# Community to Clinic Navigation to Improve Diabetes Outcomes

> **NIH NIH R01** · UNIVERSITY OF KENTUCKY · 2020 · $594,513

## Abstract

ABSTRACT
Reducing adverse outcomes from Type 2 Diabetes Mellitus (T2DM) requires optimal self-management and
appropriate clinical care.1 Combining an evidence-based intervention to improve diabetes self-management
with individually-tailored patient navigation to improve appropriate clinical care holds great promise. Only one
known randomized controlled trial has been tested that combines these two most essential components of
diabetes control. That trial resulted in improvements to glycemic control, blood pressure, and diabetes self-
management, but was implemented in a clinical setting.2 We aim to enhance this work by recruiting from and
locating most research activities in community-based settings to insure involvement of the most vulnerable,
hardest to reach populations who may not be receiving regular health care and by leveraging Community
Health Workers and Patient Navigators, who are essential and sustainable outreach workers in health care
professional shortage areas.
We propose testing a refined intervention, “Community to Clinic Navigation” (CCN), shown to be promising,
feasible, and acceptable in our pilot study. Given that Appalachian and rural residents maintain
disproportionately high rates of T2DM and suffer tremendous burdens from diabetic complications,3 this setting
provides a perfect opportunity to test the intervention with a hard to reach population while addressing health
inequities. We will administer a 3 arm group randomized design including (1) Diabetes Self-management
Program, DSMP only; (2) tailored Patient Navigation, PN only; and (3) the combined DSMP + PN: Community
to Clinic Navigation program, CCN. Outcomes include biometrics (HbA1c, BMI, blood pressure, lipids, waist
circumference); diabetes self-management and clinic attendance, as mediators of the primary outcomes; cost
effectiveness and participant satisfaction. Persons with diabetes will be recruited through churches and other
community venues. Our project leverages sustainable assets available in most health disparity communities--
faith organizations, community centers, federally qualified health clinics, strong social ties, and talented local
lay people who can be trained to educate and navigate those diagnosed with T2DM. Our sustained
involvement in Appalachian Kentucky positions our team to appropriately and efficiently test this promising
program with strong potential for future dissemination to other traditionally underserved environments.

## Key facts

- **NIH application ID:** 9988910
- **Project number:** 5R01DK112136-04
- **Recipient organization:** UNIVERSITY OF KENTUCKY
- **Principal Investigator:** Nancy E. Schoenberg
- **Activity code:** R01 (R01, R21, SBIR, etc.)
- **Funding institute:** NIH
- **Fiscal year:** 2020
- **Award amount:** $594,513
- **Award type:** 5
- **Project period:** 2017-08-01 → 2022-07-31

## Primary source

NIH RePORTER: https://reporter.nih.gov/project-details/9988910

## Citation

> US National Institutes of Health, RePORTER application 9988910, Community to Clinic Navigation to Improve Diabetes Outcomes (5R01DK112136-04). Retrieved via AI Analytics 2026-05-23 from https://api.ai-analytics.org/grant/nih/9988910. Licensed CC0.

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