BACKGROUND:Medicaid-enrolled populations are disproportionately impacted by suboptimal dietary intake leading to a high prevalence of Stage 2 cardiovascular-kidney-metabolic syndrome (CKMS), and lower Life's Essential 8 (LE8) cardiovascular health (CVH) measures. METHODS:A pilot randomized controlled trial to test the feasibility, engagement, and preliminary efficacy of a novel Food-is-Medicine (FIM) intervention in Medicaid-enrolled adults with Stage 2 CKMS. SETTING:Participants were recruited from an academic medical center in an urban environment in the Midwest. DESIGN:Parallel group design. INTERVENTIONS:SUSTAIN tests a phased-approach over 24 weeks: Weeks 1-8: Instacart food vouchers (known as Fresh Funds) and home delivery, behavioral nutrition counseling and culinary education, community health worker (CHW)-led social needs coordination, and produce prescription via Mid-Ohio Farmacy (MOF) access; Weeks 9-16: study supported Instacart platform access without the vouchers (Fresh Funds), while other components remain the same; Weeks 17-24: option to continue Instacart without study support, counseling and culinary education cease, and MOF and CHW continue. Control participants receive the same intervention without counseling and culinary education or the CHW. OUTCOMES:Primary and secondary outcomes include study enrollment, adherence to intervention components (i.e., total Instacart spending, counseling sessions, number of food pantry visits, linkage with CHW), retention across study visits, acceptability (i.e, satisfaction), practicality (i.e., participant costs), adaptations to the intervention, and efficacy (i.e., dietary patterns, nutrition security, American Heart Association's Life's Essential 8). DISCUSSION:Scalable FIM approaches to improve CVH in individuals with Stage 2 CKMS are needed to inform inclusive and impactful interventions to address nutrition security. CLINICALTRIALS:gov: NCT06589336.

Community coalitions are a common implementation strategy for addressing public health challenges, such as the opioid epidemic. There remains a lack of understanding of the factors that support implementation effectiveness for community coalitions. This study leverages the HEALing Communities Study (HCS) which tested the Communities That HEAL (CTH) approach to supporting community coalitions to increase delivery of opioid overdose and naloxone distribution (OEND) and medication for opioid use disorder (MOUD) through facilitation, data-driven decision making, and a communications campaign. Using a parallel convergent, nested serial case study with a positive deviance design, we selected high performing waitlist control communities participating in the HCS for further examination. Performance was defined based on average ranking across a set of implementation measures; the top performing urban and rural community within each of the four HCS sites was then selected for in-depth case study. For selected sites, we conducted thematic analysis of qualitative interviews with coalition members (n = 41) conducted at the end of the implementation phase. Analysis was aligned with the PRISM/ RE-AIM framework. Despite achieving top performance, these communities still faced persistent and varied challenges related to OUD service delivery and access. However, community assets and policy changes provide a foundation for improvement. Implementation success was supported by representative coalition membership, high engagement, and alignment with coalition goals. Coalition members were highly collaborative and shared a vision for their community. Implementation success was also supported by coalition buy-in to the CTH process. Structured data connectivity and sharing facilitated effective strategy selection, while multi-channel communications campaigns increased awareness and uptake of OUD and MOUD services. No differences were observed across urban and rural communities. Implementation success reflects the synergy among external context, coalition strength, and intervention processes. Community coalition–based strategies benefit from ensuring representative membership and shared goals to build buy-in, while also leveraging data infrastructure and communication campaigns to promote effective implementation of EBPs. NCT04111939.

A service cascade refers conceptually to a multi-step process that occurs during the delivery of care as individuals proceed from one part of care to the next. Health care systems increasingly screen patients for unmet social needs and refer them to community-based organizations to address them, requiring a multi-step interaction between the health and social care systems, which we refer to as the social needs service cascade. This cascade is poorly understood beyond screening and referral. As part of an ongoing trial, we interviewed clinicians (n = 38), representatives from community-based organizations (n = 14), and patients with both uncontrolled type 2 diabetes and food insecurity (n = 39), to improve our understanding of the cascade. Qualitative data were analyzed thematically, and highlight key cascade steps including: (a) screening, (b) referral, (c) lag time, (d) linkage and engagement experience, and (e) resolution. These findings can inform future studies and policy approaches supporting integration between health and social care.Trial Registration: ClinicalTrials.gov NCT05472441

