Community Programs Linked to Clinical Services

Resources for Diabetes and Hypertension


Community Connections: Linking Primary Care Patients to Local Resources for Better Management of Obesity.
A recently completed pilot project, funded by the Agency for Healthcare Research and Quality, followed the experience of seven primary care practices working closely with a well-known community resource, the YMCA, and the YMCA’s Diabetes Prevention Program. This toolkit is the product of their experiences. The tool is intended to help the reader examine his or her practice, reach out to community resources, develop sustainable links, and exercise new strategies and tools to increase patient engagement. Although the YMCA, as a key partner in this project, played a critical role in developing the toolkit, the lessons and examples are intended to be translatable to any community resource and any practice willing to take the extra step to make it happen.

Community-Clinical Linkages
Create sustainable, effective linkages between healthcare and public health to improve patients’ access to care and services. In the community-clinical linkages section you will find information on referral Systems, care coordination, and Team-cased care.

Formalizing Community-Clinical Linkages: Massachusetts DPH e-Referral Project
Massachusetts Department of Public Health, Presentation, September 18, 2014
In 2013 Massachusetts was awarded the CMS State Innovation Model (SIM) Testing Award. Part of this award is to create an open-source, bi-directional referral system to formalize community-clinical linkages. This includes a software available state-wide resulting in more providers using e-Referrals across additional types of community resources. The project works closely with Massachusetts League of Community Health Centers and identified four specific types of community-based organizations: YMCAs, Councils on Aging/Senior Centers, Visiting Nurse Association, and MA Tobacco Quitline.

A Guide to Refer Your Patients with Prediabetes to an Evidence-Based Diabetes Prevention Program
As part of the National DPP, the American Medical Association (AMA) and the CDC have created this resource that care teams can use to identify patients with prediabetes, refer eligible patients to in-person or online diabetes prevention programs and create feedback loops, linking the patient’s progress in the diabetes prevention program back to the practice.

Million Hearts State Learning Collaborative Tools for Change
To help achieve the goal of Million Hearts, the Association of State and Territorial Health Officials (ASTHO) State Learning Collaborative is focused on integrating public health and healthcare efforts to improve hypertension control. ASTHO has compiled tools and resources from states, national organizations, and federal agencies to drive the work of states and territories toward achieving the goal of Million Hearts.

Pathways to Diabetes Prevention: How Colorado Organizations are Creating Healthcare Referral Systems that Work
Two case studies from Colorado highlight how organizations are creating referral systems to help Coloradans at the greatest risk for type 2 diabetes access evidence-based prevention programs in their communities.

Careers at NACDD

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