Increase clinical referrals to community-based diabetes prevention and management programs


Diabetes Prevention and Management Program Providers:

  • Asheville Buncombe Institute for Parity Achievement (ABIPA)
  • Land of Sky Regional Council-Area Agency on Aging
  • Mission Diabetes Center
  • YMCA of WNC
  • YWCA of Asheville

Clinical/Primary Care Providers (or other referral sources)

  • Asheville Family Medicine*
  • Asheville Internal Medicine*
  • Family Health Centers*
  • MAHEC Family Health
  • Mission Health Partners
  • Mission My Care Plus*
  • Trillium Family Medicine*
  • WNCCHS (Minnie Jones Clinic)

* Partners in the original pilot 2014-2015

Actions and Accomplishments

Actions & AccomplishmentsBy WhenStatus
Update Clinical Referral Tool Aug '16completed
Share Clinical Referral Tool at MAHEC's Managing Diabetes Throughout the Lifespan programAug '16completed
Share Clinical Referral Tool with all residents and providers at MAHEC Family HealthAug '16completed
Meet with WNCHHS referral specialists/staff to discuss integrating community referrals into workflowOct '16completed
Meet with MAHEC referral specialists/staff to discuss integrating community referrals into workflowOct '16completed
Meet with 211 to learn about potential for clinician referrals directly to 211Nov '16completed
Additional Resources
Evidence Base

From the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK)'s Community Partnerships Page (written for a clinical audience):

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


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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