Development of PRAPARE Social Determinants of Health Clusters and Correlation with Diabetes and Hypertension Outcomes.

INTRODUCTION: PRAPARE is a leading social risk screening tool. No studies yet have simplified the 22 PRAPARE social determinants of health (SDoH) into clusters to analyze associations with chronic disease outcomes. METHODS: A federally qualified health center conducted cross-sectional PRAPARE screening on its general adult population. Exploratory and confirmatory factor analyses were used to identify SDoH clusters and construct cluster scores and SDoH total risk scores. Logistic regression assessed relationships between cluster scores and uncontrolled diabetes and/or hypertension. RESULTS: Of the 11,773 adults who answered the survey, 716 had diabetes only, 2,388 had hypertension only, 1,477 had both, and 7,192 had neither. We found 3 composite SDoH clusters (social background, social insecurities, insurance/employment) and 3 standalone clusters (housing status, social isolation, poverty). Among patients with diabetes, those at risk in social background, social insecurities, and insurance/employment were more likely to have uncontrolled diabetes. Among patients with hypertension, those at more risk in social insecurities were more likely to have uncontrolled hypertension. CONCLUSIONS: We simplified the 22 PRAPARE SDoH into 3 composite clusters and 3 individual clusters and demonstrated the reliability and validity of PRAPARE. The 3 composite clusters were positively associated with uncontrolled diabetes and/or hypertension.

Collecting Social Determinants of Health Data in the Clinical Setting: Findings from National PRAPARE Implementation.

BACKGROUND: The Protocol for Responding to and Assessing Patient Assets, Risks, and Experiences (PRAPARE) is a nationally recognized standardized protocol that goes beyond medical acuity to account for patients' social determinants of health (SDH). AIMS: We described the magnitude of patient SDH barriers at health centers. METHODS: Health centers across three PRAPARE implementation cohorts collected and submitted PRAPARE data using a standardized data reporting template. We analyzed the scope and intensity of SDH barriers across the cohorts. RESULTS: Nationally, patients faced an average of 7.2 out of 22 social risks. The most common SDH risks among all three cohorts were limited English proficiency, less than high school education, lack of insurance, experiencing high to medium-high stress, and unemployment. CONCLUSIONS: Findings demonstrated a high prevalence of SDH risks among health center patients that can be critical for informing social interventions and upstream transformation to improve health equity for underserved populations.

Assessing the Impact of Electronic Health Record Interventions on Hepatitis B Screening and Vaccination.

BACKGROUND: Hepatitis B virus (HBV) infection is a major health disparity between Asian Americans, Native Hawaiians, and Pacific Islanders compared with other racial/ethnic groups in the U.S. AIMS: Our aims were to determine the effectiveness of an electronic health record (EHR) data-driven clinical intervention to improve HBV screening and vaccination rates at a community health center primarily serving Asian American patients. METHODS: Using a community-engaged approach, we conducted a study to compare the differences in screening and vaccination rates for 6,429 patient encounters before and after implementation of the EHR intervention. A multivariable logistic regression analysis was conducted to estimate the effect of the intervention. RESULTS: Analyses indicated that patients who visited the clinic after implementing the EHR intervention were more likely to be screened (OR=1.8, p<.001) and vaccinated (OR=2.8, p<.001) for hepatitis B. CONCLUSIONS: Electronic health record interventions implemented using a community-engaged approach may improve delivery of appropriate care to patients at risk for hepatitis B in a community health setting.

Results of the Community Health Applied Research Network (CHARN) National Research Capacity Survey of Community Health Centers.

BACKGROUND: The mission of the Community Health Applied Research Network (CHARN) is to build capacity to carry out Patient-Centered Outcomes Research at community health centers (CHCs), with the ultimate goal to improve health care for vulnerable populations. OBJECTIVES: The CHARN Needs Assessment Staff Survey investigates CHCs' involvement in research, as well as their need for research training and resources. Results will be used to guide future training. METHODS: The survey was developed and implemented in partnership with CHARN CHCs. Data were collected across CHARN CHCs. Data analysis and reports were conducted by the CHARN data coordinating center (DCC). RESULTS: Survey results highlighted gaps in staff research training, and these gaps varied by staff role. CONCLUSIONS: There is considerable variation in research involvement, partnerships, and focus both within and across CHCs. Development of training programs to increase research capacity should be tailored to address the specific needs and roles of staff involved in research.

