Bringing Social Context into Diabetes Care: Intervening on Social Risks versus Providing Contextualized Care

Benefits, Challenges, and Opportunities in Addressing Medicaid Beneficiaries' Non-Medical Risks to Health: A Qualitative Analysis

CONTEXT

North Carolina's Healthy Opportunities Pilots (HOP) is a Medicaid 1115 Waiver program that seeks to address nonmedical risks to health for Medicaid beneficiaries through multisector collaboration. Among other stakeholders, HOP involves collaboration between human services organizations that deliver interventions, network leads, which establish and oversee the human services organizations within a region of the state.

OBJECTIVE

To understand how employees at human services organizations and network leads prepared to deliver HOP services.

DESIGN

Qualitative analysis of semistructured interviews. Interviews were conducted between April and June 2022. Interviews were recorded, transcribed verbatim, coded thematically, and analyzed using a conceptual model derived from the consolidated framework for implementation research.

SETTING

Organizations within North Carolina counties participating in HOP.

PARTICIPANTS

Employees of human services and network lead organizations across all 3 HOP regions of North Carolina.

RESULTS

The researchers interviewed 37 participants. Overall, organizations experienced benefits from HOP participation, including capacity-building resources, flexibility in allocating resources, and creating community-wide enthusiasm for addressing nonmedical risks to health. There were also key challenges. These included the time needed to build capacity, adjustments to the work processes and regulations inherent to multisector collaboration, geographic variation in availability of services to offer, and the difficulty of addressing different needs. Finally, participants recognized substantial opportunities that HOP presented, including membership in a more extensive network, exposure to a learning community, and a more sustainable funding source.

CONCLUSIONS

The perspectives of individuals preparing to deliver HOP services offer important lessons for those developing and implementing large-scale programs that can address nonmedical threats to health.

Food Insecurity and Hypoglycemia among Older Patients with Type 2 Diabetes Treated with Insulin or Sulfonylureas: The Diabetes & Aging Study

BACKGROUND

Severe hypoglycemia is a serious adverse drug event associated with hypoglycemia-prone medications; older patients with diabetes are particularly at high risk. Economic food insecurity (food insecurity due to financial limitations) is a known risk factor for hypoglycemia; however, less is known about physical food insecurity (due to difficulty cooking or shopping for food), which may increase with age, and its association with hypoglycemia.

OBJECTIVE

Study associations between food insecurity and severe hypoglycemia.

DESIGN

Survey based cross-sectional study.

PARTICIPANTS

Survey responses were collected in 2019 from 1,164 older (≥ 65 years) patients with type 2 diabetes treated with insulin or sulfonylureas.

MAIN MEASURES

Risk ratios (RR) for economic and physical food insecurity associated with self-reported severe hypoglycemia (low blood glucose requiring assistance) adjusted for age, financial strain, HbA1c, Charlson comorbidity score and frailty. Self-reported reasons for hypoglycemia endorsed by respondents.

KEY RESULTS

Food insecurity was reported by 12.3% of the respondents; of whom 38.4% reported economic food insecurity only, 21.1% physical food insecurity only and 40.5% both. Economic food insecurity and physical food insecurity were strongly associated with severe hypoglycemia (RR = 4.3; p = 0.02 and RR = 4.4; p = 0.002, respectively). Missed meals ("skipped meals, not eating enough or waiting too long to eat") was the dominant reason (77.5%) given for hypoglycemia.

CONCLUSIONS

Hypoglycemia prevention efforts among older patients with diabetes using hypoglycemia-prone medications should address food insecurity. Standard food insecurity questions, which are used to identify economic food insecurity, will fail to identify patients who have physical food insecurity only.

Contextual Factors Relevant to Implementing Social Risk Factor Screening and Referrals in Cancer Survivorship: A Qualitative Study

Introduction

Social risk factors such as food insecurity and lack of transportation can negatively affect health outcomes, yet implementation of screening and referral for social risk factors is limited in medical settings, particularly in cancer survivorship.

Methods

We conducted 18 qualitative, semistructured interviews among oncology teams in 3 health systems in Washington, DC, during February and March 2022. We applied the Exploration, Preparation, Implementation, Sustainment Framework to develop a deductive codebook, performed thematic analysis on the interview transcripts, and summarized our results descriptively.

Results

Health systems varied in clinical and support staff roles and capacity. None of the participating clinics had an electronic health record (EHR)-based process for identifying patients who completed their cancer treatment ("survivors") or a standardized cancer survivorship program. Their capacities also differed for documenting social risk factors and referrals in the EHR. Interviewees expressed awareness of the prevalence and effect of social risk factors on cancer survivors, but none employed a systematic process for identifying and addressing social risk factors. Recommendations for increasing screening for social risk factors included designating a person to fulfill this role, improving data tracking tools in the EHR, and creating systems to maintain up-to-date information and contacts for community-based organizations.

Conclusion

The complexity of cancer care workflows and lack of reimbursement results in a limited ability for clinic staff members to screen and make referrals for social risk factors. Creating clinical workflows that are flexible and tailored to staffing realities may contribute to successful implementation of a screening and referral program. Improving ongoing communication with community-based organizations to address needs was deemed important by interviewees.

A Randomized Controlled Trial to Improve Unmet Social Needs and Clinical Outcomes Among Adults with Diabetes

BACKGROUND

Adults with type 1 or type 2 diabetes often face financial challenges and other unmet social needs to effective diabetes self-management.

OBJECTIVE

Whether a digital intervention focused on addressing socioeconomic determinants of health improves diabetes clinical outcomes more than usual care.

DESIGN

Randomized trial from 2019 to 2023.

PARTICIPANTS

A total of 600 adults with diabetes, HbA1c ≥ 7.5%, and self-reported unmet social needs or financial burden from a health system and randomized to the intervention or standard care.

INTERVENTION

CareAvenue is an automated, e-health intervention with eight videos that address unmet social needs contributing to poor outcomes.

MEASURES

Primary outcome was HbA1c, measured at baseline, and 6 and 12 months after randomization. Secondary outcomes included systolic blood pressure and reported met social needs, cost-related non-adherence (CRN), and financial burden. We examined main effects and variation in effects across predefined subgroups.

