Addressing Social Needs
Addressing Social Needs
Better Birth Outcomes and Experiences Through Technology, Education and Reporting (BETTER)
In 2016, the U.S. ranked 29th among the 35 Organisation for Economic Co-operation and Development (OECD) countries in the area of infant mortality, with 5.9 infant deaths per 1,000. Further, while the infant mortality rate (IMR) average across the nation for white babies is five deaths per 1,000, this rate is 11 per 1,000 for black babies. The BETTER project is part of an American Heart Association (AHA) effort to build a health equity research network to identify solutions that can improve outcomes and reduce health disparities experienced by pregnant people and infants of color or those who are born into poverty.
Implementing Scalable, PAtient-centered Team-based Care for Adults with Type 2 Diabetes and Health Disparities (iPATH)
The iPATH project brings together research teams from The Ohio State University, Stanford, Harvard, and Impactivo LLC for practice-relevant work related to diabetes care in federally qualified health centers. FQHCs serve 1 in 7 members of racial/ethnic minority groups in the U.S. and see a greater prevalence of diabetes, allowing them to serve as a venue for innovating in equity-focused diabetes care. The iPATH project will endeavor to refine and implement an approach to practice transformation that was conceived to support FQHCs’ goal to achieve National Committee for Quality Assurance recognition as patient-centered medical homes. A pilot demonstrated significant decreases—with an average reduction of 31%—in poorly controlled diabetes (A1c>9%) among patients at seven clinics affiliated with an FQHC in Puerto Rico in 2017-2020. For more information, visit https://rethinkingclinicaltrials.org/demonstration-projects/ipath/.
Linking education, produce provision, and community referrals to improve diabetes care (LINK)
People with food insecurity may experience other non-medical, health-related social needs (such as transportation barriers, housing instability, and job insecurity) that decrease their ability to attain glucose control and that affect other health outcomes. Leveraging existing programs and relationships, LINK will test the combined effects of several interventions – a food referral program, a diabetes education intervention, and referrals to address other social needs – on hemoglobin A1c levels in a population of racially and ethnically diverse participants with food insecurity and uncontrolled Type 2 diabetes. Innovative solutions are warranted to combat the long-term sequelae of uncontrolled T2D combined with food insecurity that contribute to the two-fold higher all-cause mortality in T2D that disproportionality impacts people experiencing lower socioeconomic status and who are part of racial and ethnic minority populations.
SUSTAIN: Promoting sustained behavior change and nutrition security in Medicaid-enrolled individuals with Stage 2 Cardiovascular-Kidney-Metabolic Syndrome
SUSTAIN is a health system-to-community intervention intended to improve nutrition security and cardiovascular health through a Food is Medicine (FIM) intervention for people who are enrolled in Medicaid and have Stage 2 cardiovascular-kidney-metabolic syndrome (CKMS). People in this population are disproportionately impacted by poor dietary intake, leading to a high prevalence of CKMS compared to privately insured populations. SUSTAIN hypothesizes that a comprehensive FIM intervention – including medically tailored groceries, intensive behavioral nutrition therapy and addressing social needs – will improve nutrition security and Life’s Essential 8 (LE8) measures.
An Evaluation of the Mid-Ohio Farmacy Project on Hypertension and Related Comorbidities
Using a mixed-methods design, this study seeks to build a multi-stakeholder understanding of the patient, provider, and community factors that support the implementation and use of the Mid-Ohio Farmacy, a primary care clinic-based food referral program, for patients with hypertension, diabetes, and obesity.