Improving Chronic Disease Outcomes Across the Lifespan by Addressing Structural Racism

项目概要 结构性种族主义根植于社会结构中，限制了种族化群体的机会和资源。 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/民族健康差异。专业医疗机构和保险公司 建议筛查并解决医疗保健服务中的不良 SDOH。结果，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。尽管速度如此之快 尽管 SDOH 的公平实施和有效性方面仍存在关键知识差距 改善疾病结果的筛查/转诊系统。我们团队在 WE CARE SDOH 系统上的工作， 它利用现有的临床人员和工作流程来满足家庭的社会需求，已经证明了其 提高低收入家庭转介社会服务和获得资源的效率； WE CARE 被美国儿科学会列为基于证据的 SDOH 干预措施。 然而，我们最近完成的混合有效性实施随机对照试验发现，护理人员明显增多 有色人种（与白人护理人员相比）经历更高的双重损失率，因此他们的需求未得到满足 尽管已披露，但并未得到解决。这些结果可能是由于实施不理想造成的 有色人种护理人员在医疗保健和社会服务系统中面临多层次的歧视。 凭借一支由 SDOH、实施、反种族主义和实践研究人员组成的跨学科团队，我们将 将反种族主义视角应用于“我们关心”，并开发旨在减轻种族主义的实施工具包 有色人种患者受到不平等待遇。我们将进行一项混合有效性实施研究 为种族/族裔提供服务的四家大型家庭医学 (FM) 诊所的阶梯式楔形集群 RCT 设计 来自马萨诸塞州伍斯特市的不同低收入家庭。我们的具体目标是： (1) 完善 WE 使用反种族主义视角和社区参与方法的 CARE 实施协议：(a) 对家庭进行关键知情人访谈，以确定 SDOH 筛查/转介中与种族主义相关的障碍； (b) 向系统级利益攸关方提出这些障碍，以征求对解决患者问题的战略的意见 担忧；并创建一个反种族主义知情工具包，用于实施 SDOH 筛查/转诊系统； (2) 通过在 FM 实践中部署完善的协议来实施 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WE的有效性 关心流行的儿科和成人慢性病的结果。该提案有可能创造 社区和患者参与的新策略，用于实施 SDOH 筛查和转诊系统 有潜力减少种族/民族健康不平等的医疗保健和社会服务系统。已对齐 NIMHD 的使命和“健康人民 2030”的总体目标是“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.”