CDC - Centers for Disease Control and Prevention  NIDDK - National Institute of Diabetes and Digestive and Kidney Diseases

NDEP is a partnership of the National Institutes of Health, the Centers for Disease Control and Prevention, and more than 200 public and private organizations.

Develop Community Partnerships

Increasing access to effective community resources through linkages with relevant agencies and organizations is a cost-effective way to obtain important services such as nutrition counseling or peer-support groups. [2] Health care systems taking a partnership approach with community resources and organizations, and linking patients to those resources is key to self-management success. Patients live, work, and play in social and physical environments outside the health care system. Look for community resources and support networks. Linking patients to these resources is critical for long-term results. [3]

Community partnerships may:


Community is defined broadly as the places people live, learn, work, worship and play.

  • Be traditional services (diabetes education sessions) that can extend a health system's patient care
  • Help patients who have special needs (e.g., blindness) or limited resources (e.g. no transportation)
  • Be very non-traditional, yet supportive:
    • Beauty and barber shops may have access to hard-to-reach populations
    • Shoe stores may partner to raise foot care awareness
    • Faith-based organizations can offer support group opportunities.

Community Partnerships: Nine Steps

By following these 9 steps, you can develop important partnerships with other organizations, agencies and businesses in your community to provide support and resources for patients with diabetes.

  1. Identify community-based team members

    In addition to creating linkages to community-based services, there should be a mechanism for relevant community members (people who have diabetes, are family members of persons with diabetes, or who have prediabetes) to participate in the diabetes team.

    Community-based team members’ roles might include:

    • Outreach regarding individual patient’s needs
    • Screening for diabetes and hypertension
    • Following-up and problem-solving with self-management needs
    • Providing basic diabetes information, emotional support, strategies for living with diabetes; accentuating preventive services
    • Collaborating on addressing community approaches to diabetes care & prevention
  2. Identify needs and align with resources already available in your area for patients, their families, and medical staff.


    • Humanitarian organizations such as the Lions Club may provide education programs as well as financial and other assistance to diabetic patients with eye disease. Contact or check local phone book.
    • Diabetes support groups may provide a variety of services: ask local hospitals, the State Diabetes Control program, local American Diabetes Association branch, or the American Association of Diabetes Educators about local support group activities. Check listings in local newspapers.
    • Other medical providers in community may conduct outreach activities:
      • Physical therapist, podiatrist, pharmacist, dietitian, certified diabetes educator, optometrist, ophthalmologist, dentist, dental hygienist
      • Think creatively – physical therapists can screen for neuropathy, measure for protective footwear and provide patient education if podiatry services are not easily accessible in your area.
  3. Create new partnerships to create new resources.

    Conduct a brainstorming session with your healthcare team: what are your needs now? What might you need in the future? Are there any gaps in available community services or resources? Assess the situation using data collected about your patient population, identify community resources to fulfill your needs, and update your assessment as you learn more.

    Explore ways to listen to community members’ diabetes and diabetes care needs:


    • Sponsor a “Listening to the Voice of the Community” event.
    • Local fitness or weight loss clubs that may have introductory offers or consider creating such offers to those referred by a physician.
    • Contact the local Cooperative Extension Office (CES) or nutrition department at a local university about possible referrals promoting nutrition and health. The CES network links the research and education programs of the U.S. Department of Agriculture to the land-grant universities in each state and to county-level government. Contact check local government pages in the phone book.
    • Partner with service-oriented youth clubs (e.g., Scouts) to provide assistance to the disabled, seniors, or those with other healthcare access limitations (childcare needs, language barriers).
    • Link to pharmaceutical companies for free or discounted medications.
    • Regional academic centers may accept a certain number of indigent referrals, or send a subspecialty fellow to do clinic on a periodic basis.
    • Diabetes is more than blood glucose control: set up a referral system for smoking cessation programs in the community.
    • Contact regional health plans
      • To coordinate with them on guidelines and process and outcome measurements.
      • Tell them what your needs are to accomplish common goals of decreased morbidity and hospitalization.

    Examples of Community Partnership Opportunities

    Community partner

    Resource opportunity

    Mississippi, Qualified Health Center Program funds from the State tobacco settlement

    Purchase diabetes testing supplies, shoes, payment for lab testing, eye exams, cardiology evaluations

    Local chapter of school for the blind

    Provider education on available equipment (such as glucometers for the visually-impaired) and patient education in equipment use

    Independent Certified Diabetes Educator

    Exchange of free patient education for indigent patients in exchange for volunteer physician lecture on complications or other medical issue

  4. Make the resources accessible.

    Don't just hand patients a list – work with the health system to coordinate planning and referrals. Link patients to community resources via a designated staff person (e.g., nurse case manager). Develop supportive programs and policies with community organizations so they contact patients, and know how to refer back to the health care system when problems are identified. Formalize a policy to be sure it survives staff turnover.

