In Brief

Addressing complex challenges such as diabetes calls for a comprehensive approach in which health care organizations and communities work together for change. This article describes approaches and lessons learned from eight clinic-community demonstration projects funded through the Diabetes Initiative of the Robert Wood Johnson Foundation.

The health and economic burden of diabetes continues to grow, challenging individuals, families, the health care system, and society as a whole.13 Addressing complex challenges such as diabetes calls for a comprehensive approach in which health care organizations and communities work together for change.46 Collaboration extends the range, variety, and coordination of existing services and builds their capacity to mobilize resources and better respond to the needs of their populations.

The Building Community Supports for Diabetes Care (BCS) program of the Robert Wood Johnson Foundation Diabetes Initiative required that projects build community supports for diabetes care through clinic-community partnerships.7  The BCS projects demonstrate how clinic-community partnerships of various types can promote self-management more comprehensively and seamlessly than any partner could do alone. They also serve as “real-world” models for the “Community Resources and Policies” component of the Chronic Care Model.8 

This article will describe organizing approaches to partnership among the eight BCS sites, levels of partnership activity, and examples of intervention strategies used. For purposes of this article, “community supports” refers to those resources and policies in a community that can positively affect health and lifestyle choices. From an ecological perspective, these include a range of influences, such as organizational policies and practices, the physical environment, the information environment,social and cultural factors, and laws and regulations. Community supports enhance the availability of resources, as well as access to them.

BCS partnerships are as varied as the communities and populations they serve. In four of the sites, the lead agency was a nonprofit community-based organization. In two sites, public health agencies were the lead organization. And in the other two, health care provider organizations took the lead. Five of the projects grew out of existing partnerships or coalitions, whereas three used the grant opportunity as a catalyst for action, including building new partnerships (Table 1).

Table 1.

Characteristics of BCS Partnerships

Characteristics of BCS Partnerships
Characteristics of BCS Partnerships

Partnerships did not remain static. Existing coalitions sometimes had broader missions, and the designation of diabetes as a specific priority sometimes brought in new partners or shifted relationships. In addition,partnerships grew or changed as projects matured or new opportunities presented themselves. The approach to clinic-community partnerships in the BCS projects depended on the focus of the lead agency, the setting, and the resources and opportunities available in each community.

MaineGeneral Health, located in Waterville, Maine, is one example of a health care lead agency whose BCS project grew out of an existing partnership,in this case, the Planned Approach to Community Health (PATCH) coalition. This group had a long history of assessing the needs of the population, developing plans, and finding resources to address gaps. In 2001, they identified diabetes as a priority area and, drilling down even further, identified lack of physical activity (a result, in part, of the long, harsh winters in rural Maine) as a particular barrier to self-management. In the context of this broader effort, they developed a targeted strategy for increasing opportunities for and motivating people to engage in physical activity. By contrast, the Minneapolis American Indian Center (MAIC) in Minnesota is a community organization that seized an opportunity to develop a relationship with the newly formed Native American Community Clinic (NACC) in Minneapolis. They were both interested in addressing the burden of diabetes, and they had complementary strengths. Because the clinic was new and there was no existing diabetes program at MAIC, they built their partnership and programming from the ground up.

BCS partners worked together to create or improve community resources and supports for self-management. Some partners contributed to the BCS projects materially by offering programs, services, supplies, space, funds, staff time,volunteers, and other resources. Others contributed in intangible ways, such as providing access to populations and services, expertise, opportunities, and credibility.

Forms of partnership can vary depending on whether the organizations are competitors, how many partners are involved, and the level of collaboration undertaken. Levels of working together fall along a continuum from networking to coordination to full collaboration that involves sharing of resources. Each successive level requires a bigger investment of time and resources from the partnering agencies. Depending on their goals and history together,partnerships that begin by networking may evolve to deeper levels of collaboration after having some success and building trust.9 

The BCS grantees exemplify the continuum and evolution of collaboration. They build supports for diabetes care in four key ways.