RESULTS

Seventy-eight percent of CareAvenue participants completed one or more modules of the website. At 12-month follow-up, there were no significant differences in HbA1c changes between CareAvenue and control group (p = 0.24). There were also no significant between-group differences in systolic blood pressure (p = 0.29), met social needs (p = 0.25), CRN (p = 0.18), and perceived financial burden (p = 0.31). In subgroup analyses, participants with household incomes 100-400% FPL (1.93 (SE = 0.76), p < 0.01), 201-400% FPL (1.30 (SE = 0.62), p < 0.04), and > 400% FPL (1.27 (SE = 0.64), p < 0.05) had significantly less A1c decreases compared to the control group.

CONCLUSIONS

On average, CareAvenue participants did not achieve better A1c lowering, met needs, CRN, or perceived financial burden compared to control participants. CareAvenue participants with higher incomes achieved significantly less A1c reductions than control. Further research is needed on social needs interventions that consider tailored approaches to population subgroups.

CLINICAL TRIALS REGISTRY

ClinicalTrials.gov ID NCT03950973, May 2019.

Awareness, Adjustment, Assistance, Alignment, and Advocacy: Operationalizing Social Determinants of Health Topics in Undergraduate Medical Education Curricula

Social and economic factors, such as those related to food, housing, and transportation, are major drivers of health and health inequities. Multiple national professional organizations have articulated roles for physicians in identifying and addressing social determinants of health (SDOH) and the need to include SDOH in all stages of physician education. Despite encouragement from these professional organizations, medical schools still do not routinely offer SDOH education alongside basic and clinical sciences curricula. A recent national expert consensus process identified priority SDOH knowledge domains and professional skills for medical students but lacked an organizing schema and specific pedagogical examples to help translate prioritized skills into routine pedagogical practice. One such schema is the 5As framework developed by the National Academies of Sciences, Engineering, and Medicine, which elaborates on 5 strategies to strengthen social care: awareness, adjustment, assistance, alignment, and advocacy. In this article, the authors highlight and provide examples of how mapping SDOH skills to the 5As framework can help educators meaningfully operationalize SDOH topics into specific curricular activities during the preclinical and clinical stages of undergraduate medical education. As a foundational first step in this direction, medical schools should conduct an internal curricular review of social care content (ideally mapped to the 5As framework) and identify opportunities to integrate these topics into existing courses when relevant (e.g., in social medicine, population health, and health systems science courses). Given that health and social care integration is highly context dependent, each medical school will likely need to tailor curricular changes based on their own institutional needs, mission, patient populations, and ties to the community. To increase interinstitutional alignment, medical schools might consider using or adapting peer-reviewed materials and assessments curated and centralized by the National Collaborative for Education to Address the Social Determinants of Health.

Economic burden, financial stress, and cost-related coping among people with uncontrolled diabetes in the U.S

Granular information on material deprivation including financial and economic well-being among people with diabetes can better inform policy, practice and interventions to support diabetes management. The purpose of this study was to describe in-depth the state of economic burden, financial stress, and coping among people with high A1c. Data came from the 2019-2021 baseline assessment in an ongoing U.S. trial that addresses social determinants of health among people with diabetes and high A1c who report at least one financial burden or cost-related non-adherence (CRN) (n = 600). Mean age of participants was 53 years. Planning behaviors were the most common financial well-being behavior, while savings was least frequently endorsed. Nearly a quarter of participants report spending more than $300 per month out-of-pocket to manage all of their health conditions. Participants reported spending the most out-of-pocket on medications (52%), special foods (40%), doctor's visits (27%), and blood glucose supplies (22%). Along with health insurance, these were also the most cited as sources of financial stress and where assistance. Seventy-two percent reported high levels of financial stress. Maladaptive coping was evident through CRN, and less than half engaged in adaptive coping such as talking to a doctor about cost or using a resource to address their needs. Economic burden, financial stress, and cost-related coping are highly relevant constructs among people with diabetes and high A1cs. More evidence-generation is needed for diabetes self-management programs to address sources of financial stress, facilitate behaviors to enhance financial well-being, and address unmet social needs to alleviate economic burdens.

Eliminating Food Insecurity in the USA: a Target Trial Emulation Using Observational Data to Estimate Effects on Health-Related Quality of Life

BACKGROUND

Food insecurity is associated with many aspects of poor health. However, trials of food insecurity interventions typically focus on outcomes of interest to funders, such as healthcare use, cost, or clinical performance metrics, rather than quality of life outcomes that may be prioritized by individuals who experience food insecurity.

OBJECTIVE

To emulate a trial of a food insecurity elimination intervention, and quantify its estimated effects on health utility, health-related quality of life, and mental health.

DESIGN

Target trial emulation using longitudinal, nationally representative data, from the USA, 2016-2017.

PARTICIPANTS

A total of 2013 adults in the Medical Expenditure Panel Survey screened positive for food insecurity, representing 32 million individuals.

MAIN MEASURES

Food insecurity was assessed using the Adult Food Security Survey Module. The primary outcome was the SF-6D (Short-Form Six Dimension) measure of health utility. Secondary outcomes were mental component score (MCS) and physical component score (PCS) of the Veterans RAND 12-Item Health Survey (a measure of health-related quality of life), Kessler 6 (K6) psychological distress, and Patient Health Questionnaire 2-item (PHQ2) depressive symptoms.

KEY RESULTS

We estimated that food insecurity elimination would improve health utility by 80 QALYs per 100,000 person-years, or 0.008 QALYs per person per year (95% CI 0.002 to 0.014, p = 0.005), relative to the status quo. We also estimated that food insecurity elimination would improve mental health (difference in MCS [95% CI]: 0.55 [0.14 to 0.96]), physical health (difference in PCS: 0.44 [0.06 to 0.82]), psychological distress (difference in K6: -0.30 [-0.51 to -0.09]), and depressive symptoms (difference in PHQ-2: -0.13 [-0.20 to  -0.07]).

CONCLUSIONS

Food insecurity elimination may improve important, but understudied, aspects of health. Evaluations of food insecurity interventions should holistically investigate their potential to improve many different aspects of health.

The role of structural racism and geographical inequity in diabetes outcomes

Diabetes is pervasive, exponentially growing in prevalence, and outpacing most diseases globally. In this Series paper, we use new theoretical frameworks and a narrative review of existing literature to show how structural inequity (structural racism and geographical inequity) has accelerated rates of diabetes disease, morbidity, and mortality globally. We discuss how structural inequity leads to large, fixed differences in key, upstream social determinants of health, which influence downstream social determinants of health and resultant diabetes outcomes in a cascade of widening inequity. We review categories of social determinants of health with known effects on diabetes outcomes, including public awareness and policy, economic development, access to high-quality care, innovations in diabetes management, and sociocultural norms. We also provide regional perspectives, grounded in our theoretical framework, to highlight prominent, real-world challenges.

