Creating healthy communities
Chronic diseases like type 2 diabetes, heart disease, and stroke take a personal toll on our families and have a significant economic cost as well. Healthcare partners are key to screening and referring patients to community-based resources and evidence-based self-management programs.
Linkages happen in different sectors
As individuals, we do not have the ability to address fully or sustainably community-wide health challenges. When clinical and community sectors work synergistically, they can improve care and support patients better than either of these sectors could do alone. When we build systems that support each other toward success, we are able to achieve population health.
Our evidence-based models for change generally engage three sectors:
Community
Provides services, programs, or resources to community members in non-health care settings.
Public health
Lead efforts to build and improve linkages between community and clinical sectors.
Clinical
Provides services, programs, or resources directly related to medical diagnoses or treatment of community members by health care workers in health care settings.
Examples of community-clinical strategies
Quit Partner Referrals
Helping people quit by increasing access to commercial tobacco treatment resources. Local public health work with partner sites to promote and refer eligible and interested patients/clients to Quit Partner services, Minnesota’s free program to quit nicotine—including smoking, vaping and chewing—with one-on-one coaching and other helpful tools.
Age-Friendly Public Health Systems
Supports local public health to integrate healthy aging into core public health functions, demonstrating leadership in creating communities where older adults can thrive. It provides a standardized framework and pathway for SHIP grantees who choose to advance age friendly public health practices through partnerships, equity, and systems change.
Supporting Students with Chronic Conditions
Supports school health professionals and community health care providers who wish to improve bidirectional communication processes by better coordination of chronic condition management in schools. Securing consent from a family to share information is only part of the puzzle in successfully coordinating care across sectors. Trusting relationships, systematic communication norms, and family engagement are also critical.
Food is Medicine
"Food Is Medicine" programs recognize the connection between nutritious food and chronic disease. These types of clinical-community linkages are growing in popularity and are an opportunity to link clinical and community partners. SHIP identifies these as Food Rx programs and are partnerships between a health system (e.g., primary care clinic, hospital) and food system (e.g., farmers market, food shelf). Patients are screened for food insecurity and other possible chronic disease risk factors, such as high blood pressure or diabetes risk factors. Based on their screening, they receive a healthy food “prescription” that can be redeemed in partnership with a community food system partner, such as a food shelf, grocery store or food hub.
Patient Self-Management with Clinical Support
Evidence-based, lifestyle-change programs equip individuals with the skills, confidence, and ongoing clinical guidance needed to manage chronic conditions, improve daily health behaviors, and prevent disease progression. These programs blend structured self-management support with coordinated clinical oversight so patients can make sustainable lifestyle changes that improve outcomes, reduce complications, and enhance quality of life.
