PARKS, RECREATION AND

HEALTHCARE: PARTNERSHIPS
TO ADVANCE COMMUNITY
WELLNESS HUBS
 Cover image:
Children enjoy a healthy meal
through the Summer Lunch Program
hosted by Integral Youth Services.
Photo courtesy of Integral Youth
Services (Klamath Falls, Oregon).

© 2022 National Recreation and Park Association

 Table of
Contents

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
2 . . . . The Role of Parks and Recreation and Healthcare Organizations

Building Block: Prepare to Partner . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

3 . . . . Conduct a Community Assessment
4 . . . . Conduct an Organizational Self-Assessment
4 . . . . Identify Potential Partners
5 . . . . Assess Partner Readiness
6 . . . . Establish Your Value Proposition
Building Block: Coordinate Your Partnership . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
7 . . . . Create Your Shared Vision
8 . . . . Identify Champion(s)
9 . . . . Define Partnership Roles and Responsibilities
9 . . . . Establish Transparent Protocols
Building Block: Put the Pieces Together . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
10 . . . Determine Implementation Model
11 . . . Level Set: Agreeing on a Screening and Referral Approach
13 . . . Develop the Implementation Plan
13 . . . Pilot Your Implementation Plan
Building Block: Assess Your Initiative . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
14 . . . Identify Key Metrics and Measures of Success
15 . . . Identify a Data-Sharing Plan
Building Block: Sustain Your Partnership and Initiative . . . . . . . . . . . . . . . . . . . . . . 16
16 . . . Expand Financial Streams
16 . . . Scale Up Your Initiative
Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

Park and Recreation and Healthcare Partnerships to Advance Community Wellness Hubs | 1
 Introduction
PHOTO COURTESY OF CHICAGO PARK DISTRICT.

Children learn about plants through a

hands-on activity by the Get Growing
Foundation’s Plant Truck Chicago.

P ark and recreation agencies are a cornerstone of communities and offer individuals the opportunity to be active, healthier,
and connect with nature and each other. However, if there’s one thing park and recreation professionals know, it’s that
through partnerships with other community stakeholders, agencies can play a much greater role in influencing the health
and well-being of their communities.

Community Specifically, park and recreation agencies have a unique opportunity to con-
Wellness Hubs tribute to local food and nutrition systems by serving as Community Well-
ness Hubs. Under this model, park and recreation agencies can engage key
NRPA defines Community Wellness community players and coordinate services that expand access to and quality
Hubs as trusted gathering places of food and nutrition services, while connecting people to additional health
that connect every member of the and social resources. Whether it be providing meal programs, hosting farmers
markets, or supporting the Supplemental Nutrition Assistance Program
community to essential programs,
(SNAP) and the Special Supplemental Nutrition Program for Women, Infants
services and spaces that advance and Children (WIC) enrollment and retention, park and recreation agencies
health equity, improve health out- have an opportunity to partner with community stakeholders to offer coor-
comes, and enhance quality of life. dinated and integrated services that help address upstream challenges and
barriers to the social determinants of health.

2 | 2022 National Recreation and Park Association

The Role of Parks and Recreation
and Healthcare Organizations
Park and recreations’ reach and impact can be extended by
partnering with healthcare organizations. Many community-
based organizations (CBOs), including parks and recreation, are
adapting to the changing healthcare landscape by exploring
new opportunities to engage healthcare providers and payers
in partnerships.

Much like parks and recreation, healthcare agencies often oper-

ate as a pillar of the community and aim to address population
health challenges by advancing health and wellness. Moreover,
there is increasing interest on the part of healthcare to engage
in community-based partnerships, as they are increasingly rec-
ognizing the impact of social factors — such as access to food
— on the health and longevity of their patients. For example,
ensuring patients have access to healthy foods has been found
to lower healthcare utilization and costs.1 In addition, there is
emerging evidence that screening for and attempting to ad-
dress unmet needs within a primary care setting can improve
patient health.2 Partnerships with healthcare organizations pro-
vide the opportunity to leverage their skills, resources and cred-
ibility to offer robust, dynamic and accessible services, as well
as establish a system of health and wellness that supports the
community at large.

However, establishing a successful and sustainable partnership

requires thoughtful planning and investment on both ends. This
toolkit walks park and recreation agencies through key steps
to consider when planning, coordinating and implementing a
partnership with a healthcare organization.

What Are Payers?

Payers are organizations — such as health plan
PHOTO COURTESY OF THE TOWN OF VIVIAN, LOUISIANA.

providers, Medicare and Medicaid — that are

responsible for processing patient eligibility, en-
rollments, claims and payments. Payers are not
the same as providers.

1 Tsega M., Lewis C., McCarthy D., Shah T., Coutts, K. (2019, July 19). Review of Evidence
on the Health Care Impacts of Interventions to Address the Social Determinants of
Health. CommonWealth Fund. Retrieved from: https://www.commonwealthfund.org/
publications/2019/jun/roi-calculator-evidence-guide Community members are
2 Berkowitz S.A., Hulberg A.C., Standish S., Reznor G., Atlas S.J. (2017). “Addressing Un- served samples of a healthy
met Basic Resource Needs as Part of Chronic Cardiometabolic Disease Management.” meal at a community center.
JAMA Internal Medicine. 177(2):244–252. doi:10.1001/jamainternmed.2016.7691

Park and Recreation and Healthcare Partnerships to Advance Community Wellness Hubs | 3
 Building
Block:
Prepare to
Partner
PHOTO COURTESY OF DAWN CRIBB.

