Integrating Social Care and Medical Care: From the Why to the How and Back Again Mina Silberberg PhD Affiliation Mina Silberberg is a faculty member in the Division of Community Health, Department of Family Medicine and Community Health, at Duke School of Medicine. She is also affiliated with the department's Division of Family Medicine, the Duke Global Health Institute, the Duke Margolis Institute for Health Policy, the Duke Department of Head and Neck Surgery & Communication Sciences, and the Duke Clinical and Translational Science Institute, where she serves as faculty director of the Community Engaged Research Initiative. CopyRightAll correspondence should be directed to Mina Silberberg, Duke Division of Community Health, DUMC 104652, Durham, NC 27710 (e-mail: mina.silberberg@duke.edu). Reprints can be ordered at https://ajph.org by clicking the "Reprints" link. https://doi.org/10.2105/AJPH.2024.307664 Accepted: March 10, 2024 Published Online: April 04, 2024

Tenancy support services (TSS) allow homeless or institutionalized people with disabilities to obtain and maintain housing in community settings. In the United States, Medicaid is expanding to include coverage for these services. We conducted a comparison case study of two high performing North Carolina (NC) TSS provider agencies, augmented with the voices of key stakeholders in NC and experienced leaders in Louisiana, to explore promising practices for providing effective TSS. Through employing a Housing First philosophy, client centered service delivery, teams with specialized positions, a supportive environment for staff, and staff training TSS outcomes of increased housing, housing retention, improved health, social connection, and enhanced quality of life for residents were achieved. Study findings are intended to inform TSS agencies, state officials, and other stakeholders interested in effective TSS provision.

Medicaid is expanding funding for tenancy support services (TSS) that help people who have experienced homelessness or lived in institutional settings obtain and maintain housing. To identify critical considerations for Medicaid TSS regulations, we compared two successful TSS provider agencies in North Carolina, and conducted additional stakeholder interviews in North Carolina and Louisiana, which is ahead of North Carolina in expanding Medicaid-funded TSS. Stakeholder concerns focused on the impact of regulation on goals of access, quality, and flexibility, and noted tensions among these goals. Specific regulatory approaches may mitigate the tension among these goals, such as outcome- and client feedback-based accountability, and an emphasis on job-specific training. Moreover, meeting the goals of access, quality, and flexibility and mitigating their trade-offs is supported by state infrastructure that includes braided funding; horizontal and vertical coordination across agencies; and the capacity for multimodal, multilevel quality assurance and multilevel training and technical assistance.

BACKGROUND AND OBJECTIVES:Hearing loss frequently goes undiagnosed and untreated, with serious sequelae. Hearing screening facilitates diagnosis and treatment but is not routinely conducted in primary care. This study addresses the attitudes and insights of patients and primary care clinic personnel relative to the routinization of hearing screening in primary care for older adults. RESEARCH DESIGN AND METHODS:Data presented are from the qualitative portion of a larger study. The main study compared screening completion for 3 approaches to coordinating telephone-based hearing screening with primary care-1 offering hearing screening within the primary care encounter and 2 providing information for at-home screening ( 1 with and 1 without provider encouragement). Focus groups/interviews were conducted with personnel (n = 38) at the 6 participating clinics, patients who completed screening and were referred for diagnosis (n = 14), and patients who did not complete screening (n = 10). Analysis used the general inductive approach. RESULTS:Most patients had unaddressed hearing concerns prior to the study. Negative attitudes toward hearing loss/treatment were common, and experiences of family and friends influenced attitudes, but lack of urgency was the primary barrier to screening completion. Respondents favored routine primary care-based hearing screening for older adults, but clinic personnel noted challenges of time, space, workflow, and reimbursement. DISCUSSION AND IMPLICATIONS:Findings favor greater routinization of hearing screening in primary care. Routinization will be enhanced by improved reimbursement for screening and follow-up; specialist engagement with primary care and the public (including leveraging older adults' social networks); and further research on specific integration options.