Partner-developed electronic health record tools to facilitate social risk-informed care planning

OBJECTIVE

Increased social risk data collection in health care settings presents new opportunities to apply this information to improve patient outcomes. Clinical decision support (CDS) tools can support these applications. We conducted a participatory engagement process to develop electronic health record (EHR)-based CDS tools to facilitate social risk-informed care plan adjustments in community health centers (CHCs).

MATERIALS AND METHODS

We identified potential care plan adaptations through systematic reviews of hypertension and diabetes clinical guidelines. The results were used to inform an engagement process in which CHC staff and patients provided feedback on potential adjustments identified in the guideline reviews and on tool form and functions that could help CHC teams implement these suggested adjustments for patients with social risks.

RESULTS

Partners universally prioritized tools for social risk screening and documentation. Additional high-priority content included adjusting medication costs and changing follow-up plans based on reported social risks. Most content recommendations reflected partners' interests in encouraging provider-patient dialogue about care plan adaptations specific to patients' social needs. Partners recommended CDS tool functions such as alerts and shortcuts to facilitate and efficiently document social risk-informed care plan adjustments.

DISCUSSION AND CONCLUSION

CDS tools were designed to support CHC providers and staff to more consistently tailor care based on information about patients' social context and thereby enhance patients' ability to adhere to care plans. While such adjustments occur on an ad hoc basis in many care settings, these are among the first tools designed both to systematize and document these activities.

Association of Health-Related Social Needs With Quality and Utilization Outcomes in a Medicare Advantage Population With Diabetes

Importance

Recent research highlights the association of social determinants of health with health outcomes of patients with type 2 diabetes (T2D).

Objective

To examine associations between health-related social needs (HRSNs) and health care quality and utilization outcomes in a Medicare Advantage population with T2D.

Design, Setting, and Participants

This cross-sectional study used medical and pharmacy claims data from 2019. An HRSN survey was given between October 16, 2019, and February 29, 2020, to Medicare Advantage beneficiaries. Inclusion criteria were diagnosis of T2D, age of 20 to 89 years, continuous Medicare Advantage enrollment in 2019, and response to the HRSN survey. Data were analyzed between June 2021 and January 2022.

Exposures

Enrollment in Medicare Advantage, diagnosis of T2D, and completion of a survey on HRSNs.

Main Outcomes and Measures

Quality outcomes included diabetes medication adherence, statin adherence, completion of a glycated hemoglobin (HbA1c) laboratory test in the past 12 months, and controlled HbA1c. Utilization outcomes included all-cause hospitalization, potentially avoidable hospitalization, emergency department discharge, and readmission.

Results

Of the 21 528 Medicare Advantage beneficiaries with T2D included in the study (mean [SD] age, 71.0 [8.3] years; 55.4% women), most (56.9%) had at least 1 HRSN. Among the population with T2D reporting HRSNs, the most prevalent were financial strain (73.6%), food insecurity (47.5%), and poor housing quality (39.1%). In adjusted models, loneliness (odds ratio [OR], 0.85; 95% CI, 0.73-0.99), lack of transportation (OR, 0.80; 95% CI, 0.69-0.92), utility insecurity (OR, 0.86; 95% CI, 0.76-0.98), and housing insecurity (OR, 0.78; 95% CI, 0.67-0.91) were each associated with lower diabetes medication adherence. Loneliness and lack of transportation were associated with increased emergency visits (marginal effects of 173.0 [95% CI, 74.2-271.9] and 244.6 [95% CI, 150.4-338.9] emergency visits per 1000 beneficiaries for loneliness and transportation, respectively). Food insecurity was the HRSN most consistently associated with higher acute care utilization (marginal effects of 84.6 [95% CI, 19.8-149.4] emergency visits, 30.4 [95% CI, 9.5-51.3] inpatient encounters, and 17.1 [95% CI, 4.7-29.5] avoidable hospitalizations per 1000 beneficiaries).

Conclusions and Relevance

In this cross-sectional study of Medicare Advantage beneficiaries with T2D, some HRSNs were associated with care quality and utilization. The results of the study may be used to direct interventions to the social needs most associated with T2D health outcomes and inform policy decisions at the insurance plan and community level.

Implementation Support for a Social Risk Screening and Referral Process in Community Health Centers

Evidence is needed about how to effectively support health care providers in implementing screening for social risks (adverse social determinants of health) and providing related referrals meant to address identified social risks. This need is greatest in underresourced care settings. The authors tested whether an implementation support intervention (6 months of technical assistance and coaching study clinics through a five-step implementation process) improved adoption of social risk activities in community health centers (CHCs). Thirty-one CHC clinics were block-randomized to six wedges that occurred sequentially. Over the 45-month study period from March 2018 to December 2021, data were collected for 6 or more months preintervention, the 6-month intervention period, and 6 or more months postintervention. The authors calculated clinic-level monthly rates of social risk screening results that were entered at in-person encounters and rates of social risk-related referrals. Secondary analyses measured impacts on diabetes-related outcomes. Intervention impact was assessed by comparing clinic performance based on whether they had versus had not yet received the intervention in the preintervention period compared with the intervention and postintervention periods. In assessing the results, the authors note that five clinics withdrew from the study for various bandwidth-related reasons. Of the remaining 26, a total of 19 fully or partially completed all 5 implementation steps, and 7 fully or partially completed at least the first 3 steps. Social risk screening was 2.45 times (95% confidence interval [CI], 1.32-4.39) higher during the intervention period compared with the preintervention period; this impact was not sustained postintervention (rate ratio, 2.16; 95% CI, 0.64-7.27). No significant difference was seen in social risk referral rates during the intervention or postintervention periods. The intervention was associated with greater blood pressure control among patients with diabetes and lower rates of diabetes biomarker screening postintervention. All results must be interpreted considering that the Covid-19 pandemic began midway through the trial, which affected care delivery generally and patients at CHCs particularly. Finally, the study results show that adaptive implementation support was effective at temporarily increasing social risk screening. It is possible that the intervention did not adequately address barriers to sustained implementation or that 6 months was not long enough to cement this change. Underresourced clinics may struggle to participate in support activities over longer periods without adequate resources, even if lengthier support is needed. As policies start requiring documentation of social risk activities, safety-net clinics may be unable to meet these requirements without adequate financial and coaching/technical support.

