Community Programs Linked to Clinical Services

Resources for Diabetes and Hypertension

BI-DIRECTIONAL REFERRAL SYSTEM

A bi-directional referral system considers both the information going from the health care system to the referred community program or resource (e.g., a CDC recognized lifestyle change program or a diabetes self-management education program) and the information returning from that program to the health care system. Ideally, the bi-directional referral system will be integrated with an electronic health record (EHR) system and will facilitate electronic bi-directional feedback between the community program and the health care system (e-referral system.) An e-referral system can provide baseline reports on the number of referrals, number of services received, and number of pounds lost and when integrated with the EHR, health systems can evaluate the impact of these community programs on population health. With this information community-based organizations can make the case for clinically meaningful and cost-effective programming.
 

SCHOOL HEALTH (visit School Health Resource Guide)

Daily Management of Chronic Conditions in School Settings: Refers to a set of activities, actions, and protocols that collectively provide a safe and supportive environment in which the risk for an exacerbation of the chronic condition is reduced and/or eliminated. For example, establishing protocols for ensuring that daily, preventive, and/or quick-relief medications are available at school, when appropriate, and are taken as prescribed by a physician; educating students with a chronic condition about their condition and how to recognize and monitor symptoms; and providing appropriate modifications to the environment to reduce or eliminate exposure to substances that may initiate an exacerbation. Emergency Response to Chronic Conditions in School Settings: Refers to a set of activities, actions, and protocols that collectively provide a safe and supportive environment in which all parties are aware of the signs and symptoms of a worsening episode or exacerbation of a chronic condition that requires taking immediate action. For example, developing a system to immediately notify the appropriately trained individuals in the school who will respond to emergencies that may require medical support (e.g. school nurse or nursing assistant); providing training to school staff on recognizing the signs and symptoms of a critical episode (observing a change in behavior due to an abnormal decrease in blood glucose levels); and establishing protocols within the school or school district regarding the process for when and how to engage community-based emergency response support (e.g. emergency medical technicians or an ambulance). Whole School, Whole Community, Whole Child model: School health partners including government agencies, schools, community organizations, and others work together through a collaborative and comprehensive approach to improve health and education outcomes for students. The Whole School, Whole Community, Whole Child (WSCC) model is an expanded model to school health based on the elements of CDC’s coordinated school health approach and the whole child framework.