Overview

•  Primary care clinics (PCC), particularly in underserved areas, play a key role in connecting patients to community-based wellness resources, such as programs to prevent and manage cardiovascular disease (CVD). In 2015, 14 Mid-Western primary care clinics implemented CommunityRx-H3, a tool that utilizes evidence-based algorithms to generate a list of community-based programs.

Organization Type

• Community health system

Tech Involved

• Care coordination system
• Electronic medical record
• EMR-based registry

Team Members Involved

• Care Coordinator
• Primary Care Physicians

Workflow Steps

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Sources

Abramsohn, Emily, et al. “Implementation of Community-Based Resource Referrals for Cardiovascular Disease Self-Management.” The Annals of Family Medicine 18.6 (2020): 486-495.