Objective To map the existing literature and identify gaps related to racial and ethnic disparities in social determinants of health (SDOH) and health outcomes among individuals with traumatic spinal cord injury (tSCI) in the United States. Data Sources PubMed, Embase, CINAHL, Scopus, and Web of Science databases were searched for English-language journals up until April 2024. Reference lists of eligible articles were also screened. Study Selection A total of 5,893 records were screened by title and abstract by two pairs of independent reviewers. Two reviewers independently assessed the remaining 549 records using predetermined exclusion and inclusion criteria. Data Extraction SDOH outcomes were classified into five categories using the Healthy People 2030 framework: economic stability, healthcare access and quality, neighborhood environment, education access and quality, and social and community context. Health outcomes were grouped into conceptually related categories based on the primary outcomes (e.g., functional independence, mental, bowel/bladder, and metabolic health). Data Synthesis Of the 549 studies screened via full-text review, 143 were included in the final synthesis. Across the literature, racial and ethnic differences are described in every SDOH domain and in several clinical outcomes, although the volume and quality of supporting evidence vary. Studies often report that minoritized people with tSCI face lower employment rates and wages, more discrimination in healthcare settings, and are more likely to live in socio-economically disadvantaged neighborhoods. Health-related publications frequently note lower functional independence, higher rates of secondary complications, and reduced quality of life for these groups. Conclusions The scoping review revealed racial and ethnic inequities in SDOH and health outcomes among individuals with tSCI in existing literature. Future in-depth investigations are necessary to understand the drivers of these disparities and to inform effective strategies for addressing them.

Stigma is a primary barrier to opioid use disorder (OUD) intervention implementation, undermining treatment outcomes. Some scholars have argued that stigma from service providers is the greatest barrier to recovery. Strategies to address service provider stigma are undertheorized and typically focus on one-time individual education, despite evidence that a long-term approach that engages macro, meso and micro social levels is necessary for effective stigma mitigation. We qualitatively analyze 170 interviews with community coalition members participating in the Healing Communities Study (HCS), conducted from May to June 2022, to identify perceptions of service provider OUD and OUD intervention stigma, and strategies to mitigate stigma. HCS was a longitudinal, cluster randomized wait-listed controlled trial that aimed to reduce opioid overdose deaths in four states. Our analysis included deductive and inductive components, framed by the Health Stigma Discrimination Framework to leverage the multi-level structure of the HCS. Participants shared perceptions of blame and burnout as key service provider OUD stigma drivers. Drivers of OUD intervention stigma included perceptions that OUD medications enable drug use, providers’ preference for abstinence only treatment, and refusal to consider OUD treatment (distancing). Strategies identified to reduce stigma included formal and informal education opportunities over extended timeframes, education from expert peers, and cross-sector collaboration. OUD stigma drivers cooccur and may influence the development of OUD intervention stigma, diminishing treatment outcomes. Anti-stigma approaches should take a multi-level, intersectional, longitudinal approach. Strategies must also recognize the importance of varied, ongoing educational opportunities, providing service providers adequate time and opportunity for meaningful learning and reassessment of stigmatized attitudes and beliefs. Community coalitions may be effective leaders in designing and implementing cross-sector strategies across social levels to promote community cohesion and reduce service provider OUD and intervention stigma.

Introduction:Large portions of patients served at community health centers have diabetes or hypertension. This study aimed to identify the factors related to diabetes and hypertension performance among community health centers. Methods:The authors estimated multivariable linear regression models to examine the association of characteristics (percentage of patients at high risk of cardiovascular events on statin therapy, female, overweight or obese, homeless, veterans, gender minorities, sexual orientation minorities, best served in a non-English language, or with diabetes or hypertension and log of revenue per patient) with diabetes (proportion of patients with HbA1c >9.0) and hypertension (proportion of patients with high blood pressure) control. The sample included community health centers in the 2023 Uniform Data System data set. Results:Variables significantly associated with lower diabetes control were percentage of patients who were unhoused (0.10; 95% CI=0.07, 0.13) and patients best served in a non-English language (0.03; 95% CI=0.01, 0.05); variables significantly associated with higher diabetes control were percentage of patients who were at high risk of cardiovascular events and on statin therapy (-0.17; 95% CI= -0.22, -0.12) and those who were veterans (-0.86; 95% CI= -1.12, -0.59); variables significantly associated with lower hypertension control were percentage of patients who were unhoused (0.06; 95% CI=0.03, 0.09) and patients who were hypertensive (0.10; 95% CI=0.04, 0.16) and log of revenue per patient (0.73; 95% CI=0.17, 1.30); and variables significantly associated with higher hypertension control were percentage of patients who were at high risk of cardiovascular events and on statin therapy (-0.35 95% CI= -0.39, -0.30), patients who were overweight or obese (-0.04; 95% CI= -0.07, -0.01), and veterans (-0.82; 95% CI= -1.08, -0.55). Conclusions:Community health centers with higher proportions of unhoused patients may require extra support. Encouraging delivery of evidence-based care may help performance.

