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Principal Investigator: RACHEL GOLD
Organization: KAISER FOUNDATION RESEARCH INSTITUTE
Fiscal Year: 2024
Award: $575,889
Funding agency: National Institute on Minority Health and Health Disparities
PROJECT SUMMARY/ABSTRACT: Factors such as food, transportation, and housing instability, social
isolation, and neighborhood conditions profoundly impact health outcomes. Shaped by a long history of
racial, social, and economic inequity in the US, such factors also underlie health inequities. Many healthcare
leaders now recommend systematic documentation of these social risk factors. Yet while social risk data are
increasingly available in electronic health records (EHR), research is lacking on how healthcare teams
can use these data to improve patient health and decrease health inequities. Social risk-targeted care
(referrals to service agencies) can improve health outcomes, but recent research suggests that such
improvements are not solely the result of addressing social conditions. Another path to improved outcomes
involves social risk-informed care: modifying care plans to account for patients’ social risks (e.g., adjusting
insulin prescribing so that when food benefits run out at the end of the month, patients are less likely to be
hospitalized with hypoglycemia). Such social risk-informed care may seem intuitive, but very little research
has examined how care teams can effectively and systematically make such adaptations. This study will be
the first to examine how EHR-based clinical decision support (CDS) could support the provision of
contextualized, social risk-informed care. Our Aims are: 1. Obtain stakeholder input from community
health center (CHC) staff and patients on care plan adaptations that could mitigate social risks’ impact on
patient health and ability to adhere to care recommendations. Develop and pilot-test EHR-integrated CDS
tools that present social risks and suggest relevant care plan adaptations. 2. Randomize 12 CHCs to
receive: Arm 1) a CDS tool with a social risk summary, links to social service information, and a reminder to
consider social risks in care planning; or Arm 2) a CDS tool with the same summary, reminder, and links,
plus specific care plan adaptation suggestions tailored to a given patient’s social risks. Assess each tool’s
impact on selected national Care Quality Measures (CQM), accounting for secular trends. 3. Assess
enactment of the tools’ suggested care plan adaptations, and patient / staff perceptions of the tools’ usability
and impact on care quality and patient-provider interactions. Our setting is the nation’s largest group of
CHCs on a single EHR. The PIs’ work on an upcoming National Academies report directly informed the
social risk-informed CDS proposed here. This proposal addresses PAR-19-093’s calls for research on “using
HIT to reduce disparities by increasing ... higher quality care, & improving patient-clinician communication,
and health outcomes,” and on “models for the inclusion and utility of SDoH in EHR systems/CDS tools that
… improve health equity.” The tools developed here will be made available immediately for
implementation in any EHR system, enabling rapid dissemination and greater impact of study findings.
Terms: <Academy><Accounting><Active Follow-up><Address><Affect><American College of Physicians><Application Context><Assessment instrument><Assessment tool><BP control><BP management><Caring><Clinical><Clinical Decision Support Systems><Community Health Centers><Data><Decrease disparity><Depression screen><Disparity population><Documentation><Drugs><EHR system><Economics><Electronic Health Record><Engineering><Evaluation><Feedback><Food><Glycohemoglobin A><Glycosylated hemoglobin A><Hb A1><Hb A1a+b><Hb A1c><HbA1><HbA1c><Health><Health Care Providers><Health Care Systems><Health Care Team><Health Inequity><Health Personnel><Healthcare><Healthcare Providers><Healthcare Systems><Healthcare Team><Healthcare worker><Hemoglobin A(1)><History><Homelessness><Hospital Admission><Hospitalization><Housing><Humulin R><Hypoglycemia><Inequalities in Health><Inequities in Health><Inequity><Information Services><Insulin><Intervention><Intervention Strategies><Interview><Intuition><Laboratories><Link><Lower disparity><Measures><Medical><Medical Care Team><Medication><Medicine><Modeling><National Academy of Sciences><Neighborhood Health Center><Neighborhoods><Novolin R><Outcome><Patient outcome><Patient-Centered Outcomes><Patient-Focused Outcomes><Patients><Perception><Pharmaceutical Preparations><Process><Provider><Public Health><QOC><Quality of Care><Race><Races><Randomized><Recommendation><Recording of previous events><Refrigeration><Regular Insulin><Reporting><Research><Risk><Risk Factors><Running><Services><Shapes><Social Conditions><Social Service><Social Work><Social isolation><Societal Conditions><Suggestion><Survey Instrument><Surveys><Testing><Transportation><United States National Academy of Sciences><Visit><Work><access to health care><access to healthcare><accessibility of health care><accessibility to health care><accessibility to healthcare><active followup><arm><blood pressure control><blood pressure management><clinical decision support><clinical risk><community factor><community-level factor><contextual factors><depression screening><design><designing><disadvantaged group><disadvantaged individual><disadvantaged people><disadvantaged population><disadvantaged subgroup><disparities across groups><disparity across subgroups><disparity among groups><disparity among subgroups><disparity between groups><disparity between subgroups><disparity in health><disparity reduction><drug/agent><economic><electronic health care record><electronic health medical record><electronic health plan record><electronic health record system><electronic health registry><electronic medical health record><experience><follow up><follow-up><followed up><followup><food resource><group disparity><group inequality><group inequity><health care><health care access><health care availability><health care personnel><health care service access><health care service availability><health care worker><health disparity><health equity><health inequalities><health outcome disparity><health outcome inequality><health outcome inequity><health provider><health workforce><healthcare access><healthcare accessibility><healthcare availability><healthcare personnel><healthcare service access><healthcare service availability><hemoglobin A1c><histories><homeless><housing instability><hypoglycemic><hypoglycemic episodes><improved><improved outcome><inequalities among populations><inequalities between populations><inequalities in populations><inequality across populations><inequality among groups><inequality between groups><inequality in groups><inequitable health outcome><inequities among populations><inequities between populations><inequities in populations><inequity across groups><inequity across populations><inequity between groups><inequity in groups><innovate><innovation><innovative><instably housed><interventional strategy><intuitive><medical personnel><mitigate disparity><participant engagement><patient engagement><patient oriented outcomes><patient-clinician communication><patient-doctor communication><patient-provider communication><pilot test><population inequality><population inequity><primary outcome><racial><racial background><racial origin><randomisation><randomization><randomly assigned><reduce disparity><reduction in disparity><response><safety net><screening><screenings><secondary analysis><secondary outcome><social><social determinants><social engagement><social health determinants><social involvement><social participation><sociodeterminant><subgroup disparity><support tools><tool><treatment provider><trend><unequal group><unequal health outcome><unequal population><unhoused><unstable housing><unstably housed><usability>