Project Summary/Abstract Low-income and racial/ethnic minority populations experience disparately high rates of chronic disease incidence and poor disease outcomes, as well as the social and contextual risks that hinder disease management. Care management is an evidence-based strategy for chronic disease management. It involves coordinating the necessary, appropriate care for an individual's needs, including connecting them to community-based organizations (CBOs) to address social risks. Increasingly, payors (e.g., CMS and state Medicaid / Managed Care Organizations) are reimbursing healthcare providers for conducting social risk screening and making related referrals that involve clinic-CBO linkages as part of care management. However, in under-resourced care settings, the systematic implementation of these activities is often substantially hampered by the initial investment in technology and workflow redesign needed to operationalize such tasks. Such barriers to establishing clinic-CBO linkages are most pronounced in Community Health Centers (CHCs), non-profit primary care safety net clinics serving health disparate populations. There is a clear need to identify best practices for supporting CHCs' ability to connect and match patients to available services using electronic health record (EHR)-based clinic-CBO linkage functionality, as improving receipt of needed services could reduce health disparities. In 2022, a national network of CHCs sharing one EHR made available a new EHR- integrated application (Compass Rose) that is designed to support care management, including assessing patients' social risks, referring them to CBOs, and tracking referral outcomes . However, extensive evidence shows that targeted implementation support (such as training, championship, practice facilitation, and audit and feedback) may be critical to enhance clinical organizations' and care providers' adoption of new technologies. We will partner with CHC stakeholders to develop and refine implementation strategies designed to support the implementation and optimization of EHR-based tools (and related workflows) for CHC team coordination and use of clinic-CBO linkages. Our specific aims are to: 1) identify barriers and facilitators to CHCs' use of EHR-based care management functions as a means to systematize (i) referring patients with social risks to CBOs and (ii) assessing referred patients' service receipt (closed-loop referral); 2) partner with community stakeholders to refine a set of implementation strategies to optimize their potential to support CHCs' adoption of linkage functionality in Compass Rose; and 3) conduct a trial of whether the refined strategies improve clinic-CBO linkages for patients with social risks. Study findings will provide knowledge needed to support CHCs' adoption of existing technologies for clinic-CBO linkages, as a pragmatic means to reduce health inequities. As the first trial of strategies to support the implementation of clinic-CBO linkages via adoption of an EHR-based care management application in the primary care safety net setting, the proposed work directly addresses NINR's goal of increasing clinical-CBO linkages in health disparate populations.

Project Narrative Primary care organizations serving populations experiencing health disparities often struggle to effectively link patients with needed community-based services to address individual social risks, due to the up-front investment in health information technology infrastructure and workflow redesign. Care management programs are designed to address whole-person care, including these clinic-community linkages. This study aims to evaluate the effectiveness of implementation strategies to support care management team use of electronic health record-based functionality to support clinic-community linkages for patients with social risks.