Improving Chronic Disease Outcomes Across the Lifespan by Addressing Structural Racism

项目总结 结构性种族主义植根于限制种族主义机会和资源的社会结构 组。这表现为健康的社会决定因素(SDOH)--人们所处的社会环境 出生、生活和年龄--以及种族/民族健康差距。专业医疗机构和保险公司 建议在医疗保健提供过程中筛查-并解决-不利的SDOH。因此，医疗保健 系统，特别是那些为低收入患者服务的系统，正在实施SDOH筛查。尽管如此迅速 尽管如此，在公平执行和有效执行SDOH方面仍然存在严重的知识差距 关于改善疾病结局的筛查/转诊系统。我们团队在WE CARE SDOH系统上的工作， 它利用现有的临床工作人员和工作流程来满足家庭的社会需求，已经证明了它的 在增加低收入家庭转介社会服务和获得资源方面的成效； 我们的关怀被美国儿科学会引用为基于证据的SDOH干预措施。 然而，我们最近完成的混合有效性-实施RCT发现明显更多的照顾者 有色人种(与白人照顾者相比)经历更高的双重缺失率，因此他们的需求未得到满足 尽管被披露了，但没有得到解决。这些结果很可能是由于与次优实施相关的 有色人种照料者在医疗保健和社会服务系统中面临的多重歧视。 通过一个由SDOH、实施、反种族主义和基于实践的研究人员组成的跨学科团队，我们将 将反种族主义的视角应用到我们的关怀中，并开发了一个旨在缓解 对有色人种患者的不平等待遇。我们将进行一项混合有效性-实施研究， 为种族/民族服务的四家大型家庭医学(FM)诊所的阶梯式楔形群集式随机对照试验设计 来自马萨诸塞州伍斯特的多样化低收入家庭。我们的具体目标是：(1)完善我们的 使用反种族主义镜头和社区参与办法的关怀执行议定书：(A) 与家庭进行关键的线人面谈，以确定与种族主义有关的障碍，以防止SDOH筛查/转介； (B)向系统级别的利益攸关方介绍这些障碍，以征求对解决患者问题的战略的意见 建立一个反种族主义信息工具包，用于实施SDOH筛查/转诊系统； (2)通过在FM实践中部署改进的协议来实施We CARE，并评估实施情况 结果包括公平性、适当性和以患者为中心；(3)评估我们的有效性 关注流行的儿童和成人慢性病的结果。这项提议有可能创造出 实施SDOH筛查和转诊系统的社区和患者参与的新战略 有可能减少种族/族裔健康不平等的医疗保健和社会服务体系。它是对齐的 S的使命和《2030年健康人》的总目标是“消除健康差距”。

PROJECT SUMMARY Structural racism is embedded in societal structures that limit opportunities and resources for racialized groups. This manifest as social determinants of health (SDOH)—the social circumstances in which people are born, live, and age—and as racial/ethnic health disparities. Professional medical organizations and insurers recommend screening for—and addressing—adverse SDOH within healthcare delivery. As a result, healthcare systems especially those serving low-income patients are implementing SDOH screening. Despite this rapid uptake, critical knowledge gaps remain regarding the equitable implementation and effectiveness of SDOH screening/referral systems on improving disease outcomes. Our team’s work on the WE CARE SDOH system, which leverages extant clinical staff and workflows to address families’ social needs, has demonstrated its effectiveness on increasing referrals to social services and receipt of resources among low-income families; WE CARE has been cited as an evidence-based SDOH intervention by the American Academy of Pediatrics. However, our recently completed hybrid effectiveness-implementation RCT found significantly more caregivers of color (compared to white caregivers) experiencing higher rates of double loss whereby their unmet needs were not addressed despite being disclosed. These results are likely due to suboptimal implementation related to multiple levels of discrimination that caregivers of color face in the healthcare and social service systems. With an interdisciplinary team of SDOH, implementation, antiracism, and practice-based researchers, we will apply an antiracism lens to WE CARE and develop an implementation toolkit aimed at mitigating unequal treatment for patients of color. We will conduct a hybrid effectiveness-implementation study with a stepped wedge cluster RCT design in four large family medicine (FM) clinics that serve racially/ethnically diverse low-income families from Worcester, Massachusetts. Our specific aims are to: (1) Refine the WE CARE implementation protocol using an antiracism lens and community engagement approach to: (a) conduct key informant interviews with families to identify racism-related barriers to SDOH screening/referral; (b) present these barriers to systems-level stakeholders to elicit input on strategies to address patient concerns; and create an antiracist-informed toolkit for the implementation of SDOH screening/referral systems; (2) Implement WE CARE by deploying the refined protocol in FM practices and assess implementation outcomes including equity, appropriateness, and patient-centeredness; (3) Evaluate the effectiveness of WE CARE on prevalent pediatric and adult chronic diseases outcomes. This proposal has the potential to create novel community- and patient-engaged strategies for implementing SDOH screening and referral systems into healthcare and social service systems with the potential to reduce racial/ethnic health inequities. It is aligned with the NIMHD’s mission and Healthy People 2030’s overarching goal to “eliminate health disparities.”