Community-Clinical Linkages: NCCDPHP’s Program Successes
Connections made between health care, public health, and community organizations to improve population health are called community-clinical linkages. These connections can reduce health disparities by bridging the gap between clinical care, community or self-care, and the public health infrastructure. That’s why they are one of the key social determinants of health (SDOH).
CDC’s National Center for Chronic Disease Prevention and Health Promotion funds partners to improve community-clinical linkages as part of our work to achieve health equity. Following are examples of successful projects.
South Carolina Reaches Women Who Face Barriers to Breast and Cervical Cancer Screening
In 1991, South Carolina was one of the first states to receive funding from the National Breast and Cervical Cancer Early Detection Program, which screens women who have low incomes and no health insurance. As of 2020, the state’s screening program, Best Chance Network, had screened about 135,000 women and found more than 1,600 invasive breast cancers, 550 pre-breast cancers, 1,100 invasive cervical cancers, and 3,200 pre-cervical cancers.
To reach African American and Hispanic women and to increase the number of women who returned for routine screening, the Best Chance Network used data from the South Carolina Central Cancer Registry to decide where to focus its efforts. These data provide rates of new cases and deaths from breast and cervical cancer at the state, county, and zip code levels.
To reach African American women, the program worked with the South Carolina Witness Project, a faith-based organization that educates women on cancer risk factors and recommended cancer screening tests. Catawba Indian Nation and non-federal tribes were reached through the South East American Indian Council, Inc. The program worked with Closing the Gap in Healthcare to explain the importance of cancer screening at beauty salons and partnered with several large stores to host mobile screening events and set internal policies to encourage cancer screening.
The Best Chance Network’s patient navigators address barriers that may prevent patients from getting recommended cancer screenings. The program works with community-based organizations to provide support services, including transportation, to patients who live in counties with low screening rates and high rates of new cancers and cancer deaths.
To expand its patient navigation reach, the program worked with AccessHealth Horry and Chronic Care Staffing to identify women who were 1 to 3 years overdue for screening so they could be linked to a medical home and resume cancer screening.
The program also found that many women who had an abnormal test result didn’t return for follow-up care. In partnership with the South Carolina Office of Rural Health, the program worked with doctors throughout the state, including 87 doctors in rural areas, to improve their practices and reduce barriers.
- Rescreening rates in South Carolina increased from 46% in 2015 to 65% in June, 2020.
- From June 30, 2019, to June 29, 2020, the Best Chance Network screened more than 14,000 women for breast and cervical cancer. That was 2,500 more women than projected, despite COVID-19 challenges.
- The average time for receiving follow-up care improved from 6 months in 2017 to 10 business days in 2020.
- In 2019, the Best Chance Network partnered with mobile van providers to conduct 62 mobile mammography clinics throughout the state, screening more than 700 women.
Montana Telemedicine Network Increases Rural Diabetes Education
A person with diabetes is at high risk of heart disease, stroke, and other serious complications, such as kidney failure, blindness, and amputation of a toe, foot, or leg. In the last 20 years, the number of adults diagnosed with diabetes has more than doubled as the US population has aged and become more overweight.
Diabetes self-management education and support (DSMES) is a proven, cost-effective way to help people with diabetes improve their health. However, 62% of rural counties don’t have DSMES services. In the United States, rural populations have higher rates of diabetes and lower rates of participation in DSMES compared to residents of urban areas.
In 2012, the Eastern Montana Telemedicine Network (EMTN) linked five rural clinics to Diabetes Care and Education Specialists at Billings Clinic. This specialist care was not available locally, so the connection decreased travel time and expense for patients, who go to a nearby doctor’s office to meet on camera with a diabetes care team in Billings.
Among the rural clinics whose patients received DSMES this way, the practice of checking blood glucose correctly for 6 months improved from 31% at baseline to 61% after the intervention, and healthy diet improved from 8% to 29%. From 2012 to 2019, the number of clinics linking patients to DSMES services across the state grew from 28 to an all-time high of 47.
DSMES services can help people with their diabetes management during times of emergency when health care providers are unavailable to provide support or offer guidance in a regular health care setting. The Billings Clinic continues to be the hub of the EMTN, which supports over 40 partner sites throughout Montana, western North Dakota, and northern Wyoming.
During the COVID-19 pandemic, the Montana Department of Health and state DSMES delivery site partners have been bringing care even closer to home by piloting the use of apps to support diabetes care and education specialists in maintaining connections with their patients day-to-day between telemedicine visits.
Tribal Wellness Program Provides Culturally Appropriate Trainings to Prevent and Manage Chronic Diseases
American Indians and Alaska Natives have the highest rate of diabetes of all US racial and ethnic groups. Culture and traditions that once supported good health have been severely disrupted by colonialism, loss of land, and policies such as assimilation, relocation, and tribal termination.
Finding an approach that works for preventing and managing chronic diseases in this population requires adapting proven approaches to cultural needs. From 2014 to 2019, CDC’s Healthy Tribes program funded the Albuquerque Area Southwest Tribal Epidemiology Center’s (AASTEC) Partners in Good Health and Wellness (PGHW) Program to improve the connection between the community and the clinical sector. The program provided culturally adapted training to 120 tribal health workers in AASTEC’s Indian Health Service area.
After each training, AASTEC revised the curriculum to include content specific to Native Americans. For example, the program developed videos to show how to use motivational interviewing that worked best for these populations, nutrition modules that emphasized Native traditional foods, and discussion of traditional tobacco in the context of harms from commercial tobacco. Tribal leaders were involved with in-person training and the graduation ceremony, and teaching tools were shared to help students transition to teachers.
Participants completed a 16-week course, including weekly “teleclinics,” and learned up to five skills, including counseling and education on foot health, blood pressure, blood glucose, weight management, and depression screening. Trainees had an overall pass rate of 98%. In 2019, PGHW expanded to national implementation, reaching tribes in Arizona, Kansas, Nevada, Oklahoma, and Texas, and in summer 2020 it moved to a virtual platform because of the COVID-19 pandemic.
For people with diabetes, self-care and healthy eating are essential for preventing complications like heart disease, nerve damage, and blindness. Tribal health workers can share information and tips that are customized for their tribal members to bridge the gap between clinic and community.