Background: The rapid expansion of telehealth-delivered medication for opioid use disorder (MOUD) during the COVID-19 pandemic highlighted critical digital divide issues in communities. How community context influences the digital divide remains unclear, creating uncertainty about ameliorating the gaps in access to tele-MOUD. Methods: We qualitatively examined the perspectives of 315 opioid community coalition members who were part of the HEALing Communities Study (HCS) to understand how the digital divide created access barriers in urban and rural communities. Primary coding for all interviews used a deductive approach with codes derived from the Reach, Effectiveness, Adoption, Implementation, Maintenance/Practical Robust Implementation and Sustainability Model overarching HCS framework. Secondary coding used the nine determinants of Lythreatis's 2022 digital divide framework, and inductive thematic analysis was used to identify themes with each of the nine determinants. Results: Shared issues across communities related to the digital divide, including trust, social support, technological infrastructure, digital literacy, policy changes, and pandemic-related disruptions, critically influenced telehealth expansion and effectiveness. Rural communities reported specific barriers around infrastructure and socioeconomics, whereas urban communities reported specific barriers around sociodemographic factors. Conclusions: To address these digital divide issues, policymakers should continue to invest in rural infrastructure and improve internet access for underserved populations. Clear guidelines are also needed for when tele-MOUD is appropriate versus in-person visits and when urine drug screening is necessary. Additionally, emphasizing patient choice and maintaining in-person care is important to support equitable access to these services.

BACKGROUND:Clinical management of Type 2 diabetes (T2D) can be hindered by patients' nonmedical, health-related social needs such as financial strain, housing instability, or food insecurity. PURPOSE:The objective of this study was to characterize the contextual factors and processes that influence care team members' abilities to address social needs impacting T2D management in outpatient settings. METHODOLOGY/APPROACH:We conducted semistructured, qualitative interviews (N = 38) in tandem with the launch of a randomized controlled trial testing a patient-level intervention to improve diabetes outcomes in individuals experiencing food insecurity. We purposively selected a diverse array of care team members (e.g., physicians, social workers, diabetes educators, dietitians, community health workers) working across varying ambulatory clinics (e.g., family medicine, general internal medicine, endocrinology). All were affiliated with an academic medical center serving a diverse population in a Midwestern metropolitan area. Guided by a process evaluation framework, interview transcripts were coded and analyzed for themes via iterative deductive and inductive processes. RESULTS:Contextual factors influencing T2D management for patients with social needs included telehealth policy, insurance coverage, and partnerships. Relevant implementation processes were categorized along a temporal continuum: previsit (i.e., transportation, social needs screening), during visit (i.e., appointment duration, care team member awareness, and communication of resources), and postvisit (i.e., closed-loop referrals). Mechanisms of impact included availability of support staff as well as availability of programs and resources to address social needs. CONCLUSIONS:Strengthening partnerships and considering logistics can help promote awareness of existing programs, facilitate bidirectional communication about use of services, and support overall clinical management of T2D for patients with social needs.

