CEAL Teams Put Social Care Front and Center in Health Care

Decades of research show that social factors — such as access to nutritious food, stable housing, or reliable transportation — are central to people’s health. Yet these kinds of upstream, nonmedical needs are rarely addressed in a doctor’s office. Two CEAL research teams are studying structured ways to do just that. Deploying community health workers (CHWs) to connect patients to social services, studies conducted by CEAL’s Network for Community-Engaged Primary Care Research (NCPCR) and the Arizona CEAL Regional Team are uncovering insights into integrating social care services into health care delivery and their impacts on the health of people with or at risk of chronic disease.

Measuring patient outcomes

NCPCR’s randomized clinical trial, CHW-SYSTIM (Community Health Workers Systematically Assessing and Addressing Social Determinants of Health [SDOH] to Improve Outcomes In Community-based Health Centers), is taking place in 26 community health centers (CHCs) across the country. CHCs provide an affordable health care option for millions of people and generally provide care regardless of one’s ability to pay. As such, they serve as health care lifelines for communities with limited access to medical care.

In the NCPCR study, CHWs in CHCs meet with participants who have uncontrolled diabetes and/or hypertension to identify the barriers to effective disease management and then refer patients to social services to help meet their social needs.

In the Arizona study, called Linking Social Care with Healthcare Systems to Address SDOH, health care providers at 10 sites connect patients to CHWs either in person or via a toll-free phone number to assess their social needs and make referrals to help. For example, a patient with transportation challenges may be referred to services providing assistance with ride-sharing services or transportation vouchers to get to and from appointments. This work is powered by a partnership with the Arizona Community Health Workers Association, which represents 1,500 CHWs statewide.

At the patient level, both studies will look at physical measures to see how the intervention affected personal health. The NCPCR study will assess changes in blood sugar levels (for those with diabetes) and in blood pressure (for those with hypertension). The Arizona team will also study these kinds of physical effects, in addition to other changes, like changes in health care utilization.

“There is a real need to understand how CHWs can best serve as a clinical resource bridging to social care, and to measure the direct effects on health of these CHW-led efforts,” says Rachel Gold, NCPCR multiple principal investigator (MPI) and senior investigator at NCPCR awardee OCHIN, one of the partnering programs of NCPCR.

Assessing systems-level benefits

Beyond impacts at the patient level, both studies are also looking at broader implications for health care delivery.

For the NCPCR study, that means assessing how well the CHCs strengthen their processes for social care screening and referrals, along with their ties to community resource providers. Even more broadly, the CHW-SYSTIM trial will highlight the ability to conduct community-engaged primary care clinical research by working with CHCs. “Like the communities they serve, CHCs are often not a part of clinical research,” says Dominic Mack, family physician and director of the Morehouse School of Medicine’s National Center for Primary Care and NCPCR MPI. “Through this study, CHCs can lead the way in showing how to systematically adopt social care interventions.”

The Arizona team will conduct surveys and interviews to help identify barriers and assess how ready health systems are to embed social needs care. They will also study metrics, including the percentage of providers still using the referral service after 3 years. “The goal is not just to establish, but also sustain the ability of systems to work together more easily to meet health-related social needs,” says Sairam Parthasarathy, professor of medicine at the University of Arizona and Arizona CEAL Regional Team MPI.

Making immediate impacts

Although the studies are taking place over multiple years, both are already having an immediate impact on people’s lives. A participant in the Arizona research project, for instance, was recently able to connect with needed mental health services through an existing trusted relationship with a participating CHW. And, CHWs in the NCPCR study report becoming better established as care team members, providing valuable patient support and experiencing professional satisfaction in turn.

In this way, the two studies are not just holding promise to strengthen health care systems and improve people’s lives — they’re already delivering.