Develop pathways to neighborhood/community-based resources to support patient health goals that could include one or more of the following:
- Maintain formal (referral) links to community-based chronic disease self-management support programs, exercise programs and other wellness resources with the potential for bidirectional flow of information; and/or provide a guide to available community resources.
- Including through the use of tools that facilitate electronic communication between settings;
- Screen patients for health-harming legal needs;
- Screen and assess patients for social needs using tools that are preferably health IT enabled and that include to any extent standards-based, coded question/field for the capture of data as feasible and available as part of such tool; and/or
- Provide a guide to available community resources.
Availability of formal links to community-based health and wellness programs potentially including availability of resource guides that address identified social determinants of health
1) Community-Based Chronic Disease Self-Management Programs - Documentation of community-based chronic disease self-management support programs, exercise programs, and other wellness resources (including specific names) with which practices have formal referral links and have potential bidirectional flow of information; or
2) Provision of Community Resource Guides - Medical record demonstrating provision of a guide to community resources to meet identified social determinants of health (e.g., safe housing, transportation, social support).