As accountable care organizations have proliferated across the healthcare landscape, research into the factors contributing to accountable care organization development for adults has identified useful approaches to managing care under this care model. Yet, investigation into pediatric accountable care organizations is lacking, leaving policy-makers and pediatric accountable care organization administrators unable to better address the unique challenges of caring for children. To address this gap and identify differences between accountable care organizations serving these two populations, two pediatric and two adult accountable care organizations operating in the private sector were compared in this study. A comparative case study design consisting of two site visits to each of the accountable care organizations was used to conduct this research. The four accountable care organizations included in this study were purposely selected to provide geographic and population diversity. Site visits were conducted in Columbus, Ohio, USA, Kansas City, Missouri, USA, Golden Colorado, USA, and Chicago, Illinois, USA from 2013 to 2014. The case studies consisted of 89 key informant interviews performed during site visits to each of the organizations, supplemented by document collection and follow-up telephone interviews. All interviews were analyzed via both inductive and deductive methods to identify differences between the pediatric and adult accountable care organizations. For this comparative analysis, the aim was to study both pediatric and adult accountable care organizations to identify differences in accountable care organization development and management practices that may exist, focusing in particular on process aspects that might vary. Our study found that pediatric accountable care organizations have unique approaches to care management and cost control. Specifically, there were four key differences identified between the types of accountable care organizations: 1) the role of primary care; 2) the challenge of cost control; 3) the importance of scale; and 4) approaches to measurement. These findings can help better focus efforts to implement and standardize the accountable care organization model to meet needs of the pediatric population. Future research should be undertaken to further understand the circumstances and goals of pediatric ACOs.

Introduction: Medicaid-enrolled populations are disproportionately impacted by suboptimal nutrition leading to lower Life’s Essential 8 (LE8) cardiovascular health (CVH) scores and greater prevalence of Stage 2 cardiovascular-kidney-metabolic syndrome (CKMS) as defined by the American Heart Association (AHA). With support from the AHA Health Care by Food TM Initiative and leveraging existing academic-community-government-industry partnerships, our team is assessing the feasibility, engagement, and preliminary efficacy of SUSTAIN , a novel Food is Medicine (FIM) intervention in Medicaid-enrolled individuals with Stage 2 CKMS. Hypothesis: Our overall hypothesis is that a comprehensive FIM intervention including culturally appropriate and home-delivered groceries, intensive and tailored behavioral nutrition counseling, and social care coordination will improve nutrition security and CVH compared to individuals receiving home-delivered groceries only. Methods: Informed by the socioecological model and human-centered design, SUSTAIN is a 24-week randomized controlled trial (RCT) of Medicaid-enrolled individuals (n=100) with Stage 2 CKMS to: Aim 1 : Determine the feasibility and engagement of participants in the SUSTAIN intervention compared to enhanced usual care over 24 weeks through mixed-methods measurement of participant enrollment, adherence, retention, and engagement (counseling, screenings, referrals, and uptake); Aim 2 : Determine the preliminary efficacy of the SUSTAIN intervention compared to enhanced usual care in improving behavior change as measured by nutrition security, LE8 measures, biometrics, and purchasing behaviors over 24 weeks to determine effect estimates to robustly power a future RCT. Results: Initial recruitment efforts have enrolled 46 individuals; 148 failed to meet eligibility criteria. Primary reasons for ineligibility were other diagnoses (e.g., heart failure) (n=107) and non-English speaking (n=31). A minority of participants were ineligible due to unwillingness to use mobile phone-based technology (n=2) or lack of backup form of payment for grocery vendor (n=3). Conclusions: Innovative FIM solutions are urgently needed. SUSTAIN will explicate the feasibility, engagement, and preliminary efficacy of SUSTAIN, leading to a scalable FIM nutrition-security-based model to improve CVH in Stage 2 CKMS. SUSTAIN has the potential to drive a paradigm shift in healthcare, fostering healthier, nutrition-secure and resilient communities.

Increasingly, health systems are collecting and using social needs data, yet there is limited information about individuals’ preferences for how social needs information is shared among providers for treatment purposes. To explore the connection between experiencing social needs and concerns about healthcare providers sharing social needs information. A nationally representative, cross-sectional study of 6252 US community-dwelling adults (≥ 18 years of age) who responded to the Health Information National Trends Survey (HINTS 6) (response rate 28.1

Introduction:The opioid epidemic in the USA presents a multifaceted challenge regulated by a patchwork of federal, state and local policies. In some communities, cross-sector coalitions navigate this complex policy environment to address the epidemic. However, limited research has explored these public health-oriented community coalitions and their interactions with the policy landscape. This study explores how cross-sector public health-oriented community coalition members perceive and navigate the multidimensional policy landscapes to address the opioid epidemic. Methods:Using data from 304 semistructured HEALing Communities Study coalition member interviews conducted April-June 2021 in 67 communities in Kentucky, New York, Massachusetts and Ohio, we inductively analysed participants' discussions of opioid-related policies to characterise themes and subthemes. Results:We describe two themes where coalitions and policy intersect: policy landscape barriers and navigation and mitigation strategies to address policy barriers. Participants revealed community misunderstandings and lack of knowledge of opioid-related policies. Furthermore, participants shared how these policies often hindered coalitions' initiatives to address substance use. Nevertheless, community coalitions functioned despite these policy challenges through knowledge sharing, innovation and policy advocacy. Conclusions:Cross-sector public health-oriented community coalitions serve a vital role in navigating the complexities of the multidimensional policy landscape regulating substance use services. Insights from these findings may encourage policy-makers to support community coalitions in pursuing solutions to the opioid crisis and other public health crises. Trial registration number:NCT04111939.