Background: Place-based initiatives (PBIs) invest in a geographic area and often build community power to improve well-being. However, there can be differences in results for different groups within a community. Methods: In six communities, we measured differences in “power to” by race/ethnicity at two points for the first phase of the PBI Healthy Places North Carolina (HPNC) using five indicators: (1) representation in network of actors collaborating to improve health, (2) leadership attributes, (3) perceived change in attributes due to HPNC, (4) network centrality, and (5) perceived change in network ties due to HPNC. Results: Latine populations were underrepresented. In four (majority White) communities, there were indications of White advantage. In one, White centrality was greater than non-White. In another, White actors consistently rated themselves higher for leadership attributes. In two, a gap in leadership attributes favoring White actors appeared at Wave 2. In two counties with African American majorities, non-White attributes ranked higher than White. Conclusions: Each indicator provided unique insight. Results provide new evidence of measurement validity and reliability. Results indicate that when PBIs designed to address the needs of low-resource communities do not proactively concern themselves with racial/ethnic equity and power (as HPNC would do in the years after this study), they may result in greater White benefit from PBI or failure to close existing gaps. Findings aligned with the “political reality” model of the correspondence between the size of African American population and their perceived self-efficacy. Changes over time and inter-county differences confirm need for early measurement of power differences and changes.

Multisector stakeholders, including, community-based organizations, health systems, researchers, policymakers, and commerce, increasingly seek to address health inequities that persist due to structural racism. They require accessible tools to visualize and quantify the prevalence of social drivers of health (SDOH) and correlate them with health to facilitate dialog and action. We developed and deployed a web-based data visualization platform to make health and SDOH data available to the community. We conducted interviews and focus groups among end users of the platform to establish needs and desired platform functionality. The platform displays curated SDOH and de-identified and aggregated local electronic health record data. The resulting Social, Environmental, and Equity Drivers (SEED) Health Atlas integrates SDOH data across multiple constructs, including socioeconomic status, environmental pollution, and built environment. Aggregated health prevalence data on multiple conditions can be visualized in interactive maps. Data can be visualized and downloaded without coding knowledge. Visualizations facilitate an understanding of community health priorities and local health inequities. SEED could facilitate future discussions on improving community health and health equity. SEED provides a promising tool that members of the community and researchers may use in their efforts to improve health equity.

With place-based philanthropy, a foundation provides extensive, long-term support for a comprehensive mix of programs within specific communities, with the expectation that this will produce benefits at a communitywide level. One of the key questions in designing a place-based initiative is how much the foundation will control local decision-making. In some initiatives, the foundation dictates the issues that community groups must address and/or the nature of the planning process that will be used to develop solutions. This sometimes produces ineffective or irrelevant solutions. In contrast, other initiatives allow local groups considerable discretion in naming the issues and choosing the solutions, but the resulting strategies can suffer from a lack of cohesion and rigor. We propose that this distinction between foundation-driven and community-driven approaches is a polarity that needs to be actively managed in order to produce positive and sustained impacts. Healthy Places North Carolina, funded by the Kate B. Reynolds Charitable Trust, began with a highly community-driven orientation, experienced the limitations and complications, and then shifted to a more focused approach. While still supporting locally developed solutions, the Trust prioritized health equity, limited the set of issues for which it would offer funding, and emphasized systems change as a key element in the solutions it would fund. While this pivot was essential to the observed successes, the initiative would not have succeeded if the Trust had begun where it ended up. Neither the foundation-driven approach nor the community-driven approach is “good” in an absolute sense. Instead, foundations should make an informed choice as to the best place to begin, and then rely on warning signs to determine when it is time to adjust in order to take the work to the next level and avoid the pitfalls associated with the initial model.

