Article Title

Connecting Primary Care Patients to Community Resources: Lessons Learned From the Development of a New Lay Primary Care Team Role

Publication Date



implementation science, primary care teams


Background/Aims: Social determinants of health play a critical role in both the prevalence and outcomes of a wide range of chronic illnesses. The growing recognition of both the role that social determinants play in population health outcomes and the need to address these requires stronger partnerships between primary care teams and community organizations. In support of this goal, the Learning to Integrate Neighborhoods and Clinical Care (LINCC) project, funded by the Patient-Centered Outcomes Research Institute and implemented at Group Health, convened patients and staff to co-design a new role on the primary care team aimed at helping patients better connect with community resources through one-on-one coaching and follow-up. We implemented this program in three pilot clinics to assess the challenge of incorporating this new team member into primary care practices and the potential impact this program would have if scaled to the entire delivery system.

Methods: We used a mixed-methods approach to document and evaluate the design and implementation of this new role. Data collection included patient surveys, review of electronic health record documentation, site visits, staff interviews and patient focus groups.

Results: We will present a case study on the implementation and evaluation of this role (analysis in progress) with a focus on findings and lessons learned that will enable others to learn from or replicate this pilot. Our findings will include documentation of the patient-centered design and specific scope of work for the role, its integration into the primary care team, and specific tools and approaches developed. We also will report process measures including patient volume, descriptions of the patients served, percentage of patients who completed an action plan, progress made toward accomplishing goals, resources referred and used, and patient satisfaction with the services received.

Conclusion: The LINCC project helped patients connect to community resources by providing deep knowledge of local resources, personalized coaching, goal setting and follow-up, and an ongoing connection to the primary care team. Preliminary findings highlight the challenges and successes associated with implementing this role and show promising results in terms of patient receptivity and satisfaction with the service.




July 5th, 2016


August 12th, 2016