The Evaluation Roadmap is based on an understanding of clinical-community resource relationships rooted in a previously developed conceptual framework. This conceptual framework is premised on clinical-community resource relationships in which patient referrals originate from the clinic toward the community resource, although reciprocity within the relationship is also considered. The conceptual framework describes six interrelated components that may influence the effectiveness of a clinic's effort to connect a patient with a community resource to successfully receive a clinical preventive service. These six components include:
Three basic elements:
Three dyadic relationships between these three basic elements:
The clinical-community resource relationship, which is the central emphasis of the Roadmap, is one of the basic interrelated components of the conceptual framework.
The conceptual framework is represented in Figure A-1. The three interconnected circles of this Venn diagram represent the three basic elements of the framework—the primary care clinic/clinician, the patient, and the community resource.
The areas of intersection of the three circles represent relationships between the three basic elements. The three dyadic relationships between the three basic elements are fundamental aspects of the conceptual framework.
In the Atlas (Clinical-Community Relationships Measures Atlas [Dymek et al., 2013]), we pair the six basic factors of the conceptual framework with Donabedian's structure-outcome-process model (Donabedian, 1980) to organize various domains of measurement that might be used to evaluate clinics' efforts to connect patients with community resources for preventive services. This framework for thinking about the elements and relationships is also useful for considering high-priority research and evaluation needs, and we have used it as an important guide in developing this Evaluation Roadmap.
Our conceptual framework expands on the idea of a bridge between primary care practices and community resources as described by Etz et al. (Etz et al., 2008). The larger bridge imposed over the Venn diagram in Figure A-1 represents this connection between the clinic/clinician and the community resource. The Etz bridge includes foundational ("anchor") characteristics of the clinic/clinician and the community resource, as well as the relationship between the two. Our conceptual framework adds the critical element of the patient to this bridge. Given that the real-world function of connections between clinics and community resources to actually deliver preventive services cannot occur without patients, including patient-related factors is essential. By including the patient element in the framework, we consider the potential influence of patient characteristics and the relationships of patients with clinics/clinicians and with community resources.
Defining "Linkage". Including the patient element with the clinic/clinician and community resource elements produces the central area of the Venn diagram above, where all three circles intersect. This area at the center of the diagram is of particular interest, as it represents the combined interactive influences of all three basic elements and their three respective dyadic relationships. The larger bridge in the diagram can represent relationships that are established with the intent of facilitating the referral of patients to receive preventive services, or existing relationships between clinics and community resources that are not specific to the delivery of clinical preventive services, but which might nonetheless facilitate the delivery of those services. The smaller bridge at the center of the diagram represents the process of placing actual patients on that existing bridge to connect them with community resources to receive needed preventive services. We refer to the former concept, represented by the larger bridge, as "clinical-community resource relationships", which is one of the six basic interrelated components of the conceptual framework. We refer to the latter concept, represented by the smaller bridge at the center of the diagram, as a "linkage". A linkage, therefore, represents the combined influence of all six basic factors in the actual realization (or not) of a primary care patient being connected with a community resource for delivery of a preventive service.
It is important to note that the symmetry of the diagram does not imply that each of the basic six factors necessarily exerts an equal influence in making a linkage for the delivery of a clinical preventive service. In fact, the relative influence of factors is generally expected to vary according to the particular preventive service and the specific circumstances of individual clinics, clinicians, patients, community resources, and communities. The relevance of situational variability in the influence of different factors, including the clinical-community resource relationship, is discussed in more detail in Section 1-3, "The Importance of Context."