Community-clinical linkages

 
Domain 4: community-clinical linkages - Ensures individuals with or at high risk of chronic diseases have access to effective community resources to prevent or manage disease and improve quality of life.
 
Current activities
 
Community health workers and patient navigators
These activities champion the use of ancillary care team members and support linkages between health systems and community resources.
 
Community pharmacist integration
These projects promote the inclusion of pharmacists the care team and highlight the value of provision of medication therapy management services to support the control of high blood pressure and/or diabetes.
 
Diabetes Self-Management Education (DSME)
These strategies promote participation in ADA-recognized, AADE-accredited, state-accredited/certified, and/or Stanford licensed DSME programs.
 
National Diabetes Prevention Program (NDPP)
The work around this program aims to strengthen referral mechanisms, and increase the use of and reimbursement for the NDPP statewide.