The Effect of Screening and Referral for Social Determinants of Health on Veterans' Outcomes

健康社会决定因素的筛查和转诊对退伍军人结果的影响

• 批准号: 10761691
• 负责人: Deborah Gurewich
• 金额: --
• 依托单位: VA BOSTON HEALTH CARE SYSTEM
• 依托单位国家: 美国
• 财政年份: 2021
• 资助国家: 美国
• 起止时间: 2021-02-01 至 2024-09-30
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/10761691
• 关键词: Address; Adherence; Affect; Ambulatory Care; American Heart Association; Appointment; Blood Pressure; Cardiovascular Diseases; Cardiovascular system; Caring; Cessation of life; Characteristics; Clinic; Clinical; Communities; Comprehensive Health Care; Data; Disease Outcome; Distal; Emotional; Employment; Ensure; Food; Funding; Future; Goals; Health; Health Policy; Health Priorities; Health Resources; Health behavior; High Prevalence; Homelessness; Hospitalization; Housing; Human Resources; Individual; Inpatients; Intervention; Intervention Studies; Interview; Investments; Legal; Link; Medical; Methodology; Methods; Modeling; Morbidity - disease rate; Outcome; Patient-Centered Care; Patients; Persons; Pharmaceutical Preparations; Phase; Policy Maker; Prevalence; Primary Care; Process; Randomized; Randomized, Controlled Trials; Recommendation; Research; Resources; Rest; Risk Factors; Safety; Services; Shapes; Site; Social Well-Being; Social Work; Social Workers; Social isolation; System; Testing; Transportation; Veterans; Work; arm; cardiovascular disorder risk; care coordination; compare effectiveness; disability; disparity reduction; efficacy evaluation; evidence base; follow-up; food insecurity; glycemic control; health care service utilization; health equity; improved; improved outcome; innovation; mortality; personalized care; population health; post intervention; primary outcome; programs; response; screening; screening guidelines; secondary outcome; social; social determinants; social health determinants; sociodemographics; stakeholder perspectives; success; tool; treatment adherence; urgent care; violence exposure

Background: Despite medical advances, up to 70% of health outcomes are due to social determinants of health (SDoH) - the conditions in which people live and work that shape whether basic needs (e.g., housing, food) are met. These associations are especially well documented for cardiovascular disease (CVD). In response, health policy leaders recommend screening and referral (S&R) for unmet needs in clinical settings, and the American Heart Association recently concluded that the most significant opportunities for reducing CVD death and disability lie with addressing the social determinants of cardiovascular outcomes. A limited but promising evidence base supports these recommendations but more rigorous research is needed to guide how best to intervene on unmet needs that affect health. Significance/Impact: This project addresses the Office of Social Work’s priority to link Veterans with resources and services in support of treatment goals, the Office of Patient Centered Care and Cultural Transformation’s priority to enhance the physical, emotional, and social well-being of the whole person, the Office of Health Equity’s priority to reduce disparities, and the HSR&D priorities of health equity and population health. Our study will provide much-needed evidence to document the burden of Veterans’ unmet needs, inform how best to address unmet needs, and assess how such a process can affect adherence (to medications and appointments), utilization, and clinical outcomes. Innovation: VA currently systematically screens for only two unmet needs (homelessness and food insecurity). Identification of other unmet needs (and referral to address them) occurs on an ad hoc basis, with varying approaches among clinics/ clinicians. We will implement comprehensive screening of eight unmet needs and systematic referral, developing tools and processes that, if efficacious, can be implemented within VA (and other) clinical systems. VA is currently funding several studies related to SDoH, but none test interventions that systematically identify a wide range of unmet social needs among Veterans and connect Veterans with identified needs to social service resources. Specific Aims: 1) Describe the burden and distribution of eight unmet needs (i.e., housing; food insecurity; utility insecurity; transportation; legal guidance; employment; safety; and social isolation) among Veterans with or at-risk for CVD, and identify their associations with sociodemographic characteristics, and baseline health- related behaviors and clinical outcomes; 2) Compare the effects of three S&R study intervention conditions of varying intensity on Veterans’ connection to new SDoH resources (primary outcome), reduction of unmet needs, adherence, and clinical outcomes, and 3) Identify barriers and facilitators to Veterans’ connecting with social services and having needs met, and explanatory factors for observed RCT outcomes. Methodology: We propose a 3-year, two-phased mixed methods study. In Phase One (Aims 1 and 2), we will implement a three-armed randomized controlled trial at three VA sites to compare outcomes among Veterans randomized within each site to one of three study conditions: screening only; screening plus provision of tailored resource sheets; or screening plus resource sheets plus social work support. For each Veteran, we will examine associations of unmet needs with baseline outcomes (Aim 1), and longitudinally examine the impact of each approach on connection to new SDoH resources and follow-up outcomes over a 12-month period (Aim 2). In Phase Two (Aim 3), we will conduct interviews with Veterans and representatives of the VA- and community-based programs to which Veterans are referred because of the trial to identify facilitators and barriers and potential explanatory factors related to the relative success of the interventions. Implementation/Next Steps: If the intervention yields positive results, findings will be used by partners to support more widespread implementation of it throughout VA.

