National Healthcare Quality and Disparities Report
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Search All Research Studies
Topics
- Access to Care (1)
- Ambulatory Care and Surgery (1)
- Care Management (1)
- Children/Adolescents (2)
- Chronic Conditions (2)
- Community-Based Practice (8)
- Diabetes (1)
- Electronic Health Records (EHRs) (2)
- Emergency Department (1)
- Emergency Medical Services (EMS) (1)
- Evidence-Based Practice (3)
- Guidelines (3)
- Healthcare Delivery (5)
- Healthcare Utilization (1)
- Health Information Technology (HIT) (3)
- Health Insurance (1)
- Health Services Research (HSR) (1)
- Implementation (2)
- Low-Income (2)
- Medicaid (2)
- Organizational Change (1)
- Patient-Centered Healthcare (1)
- Practice Improvement (1)
- Prevention (2)
- (-) Primary Care (23)
- Provider (1)
- Provider: Clinician (2)
- Public Health (1)
- Research Methodologies (2)
- Risk (2)
- Screening (7)
- (-) Social Determinants of Health (23)
- Teams (1)
- U.S. Preventive Services Task Force (USPSTF) (3)
- Urban Health (4)
- Vulnerable Populations (2)
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AHRQ Research Studies
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Research Studies is a compilation of published research articles funded by AHRQ or authored by AHRQ researchers.
Results
1 to 23 of 23 Research Studies DisplayedAckerman SL, Wing H, Acves B
“We were trying to do quality versus quantity”: challenges and opportunities at the intersection of standardized and personalized social care in community health centers.
The purpose of this study was to explore activities to incorporate social risk programs into community health centers (CHCs) providing primary care services in Oregon. CHCs took part in either one or both of two large programs with the goal of incorporating standardized social risk screening and referral processes. The researchers conducted 42 semi-structured interviews with clinicians, managers and staff at 12 clinics affiliated with five CHCs to understand implementation procedures and challenges to those procedures. Thematic analysis utilized the Normalization Process Theory (NPT) to discover the dynamic, interactional nature of activities to integrate a complex sociotechnical intervention. The study found that standardized social care was expected to correspond well with institutional commitments and priorities. However, challenges maintaining support among staff was encountered, affected by competing priorities, staff turnover, and uncertainties about roles and responsibilities. The new tools were frequently altered or abandoned to retain the advantages of existing social care practices. Across clinics, the association between standardized procedures and existing social care activities, had a key role in patterns of adoption, non-adoption and adaptation, with standardized tools frequently experienced as undermining more relational, team-based social care.
AHRQ-funded; HS026435.
Citation: Ackerman SL, Wing H, Acves B .
“We were trying to do quality versus quantity”: challenges and opportunities at the intersection of standardized and personalized social care in community health centers.
SSM Qual Res Health 2023 Jun; 3:100267. doi: 10.1016/j.ssmqr.2023.100267..
Keywords: Community-Based Practice, Social Determinants of Health, Primary Care
Harle CA, Wu W, Vest JR
Accuracy of electronic health record food insecurity, housing instability, and financial strain screening in adult primary care.
The objective of this study was to assess the accuracy of electronic health record–based multidomain screening questionnaires on social risk factors. Researchers used single-domain questionnaires on individual factors such as food insecurity, housing instability, and financial strain as external standards.
AHRQ-funded; HS028636.
Citation: Harle CA, Wu W, Vest JR .
Accuracy of electronic health record food insecurity, housing instability, and financial strain screening in adult primary care.
JAMA 2023 Feb 7; 329(5):423-24. doi: 10.1001/jama.2022.23631..
Keywords: Electronic Health Records (EHRs), Health Information Technology (HIT), Primary Care, Screening, Social Determinants of Health
Beidler LB, Razon N, Lang H
"More than just giving them a piece of paper": interviews with primary care on social needs referrals to community-based organizations.
