Skip to main content

Main menu

  • Home
  • Current Issue
  • Content
    • Current Issue
    • Early Access
    • Multimedia
    • Podcast
    • Collections
    • Past Issues
    • Articles by Subject
    • Articles by Type
    • Supplements
    • Plain Language Summaries
    • Calls for Papers
  • Info for
    • Authors
    • Reviewers
    • Job Seekers
    • Media
  • About
    • Annals of Family Medicine
    • Editorial Staff & Boards
    • Sponsoring Organizations
    • Copyrights & Permissions
    • Announcements
  • Engage
    • Engage
    • e-Letters (Comments)
    • Subscribe
    • Podcast
    • E-mail Alerts
    • Journal Club
    • RSS
    • Annals Forum (Archive)
  • Contact
    • Contact Us
  • Careers

User menu

  • My alerts

Search

  • Advanced search
Annals of Family Medicine
  • My alerts
Annals of Family Medicine

Advanced Search

  • Home
  • Current Issue
  • Content
    • Current Issue
    • Early Access
    • Multimedia
    • Podcast
    • Collections
    • Past Issues
    • Articles by Subject
    • Articles by Type
    • Supplements
    • Plain Language Summaries
    • Calls for Papers
  • Info for
    • Authors
    • Reviewers
    • Job Seekers
    • Media
  • About
    • Annals of Family Medicine
    • Editorial Staff & Boards
    • Sponsoring Organizations
    • Copyrights & Permissions
    • Announcements
  • Engage
    • Engage
    • e-Letters (Comments)
    • Subscribe
    • Podcast
    • E-mail Alerts
    • Journal Club
    • RSS
    • Annals Forum (Archive)
  • Contact
    • Contact Us
  • Careers
  • Follow annalsfm on Twitter
  • Visit annalsfm on Facebook
Meeting ReportCommunity-based participatory research

Evaluating the Feasibility of Enhanced Care Planning and Clinical-Community Linkages for Primary Care Teams to Better Address

Jennifer Hinesley, Paulette Lail Kashiri, Jacqueline Britz, Alex Krist, Kristen O’Loughlin, Benjamin Webel, Alicia Richards and Roy Sabo
The Annals of Family Medicine January 2023, 21 (Supplement 1) 3660; DOI: https://doi.org/10.1370/afm.21.s1.3660
Jennifer Hinesley
PsyD
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Paulette Lail Kashiri
MPH
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Jacqueline Britz
MD, MSc
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Alex Krist
MD, MPH
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Kristen O’Loughlin
MA, MS
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Benjamin Webel
BA
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Alicia Richards
BS
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Roy Sabo
PhD
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
  • Article
  • eLetters
  • Info & Metrics
  • PDF
Loading

Abstract

Context: Patients with MCC have a range of needs that extend beyond traditional medical care including behavioral, mental health, and social needs. While primary care does its best to address these needs, few practices can undertake a systematic approach without broader health system and coordinated community support. We are conducting a randomized controlled trial to compare a package of four tools (an online health risk assessment called My Own Health Report (MOHR), patient navigator, community health worker, and linkage to community programs) versus usual care to better address these root causes of poor health.

Objective: To assess the feasibility of patient navigation as part of an enhanced care planning approach.

Study Design and Analysis: Clinician level randomized control trial and descriptive analyses.

Dataset: MOHR study and navigator field notes.

Population Studied: Practices from the Virginia Ambulatory Care Outcomes Research Network (ACORN) in the Greater Richmond metro and the Northern Virginia areas participated. 12 practices, 45 clinicians, 87 intervention patients, and 109 control patients have participated in the trial.

Intervention/Instrument: Study and navigator field notes in MOHR.

Outcome Measures: We determined navigator recruitment for practices and clinicians, the number of navigator phone contacts for patients assigned to the care planning condition, and the length of these contacts.

Results: Only 1 of 12 practices had staff that could serve as a patient navigator, even for extra pay. For the other 11 practices, a research team member needed to provide navigation services. On average, 95 patients needed 25 weeks of support to work on their care plans for health behaviors, mental health, and social needs. The average time for each patient session is about 7 minutes. As navigation sessions do not occur every week, this is an average total contact time of 124 minutes or about 2.1 minutes per week.

