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

背景：尽管医学取得了进步，但高达70%的健康结果是由 健康(SDoH)--人们的生活和工作条件是否决定了基本需求(例如，住房、 食物)得到满足。对于心血管疾病(CVD)来说，这些关联尤其有文献记载。在……里面 作为回应，卫生政策领导人建议对临床环境中未得到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，减少 心血管疾病的死亡和残疾取决于解决心血管结果的社会决定因素。一个有限的但 有希望的证据支持这些建议，但还需要更严格的研究来指导如何 最好是对影响健康的未得到满足的需求进行干预。 意义/影响：该项目涉及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 优先增进全人的身体、情感和社会福祉，卫生办公室 减少差距的公平优先事项，以及健康公平和人口健康的高铁与发展优先事项。我们的 研究将提供急需的证据来记录退伍军人未得到满足的需求的负担，告知如何最好地 解决未得到满足的需求，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：退伍军人管理局目前只系统地筛选两种未得到满足的需求(无家可归和粮食不安全)。 确定其他未得到满足的需求(并转介以解决这些需求)是在临时基础上进行的，具有不同的 诊所/临床医生之间的方法。全面开展八项未满足需求筛查工作， 系统的推荐、开发工具和流程，如果有效，可以在退伍军人管理局(和 其他)临床系统。弗吉尼亚州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未得到满足的广泛社会需求，并将退伍军人与 确定对社会服务资源的需求。 具体目标：1)说明八项未得到满足的需求的负担和分配情况(即住房；粮食不安全； 效用不安全；交通；法律指导；就业；安全；和社会孤立) 或处于心血管疾病的风险中，并确定它们与社会人口特征和基线健康的关系- 2)比较三种S&R研究干预条件对儿童精神分裂症的干预效果。 不同强度的退伍军人连接到新的SDoH资源(主要结果)，减少未满足的 需求、依从性和临床结果，以及3)确定退伍军人与 社会服务和需求得到满足，以及观察到的随机对照试验结果的解释因素。 方法：我们提出了一项为期3年、分两个阶段的混合方法研究。在第一阶段(目标1和2)，我们将 在退伍军人中的三个地点实施三组随机对照试验以比较结果 在每个站点内随机选择以下三种研究条件之一：仅筛查；筛查加提供 量身定制的资源表；或筛选+资源表+社会工作支持。对于每一位退伍军人，我们将 检查未满足的需求与基准结果之间的关联(目标1)，并纵向检查其影响 关于连接新的SDoH资源的每种方法和12个月期间的后续结果(AIM 2)。在第二阶段(目标3)，我们将与退伍军人和退伍军人管理局的代表进行访谈-和 退伍军人因试验而被推荐参加的基于社区的计划，以确定协助者和 与干预措施的相对成功有关的障碍和潜在的解释因素。 实施/后续步骤：如果干预产生积极结果，合作伙伴将利用调查结果 支持在退伍军人事务部更广泛地实施信息技术。

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.