Southeast Collaborative for Innovative and Equitable Solutions to Chronic Disease Disparities

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Project Summary The United States continues to experience some of the worst health disparities in the world, in part due to the inability to address social drivers of health (SDoH). These SDoH, such as income, education/health literacy, and built environment, contribute to an estimated 50% of health inequities. The National Academy of Sciences, Engineering, and Medicine (NASEM) and other organizations have called for the systematic incorporation of SDoH assessment into electronic health records (EHRs) and clinical care. Further, new 2023 regulations from The Joint Commission now require SDoH screening, adding urgency to the need to study and establish best practices. However, surprisingly little research has evaluated implementation of SDoH data collection, assessed how multidisciplinary health care teams can best address SDoH in clinical practice, or measured the effects of social risk-informed care on patient outcomes in patients with chronic conditions, where health disparities are widespread. Concerns also exist about potential unintended consequences, such as administrative burden to clinics and stigmatization of patients. As a result, most practices do not address SDoH systematically, missing an important opportunity to foster health equity. The goal of this project is to develop and evaluate a multi-level initiative to collect and address SDoH as part of the clinical care of adult primary care patients with type 2 diabetes, plus hypertension and/or hyperlipidemia. The proposed research builds on the substantial preliminary work and expertise of our interdisciplinary research team in the measurement of SDoH and interventions to address them, as well as health disparities, implementation science, and health information technology. In Aim 1, we will use qualitative methods to assess the perspectives of stakeholders – investigators already involved in activities related to community engagement and social drivers, patients, clinicians, clinic staff, and community organization leaders – on the collection and use of patient-reported SDoH, how to optimize integration of SDoH information and clinical decision support tools in the EHR, and how to minimize potential barriers to implementation and unintended consequences. In Aim 2, we will implement a multi-level initiative (SDoH data collection, training and tools for health care professionals, care coordinator and pharmacist support, and community resources) and evaluate its effect on clinical outcomes, including hemoglobin A1c, blood pressure, and cholesterol. In Aim 3, we will perform a mixed-methods evaluation of implementation using the RE-AIM QuEST framework to inform scale-up and spread. This research will fill critical gaps in knowledge related to real-world implementation of SDoH data collection and provision of social risk-informed care. Findings will be relevant across a broad range of chronic medical conditions affected by social risk factors and health disparities, enhancing the project's potential for impact.