The purpose of this qualitative study was to describe primary care practice’s referrals to community-based organizations. The researchers utilized semi-structured interviews with 50 healthcare administrators in charge of social care efforts within their organization. Fifty diverse United States healthcare organizations and agencies were included. The study found that social needs referrals were an essential element of administrator’s social care activities. Administrators described the optimal referral program as one which places limited burden on care teams, provides patients with customized referrals, and facilitates closed-loop referrals. The researchers identified three key challenges organizations encounter when trying to implement the optimal referrals program: 1) developing and maintaining resources lists; 2) aligning referrals with patient needs; and 3) measuring the efficacy of referrals. Administrators The study concluded that primary care practice referrals to community-based organizations were used to improve patients' social conditions, but administrators report challenges providing customized and current information to their patients.
AHRQ-funded; HS024075.
Citation: Beidler LB, Razon N, Lang H .
"More than just giving them a piece of paper": interviews with primary care on social needs referrals to community-based organizations.
J Gen Intern Med 2022 Dec;37(16):4160-67. doi: 10.1007/s11606-022-07531-3..
Keywords: Primary Care, Social Determinants of Health, Community-Based Practice, Healthcare Delivery
Fraze TK, Beidler LB, Gottlieb LM
A missed opportunity? How health care organizations engage primary care clinicians in formal social care efforts.
The purpose of this study was to explore how health care organizations include clinicians in formal social care efforts. Administrators of 29 health care organizations participated in 33 semi-structured interviews in 2019. Administrators were hesitant to increase primary care providers' responsibilities with social care activities, but believed clinicians could engage in social care programs in 4 ways: 1) Strengthen relationships with patients by discussing social risks; 2) adjust follow-up clinical care plans based on social risks; 3) adapt prescriptions based on social risks; and (4) refer patients to other care team members who can directly assist with social risks.
AHRQ-funded; HS024075.
Citation: Fraze TK, Beidler LB, Gottlieb LM .
A missed opportunity? How health care organizations engage primary care clinicians in formal social care efforts.
Popul Health Manag 2022 Aug;25(4):509-16. doi: 10.1089/pop.2021.0306..
Keywords: Primary Care, Provider: Clinician, Social Determinants of Health
Heller CG, Rehm CD, Parsons AH
The association between social needs and chronic conditions in a large, urban primary care population.
This study sought to understand the association between social needs and chronic health conditions using a screening tool and clinical data from Electronic Health Records. From April 2018 to December 2019, 33,550 adult patients completed a 10-item social needs screening tool during primary visits in Bronx and Westchester Counties, NY. A positive, cumulative association between social needs and each of the eight outcomes asked about was found. The relationship was strongest for elevated PHQ-2 (depression screening), alcohol/drug use disorder, and smoking. Those with 3 or greater social needs were 3.9 times more likely to have an elevated PHQ-2 than those without needs. Healthcare transportation challenges was associated with each condition and was the most strongly associated need with half of conditions in the fully-adjusted models. Examples included those with an alcohol/drug use disorder (84% more likely), and smokers (41% more likely).
AHRQ-funded; HS026396.
Citation: Heller CG, Rehm CD, Parsons AH .
The association between social needs and chronic conditions in a large, urban primary care population.
Prev Med 2021 Dec;153:106752. doi: 10.1016/j.ypmed.2021.106752..
Keywords: Chronic Conditions, Urban Health, Primary Care, Low-Income, Social Determinants of Health, Screening
Fraze TK, Beidler LB, Fichtenberg C
Resource brokering: efforts to assist patients with housing, transportation, and economic needs in primary care settings.
This study reviewed how 29 diverse health care organizations assisted patients with housing, transportation, and economic needs in primary care settings. Semistructured interviews were conducted with leaders and frontline staff. Organizations used case management programs to assist patients with social needs through referrals to community-based organizations (CBOs) and regular follow-up. About one-half incorporated care into established case management programs, and the remaining described standalone programs. While all organizations referred patients to CBOs, some also provided more intense services such as assistance in completing patients’ applications for services or conducting home visits. Challenges described by the organizations include: 1) effectively engaging CBOs; 2) obtaining buy-in from clinical staff; 3) considering patients' perspectives; and 4) ensuring program sustainability.
