Evaluation of the Learning to Integrate Neighborhoods and Clinical Care Project: Findings from Implementing a New Lay Role into Primary Care Teams to Address Social Determinants of Health

Hsu, Clarissa; Hertel, Erin; Johnson, Eric A.; Cahill, Carol; Lozano, Paula; Ross, Tyler; Ehrlich, Kelly; Coleman, Katie; BlueSpruce, June; Cheadle, Allen; Matthys, Juno; Chapdelaine, Michelle; Gray, Marlaine Figueroa; Tufte, Janice; Robbins, Michele

doi:10.7812/tpp/18-101

Cited by 16 publications

(10 citation statements)

References 23 publications

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“…Our findings also provide concrete examples of the valuable role that practice staff such as care managers play in facilitating efforts to address social needs. Several recent studies and reports have emphasised the need to invest in practice staff whose roles include a focus on identifying and assisting patients with HRSN (Bryant et al., 2020; Ellis et al., 2021; Hsu et al., 2018; Islam et al., 2020; Kovach et al., 2019; Rojas L & Project S, 2020). Indeed, our findings suggest that staff members’ skills in relationship‐building and empathetic understanding of their patients’ lived realities are pivotal to a practice's success in connecting patients with resources and assistance.…”

Section: Discussionmentioning

confidence: 99%

Implementing health‐related social needs screening in western Colorado primary care practices: Qualitative research to inform improved communication with patients

Broaddus-Shea

Duarte

Jantz³

et al. 2022

Health Social Care Comm

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Social determinants profoundly impact health. Many primary care practices now seek to screen their patients for health-related social needs (HRSN) and refer them to resources in the community. However, there is little empirical evidence to guide communication with patients in order to ensure their comfort with the process and increase the likelihood that it results in positive outcomes. This paper describes the first phase of the Improving Messaging Around Gaps in Needs and rEfferals (IMAGINE) study-a multi-phase study aiming to develop and test patient-centred messages about screening and referral for HRSN. In this initial qualitative phase, our objective was to identify communication strategies that might make western Colorado primary care patients more comfortable with the HRSN screening and referral process. From May to July 2020 we interviewed 10 staff members responsible for HRSN screening from primary care practices participating in the western Colorado Accountable Health Communities (AHC) initiative and 20 patients from 2 of these practices. We used a rapid qualitative analysis process that involved summarising interview transcripts across key domains of interest and then identifying emergent themes within each domain using a data matrix. Through this process, we examined current communication about HRSN screening, as well as suggestions for messages and other strategies that could improve communication. In most practices, the AHC Screening Tool was handed to patients by front desk staff at check-in with little explanation as to its purpose. Patients and staff alike recommended that patients be provided with information that: normalises the screening and referral process; assures privacy; clarifies that the purpose is to help and support rather than judge or report; emphasises community benefits; and respects patient autonomy. Interviewees also suggested broader strategies to support more effective communication, such as practice staff and clinicians building trusting relationships with patients and understanding and acknowledging the complex structural barriers that often prevent patients from accessing meaningful assistance. These findings provide actionable suggestions for improving communication about HRSN screening and referral in primary care settings. The next steps include developing specific messages based on these findings and testing their impact on screening tool completion rate, referral uptake, and patient-reported comfort with the process.

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Section: Discussionmentioning

confidence: 99%

Implementing health‐related social needs screening in western Colorado primary care practices: Qualitative research to inform improved communication with patients

Broaddus-Shea

Duarte

Jantz³

et al. 2022

Health Social Care Comm

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“…23,24 Community health workers are increasingly used in primary care settings to assist with social and economic needs; however, research surrounding integration of these personnel into oncology settings is limited. 25 It is possible that use of such peer-based workers in underserved settings may be a cost-effective solution for alleviating cancer provider burden (as has been demonstrated in primary care settings 26 and, to some extent, cancer care settings [18][19][20][21] ); however, role clarity on the cancer care team and training for cancer care providers on how to best use these personnel will be essential for their integration. Further research is necessary to understand under what conditions such personnel can be optimally used to reduce cancer care disparities and improve outcomes.…”

Section: Responders (%)mentioning

confidence: 99%

Challenges and Solutions to Support Oncology Professionals Serving Underserved Populations With Cancer in the United States: Results From the ASCO Serving the Underserved Task Force

