Implementation of community-based resource referrals for cardiovascular disease self-management

Emily Abramsohn*, Megan Depumpo, Kelly Boyd, Tiffany Brown, Milton F. Garrett, Abel Kho, Chenab Navalkha, Kelsey Paradise, Stacy Tessler Lindau

*Corresponding author for this work

Research output: Contribution to journalArticlepeer-review


PURPOSE Describe primary care practices’ implementation of CommunityRx-H3, a community resource referral intervention that utilized practice facilitators to support cardiovascular disease (CVD) prevention quality improvement. METHODS Qualitative focus groups were conducted with practice facilitators to elicit perceptions of practices’ experiences with CommunityRx-H3, practice-level factors affecting, and practice facilitator strategies to promote implementation. Qualitative data were analyzed using directed content analysis. The Consolidated Framework for Implementation Research was applied deductively to organize and interpret findings. RESULTS Fourteen of all 19 practice facilitators participated. Practice facilitators perceived that staff attitudes about connecting patients to community resources for CVD were largely positive. Practices were already using a range of non-systematic strategies to refer to community resources. Practice-level factors that facilitated CommunityRx-H3 implementation included clinician “champions,” engaged practice managers, and a practice culture that valued community resources. Implementation barriers included a practice’s unwillingness to integrate the intervention into existing workflows, limited staff capacity to complete the resource inventory, and unavailability or cost of materials needed to print the resource referral list (“HealtheRx-H3”). Practice facilitator strategies to promote implementation included supporting ongoing customization of the HealtheRx-H3 and material support. Practice facilitators felt implementation would be improved by integration of CommunityRx-H3 with electronic medical record workflows and alternative methods for engaging practices in the implementation process. CONCLUSIONS Practice facilitators are increasingly being utilized by primary care practices to support quality improvement interventions and, as shown here, can also play an important role in implementation science. This study yields insights to improve implementation of community resource referral solutions to support primary care CVD prevention efforts.

Original languageEnglish (US)
Pages (from-to)486-495
Number of pages10
JournalAnnals of family medicine
Issue number6
StatePublished - Nov 1 2020


  • Community resource referrals
  • Implementation science
  • Practice facilitation
  • Qualitative research
  • Quality improvement

ASJC Scopus subject areas

  • Family Practice

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