Children sit down to enjoy lunch

during Camp Superstars, a
program hosted by the DeKalb
Department of Recreation,
Parks and Cultural Affairs in
Decatur, Georgia.

P rior to implementing a new or expanding an ongoing initiative, such as a community wellness hub, it is important to
pause and take steps to understand your community’s efforts to date, priorities, assets and key players. This will equip
you with the information needed to conceptualize what a successful healthcare partnership supporting community nutrition
might look like.

Conduct a Community Assessment

Before approaching prospective partners, it is important to authentically engage the community to better understand key
needs and priorities and examine past community-level efforts to address food access and nutrition security. This might
include reaching out to other CBOs and partners or central community leaders, and it should involve speaking directly with
community members to conduct a community needs assessment. Engaging in a community needs assessment exercise
increases your understanding of the complex factors that contribute to gaps in the food access landscape and provide
you with the information needed to more efficiently address the root causes and symptoms of food insecurity within your
community. Understanding the ways in which community members access food, as well as examining the past efforts of
other organizations can help your agency either identify successful efforts that you might be able to build upon, or identify
unsuccessful efforts from which you can learn.

4 | 2022 National Recreation and Park Association

Key challenges to prepare for:
➢ Temptation to skip this step. It can be challenging to prioritize conducting an assessment of the community’s past
efforts and current resources, especially when you’re working under a tight timeline with limited resources. However,
taking the time to do this is imperative to centering community voices in your partnership; to preventing you from
reinventing the wheel and making mistakes that already have been made; and to helping you maximize lessons
learned.
Resources:
➢ (Template) Root Cause Analysis Resources – The 5 Whys3
➢ (Template) Root Cause Analysis Template Collection4
➢ (Tool) Conducting a Community Needs Assessment5
➢ (Trainings and Tools) Community Health Assessment (CHA)/Community Health Improvement Plan (CHIP) Trainings
and Tools6

Conduct an Organizational Self-Assessment

The next step is to conduct an organizational self-assessment in relation to your readiness to work and partner with a healthcare
organization. Many CBOs, including park and recreation agencies, are adapting to the changing healthcare landscape by explor-
ing new opportunities to engage healthcare. Often, these cross-sector partnership opportunities encourage CBOs to adapt and
change in many ways, in order to successfully attract and retain healthcare partners. A self-assessment can help your agency
gauge its current level of healthcare partnership readiness and offer examples of what readiness looks like across different areas,
such as Information Technology (IT) infrastructure and resources, leadership buy-in, and marketing and outreach.

Resources:
➢ (Tool) Readiness Assessment7

Identify Potential Partners

Next, you want to take stock of those stakeholders in your community who may be beneficial partners, such as those work-
ing on efforts related to chronic disease, food access and nutrition security, park accessibility, etc.

You can start this process by conducting a stakeholder mapping exercise. Stakeholder maps help you lay out who is working
in the food access and nutrition security space, what they bring to the table, and how you may be best positioned to support
these efforts. While you ultimately want to narrow in on a healthcare partner, this exercise prevents you from overlooking
key community players and increases the chances of securing widespread buy-in and support during the implementation
phase. This community-level engagement and buy-in is critical to ensuring your community wellness hub strategies are well
supported, coordinated and sustainable.

A key element of this exercise is assessing the degree of financial and nonfinancial influence your prospective healthcare
partner has. For example, a local private physician practice and a regional hospital have different funding streams and spheres
of influence. These are important factors when considering the sustainability of your community wellness hub initiative and
moving beyond grant funding.

3 National Implementation Research Network. “Root Cause Analysis Resources: Understanding Community Need.” Retrieved from https://unc.live/3gV0GEQ
4 Smartsheet. (2017, January 30). Free Root Cause Analysis Templates: The Complete Collection. Retrieved from https://www.smartsheet.com/free-root-cause-analysis-
templates-complete-collection
5 National Recreation Park Association (NRPA). Community Needs Assessment. Retrieved from https://www.nrpa.org/publications-research/evaluation-resource-hub/
community-needs-assessments
6 National Association of County and City Health Officials (NACCHO). Community Health Assessment (CHA)/Community Health Improvement Plan (CHIP) Trainings and
Tools. Retrieved from https://bit.ly/3rWmBBO
7 Aging and Disability Business Institute. Readiness Assessment. Retrieved from https://www.aginganddisabilitybusinessinstitute.org/assessment-tools/readiness-assessment

Park and Recreation and Healthcare Partnerships to Advance Community Wellness Hubs | 5
 Two volunteers take care of
the East End/Valley Street
Community Garden that was
established through a grant that
NRPA gave to Asheville (North
Carolina) Parks and Recreation.
PHOTO COURTESY OF ASHEVILLE PARKS AND RECREATION.