Evaluation of an Integrated Intervention to Address Clinical Care and Social Needs Among Patients with Type 2 Diabetes

BACKGROUND

The Providence Diabetes Collective Impact Initiative (DCII) was designed to address the clinical challenges of type 2 diabetes and the social determinants of health (SDoH) challenges that exacerbate disease impact.

OBJECTIVE

We assessed the impact of the DCII, a multifaceted intervention approach to diabetes treatment that employed both clinical and SDoH strategies, on access to medical and social services.

DESIGN

The evaluation employed a cohort design and used an adjusted difference-in-difference model to compare treatment and control groups.

PARTICIPANTS

Our study population consisted of 1220 people (740 treatment, 480 control), aged 18-65 years old with a pre-existing type 2 diabetes diagnosis who visited one of the seven Providence clinics (three treatment and four control) in the tri-county area of Portland, Oregon, between August 2019 and November 2020.

INTERVENTIONS

The DCII threaded together clinical approaches such as outreach, standardized protocols, and diabetes self-management education and SDoH strategies including social needs screening, referral to a community resource desk, and social needs support (e.g., transportation) to create a comprehensive, multi-sector intervention.

MAIN MEASURES

Outcome measures included SDoH screens, diabetes education participation, HbA1c, blood pressure, and virtual and in-person primary care utilization, as well as inpatient and emergency department hospitalization.

KEY RESULTS

Compared to patients at the control clinics, patients at DCII clinics saw an increase in diabetes education (15.5%, p<0.001), were modestly more likely to receive SDoH screening (4.4%, p<0.087), and had an increase in the average number of virtual primary care visits of 0.35 per member, per year (p<0.001). No differences in HbA1c, blood pressure, or hospitalization were observed.

CONCLUSIONS

DCII participation was associated with improvements in diabetes education use, SDoH screening, and some measures of care utilization.

A decade of socioeconomic inequality in type 2 diabetes area-level prevalence: an unshakeable status quo?

AIMS

It is well known that there is a socioeconomic gradient in the prevalence of many chronic diseases, including type 2 diabetes (T2DM). We present a simple assessment of the macro-level association between area socioeconomic disadvantage and the area-level prevalence of T2DM in Danish municipalities and the development in this relationship over the last decade.

METHODS

We used readily available public data on the socioeconomic composition of municipalities and T2DM prevalence to illustrate this association and report the absolute and relative summary measures of socioeconomic inequality over the time period 2008-2018.

RESULTS

The results show a persistent relationship between municipality socioeconomic disadvantage and T2DM prevalence across all analyses, with a modelled gap in T2DM prevalence between the most and least disadvantaged municipalities, the slope index of inequality, of 1.23 [0.97;1.49] in 2018.

CONCLUSIONS

These results may be used to indicate areas with specific needs, to encourage systematic monitoring of socioeconomic gradients in health, and to provide a descriptive backdrop for a discussion of how to tackle these socioeconomic and geographic inequalities, which seem to persist even in the context of the comprehensive welfare systems in Scandinavia.

The National Clinical Care Commission Report to Congress: Leveraging Federal Policies and Programs for Population-Level Diabetes Prevention and Control: Recommendations From the National Clinical Care Commission

The etiology of type 2 diabetes is rooted in a myriad of factors and exposures at individual, community, and societal levels, many of which also affect the control of type 1 and type 2 diabetes. Not only do such factors impact risk and treatment at the time of diagnosis but they also can accumulate biologically from preconception, in utero, and across the life course. These factors include inadequate nutritional quality, poor access to physical activity resources, chronic stress (e.g., adverse childhood experiences, racism, and poverty), and exposures to environmental toxins. The National Clinical Care Commission (NCCC) concluded that the diabetes epidemic cannot be treated solely as a biomedical problem but must also be treated as a societal problem that requires an all-of-government approach. The NCCC determined that it is critical to design, leverage, and coordinate federal policies and programs to foster social and environmental conditions that facilitate the prevention and treatment of diabetes. This article reviews the rationale, scientific evidence base, and content of the NCCC's population-wide recommendations that address food systems; consumption of water over sugar-sweetened beverages; food and beverage labeling; marketing and advertising; workplace, ambient, and built environments; and research. Recommendations relate to specific federal policies, programs, agencies, and departments, including the U.S. Department of Agriculture, the Food and Drug Administration, the Federal Trade Commission, the Department of Housing and Urban Development, the Environmental Protection Agency, and others. These population-level recommendations are transformative. By recommending health-in-all-policies and an equity-based approach to governance, the NCCC Report to Congress has the potential to contribute to meaningful change across the diabetes continuum and beyond. Adopting these recommendations could significantly reduce diabetes incidence, complications, costs, and inequities. Substantial political resolve will be needed to translate recommendations into policy. Engagement by diverse members of the diabetes stakeholder community will be critical to such efforts.

Housing Insecurity Among Patients With Cancer

Social determinants of health are the economic and environmental conditions under which people are born, live, work, and age that affect health. These structural factors underlie many of the long-standing inequities in cancer care and outcomes that vary by geography, socioeconomic status, and race and ethnicity in the United States. Housing insecurity, including lack of safe, affordable, and stable housing, is a key social determinant of health that can influence-and be influenced by-cancer care across the continuum, from prevention to screening, diagnosis, treatment, and survivorship. During 2021, the National Cancer Policy Forum of the National Academies of Science, Engineering, and Medicine sponsored a series of webinars addressing social determinants of health, including food, housing, and transportation insecurity, and their associations with cancer care and patient outcomes. This dissemination commentary summarizes the formal presentations and panel discussions from the webinar devoted to housing insecurity. It provides an overview of housing insecurity and health care across the cancer control continuum, describes health system interventions to minimize the impact of housing insecurity on patients with cancer, and identifies challenges and opportunities for addressing housing insecurity and improving health equity. Systematically identifying and addressing housing insecurity to ensure equitable access to cancer care and reduce health disparities will require ongoing investment at the practice, systems, and broader policy levels.

Equity of referrals to type 2 diabetes rehabilitation in a universal welfare state

Objective

Despite aims of equal access to treatment and care in the Nordic countries, marked socioeconomic inequality in the development of type 2 diabetes (T2D) complications persists. The study purpose was to estimate the associations of individual socioeconomic position and deprivation at the general practitioner (GP) level with referrals to T2D rehabilitation.Research Design and Methods: In 2015-2018, 3390 people affiliated with 432 primary GPs living in the municipality of Copenhagen were identified through registry data as newly diagnosed with T2D. Of these, 656 (19%) individuals were referred to municipal rehabilitation services in 2015-2021. Individual socioeconomic position was measured by education, income, and employment. The Danish Deprivation Index (DADI) was used as a measure of GP-level deprivation.