  1. Working with existing services, they coordinate, encourage the use of,and enhance access to those services. For example, as a first step to linking people and services, Richland County Health Department in Sidney,Mont., created a community resource guide for people with diabetes and promoted it to providers and patients. In the process of putting it together,they learned of services about which they had previously been unaware and also became aware of some significant gaps.

    Referrals represent a higher level of coordination. The Sunset Health Center, a partner of Campesinos Sin Fronteras (CSF) in Somerton, Ariz.,referred patients directly to the promotoras (community health workers) for follow-up and support. As the partnership progressed, the health center created space for promotoras employed by CSF to be onsite to maximize access and success of referrals.

    In an example of mutual support, a partner of the Galveston County Health District (GCHD) in Texas, Jesse Tree, offers space for community self-management classes. People who attend classes there and also use Jesse Tree's social services are provided expedited access to Jesse Tree's food services, as well as free blood pressure checks and glucose strips to support regular monitoring.

    Coordination and collaboration create synergy within a community. In Homestead, Fla., Open Door Health Center (ODHC) partners assist with project activities, such as multi-ethnic cooking classes and community outreach. Importantly, they also added diabetes-related services and resources to their own agency's efforts and increased their collaboration with each other to better serve their community.

  2. They work together to identify gaps and create new programs, services,or policies that complement existing services. In the Center for African American Health (CAAH) in Denver, Colo., an assessment of parishioners revealed little or no access to diabetes self-management education. CAAH followed up by working with the Eastside Health Center and advisors to create a community-based educational program to fill the gap. In Minneapolis, the MAIC project identified cost as a barrier to access to physical activity. They developed a partnership with a gym serving the same populations that allowed BCS program participants to get free memberships as long as they used the facility at an agreed-upon level of consistency. In Rich-land County, Mont.,and Waterville, Maine, the primary barrier to physical activity was the lack of indoor facilities that would enable people to exercise year round. Both projects were successful in securing new indoor options for physical activity. In Galveston, Tex., program participants frequently asked for classes on healthy cooking to assist them in their diabetes self-management. In response,GCHD collaborated with the Texas Cooperative Extension Family and Consumer Sciences Service to develop the “Whisking Your Way to Health”class.TBL1 

  3. They provide leadership and a forum to raise awareness about diabetes and create consumer demand for resources and supports. In part, serving as the lead agency (i.e., the one who receives the grant funds) confers a coordinating role on the BCS grantees. Leveraging those resources to have the greatest impact on diabetes in their respective communities requires strategic partnerships and an understanding of the multiple and complex societal interactions that influence diabetes self-management. For example, the Montana-Wyoming Tribal Leaders Council (TLC) grant supported the development and strengthening of a community-based collaborative and participatory approach that involved tribal health personnel, the Indian Health Service, and an academic partner. Where there had been lack of coordination and funding for diabetes self-management education and support, the BCS project provided the opportunity to work together, creating synergy and new opportunities for program development. The experience benefited the partners beyond their participation in the BCS project. Moreover, other tribes served by TLC have the expectation that materials and lessons learned at the two project intervention sites will also become available to them.

    In Richland County, Mont., few diabetes self-management resources existed outside the clinic setting before the creation of the Richland County Community Diabetes Project (RCCDP); community agencies and clinical providers seldom talked together about diabetes. RCCDP brought these groups together for regular discussion. They used an ecological approach and began nonclinical activities, such as placing diabetes educational materials in the library,initiating walking groups, and assessing their community for walkability. As they gained support from medical providers, they were able to implement several new self-management interventions and link clinical and community care models to strengthen the continuum of care.

