Community–Clinical Linkages: The Effects of the Healthy Here Wellness Referral Center on Chronic Disease Indicators Among Underserved Populations in New Mexico

Abstract

The majority of U.S. adults are living with at least one chronic condition, and people of color bear a disproportionate burden of chronic disease. Prior research identifies community–clinical linkages (CCLs) as a strategy for improving health. CCLs traditionally use health care providers to connect patients to community-based self-management programs. The purpose of this study was to examine the effectiveness of a centralized CCL system on health indicators and health disparities. Administrative health data were merged with referral system data to conduct a quasi-experimental comparative time series study with a comparison group of nonreferred patients. Interrupted time-series comparisons within referred patients were also conducted. Of the 2,920 patients meeting inclusion criteria, 972 (33.3%) received a referral during the study period (January 2019—September 2021). Hemoglobin A1c levels, used to diagnose diabetes, declined significantly among referred patients, as did disparities among Hispanic/Latinx participants compared with non-Hispanic White participants. No changes were observed in body mass index (BMI). Blood pressure increased among both referred and nonreferred patients. CCLs with a centralized referral system can effectively reduce markers of diabetes and may contribute to the maintenance of BMI. The observed increase in blood pressure may have been affected by the COVID-19 pandemic and warrants further study. Practitioners can work with community partners to implement a centralized CCL model, either on its own or to enhance existing clinician or community health worker-based models.