The Effect of Screening and Referral for Social Determinants of Health on Veterans' Outcomes

健康社会决定因素的筛查和转诊对退伍军人结果的影响

• 批准号: 10355413
• 负责人: Deborah Gurewich
• 金额: --
• 依托单位: VA BOSTON HEALTH CARE SYSTEM
• 依托单位国家: 美国
• 财政年份: 2021
• 资助国家: 美国
• 起止时间: 2021-02-01 至 2024-01-31
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/10355413
• 关键词: Address; Adherence; Affect; Ambulatory Care; American Heart Association; Appointment; Blood Pressure; Cardiovascular Diseases; Cardiovascular system; Caring; Cessation of life; Characteristics; Clinic; Clinical; Communities; Comprehensive Health Care; Data; Disease Outcome; Distal; Emotional; Employment; Ensure; Food; Funding; Future; Goals; Health; Health Policy; Health Priorities; Health Resources; Health behavior; High Prevalence; Homelessness; Hospitalization; Housing; Human Resources; Individual; Inpatients; Intervention; Intervention Studies; Interview; Investments; Legal; Link; Medical; Methodology; Methods; Modeling; Morbidity - disease rate; Outcome; Patient-Centered Care; Patients; Persons; Pharmaceutical Preparations; Phase; Policy Maker; Prevalence; Primary Care; Process; Randomized; Randomized, Controlled Trials; Recommendation; Research; Resources; Rest; Risk Factors; Safety; Services; Shapes; Site; Social Well-Being; Social Work; Social Workers; Social isolation; System; Testing; Transportation; Veterans; Work; arm; cardiovascular disorder risk; care coordination; compare effectiveness; disability; disparity reduction; efficacy evaluation; evidence base; follow-up; food insecurity; glycemic control; health care service utilization; health equity; improved; improved outcome; innovation; mortality; personalized care; population health; post intervention; primary outcome; programs; response; screening; screening guidelines; secondary outcome; social; social determinants; social health determinants; sociodemographics; stakeholder perspectives; success; tool; treatment adherence; urgent care; violence exposure

Background: Despite medical advances, up to 70% of health outcomes are due to social determinants of health (SDoH) - the conditions in which people live and work that shape whether basic needs (e.g., housing, food) are met. These associations are especially well documented for cardiovascular disease (CVD). In response, health policy leaders recommend screening and referral (S&R) for unmet needs in clinical settings, and the American Heart Association recently concluded that the most significant opportunities for reducing CVD death and disability lie with addressing the social determinants of cardiovascular outcomes. A limited but promising evidence base supports these recommendations but more rigorous research is needed to guide how best to intervene on unmet needs that affect health. Significance/Impact: This project addresses the Office of Social Work’s priority to link Veterans with resources and services in support of treatment goals, the Office of Patient Centered Care and Cultural Transformation’s priority to enhance the physical, emotional, and social well-being of the whole person, the Office of Health Equity’s priority to reduce disparities, and the HSR&D priorities of health equity and population health. Our study will provide much-needed evidence to document the burden of Veterans’ unmet needs, inform how best to address unmet needs, and assess how such a process can affect adherence (to medications and appointments), utilization, and clinical outcomes. Innovation: VA currently systematically screens for only two unmet needs (homelessness and food insecurity). Identification of other unmet needs (and referral to address them) occurs on an ad hoc basis, with varying approaches among clinics/ clinicians. We will implement comprehensive screening of eight unmet needs and systematic referral, developing tools and processes that, if efficacious, can be implemented within VA (and other) clinical systems. VA is currently funding several studies related to SDoH, but none test interventions that systematically identify a wide range of unmet social needs among Veterans and connect Veterans with identified needs to social service resources. Specific Aims: 1) Describe the burden and distribution of eight unmet needs (i.e., housing; food insecurity; utility insecurity; transportation; legal guidance; employment; safety; and social isolation) among Veterans with or at-risk for CVD, and identify their associations with sociodemographic characteristics, and baseline health- related behaviors and clinical outcomes; 2) Compare the effects of three S&R study intervention conditions of varying intensity on Veterans’ connection to new SDoH resources (primary outcome), reduction of unmet needs, adherence, and clinical outcomes, and 3) Identify barriers and facilitators to Veterans’ connecting with social services and having needs met, and explanatory factors for observed RCT outcomes. Methodology: We propose a 3-year, two-phased mixed methods study. In Phase One (Aims 1 and 2), we will implement a three-armed randomized controlled trial at three VA sites to compare outcomes among Veterans randomized within each site to one of three study conditions: screening only; screening plus provision of tailored resource sheets; or screening plus resource sheets plus social work support. For each Veteran, we will examine associations of unmet needs with baseline outcomes (Aim 1), and longitudinally examine the impact of each approach on connection to new SDoH resources and follow-up outcomes over a 12-month period (Aim 2). In Phase Two (Aim 3), we will conduct interviews with Veterans and representatives of the VA- and community-based programs to which Veterans are referred because of the trial to identify facilitators and barriers and potential explanatory factors related to the relative success of the interventions. Implementation/Next Steps: If the intervention yields positive results, findings will be used by partners to support more widespread implementation of it throughout VA.