6 | 2022 National Recreation and Park Association

Key challenges to prepare for: “We have a child
➢ Find a partner that honors and respects your community participants.
It can be difficult to assess whether a prospective partner’s support
hunger coalition that
for your community wellness hub comes from a desire to advance has the same goals
food justice and promote sustainable, community-led development,
or because it meets other financial or reputation-related priorities.
around sustainability and
Depending on the power dynamics at play, this imbalance could food security.”
ultimately come into conflict with both your priorities, and the com-
– Integral Youth Services,
munity at large. It is critical to research your prospective partner’s Klamath Falls, Oregon
mission, values and goals to ensure that you are aligned. Creating
memorandums of understanding (MOUs) also is an effective way
of reinforcing the value and power that a community organization

brings to the partnership (see the Establishing Transparent Protocols
section for more information). “The local park and
➢ Consider how you plan to connect with healthcare partners. Getting
recreation agency
your “foot in the door” with a healthcare partner can be challenging has been a thriving force
and cultivating a relationship into a partnership may be a long-term
commitment. During your stakeholder mapping exercise, you may
for over 10 years
have identified some existing partnerships or found that you overlap and is trusted.
with community organizations that intersect with your prospective
When ideas sparked
healthcare partner. You also may already participate in task forces or
committees together. Consider these touchpoints, as these may make about potential projects,
it easier to establish a connection with a prospective healthcare partner.
their transparency
Resources: and constant open lines
➢ (Tool) Sample Stakeholder Mapping Template8
of communications
Assess Partner Readiness allowed for a push in
Before approaching your prospective partner, it is helpful to have a sense community involvement.”
of their level of readiness so that you can determine the support you may – Memorial Hermann
need to provide, and the strengths you may need to leverage to make this a Community Benefit
successful partnership. Take a look at the following four levels of readiness Corporation, Houston
and identity which level your prospective partner falls in:
Level 1: Wants to address food access and nutrition security, but hasn’t done so because they lack information
about why food insecurity should be a priority and an understanding of how to approach the issue
Level 2: Wants to address food insecurity, but it isn’t a high organizational priority due to competing factors
Level 3: Wants to more effectively reach individuals and families in the community with health/nutrition education
messages and/or health/nutrition education programming
Level 4: Wants to implement an intervention to effectively and immediately address the needs of their food inse-
cure patients

Resources:
➢ (Additional Reading) “Assessing Readiness and Creating Value Through Food Bank-Health Care Partnerships”9

8 Health Service Executive. (2018). People’s Needs Defining Change: Health Services Change Guide. “Guidance on Stakeholder Mapping and Analysis.” Retrieved from https://
bit.ly/3LE484N
9 Feeding America. (2018). “Assessing Readiness and Creating Value Through Food Bank-Health Care Partnerships.” Retrieved from https://bit.ly/3gTE2wz

Park and Recreation and Healthcare Partnerships to Advance Community Wellness Hubs | 7
 Establish Your Value Proposition
It is now time to prepare and deliver your value proposition pitch to your prospective partner. A well-thought-out value prop-
osition can help you differentiate your agency, highlight your strengths and value add, and articulate how a partnership with
you can help them to meet their needs or fill service gaps within the community. Your value proposition should be clear,
concise and compelling, as well as elevate your credibility and high-level goals.

In putting together a value proposition, work with your internal team to prepare responses to the following questions:
1. Whom are you addressing?
2. What do they want and/or need? What are their biggest concerns/unmet needs?
3. What can parks and recreation provide? What are you offering?
4. What’s the benefit to the patient/client? What problem does it solve for them?
5. What makes this a unique proposition compared to alternatives?

Key challenge to prepare for:

➢ Parks and recreation may be only thought of as providers of physical activity or traditional recreation services:
When people think of parks and recreation, they are often thinking about physical activity. While this could be where
your partnership starts, it is important to be clear from the beginning that your aim is to leverage parks and recreation’s
position to support initiatives that address key community challenges in addition to physical activity, such as food
access, nutrition security, chronic disease and mental health.

Resources
➢ (Tool) “Value Proposition Tool: Articulating Value within Community-Based and Health Care Organization Partnerships”10

The Burlington Department

of Parks, Recreation
and Waterfront provides
opportunities for school-aged
children and older adults to
connect and access healthy
meals.

NRPA PHOTO

10 Nonprofit Finance Fund. “Resources for Community-Based Organization and Healthcare Partnerships.” Retrieved from https://nff.org/fundamental/resources-community-
based-organization-and-healthcare-partnerships

8 | 2022 National Recreation and Park Association

 Building
Block:
Coordinate
Your
Partnership

N ow that you’ve conducted assessments at the community, organizational and partnership levels, you have, hopefully,
identified a partner that you are well-positioned to collaborate with. Next, you must take steps to create a sense of
common purpose and vision for success to increase the ease and effectiveness of your partnership.

