Patient-Centered Team-Based Care Model

Community Linkages

Community Community Community Triple Aim of Health Care Team Parent Organization Hallmarks of Practice Engaged Patient Core Principles Workforce Diversity

Community Durable Linkages and Connections

Infrastructure extends beyond the walls of the health system to the community. It includes durable linkages and connections to communities. Patients, caregivers, and their family and support systems live outside the walls of health care systems.  Durable linkages and connections between health systems and communities (organizations, agencies, providers, health departments, community health workers) represent a critical and reciprocal interface of mutual influence. It provides a mechanism and opportunity for investment in healthy communities. Durable linkages and connections extend the services of the health system into the community where patients (caregivers, families, and support systems) live, grow, work, learn, and play.

Health systems are an integral resource for communities health systems need the community.  Community -clinical linkages help:

  • Patients change unhealthy behaviors
  • Provide services clinicians cannot
  • Connect patients to agencies for whom their services were designed (AHRQ)
  • Build healthy communities

Developing durable linkages between teams, parent organizations, and communities requires co-leadership with communities. It takes the work of many to improve the health of all. The authors of this publication recommend review of the inclusive systems model and partners described on page 46 in the Wisconsin Department of Health Services publication, Healthiest Wisconsin 2020: Everyone living better, longer.  It is available online at https://www.dhs.wisconsin.gov/hw2020/report.htm.