The Clinic to Community Linkage (CCL) program is a new way to connect patients with chronic diseases to community resources via United Way 2-1-1. CCL for adult patients focuses on individuals with hypertension and elevated blood pressure (≥140/90mmHg) seen at participating clinics (initially MetroHealth J Glen Clinic) CCL for pediatric patients focuses on children ages 2-18 with the body mass index (BMI) ≥ 85th percentile and/or children with an asthma diagnosis at three different health centers (Care Alliance, University Hospitals Rainbow Babies and Children, and MetroHealth Buckeye Health Center).
The goals of CCL are to:
1) Help patients lower their BMI percentile, gain control of their asthma, and improve their overall health
2) Address social determinants of health that impact health and well-being
CCL will achieve these outcomes by connecting patients to community resources for healthy eating, active living (HEAL), disease self-management, and other resources for social and economic needs.
How it Works
CCL begins with an electronic referral that is sent securely from a patient’s primary care provider to United Way of Greater Cleveland. Once the referral is received by United Way, a specially trained Navigation Specialist will contact the patient or parent/guardian (P/G) of the patient within 2 business days about community resources that will assist the patients with free or low-cost resources for healthy eating, physical activity, and/or asthma management. The Navigation Specialist will also identify other social or economic needs (housing, utilities, or transportation, for example) and refer the patient or P/G to appropriate community resources. After the patient or P/G is referred to community resources, the Navigator will follow-up with the patient on those referrals and determine if the patient’s needs were met. If the need has not been met, the Navigator will continue to work with patient or P/G until the need is either met or is determined to be unresolvable by both parties.