Create Your Shared Vision

Partners are more likely to commit to an initiative if they believe that its goals and mission align with their own. This is why
it is recommended that you collaborate with your healthcare partner to develop a shared vision for your community wellness
hub initiative. This could come in the form of a vision statement, which is essentially a set of guiding principles that outline
the goals of the partnership and articulate a mission of promoting food access and nutrition security for all people. The mis-
sion and goals of your partnership should focus on clearly defined food access and nutrition security opportunities within the
community. Given that goals may change over time, it is important that you continue monitoring these opportunities within
your community and your partner priorities, so that you are able to make adjustments as you move forward.

A team meets to collaborate in a park.

PHOTO COURTESY OF OLEKSANDRA POLISHCHUK, DREAMSTIME.

Park and Recreation and Healthcare Partnerships to Advance Community Wellness Hubs | 9
 Vegetables getting
ready to be sold at
the monthly juniors
farmers market
organized by Grow
Appalachia: Berea
Kids Eat in Berea,
Kentucky.
NRPA PHOTO

Key challenge to prepare for:

➢ Reconciling differing priorities. While you and your healthcare partner likely share a common vision for improving
health outcomes by addressing food security, there may be other differing priorities to be aware of. These could be
optimizing revenue, receiving recognition or increasing opportunities for other partnerships. You need to work closely
with your partner to build consensus around opportunities to expand your vision beyond promoting food access to
promoting nutrition security and food justice, as well. As you and your partner work toward a shared vision, ensure
that you are working together to reconcile these differing priorities through transparency.

Resources:
➢ (Templates and Samples) Public Health Infrastructure: MAPP Visioning11
➢ (Tool) “Sample Visioning Process for Partnerships”12

Identify Champion(s)
Identifying a champion within your partner’s healthcare organization is essential to ensuring that your initiative is continu-
ously prioritized. Champions are well-respected, influential, and offer a level of expertise that can increase the legitimacy of
your initiative within the eyes of the healthcare organization, as well as the community at large. Champions can offer access
to networks, convene community members and stakeholders, and create a sense of trust in the initiative. While a healthcare
champion is often a staff member who helps connect patients to community resources, such as a community health worker
or patient coordinator/navigator, do not overlook other team members — such as electronic health record (EHR) champions,
project managers and providers.

Key challenges to prepare for:

➢ Staff turnover. While having a healthcare champion in addition to your own organization’s community wellness hub
champion can dramatically increase the chances of a successful partnership, this success cannot hinge on a single
individual in either organization. Staff turnover and burnout pose a huge risk to partnerships, particularly between
community-based and healthcare organizations, which both often have high turnover rates. In order for your part-
nerships to withstand the threat of staff turnover, ensure that multiple staff members are aware of and involved in
ongoing partnership initiatives, and that communication protocols and workflow processes are well-established.

Resources:
➢ (Additional Reading) “To Close a Deal, Find a Champion”13
➢ (Additional Reading) Using Champions and Opinion Leaders to Support Learning, Evidence-Based Practice and Qual-
ity Improvement14

11 National Association of County and City Health Officials (NACCHO). Mobilizing for Action through Planning and Partnerships (MAPP). Phase 2: Visioning. Retrieved from
https://bit.ly/3sR9ktk
12 Youth Development Executives of King County. “Sample Visioning Process for Partnerships.” Retrieved from https://ydekc.org/wp-content/uploads/2018/11/Sample-Visioning-
Process-for-Partnerships.pdf
13 Weinstein, P.V. (2014, September 12). “To Close a Deal, Find a Champion.” Harvard Business Review. Retrieved from https://hbr.org/2014/09/to-close-a-deal-find-a-champion
14 Brach, C. (2018, August). Using Champions and Opinion Leaders to Support Learning, Evidence-Based Practice, and Quality Improvement. Agency for Healthcare Research and
Quality. Retrieved from https://www.ahrq.gov/sites/default/files/wysiwyg/evidencenow/tools-and-materials/using-champions.pdf

10 | 2022 National Recreation and Park Association

Define Partnership Roles and Responsibilities
Your initiative is more likely to be successful if each partner is able to meaningfully engage and contribute. It is important
that you set clear expectations of what meaningful engagement and contribution look like, and identify who is responsible
for what. Contributions, particularly from healthcare organizations, must extend beyond providing funding or leveraging
an established reputation. While CBOs may be responsible for community engagement, coordination and service delivery,
healthcare partners should consider offering facility space and utilities, staff and volunteers, data sharing and analytic capa-
bilities, nutrition education curricula, grant writing assistance and/or IT support. Documentation of these roles can help all
parties prepare for inevitable turnover.

Key challenges to prepare for:

➢ Power Imbalances. In certain spheres and communities, healthcare partners may have more funding, resources and
credibility than CBOs. This means that community/healthcare partnerships are at risk of prioritizing the goals and
objectives of the healthcare partner over those of the community-based partner. That said, establishing your partner-
ship’s program delivery model (see the Determine Implementation Model section below for more information) and
roles and responsibilities before deploying interventions can help to mitigate these power imbalances. If expectations
are made clear early on, there will be less opportunity for either partner to step outside of these agreements to prior-
itize their own objectives.

