DEDICATE: aDvancing carE management aDoption In Community heAlTh cEnters

项目总结/摘要 低收入和少数种族/族裔人口的慢性病发病率非常高 发病率和不良疾病结局，以及阻碍疾病的社会和背景风险 管理护理管理是慢性病管理的循证策略。它涉及 协调必要的，适当的照顾个人的需要，包括将他们连接到 社区组织（CBO）应对社会风险。越来越多的付款人（例如，CMS和状态 Medicaid/Managed Care Organizations）为医疗保健提供者承担社会风险提供补偿 筛查和相关转介涉及诊所-CBO联系作为护理管理的一部分。然而，在这方面， 在资源不足的护理环境中，这些活动的系统实施往往是实质性的， 由于对技术的初始投资和为执行这些任务而重新设计工作流程， 这种建立诊所-社区卫生组织联系的障碍在社区卫生中心最为明显， 非营利初级保健安全网诊所，为健康状况不同的人群提供服务。显然需要确定 支持社区卫生中心使用电子技术将患者与可用服务联系和匹配的能力的最佳实践 基于健康记录（EHR）的诊所-CBO链接功能，因为改善所需服务的接收可以 减少健康差距。2022年，全国社区卫生中心网络共享一个电子健康记录，提供了一个新的电子健康记录- 综合应用程序（指南针玫瑰），旨在支持护理管理，包括评估 患者的社会风险，将他们转介给社区组织，并跟踪转介结果 . 然而，大量证据表明， 表明有针对性的实施支持（如培训、冠军、实践促进和审计） 和反馈）可能是至关重要的，以提高临床组织和护理提供者的采用新的 技术.我们将与CHC利益相关者合作，制定和完善实施战略， 支持CHC团队实施和优化基于EHR的工具（和相关工作流程） 协调和使用诊所-CBO联系。我们的具体目标是：1）确定障碍和促进因素， 社区健康中心利用以健康档案为本的护理管理功能，系统化（i）转介有 社区组织的社会风险，以及（ii）评估转诊患者的服务接受情况（闭环转诊）; 2）与 社区利益攸关方完善一套实施战略，以最大限度地发挥其支持 CHC在Compass Rose中采用链接功能;以及3）进行试验，以确定改进后的 战略改善临床CBO的联系，为患者的社会风险。研究结果将提供知识 需要支持社区卫生中心采用现有技术进行诊所与国会预算办公室的联系，作为一种务实的手段， 减少卫生不平等。作为支持实施诊所-CBO联系战略的第一次试验， 在基层医疗安全网采用以电子健康记录为本的医疗管理应用系统， 这项工作直接解决了NINR的目标，即在健康不同的人群中增加临床-CBO联系。

Project Summary/Abstract Low-income and racial/ethnic minority populations experience disparately high rates of chronic disease incidence and poor disease outcomes, as well as the social and contextual risks that hinder disease management. Care management is an evidence-based strategy for chronic disease management. It involves coordinating the necessary, appropriate care for an individual's needs, including connecting them to community-based organizations (CBOs) to address social risks. Increasingly, payors (e.g., CMS and state Medicaid / Managed Care Organizations) are reimbursing healthcare providers for conducting social risk screening and making related referrals that involve clinic-CBO linkages as part of care management. However, in under-resourced care settings, the systematic implementation of these activities is often substantially hampered by the initial investment in technology and workflow redesign needed to operationalize such tasks. Such barriers to establishing clinic-CBO linkages are most pronounced in Community Health Centers (CHCs), non-profit primary care safety net clinics serving health disparate populations. There is a clear need to identify best practices for supporting CHCs' ability to connect and match patients to available services using electronic health record (EHR)-based clinic-CBO linkage functionality, as improving receipt of needed services could reduce health disparities. In 2022, a national network of CHCs sharing one EHR made available a new EHR- integrated application (Compass Rose) that is designed to support care management, including assessing patients' social risks, referring them to CBOs, and tracking referral outcomes . However, extensive evidence shows that targeted implementation support (such as training, championship, practice facilitation, and audit and feedback) may be critical to enhance clinical organizations' and care providers' adoption of new technologies. We will partner with CHC stakeholders to develop and refine implementation strategies designed to support the implementation and optimization of EHR-based tools (and related workflows) for CHC team coordination and use of clinic-CBO linkages. Our specific aims are to: 1) identify barriers and facilitators to CHCs' use of EHR-based care management functions as a means to systematize (i) referring patients with social risks to CBOs and (ii) assessing referred patients' service receipt (closed-loop referral); 2) partner with community stakeholders to refine a set of implementation strategies to optimize their potential to support CHCs' adoption of linkage functionality in Compass Rose; and 3) conduct a trial of whether the refined strategies improve clinic-CBO linkages for patients with social risks. Study findings will provide knowledge needed to support CHCs' adoption of existing technologies for clinic-CBO linkages, as a pragmatic means to reduce health inequities. As the first trial of strategies to support the implementation of clinic-CBO linkages via adoption of an EHR-based care management application in the primary care safety net setting, the proposed work directly addresses NINR's goal of increasing clinical-CBO linkages in health disparate populations.