背景：尽管医疗进展，多达70％的健康成果是由于社会决定者的 健康（SDOH） - 人们生活和工作的条件是否需要基本需求（例如住房，， 满足食物）。这些关联对于心血管疾病（CVD）尤其有效。在 回应，卫生政策领导者建议在临床环境中筛查和转诊（S＆R），以满足临床环境的需求， 美国心脏协会最近得出结论，减少最重要的机会 CVD死亡和残疾在于针对心血管结局的社会决定者。有限，但是 有希望的证据基础支持这些建议，但需要更严格的研究来指导如何 最好干预影响健康的未满足需求。 意义/影响力：该项目介绍社会工作办公室优先考虑退伍军人与资源联系起来 以及支持治疗目标的服务，以患者为中心的护理和文化转型办公室 优先提高整个人的身体，情感和社会福祉，卫生办公室 股权减少分布的优先事项以及健康公平和人口健康的HSR＆D优先事项。我们的 研究将提供急需的证据，以记录Burnen的退伍军人未满足需求，告知如何最好的 解决未满足的需求，并评估这种过程如何影响依从性（对药物和 预约），利用和临床结果。 创新：VA目前仅针对两个未满足的需求（无家可归和粮食不安全）进行系统筛选。 确定其他未满足的需求（并转介以解决这些需求）发生在临时的基础上，并有所不同 诊所/临床医生之间的方法。我们将对八个未满足的需求进行全面筛选，并 系统推荐，开发工具和流程，如果有效，可以在VA中实施 其他）临床系统。 VA目前正在资助与SDOH有关的几项研究，但没有测试干预措施 系统地确定退伍军人之间的各种未满足的社会需求，并将退伍军人与 确定的需要社会服务资源。 具体目的：1）描述八个未满足需求的燃烧和分布（即住房；粮食不安全； 公用事业不安全感；运输;法律指导；就业；安全;和社会隔离）在退伍军人中 或CVD的高风险，并确定其与社会人口统计学特征的关联，以及基线健康 - 相关行为和临床结果； 2）比较三个S＆R研究干预条件的影响 退伍军人与新的SDOH资源的联系（主要结果）的强度有所不同，降低未满足 需求，依从性和临床结果，以及3）确定退伍军人与退伍军人的联系 社会服务和需求满足，以及观察到的RCT结果的解释性因素。 方法论：我们提出了一项为期3年的两步混合方法研究。在第一阶段（目标1和2）中，我们将 在三个VA站点实施三臂随机对照试验，以比较退伍军人的结果 在每个站点中随机分配到三个研究条件之一：仅筛选；筛选加上 量身定制的资源表；或筛选加资源表以及社会工作支持。对于每位退伍军人，我们将 检查未满足的需求与基线结果（AIM 1）的关联，并纵向检查影响 在12个月内与新SDOH资源连接和后续成果的连接的每种方法（AIM 2）。在第二阶段（AIM 3）中，我们将对退伍军人进行采访，并代表VA和VA和 由于审判以确定促进者和 与干预措施相对成功有关的障碍和潜在剥夺因素。 实施/下一步：如果干预产生积极的结果，则合作伙伴将使用调查结果 在整个VA中支持更多的宽度实施。