CommunityRx – Chronic Kidney Disease (CRx-CKD)” An EMR-integrated community resources referral intervention to address structural racism and kidney health disparities in rural North Carolina

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Project Summary/Abstract Mitigating progressive chronic kidney disease (CKD) to avoid kidney failure is well known -- management of CKD and its multimorbidity (hypertension, diabetes, obesity, and cardiovascular disease). Yet unequal access to and utilization of quality medical and social resources present a significant and under-addressed barrier to optimal management, especially in rural settings. As advocated by the National Academies, we propose to address the endemic effects of structural racism and systemic drivers of health by using an intervention that integrates medical with social care for African Americans adults in rural eastern North Carolina. The intervention, CommunityRx (CRx), systematically matches people to nearby community resources using evidence-based algorithms at the point of care with a health care provider. CRx utilizes a three- pronged approach to address integrated care among patients and caregivers: (a) comprehensive, ongoing assessment of community resources (eligibility, capacity, quality) using feet-on-the street (see Meaningful Active Productive Science in Service to Communities (MAPSCorps) below) and phone survey methods; (b) integration of a simple automatic resource referral process into routine, Electronic Health Record (EHR)-based clinical workflows; and (c) availability of a community resource navigator. CRx for CKD (CRx-CKD) is an application of this infrastructural approach to address CKD multimorbidity. Our community-engaged and multidisciplinary health equity research team will leverage our infrastructural intervention and implementation science expertise to test the effects of CRx-CKD through three related aims. Aim 1 will contextualize implementation and effectiveness of a rural infrastructural integrated care intervention by (a) building an inclusive model with system science to describe how structural racism affects CKD progress on and its mitigation through integrated care; and (b) conducting a network analysis to evaluate structures of clinic-community connectivity. Aim 2 will optimize Crx-CKD implementation through the Consolidated Framework of Implementation Research to ensure organizational readiness, fidelity, and acceptability. With aim 3, we will test the effectiveness of the CRx-CKD intervention with a pragmatic cluster randomized controlled trial at the clinic level. Three hundred seventy-five African American individuals with CKD multimorbidity at the intervention clinics will be compared to 375 individuals at usual care clinics for the primary outcome of reduction of the glomerular filtration slope decline and reduction of albuminuria; other, secondary outcomes include control of blood pressure, control of blood sugar, weight reduction, and blood lipid management.