This website uses cookies to store information on your computer. Some of these cookies are used for visitor analysis, others are essential to making our site function properly and improve the user experience. By using this site, you consent to the placement of these cookies. Click Accept to consent and dismiss this message or Deny to leave this website. Read our Privacy Statement for more.
Community e-Connect

Community e-Connect

How to Achieve Successful Bi-Directional Electronic Referrals

Six states are currently utilizing their Year 1 1815 and/or 1817 funding to implement Community e-Connect, and NACDD would like to offer the opportunity to additional states for Year 2.

Community e-Connect is a bi-directional linkage between clinical electronic health records (EHRs) and community-based organizations (CBOs). Clinical providers electronically refer patients with diabetes, pre-diabetes, or hypertension to CBOs with programs that can help control these conditions. In turn, CBOs document a patient’s enrollment, their attendance and progress, and electronically send this information back to the clinical provider, where it goes directly into the patient’s EHR.

Using this system, sites in Massachusetts were able to show a sustained decrease in systolic blood pressure of 3.4 mm Hg for patients who received services in community settings compared to a matched sample of patients whose blood pressure was “out of control." By the standards of the American Heart Association, these interventions were “highly cost effective.”

Community e-Connect directly supports the following strategies and activities outlined in CDC-RFA-DP18-1815PPHF18:

  • A.6. Implement strategies to increase enrollment in CDC-recognized lifestyle change programs Diabetes Management and/or Type 2 Diabetes Prevention
  • B.7 Implement systems to facilitate systematic referral of adults with hypertension and/or high blood cholesterol to community programs/resources
 Community e-Connect may also impact these strategies and activities in CDC-RFA-DP18-1815PPHF18:
  • A.3. Increase engagement of pharmacists in the provision of medication management or DSMES for people with diabetes
  • A.4. Assist health care organizations in implementing systems to identify people with prediabetes and refer them to CDC-recognized lifestyle change programs for type 2 diabetes prevention
  • B.5. Develop a statewide infrastructure to promote sustainability for CHWs to promote management of hypertension and high blood cholesterol

Community e-Connect Overview - Year 2 slide deck (.pptx)

Review this presentation for additional information on the process and next steps. If states are interested in finding out more about year 2 participation after reviewing all materials, please contact Susan Svencer,

National Association of Chronic Disease Directors
325 Swanton Way
Decatur, GA 30030
Hours of Operation: Mon. - Fri., 8 a.m. - 4:30 p.m.