Community-Clinical Linkages for Diabetes Prevention and Management
The incidence of Type 2 diabetes has continued to rise despite known effective interventions—such as the National Diabetes Prevention Program (DPP) from the Centers for Disease Control and Prevention (CDC)—to prevent or delay diabetes through lifestyle changes. People of certain racial or ethnic subgroups and those with lower incomes are at a higher risk of developing diabetes. They also face greater obstacles to participating in DPP.
Community Clinical Linkages (CCLs) are connections between community and clinical sectors to improve population health. CCLs can create the necessary change in systems’ policies, practices, and norms to connect people at higher risk of developing diabetes with effective interventions such as DPP. To do so, CCLs must effectively engage service providers across sectors who may have limited experience and infrastructure to work together; as well as the populations they serve, who may mistrust healthcare and other systems due to past experiences.
With funding from the CDC, AIR and the Santa Clara County Public Health Department (SCC PHD) are learning how shared measurement can strengthen CCLs to improve participation in and access to evidence-based lifestyle change programs in the county.
AIR and SCC PHD hypothesize that a shared measurement approach (i.e., collaborative identification of core measures, shared values, factors meaningful for success, barriers that may be preventing progress and strategies to overcome them, and ways to monitor progress) can improve participation and coordination among systems and related service providers to meet different community needs and lead to more effective diabetes prevention programming and reduced disparities in diabetes outcomes.