In a context of social inequity, research translation naturally furthers health inequity. As Fundamental Cause Theory (FCT) explains-and an associated empirical literature illustrates-those with more resources benefit earlier and more from scientific innovation than those with fewer resources. Therefore, research translation of its own course creates and widens health disparities based on socioeconomic status and race/ethnicity. Yet, the conversation about research translation has yet to center this critical reality, undermining our efforts to address heath inequity. Moving toward sustainable health equity requires that we build the evidence base for, prioritize, and institutionalize translation approaches that center the needs and assets of low-resource populations (with community engagement helping toward that end). However, even the impact of that approach will be limited if we as a society do not mobilize knowledge to address social inequity and the many ways in which it shapes health. The health research community should engage the FCT paradigm to think critically about resource allocation among different kinds of research and action. Moreover, in our contributions to discussions about the road to health equity, we must be forthcoming about the reality FCT describes and the limitations it indicates for achieving health equity through translation of biomedical, clinical, health services, and health behavior research alone.

Problem: Translating research to support practice is becom-ing a more prominent goal in the scientific community. However, further innovation and research is needed on effective approaches to this endeavor. Purpose: This case study describes an approach that com-bines the insights of diffusion of innovation theory with the philosophy and practices of community engagement. Key Points: Elements of our approach included staged dis-semination, iterative active engagement, multi-pronged and tailored messaging, use of networks, contextualization of study findings, and emergent strategy. Our work proceeded in five stages, from laying the groundwork to deepened partnership. Conclusions: Our experience illustrates the challenges and confirms the benefits of a community engaged, partnered, and non-linear approach to research translation aimed at improving public health.

Abstract:Background: Convenience stores play an important role in supporting community-dwelling older adults' lives. We started community-based participatory research (CBPR) in Nerima City, Tokyo Metropolitan area in Japan to develop a collaborative relationship to support older adults in the community-based integrated care system.Objectives: This study aimed to describe the CBPR process and evaluate building face-to-face relationships between health/social care professionals and the owners/employees of convenience stores.Methods: Using CBPR, health/social care professionals in community general support centers (CGSCs) directly approached convenience stores based on the public support agreement between the convenience store chain company and the municipality. To evaluate the face-to-face relationship building between convenience store owners/employees and CGSCs' staff, we administered questionnaire surveys to convenience stores in Nerima City and two control cities from 2017 to 2019, and about 100 convenience stores completed the survey each year.Results: Statistical analyses showed significant improvements in their knowledge for relationships with the CGSCs in Nerima City, including "knowledge of the CGSCs' function" (P = 0.001), "knowing individual professionals in the CGSCs" (P = 0.023), and "knowledge of when to contact the CGSCs" (P = 0.002), compared with control cities. Helping behavior for older adults at convenience stores also increased significantly in Nerima City (P = 0.034).Conclusions: The CGSCs' direct approach based on the public support agreement would effectively promote building relationships at convenience stores, leading to an age-friendly community.

Objectives: The prevalence of hearing loss increases with age. Untreated hearing loss is associated with poorer communication abilities and negative health consequences, such as increased risk of dementia, increased odds of falling, and depression. Nonetheless, evidence is insufficient to support the benefits of universal hearing screening in asymptomatic older adults. The primary goal of the present study was to compare three hearing screening protocols that differed in their level of support by the primary care (PC) clinic and provider. The protocols varied in setting (in-clinic versus at-home screening) and in primary care provider (PCP) encouragement for hearing screening (yes versus no). Design: We conducted a multisite, pragmatic clinical trial. A total of 660 adults aged 65 to 75 years; 64.1% female; 35.3% African American/Black completed the trial. Three hearing screening protocols were studied, with 220 patients enrolled in each protocol. All protocols included written educational materials about hearing loss and instructions on how to complete the self-administered telephone-based hearing screening but varied in the level of support provided in the clinic setting and by the provider. The protocols were as follows: (1) no provider encouragement to complete the hearing screening at home, (2) provider encouragement to complete the hearing screening at home, and (3) provider encouragement and clinical support to complete the hearing screening after the provider visit while in the clinic. Our primary outcome was the percentage of patients who completed the hearing screening within 60 days of a routine PC visit. Secondary outcomes following patient access of hearing healthcare were also considered and consisted of the percentage of patients who completed and failed the screening and who (1) scheduled, and (2) completed a diagnostic evaluation. For patients who completed the diagnostic evaluation, we also examined the percentage of those who received a hearing loss intervention plan by a hearing healthcare provider. Results: All patients who had provider encouragement and support to complete the screening in the clinic completed the screening (100%) versus 26.8% with encouragement to complete the screening at home. For patients who were offered hearing screening at home, completion rates were similar regardless of provider encouragement (26.8% with encouragement versus 22.7% without encouragement); adjusted odds ratio of 1.25 (95% confidence interval 0.80–1.94). Regarding the secondary outcomes, roughly half (38.9–57.1% depending on group) of all patients who failed the hearing screening scheduled and completed a formal diagnostic evaluation. The percentage of patients who completed a diagnostic evaluation and received a hearing loss intervention plan was 35.0% to 50.0% depending on the group. Rates of a hearing loss intervention plan by audiologists ranged from 28.6% to 47.5% and were higher compared with those by otolaryngology providers, which ranged from 15.0% to 20.8% among the groups. Conclusions: The results of the pragmatic clinical trial showed that offering provider encouragement and screening facilities in the PC clinic led to a significantly higher rate of adherence with hearing screening associated with a single encounter. However, provider encouragement did not improve the significantly lower rate of adherence with home-based hearing screening.

