Although it is known that the social determinants of health have a larger influence on health outcomes than health care, there currently is no structured way for primary care providers to identify and address nonmedical social needs experienced by patients seen in a clinic setting. We developed and piloted WellRx, an 11-question instrument used to screen 3048 patients for social determinants in 3 family medicine clinics over a 90-day period. Results showed that 46% of patients screened positive for at least 1 area of social need, and 63% of those had multiple needs. Most of these needs were previously unknown to the clinicians. Medical assistants and community health workers then offered to connect patients with appropriate services and resources to address the identified needs. The WellRx pilot demonstrated that it is feasible for a clinic to implement such an assessment system, that the assessment can reveal important information, and that having information about patients' social needs improves provider ease of practice. Demonstrated feasibility and favorable outcomes led to institutionalization of the WellRx process at a university teaching hospital and influenced the state department of health to require managed care organizations to have community health workers available to care for Medicaid patients.

BackgroundDiabetes risk is extremely high for Latinos from low-income households. Health guidelines recommend that individuals learn strategies to self-manage their diabetes, but getting people to adopt required lifestyle changes is challenging and many people are not able to prevent their pre-diabetes from escalating or effectively control their diabetes. Systematic reviews show that culturally competent self-management programs can significantly improve diabetes outcomes and different models for culturally competent programming have been developed.MethodsThis patient-engaged study will compare the effectiveness of two distinct evidence-based models for culturally competent diabetes health promotion at two sites that serve a large Latino patient population from low-income households: 1) The Diabetes Self-Management Support Empowerment Model, an educational session approach, and 2) The Chronic Care Model, a holistic community-based program. Data collection will involve interviews, focus groups, surveys and assessments of each program; and testing of patient participants for A1c, depression, Body Mass Index (BMI), and chronic stress with hair cortisol levels. We will recruit a total of 240 patient-social support pairs: Patients will be adults (men and women over the age of 18) who: 1.) Enter one of the two diabetes programs during the study; 2.) Self-identify as “Latino;” 3.) Are able to identify a social support person or key member of their social network who also agrees to participate with them; 4.) Are not pregnant (participants who become pregnant during the study will be excluded); and 5.) Have household income 250% of the Federal Poverty Level (FPL) or below. Social supports will be adults who are identified by the patient participants. PRIMARY OUTCOME: Improved capacity for diabetes self-management measured through improvements in diabetes knowledge and diabetes-related patient activation. SECONDARY OUTCOME: Successful diabetes self-management as measured by improvements in A1c, depression scale scores, BMI, and circulating levels of cortisol to determine chronic stress.DiscussionOur hypothesis is that the program model that interfaces most synergistically with patients’ culture and everyday life circumstances will have the best diabetes health outcomes.Trial registrationThis study was registered with ClinicalTrials.gov on December 16, 2016 (Registration #NCT03004664).

Background Female Mexican Immigrants (FMIs) experience high rates of depression compared with other populations. For this population, depression is often exacerbated by social isolation associated with the experience of immigration. Aim 1. To measure whether a culturally situated peer group intervention will reduce depression and stress associated with the experience of immigration. Aim 2. To test whether an intervention using a “women’s funds of knowledge” approach results in improved resilience, knowledge and empowerment. Aim 3. To investigate whether a culturally situated peer group intervention using a women’s funds of knowledge approach can give participants a sense and experience of social and physical connection (“emplacement”) that is lost in the process of immigration. Methods This mixed-methods study will implement “Tertulias” (“conversational gatherings” in Spanish), a peer support group intervention designed to improve health outcomes for FMI participants in Albuquerque, New Mexico. We will document results of the intervention on our primary hypotheses of a decrease in depression, and increases in resilience and social support, as well as on our secondary hypotheses of decreased stress (including testing of hair cortisol as a biomarker for chronic stress), and an increase in social connectedness and positive assessment of knowledge and empowerment. Discussion This project will address mental health disparities in an underserved population that experiences high rates of social isolation. Successful completion of this project will demonstrate that health challenges that may appear too complex and too hard to address can be using a multi-level, holistic approach. Our use of hair samples to test for the 3-month average levels of systemic cortisol will contribute to the literature on an emerging biomarker for analyzing chronic stress. Trial registration This study was registered with ClinicalTrials.gov on 2/3/20, Identifier #NCT04254198.

Key Points Question How quickly can primary care practices report electronic clinical quality measures based on evidence-based guidelines for cardiac care? Findings In this quality improvement study of 211 primary care practices, the median time to report any baseline electronic clinical quality measure was 8.2 months. Time to report varied by measure type and practice characteristics. Meaning This study suggests that clinical quality measure reporting still takes a great deal of time and effort, and as the health care system increasingly moves to value-based structures that require electronic clinical quality measures, some practices may be left behind without better incentives and support.

Our philosophical framework for research with low-income Latino patients with diabetes prioritizes hiring research staff who share the culture and language of the population of study. Inclusive research design requires an active role by patient stakeholders with training opportunities in a collaborative learning environment to allow patient stakeholder data collectors (PSDCs) to build on existing strengths and expertise. To develop this manuscript, our team reflected on our collective experiences in implementing research-specific trainings for PSDCs. Although our population of study is known to be difficult to recruit and retain, our PSDCs have successfully enrolled participants on schedule, and attrition is low. Although language, institutional requirements, and funding restrictions presented training challenges, we overcame these by using a flexible approach and by incorporating the data collectors’ expertise in refining our protocols. We propose that our success in recruiting and retaining participants is a reflection of our engaged research strategy and framework and demonstrates that engagement promotes better science. However, our experience also demonstrates research institutions need to make policy and infrastructural improvements to reduce barriers and make engaged approaches