Objectives Increasing demands on main care providers have created a need for systems-level initiatives to improve main care delivery. care providers residents clinical support staff and administrative staff in residency programs. Results show that participation in a higher quantity of live learning sessions resulted in a significant increase in patient centered medical home acknowledgement attainment and significant improvements in overall performance in diabetic process measures including vision exams (14.3% p=0.004) vision referrals (13.82% p=0.013) foot exams (15.73% p=0.003) smoking cessation (15.83% p=0.012) and self-management goals (25.45% p=0.001). As a community-clinical linkages model CHT entails main care practices community health workers (CHWs) and community partners. Results suggest that CHT users successfully work together to coordinate comprehensive care for the individuals they serve. Further individuals exposed to CHWs experienced increased stability in access to health insurance (p=0.001) and prescription drugs (p=0.000) and the need for health education counseling (p=0.000). Conclusion Findings from this study show that these two system-level strategies have the promise to improve main care delivery. Additional research can Asarinin determine the extent to which these strategies can improve other health outcomes. consists of CHWs who are primarily responsible for linking clients to community-based and local State agencies that can provide financial and other tangible resources to meet clients’ needs such as vouchers for heating and transportation assistance. A chronic care Asarinin CHW provides comparable services but primarily functions as a health coach to clients to improve their self-management skills related to chronic disease. (3) The has more than 30 community partners that provide a variety of services to the community (i.e. housing legal aid or mental health services). (4) And lastly the Administrative Core has a program manager and a care integration coordinator who provide oversight for the CHT and coordinate efforts of the CHT users. Through ARHGEF11 the work of the CHWs the CHT model demonstrates how community-clinical linkages can support main care providers by providing a range of services to community users as illustrated in Physique 2. In this model Advanced Main Care Practices the Community Connections Team and the Community are overlapping domains. For additional details on the St. Johnsbury CHT model please refer to the Implementation Guide for General public Health Practitioners21 and a separate cost analysis of this model.22 Physique 2 An Illustration of the Community-Clinical Linkages in the St. Johnsbury CHT Model Findings To assess outcomes of the St. Johnsbury CHT the experts examined data from three data sources: 1) a sample of variables extracted from EHRs 2 a sample of CHW records and 3) qualitative interviews with main care providers in the St. Johnsbury CHT. The EHRs sample presented Asarinin in Table 2 included 2711 patients between the ages of 18 and 85 years with a diagnosis of hypertension and at least one blood pressure measurement during the study observation period. 22.4% of patients also experienced diabetes. 51.0% of this sample were Medicare patients while another 5.8% were Medicaid patients. 21.5% of the sample experienced a least one ER visit during the observation period and 6.9% had an inpatient hospital stay during this period. Among those exposed to a CCC or CHW there was a higher proportion of patients with diabetes comorbidity emergency room visits and in-patient hospital stays. This suggests that CHT users are serving patients with greater health needs. Also higher proportions of patients exposed to one component were exposed to other CHT components compared to patients who were not exposed which might suggest that the CHT users work together to coordinate care for the individuals they serve. Table 2 Results from the St. Johnsbury CHT Case Study Analyses The CHW sample was comprised of 210 adults over the age of 18 who experienced at least two encounters (in-person or via telephone) with the CCT January 1 – August 19 2013 In their records CHWs subjectively appraised clients at each encounter on a set of topics commonly Asarinin Asarinin resolved by the CCT using a level of 0 to 10 (where 0 means a.