Assets-based interventions can address child health disparities by connecting families to existing community resources. Community collaboration when designing interventions may identify barriers and facilitators to implementation. The objective of this study was to identify crucial implementation considerations during the design phase of an asset-based intervention to address disparities in childhood obesity, Assets for Health. We conducted focus groups and semi-structured interviews with caregivers of children (<18 years) (N = 17) and representatives of community-based organizations (CBOs) which serve children and families (N = 20). Focus group and interview guides were developed based on constructs from the Consolidated Framework for Implementation Research. Data were analyzed using rapid qualitative analysis and matrices were used to identify common themes within and across groups of community members. Desired intervention characteristics included an easy-to-use list of community programs that could be filtered based on caregiver preferences and local community health workers to promote trust and engagement among Black and Hispanic/Latino families. Most community members felt an intervention with these characteristics could be advantageous versus existing alternatives. Key outer setting characteristics which were barriers to family engagement included families’ financial insecurity and lack of access to transportation. The CBO implementation climate was supportive but there was concern that the intervention could increase staff workload beyond current capacity. Assessment of implementation determinants during the intervention design phase revealed important considerations for intervention development. Effective implementation of Assets for Health may depend on app design and usability, fostering organizational trust and minimizing the costs and staff workload of caregivers and CBOs, respectively.

National Clinician Scholars Program, Duke University, Durham, North Carolina, USA Department of Surgery, Division of Urology, Duke University School of Medicine, Durham, North Carolina, USA Health Services Research and Development, Durham VA Healthcare System, Durham, North Carolina, USA Duke-Margolis Center for Health Policy, Duke University, Durham, North Carolina, USA Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA Department of Family Medicine and Community Health, Duke University School of Medicine, Durham, North Carolina, USA Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA Department of Orthopedic Surgery, Duke University School of Medicine, Durham, North Carolina, USA Duke Clinical Research Institute, Durham, North Carolina, USA Duke Cancer Institute, Durham, North Carolina, USA Sanford School of Public Policy, Duke University, Durham, North Carolina, USA

Background and Objectives: Community engagement (CE), including community-engaged research, is a critical tool for improving the health of patients and communities, but is not taught in most medical curricula, and is even rarer in leadership training for practicing clinicians. With the growth of value-based care and increasing concern for health equity, we need to turn our attention to the benefits of working with communities to improve health and health care. The objective of this brief report is to increase understanding of the perceived benefits of CE training for primary care clinicians, specifically those already working. Methods: We assessed perceived benefits of CE training for primary care clinicians participating in health care transformation leadership training through analysis of learner reflection papers. Results: Clinicians (n=12) reported transformational learning and critical shifts of perspective. Not only did they come to value and understand CE, but the training changed their perception of their roles as clinicians and leaders. Conclusions: Educating primary care clinicians in CE as a foundational principle can orient them to the criticality of stakeholder engagement for daily practice, practice transformation, and population health improvement, and provides them with a new understanding of their roles as clinicians and leaders.

