Empowering Independent Practices with Tailored Resources for Drivers of Health

While physicians recognize the critical role of addressing drivers of health (DOH), such as utilities access or interpersonal safety, to improve patient outcomes, many lack the necessary resources and support. By leveraging Let’s Take 5 resources from The Physicians Foundation as a guide, the Maine Medical Association, Center for Quality Improvement (MMA-CQI) equipped six independent primary care practices with the tools to address their patients’ needs related to DOH.

The initiative began with MMA-CQI developing a baseline assessment to gauge how the practices were addressing DOH. These insights allowed MMA-CQI to work closely with each practice, pinpointing specific challenges and opportunities. 

“Our practices have close ties to their communities, and they already knew many of the challenges their patients were facing,” said Amy Carter, Director of the MMA’s Center for Quality Improvement. “The next step was to ensure that the collection of DOH data was consistent, documented and integrated into practice operations. We also wanted to ensure that DOH resources were tailored for each practice to engage with their community members.” 

To facilitate this change, MMA-CQI introduced workflows based on the Let’s Take 5 Steps Implementation Guide, streamlining the DOH screening process and making it more manageable for practices with limited staff. Additionally, MMA-CQI, in partnership with The Hanley Center for Health Leadership and Primary Care Plus (PCPlus), hosted trainings that used the Let’s Take 5 Conversation Starter to support physicians and staff to navigate difficult conversations. During MMA-CQI’s individual technical assistance meetings, they identified some beneficial implementations for practices in tight-knit tribal communities, where discussing DOH openly or filling out written forms is often a challenge, due to privacy concerns and institutional mistrust. To overcome this challenge, MMA-CQI developed trifold brochures for waiting areas to indirectly refer patients to community resources, such as food pantries and resources for transportation, interpersonal safety and housing. 

“This emphasized the importance of understanding your patients and community partners,” Carter said. “Even if patients are not willing to discuss DOH, this resource provides a way for them to access the support they need.”

MMA-CQI also held a webinar on integrating community health workers (CHWs) into practices. As a result, one practice began a contract with CHWs to support patients with complex, multilayered DOH challenges—beginning with five high-risk patients. The practice and CHWs coordinated to ensure patients successfully accessed the support they needed, using closed-loop referrals. 

Through such efforts, MMA-CQI has demonstrated a comprehensive approach to supporting independent practices in Maine, enabling them to better address the needs of their patients and communities. 

This program was made possible by funding from The Physicians Foundation as part of their DOH grant program. Learn more here.