背景：尽管医学进步，高达70%的健康结果是由于社会决定因素， 健康（SDoH）-人们生活和工作的条件，这些条件决定了基本需求（例如，壳体， 食物）满足。这些关联在心血管疾病（CVD）中尤其有据可查。在 作为回应，卫生政策领导人建议对临床环境中未满足的需求进行筛查和转诊（S&R）， 美国心脏协会最近得出结论， 心血管疾病死亡和残疾的关键在于解决心血管疾病结局的社会决定因素。有限但 有希望的证据基础支持这些建议，但需要更严格的研究来指导如何 最好是对影响健康的未满足需求进行干预。 意义/影响：该项目解决了社会工作办公室将退伍军人与资源联系起来的优先事项 和服务，以支持治疗目标，以病人为中心的护理和文化转型办公室的 优先提高身体，情感和整个人的社会福祉，卫生办公室 公平的优先事项是减少差距，而卫生、社会和发展战略的优先事项是卫生公平和人口健康。我们 这项研究将提供急需的证据，以记录退伍军人未满足需求的负担， 解决未满足的需求，并评估这样的过程如何影响依从性（药物和 预约）、利用率和临床结果。 创新：退伍军人事务部目前只系统地筛选两个未满足的需求（无家可归和粮食不安全）。 确定其他未满足的需求（并转介以解决这些需求）是临时性的， 诊所/临床医生之间的方法。我们会全面甄别八项未获满足的需要， 系统的转诊，开发工具和流程，如果有效，可以在VA内实施（以及 临床系统。VA目前正在资助几项与SDoH相关的研究，但没有一项测试干预措施， 系统地确定退伍军人中广泛的未满足的社会需求，并将退伍军人与 确定社会服务资源的需求。 具体目标：1）描述八个未满足需求的负担和分布情况（即，住房;粮食不安全; 公用事业不安全;交通;法律的指导;就业;安全;和社会隔离） 或有CVD风险，并确定其与社会人口统计学特征和基线健康的相关性- 相关行为和临床结果; 2）比较三种S&R研究干预条件的效果， 退伍军人与新的SDoH资源的联系强度不同（主要结局），未满足的 需求，依从性和临床结果，以及3）识别退伍军人与 社会服务和满足需求，以及观察到的RCT结果的解释因素。 方法：我们提出了一个为期3年，两个阶段的混合方法研究。在第一阶段（目标1和2），我们将 在三个VA站点实施三组随机对照试验，以比较退伍军人的结局 在每个研究中心内随机分配至三种研究条件之一：仅筛选;筛选+提供 定制的资源表;或筛选加上资源表加上社会工作支持。对于每一个老兵，我们将 检查未满足的需求与基线结果的关联（目标1），并纵向检查影响 在12个月内，每种方法与新的卫生署资源的联系和后续结果（目的 2）。在第二阶段（目标3），我们将与退伍军人和退伍军人事务部的代表进行访谈， 退伍军人因试验而被推荐的基于社区的计划，以确定促进者， 与干预措施的相对成功有关的障碍和潜在的解释因素。 执行/下一步：如果干预措施产生积极结果，合作伙伴将利用调查结果， 支持它在整个VA更广泛的实施。