AHRQ-funded; HS024075.
Citation: Fraze TK, Beidler LB, Fichtenberg C .
Resource brokering: efforts to assist patients with housing, transportation, and economic needs in primary care settings.
Ann Fam Med 2021 Nov-Dec;19(6):507-14. doi: 10.1370/afm.2739..
Keywords: Social Determinants of Health, Primary Care, Care Management
Davidson KW, Krist AH, Tseng CW
AHRQ Author: Mills J, Borsky A
Incorporation of social risk in US Preventive Services Task Force Recommendations and identification of key challenges for primary care.
The authors assessed how social risks have been considered in USPSTF recommendation statements and identified current gaps in evidence needed to expand the systematic inclusion of social risks in future recommendations. They concluded that their report serves as a benchmark and foundation for ongoing work to advance the goal of ensuring that health equity and social risks are incorporated into USPSTF methods and recommendations.
AHRQ-authored.
Citation: Davidson KW, Krist AH, Tseng CW .
Incorporation of social risk in US Preventive Services Task Force Recommendations and identification of key challenges for primary care.
JAMA 2021 Oct 12;326(14):1410-15. doi: 10.1001/jama.2021.12833..
Keywords: U.S. Preventive Services Task Force (USPSTF), Primary Care, Social Determinants of Health, Risk, Evidence-Based Practice, Research Methodologies, Guidelines
Chambers EC, McAuliff KE, Heller CG
Toward understanding social needs among primary care patients with uncontrolled diabetes.
This study examined the relationship between unmet social needs and diabetes among a predominantly Black and Hispanic patient population in a large urban hospital system in Bronx, New York. A total of 5846 patients with diabetes seen at a primary care visit between April 2018 and December 2019 were included and completed a social needs screener. Twenty-two percent of the patient sample had at least 1 unmet social need, with the most prevalent unmet needs being housing issues, food insecurity, and lack of healthcare transportation. Patients with more unmet needs had a greater likelihood of uncontrolled diabetes, with lack of healthcare transportation and food insecurity having the greatest likelihood.
AHRQ-funded; HS026396.
Citation: Chambers EC, McAuliff KE, Heller CG .
Toward understanding social needs among primary care patients with uncontrolled diabetes.
J Prim Care Community Health 2021 Jan-Dec;12:2150132720985044. doi: 10.1177/2150132720985044..
Keywords: Diabetes, Chronic Conditions, Primary Care, Vulnerable Populations, Social Determinants of Health
Davidson KW, Kemper AR, Doubeni CA
AHRQ Author: Mills J, Borsky A
Developing primary care-based recommendations for social determinants of health: methods of the U.S. Preventive Services Task Force.
This article highlights social determinants already included in USPSTF recommendations and proposes a process by which others may be considered for primary care preventive recommendations. By reviewing the evidence on the effects of screening and interventions on social determinants relevant to primary care, the USPSTF will continue to be able to provide recommendations on clinical preventive services to improve the health of all Americans.
AHRQ-authored.
Citation: Davidson KW, Kemper AR, Doubeni CA .
Developing primary care-based recommendations for social determinants of health: methods of the U.S. Preventive Services Task Force.
Ann Intern Med 2020 Sep 15;173(6):461-67. doi: 10.7326/m20-0730..
Keywords: U.S. Preventive Services Task Force (USPSTF), Primary Care, Social Determinants of Health, Evidence-Based Practice, Guidelines, Screening, Prevention
Fiori KP, Heller CG, Rehm CD
Unmet social needs and no-show visits in primary care in a US Northeastern urban health system, 2018-2019.
This study used results from a 10-item social needs screener conducted across 19 primary care practices in Bronx County, New York to determine reasons for no-show appointments between April 2018 and July 2019. They examined the association between unmet needs and a 2-year history of missed appointments from 41,637 patients. Overall, the no-show appointment rate was 26.6%. Patients with 1 or more unmet social needs had a significantly higher no-show proportion (31.5%) than those without (26.3%). The strongest association with no-shows was with transportation problems.
