NACDD continues to lead in the 5-year cooperative effort to develop and implement a new arthritis care model, the Public Health Framework for Collaborative Arthritis Management and Wellbeing. Starting in 2023 with the introduction of the Framework, we’ve been engaged in piloting the Framework in Iowa through a partnership with Iowa Community HUB and Primary Health Care, a Federally Qualified Health Center (FQHC) in Des Moines. These partners were selected for their strong track record of fostering meaningful community-clinical collaboration.

Expert Panel 2.0

An Expert Advisory Panel guides the implementation of the Framework, bringing together expertise from across the healthcare and public health spectrum. The panel includes specialists in primary care medicine, rheumatology, physical therapy, health system management, informatics, community-based organization leadership, and state public health. This multidisciplinary approach ensures comprehensive oversight of the Framework’s implementation. The panel meets quarterly to provide critical guidance on the pilot project’s execution. Their oversight has been instrumental in refining the Framework’s approach to integrated care delivery.

Two innovative components that attend panel meetings and operate in parallel are our project’s Learning Advisors and National Partners. A CDC-Funded Arthritis recipient, North Carolina, serves as a Learning Advisor, positioning themselves to implement the Framework in the future based on insights from the current pilot. National partners, including the Arthritis Foundation, Osteoarthritis Action Alliance, YMCA of the USA, and National Recreation and Park Association, who were integral to the Framework’s design, continue their involvement through the panel’s work.

Pilot Project

The first year of the pilot focused on building a robust and sustainable infrastructure and partnership between Iowa Community HUB and Primary Health Care (PHC) in Des Moines. This foundational work yielded crucial insights about implementing care models as we look toward the future.

A key learning was the importance of engaging multiple champions with varied skills and organizational touchpoints. These champions in both organizations proved essential in navigating both clinical and operational changes. The project team discovered that understanding existing clinical workflows and tools was fundamental to successful integration of the Framework.

A site visit to the partners and Iowa Health and Human Services (HHS) emerged as crucial for building mutual understanding and assessing needs. The team found that while community care hub concepts were initially unfamiliar to clinical staff, direct interaction and multiple training approaches helped bridge this knowledge gap. Technical aspects of referral and communication systems require careful attention.

On the technical side, both organizations undertook substantial infrastructure development, including modifications to PHC’s electronic health record system and enhancements to Iowa Community HUB’s bidirectional e-referral capabilities. These changes were guided by careful attention to data availability and communication needs between partners.

Perhaps most significantly, the pilot is reinforcing that this type of change to a complex system requires patience and persistence. Community-clinical connections require time and commitment.  The arthritis team is balancing ambitious goals with realistic timelines, recognizing that sustainable change often develops incrementally.

Plans for Scale and Spread

The Framework’s expansion strategy builds on NACDD’s technical assistance approach with the arthritis funded state programs, leveraging existing partnerships and infrastructure to extend the model’s reach. North Carolina is leading the way as an early adopter, having participated as a learning advisor during the Iowa pilot. Their implementation is already underway, informed by direct observations and insights gained from the pilot project.

This peer-to-peer learning model demonstrates the Framework’s potential for wider adoption across state public health programs. North Carolina’s transition from observer to implementer provides a valuable blueprint for other states in the adoption of the Framework.

The scale and spread strategy will emphasize the importance of context and state-specific adaptations while maintaining fidelity to the Framework’s core elements. We will ensure that future framework implementation can be adapted for diverse healthcare settings beyond FQHCs, including private practices, hospital-based clinics, rehabilitation settings, and integrated health systems. The Framework’s flexibility allows for engagement of an expanded set of care team members including community health workers, physical therapists, and behavioral health specialists, primary care physicians, rheumatologists, nurse practitioners, and physician assistants. This approach to expansion will allow each state to build on the foundational learnings from Iowa while tailoring local implementation to their unique healthcare landscape, workforce capacity, and community needs.

Coming in the Final Year:  Resource Development and Dissemination

Beginning in late 2025, NACDD will develop a comprehensive suite of resources to support states in adopting and implementing the Framework successfully. These materials will address the needs of multiple interest holders and approach Framework adoption across implementation stages.

For state chronic disease leaders, NACDD will be creating targeted training programs that will equip them with the knowledge and tools needed to guide Framework implementation in their jurisdictions. These trainings will incorporate key learnings from the Iowa pilot and North Carolina’s early adoption experience, providing practical strategies for building effective community-clinical partnerships.

Clinical sites will benefit from specialized training resources that will address both operational and clinical aspects of Framework implementation. Drawing from the pilot’s experiences, these materials will cover crucial topics including workflow integration, staff training approaches, and strategies for championing organizational change.

This effort is part of the “Advancing Arthritis Public Health Priorities Through National Partners, Component 2” project supported by the Centers for Disease Control and Prevention (CDC) of the U.S. Department of Health and Human Services (HHS) as part of a financial assistance award totaling $1,461,914 with 100 percent funded by CDC/HHS. The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement by, CDC/HHS or the U.S. Government.

This project sits within NACDD’s Center for Advancing Healthy Communities.