Leveraging Community-clinical Linkages to Address Unmet Social Needs for People with Diabetes Living in Rural Settings

Abstract Kentucky suffers from persistently high rates of diabetes and its associated complications. High prevalence of unmet social needs and poor coordination between clinical and community services exacerbates these outcomes. Community-clinical linkages are an effective approach to address unmet social needs and, ultimately, improve diabetes outcomes and patient quality of life. This study will develop and test a co-created, community-driven approach to building a strong social needs screening, referral, and resolution network based on community-clinical linkages to address the spectrum of social needs impacting individuals living with diabetes. We will accomplish this through the following aims: (1) to conduct a community scan to learn about community and clinical sectors and community-clinical linkages (CCL) across rural Kentucky that are working to address unmet social needs for people living with diabetes and use an established implementation science framework (PRISM) to identify determinants of successful CCL and map these determinants to intervention strategies and outcomes; (2) to use a rapid quality improvement framework (rapid process improvement workshop, RPIW) to bring together stakeholders from clinical and community sectors plus patient advocates to co-create scalable strategies to address unmet social needs through community-clinical linkages (CCL) for people living with diabetes and to implement the developed strategy in two rural communities in Kentucky; (3) to evaluate the feasibility, acceptability, sustainability and transferability to other potential sites of the intervention via stakeholder and participant survey and interview data using an established implementation science framework (PRISM). The goal of this study is to develop an implementation strategy that can be scaled in rural communities across the country to develop community-tailored social needs screening, referral, and resolution models with the goal of improving patient quality of life.