This project will engage patients and health care teams to develop, implement, and rigorously evaluate a new lay health worker role (Community Resource Specialist, CRS) for primary care teams. The CRS will link patients and healthcare clinics with community resources.

Patients are served best when multiple organizations work together to meet healthcare needs. In the Chronic Care Model, community resources supplement productive interactions between patients and care teams. However, healthcare delivery systems and health research have given relatively little attention to the model's community features. This project engages patients in designing a primary care community liaison role (Community Resource Specialist, CRS) connecting patients to clinic and community resources that support chronic disease prevention and management. The CRS role will enhance primary care by better integrating community resources into patient care.

The proposed design effort will:

• develop tools and work processes that promote meaningful patient engagement in creating a CRS concept and role
• integrate the CRS role into primary care teams
• assess effects of this role on patient-centered outcomes.

The patient engagement process will use principles from Lean, a quality improvement method, to engage all primary care stakeholders, particularly patients and clinical staff. The project will integrate community resources into the patient-centered medical home model of Group Health, a nonprofit healthcare system that provides coverage and care.

The project will enhance patient resources and options for managing and preventing chronic illness and improve patient-centered outcomes.

The project's specific aims are:

• Aim 1: Develop, implement, and evaluate new methods to involve patients intensively in care design. The investigators will create processes and tools to select and train participants and facilitate their productive contributions to care design. The investigators will document the approach's benefits and challenges using qualitative and quantitative data.
• Aim 2: Design and pilot a new CRS role for primary care teams. Robust engagement of patients in designing this new primary care team role will result in innovative, patient-centered solutions. The investigators will pilot this service at three clinics. The aim of the new service is to help patients more readily access the healthcare and community resources they need for preventing and treating chronic disease. The CRS also may help educate clinic staff about available community resources and increase the primary care team's use of holistic approaches to health.
• Aim 3: Evaluate the design and efficacy of the CRS. The investigators will conduct both formative and outcome evaluations of the CRS role.

Inclusion Criteria:

• Enrolled at Group Health Cooperative, Seattle, Washington, in one of three pilot primary care clinics
• Referred or self-referred to the CRS for connection to community resources to support health goals

Exclusion Criteria:

• Not enrolled at Group Health
• Not enrolled in one of the pilot clinics

Group Health primary care patients at one of three pilot clinics who are referred or self-refer to work with a Community Resource Specialist (CRS)

No adverse events were reported to us. However this was not a clinical trial. It was an evaluation of a delivery system innovation.

This was not a clinical trial. It is was a single-group observational evaluation of a delivery system innovation.