Establish Transparent Protocols

Establishing systems to document decisions, as well as creating transparent communication protocols help to ensure that
both parties are fully involved in the implementation process. Documenting vision statements, financial plans, action plans,
and roles and responsibilities can help the partnership operate more efficiently and set the partnership up to persist if/
when staff leave. Scopes of work, contracts, pledges and signed letters of agreement are all helpful ways to capture protocols
and procedures that have been agreed upon by both parties. MOUs or Business Associate Agreements (BAA) are particularly
important to secure if you plan to share data between partners.

Setting expectations for communication is particularly important

as you establish your partnership. Given that individual staff play “Every program is creating
key roles in the implementation of joint programming, there must
be open lines of communication between main points of contact.
(memorandums of
This also increases your partnership’s ability to withstand staff understanding) MOUs if
turnover or organizational changes that might occur. Ongoing
communication is necessary to discuss progress and challenges,
they’re needed. They assign a
programs and referral timeline, and any changes to key staffing and representative, we strategize,
responsibilities that might impact the referral process.
create development plans,
Resources: and move forward with those
➢ (Tool) “Sample Memorandum of Understanding
Template”15 implementation efforts.”
➢ (Tool) “Business Associate Agreement Template”16 – Memorial Hermann Community
Benefit Corporation, Houston

15 Centers for Disease Control and Prevention. “Sample Memorandum of Understanding Template.” Retrieved from https://www.cdc.gov/cancer/ncccp/doc/samplemoa
template.doc
16 Fairview Physician Associates Network. “Business Associate Agreement Template.” Retrieved from http://www.fpanetwork.org/fv/groups/internet/documents/web_
content/c_816005.pdf

Park and Recreation and Healthcare Partnerships to Advance Community Wellness Hubs | 11
 Building
Block:
Put the
Pieces
Together
PHOTO COURTESY OF PONGPIPAT YATRA, DREAMSTIME.

A group of people come together to enjoy fitness activities in a park.

D uring the implementation phase, you should determine a model that makes the most sense for your program and de-
velop formalized workflows for the elements that each partner is responsible for.

Determine Implementation Model

Partnerships between CBOs and healthcare providers have the potential to leverage complementary skills and expertise to
address needs in the community, while increasing the accessibility of community-based preventive and chronic-care services.
You and your healthcare partner must be intentional about how you deliver this care and implement your project. Approach-
es to project implementation in the context of a community/healthcare partnership often fall into two categories:
1. Co-location of services at a centralized location
2. Coordination of services between organizations

12 | 2022 National Recreation and Park Association

Co-location of services at a centralized location. Under this model, both members of the partnership come together to
deliver programs and services in a central location. This may take the form of a “hub,” where interdisciplinary and cross-sector
health and wellness efforts take place in a single location. If your priority population is not centrally located, partners can
come together to ensure that comprehensive services are offered to those who would benefit from them.
➢ Examples of co-located services include: cooking classes, food lockers, and farmers markets at park sites where
healthcare services are being provided. Within a clinic setting, these could include health/wellness fairs, nutrition
education classes, or enrollment and participation in federal nutrition programs (e.g., SNAP, The Summer Food Service
Program [SFSP], The National School Lunch Program [NSLP], Child and Adult Care Food Program [CACFP], etc.).

Coordination of services between organizations. Under this model, both members of the partnership offer discrete, yet
coordinated, services that provide care at different points along the same continuum. This often takes the form of the health-
care partner screening for food access and nutrition security and referring patients to programming and services delivered by
you, the CBO. This implementation model often requires an extra level of investment in workflow and procedural develop-
ment, considering that it’s a heavier lift for healthcare partners and requires an alteration of their day-to-day operations. For
this reason, we will go into a deeper explanation of how to establish referral networks from your healthcare partner to your
community-based programs and services.
➢ Example of coordinated services include: a fruit and vegetable prescription program, such as a food pharmacy or
healthcare referral to nutrition hubs or other food security services run by park and recreation partners.

A depiction of the ways services are coordinated with and without a central location. For more information on referral systems, visit
NRPA’s resource, Increasing Referrals to Community-Based Programs and Services: An Electronic Health Record Referral Process.17

17 NRPA. Increasing Referrals to Community-Based Programs and Services: An Electronic Health Record Referral Process. Retrieved from https://www.nrpa.org/our-work/
partnerships/initiatives/healthy-aging-in-parks/community-integrated-health-strategies/

Park and Recreation and Healthcare Partnerships to Advance Community Wellness Hubs | 13
 PHOTO COURTESY OF MONKEY BUSINESS IMAGES, DREAMSTIME.

A healthcare worker
meets with a patient.

