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CCD Domain 4

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Coordinated Chronic Disease

Domain 4:  Community-Clinical Linkages


Domain 4: Strategies to improve community-clinical linkages  ensuring that communities support and clinics refer patients to programs that improve management of chronic conditions. Such interventions ensure those with or at high risk for chronic diseases have access to quality community resources to best manage their conditions or disease risk.

Community-clinical linkages help ensure that people with or at high risk of chronic diseases have access to community resources and support to prevent, delay or manage chronic conditions once they occur. These supports include interventions such as clinician referral, community delivery and third-party payment for effective programs that increase the likelihood that people with heart disease, diabetes or prediabetes, and arthritis will be able to "follow the doctor’s orders” and take charge of their health – improving their quality of life, averting or delaying onset or progression of disease, avoiding complications (including during pregnancy), and reducing the need for additional health care. 

Examples of Activities

  • Available, accessible arthritis, diabetes, chronic disease self-management education programs, including physical activity programs, to reach at risk populations in community settings, such as worksites, YMCA/YWCAs, schools, senior centers, and other local organizations.
  • Increase use of the CDC-approved evidence-based lifestyle change program to prevent or delay onset of type 2 diabetes among people at high risk.
  • Implement systems to increase provider referrals of people with prediabetes or multiple diabetes risk factors to sites offering the CDC-approved lifestyle change program.
  • Use of allied health professionals to enhance management of high blood pressure/cholesterol, A1C (e.g., pharmacist and/or dental provider model).
  • Use of allied health providers (nurses, dentists, etc.), community health workers, and/or patient navigators in supporting control of high blood pressure, high cholesterol, and A1C.
  • Develop guidelines and systems within clinical care and community settings to address cancer survivorship by ensuring appropriate follow up care and promoting lifestyle interventions to reduce risk of recurrence.    
  • Effective outreach to the population to increase use of clinical and other preventive services.
  • Delivery of school-based dental sealant programs.
  • Safe and effective use of contraception appropriate for women and men with chronic medical conditions.
  • Coverage/reimbursement for diabetes self-management education and chronic disease self-management support programs.

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National Association of Chronic Disease Directors
325 Swanton Way
Decatur, GA 30030
Phone (770) 458-7400
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