Implementation of EMR-Integrated Referrals to Link Clinical and Community Services to Reduce Health Inequity

摘要 心血管疾病(CVD)对非洲人造成不成比例的发病率和死亡率负担 东南部农村的美国人。这种过度行为很大程度上直接或间接地归因于社会 健康的决定因素和由此产生的与健康相关的社会需求。虽然心血管疾病预防干预措施 尽管减少了总体疾病负担，但它们未能消除心血管疾病方面的种族和地理差异。新的 负责任的健康社区等护理模式通过以下方式满足与健康相关的社会需求 筛查、转诊和社区导航服务，并已开始显示健康状况有所改善 护理费用、使用和心血管疾病风险因素。农村少数民族社区，在那里心血管疾病风险因素和负担 社会需求高，医疗设施可能更脆弱，资源密度可能更低， 更需要有效和可扩展的解决方案来满足卫生和社会需求。我们的建议是 以班杜拉的自我效能感理论、格雷的自我和家庭管理框架和安徒生的 卫生服务使用行为模式。我们将使用综合框架来实施 健康促进社区资源数据整合实施及效果研究 通过社区处方(CRX)进入电子病历。CRX-CVD干预是一种数字解决方案，将患者与 以社区为基础的资源，以满足农村再生障碍性贫血与健康相关的社会需求和心脏代谢健康 病人。我们的总体目标是找出影响执行的因素并评估健康 闭路转诊系统对农村社区健康促进资源的影响。我们使用一种 混合II实施有效性设计，用于对患者(成人18岁)进行受控务实试验 2-17岁的儿童；N=750)在北方农村的联邦合格卫生中心系统中 卡罗莱纳。我们假设，整合闭环转诊将增加患者对社区的了解 资源，增强管理心血管疾病危险因素的自我效能，增加社区资源的利用率，以及 改善心脏代谢状况的标志物。据我们所知，这次审判将是第一次评估 针对再生障碍性贫血成人的低强度、可扩展、临床启动的干预措施的实施及其健康影响 以及有患心血管疾病风险的儿童。此外，我们将进行与实施相关的成本效益分析 CRX-CVD的情况，以告知干预措施的扩展。长期目标是确定可扩展的干预措施，以 减少非裔美国人的心血管疾病风险和与健康相关的社会需求 健康。

ABSTRACT Cardiovascular disease (CVD) exerts a disproportionate burden of morbidity and mortality on African Americans in the rural southeast. Much of this excess has been attributed, directly and indirectly, to social determinants of health and resulting health-related social needs. While CVD prevention interventions have reduced overall disease burden, they have failed to eliminate racial and geographic disparities in CVD. New models of care, such as Accountable Health Communities, address health-related social needs through screening, referral, and community navigation services and have begun to demonstrate improvement in health care cost, use, and CVD risk factors. Rural minority communities, where the burden of CVD risk factors and social needs are high, healthcare facilities may be more fragile and density of resources may be lower, have even greater need for effective and scalable solutions to addressing health and social needs. Our proposal is anchored by Bandura's Self-Efficacy theory, Grey's Self and Family Management Framework, and Andersen's Behavioral Model of Health Services Use. We will use the Consolidated Framework for Implementation Research to study implementation and effectiveness of integrating health-promoting community resource data into the EMR via CommunityRx (CRx). The CRx-CVD intervention is a digital solution that links patients with community-based resources to address health-related social needs and cardiometabolic health in rural AA patients. Our overall objective is to identify factors that influence implementation and assess the health impact of a closed-loop referral system to community health-promoting resources in a rural setting. We use a hybrid II implementation effectiveness design to conduct a controlled pragmatic trial of patients (adults 18 years and over, children 2-17 years; N=750) in a system of federally qualified health centers in rural North Carolina. We hypothesize that integration of closed-loop referrals will increase patient knowledge of community resources, enhance self-efficacy to manage CVD risk factors, increase utilization of community resources and improve markers of cardiometabolic conditions. To our knowledge, this trial will be the first to evaluate the implementation and health impact of a low intensity, scalable, clinic-initiated intervention targeting AA adults and children at risk of CVD. Furthermore, we will conduct cost-effectiveness analysis related to implementation of CRx-CVD to inform scaling the intervention. The long-term goal is to identify scalable interventions to reduce CVD risk and health-related social needs of African Americans using a “whole person” approach to health.