Southeast Collaborative for Innovative and Equitable Solutions to Chronic Disease Disparities

项目摘要 美国继续经历着世界上一些最严重的健康差距，部分原因是 无法解决健康的社会驱动因素(SDoH)。这些SDOH，如收入、教育/健康 据估计，识字和建筑环境造成了50%的健康不平等。美国国家科学院 科学、工程和医学(NASEM)和其他组织呼吁系统地 将SDoH评估纳入电子健康记录(EHR)和临床护理。此外，新的2023年 联合委员会的法规现在要求SDoH筛查，增加了研究和 建立最佳实践。然而，令人惊讶的是，很少有研究评估SDoH数据的实施 收集，评估多学科医疗团队如何在临床实践中最好地解决SDoH，或 测量社会风险知情护理对慢性病患者预后的影响， 那里的健康差距很大。也存在对潜在的意外后果的担忧，如 作为对诊所的行政负担和对患者的污名化。因此，大多数实践都没有解决 SDOH系统地，错失了促进卫生公平的重要机会。 该项目的目标是开发和评估一个多层次的倡议，以收集和处理SDoH AS 成人初级保健2型糖尿病合并高血压和/或 高脂血症。拟议的研究是建立在我们的大量前期工作和专业知识的基础上的 SDoH测量和干预方面的跨学科研究小组，以及 健康差距、实施科学和健康信息技术。 在目标1中，我们将使用定性的方法来评估利益相关者的观点--调查人员已经 参与与社区参与和社会推动者、患者、临床医生、诊所工作人员以及 社区组织领袖--关于收集和使用患者报告的SDoH，如何优化 SDoH信息和临床决策支持工具在电子病历中的集成，以及如何将潜力降至最低 执行障碍和意想不到的后果。在目标2中，我们将实施多层次的倡议 (卫生保健专业人员、护理协调员和药剂师的SDoH数据收集、培训和工具 支持和社区资源)，并评估其对临床结果的影响，包括血红蛋白A1c， 血压和胆固醇。在目标3中，我们将使用以下方法对实施进行混合方法评估 RE-AIM Quest框架，为扩大和传播提供信息。 这项研究将填补与SDoH数据实际实施相关的知识的关键空白 收集和提供了解社会风险的护理。这些发现将与广泛的慢性疾病相关 受社会风险因素和健康差距影响的医疗条件，增强了该项目的潜力 冲击力。

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.