National Healthcare Quality and Disparities Report
Latest available findings on quality of and access to health care
Data
- Data Infographics
- Data Visualizations
- Data Tools
- Data Innovations
- All-Payer Claims Database
- Healthcare Cost and Utilization Project (HCUP)
- Medical Expenditure Panel Survey (MEPS)
- AHRQ Quality Indicator Tools for Data Analytics
- State Snapshots
- United States Health Information Knowledgebase (USHIK)
- Data Sources Available from AHRQ
Search All Research Studies
Topics
- Children/Adolescents (3)
- Chronic Conditions (1)
- (-) Community-Based Practice (14)
- Community Partnerships (1)
- Electronic Health Records (EHRs) (2)
- Emergency Department (1)
- Healthcare Delivery (6)
- Healthcare Utilization (1)
- Health Information Technology (HIT) (2)
- Health Services Research (HSR) (1)
- Hospitalization (1)
- Implementation (2)
- Low-Income (1)
- Medicaid (1)
- Organizational Change (1)
- Practice Improvement (1)
- Primary Care (8)
- Provider (1)
- Provider: Clinician (1)
- Racial and Ethnic Minorities (1)
- Rural/Inner-City Residents (1)
- Screening (3)
- (-) Social Determinants of Health (14)
- Teams (1)
- Urban Health (2)
- Vaccination (1)
- Vulnerable Populations (3)
- Workflow (1)
AHRQ Research Studies
Sign up: AHRQ Research Studies Email updates
Research Studies is a compilation of published research articles funded by AHRQ or authored by AHRQ researchers.
Results
1 to 14 of 14 Research Studies DisplayedHeintzman J, Springer R, Marino M
Latino adolescent-mother language concordance, neighborhood deprivation, and vaccinations in community health centers.
Researchers examined the association between adolescent-mother language concordance and neighborhood social deprivation with adolescent vaccination completion in order to understand social/family factors related to Latino adolescent vaccination. They used a multistate, EHR-based dataset of community health center patients to compare three Latino groups; their sample included over 56,000 adolescent-mother dyads. Their findings indicated that English-preferring adolescents with Spanish-preferring mothers had the highest completion rates. The researchers concluded that future studies could attempt to understand what advantage this language dyad may have in adolescent vaccination completion.
AHRQ-funded; HS025962.
Citation: Heintzman J, Springer R, Marino M .
Latino adolescent-mother language concordance, neighborhood deprivation, and vaccinations in community health centers.
Matern Child Health J 2023 Nov; 27(11):2026-37. doi: 10.1007/s10995-023-03742-0..
Keywords: Racial and Ethnic Minorities, Community-Based Practice, Vaccination, Children/Adolescents, Vulnerable Populations, Social Determinants of Health
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.
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
Shi M, Fiori K, Kim RS
Social needs assessment and linkage to community health workers in a large urban hospital system.
The purpose of this study was to determine predictors of successful linkage with a community health worker (CHW) in patients with social needs. The researchers utilized a cross-sectional analysis of social needs assessments administered in an urban health system between April 2018 and December 2019. Social needs in the study included safety, getting along with household members, housing quality, housing instability, food insecurity, care for dependents, healthcare cost, healthcare related transportation, utilities, and legal assistance. Patients were entered into a separate database when they encountered a CHW. The main outcome was a successful "linkage," which was defined as having a positive social needs assessment in the medical record with a corresponding record in the CHW database. The study found that 25% of patients with at least 1 social need accepting help were linked to a CHW. Positive predictors included female gender, Spanish language preference compared to English, and having a food-related need. Negative predictors included age 18 to 65 and 0 to 5 compared to over 65, non-Hispanic White race compared to Hispanic race, and having needs of getting along with household members and safety.
AHRQ-funded; HS026396.
Citation: Shi M, Fiori K, Kim RS .
Social needs assessment and linkage to community health workers in a large urban hospital system.
J Prim Care Community Health 2023 Jan-Dec; 14:21501319231166918. doi: 10.1177/21501319231166918..