Level Set: Agreeing on a Screening and Referral Approach

If your partnership is interested in establishing a community-based screening and referral system for food access and nu-
trition security, it is important to come to a consensus about what tools and processes will be used. Understanding these
dynamics can help identify opportunities for synergy and integration
between your team and your healthcare partner.
“We are creating a
To start, you could consider discussing the following questions with
community hub that we can your healthcare partner:
use with partners to provide 1. Why is this screening and referral process relevant to the
additional services to combat healthcare setting? By conducting food access and nutrition
security screenings and referrals, health centers can improve health
inequity.”
outcomes for individuals, design better care teams to deliver
– Integral Youth Services, patient-centered services and execute payment models that sustain
Klamath Falls, Oregon value-based care. By partnering with a CBO and expanding its
cross-sector relationships, healthcare organizations also have the
opportunity to address community-level needs, redesign systems
of prevention, and advocate for change on local policies. Identifying
“They [healthcare provider] which of these outcomes are most meaningful to your healthcare
partner can help you find opportunities for collaboration.
were excited about this as
2. How will the screening and referral process be implemented in
it will connect people with
the context of the healthcare setting? To implement an integrated,
resources in the community. coordinated screening and referral process, it is helpful to have a
strong understanding of what data collection and documentation
We don’t always have
methods your partner already is using. For example, does your
resources in the larger area healthcare partner currently use a standardized screener for food
insecurity? If they don’t have a screener in place, you can work with
because we’re rural.”
them to figure out what makes the most sense for their setting and
– City of Kerman Parks care processes, and how this might intersect with your goals.
and Recreation
Kerman, California

14 | 2022 National Recreation and Park Association

3. What can parks and recreation do once the screening has been completed and a patient is referred? This is where
you have the chance to shine and offer direct involvement in your healthcare partner’s workflow. One common barrier
for healthcare organizations in conducting food access and nutrition security screenings is a lack of community-level
partnerships and ongoing availability of community resources, which prevents them from confidently making a referral.
However, through your partnership’s community-based referral agreement, healthcare partners have a greater capacity to
understand the resources available within the community and how patients can access those resources.

“Aunt Bertha (now findhelp.org) has a capacity for us to refer to resources.

If there were something like a regularly scheduled connection point
or service we knew we could connect people to, I could then use the tool
to refer people. I wouldn’t regularly refer though, if it was an event, versus
a regular service. For example, a quarterly health event isn’t something
we would refer to. If there was regularity though; for instance, on the first
Saturday of the month, it could be made available as a referral resource
within a ZIP code. We haven’t yet figured out the mobile food pantry
and how referrals would happen there, but if it’s regularly scheduled,
then that could be a referral point for us. When people look for resources,
they are searching by topic like food insecurity, and by ZIP code,
so we are referring to resources that are available with regularity.”
– Arkansas Children’s Hospital, Little Rock, Arkansas

4. How might parks and recreation help close the referral loop for referred patients? Another common challenge health-
care organizations face in community-clinical partnerships is retrieving information on their patients once a referral has
been placed. You could consider working with your healthcare partners to identify a simple and secure system for sharing
data related to patients’ referral uptake, services received, etc. (see the Identify Key Metrics and Measures of Success
section below for more information).

Walking through these questions and developing a shared understanding of workflow processes within the healthcare set-
ting can help you to assess the level of buy-in from your healthcare partner and ensure that your partnership develops an
effective referral system.

Resources:
➢ (Additional Reading) Screen and Intervene: A Toolkit for Pediatricians to Address Food Insecurity18
➢ (Additional Reading) “Strategies for Supporting Health Center Patients Experiencing Food Insecurity”19
➢ (Tool) “The Hunger Vital Sign”20

18 Ashbrook, A., Essel, K., Montez, K., and Bennet-Tejes, D. (2021, January). Screen and Intervene: A Toolkit for Pediatricians to Address Food Insecurity. American Academy of
Pediatrics and Food Research & Action Center. Retrieved from https://frac.org/wp-content/uploads/FRAC_AAP_Toolkit_2021.pdf
19 Health Information and Technology, Evaluation and Quality Center. (2021, May). “Strategies for Supporting Health Center Patients Experiencing Food Insecurity.” Retrieved
from https://hiteqcenter.org/Resources/HITEQ-Resources/strategies-for-supporting-health-center-patients-experiencing-food-insecurity
20 Children’s HealthWatch. (2014, May). “The Hunger Vital Sign: A New Standard of Care for Preventive Health.” Children’s HealthWatch Policy Action Brief. Retrieved from
https://bit.ly/3gQlVaS

Park and Recreation and Healthcare Partnerships to Advance Community Wellness Hubs | 15
 Key steps to develop a referral process strategy.

Develop the Implementation Plan

Park and recreation and healthcare staff must develop a joint strategy around the referral process. While this looks different
depending on the size of your organization, resources available, and the level of experience implementing community-based
referrals, this strategy should outline and document:
1. Workflows of both the healthcare partner and parks and recreation
2. Identification of key staff and their roles/responsibilities
3. Communications plan
4. Specifics of implementation efforts (e.g., outline of the location, dates and times programming is being offered)
5. Marketing strategy and communication materials (e.g., parks and recreation may consider developing communica-
tion materials that can be shared with healthcare partners and their patients, describing their services)
6. Training of healthcare and park and recreation staff on engaging referred participants (as needed)
7. Outline of evaluation activities for both the healthcare partner and parks and recreation

Many of these assessments and decisions already have been made through steps outlined earlier in this resource; however,
it is important to document the specifics once the program and partnership have been refined.