Results

Patients were more likely to be referred to municipal rehabilitation if they had low vs. high income (hazard ratio (HR) 2.87 [women], 1.64 [men]), were not employed vs. employed (HR 1.95 [women], 1.23 [men]) and were affiliated with GPs with a low vs. very high level of deprivation (HR 7.63 [women], 4.30 [men]). The results suggest that GPs practice proportionate universalism by allocating treatment to lower socioeconomic individuals in likely higher need of care. However, the overall HR for referrals was lower among GPs with more deprived patient populations, indicating unequal treatment of all citizens, which conflicts with the aims of general universal health care. Inequality in rehabilitation healthcare services must be further addressed and investigated to prevent exacerbating health disparities.

Cross-Sectional Associations: Social Risks and Diabetes Care Quality, Outcomes

INTRODUCTION

Social risks (e.g., food/transportation insecurity) can hamper type 2 diabetes mellitus (T2DM) self-management, leading to poor outcomes. To determine the extent to which high-quality care can overcome social risks' health impacts, this study assessed the associations between reported social risks, receipt of guideline-based T2DM care, and T2DM outcomes when care is up to date among community health center patients.

METHODS

A cross-sectional study of adults aged ≥18 years (N=73,484) seen at 186 community health centers, with T2DM and ≥1 year of observation between July 2016 and February 2020. Measures of T2DM care included up-to-date HbA1c, microalbuminuria, low-density lipoprotein screening, and foot examination, and active statin prescription when indicated. Measures of T2DM outcomes among patients with up-to-date care included blood pressure, HbA1c, and low-density lipoprotein control on or within 6‒12 months of an index encounter. Analyses were conducted in 2021.

RESULTS

Individuals reporting transportation or housing insecurity were less likely to have up-to-date low-density lipoprotein screening; no other associations were seen between social risks and clinical care quality. Among individuals with up-to-date care, food insecurity was associated with lower adjusted rates of controlled HbA1c (79% vs 75%, p<0.001), and transportation insecurity was associated with lower rates of controlled HbA1c (79% vs 74%, p=0.005), blood pressure (74% vs 72%, p=0.025), and low-density lipoprotein (61% vs 57%, p=0.009) than among those with no reported need.

CONCLUSIONS

Community health center patients received similar care regardless of the presence of social risks. However, even among those up to date on care, social risks were associated with worse T2DM control. Future research should identify strategies for improving HbA1c control for individuals with social risks.

TRIAL REGISTRATION

This study is registered at www.

CLINICALTRIALS

gov NCT03607617.

Bridge to Health/Puente a la Salud: a pilot randomized trial to address diabetes self-management and social needs among high-risk patients

Social needs contribute to persistent diabetes disparities; thus, it is imperative to address social needs to optimize diabetes management. The purpose of this study was to determine determine the feasibility and acceptability of health system-based social care versus social care + behavioral intervention to address social needs and improve diabetes self-management among patients with type 2 diabetes. Black/African American, Hispanic/Latino, and low-income White patients with recent hemoglobin A1C (A1C) ≥ 8%, and ≥1 social need were recruited from an integrated health system. Patients were randomized to one-of-two 6-month interventions: (a) navigation to resources (NAV) facilitated by a Patient Navigator; or (b) NAV + evidence-based nine-session diabetes self-management support (DSMS) program facilitated by a community health worker (CHW). A1C was extracted from the electronic health record. We successfully recruited 110 eligible patients (54 NAV; 56 NAV + DSMS). During the trial, 78% NAV and 80% NAV + DSMS participants successfully connected to a navigator; 84% NAV + DSMS connected to a CHW. At 6-month follow-up, 33% of NAV and 34% of NAV + DSMS participants had an A1C < 8%. Mean reduction in A1C was clinically significant in NAV (-0.65%) and NAV + DSMS (-0.72%). By follow-up, 89% of NAV and 87% of NAV + DSMS were successfully connected to resources to address at least one need. Findings suggest that it is feasible to implement a health system-based social care intervention, separately or in combination, with a behavioral intervention to improve diabetes management among a high-risk, socially complex patient population. A larger, pragmatic trial is needed to test the comparative effectiveness of each approach on diabetes-related outcomes.

Solutions to Address Inequity in Diabetes Technology Use in Type 1 Diabetes: Results from Multidisciplinary Stakeholder Co-creation Workshops

Background: Racial-ethnic inequity in type 1 diabetes technology use is well documented and contributes to disparities in glycemic and long-term outcomes. However, solutions to address technology inequity remain sparse and lack stakeholder input. Methods: We employed user-centered design principles to conduct workshop sessions with multidisciplinary panels of stakeholders, building off of our prior study highlighting patient-identified barriers and proposed solutions. Stakeholders were convened to review our prior findings and co-create interventions to increase technology use among underserved populations with type 1 diabetes. Stakeholders included type 1 diabetes patients who had recently onboarded to technology; endocrinology and primary care physicians; nurses; diabetes educators; psychologists; and community health workers. Sessions were recorded and analyzed iteratively by multiple coders for common themes. Results: We convened 7 virtual 2-h workshops for 32 stakeholders from 11 states in the United States. Patients and providers confirmed prior published studies highlighting patient barriers and generated new ideas by co-creating solutions. Common themes of proposed interventions included (1) prioritizing more equitable systems of offering technology, (2) using visual and hands-on approaches to increase accessibility of technology and education, (3) including peer and family support systems more, and (4) assisting with insurance navigation and social needs. Discussion: Our study furthers the field by providing stakeholder-endorsed intervention ideas that propose feasible changes at the patient, provider, and system levels to reduce inequity in diabetes technology use in type 1 diabetes. Multidisciplinary stakeholder engagement in disparities research offers unique insight that is impactful and acceptable to the target population.

ICD-10 Z-Code Health-Related Social Needs and Increased Healthcare Utilization

INTRODUCTION

Health-related social needs are known drivers of health and health outcomes, yet work to date to examine health-related social needs using ICD-10 Z-codes remains limited. This study seeks to evaluate the differences in the prevalence of conditions as well as utilization and cost between patients with and without health-related social needs.