    • Lay health workers (e.g., promotoras, parish nurses, community health workers) may offer a liaison between health care services and community resources, and can provide effective self-management support.
  5. Periodically review your community partnerships.

    Are there new partnerships that can be developed to fill the gaps in needed services?

    • Meals on Wheels and SeniorCenter services - are you all working together when it comes to appropriate dietary choices for people with diabetes?
    • Who are the leaders in local ethnic minority communities? Share your concerns about patient needs – they may already have information and resources to help with diabetes care. Team up with high profile community members for social marketing to the community.
  6. Think broadly: partner on a local, state, and national level.

    Don't miss an opportunity. Contact local officials about your needs. Local officials may include themayor, sheriff, district health officers, health departments, legislative officials, State Diabetes Control Programs, or representatives from theNational Diabetes Education Program, Centers for Disease Control and Prevention, National Institutes of Health, American Diabetes Association, American Association of Diabetes Educators, American Heart Association, or pharmaceutical industry.

  7. Think collaboratively.
    • Link with large and small employers for work-based diabetes self-management support programs. Contact
    • Enlist universities for community projects. A community assessment to determine strengths and needs may be a project for a master's level student.
    • Share knowledge via the web. The Health Resources and Services Administration operates a web-based knowledge management system that provides multiple means for the healthcare quality improvement community to share knowledge and contribute to each others’ work.
    • Partner with CDC’s Racial and Ethnic Approaches to Community Health (REACH).
  8. Support your community.

    Volunteer as a guest lecturer, visit a school health program, or participate in a community event. These actions can go a long way to show your support of community activities.

  9. Pursue public policy to support healthy lifestyles.

    Local and state health policies, insurance benefits, civil rights laws for persons with disabilities, and other health-related regulations play a critical role in chronic illness care. Advocacy by medical organizations on behalf of their patients can make a difference in developing community support for health self-management behaviors especially related to healthy eating and increased physical activity.

Other Examples of Community Partnerships

  1. Consider Becoming a Partner with the National Diabetes Education Program (NDEP)

    Take advantage of all the support, resources, tools, and expertise the NDEP offers for educating your organization's constituents.

  2. Utilize Traditional Partners
    Diabetes educators
    Diabetes clinicians
    Clinical directors
    Diabetes case mangers
  3. Utilize Non-traditional Community Partners
    Community health nurses
    4-H clubs
    Grocery stores
    Health board members
    Public health educators
    Radio/TV stations
    Racial and ethnic community groups
    School nurse, teachers, and coaches

    Non-traditional partnerships can provide:

    Cultural knowledge
    Donated space
    Expert information on diabetes
    Food contributions
    Free advertising
    Health care
    Medical information
    Paper supplies
    Program implementation
    Special talent
    Support services

    Example: Tailor existing patient education materials to your needs (NDEP materials are public domain), and ask community partners to donate printing, artwork, even storage space.

  4. Partner with Special Populations

    There are additional needs, considerations and opportunities for special populations. There may be other key partnership links. You can find NDEP materials for these populations by using the age, language, and ethnicity criteria on NDEP’s publications and resources pages.

    Community partnerships are key for providing appropriate, consistent and effective care for homeless and migrant patients.

Resources and References

Academy of Nutrition and Dietetics (AND)

American Association of Diabetes Educators (AADE)
Call 1-800-TEAMUP4 to find a local diabetes educator

American Diabetes Association (ADA)
1-800-DIABETES (1-888-342-2383)

CDC’s Diabetes Public Health Resources presents a list of relevant projects and programs.

Community Needs and Resources Toolkit. 2009

The full toolkit is available online at:

Guide to Community Preventive Services is a free resource about programs and policies to improve health and prevent disease in communities.

(support groups, the Bag of Hope/Teen Pak outreach program, advocacy initiatives to influence public policy regarding diabetes care and research) 1-800-223-1138

Lions Club International

Migrant Health Promotion involves communities to improve health in farm worker and border communities.

National Diabetes Information Clearinghouse
(brochures, how-to kits, other materials)
1-800-860-8747 or (301) 654-3327

State CooperativeExtensionOffices
CooperativeState Research, Education, and Extension Service (CSREES) 202-720-3029

State Diabetes Control Programs

Ten Essential Public Health Services

Three Core Public Health Functions


1. Woolf SH, Glasgow RE, Krist A, et al.: Putting it together: finding success in behavior change through integration of services. Ann Fam Med 2005; 3 Suppl 2: S20-7.

2. Wagner EH, Austin BT, Davis C, Hindmarsh M, Schaefer J, Bonomi A: Improving chronic illness care: translating evidence into action. Health Aff (Millwood) 2001; 20(6): 64-78.

3. Glasgow RE, Davis CL, Funnell MM, Beck A: Implementing practical interventions to support chronic illness self-management. Jt Comm J Qual Saf 2003; 29(11): 563-74.