Learning Session 10

Navigating Outreach Collaborations to Support Community/Clinical Linkages

Speaker: Dorothy C. Boersma, MD, MPH
Chief Medical OfficerOpen Door Health Services
Muncie, Indiana

Date: June 10, 2016

Brief Bio:
Dorothy Boersma completed medical school at Indiana University in Indianapolis with an internship at Children’s Memorial Hospital in Dallas, Texas.  She worked in private practice for 15 years and at community health centers for 12 years. She completed a Master’s in Public Health in 2007 and is board-certified by the National Board of Public Health Examiners.  She is a member of the Indiana State Medical Association.  She has been married for 40 years with 5 children and 6 grandchildren who are the joy of her life.  She loves quilting and music and has been a church pianist for many years.

Watch the Presentation (22 minutes)


  • Transcript

Objectives of the presentation:

  • Participants will learn strategies that have created successful linkages and referral systems between community/population-based organizations and clinical healthcare providers.

Main points to be covered:

  • Successes through collaborations between healthcare providers and community based entities to promote hypertension control.
  • How state and local health departments can promote these community/clinical linkages to healthcare providers and community based organizations, both at a state wide population-based level, as well as at the local community level, to reach high risk populations on awareness and control of hypertension.

Main points presented:

  • Open Door received funding that allowed adding a community health worker (CHW) to their team based care model for the past nine months. Barriers to hiring the CHW included determining the role within the clinical team, what CHW’s are allowed to do and the need for a bilingual worker based on patient’s backgrounds.
  • CHW worked on several interventions to reach out to patients with hypertension at the Open Door locations and a local urgent care site.
  • CHW reviewed the list of Open Door patients with elevated hypertension but no diagnosis of hypertension. CHW worker identified 66 patients, of which 42 had appointments. The remaining 24 were called. Fourteen made an appointment, with 10 being reevaluated and diagnosed with hypertension. Of the 66, 25 now have a diagnosis and are being treated.
  • CHW contacted 31 patients with hypertension who were to have a hospital follow-up and conducted brief action planning. Eleven have set goals and will be followed-up on their goal and whether their hypertension was improved.
  • CHW contacted 273 patients with a diagnosis of hypertension but no follow-up or visit to Open Door within the last 6 months. Thirty appointments were made, with most of the patients having control of their hypertension and half had reduced their hypertension. This was time intensive and the intervention is being evaluated as to whether it was an effective intervention per the time provided by the CHW.
  • CHW contacted the urgent care clinic in town to identify the urgent care patients who are an Open Door patient and received a documented elevated hypertension measurement during the visit but has received no further follow-up. Sending a letter to the physician to increase awareness about the hypertension and refer the patient to Open Door for further follow-up.
  • Initiated a Red Heart magnet reminder for patients with hypertension, based on a success story noted in a previous National Forum podcast. The magnet is placed inside the patient room, and if patient has an elevated blood pressure reading, the magnet goes on the outside of the door as a reminder to the physician and physician assistant to discuss and re-evaluate the reading. In mobile clinics with no metal doors, sticky notes are used.
  • Open Door has partnered with the local county extension offices, hospitals, minority health coalition and YMCA, as well as the state level health department and CHW Association.

Main take-away points:

  • Clinical system changes to hypertension assessment and control include regularly scheduled classes for staff on the proper technique for blood pressure measurement, reminder messages to healthcare providers during clinic visits, and use of community health workers to initiate patient follow-up with hypertensive patients.
  • Clinics should determine the role they want a CHW to play in the team based care model, find training for the CHW in heart disease prevention and control, and clarify with the state CHW association what actions the CHW is allowed to do within the community/clinical setting.
  • Other social and behavioral needs were identified during the follow-up visits, which initiated a connection with the social worker community.
  • Team based care with a CHW works to improve hypertension control.