Conclusions: Helping patients create care plans and connecting them with a patient navigator for the short-term may have long-term benefits for patients and care teams. Yet, this model of team-based care is not currently feasible for many practices. Primary care will benefit from increased health system and community support to make this model more viable to better support the complex needs of patients with MCCs.

  • © 2023 Annals of Family Medicine, Inc.
Previous
Back to top

In this issue

The Annals of Family Medicine: 21 (Supplement 1)
The Annals of Family Medicine: 21 (Supplement 1)
Vol. 21, Issue Supplement 1
1 Jan 2023
  • Table of Contents
  • Index by author
Download PDF
Article Alerts
Sign In to Email Alerts with your Email Address
Email Article

Thank you for your interest in spreading the word on Annals of Family Medicine.

NOTE: We only request your email address so that the person you are recommending the page to knows that you wanted them to see it, and that it is not junk mail. We do not capture any email address.

Enter multiple addresses on separate lines or separate them with commas.
Evaluating the Feasibility of Enhanced Care Planning and Clinical-Community Linkages for Primary Care Teams to Better Address
(Your Name) has sent you a message from Annals of Family Medicine
(Your Name) thought you would like to see the Annals of Family Medicine web site.
CAPTCHA
This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.
5 + 0 =
Solve this simple math problem and enter the result. E.g. for 1+3, enter 4.
Citation Tools
Evaluating the Feasibility of Enhanced Care Planning and Clinical-Community Linkages for Primary Care Teams to Better Address
Jennifer Hinesley, Paulette Lail Kashiri, Jacqueline Britz, Alex Krist, Kristen O’Loughlin, Benjamin Webel, Alicia Richards, Roy Sabo
The Annals of Family Medicine Jan 2023, 21 (Supplement 1) 3660; DOI: 10.1370/afm.21.s1.3660

Citation Manager Formats

  • BibTeX
  • Bookends
  • EasyBib
  • EndNote (tagged)
  • EndNote 8 (xml)
  • Medlars
  • Mendeley
  • Papers
  • RefWorks Tagged
  • Ref Manager
  • RIS
  • Zotero
Get Permissions
Share
Evaluating the Feasibility of Enhanced Care Planning and Clinical-Community Linkages for Primary Care Teams to Better Address
Jennifer Hinesley, Paulette Lail Kashiri, Jacqueline Britz, Alex Krist, Kristen O’Loughlin, Benjamin Webel, Alicia Richards, Roy Sabo
The Annals of Family Medicine Jan 2023, 21 (Supplement 1) 3660; DOI: 10.1370/afm.21.s1.3660
Twitter logo Facebook logo Mendeley logo
  • Tweet Widget
  • Facebook Like
  • Google Plus One

Jump to section

  • Article
  • eLetters
  • Info & Metrics
  • PDF

Related Articles

  • No related articles found.
  • Google Scholar

Cited By...

  • No citing articles found.
  • Google Scholar

More in this TOC Section

  • Contextualizing Diabetes and Obesity Care for Immigrant and Refugee Populations
  • Primary Care Physicians’ Perspectives on Identifying Familial Hypercholesterolaemia in Primary Care: A Qualitative Study
  • Community Engaged Translation of Adverse Childhood Experiences Information Into Locally Relevant Public Health Messaging
Show more Community-based participatory research

Similar Articles

Content

  • Current Issue
  • Past Issues
  • Early Access
  • Plain-Language Summaries
  • Multimedia
  • Podcast
  • Articles by Type
  • Articles by Subject
  • Supplements
  • Calls for Papers

Info for

  • Authors
  • Reviewers
  • Job Seekers
  • Media

Engage

  • E-mail Alerts
  • e-Letters (Comments)
  • RSS
  • Journal Club
  • Submit a Manuscript
  • Subscribe
  • Family Medicine Careers

About

  • About Us
  • Editorial Board & Staff
  • Sponsoring Organizations
  • Copyrights & Permissions
  • Contact Us
  • eLetter/Comments Policy

© 2025 Annals of Family Medicine