Patel,

Hinyard,

Merrill

et al. 2024

JCO Oncol Pract

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PURPOSE Little data exist regarding approaches to support oncology professionals who deliver cancer care for underserved populations. In response, ASCO developed the Serving the Underserved Task Force to learn from and support oncology professionals serving underserved populations. METHODS The Task Force developed a 28-question survey to assess oncology professionals' experiences and strategies to support their work caring for underserved populations. The survey was deployed via an online link to 600 oncology professionals and assessed respondent and patient demographic characteristics, clinic-based processes to coordinate health-related social services, and strategies for professional society support and engagement. We used chi-square tests to evaluate whether there were associations between percent full-time equivalent (FTE) effort serving underserved populations (<50% FTE v ≥50% FTE) with responses. RESULTS Of 462 respondents who completed the survey (77% response rate), 79 (17.1%) were Asian; 30 (6.5%) Black; 43 (9.3%) Hispanic or Latino/Latina; and 277 (60%) White. The majority (n = 366, 79.2%) had a medical doctor degree (MD). A total of 174 (37.7%) had <25% FTE, 151 (32.7%) had 25%-50% FTE, and 121 (26.2%) had ≥50% FTE effort serving underserved populations. Most best guessed patients' sociodemographic characteristics (n = 388; 84%), while 42 (9.2%) used data collected by the clinic. Social workers coordinated most health-related social services. However, in clinical settings with high proportions of underserved patients, there was greater reliance on nonclinical personnel, such as navigators (odds ratio [OR], 2.15 [95% CI, 1.07 to 4.33]) or no individual (OR, 2.55 [95% CI, 1.14 to 5.72]) for addressing mental health needs and greater reliance on physicians or advance practice practitioners (OR, 2.54 [95% CI, 1.11 to 5.81]) or no individual (OR, 1.91 [95% CI, 1.09 to 3.35]) for addressing childcare or eldercare needs compared with social workers. Prioritization of solutions, which did not differ by FTE effort serving underserved populations, included a return-on-investment model to support personnel, integrated health-related social needs screening, and collaboration with the professional society on advocacy and policy. CONCLUSION The findings highlight crucial strategies that professional societies can implement to support oncology clinicians serving underserved populations with cancer.

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“…Interventions were implemented in various settings for hospital-based initiatives, including post hospital discharge [221] , the emergency department [222], and clinics specializing in different medical disciplines [223][224][225][226][227]. On the other hand, community-based initiatives concentrated mainly on integrating interventions into primary care services [228][229][230][231]. The social and healthcare supportive programs included a range of initiatives designed towards improving community health.…”

Section: Sdoh Interventionsmentioning

confidence: 99%

“…Health outcomes, such as improvements in health metrics, reductions in disease incidence, changes in vital signs, and quality of life, are commonly used as measures to determine the feasibility of initiating an intervention (n = 10). Several studies have also assessed social SDoH in relation to patient satisfaction and acceptability [230,235,237,238]. Since most programs were new efforts, it was not possible to determine the effectiveness of the intervention in the short term, nor could the potential generalizability be assessed.…”

Section: Sdoh Interventionsmentioning

confidence: 99%

Realizing the Potential of Social Determinants Data: A Scoping Review of Approaches for Screening, Linkage, Extraction, Analysis and Interventions

Li,

Mowery,

et al. 2024

Preprint

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Background Social determinants of health (SDoH) like socioeconomics and neighborhoods strongly influence outcomes, yet standardized SDoH data is lacking in electronic health records (EHR), limiting research and care quality. Methods We searched PubMed using keywords "SDOH" and "EHR", underwent title/abstract and full-text screening. Included records were analyzed under five domains: 1) SDoH screening and assessment approaches, 2) SDoH data collection and documentation, 3) Use of natural language processing (NLP) for extracting SDoH, 4) SDoH data and health outcomes, and 5) SDoH-driven interventions. Results We identified 685 articles, of which 324 underwent full review. Key findings include tailored screening instruments implemented across settings, census and claims data linkage providing contextual SDoH profiles, rule-based and neural network systems extracting SDoH from notes using NLP, connections found between SDoH data and healthcare utilization/chronic disease control, and integrated care management programs executed. However, considerable variability persists across data sources, tools, and outcomes. Discussion Despite progress in identifying patient social needs, further development of standards, predictive models, and coordinated interventions is critical to fulfilling the potential of SDoH-EHR integration. Additional database searches could strengthen this scoping review. Ultimately widespread capture, analysis, and translation of multidimensional SDoH data into clinical care is essential for promoting health equity.

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Evaluation of the Learning to Integrate Neighborhoods and Clinical Care Project: Findings from Implementing a New Lay Role into Primary Care Teams to Address Social Determinants of Health

Cited by 16 publications

References 23 publications

Implementing health‐related social needs screening in western Colorado primary care practices: Qualitative research to inform improved communication with patients

Implementing health‐related social needs screening in western Colorado primary care practices: Qualitative research to inform improved communication with patients

Challenges and Solutions to Support Oncology Professionals Serving Underserved Populations With Cancer in the United States: Results From the ASCO Serving the Underserved Task Force

Realizing the Potential of Social Determinants Data: A Scoping Review of Approaches for Screening, Linkage, Extraction, Analysis and Interventions

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