|Barrier||Activities to Address Barrier|
|1. The community programs are grant funded (leading to clinicians' perception, and sometimes the reality, that they change frequently, are not reliably available)||1. We are communicating with providers about grant life and local, ongoing program support|
|2. Electronic Medical Records do not have a place for this kind of community resource referrals, making it difficult to institutionalize community referrals||2. Each practice will address this differently. One partner practice has created a Diabetes reference folder in the EHR where clinicians can find referral information.|
|3. There is no single entry point, no one phone number to call to refer a client to these various diabetes prevention and management programs.||3. Again, practices are addressing this differently. We are working with 211 so that they can be a single clinical referral point. One practice has chosen to work closely with and refer to just one community program that best fits their clients' demographics, eliminating this problem.|
|4. Primary Care providers assume in-house educators or endocrinology referrals are providing full range of support--from med titration to nutrition and activity coaching, though this is often not the case.||4. CHIP workgroup is focusing on long-term culture-change, as ACO looks more and more to population health, community diabetes programs are increasing their own visibility and developing relationships with primary care providers to extend support for clients outside clinic walls.|
For more information about this workgroup, its goals, action items, etc., please click "Workgroup Overview" on the right sidebar. You can also click here to see the Community Scorecard--local diabetes data, active partners, current initiatives and community strategies.