Routine Screening Toolkit: Community outreach

Step 1: Community outreach

A successful routine screening program begins with outreach strategies rooted in engagement outside the community health center’s walls, forming long-term bonds with the community and delivering educational messages that stick.

AMA 6-month Community of Practice on routine screening

AMA seeks community health center and emergency department physicians interested in increasing routine screening for HIV, STIs, viral hepatitis and LTBI.

Apply by Jan. 10, 2025

Critical considerations at this stage

Health care is not a priority compared to income, housing or food insecurity
Distrust of institutional health
Lack of awareness in the community about the need for routine screening
Lack of knowledge on costs and affordability of screening
Shortage of access to sites that provide screening
Lack of adequate transportation to clinics
Misconceptions about disease transmission
Fear of finding out one’s status and the associated stigma in the community

Strategies you can implement

Build strong community partnerships
1. Building trusted relationships is critical to normalizing routine screening. Establishing a referral program through network of affiliates and community, medical and social service organizations, including those organizations who may already be doing community-based testing, will link more patients to your community health center for screening and care.
2. Related resources
- Tool for Tracking Partners and Partnership Activities: Pages 81-88 from the Health Resources and Services Administration’s (HRSA) Integrating HIV Care, Treatment & Prevention Services into Primary Care–A Toolkit for Health Centers guide includes a Partnership Toolkit that provides a comprehensive list of key considerations, steps and templates to help guide your organizations’ community relationship building and tracking.
- Partnership Mapping Template (PDF): This template provides a framework to help your organization keep track of relationships with non-clinical services and outpatient clinics that will support both community outreach and a sustainable linkage to care program.
Increase local and digital visibility
1. More traditional approaches such as on-the-street flyers and targeted social media ads help establish visibility of a clinic’s services and notify the public of its accessibility and affordability.
2. Related resources
- Social and Digital Marketing Material and Campaign Examples: The CDC’s National Prevention Information Network includes information and links to digital marketing examples and marketing campaigns executed by a variety of organizations.
Establish an integrated approach to care
1. Employ a holistic social determinants of health (SDOH) approach to your care, offering wrap-around services such as mental health care and non-clinical support with employment or housing, to initiate screening and ensure longer term care.
2. Related resources
- Tools for Putting Social Determinants of Health into Action: This CDC webpage compiles a series of tools and resources that health care practitioners can review in order to embed strategies to address social determinants of health in their organization.
- Health-Related Social Needs Screening Tool (PDF): This resource from the Centers for Medicare and Medicaid Services can help clinicians find out patients’ needs in five core domains including housing instability, food insecurity, transportation problems, utility help needs and interpersonal safety.
- PRAPARE Screening Tool and Implementation Toolkit: Developed in partnership between the National Association of Community Health Centers, the Association of Asian Pacific Community Health Organizations, and the Oregon Primary Care Association the Protocol for Responding to and Assessing Patients’ Assets, Risks, and Experiences (PRAPARE) is a national standardized patient risk assessment protocol designed to engage patients in assessing and addressing social determinants of health.
  
  Care team training on the SDOH:
  - AMA STEPS Forward® Module: Addressing Social Determinants of Health: This learning module from AMA STEPS Forward® outlines how to identify methods to understand the unique health needs of your community and formulate a plan to help your organization begin to address social determinants of health.
  - Social Determinants of Health foundational course: This case-based virtual course from Aquifer provides foundational knowledge and a framework for building skills that minimize the effects of social determinants of health, on health outcomes.
  - Training Primary Care Residents on the Social Determinants of Health: This resource from the Greater New York Hospital Association includes foundational content that can be used when teaching social determinants of health concepts to both primary care residents as well as other care team members involved in the routine screening process.
Meet patients where they are
1. Expanding or building partnerships for testing outside of the clinical setting—and bringing it to local clubs, bars, rehab centers or on-the-street mobile clinics—helps overcome transportation barriers and normalize screening in the community.
2. Related resources
- HIV Testing in Non-Clinical Settings: This CDC webpage compiles a series of guidelines, recommendations and job aids that supports HIV testing in non-clinical setting.
- Implementing HIV Testing in Nonclinical Settings: A Guide for HIV Testing Providers (PDF): The purpose of this guide from the CDC is to familiarize clinicians with key programmatic issues that impact delivery of HIV testing services in nonclinical setting.
Provide patient-centric education materials
1. Patient education materials that are linguistically and culturally reflective of populations disproportionately affected (such as Baby Boomers for HCV or refugees for LTBI) help patients overcome shame and understand the need for routine screening.
2. Related resources
3. Patient Education Materials from the CDC: These links compile downloadable patient education materials from the CDC with resources targeted to different patient demographics and available in multiple languages.
- HIV Consumer Info Sheets
- Viral hepatitis Patient Education Materials
- STIs Patient Education Resources from the CDC
- How to prevent STIs, LTBI and TB disease resources
  - Find TB Resources: TB Education & Training from the CDC
  - Tuberculosis Patient & General Public Materials
- JAMA Network™ Patient Pages: JAMA Patient Pages are free patient resources designed to distill high-quality evidence and updated guidance from USPSTF into a more accessible patient friendly format to help guide patient decisions. These resources can also be helpful to reference as your clinic or institution develops their own patient-friendly educational resources.
- HIV
- Viral hepatitis
- STIs
- LTBI
  - Screening for Latent Tuberculosis HIV Testing in Non-Clinical Settings: This CDC webpage compiles a series of guidelines, recommendations and job aids that supports HIV testing in non-clinical setting.

Disclaimer: This page contains resources supplied by third party organizations. Inclusion of these materials on this page does not imply endorsement of these resources or corresponding organization.

Next steps

The HIV, STIs, Viral Hepatitis and LTBI Routine Screening Toolkit is organized across the screening continuum and offers helpful resources and best practices for the care team.