LEXINGTON, Ky. (Sep. 1, 2025) — A team of researchers at the University of Kentucky have a new initiative to tackle one of Kentucky’s toughest public health challenges: diabetes in rural communities.
The team is working to build up connections in these areas to address social needs like food insecurity, housing instability and limited transportation that often go unmet.
Mary Beth Lacy, Ph.D., and Rachel Hogg-Graham, Dr.P.H., in the University of Kentucky College of Public Health (CPH) are leading the study titled “Leveraging community-clinical linkages to address unmet social needs for people with diabetes living in rural settings.”
Both are co-principal investigators of the three-year, more than $1.4 million contract with the U.S. Centers for Disease Control and Prevention (CDC).
The purpose of the project is to connect the dots between clinical care and the community organizations that help people meet basic needs.
With Kentucky’s rural diabetes rates exceeding 20% — well above the 13.3% state average and 10.8% nationally — the project aims to turn the tide by rethinking how systems work together.
“This project was in response to a policy change that the Centers for Medicare and Medicaid Services implemented in 2024,” said Lacy, a CPH assistant professor of epidemiology. “Hospitals across the country are now required to screen for social drivers of health — food insecurity, housing instability, transportation needs, utility difficulties and interpersonal safety. But there was very little guidance around how to actually do that or what to do next for patients who screen positive.”
The effort is focused on building effective community-clinical linkages (CCLs) — formalized systems of communication and cooperation between medical providers and community-based organizations. In practice, this means figuring out how to screen patients, make effective referrals and ensure those referrals lead to real support.
“Some portion of patients will have unmet social needs and need assistance,” Lacy said. “There’s an increase in demand for a limited number of services, and that makes partnerships absolutely critical.”
From the beginning, the project has been rooted in collaboration. CPH’s team is working alongside the Kentucky Regional Extension Center (KREC), clinical partners in both Eastern and Western Kentucky, including UK King’s Daughters and KentuckyCare, and local community-based organizations in those regions.
Phase one of the project involves statewide surveys and focus groups to understand current practices and gaps in service. Phase two brings clinics and community partners together to co-design referral and response systems. In the final phase, those systems will be implemented and evaluated for effectiveness.
“We have been intentional in our outreach to various partners already working in this space to learn what’s working, what’s not and what we might improve,” Lacy said. “We’re also circling back with them to share our findings, so the feedback loop is active and local.”
Hogg-Graham, chair of the Department of Health Management and Policy in CPH, emphasized how essential those partnerships are — and not just for practical support.
“The clinical and community partners are the crux of making any of this work,” she said. “They’re the experts. They’re living and breathing these issues every day and experiencing the administrative changes that come with new policies. It’s critical that they help guide the research, so we’re asking the right questions and returning information that’s useful.”
One of the biggest challenges, she noted, is the persistent disconnect between clinic-based care and community services — a gap that leaves patients without follow-through.
“You can screen a patient and make a referral, but if that referral doesn’t go anywhere — if the clinic never hears back and the patient never gets support — then the system fails. We’re trying to build a bidirectional process, so that communication goes both ways and outcomes improve,” said Hogg-Graham.
The project is also timely. In addition to the new Centers for Medicare and Medicaid Services (CMS) rules, the Kentucky Cabinet for Health and Family Services in 2024 began requiring university-affiliated hospitals to implement social needs screening in outpatient settings for both adults and children. Many rural clinics have long included social support as part of their mission, but the new requirements have broadened the scope and urgency of this work.
“The goal is not just to identify unmet needs,” Hogg-Graham said. “It’s to connect people to services, track whether those services were utilized and evaluate the impact — all while creating a system that’s more seamless and addresses needs.”
The research team consists of experts in diabetes care, systems science, implementation science and clinical quality improvement, including Margaret McGladrey, Ph.D., Meredith Duncan, Ph.D., Kory Heier, Maddey Culbertson, Emily Clear, Candace Brancato and Kelsey Carter from CPH; Jessica Elliott, Michelle Hibbard, Claire Weeks and Kathryn Carozza from the Kentucky Regional Extension Center; Lars Peterson, M.D., Ph.D., from the UK College of Medicine; Aaron Kruse-Diehr, Ph.D., from Augusta University and Glen Mays, Ph.D., from the Colorado School of Public Health.
“It’s been amazing to see the team come together and shape the work,” Hogg-Graham said. “It’s truly transdisciplinary — everyone brings something valuable to the table.”
Ultimately, the team hopes to develop a toolkit and model that can be adapted by other communities to improve health systems integration and response.
“While this project is focused on diabetes, the model and findings could be applied to broader patient populations or other conditions,” Lacy said. “The lessons learned cross boundaries.”
“This really is about changing systems — strengthening the way clinical and community services interact, so that we’re not just treating diseases, we’re meeting people’s needs,” said Hogg-Graham. “That’s the kind of change that can ripple across many aspects of health.”
This project is supported by the Centers for Disease Control and Prevention (CDC) of the U.S. Department of Health and Human Services (HHS) as part of an award totaling $1.4 million with 0% financed with non-governmental sources. The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement, by CDC, HHS, or the U.S. Government. For more information, please visit CDC.gov.
