AZCEALLinking Social Care with Healthcare Systems to Address Social Determinants of Health

Social drivers of health contribute significantly to disparities in health outcomes for many chronic diseases in low income populations. Social drivers of health and health related social needs exacerbate stress, allostatic load, chronic pain, and cardiovascular outcomes. And in recent years, the consistent and compelling evidence regarding how Social drivers of health influences health has led to growing recognition within healthcare systems of the need to addressing health-related factors upstream of the clinical encounter. Whilst health systems have started collecting patient-level Social drivers of health, most front-line healthcare workers have little time, skill, or resources to address Social drivers of health challenges (Implementation Gap). And, in the health systems we serve, social worker positions employed and embedded within healthcare systems -- the key clinician professional group skilled at addressing SDOH -- are being cut for short term financial performance, leaving vulnerable patient populations disconnected from existing community resources and professional support. Community Health Workers (CHWs) are entry-level paraprofessionals known to provide robust support to link high risk populations with health and social services that could help high risk patient-clients cope with or mitigate the effects of Social drivers of health. Yet, despite their known effectiveness and the prevalent identification of Social drivers of health within healthcare systems, CHWs largely operate outside of healthcare systems and are not effectively linked to those systems in a manner to help patient-clients address identified Social drivers of health challenges and health related social needs. The key research questions that pertain to addressing Social drivers of health elements within healthcare systems are: (a) How to integrate social care (i.e., services that address health-related social risk factors and needs) into clinical practice settings? and (b) what kind of infrastructure is needed to facilitate such activities? To address these important questions, the overarching goal of the Arizona Community Engagement Alliance (AZ-CEAL) will be to disseminate and implement social care integration within healthcare systems by connecting healthcare providers within systems with trained community health workers within the communities while studying process-level (implementation) and client-level (patient outcome) metrics in a stepped wedge design approach within a large statewide healthcare system. This 4-year project proposal will address the overarching overall goal by continuing to leverage our community based participatory research relationship with the Arizona Community Health Worker (AzCHOW) Association representing 1500 CHWs and 200 CHW employers statewide to refine and train CHWs in interventions aimed at addressing Social drivers of health within healthcare delivery settings. We propose an initial planning phase (9 months) that will enable refinement of the evidence-based CHWs and their core competency trainings that are tailored to address care within Arizona healthcare settings and build the linkage infrastructure to connect them with healthcare providers and their patients within healthcare settings. In the implementation phase (39 months), we will undertake a stepped wedge cluster randomized trial to evaluate the process-level (implementation) and client-level (patient outcome) metrics. We will conduct this study within a statewide large healthcare system with 10 clusters per step. We will collect implementation outcomes data consistent with the RE-AIM framework. We will measure effects on process-level outcomes (SDOH elements) measured by patient reports (CEAL Common survey) and healthcare system-data ("No-show" rates) as well as patient-level (client) outcomes (blood pressure, HbA1C, lipid profile, stress, healthcare utilization \[i.e., composite outcome of unplanned office visits, urgent care visits, emergency room visits, and hospitalization\] and even death). The conceptual framework for our proposal is based upon the five activities to better integrate social care into health care delivery that was advocated by the National Academy of Sciences. The activities are to improve awareness, adjustment, assistance, alignment, and advocacy for social care within healthcare systems with multi-level interventions at the community- and systems-level.