Improving Access to Community-Based Health Services: A Quality Improvement Initiative Addressing Obesity and Depression in a Residency Clinic

BACKGROUND AND OBJECTIVES: Obesity and depression are major public health concerns, particularly among low-income populations. Our Community Health Needs Assessment revealed that these issues are also prevalent in our local community. Despite the availability of community-based health initiatives in our clinic, utilization of the services by the target population and referral from the providers remains low. The primary aim was to increase open-loop documented referrals of patients with obesity and depression to the Shirvan Family Live Well Center. METHODS: This project was conducted at a Federally Qualified Health Center staffed by internal medicine residents and preceptors. A formal referral process in the electronic medical record was implemented alongside resident and preceptor resource-education sessions. Referrals were tracked over 17 weeks. Pre- and post-intervention surveys assessed changes in provider awareness and engagement. Run charts were used to monitor weekly referrals. RESULTS: Before the intervention, although all participants were aware of the Shirvan Family Live Well Center, only 48% knew how to refer patients, and just 40% had previously made referrals. Post-intervention surveys showed increased provider engagement and referral activity. Run chart analysis over 17 weeks demonstrated an initial increase in referrals, a temporary decline due to a down period of the electronic medical record, and a subsequent sustained positive shift in referral volume after system restoration, including an astronomical data point at week 9. Despite improvements, limited time during clinic visits (61.1%) and lack of ongoing resource awareness (22.2%) remained key barriers. CONCLUSIONS: Implementing a formal referral system combined with targeted provider education successfully increased provider awareness and referral behaviors. Because referral completion and patient engagement were not assessed, the findings should be interpreted as improvements in provider referral behavior rather than demonstrated patient-level impact. Sustaining improvements will require ongoing reinforcement and, in future projects, closing the referral loop to expand access to community-based health initiatives and to address health disparities in underserved populations. Further study is needed to assess the engagement rate after referral and the outcomes of the patients.