AHRQ-funded; HS026396.
Citation: Fiori KP, Heller CG, Rehm CD .
Unmet social needs and no-show visits in primary care in a US Northeastern urban health system, 2018-2019.
Am J Public Health 2020 Jul;110(S2):S242-s50. doi: 10.2105/ajph.2020.305717..
Keywords: Urban Health, Primary Care, Access to Care, Social Determinants of Health
Fiori KP, Rehm CD, Sanderson D
Integrating social needs screening and community health workers in primary care: the community linkage to care program.
This study used logistic regression to identify factors associated with successful social service uptake in an urban pediatric practice. Out of 4948 households screened for social needs from December 2017 to November 2018, 20% self-reported at least one factor. Only 43% of the 287 households with unmet needs reported social service uptake. Greater than 4 outreach encounters were significantly associated with successful referrals. This study suggests the need for additional research and an opportunity for further program optimization.
AHRQ-funded; HS026396.
Citation: Fiori KP, Rehm CD, Sanderson D .
Integrating social needs screening and community health workers in primary care: the community linkage to care program.
Clin Pediatr 2020 Jun;59(6):547-56. doi: 10.1177/0009922820908589..
Keywords: Children/Adolescents, Community-Based Practice, Primary Care, Social Determinants of Health, Implementation, Low-Income
Cohen DJ, Wyte-Lake T, Dorr DA
Unmet information needs of clinical teams delivering care to complex patients and design strategies to address those needs.
The authors sought to identify the unmet information needs of clinical teams delivering care to patients with complex medical, social, and economic needs, and to propose principles for redesigning electronic health records (EHR) to address these needs. They concluded that developing EHR tools that are simple, accessible, easy to use, and able to be updated by a range of professionals is critical. They recommended that the identified information needs and design principles inform developers and implementers working in community health centers and other settings where complex patients receive care.
AHRQ-funded; HS023324.
Citation: Cohen DJ, Wyte-Lake T, Dorr DA .
Unmet information needs of clinical teams delivering care to complex patients and design strategies to address those needs.
J Am Med Inform Assoc 2020 May;27(5):690-99. doi: 10.1093/jamia/ocaa010..
Keywords: Healthcare Delivery, Teams, Electronic Health Records (EHRs), Health Information Technology (HIT), Social Determinants of Health, Community-Based Practice, Primary Care
Heller CG, Parsons AS, Chambers EC
Social risks among primary care patients in a large urban health system.
The objective of this study was to understand the variability in the number and types of social risks overall and in population subgroups among primary care patients routinely screened in a large urban health system. Participants across nineteen ambulatory sites in the Bronx, New York, completed a 10-item screener. Findings showed that there were important differences in the prevalence of overall and individual social risks by subgroup. These findings should be considered to inform clinical care and social risk screening and interventions.
AHRQ-funded; HS026396.
Citation: Heller CG, Parsons AS, Chambers EC .
Social risks among primary care patients in a large urban health system.
Am J Prev Med 2020 Apr;58(4):514-25. doi: 10.1016/j.amepre.2019.11.011..
Keywords: Social Determinants of Health, Primary Care, Urban Health, Risk, Vulnerable Populations
Kaufman A, Dickinson WP, Fagnan LJ
The role of health extension in practice transformation and community health improvement: lessons from 5 case studies.
The states of New Mexico, Oklahoma, Oregon, Colorado, and Washington stand out in stretching the boundaries of health extension; their stories reveal lessons learned regarding the successes and challenges. All states saw the need for long-term, sustained fundraising beyond grants in an environment expecting a short-term return on investment, and they were challenged operating in a shifting health system landscape where the creativity and personal relationships built with small primary care practices was hindered when these practices were purchased by larger health delivery systems.
AHRQ-funded; HS020890; HS020972; HS23904; HS023908.
Citation: Kaufman A, Dickinson WP, Fagnan LJ .
The role of health extension in practice transformation and community health improvement: lessons from 5 case studies.
