ASCEND: ApproacheS to CHC ImplEmeNtation of SDH Data Collection and Action

项目摘要/摘要：健康风险、结果和对有/处于风险人群的护理质量 糖尿病(DM)深受非临床因素的影响，这些因素被称为“健康的社会决定因素” (SDH)。不同的公共卫生领导人和倡议--包括医学研究所、公共卫生办公室 年《医疗保险接入和芯片再授权法案》卫生信息技术国家协调员 2015年，以及2016年医疗保险和医疗补助服务中心的质量战略-强调 将患者的SDH数据记录在电子健康记录(EHR)中，并使用这些数据为护理提供信息。 然而，对于如何帮助初级保健团队定期收集SDH数据并采取行动，人们知之甚少 基于EHR的工具。这一知识差距对社区卫生中心(CHC)来说尤其成问题 为我们国家最脆弱的患者服务，他们的糖尿病患病率和风险(特别是肥胖率)是 高于一般人群，其健康受SDH的影响特别大。拟议中的审判 建立在NIDDK资助的试点研究的基础上，在该研究中，我们开发了一套基于EHR的SDH数据管理 初级保健中心的工具。2016年6月，这些工具在19个州的440个社区卫生中心投入使用， 但共享一个集中管理的电子病历。在证明了可以为CHC构建SDH数据工具之后，我们 现在建议评估：是否以及如何务实地实施支持其他 实践改变的类型也将帮助CHC团队系统地识别并采取行动 有糖尿病风险的成人患者的SDH相关需求；以及这样做对糖尿病风险的影响 管理层。我们将按如下方式执行此操作。步骤1：在440中评估当前基于EHR的SDH数据收集 CHC；使用这些形成的结果来磨练一套帮助CHC常规收集SDH数据的方法 并将其整合到护理计划中。第二步：进行务实、阶梯式、整群随机试验。 30个社区卫生控制中心将被随机分配到5个6个月的楔形中的一个，错开时间接受 干预：可扩展的实施支持包，包括技术援助、培训和六个 与SDH实施团队联系数月，该团队将量身定制支持以满足每个CHC的需求。步骤 3：对以下方面的影响进行现实评估：(1)将SDH数据收集纳入工作流程；(2) 将SDH数据集成到CARE中；以及(Iii)DM风险管理(受控BP、HbA1c、BMI、血脂等；向上- 到目前为止的推荐护理)。根据PAR-15-157，我们将测试务实的实施策略， 可复制，在常规条件下提供，利用现有资源，并针对标准护理流程。 我们的多学科团队包括SDH、实施科学、信息学和初级保健方面的专家 转型。研究成果将包括可扩展的战略；结果将为SDH数据收集和 行动实施指南和材料，供全国社区卫生保健机构和初级保健提供者使用。

PROJECT SUMMARY/ABSTRACT: Health risks, outcomes, and care quality for people with / at risk for diabetes mellitus (DM) are profoundly affected by non-clinical factors called ‘social determinants of health’ (SDH). Diverse public health leaders and initiatives – including the Institute of Medicine, the Office of the National Coordinator for Health Information Technology, the Medicare Access & CHIP Reauthorization Act of 2015, and the Centers for Medicare & Medicaid Services 2016 Quality Strategy – emphasize the importance of documenting patients’ SDH data in electronic health records (EHRs), and using this data to inform care. However, little is known about how to help primary care teams routinely collect and act on SDH data using EHR-based tools. This knowledge gap is particularly problematic for the community health centers (CHCs) serving our nation’s most vulnerable patients, whose DM prevalence and risk (notably, obesity rates) are higher than the general population’s, and whose health is particularly impacted by SDH. The proposed trial builds on an NIDDK-funded pilot study in which we developed a suite of EHR-based SDH data management tools for primary care CHCs. In June 2016, these tools went live in 440 CHCs that are located in 19 states, but share a centrally-managed EHR. Having demonstrated that ‘SDH data tools’ can be built for CHCs, we now propose to assess: whether and how pragmatic implementation strategies that support other types of practice change will also help CHC teams systematically identify and take action on the SDH-related needs of adult patients with / at risk for DM; and, the impact of doing so on DM risk management. We will do this as follows. Step 1: Evaluate current EHR-based SDH data collection in 440 CHCs; use those formative results to hone a set of approaches for helping CHCs routinely collect SDH data and integrate it into care plans. Step 2: Conduct a pragmatic, stepped-wedge, cluster-randomized trial. Thirty CHCs will be randomized to one of five 6-month wedges, with staggered timing for receiving the intervention: a scalable implementation support package including technical assistance, training, and six months of access to an ‘SDH Implementation Team’ that will tailor support to meet each CHC’s needs. Step 3: Conduct a realist evaluation of how the impact on: (i) integration of SDH data collection into workflows; (ii) integration of SDH data into care; and (iii) DM risk management (controlled BP, HbA1c, BMI, lipids, etc.; up- to-date recommended care). Per PAR-15-157, we will test implementation strategies that are pragmatic, replicable, delivered under routine conditions, use existing resources, and target standard care processes. Our multidisciplinary team includes experts in SDH, implementation science, informatics, and primary care transformation. Study deliverables will include scalable strategies; results will inform SDH data collection and action implementation guidelines and materials for use by CHCs and primary care providers nationwide.