  4. They provide a forum for community input and participation. One of the clearest cases of this is the Diabetes Community Council created in the MAIC project. The council is made up of community members from the population of focus. In a participatory approach that they call the Circle Model, the council worked as co-developers with MAIC staff, the NACC, and their evaluation partner, Wilder Research, to plan, implement, and evaluate their diabetes project. A basic tenet of this process is that programs and services are best shaped by those for whom they are intended. The council shared decision-making at all levels, including how the resources for the program were allocated. As a result, the project funded a case manager at NACC when it became clear that case management was among the highest perceived needs. At another site (TLC), participant input resulted in changing the format of the diabetes education class to include more experiential learning and use of cultural foods.

Community participation has taken a different form in Galveston. Volunteer community health coaches are trained to lead the “Take Action”TBL2 diabetes self-management course. Coaches come from both lay and professional backgrounds. They include former class participants, interested community members, community and parish nurses, health education center staff, local pharmacists, nursing students. Coaches lead classes in their own communities,enabling reach into many areas of the county previously lacking access self-management education.

Table 2.

Examples of BCS Interventions by Ecological Level

Examples of BCS Interventions by Ecological Level
Examples of BCS Interventions by Ecological Level

The ODHC project greatly expanded opportunities for while simultaneously training clinicians and community agency staff aspects of patient-centered diabetes care and self-management. They provided training in popular education to community agencies that facilitated consistency in the agencies' approaches to client interaction improvement in communication with clients. They also offer volunteer opportunities to clinicians in training that benefit the center and provide clinicians self-management support experience that they can take their practices.

The framework of the Diabetes Initiative Resources and Supports for Self-Management (RSSM) was developed from an ecological perspective of diabetes.10  Viewing diabetes ecologically helps identify avenues for intervention at different societal levels individual; family, friend, or organization or system; and community or policy) and opportunities synergy.5,11 Although the individual projects' interventions varied according to local needs and resources, each worked with its partners to fill and improve linkages across levels. Table 2lists some of the strategies used by the BCS projects by ecological level.

It is significant to note that, in six of the eight sites, there are clear roles for peers, and in four sites, peers are central to the intervention activities. They implement key aspects of the projects and serve as advocates and role models for their clients. They are often the link between the community and the health care setting for those they serve. Furthermore, the relationships between peers and clients are themselves therapeutic and therefore key to building community support.1215 

Developing community supports for chronic illness care represents a shift in perspective and requires different types of expertise and resources than those needed for care of acute conditions. Partnerships and collaborations that bring together complementary skills and resources are indeed essential if the linkages across ecological levels are to be made and real change in the diabetes burden is to be achieved.1620 

However, working in partnership requires commitment, time, and skills that may be new to clinicians and community organizations. The eight BCS sites were demonstration projects with a 15-month lead time for planning, testing approaches to programming, and making adjustments as needed before their 30-month implementation phase. The sites found this lead time invaluable for engaging partners, learning to work together in mutually beneficial ways, and building trust. Having the freedom and flexibility to respond to changing circumstances and continue to make improvements throughout the implementation phase proved critical to the success of each BCS project.

The partnership approaches modeled by the BCS projects show promise for building community supports for diabetes care. Continued support for implementation and evaluation of partnerships to build community supports for self-management will benefit chronic illness care and patient self-management for diabetes and other chronic conditions.

Carol A. Brownson, MSPH, and Mary L. O'Toole, PhD, are deputy directors of the Robert Wood Johnson Foundation Diabetes Initiative at its National Program Office at Washington University School of Medicine in St. Louis, Mo. Gowri Shetty, MS, MPH, previously the evaluation coordinator for the Diabetes Initiative, is a senior epidemiologist in the Tobacco Education and Prevention Program at the Arizona Department of Health Services in Phoenix, and Victoria V. Anwuri, MPH, is the program coordinator. Edwin B. Fisher, PhD, is national program director for the Diabetes Initiative and chair of the Department of Health Behavior and Health Education in the School of Public Health at the University of North Carolina in Chapel Hill.

Support for this article was provided by a grant from the Robert Wood Johnson Foundation in Princeton, N.J.

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