Ann Fam Med 2019 Aug 12;17(Suppl 1):S67-s72. doi: 10.1370/afm.2409..
Keywords: Community-Based Practice, Health Services Research (HSR), Healthcare Delivery, Organizational Change, Primary Care, Social Determinants of Health, Practice Improvement
Krist AH, Davidson KW, Ngo-Metzger Q
AHRQ Author: Ngo-Metzger Q
What evidence do we need before recommending routine screening for social determinants of health?
This editorial, co-written by two members of the U.S. Preventive Services Task Force (USPSTF), and a member of the Agency for Healthcare Research and Quality (AHRQ) discusses the need to determine if social determinants of health (SDOH) should be discussed during a primary care visit. At the present time only 2 USPSTF recommendations are social determinants (intimate partner violence, elder abuse, and abuse of vulnerable adults; and child maltreatment). However, there are recommendations for nine health behaviors and three mental health behaviors that are included in SDOH. There is an absence of evidence of benefit for routine screening for many of the social determinants, and the USPSTF is currently conducting an evaluation to understand the state of screening for SDOH.
AHRQ-authored.
Citation: Krist AH, Davidson KW, Ngo-Metzger Q .
What evidence do we need before recommending routine screening for social determinants of health?
Am Fam Physician 2019 May 15;99(10):602-05..
Keywords: Evidence-Based Practice, Guidelines, Primary Care, Screening, Social Determinants of Health, U.S. Preventive Services Task Force (USPSTF)
Fiori K, Patel M, Sanderson D
From policy statement to practice: integrating social needs screening and referral assistance with community health workers in an urban academic health center.
The authors described their experience implementing a novel social needs screening program at an academic pediatric clinic. They found that, on average, 76% of providers had their patients screened on more than half of eligible well-child visits. Their experience suggested that screening for social needs at well-child visits is feasible as part of routine primary care. They recommended that success would best be achieved by leveraging resources, obtaining provider buy-in, and defining program components to sustain activities.
AHRQ-funded; HS026396.
Citation: Fiori K, Patel M, Sanderson D .
From policy statement to practice: integrating social needs screening and referral assistance with community health workers in an urban academic health center.
J Prim Care Community Health 2019 Jan-Dec;10:2150132719899207. doi: 10.1177/2150132719899207..
Keywords: Children/Adolescents, Community-Based Practice, Healthcare Delivery, Implementation, Screening, Social Determinants of Health, Urban Health, Workflow, Primary Care
Herrera CN, Brochier A, Pellicer M
Implementing social determinants of health screening at community health centers: clinician and staff perspectives.
Screening for social determinants of health (SDOH) during primary care office visits is recommended by pediatric and internal medicine professional guidelines. Less is known about how SDOH screening and service referral can be successfully integrated into clinical practice. SDOH screening and referral care models can help support the mission of community health centers by identifying unmet material needs. Additional support for SDOH models might include piloting the SDOH screening model workflow and formalizing the workflow before implementation, including the specific roles for clinicians, staff, and patient navigators.
AHRQ-funded; HS022242.
Citation: Herrera CN, Brochier A, Pellicer M .
Implementing social determinants of health screening at community health centers: clinician and staff perspectives.
J Prim Care Community Health 2019 Jan-Dec;10:2150132719887260. doi: 10.1177/2150132719887260..
Keywords: Social Determinants of Health, Screening, Community-Based Practice, Primary Care, Provider: Clinician, Provider
Cottrell EK, Gold R, Likumahuwa S
Using health information technology to bring social determinants of health into primary care: a conceptual framework to guide research.
The investigators recently proposed a conceptual framework to illustrate how health information technology can be used to bring social determinants of health information into primary care. In this paper, they describe how they are putting this conceptual model into practice within the OCHIN network of community health centers by highlighting examples of ongoing research, identifying knowledge gaps, and outlining a roadmap of future research to move the field forward.
Citation: Cottrell EK, Gold R, Likumahuwa S .
Using health information technology to bring social determinants of health into primary care: a conceptual framework to guide research.
AHRQ-funded; 233201500020I..
