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MT11: Health Care Clinical-Community Linkages

Framework Component

Changes – Multi-Sector

Indicator Description

Community health initiatives that link health care systems with community groups to meet the community’s nutrition, physical activity, or obesity prevention needs.

Background and Context

With the passage of the Patient Protection and Affordable Care Act (PPACA) and the release of 2010 National Prevention Strategy, health care providers play an even more important role in improving the population’s health. The Department of Health and Human Services reimburses providers for the quality and effectiveness of their services with special attention given to the community and social determinants of health. The PPACA imposes new requirements on certain nonprofit organizations that operate one or more hospitals to conduct a community health needs assessment and adopt an implementation strategy at least once every 3 years. These strategies may align with the tenets of SNAP-Ed and provide grant or community benefit funding to community-serving organizations that work to improve health and prevent disease among indigent populations.

This indicator showcases some important structural and process relationships between health care providers, often working in primary care, and community resources provided in a non-clinical setting. The relationship between primary care providers and community resources may take the form referrals and linkages between clinicians and community preventive services. Local SNAP-Ed agencies can enable health centers to meet their PPACA mandates and provide community-based services to address nutrition and weight through educational and policy approaches.

Outcome Measures

MT11a. Community resource capacity to deliver preventive services
MT11b. Number of health centers that provide screening and follow-up for:

  • Food security status
  • Adolescent weight status
  • Adult weight status
MT11c. Number of health centers that give families innovative prescriptions or vouchers for:

  • Fruits and vegetables
  • Physical activity
MT11d. Number of nonprofit hospitals with community benefit programs focused on community health or obesity prevention in SNAP-Ed eligible communities, and program characteristics, including funding
MT11e. Estimated number of people in the target population who have increased access to or benefit from the community health policy or intervention

  • Total number of persons in the census-defined area(s) or patient population
  • Number and proportion of persons who are SNAP-Ed eligible

What to Measure

The HRSA Clinical-Community Relationships Measures Atlas (CCRMA) includes measures and tactics to evaluate programs based on clinical-community relationships for the delivery of clinical preventive services.

To measure community resource capacity to deliver preventive services, CCRMA recommends conducting a survey of community-serving organizations in a given jurisdiction to assess the number and type of community preventive resources and the extent to which they are able to meet the community’s nutrition, physical activity, or obesity prevention needs. Alternatively, conduct in-depth interviews or observations of community resource providers and prepare a narrative of the availability of community resources linked with health centers. Community preventive service providers may include community health workers or community health education liaisons, or another service provider working in a non-clinical setting.

Evaluating systems changes, such as those listed in MT11b, requires tracking of health centers, such as Federally qualified health centers (FQHCs), that routinely screen for conditions of interest and provide a referral to a community resource, such as SNAP-Ed, or enrollment in federal nutrition assistance programs. Some models may include provider prompts as part of an electronic medical system. The “screen and intervene” model, pioneered by the Oregon Food Bank and the Oregon Childhood Hunger Coalition, offers health care staff two nationally used and validated screening questions and options for administering them. Meanwhile, measurements of height, weight, and body mass index (BMI) for everyone over 2 years of age are core components of the clinical quality improvement necessary for health care institutions to receive incentive payments for their electronic health records. Checking for the categorical presence or absence of a screening program is a good place to start; an advanced evaluation would consider the proportion of patients who are screened and offered follow-up.

Evaluating health care prescriptions for fruits and vegetables or physical activity begins with identifying clinics that offer these programs and approaches. For a sample of prescription programs, track the number of patients or families who enroll, the types of prescriptions they receive, number of redemptions, and associated client satisfaction with the program.

Finally, to evaluate community health initiatives, contact state hospital associations or state or local health departments to identify the types of community benefit programs and funding levels in effect within your state or local project area. Use the Community Health Needs Assessment toolkit, a free web-based platform designed to assist hospitals, nonprofit organizations, state and local health departments, financial institutions, and other organizations seeking to better understand the needs and assets of their communities and to collaborate to make measurable improvements in community health and well-being.



Surveys and Data Collection Tools
Data are available at the national, state, grantee, and ZIP code level for:

  1. Adolescent Weight Screening and Follow Up [MT11c2]
  2. Adult Weight Screening and Follow Up [MT11c3]
Two-item screener [MT11c1]

  1. “Within the past 12 months we worried whether our food would run out before we got money to buy more.”
    Responses: often true, sometimes true, never true, don’t know, or refused
  2. “Within the past 12 months the food we bought just didn’t last and we didn’t have money to get more.”
    Responses: often true, sometimes true, never true, don’t know, or refused

Additional evaluation tools to measure MT11 can be found in the SNAP-Ed Library.

Key Glossary Terms

Additional Resources or Supporting Citations

American Academy of Pediatrics. (2015) Promoting Food Security for All Children

Hager ER, et al. (2010). Development and validity of a 2-item screen to identify families at risk for food insecurity. Pediatrics, 126: e26-e32.

Himmelman A. (2002). Collaboration for a change: Definitions, decision-making models, roles, and collaboration process guide. Unpublished work. Partnership Continuum Inc., Minneapolis, MN.

Catholic Health Association of the United States. Evaluating the impact of your community benefit program.