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

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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.