METHODS

Using the 2017 Florida State Emergency Department and State Inpatient Databases, this study identified patients with documented health-related social needs using ICD-10 Z-codes. The prevalence ratio was calculated for 14 conditions that are the leading causes of mortality and economic costs. In addition, ratios for the median total number of negative health events and total annual costs between patients with health-related social needs and those without health-related social needs across these conditions were calculated. Data analysis was conducted in 2021.

RESULTS

Of 4,477,772 patients, 46,081 (1.0%) had documented health-related social needs and had 4 times the negative health events and 9.3 times the total annual costs. Trends of increased negative health events and costs were seen across all examined conditions; patients with health-related social needs had 2.5-3.5 times the negative health events and 2-18 times greater total costs. The biggest difference in negative health events was seen in patients with unintentional injuries and depression and psychoses (3.5 times for patients with health-related social needs), whereas the biggest difference in total costs was for unintentional injuries (18.4 times for patients with health-related social needs).

CONCLUSIONS

This study shows the increased prevalence of numerous high-priority conditions as well as increased utilization and costs among patients with documented health-related social needs.

Social Risk Factors and Desire for Assistance Among Patients Receiving Subsidized Health Care Insurance in a US-Based Integrated Delivery System

PURPOSE

Because social conditions such as food insecurity and housing instability shape health outcomes, health systems are increasingly screening for and addressing patients' social risks. This study documented the prevalence of social risks and examined the desire for assistance in addressing those risks in a US-based integrated delivery system.

METHODS

A survey was administered to Kaiser Permanente members on subsidized exchange health insurance plans (2018-2019). The survey included questions about 4 domains of social risks, desire for help, and attitudes. We conducted a descriptive analysis and estimated multivariate modified Poisson regression models.

RESULTS

Of 438 participants, 212 (48%) reported at least 1 social risk factor. Housing instability was the most common (70%) factor reported. Members with social risks reported more discomfort being screened for social risks (14.2% vs 5.4%; P = .002) than those without risks, although 90% of participants believed that health systems should assist in addressing social risks. Among those with 1-2 social risks, however, only 27% desired assistance. Non-Hispanic Black participants who reported a social risk were more than twice as likely to desire assistance compared with non-Hispanic White participants (adjusted relative risk [RR] 2.2; 95% CI, 1.3-3.8).

CONCLUSIONS

Athough most survey participants believed health systems have a role in addressing social risks, a minority of those reporting a risk wanted assistance and reported more discomfort being screened for risk factors than those without risks. Health systems should work to increase the comfort of patients in reporting risks, explore how to successfully assist them when desired, and offer resources to address these risks outside the health care sector.VISUAL ABSTRACT.

Equity in Psychosocial Outcomes and Care for Racial and Ethnic Minorities and Socioeconomically Disadvantaged People With Diabetes

The role of social determinants of health (SDOH) in promoting equity in diabetes prevalence, incidence, and outcomes continues to be documented in the literature. Less attention has focused on disparities in psychosocial aspects of living with diabetes and the role of SDOH in promoting equity in psychosocial outcomes and care. In this review, the authors describe racial/ethnic and socioeconomic disparities in psychosocial aspects of living with diabetes, discuss promising approaches to promote equity in psychosocial care, and provide future research directions.

Joint effects of educational attainment, type 2 diabetes and coexisting morbidity on disability pension: results from a longitudinal, nationwide, register-based study

AIMS/HYPOTHESIS

High prevalence of coexisting morbidity in people with type 2 diabetes highlights the need to include interactions with education and comorbidity in the assessments of societal consequences of type 2 diabetes. The purpose of this study was to estimate the joint effects of education, type 2 diabetes and six frequent comorbidities.

METHODS

Nationwide administrative register data on type 2 diabetes diagnosis, hospital admissions, education and disability pension were grouped at the individual level by means of a unique personal identification number. Included were all people (N = 2,281,599) in the age span of 40-59 years living in Denmark in the period 2005 to 2017, covering a total of 17,754,788 person-years. We used both Cox proportional hazards and Aalen additive hazards models to estimate relative and absolute joint effects of type 2 diabetes, educational attainment and six common comorbidities (CVD, cancer and cerebrovascular, respiratory, musculoskeletal and psychiatric diseases). We decomposed the joint effects of educational level, type 2 diabetes and comorbidities into main effects and the interaction effect, measured as extra cases of disability pension.

RESULTS

Lower level of educational attainment, type 2 diabetes and comorbidities independently contributed to additional granted disability pensions. The joint number of cases of disability pension exceeded the sum of the three exposures, which is explained by a synergistic effect of lower educational level, type 2 diabetes and comorbidity.

CONCLUSIONS/INTERPRETATION

In this population study, the joint effects of type 2 diabetes, lower education and comorbidity were associated with larger than additive rates of disability pension. An integrated approach that takes into account socioeconomic barriers to type 2 diabetes rehabilitation may slow down disease progression and increase the working ability of socially disadvantaged people.

Using Electronic Health Record-Based Clinical Decision Support to Provide Social Risk-Informed Care in Community Health Centers: Protocol for the Design and Assessment of a Clinical Decision Support Tool

Background

Consistent and compelling evidence demonstrates that social and economic adversity has an impact on health outcomes. In response, many health care professional organizations recommend screening patients for experiences of social and economic adversity or social risks—for example, food, housing, and transportation insecurity—in the context of care. Guidance on how health care providers can act on documented social risk data to improve health outcomes is nascent. A strategy recommended by the National Academy of Medicine involves using social risk data to adapt care plans in ways that accommodate patients’ social risks.

Objective

This study’s aims are to develop electronic health record (EHR)–based clinical decision support (CDS) tools that suggest social risk–informed care plan adaptations for patients with diabetes or hypertension, assess tool adoption and its impact on selected clinical quality measures in community health centers, and examine perceptions of tool usability and impact on care quality.

Methods

A systematic scoping review and several stakeholder activities will be conducted to inform development of the CDS tools. The tools will be pilot-tested to obtain user input, and their content and form will be revised based on this input. A randomized quasi-experimental design will then be used to assess the impact of the revised tools. Eligible clinics will be randomized to a control group or potential intervention group; clinics will be recruited from the potential intervention group in random order until 6 are enrolled in the study. Intervention clinics will have access to the CDS tools in their EHR, will receive minimal implementation support, and will be followed for 18 months to evaluate tool adoption and the impact of tool use on patient blood pressure and glucose control.

