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Rural Health Information Hub

Clinical Partnerships Model

In this model, healthcare providers work together to promote and support diabetes management and prevention programs. Programs can collaborate with a range of healthcare and community providers and organizations to extend the reach of services, increase access, and improve coordination of diabetes care.

Effective partnerships will include several types of healthcare professionals, including clinical and non-clinical healthcare workers. Clinical partnerships can expand the care team to involve a range of practitioners, such as:

  • Primary care providers
  • Ophthalmologists
  • Dietitians
  • Pharmacists
  • Nurses and nurse case managers
  • Optometrists
  • Podiatrists
  • Mental health professionals
  • Dental professionals
  • Diabetes educators
  • Community health workers
  • Volunteer lay persons

Partnerships may help to build community-based support for people with diabetes. Involving non-clinical professionals and community-based organizations in diabetes education and self-management may help to:

  • Improve patient adherence to medication guidelines, monitoring recommendations, and lifestyle changes that can enhance glucose control for diabetes.
  • Minimize miscommunication and misunderstandings in the provider-patient relationship outside of clinical visits.
  • Reduce the burden of follow-up on providers.
  • Reduce the burden of travel time and distance on rural patients and their families.

Using a team approach to provide diabetes care, management, and education services can improve coordination of care and continuity between practices and providers. It can also expand the types of services available within communities, addressing some of the common rural barriers to accessing healthcare and health education. See the Healthcare Access in Rural Communities topic guide for more information on the key issues affecting healthcare access among rural populations.

Implementation Considerations

The success of clinical partnerships and using a team approach for diabetes prevention and management requires leadership support and commitment, active participation from members of the care team, effective communication, and adequate resources. According to the National Diabetes Education Program, the six steps to creating or expanding a team are:

  1. Ensuring leadership commitment
  2. Identifying team members
  3. Describing the patient population
  4. Assessing available resources
  5. Developing a system that supports coordinated and continuous care
  6. Evaluating process and outcomes

Ensuring the ongoing success of the team involves efforts to promote patient satisfaction and participation in care, promoting a community support network for diabetes patients, maintaining clear communication and coordination with the team, providing patient follow-up, and using information technology, such as telehealth to support patient care.

Rural programs using partnerships to provide diabetes education and care should:

  • Encourage communication between healthcare providers and community stakeholders
  • Provide services where the priority populations live, work, and play
  • Encourage cross-referrals and coordinated follow-up
  • Coordinate and disseminate clearly-worded, culturally appropriate educational materials
  • Share findings from diabetes and self-management programs with the community
  • Encourage local organizations to promote wellness (such as healthy break areas and competitive incentives to encourage healthy behaviors)

Program Clearinghouse Examples

Resources to Learn More

Redesigning the Health Care Team: Diabetes Prevention and Lifelong Management
Provides information and guidance when forming a multidisciplinary care team for diabetes prevention and management.
Organization: National Diabetes Education Program, National Institutes of Health, Centers for Disease Control and Prevention
Date: 6/2011