Defining and Rating the Effectiveness of Enabling Services Using a Multi-stakeholder Expert Panel Approach.

The Affordable Care Act provides opportunities to reimburse non-medical enabling services that promote the delivery of medical care for patients with social barriers. However, limited evidence exists to guide delivery of these services. We addressed this gap by convening community health center patients, providers, and other stakeholders in two panels that developed a framework for defining and evaluating these services. We adapted a group consensus method where the panelists rated services for effectiveness in increasing access to, use, and understanding of medical care. Panelists defined six broad categories, 112 services, and 21 variables including the type of provider delivering the service. We identified 16 highest-rated services and found that the service provider's level of training affected effectiveness for some but not all services. In a field with little evidence, these findings provide guidance to decision-makers for the targeted spread of services that enable patients to overcome social barriers to care.

The Community Health Applied Research Network (CHARN) Data Warehouse: a Resource for Patient-Centered Outcomes Research and Quality Improvement in Underserved, Safety Net Populations.

BACKGROUND: The Community Health Applied Research Network, funded by the Health Resources and Services Administration, is a research network comprising 18 Community Health Centers organized into four Research Nodes (each including an academic partner) and a data coordinating center. The network represents more than 500,000 diverse safety net patients across 11 states. OBJECTIVE: The primary objective of this paper is to describe the development and implementation process of the CHARN data warehouse. METHODS: The methods involved regulatory and governance development and approval, development of content and structure of the warehouse and processes for extracting the data locally, performing validation, and finally submitting data to the data coordinating center. PROGRESS TO DATE: Version 1 of the warehouse has been developed. Tables have been added, the population and the years of electronic health records (EHR) have been expanded for Version 2. CONCLUSIONS: It is feasible to create a national, centralized data warehouse with multiple Community Health Center partners using different EHR systems. It is essential to allow sufficient time: (1) to develop collaborative, trusting relationships among new partners with varied technology, backgrounds, expertise, and interests; (2) to complete institutional, business, and regulatory review processes; (3) to identify and address technical challenges associated with diverse data environments, practices, and resources; and (4) to provide continuing data quality assessments to ensure data accuracy.

Building research infrastructure in community health centers: a Community Health Applied Research Network (CHARN) report.

This article introduces the Community Health Applied Research Network (CHARN), a practice-based research network of community health centers (CHCs). Established by the Health Resources and Services Administration in 2010, CHARN is a network of 4 community research nodes, each with multiple affiliated CHCs and an academic center. The four nodes (18 individual CHCs and 4 academic partners in 9 states) are supported by a data coordinating center. Here we provide case studies detailing how CHARN is building research infrastructure and capacity in CHCs, with a particular focus on how community practice-academic partnerships were facilitated by the CHARN structure. The examples provided by the CHARN nodes include many of the building blocks of research capacity: communication capacity and "matchmaking" between providers and researchers; technology transfer; research methods tailored to community practice settings; and community institutional review board infrastructure to enable community oversight. We draw lessons learned from these case studies that we hope will serve as examples for other networks, with special relevance for community-based networks seeking to build research infrastructure in primary care settings.

Capability for change at community health centers serving Asian Pacific Islanders: an exploratory study of a cancer screening evidence-based intervention.

BACKGROUND: Understanding and enhancing change capabilities, including Practice Adaptive Reserve (PAR), of Community Health Centers (CHCs) may mitigate cancer-related health disparities. MATERIALS AND METHODS: Using stratified random sampling, we recruited 232 staff from seven CHCs serving Asian Pacific Islander communities to complete a self-administered survey. We performed multilevel regression analyses to examine PAR composite scores by CHC, position type, and number of years worked at their clinic. RESULTS: The mean PAR score was 0.7 (s.d. 0.14). Higher scores were associated with a greater perceived likelihood that clinic staff would participate in an evidence-based intervention (EBI). Constructs such as communication, clinic flow, sensemaking, change valence, and resource availability were positively associated with EBI implementation or trended toward significance. CONCLUSIONS: PAR scores are positively associated with perceived likelihood of clinic staff participation in cancer screening EBI. Future research is needed to determine PAR levels most conducive to implementing change and to developing interventions that enhance Adaptive Reserve.