Results

This study was funded in January 2020 by the National Institute on Minority Health and Health Disparities of the National Institutes of Health. Formative activities will take place from April 2020 to July 2021, the CDS tools will be developed between May 2021 and November 2022, the pilot study will be conducted from August 2021 to July 2022, and the main trial will occur from December 2022 to May 2024. Study data will be analyzed, and the results will be disseminated in 2024.

Conclusions

Patients’ social risk information must be presented to care teams in a way that facilitates social risk–informed care. To our knowledge, this study is the first to develop and test EHR-embedded CDS tools designed to support the provision of social risk–informed care. The study results will add a needed understanding of how to use social risk data to improve health outcomes and reduce disparities.

International Registered Report Identifier (IRRID)

PRR1-10.2196/31733

Update on Approaches to Improve Delivery and Quality of Care for People with Diabetes

To translate improvements in diabetes management into improved outcomes, it is essential to improve care delivery. To help guide clinicians and health organizations in their efforts to achieve these improvements, this article briefly describes key components underpinning effective diabetes care and six categories of innovations in approaches to improve diabetes care delivery: (1) team-based clinical care; (2) cross-specialty collaboration/integration; (3) virtual clinical care/telehealth; (4) use of community health workers (CHWs) and trained peers to provide pro-active self-management support; (5) incorporating screening for and addressing social determinants of health into clinical practice; and (6) cross-sectoral clinic/community partnerships.

Bridge to Health/ Puente a la Salud: Rationale and design of a pilot feasibility randomized trial to address diabetes self-management and unmet basic needs among racial/ethnic minority and low-income patients

Introduction

Racial/ethnic and socioeconomic disparities in diabetes prevalence and management persist. Unmet basic needs such as food insecurity and unstable housing interfere with optimal diabetes self-management. Bridge to Health/Puente a la Salud is a randomized pilot trial designed to examine the feasibility of testing the effectiveness of addressing unmet basic needs via navigation services versus navigation plus diabetes self-management support (DSMS) on improving diabetes-related outcomes among racial/ethnic minority and low-income patients with uncontrolled diabetes.

Material and methods

We recruited and randomized 110 African American, Hispanic, and Medicaid patients (any race/ethnicity) with diabetes and recent hemoglobin A1C ≥ 8% to one of two 6-month interventions: 1) Navigation only; or 2) Navigation + DSMS. In both arms, practice-embedded patient navigators help participants navigate social services and community-based resources to address unmet basic needs. In Navigation + DSMS, participants are also assigned to a community health worker (CHW) embedded in a local community-based organization who provides additional navigation support and delivers DSMS. A1C and unmet basic needs data are collected via routine lab and survey, respectively, at baseline and 6-month follow-up. Qualitative interviews with participants, health system leaders, CHWs, and patient navigators are conducted to explore intervention acceptability and determinants of implementation in a health care setting.

Discussion

Findings from this pilot feasibility study will enhance understanding about acceptability, preliminary clinical effectiveness, and facilitators and barriers to implementation of the Navigation only and Navigation + DSMS interventions and inform refinements of the overall study design for the larger, randomized clinical trial.

Prevalence of Unmet Basic Needs and Association with Diabetes Control and Care Utilization Among Insured Persons with Diabetes

Unmet basic needs (eg, food insecurity, inadequate housing) are major barriers to diabetes self-management. The purpose of this study was to identify the prevalence of unmet basic needs and examine the association with diabetes control and care utilization among insured persons with diabetes. A total of 4043 adult patients with diabetes were screened for unmet basic needs using Your Current Life Situation, a screener for unmet basic needs, during a clinical encounter or as an online survey, during the study period (January 1, 2016-August 31, 2017). Hemoglobin A1c and care utilization (outpatient, emergency department [ED], hospitalization, diabetes-related prescription refills) were extracted from the electronic health record 12 months prior to screening. The authors compared patients with unmet basic needs to those with no needs on poor diabetes control (ie, A1c ≥8%) and care utilization using multivariable regression models. Of the 4043 patients screened, 25% endorsed ≥1 unmet basic need. In adjusted analyses, the presence of unmet basic needs was associated with an increased likelihood of having an A1c ≥8% (OR = 1.77; 95% CI 1.47, 2.13), more outpatient visits (incidence rate ratio [IRR] = 1.3; 1.2, 1.4), more ED visits (IRR = 2.3; 2.0, 2.6), more hospitalizations (IRR = 1.8; 1.5, 2.2), and more delays in refilling diabetes medication (IRR = 1.21; 1.13, 1.30). Findings indicate that unmet basic needs are highly prevalent, even among an insured patient population, and are associated with poor diabetes-related clinical outcomes and excess utilization. Future studies to determine best strategies to integrate this information into treatment planning are warranted.

Comparison of Community-Level and Patient-Level Social Risk Data in a Network of Community Health Centers

IMPORTANCE

Responding to the substantial research on the relationship between social risk factors and health, enthusiasm has grown around social risk screening in health care settings, and numerous US health systems are experimenting with social risk screening initiatives. In the absence of standard social risk screening recommendations, some health systems are exploring using publicly available community-level data to identify patients who live in the most vulnerable communities as a way to characterize patient social and economic contexts, identify patients with potential social risks, and/or to target social risk screening efforts.

OBJECTIVE

To explore the utility of community-level data for accurately identifying patients with social risks by comparing the social deprivation index score for the census tract where a patient lives with patient-level social risk screening data.

DESIGN, SETTING, AND PARTICIPANTS

Cross-sectional study using patient-level social risk screening data from the electronic health records of a national network of community health centers between June 24, 2016, and November 15, 2018, linked to geocoded community-level data from publicly available sources. Eligible patients were those with a recorded response to social risk screening questions about food, housing, and/or financial resource strain, and a valid address of sufficient quality for geocoding.

EXPOSURES

Social risk screening documented in the electronic health record.

MAIN OUTCOMES AND MEASURES

Community-level social risk was assessed using census tract-level social deprivation index score stratified by quartile. Patient-level social risks were identified using food insecurity, housing insecurity, and financial resource strain screening responses.

RESULTS

The final study sample included 36 578 patients from 13 US states; 22 113 (60.5%) received public insurance, 21 181 (57.9%) were female, 17 578 (48.1%) were White, and 10 918 (29.8%) were Black. Although 6516 (60.0%) of those with at least 1 social risk factor were in the most deprived quartile of census tracts, patients with social risk factors lived in all census tracts. Overall, the accuracy of the community-level data for identifying patients with and without social risks was 48.0%.