Resources:
➢ (Tool) Workflow and Process Analysis for Community Care Coordination21

Pilot Your Implementation Plan

The implementation of this referral will look different for your agency and your healthcare partner. For example, your healthcare
partners are responsible for developing processes to identify and refer patients to community-based services, communicating
that referral to the patient, and following up with both parks and recreation and the patient to close the loop. Park and recreation
staff are responsible for delivering and evaluating services to patients who are referred for food and nutrition services.
Determining exactly what this looks like for your partnership takes some iteration — begin by piloting the implementation
plan you have agreed on for a specified period of time (e.g., one to three months). After the pilot has concluded, come
together to discuss what went well and what did not, and how to modify/improve it. The ultimate goal is expansion of the pilot.

Some discussion topics could include:

➢ Whom did we elicit feedback from? Whom have we not reached out to?
➢ What have been the major pain points of our pilot rollout? What did we overlook in our planning?
➢ What data are we collecting? Are we successfully collecting the data we need?
➢ What about our partnership communication was effective? What was ineffective?
21 Stratis Health and KHA REACH. (2014). Workflow and Process Analysis for CCC. Retrieved from https://stratishealth.org/wp-content/uploads/2020/07/3-Workflow-and-
Process-Analysis-for-CCC.pdf

16 | 2022 National Recreation and Park Association

 Building
Block:
Assess Your
Initiative

M aking data collection and sharing a central component of your initiative increases your ability to draw a clear line
between intervention and impact. Collecting and intentionally communicating data is a critical component of your
community wellness hub’s sustainability. For example, beyond helping you identify ways to strengthen your initiative, you
can use data to communicate the project’s successes to policymakers and stakeholders, identify and establish new partner-
ships, and secure additional funding.

Identify Key Metrics and Measures of Success

“If we can’t measure
In order to properly assess your impact on improving nutrition security, part-
nering organizations must work together early on to identify a common set impact, it’s challenging
of key metrics and measures of success. Each organization will likely be in-
to sustain
terested in different types of data that align with their respective long-term
objectives. For example, your healthcare partner may be more interested in in the long run.”
using outcome data to ultimately secure administrative buy-in, while park and – Arkansas Children’s Hospital,
recreation agencies may be more interested in using outcome data to assess Little Rock, Arkansas
program success or secure future funding.

Of the data you are interested in collecting, it is important for you to come together with your healthcare partner to deter-
mine what data would be valuable to share with one another as part of the partnership. Be sure to also consider the data
needed from a quality improvement lens. Once you’ve laid this foundation, you can consider other metrics and measures
that might be useful or advantageous to collect for long-term purposes.

Groundwork Indy
(Indianapolis) hosts a
informational booth to let
the community know about
its youth development
PHOTO COURTESY OF INDY PARKS AND RECREATION.

programs that connect youth

to the environment and
teach about local food and
nutrition through gardening.

Park and Recreation and Healthcare Partnerships to Advance Community Wellness Hubs | 17
 Potential metrics may include:

Process measures: Focused on ● Number of screenings done (by healthcare partner)

program participation or reach ● Number of referrals to parks and recreation (by healthcare partner)
● Number of contacts made with patients who were referred
● Number of completed referrals, or the number of people assisted by parks and
recreation, who were referred from the healthcare partner
○ Percentage of completed referrals made to parks and recreation
● Number of attendees at shared events
Outcome measures: Typically ● Health outcome measures (e.g., HbA1c blood test for patients who are diabetic and
focused on specific health received services through a community wellness hub)
results related to program ● Results of subsequent food security or social need screening (i.e., responses to food
intervention or impact on security or social need screening questions and whether those show improvement)
community needs and for patients who received services through a parks and recreation partnership
population health status

Identify a Data-Sharing Plan

After you have identified what information will be shared between you and your partner, the next step is to determine how
this information will be shared. It is likely that you and your healthcare partners have different systems and processes for
storing and sharing data.

Early on in your partnership, discuss and come to an agreement on the following questions:
➢ Who holds the data that results from the partnership/program?
➢ How is the data shared (e.g., Stored in a shared location? Shared via secure email)?
➢ Who has access to the data?
➢ How is the data shared outside of your organizations (e.g., for reporting, decision-making purposes, etc.)

Healthcare Considerations: HIPAA

The Health Insurance Portability and Accountability Act (HIPAA) considerations are a key healthcare concern, and you
need to work together to determine how to safely and securely collect and share data. Your partnership agreement out-
lines how data is shared; however, if it is determined that personal identifying information cannot be shared between
park and recreation agencies and your healthcare partner, there are other approaches you can take to exchange critical
information while remaining HIPAA compliant. These include:
1. Healthcare partner and parks and recreation use a shared, secure method for referrals, such as secure email
(e.g., Virtru) or a secure online platform (e.g., UniteUs or findhelp.org)
2. Responsibility is placed on the patient to contact the CBO
3. Only aggregate information is shared between park and recreation agencies and the healthcare provider

Key challenge to prepare for:

➢ Capacity to securely store and share data. If you’re interested in implementing a robust data sharing system
with your healthcare partner, it is likely that you will need to implement a secure system, in order to protect
personal identifiable information (PII). It’s important to consider your internal capacity to securely store information
(e.g., spreadsheet on a secure drive) or share information with your healthcare partner (e.g., Virtru).

