U.S. Department of Health and Human Services

Community Partnerships

Patients live, work, and play in social and physical environments outside the health care system. Therefore, clinic-community partnerships are key to building community support for diabetes self-management.1,2 Increasing patient access to effective community resources through linkages with relevant agencies and organizations is a cost-effective way to obtain important services such as nutrition counseling or peer-support groups.3,4 Furthermore, clinic-community partnerships have demonstrated benefits at the individual, organizational, and community levels.5 For example, clinic-community partnerships result in better clinical outcomes; increased capacity for outreach; improved access to community resources; enhanced community engagement in diabetes support; and, ultimately, reductions in morbidity and mortality and improvements in quality of life related to diabetes.6,7

Community partnerships may:

  • Be traditional services (diabetes education sessions) that can extend a health practice’s patient care
  • Help patients who have special needs (e.g., blindness) or limited resources (e.g., no transportation)
  • Be very non-traditional, yet supportive:
    • Beauty and barber shops may have access to hard-to-reach populations.
    • Shoe stores may partner to raise foot care awareness.
    • Faith-based organizations can offer support group opportunities.

Community Partnerships: Ten Steps

By following these 10 steps, health care practices can develop important partnerships with other organizations, agencies, and businesses in their communities to provide support and resources for patients with diabetes.

  1. Identify community-based team members.
    In addition to creating linkages to community-based services, there should be a mechanism for relevant community members (people who have diabetes, are family members of persons with diabetes, or have pre-diabetes) to participate in the diabetes team.
    Community-based team members’ roles might include:
    • Outreach regarding individual patients’ needs
    • Screening for diabetes and hypertension
    • Following-up and problem-solving with self-management needs
    • Providing basic diabetes information, emotional support, and strategies for living with diabetes; accentuating preventive services
    • Collaborating on addressing community approaches to diabetes care and prevention

  2. Identify needs and align with resources already available in your area for patients, their families, and medical staff.
    For example:
    • Humanitarian organizations such as the Lions Club may provide education programs as well as financial and other assistance to diabetic patients with eye disease.
    • Diabetes support groups may provide a variety of services. Local hospitals, the State Diabetes Control Program, the local American Diabetes Association branch, or the American Association of Diabetes Educators may offer support group activities.
    • Other health care professionals in the community may conduct outreach activities:
      • Such professionals may include physical therapists, podiatrists, pharmacists, registered dietitian nutritionists, certified diabetes educators, optometrists, ophthalmologists, dentists, and dental hygienists.
      • Think creatively — physical therapists can screen for neuropathy, measure for protective footwear, and provide patient education if podiatry services are not easily accessible in your area.

  3. Create new partnerships to create new resources.
    Conduct a brainstorming session with your health care team, asking questions such as “What are your needs now? What might you need in the future? Are there any gaps in available community services or resources?” Assess the situation using data collected about your patient population, identify community resources to fulfill your needs, and update your assessment as you learn more.

  4. Explore ways to listen to community members’ diabetes and diabetes care needs.
    For example:
    • Sponsor a “Listening to the Voice of the Community” event.
    • Consider developing offers with local fitness or weight loss clubs that may have introductory offers when patients are referred to them by a physician.
    • Contact the local office of the Cooperative Extension System (CES) or nutrition department at a local university about possible referrals promoting nutrition and health. The CES network links the research and education programs of the U.S. Department of Agriculture to the land-grant universities in each state and to county-level government.
    • Partner with service-oriented youth clubs (e.g., Scouts) to provide assistance to the disabled, seniors, or those with other health care access limitations (childcare needs, language barriers).
    • Link to pharmaceutical companies for free or discounted medications.
    • Regional academic centers may accept a certain number of indigent referrals or send a subspecialty fellow to do clinic on a periodic basis.
    • Diabetes is more than blood glucose control: Set up a referral system for smoking cessation programs in the community.
    • Contact regional health plans.
      • Coordinate with them on guidelines and process and outcome measurements.
      • Tell them what your needs are to accomplish common goals of decreased morbidity and hospitalization.

    ​Examples of Community Partnership Opportunities ​
    ​Community partner ​Resource opportunity
    ​Mississippi, Qualified Health Center Program funds from the state tobacco settlement ​Purchase diabetes testing supplies, shoes, payment for lab testing, eye exams, cardiology evaluations
    ​Local chapter of school for the blind ​Provider education on available equipment (such as glucometers for the visually impaired) and patient education in equipment use
    ​Independent certified diabetes educator ​Exchange of free patient education for indigent patients for volunteer physician lecture on complications or other medical issues

  5. Make the resources accessible.
    Do not just hand patients a list of resources; work with the health system to coordinate planning and referrals. Link patients to community resources via a designated staff person (e.g., nurse case manager). Develop supportive programs and policies with community organizations so they contact patients, and know how to refer back to the health care system when problems are identified. Formalize a policy to be sure it survives staff turnover.
    • Lay health workers (e.g., promotoras, parish nurses, community health workers) may offer a liaison between health care services and community resources, and they can provide effective self-management support.