Improving Asian American, Native Hawaiian, and Pacific Islander health: national organizations leading community research initiatives.

BACKGROUND: Functionally, many CBPR projects operate through a model of academic partners providing research expertise and community partners playing a supporting role. OBJECTIVES: To demonstrate how national umbrella organizations deeply rooted in communities, cognizant of community needs, and drawing on the insights and assets of community partners, can lead efforts to address health disparities affecting their constituents through research. METHODS: Case studies of two Asian American, Native Hawaiian, and Pacific Islander national organizations. RESULTS: Strategically engaging a diverse range of partners and securing flexible funding mechanisms that support research were important facilitators. Main challenges included limited interest of local community organizations whose primary missions as service or health care providers may deprioritize research. CONCLUSIONS: Efforts to make research relevant to the work of community partners and to instill the value of research in community partners, as well as flexible funding mechanisms, may help to promote community-driven research.

Hepatitis B prevention and care for Asian Americans, Native Hawaiians and Pacific Islanders at community health centers.

INTRODUCTION: A needs assessment was conducted of hepatitis B education, screening, vaccination, and care within community health centers (CHCs) serving Asian Americans, Native Hawaiians, and Pacific Islanders. METHODS: Written surveys were administered to health education directors from 13 CHCs and 75 medical providers from 14 CHCs in the U.S. and affiliated Pacific Islands. RESULTS: Although hepatitis B is within the mission of CHCs and clients are screened regardless of insurance status, little financial or staffing resources are dedicated to hepatitis B services. Lack of funding is considered the greatest barrier. Better coordination between HBV prevention and primary and specialty medical services is needed. DISCUSSION: HBV cross-training for providers and allied staff, particularly around identification and screening of high risk groups and case management, would greatly enhance services along with additional funding. Findings support national hepatitis B strategy recommendations made by the Institute of Medicine and Office of Minority Health.

Use of enabling services by Asian American, Native Hawaiian, and other Pacific Islander patients at 4 community health centers.

OBJECTIVES: We sought to examine the utilization and impact of enabling services, such as interpretation and eligibility assistance, among underserved Asian American, Native Hawaiian, and other Pacific Islander (AANHOPI) patients served at 4 community health centers. METHODS: For this project, we developed a uniform model for collecting data on enabling services and implemented it across 4 health centers that served primarily AANHOPI patients. We also examined differences in patient characteristics between users and nonusers of enabling services. RESULTS: Health center patients used many enabling services, with eligibility assistance being the most used service. In addition, compared with nonusers, users of enabling services were more likely to be older, female, AANHOPI, and uninsured (P < .05). CONCLUSIONS: For underserved AANHOPI patients at community health centers, enabling services are critical for access to appropriate care. We were the first to examine uniform data on enabling services across multiple health centers serving underserved AANHOPI patients. More data on enabling services and evaluation are needed to develop interventions to improve the quality of care for underserved AANHOPI patients.

Primary health-care delivery gaps among medically underserved Asian American and Pacific Islander populations.

OBJECTIVES: Asian American and Pacific Islanders (AAPIs) historically have faced multiple social and racial/ethnic health disparities in the United States. We gathered national-level health-care data on AAPIs and examined medically underserved health service areas for them. METHODS: We used 2000 U.S. Census data and the Bureau of Primary Health Care (BPHC) 2004 dataset for primary care physician full-time equivalents per 1000 population, as well as AAPI population, AAPI poverty, and AAPI limited English proficiency, to develop an index of medically underserved AAPI counties (MUACs). The index identifies U.S. counties that do not adequately serve AAPIs. RESULTS: We identified 266 counties of medically underserved health service areas for AAPIs across the nation, representing 12% of all U.S. counties. One hundred thirty-eight (52%) MUACs were not designated as BPHC medically underserved counties. Of these counties, 20 (14%) had an AAPI population of at least 10,000, and 29 (21%) had an AAPI population of at least 5000. CONCLUSION: This project complements federal efforts to identify medically underserved health service areas and identifies U.S. counties that need new or expanded health services for medically underserved AAPIs.