CONCLUSIONS AND RELEVANCE

Although there is overlap, patient-level and community-level approaches for assessing patient social risks are not equivalent. Using community-level data to guide patient-level activities may mean that some patients who could benefit from targeted interventions or care adjustments would not be identified.

Does the effect of lifestyle intervention for individuals with diabetes vary by food insecurity status? A preplanned subgroup analysis of the REAL HEALTH randomized clinical trial

INTRODUCTION

We aimed to test the effectiveness of a lifestyle intervention (LI) for individuals with food insecurity and type 2 diabetes.

RESEARCH DESIGN AND METHODS

Adults with type 2 diabetes, body mass index ≥25 kg/m2 (or ≥23 kg/m2 if Asian), hemoglobin A1c of 6.5%-11.5% (48-97 mmol/mol) and who were willing to lose 5%-7% bodyweight were enrolled in REAL HEALTH-Diabetes. This practice-based randomized clinical trial compared LI (delivered inperson or by telephone) with medical nutrition therapy (MNT) on weight loss at 6 and 12 months. Two or more affirmative responses on the six-item US Department of Agriculture Food Security Survey Module indicated food insecurity. In this prespecified subgroup analysis, we tested using linear mixed effects models whether the intervention effect varied by food security status.

RESULTS

Of 208 participants, 13% were food insecure. Those with food insecurity were more likely to be racial/ethnic minorities (p<0.001) and have lower education (p<0.001). LI, versus MNT, led to greater weight loss at 6 months (5.1% lost vs 1.1% lost; p<0.0001) and 12 months (4.7% lost vs 2.0% lost; p=0.0005). The intervention effect was similar regardless of food security status (5.1% bodyweight lost vs 1.1% in food secure participants and 5.1% bodyweight lost vs 1.3% in food insecure participants at 6 months; 4.7% bodyweight lost vs 2.1% in food secure participants and 4.5% bodyweight lost vs 0.9% in food insecure participants at 12 months; p for interaction=0.99).

CONCLUSIONS

The REAL HEALTH-Diabetes lifestyle intervention led to meaningful weight loss for individuals with food insecurity and type 2 diabetes.

TRIAL REGISTRATION NUMBER

NCT02320253.

"Not Alone Anymore": The Experiences of Adults With Diabetes in New York's Medicaid Health Home Program

BACKGROUND

New York State Medicaid's Health Home program is an example of a natural experiment that could affect individuals with diabetes. While evaluations of interventions such as the Health Home program are generally based solely on clinical and administrative data and rarely examine patients' experience, patients may add to the understanding of the intervention's implementation and mechanisms of impact.

OBJECTIVE

The objective of this study was to qualitatively examine the health and nonmedical challenges faced by Medicaid-insured patients with diabetes and their experiences with the services provided by New York's Health Homes to address these challenges.

RESEARCH DESIGN

We performed 10 focus groups and 23 individual interviews using a guide developed in collaboration with a stakeholder board. We performed a thematic analysis to identify cross-cutting themes.

SUBJECTS

A total of 63 Medicaid-insured individuals with diabetes, 31 of whom were enrolled in New York's Health Home program.

RESULTS

While participants were not generally familiar with the term "Health Home," they described and appreciated services consistent with Health Home enrollment delivered by care managers. Services addressed challenges in access to care, especially by facilitating and reminding participants about appointments, and nonmedical needs, such as transportation, housing, and help at home. Participants valued their personal relationships with care managers and the psychosocial support they provided.

CONCLUSIONS

From the perspective of its enrollees, the Health Home program primarily addressed access to care, but also addressed material and psychosocial needs. These findings have implications for Health Home entities and for research assessing their impact.

Diabetes Management in Community Health Centers: a Review of Policies and Programs

PURPOSE OF REVIEW

Community health centers (CHCs) provide care to millions of vulnerable patients in the USA, including a disproportionate number with diabetes. Policies affecting diabetes management in CHCs therefore have broad implications for clinical practice and patient outcomes nationwide. We describe prior policies that have influenced diabetes management in CHCs, discuss current policies and programs, as well as present emerging innovations and future directions for diabetes care in this setting.

RECENT FINDINGS

Domains for current diabetes policies and programs in CHCs include coverage requirements, quality reporting and incentives, prescription discounts, healthy behavior incentives, and team-based care. Policies in these areas affect the management of diabetes at multiple levels, from organizations that support CHCs to individual health centers, and the providers and patients based there. Several domains of interrelated policies and programs impact CHC diabetes management at multiple levels. Stakeholders' understanding of these policies and programs may identify opportunities to improve diabetes care.

Study protocol: CareAvenue program to improve unmet social risk factors and diabetes outcomes- A randomized controlled trial

Despite the burdens costs can place on adults with diabetes, few evidence-based, scalable interventions have been identified that address prevalent health-related financial burdens and unmet social risk factors that serve as major obstacles to effective diabetes management. In this study, we will test the effectiveness of CareAvenue - an automated e-health tool that screens for unmet social risk factors and informs and activates individuals to take steps to connect to resources and engage in self-care. We will determine the effectiveness of CareAvenue relative to standard care with respect to improving glycemic control and patient-centered outcomes such as cost-related non-adherence (CRN) behaviors and perceived financial burden. We will also examine the role of patient risk factors (moderators) and behavioral factors (mediators) on the effectiveness of CareAvenue in improving outcomes. We will recruit 720 patients in a large health system with uncontrolled Type 1 diabetes mellitus (T1DM) or Type 2 diabetes mellitus (T2DM) who engage in CRN or perceive financial burden. Participants will be randomized to one of two arms: 1) receipt of a 15-20 min web-based program with routine follow-up (CareAvenue); or 2) receipt of contact information for existing health system assistance services. Outcomes will be assessed at baseline and 6- and 12-month follow-up. Clinical Trial Registration: ClinicalTrials.gov ID NCT03950973, May 2019.

More Than Health Care: The Value of Addressing Health, Education, and Social Service Needs Together Through Community Health Centers

Research on social determinants of health shows that factors outside of medical care including environment, education, and income also affect health. Some community health centers seek to address these by providing additional nonmedical services. Community health centers can find it difficult to justify these costs when the benefit is unclear. This review highlights studies on services like those the community health center Mary's Center provides through its Social Change Model, offering health, education, and social services in the Washington, District of Columbia metropolitan area. The review finds that most studies report positive results, though more research is needed, especially in the area of social services.