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  • WV Health Connection

Building and Strengthening Clinic/Community Linkages in WV for Diabetes Prevention and Control

Increase Use of Lifestyle Intervention Programs in Community Settings


In July 2013, the state of West Virginia was facing a growing prevalence in chronic disease. According to the 2013 Behavorial Risk Factor Surveillance System (BRFSS) Report, 41% of adults in West Virginia were told by a health care professional that they had high blood pressure, and 13% were told that they had diabetes. Approximately 8.6% reported that they had borderline or pre-diabetes. The CDC-recognized National Diabetes Prevention Program (NDPP) provides lifestyle education that could prevent borderline or those with pre-diabetes from developing the disease. However, the WV Division of Health Promotion and Chronic Disease (HPCD) also recognized that there were significant barriers to implementing and sustaining programs. First, WV lacked statewide coordination for chronic disease prevention and control programming, including those related to diabetes prevention. Second, there was a dearth of evidence-based lifestyle intervention programs, notably the NDPP, in many areas of the state due to lack of resources. Third, WV had yet to develop effective and sustainable systems that linked motivated primary care systems with community-based lifestyle management efforts.

"The Berkeley County Health Department has offered programs to decrease chronic disease in WV for the past several years. The lack of participants has been an enormous challenge for these types of programs to be successful. The Berkeley County Health Department supports Workshop Wizard in hopes that this program will blossom to be a statewide referral system to increase community members participation." - Angela Gray, BSN, RN, Nurse Director, Berkeley County Health Department

HPCD took the lead in addressing these barriers by forming a synergistic partnership that included the West Virginia University Office of Health Services Research, the WV Academy of Family Physicians, Quality Insights, and the Wigner Institute for Advanced Pharmacy Practice, Education, and Research. Together they created the WV Health Connection (, an initiative whose goal is to build and strengthen clinic/community linkages for enhanced chronic disease prevention and control with a focus on diabetes. This shared agenda served as the foundational driver for collective action that was made possible through the CDC's 1305 funding support along with additional support by the Health Policy Research Consortium, a federally-funded informatics organization that is focused on providing software infrastructure for research. The partners began by determining an implementation approach. This approach incorporated three distinct but related components. The first was leveraging electronic health records (EHRs) to identify patients with diabetes who could then be referred to community-based prevention programs, especially NDPP. The second was to increase the availability of NDPP sites throughout the state. The third component was to provide an online platform to enhance the linkage between primary care and community programming. To power WV Health Connection, the partners chose Workshop Wizard, a software based on its reputation as being a proven system for tracking and reporting lifestyle prevention and management data across points of care and also it's widespread use among partners in the mid-Atlantic and southwestern United States. The implementation approach also included the identification and engagement of four intervention regions that had sufficient infrastructure to serve as partner sites for both planning and implementation, a substantial diabetes burden, and a commitment to diabetes prevention. The presence of these factors would increase the likelihood of an observable impact in multiple WV regions within the five-year CDC funding period. This implementation approach led to the following strategies:

  • Collaborated with 13 primary care systems in the four targeted regions to use their EHR data to identify patients at-risk for diabetes and who would be appropriate candidates for referral to NDPP. These 13 systems served approximately 143,000 patients in 2013, when this effort began.

  • Established four new NDPP sites, inside the focus regions of the state, beginning in 2015 for improved state coverage.

  • Established five agreements to-date to participate with WV Health Connection in each of the four priority regions beginning in 2016. The use of WV Health Connection provided an accessible, easy to use platform that linked clinics and communities to work ensuring closed-loop referral systems and essential data sharing.

In less than five years, this collaborative implementation approach strengthened WV clinic/community linkages for diabetes prevention and control in the following ways.

  • The improved use of EHR data resulted in approximately 10,000 patients newly identified as at-risk for diabetes among collaborating clinics.

  • Exceeded the target number of persons with pre-diabetes or at high risk for type 2 diabetes who enroll in CDC-recognized lifestyle change program. (Target 214, Actual 698)

  • Four new community-based health sites are working towards NDPP recognition. West Virginia is supporting these sites to be successful and add to the four locations already at full CDC recognition status.

  • A cohort of partner sites spread across 15 locations in the focus regions have begun implementing the WV Health Connection to best support the process of engaging providers, enrolling patients, and securely tracking, reporting, and sharing data across partners. In addition, WV Health Connection is being rolled out across the state.


  1. Baus, A., Wood, G., Pollard, C., Summerfield, B., White, E. (2013). Registry-based diabetes risk schema for systematic identification of patients at risk for diabetes in West Virginia primary care centers. Perspectives in Health Information Management, 10(Fall): 1f.

For more information, contact Jessica Wright, RN, MPH, CHES, Director - West Virginia Bureau for Public Health, Division of Health Promotion and Chronic Disease ( / or 304-356-4193.

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