Resources:
(Additional Reading) Increasing Referrals to Community-Based Programs and Services: An Electronic Health Record
Referral Process17

18 | 2022 National Recreation and Park Association

 Building
Block:
Sustain Your
Partnership
and Initiative

Attendees network at the 2019 NRPA

Annual Conference in Baltimore.

PHOTO COURTESY OF CAUGHT IN THE MOMENT PHOTOGRAPHY

T here are a number of elements that you can mediate throughout the implementation process to ensure sustainability,
such as preventing disruptions from staff turnover by establishing clear and transparent protocols, or continuously
monitoring your efforts to engage in necessary quality improvement. However, there are some larger questions that you and
your partner likely need to consider, such as how to sustain funding and scale up your initiative once you have demonstrated
its success.

Expand Financial Streams

CBOs like parks and recreation are well-versed in the conflicting relationship between program sustainability and grant-
based funding. In order to sustain your initiative past grant funding, you need to look to alternative funding streams.

If your healthcare partner is a hospital, you may be able to take advantage of its community benefits program under the
Patient Protection and Affordable Care Act (ACA). For a hospital to maintain its nonprofit status, it must engage in and report
on activities that demonstrate the hospital’s promotion of community health, which includes community-based referrals
to food access and nutrition security programming. Other possible funding streams include the healthcare institution
(beyond the Community Benefits program), local health foundations, private foundations, corporate sponsorships, individual
donations or crowdsourcing.

Park and Recreation and Healthcare Partnerships to Advance Community Wellness Hubs | 19
 Richland County Recreation Commission (RCRC) staff packed boxes of
fresh produce to donate to the local food share organization as part of
the part of the #RCRC cares initiative.
PHOTO COURTESY OF FELICIA VENABLE

To take it a step further, you might consider advocating for

more sustainable funding models on a county or statewide “But with [the] program, it’s only
level. For example, you could work with other community
leaders to advocate for changes to state policies to enable
for six weeks. They’re dosed with
reimbursement of food insecurity screenings and referrals heavy activities and when they’re
within healthcare.
back in the fall, we don’t have that
consistent messaging. Through a
Scale Up Your Initiative
grant, we’re able to do this work
If your initiative is ongoing, successful and well-funded, you
may consider scaling up your initiative. This could include
year-round. [The hospital] has a
engaging additional healthcare partners or tapping into alter- tested curriculum and we have
native funding streams to expand the scope of services. You
can expand the number of days a week or month that you
their [hospital’s] support when
offer programming, expand to different park and recreation training our staff. So, it’s not just
sites/locations or partner with other park and recreation agen-
cies to integrate your services. Participating in a multi-sector
a wellness project, it’s a city-wide
partnership or community coalition is an especially effective project. This has helped us get our
approach to reaching a wider audience and identifying oppor-
footing.”
tunities for growth within your community.
– Chicago Parks District,
Chicago

20 | 2022 National Recreation and Park Association

 Conclusion
Park and recreation agencies and healthcare providers share the common goal of improving the health and well-being of
their communities. As healthcare providers become increasingly invested in addressing the social needs of their patients,
through community-clinical partnerships, parks and recreation have the unique opportunity to leverage their position and
complementary skills to improve access to community-based preventive and chronic-care services. The nature of this part-
nership will look different, depending on each partner’s resources, size, readiness to engage and level of experience. However,
through intentional coordination, integration and accountability, park and recreation agencies and healthcare partners have
the opportunity to successfully and sustainably improve health outcomes in their communities.

Acknowledgements:
The National Recreation and Park Association (NRPA) would like to thank the following organizations and individuals for
contributing, providing feedback, and developing this toolkit.

Product Coordinator – NRPA

Allison Colman, Director of Health
Maureen Neumann, Senior Program Manager

Consultant – John Snow, Inc. (JSI)

Amelia Fox, Project Associate
Nicole Giron, Consultant
Jillian Maccini, Senior Consultant
Amanda Ryder, Senior Consultant

Project Review – NRPA

Tiff Cunin, Senior Program Manager
Lauren Kiefert, Program Manager
Liliana Ruiz Fischer, Program Specialist

NRPA also would like to thank the park and recreation professionals and healthcare professionals who contributed their time
and expertise in the formative research stage of product development.

Thank you to Kim Mabon, Jennifer Nguyen and Vitisia Paynich for making this resource possible. In addition, thank you to
the many park and recreation agencies that contributed the images featured throughout this report.

This resource was made possible by the support from the Walmart Foundation. Its contents are solely the responsibility of
the authors and do not necessarily represent the views of the Walmart Foundation.

Contact Maureen Neumann at [email protected] with any questions or comments.

Park and Recreation and Healthcare Partnerships to Advance Community Wellness Hubs | 21
22377 Belmont Ridge Road, Ashburn, VA 20148
800.626.NRPA (6772) | nrpa.org