What is the challenge?

For many health care workers, a long-term relationship with their patients and with their community draws them to primary care. They recognize that one can’t really know a person without some understanding of their community and culture, and treatment is often incomplete without community-based services. In addition, many primary care practices would like to do more to make their communities healthier places to live. But the daily grind of patient care is all consuming for many practices, which can make it tough to stay focused on the communities they serve. In addition, having a community focus is not a salient part of the training most health care workers receive.

What needs to change?

Practices need to hire staff from and build connections with the important communities where their patients live and work. They also need to be aware of the other services and resources available in those communities. Learning about communities and connecting with organizations that provide services in those communities must be a leadership priority for real action to occur.

What do we gain by making these changes?

Practices that have staff who represent their patients’ communities and cultures are better able to interpret their patients’ needs and tailor treatment accordingly. When practices know about and build relationships with community service agencies, referrals are more efficient and effective and patients are more likely to get the services they need. And when practices help make their communities healthier and more supportive of people with health, social, or financial challenges, it benefits their patients, enhances the practice’s self-esteem and reputation, and can aid in retention of valuable staff. 

  1. Hire staff representative of the communities served.

    Hiring staff from the communities a practice serves provides an insider’s view of cultural norms, environmental issues, resources, and other important aspects of community life. Their presence tends to relax patients, and they can give important information to the care team about individual patients and their environments. They can also boost a practice’s competency in relevant languages and work with patients to help them understand and adhere to medical recommendations. Practices need to develop and implement recruitment, hiring, and training approaches that help them recruit and retain staff from their patients’ neighborhoods and culture. 

  2. Designate staff to coordinate community linkages.

    Gathering information about community resources and building relationships with them benefits from having a person or persons in the practice to guide and coordinate these activities. It is a natural function for social workers, but this community resource specialist role can be done well by committed, community savvy individuals with less formal training.

  3. Make an effort to learn about community strengths and weaknesses.

    It’s important to devote some staff time to understanding patients’ needs and to scan the environment to learn about resources available in the community. Start by:

    • Obtaining input from patients and their personal caregivers through patient advisory groups, focus groups, surveys, etc.
    • Making a list of the types of community services your patients need.
    • Identifying community organizations that provide those services.
    • Evaluating their accessibility and performance.

    Next, try to identify the factors that contribute positively to the community’s health, as well as those that have a negative influence.

  4. Develop relationships and agreements with key community organizations.

    As with medical specialists, relationships with key community service agencies and programs give the practice a much clearer idea of the services offered, the agency’s requirements and expectations, and the mechanics of referral. Such relationships also give community agencies important insights as to how they can better meet the needs of patients and families.

  5. Use the practice’s influence and resources to better the community.

    For several LEAP practices, being committed to their communities is as important as being committed to their patients. That commitment manifests in various ways depending on the community’s needs and the practice’s interests and resources. But in general, it involves efforts to make the community a healthier place to live and raise children. Often, practices will help develop community resources that their patients need but that aren’t currently available.

Webinar and power point presentations

Case summariesVignettes, profiles and testimonial videos

  • Case summaries

    MAs Improve language access and patient centered care

    Learn how one LEAP site, Asian Health Services, improved language access and patient-centered care. This case study, by the Healthforce Center at UCSF with funding from the Hitachi Foundation, highlights the role of the MA in better connecting with communities served.

  • Case summaries

    Case Study: Clinic-Community Connections at Maple City

    Learn how one LEAP site goes above and beyond to improving the well-being of the broader community beyond their patient population and helps patients gain resources that are not currently available elsewhere.

Role featuresJob descriptions, career ladders and other HR materials

  • Role features

    Care Coordinator Job Responsibilities

    Learn about the responsibilities of the care coordinator at one LEAP site. Working with a nurse care manager, the MA care coordinator supports care management focused on the highest-risk patients.

  • Role features

    Medical Social Worker Job Description

    Here is a job description of a traditional social worker from LEAP site Harvard Vanguard Medical Associates. Social workers are valuable assets to primary care teams to help connect patients to community resources and navigate through systems, often helping improve the health of patients by addressing social determinants of health.

Staff trainingTutorials, training manuals, etc.

  • Staff training

    Volunteer Wellness Outreach Worker Handbook and Resource Manual

    Learn about the role that volunteers play in connecting patients to community resources at LEAP site West County Health Centers, Inc. Here are excerpts from the extensive Volunteer Training Handbook: the table of contents and description of the "waiting room host" position. Hosts sit in the waiting room with a large resource binder to help connect patients to community resources. Many volunteers are also patients at West County Health Centers, Inc.

Patient materialsAction plans, brochures, team cards, welcome letters

  • Patient materials

    Community Resource Guide

    See how one LEAP site, Penobscot Community Health Care, helps patients learn about resources in their community. This Community Resource Guide is given to patients to help them improve their health beyond the clinic walls. The Guide also reflects the breadth of partnerships and relationships that PCHC maintains in their community.

  • Patient materials

    Guiding Principles of the Practice

    Understanding patients' needs and building on community assests is important enough to many LEAP sites that it is built into the practice's guiding principles, vision, or values. This reflects a commitment to the community and using staff time to connect the practice to community organizations that can help meet patients' needs.

  • Patient materials

    Practice Programs and Services Brochure

    At LEAP site 11th Street Family Health Services, patients have access to a wide variety of classes, programs, and services that are not available in their community—such as cooking classes and the ability to take home produce from the onsite community garden. Some classes are open to all community members. Check out their brochure here.

WorkflowTemplates, flow sheets and mapping aids

  • Workflow

    EMR template for community resources

    See an example screen shot of the EMR template for making community referrals at one LEAP site, High Plains Community Health Center.


  • Publications

    Safety trainings for nail salon workers

    Learn about one of the many projects that LEAP site Asian Health Services has done to help the broader community. Since discovering health issues among Vietnamese patients working in nail salon shops in 2005, the organization has conducted safety trainings for nail salon workers, helped create a statewide coalition focused on these health issues, and organized advocacy efforts to improve working conditions.