Encourage Patients with Chronic Conditions to Participate in Effective Community Programs

Improving Chronic Care: Community
  1. Review class curricula for compatibility with the clinic's self-management approach and cultural differences.
  2. Review the system for referring patients to the community agency offering the class or group.
  3. Use the registry to mail out fliers to patients. Include an endorsement from providers or respected community figures.
  4. Use volunteers to remind patients.
  5. Maintain close communication with the community sponsor.
  6. Evaluate class/group with patients.



  • Make sure the agency offering the class/group has a similar mission to yours and that both will benefit from the referrals.
  • Be willing to work with the agency to help make their curriculum compatible.
  • Constantly keep cultural sensitivity in mind.
  • Assign a staff member to be a key contact and identify a key contact at the partner agency.
  • "Prescribe" the class/group using a prescription pad.
  • Anticipate that transportation to classes/groups may be a barrier for some patients, and find solutions.
  • Keep in touch with patient participants if it is an ongoing class/group to determine problems, barriers, and provide feedback and support.
  • If the cost of patient education classes is a problem for some uninsured patients, offer to trade: A staff physician will talk at a class about diabetes meds or complications in return for a "scholarship" for an indigent patient to take the classes.

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