Introduction:Prescription opioids can contribute to risk for opioid use disorder and overdoses. Improving prescription opioid safety is a critical component in reducing opioid risks. This report aims to determine whether communities randomized to the Communities That HEAL (CTH) intervention have significantly different rates of prescription opioid safety measures. Study Design:A multisite, 2-arm, community-level, cluster randomized, unblinded, wait-list controlled comparison trial designed to assess the effectiveness of the CTH intervention in reducing opioid-related overdose deaths among community residents 18 years of age or older (adults). Setting/Participants:Sixty-seven (67) communities in Kentucky, Massachusetts, New York, and Ohio. Participants were communities in this study. Intervention:The Communities That Heal intervention consists of multiple dimensions: a coalition-driven community engagement process to select and support implementation of evidence-based practices; the Opioid-overdose Reduction Continuum of Care Approach, a compendium of evidence-based practices and technical assistance resources organized under overdose education and naloxone distribution, medication for opioid use disorder, and prescription opioid safety menus; and communication campaigns intended to reduce opioid use disorder stigma and raise awareness and demand for naloxone and medication for opioid use disorder. Main Outcomes and Measures:The main outcome was the number of adults with new incident high-risk opioid prescribing episodes after at least a 45-day washout. Other outcomes included the number of opioid-naïve adults with new opioid prescriptions limited to a 7-day supply, number of adults who received opioid prescriptions from multiple prescribers or pharmacies, and number of locations providing drug take-back services. Outcomes were assessed from July 2021 to June 2022. Results:There was no statistically significant difference in the adjusted rates for new incident high-risk opioid prescribing per 100,000 adults during the comparison period between intervention (1,094.48; 95% CI=1,063.15; 1,126.74) and wait-list control communities (1,121.90; 95% CI=1,079.62; 1,165.84). The adjusted relative rate comparing intervention to wait-list control communities was 0.98 (95% CI=0.93, 1.02; p-value=0.296). Similarly, there were no statistically significant differences between intervention and wait-list control communities for the other outcomes. Conclusions:Although no statistically significant differences were found in prescription opioid safety measures between study arms, improvement in these measures during the comparison period for both study arms suggested that there may have events outside the trial, such as published revised Center for Disease Control and Prevention clinical practice guidelines for prescribing opioids, that may have impacted study outcomes.

OBJECTIVES:Anti-tobacco public health efforts have contributed to reductions in smoking rates, but tobacco use continues, contributing to increased risk for chronic disease. Notably, the tobacco industry spends billions of dollars promoting products to consumers across various channels to attract and retain customers. This study aimed to examine the populations and settings that anti-tobacco messaging and tobacco advertising reach most frequently to inform future campaigns. STUDY DESIGN:Retrospective cross-sectional study using data from the 2022 Health Information National Trends Survey (HINTS 6; N = 6252). METHODS:Weighted descriptive statistics assessed location of anti-tobacco messages or tobacco ads respondents reported seeing. Logistic regression models examined the odds of seeing anti-tobacco messages or tobacco advertising by smoking status, e-cigarette use, and demographics. RESULTS:While 40.5 % of HINTS respondents did not notice any anti-tobacco messages in the previous 3 months, the places respondents reported seeing them most frequently were television, billboards, stores, and social media. The places respondents most often noticed tobacco advertisements were stores, billboards, television, and print media, but 52.2 % reported they did not see any ads. There were lower odds of reporting seeing anti-tobacco messages among those aged 35-49 compared to those 18-34, and lower odds of seeing tobacco ads among those 65-74 and 75 or older. Those who smoked or used e-cigarettes had higher odds of reporting seeing anti-tobacco messages and tobacco ads. CONCLUSIONS:The places people were aware they saw tobacco ads and anti-tobacco messaging were similar, and younger adults and those who currently smoked or used e-cigarettes were more likely to report seeing both anti- and pro-tobacco messaging.