CommunityRx: A Population Health Improvement Innovation That Connects Clinics To Communities

Abstract

The CommunityRx system, a population health innovation, combined an e-prescribing model and community engagement to strengthen links between clinics and community resources for basic, wellness, and disease self-management needs in Chicago. The components of CommunityRx were a youth workforce, whose members identified 19,589 public-serving entities in the 106-square-mile implementation region between 2012 and 2014; community health information specialists, who used the workforce's findings to generate an inventory of 14,914 health-promoting resources; and a health information technology (IT) platform that was integrated with three electronic health record systems at thirty-three clinical sites. By mapping thirty-seven prevalent social and medical conditions to community resources, CommunityRx generated 253,479 personalized HealtheRx prescriptions for more than 113,000 participants. Eighty-three percent of the recipients found the HealtheRx very useful, and 19 percent went to a place they learned about from the HealtheRx. All but one organization continued using the CommunityRx system after the study period ended. This study demonstrates the feasibility of using health IT and workforce innovation to bridge the gap between clinical and other health-promoting sectors.

Keywords: Cross-Sector; Determinants Of Health; Health Promotion/Disease Prevention; Information Technology; Population Health.

Exhibit 1. CommunityRx implementation region by ZIP code, showing penetration of the HealtheRx distribution, and locations of 33 clinical sites, electronic health record vendor types, and Community Health Information Specialists (CHIS)

SOURCE Authors’ analysis of CommunityRx database and population data obtained from American Community Survey, 2014, 5 Year, S0101. NOTES Penetration of the HealtheRx was measured by the estimated percent of population residing in each ZIP code that received at least one HealtheRx months 9–35 of the 36 month CommunityRx implementation period. Several Near North Health Service Corporation sites located outside the implementation region adopted the CommunityRx system after a physician trained at site #1 to use CommunityRx “hacked” the system to function at another site where he worked. This unexpected spread prompted us to expand CommunityRx prescribing functionality to all affiliated clinical sites providing care for patients who were residents in the implementation geography. ^aClinical sites included 27 Federally Qualified Health Centers (5 of these were school-based clinics) operated by 5 corporations, and 6 academic medical center-affiliated sites (4 outpatient practices and an adult and pediatric emergency department). Sites are numbered in order of deployment. ^bEnglish and Spanish-speaking CHIS were deployed at partnering community-based organizations (organizations 1–4) and with the central team (organization 5).