Keywords: Health Information Technology (HIT), Primary Care, Research Methodologies, Social Determinants of Health
LaForge K, Gold R, Cottrell E
How 6 organizations developed tools and processes for social determinants of health screening in primary care: an overview.
Little is known about how health care organizations are developing tools for identifying/addressing patients' social determinants of health (SDH). The authors of this paper describe the processes recently used by 6 organizations to develop SDH screening tools for ambulatory care and the barriers they faced during those efforts.
AHRQ-funded; HS023324.
Citation: LaForge K, Gold R, Cottrell E .
How 6 organizations developed tools and processes for social determinants of health screening in primary care: an overview.
J Ambul Care Manage 2018 Jan/Mar;41(1):2-14. doi: 10.1097/jac.0000000000000221..
Keywords: Ambulatory Care and Surgery, Prevention, Primary Care, Screening, Social Determinants of Health
Raven MC, Guzman D, Chen AH
Out-of-network emergency department use among managed Medicaid beneficiaries.
The researchers examined factors associated with out-of-network ED use among Medicaid beneficiaries. They concluded that there are a number of factors related to out-of-network ED use, including the proximity and density of out-of-network EDs, race and ethnicity, a prior history of out-of-network ED use, and individuals' connection to primary care.
AHRQ-funded; HS021700.
Citation: Raven MC, Guzman D, Chen AH .
Out-of-network emergency department use among managed Medicaid beneficiaries.
Health Serv Res 2017 Dec;52(6):2156-74. doi: 10.1111/1475-6773.12604.
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Keywords: Emergency Department, Emergency Medical Services (EMS), Medicaid, Primary Care, Social Determinants of Health
Gao YN, Nocon RS, Sharma R
What factors are associated with Medicaid patients' use of health centers?.
This study identified patient and neighborhood factors associated with health center (HC) use. Dually eligible patients and those with high chronic disease burden had lower odds of HC use. Temporary Assistance for Needy Families participants and Hispanic beneficiaries had higher odds. Local HC presence predicted higher HC use.
AHRQ-funded; HS000084.
Citation: Gao YN, Nocon RS, Sharma R .
What factors are associated with Medicaid patients' use of health centers?.
J Prim Care Community Health 2017 Jul;8(3):141-46. doi: 10.1177/2150131916687919.
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Keywords: Community-Based Practice, Healthcare Utilization, Medicaid, Primary Care, Social Determinants of Health
Weech-Maldonado R, Miller MJ, Lord JC
The relationships among socio-demographics, perceived health, and happiness.
This article explores explore the relationships among socio-demographics, perceived health, and happiness in a patient population of 221 adults recruited from 39 primary care practices in Alabama. Results suggest that policies aimed at increasing health literacy, promoting health, and reducing income disparities may be associated with greater happiness.
AHRQ-funded; HS021110.
Citation: Weech-Maldonado R, Miller MJ, Lord JC .
The relationships among socio-demographics, perceived health, and happiness.
Appl Res Qual Life 2017 Jun;12(2):289-302. doi: 10.1007/s11482-017-9517-8.
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Keywords: Primary Care, Social Determinants of Health
Fraze T, Lewis VA, Rodriguez HP
Housing, transportation, and food: how ACOs seek to improve population health by addressing nonmedical needs of patients.
The authors examined how accountable care organizations (ACOs) addressed the nonmedical needs of their patients. They found that ACOs most commonly addressed the need for transportation, housing, and food insecurity, which they identified through the primary care visit or care transformation programs. They concluded that their findings offer insights into how health care organizations such as ACOs integrate themselves with nonmedical organizations.
AHRQ-funded; HS024792.
Citation: Fraze T, Lewis VA, Rodriguez HP .
Housing, transportation, and food: how ACOs seek to improve population health by addressing nonmedical needs of patients.
Health Aff 2016 Nov;35(11):2109-15. doi: 10.1377/hlthaff.2016.0727.
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Keywords: Social Determinants of Health, Patient-Centered Healthcare, Health Insurance, Healthcare Delivery, Primary Care, Public Health