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.
Availability of formal links to community-based health and wellness programs potentially including availability of resource guides
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