BACKGROUND:Social inequity is a primary driver of health disparities, creating multiple barriers to good health. These inequities were exacerbated during the coronavirus disease 2019 (COVID-19) pandemic, with Latinx communities suffering more than others. Grassroots collaborations have long existed to address disparities.OBJECTIVE:We describe the creation and work of the Latinx Advocacy Team and Interdisciplinary Network for COVID-19 (LATIN-19; http://latin19.org/), a multisector coalition in North Carolina created to address the unique challenges of COVID-19 in the Latinx community.METHODS:We discuss challenges and solutions that LATIN-19 addressed and the impact of LATIN-19 on community partners and members.RESULTS:LATIN-19 learned of challenges including, lack of awareness, need for data systems to track disparities, the need to increase access to resources, the need for policy changes, and the need to coordinate services by community organizations.CONCLUSIONS:LATIN-19 represents a grassroots organization that has had an impact on community and community organizations that spans beyond COVID-19.

Abstract The purpose of this research was to quantify the rates of specialty care referral completion and identify variables associated with successful completion among a population of low-income, elderly and/or disabled homebound patients with barriers to accessing office-based care. This was a cross-sectional study using descriptive and multivariate predictive analysis of specialty care referral completion, operationalized as attending an appointment of the same specialty care type within 6 months of being referred. Independent variables include patient age, sex, race, marital status, health insurance, blood pressure, and body mass index. Patient characteristics, referral information, and appointment information from July 1, 2014 to July 1, 2019 were extracted from electronic health record data of patients enrolled in the Just for Us primary care home visiting program in Durham, NC. Specialty care referrals were restricted to those for office-based consultations for chronic disease co-management originating from an outpatient primary care provider. Of 443 total referrals identified from 162 patients, 36% were successfully completed. Being married and female gender were found to be associated with successful referral completion. Of the 217 total patients in the study sample, 25% were identified as not having any referrals. No included patient characteristics were found to be significantly associated with being referred to specialty care. This study demonstrates that the specialty care needs of a medically and socially vulnerable population of homebound patients are not being adequately met.

BACKGROUND:Hearing loss is a high prevalence condition among older adults, is associated with higher-than-average risk for poor health outcomes and quality of life, and is a public health concern to individuals, families, communities, professionals, governments, and policy makers. Although low-cost hearing screening (HS) is widely available, most older adults are not asked about hearing during health care visits. A promising approach to addressing unmet needs in hearing health care is HS in primary care (PC) clinics; most PC providers (PCPs) do not inquire about hearing loss. However, no cost assessment of HS in community PC settings has been conducted in the United States. Thus, this study conducted a cost-effectiveness analysis of HS using results from a pragmatic clinic trial that compared three HS protocols that differed in the level of support and encouragement provided by the PC office and the PCPs to older adults during their routine visits. Two protocols included HS at home (one with PCP encouragement and one without) and one protocol included HS in the PC office. METHODS:Direct costs of the HS included costs of: (1) educational materials about hearing loss, (2) PCP educational and encouragement time, and (3) access to the HS system. Indirect costs for in-office HS included cost of space and minimal staff time. Costs were tracked and modeled for each phase of care during and following the HS, including completion of a diagnostic assessment and follow-up with the recommended treatment plan. RESULTS:The cost-effectiveness analysis showed that the average cost per patient is highest in the patient group who completed the HS during their clinic visit, but the average cost per patient who failed the HS is by far the lowest in that group, due to the higher failure rate, that is, rate of identification of patients with suspected hearing loss. Estimated benefits of HS in terms of improvements in quality of life were also far greater when patients completed the HS during their clinic visit. CONCLUSIONS:Providing HS to older adults during their PC visit is cost-effective and accrues greater estimated benefits in terms of improved quality of life. TRIAL REGISTRATION:clinicaltrials.gov (Registration Identification Number: NCT02928107).