  6. Periodically review your community partnerships.
    Strive to identify new partnerships that can be developed to fill the gaps in needed services. For example:
    • Ensure Meals on Wheels and senior center services are working together to provide appropriate dietary choices for people with diabetes.
    • Share your concerns about patient needs with leaders in local minority communities. They may already have information and resources to help with diabetes care, but health care practices can team up with high-profile community members for social marketing to the community.

  7. Think broadly: Partner on a local, state, and national level.
    Don't miss an opportunity. Contact local officials about your needs. Local officials may include the mayor; sheriff; district health officers; health departments; legislative officials; State Diabetes Control Programs; or representatives from NDEP, the Centers for Disease Control and Prevention (CDC), the National Institutes of Health, ADA, AADE, the American Heart Association, or the pharmaceutical industry.

  8. Think collaboratively.
  9. Support your community.
    Volunteer as a guest lecturer, visit a school health program, or participate in a community event. These actions can go a long way to show your support of community activities.

  10. Pursue public policy to support healthy lifestyles.
    Local and state health policies, insurance benefits, civil rights laws for persons with disabilities, and other health-related regulations play a critical role in chronic illness care. Advocacy by medical organizations on behalf of their patients can make a difference in developing community support for health self-management behaviors, especially those related to healthy eating and increased physical activity.


Other Examples of Community Partnerships

  1. Consider becoming a partner with NDEP.
    Take advantage of all the support, resources, tools, and expertise NDEP offers for educating your organization’s constituents.

  2. Utilize traditional partners.
    • Registered Dietitians Nutritionists
    • Diabetes educators
    • Diabetes clinicians
    • Diabetes case mangers
    • Clinical directors

  3. Utilize non-traditional community partners.
    • Artists
    • Churches
    • Community health nurses
    • 4-H clubs
    • Grocery stores
    • Health board members
    • Libraries
    • Public health educators
    • Radio/TV stations
    • Racial and ethnic community groups
    • School nurse, teachers, and coaches
    • YWCA/YMCA

      
Non-traditional partnerships can provide:
    • Artwork
    • Cultural knowledge
    • Donated space
    • Expert information on diabetes
    • Food contributions
    • Free advertising
    • Health care
    • Medical information
    • Money
    • Paper supplies
    • Program implementation
    • Special talent
    • Support services
    • Transportation

      
Example: Tailor existing patient education materials to your needs (NDEP materials are public domain), and ask community partners to donate printing, artwork, or even storage space.

  4. Partner with special populations.
    There are additional needs, considerations, and opportunities for special populations. There may be other key partnership links. You can find NDEP materials for these populations by using the age, language, and ethnicity criteria on NDEP’s publications page.

    Community partnerships are key for providing appropriate, consistent, and effective care for homeless and migrant patients.

Resources

References

1. Glasgow RE, Davis CL, Funnell MM, Beck A. Implementing practical interventions to support chronic illness self-management. Jt Comm J Qual Saf. 2003;29(11):563-74.
2. Fisher EB, Brownson CA, O’Toole ML, Anwuri VV, Shetty G. Perspectives on self-management from the Diabetes Initiative of the Robert Wood Johnson Foundation. Diabetes Educ. 2007;33 Suppl 6:216S-224S.

3. Wagner EH, Austin BT, Davis C, Hindmarsh M, Schaefer J, Bonomi A. Improving chronic illness care: Translating evidence into action. Health Aff (Millwood). 2001;20(6):64-78.

4. Johnson P, Thorman Hartig M, Frazier R, et al. Engaging faith-based resources to initiate and support diabetes self-management among African Americans: A collaboration of informal and formal systems of care. Health Promot Pract. 2014;15(2 Suppl):71S-82S.
5. Cashman SB, Flanagan P, Silva MA, Candib LM. Partnering for health: Collaborative leadership between a community health center and the YWCA central Massachusetts. J Public Health Manag Pract. 2012;18(3):279-87.
6. Klug C, Toobert DJ, Fogerty M. Healthy Changes for living with diabetes: An evidence-based community diabetes self-management program. Diabetes Educ. 2008;34(6):1053-61.

7. Boyd ST, Scott DM, Augustine SC. Exercise for low-income patients with diabetes: A continuous quality improvement project. Diabetes Educ. 2006;32(3):385-93.

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