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: 9943776
• 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/9943776
• 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; Legal; Link; Medical; Methodology; Methods; Modeling; Morbidity - disease rate; Outcome; Patient-Centered Care; Patients; Persons; Pharmaceutical Preparations; Phase; Prevalence; Primary Health 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; base; cardiovascular disorder risk; care coordination; compare effectiveness; disability; disparity reduction; 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：尽管医学取得了进步，但高达 70% 的健康结果是由社会决定因素造成的 健康 (SDoH) - 人们生活和工作的条件，决定了基本需求（例如住房、 食物）得到满足。这些关联在心血管疾病 (CVD) 方面尤其有据可查。在 响应，卫生政策领导人建议针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的结论是，减少心脏负担的最重要机会是 心血管疾病死亡和残疾取决于解决心血管结果的社会决定因素。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 和支持治疗目标的服务，以患者为中心的护理和文化转型办公室 卫生办公室优先考虑增强整个人的身体、情感和社会福祉 公平优先考虑减少差距，HSR&D 优先考虑健康公平和人口健康。我们的 研究将提供急需的证据来记录退伍军人未满足的需求的负担，并告知如何最好地 解决未满足的需求，并评估这一过程如何影响依从性（药物和治疗） 预约）、利用率和临床结果。 创新：VA 目前仅系统地筛选两个未满足的需求（无家可归和粮食不安全）。 识别其他未满足的需求（并转介解决这些需求）是临时进行的，具体情况各不相同。 诊所/临床医生之间的方法。对八项未满足需求进行全面排查， 系统转介、开发工具和流程，如果有效，可以在 VA 内实施（以及 其他）临床系统。 VA 目前正在资助几项与 SDoH 相关的研究，但没有测试干预措施 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 确定对社会服务资源的需求。 具体目标： 1) 描述八种未满足需求的负担和分配（即住房；粮食不安全； 公用事业不安全；运输;法律指导；就业；安全;和社会隔离）退伍军人 或有 CVD 风险，并确定其与社会人口特征和基线健康状况的关联 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（主要成果），未满足的资源减少 需求、依从性和临床结果，以及 3) 确定退伍军人与退伍军人建立联系的障碍和促进因素 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：我们提出一项为期 3 年、分两阶段的混合方法研究。在第一阶段（目标 1 和 2），我们将 在三个退伍军人管理局地点实施三组随机对照试验，以比较退伍军人的结果 在每个中心内随机分配三种研究条件之一：仅筛选；筛选加提供 量身定制的资源表；或筛选加上资源表加上社会工作支持。对于每一位退伍军人，我们都会 检查未满足的需求与基线结果（目标 1）的关联，并纵向检查影响 每种方法与新的 SDoH 资源的连接以及 12 个月内的后续成果（目标 2）。在第二阶段（目标 3），我们将采访退伍军人以及 VA 和 基于社区的计划，退伍军人因试验而被推荐参加以确定促进者和 与干预措施相对成功相关的障碍和潜在解释因素。 实施/后续步骤：如果干预措施产生积极成果，合作伙伴将利用调查结果 支持在整个 VA 更广泛地实施它。