resources for those topics and then develop good systems for working with the organizations that provide relevant services. What you learn by fully developing one or two links at a time will translate into knowledge that your practice can use in the future.

Duncan suggests that "nurses, office managers, or front desk staff can be key players in developing and maintaining links to community resources. One of the lessons learned from this Healthy Development Collaborative is that it helps to have a point person in the practice that is the 'keeper of the list' of community resources and is in charge of keeping that information up to date." There are a variety of strategies for establishing and maintaining referral links with community resources. Such strategies can be relatively modest, such as distributing community agencies' literature to your patients, or more complex, such as assigning clinicians to work at a community clinic. Your office might already have connections to community agencies and organizations that you can improve or expand.

The unique features of your community might help or hinder coordination. In communities with a large number of organizations, one of the most challenging aspects of linking with local agencies can be the amount of duplication and overlap among target population, services offered, and funding sources. In other locales, the challenge may be a lack of appropriate agencies and services. Practices also differ in their capacity to participate in community activities. Thus, different settings and environments require different approaches to partnership and collaboration among practices and community agencies.

"As providers, when we make a referral to another professional in the community, it's really important that we know the person to whom we're referring," Duncan says. "That makes it easier for the patient to trust in the referral process. This is especially true for families who are having a hard time—which is often the case when a family needs a referral. Many community agencies have long waiting times for services, especially for people on Medicaid. Once the various providers know each other, the relationships seem to facilitate timely referrals. It's harder to turn down someone you know."

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