Although Community-Based Participatory Research (CBPR) is grounded in socioecological theories of health, using and addressing theory in CBPR can be challenging. This paper explores how theory was used and melded with community expertise in one CBPR study in Durham, North Carolina. Challenges to use of theory included time restrictions, the need to focus on meeting local needs and making short-term measurable gains, and differences among collaborators in comfort with and concern for theoretical discussion. Both community and theoretical voices were sometimes short-changed – particularly voices that were more difficult to access or integrate into existing ways of operating. Nonetheless, we were able to bring theory into our work at a number of stages and to meld theory with community expertise in ways that benefited our project. Our case study suggests the importance of creating opportunities for small group discussion; utilizing an iterative dialogic approach to melding theory and community expertise; grounding theoretical discussions in specific, concrete questions; taking the long view of CBPR, including purposefully bringing attention to theory even while responding to pragmatic concerns; and spending more time on building the capacity to collaborate of both academic and community partners. It also raises the need for funders to consider how to align their expectations of grantees with effective attention to root causes of poor health and health disparities.

BACKGROUND:Residential eviction is a component of housing instability that negatively affects physical and mental health, but the effect of eviction on health care utilization, specifically hospital readmissions and outpatient no-show rates, is not known.METHODS:We conducted a retrospective review of health care utilization of individuals evicted from public housing between January 2013 and December 2017, investigating hospital readmissions and no-show rates one year before and after eviction.RESULTS:131 individuals who had been evicted had one year of data pre-and post-eviction. The majority were African American (97.7%) and female (80.9%). There was no significant change in 30-, 60-, and 90-day hospital readmissions (p>.05). No-show rate decreased from 27.57 per person per year to 20.13 (p=.05).CONCLUSIONS:For our study population, health care utilization was not disrupted. The decreased no-show rate represents an opportunity for health systems to engage with patients on social factors affecting their health post-eviction.

Background The burden of hearing loss among older adults could be mitigated with appropriate care. This study compares implementation of three hearing screening strategies in primary care, and examines the reliability and validity of patient self-assessment, primary care providers (PCP) and diagnostic audiologists in the identification of ‘red flag’ conditions (those conditions that may require medical consultation and/or intervention). Methods Six primary care practices will implement one of three screening strategies (2 practices per strategy) with 660 patients (220 per strategy) ages 65–75 years with no history of hearing aid use or diagnosis of hearing loss. Strategies differ on the location and use of PCP encouragement to complete a telephone-based hearing screen (tele-HS). Group 1: instructions for tele-HS to complete at home and educational materials on warning signs and consequences of hearing loss. Group 2: PCP counseling/encouragement on importance of hearing screening, instructions to take the tele-HS from home, educational materials. Group 3: PCP counseling/encouragement, in-office tele-HS, and educational materials. Patients from all groups who fail the tele-HS will be referred for diagnostic audiological testing and medical evaluation, and complete a self-assessment of red flag conditions at this follow-up appointment. Due to the expected low incidence of ear disease in the PCP cohort, we will enroll a complementary population of patients ( N = 500) from selected otolaryngology head and neck surgery clinics in a national practice-based research network to increase the likelihood of occurrence of medical conditions that might contraindicate hearing aid fitting. The primary outcome is the proportion of patients who complete the tele-HS within 2 months of the PCP appointment comparing Group 3 (PCP encouragement, in-office tele-HS, education) versus Groups 2 and 1 (education and tele-HS at home, with and without PCP encouragement, respectively). The several secondary outcomes include direct and indirect costs, patient, family and provider attitudes of hearing healthcare, and accuracy of red flag condition evaluations compared with expert medical assessment by an otolaryngology provider. Discussion Determining the relative effectiveness of three different strategies for hearing screening in primary care and the assessment accuracy of red flag conditions can each lead to practice and policy changes that will reduce individual, family and societal burden from hearing loss among older adults. Trial registration Clinicaltrials.gov: NCT02928107 ; 10/10/2016 protocol version 1.