California Nonprofits, Primary Care Providers Work Together for Better Care


At A Glance

All of Orange County, California’s nearly 206,000 Vietnamese residents now have increased access to free preventive and chronic care services. In August 2015, Boat People-SOS of Orange County, California (BPSOS-CA) launched the Clinical Community Linkage (CCL) referral network to provide Vietnamese residents a better way to manage chronic conditions. The network—made up of eight nonprofits and two primary care providers (PCPs)—linked 1,027 patients to health services for managing chronic diseases and smoking cessation.

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Public Health Challenge

Vietnamese men in California had the highest prevalence of smoking compared to whites and most other Asian Americans according to a 2005 analysis of California Health Interview Survey data. About 60% of deaths among California Vietnamese men and women are caused by cancer, heart disease, and stroke, according to 2005–2010 death records. Research also shows that death by cancer is rising among Vietnamese American men. However, many speak limited English, and it may be considered culturally taboo to publicly acknowledge chronic illness. These barriers may contribute to a low health literacy rate, which could make it harder for many in the Vietnamese community to access and navigate services designed to help them better manage and prevent health problems. Consequently, chronic conditions such as type 2 diabetes and mental health issues like depression may go undiscussed and undetected.

Find Out More

Allowing for easy referrals and improved understanding among partners helped significantly increase local referral rates from the community organizations to doctors. Learn more about the organization’s efforts to improve community health at or This project is supported by CDC’s Racial and Ethnic Approaches to Community Health (REACH) cooperative agreement.

An elderly man struggled to take care of his mother and get her to her doctors’ appointments until the Vietnamese American Cancer Foundation referred him via the CCL network to a physician at Vitas Healthcare who was willing to make home visits.
- Tiffany Phuong

9842 Bolsa Ave #205

Westminster, CA 92683

Atlanta, GA 30348
Centers for Disease Control and Prevention

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BPSOS-CA worked with eight nonprofits and two PCPs to form the CCL referral network. The formation of the network allows the PCPs to pool the resources of the nonprofits to provide free services to a largely Vietnamese population, increasing efficiency of services while being sensitive to linguistic and cultural needs. BPSOS-CA created an educational campaign for Vietnamese residents with limited English to promote health services, improve understanding of basic health information, and connect them with the care they need. Examples of services provided include tobacco cessation, cancer screening, high blood pressure screening, nutrition counseling, and stroke prevention.

What's Next

BPSOS-CA continues to grow the CCL project. With help from the Kaiser Foundation, BPSOS-CA plans to offer low-income Vietnamese patients non-emergency medical transportation to and from PCP appointments and services. There are also plans to reach children in the Vietnamese community. With funding from the Centers for Medicare and Medicaid Services and the Children’s Health Insurance Program Reauthorization Act, BPSOS-CA will enroll and help retain eligible children in affordable health insurance programs. BPSOS-CA continues to invite local PCPs and nonprofit partners to the Vietnamese community to discuss the management and prevention of chronic diseases.


CCL network partners made 1,370 referrals for chronic disease management and prevention services to 1,027 residents. Ninety-eight percent of referred residents followed through with the referrals and saw the health care providers. Furthermore, BPSOS-CA saw patient care activities including referrals and treatments increase 97% across nonprofits and clinical settings in 2016. To encourage collaboration, BPSOS-CA hosted meetings among partners and rotated the meeting locations so all partners had a greater understanding of the health services available from the network coalition. That approach, used with an electronic referral (e-referral) system, allows the network to provide patients with more customized recommendations.