CTG National Network: YMCA of the USA's Lessons Learned in Closing the Clinic-to-Community Gap

YMCA of the USA and its 10 CTG sub-recipients changed systems by developing clinic-to-community linkages between health care providers and community-based organizations, expanding the reach of the YMCA's Diabetes Prevention Program into communities experiencing health disparities to reduce the incidence of type 2 diabetes. Y-USA's sub-recipients facilitated access to the YMCA's Diabetes Prevention Program by developing relationships with healthcare providers in focal communities. Sub-recipients and these providers completed the Y's Clinic-to-Community Assessment Tool to identify opportunities to strengthen clinic-to-community partnerships promoting chronic disease management and prevention to support those at risk of or living with chronic disease. The Clinic-to-Community Assessment drew upon the community-centric process of the Y's Community Healthy Living Index and expands on topics covered in the health care section of CDC's CHANGE. All sub-recipients completed a Clinic-to-Community Assessment within a year of initial funding. Of twenty-two assessments entered into an online system, 27% were community clinics, 23% were FQHCs, and 18% were private medical/physician offices. Providers were urban (73%), accepted public insurance (95%), and served low income (80%) and non-White (54%) patients. Twenty-seven percent (27%) indicated implementing policies to address the need for a chronic disease referral system to CBOs. Sub-recipients reported that the Clinic-to-Community Assessment was a first step in building relationships and bridging knowledge gaps between CBOs and providers, but underlying health care system factors limit referrals between providers and CBOs. Promising strategies tested by sub-recipients include adding specific pre-diabetes diagnoses, implementing referral prompts in EHRs, providing referral resources for patients, and addressing privacy issues.