Keywords: Urban Health, Healthcare Delivery, Social Determinants of Health, Community-Based Practice, Rural/Inner-City Residents
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
Shadowen H, O'Loughlin K, Cheung K
Exploring the relationship between community program location and community needs.
Investigators identified and geolocated community programs in Richmond, Virginia, that aid with 9 domains of needs. They identified 280 community programs that provide aid for the 9 domains, with programs most often providing financial assistance and housing support. They found no relationship between the number of community programs and the level of need, with 2 exceptions: A positive association between financial programs and financial need, and a negative association between housing programs and housing need. They concluded that community programs were generally not co-located with need.
AHRQ-funded; HS026223.
Citation: Shadowen H, O'Loughlin K, Cheung K .
Exploring the relationship between community program location and community needs.
J Am Board Fam Med 2022 Jan-Feb;35(1):55-72. doi: 10.3122/jabfm.2022.01.210310..
Keywords: Social Determinants of Health, Community-Based Practice
Vasan A, Morgan JW, Mitra N
Effects of a standardized community health worker intervention on hospitalization among disadvantaged patients with multiple chronic conditions: a pooled analysis of three clinical trials.
The purpose of this study was to analyze the effects of a standardized community health worker (CHW) intervention on hospitalization. The investigators concluded that data from three randomized clinical trials across multiple settings showed that a standardized CHW intervention reduced total hospital days and hospitalizations outside the primary health system. They indicated that this study was the largest analysis of randomized trials to demonstrate reductions in hospitalization with a health system-based social intervention.
AHRQ-funded.
Citation: Vasan A, Morgan JW, Mitra N .
Effects of a standardized community health worker intervention on hospitalization among disadvantaged patients with multiple chronic conditions: a pooled analysis of three clinical trials.
Health Serv Res 2020 Oct;55(Suppl 2):894-901. doi: 10.1111/1475-6773.13321..
Keywords: Hospitalization, Chronic Conditions, Vulnerable Populations, Social Determinants of Health, Community-Based Practice
Wallace AS, Luther B, Guo JW
Implementing a social determinants screening and referral infrastructure during routine emergency department visits, Utah, 2017-2018.
Emergency departments see a disproportionate share of low-income and uninsured patients. In this study, the investigators developed and evaluated a process for identifying social needs among emergency department patients, for facilitating access to community-based resources, and for integrating clinical and community-based data. They leveraged an academic-community partnership to develop a social needs screening tool and referral process.
AHRQ-funded; HS026505.
Citation: Wallace AS, Luther B, Guo JW .
Implementing a social determinants screening and referral infrastructure during routine emergency department visits, Utah, 2017-2018.
Prev Chronic Dis 2020 Jun 18;17:E45. doi: 10.5888/pcd17.190339..
Keywords: Social Determinants of Health, Emergency Department, Screening, Community-Based Practice, Community Partnerships
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
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
Trinacty CM, LaWall E, Ashton M
Adding social determinants in the electronic health record in clinical care in Hawai'i: supporting community-clinical linkages in patient care.
Given its distinctive history, culture, and location, Hawai'i has unique social factors impacting population health. Local health systems are striving to address these issues to meet their patients' health needs. Yet the evidence on precisely how health care systems and communities may work together to achieve these goals are limited both generally and specifically in the Hawai'i context. This article described real-world efforts by 3 local health care delivery systems that integrated the identification of social needs into clinical care using the electronic health record (EHR).
AHRQ-funded; HS023185.
Citation: Trinacty CM, LaWall E, Ashton M .
Adding social determinants in the electronic health record in clinical care in Hawai'i: supporting community-clinical linkages in patient care.
Hawaii J Med Public Health 2019 Jun;78(6 Suppl 1):46-51..
Keywords: Social Determinants of Health, Electronic Health Records (EHRs), Health Information Technology (HIT), Community-Based Practice, Healthcare Delivery, Vulnerable Populations
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
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.
.
.
Keywords: Community-Based Practice, Healthcare Utilization, Medicaid, Primary Care, Social Determinants of Health