RWJF Grant on System Integration of a SDoH Arm into a Clinical Setting

Grant Source

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Robert Wood Johnson Foundation

Contributors

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Shelly White-Means, PhD, Director of CHEER
Altha Stewart, MD,  Director for the Center for Youth Advocacy and Well-Being
Marcella Wilson, PhD, Transition to Success founder

Transition to Success
Cherokee Health Systems

Grant Abstract

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Social Determinants of Health Treatment Is an Essential Structural Change in Primary Care

A structural change in the delivery of health care for persons who live in poverty is long overdue. Unmasked by realities laid bare by COVID-19, the poverty-health connection is direct and irrefutable. Our recovery, as a nation, requires an evidence-based response to the condition of poverty. This research examines the question of whether an evidence-based tri-fold treatment of mental health, physical health, and poverty will lead to improvements in exposures to social determinants of health (sdoh), symptoms of depression and anxiety, hospitalizations and ER use, health conditions that disproportionately impact the lives of people of color, as well as reductions in cost of care for low income Medicaid-eligible patients. The intervention is the integration of Christ Community Health Systems with an evidence-based poverty treatment program called Transition to Success (TTS), recognized as a Clinton Global Initiative with an already established, trained network of care in Memphis. By adding TTS’ focus with practitioners and patients in a medical practice environment that serves a large percentage of Medicaid-eligible patients, our objective is to produce notable changes in physical health, behavioral health, and sdoh exposures. A central feature of this research is a community participatory approach. We will recruit 250 patients from six Christ Community Health System clinics in Memphis. Bivariate analysis at baseline, 3-, 6-, and 12-months will be performed to note changes in the above outcomes over time. At the end of the data collection we will execute fixed effects logistic regression and Cox-Proportional hazard modeling to explore changes in outcomes over time and the length of time for an outcome to change. We will disseminate our findings through journal submissions, professional association communications, webinars, conferences, communications with the current TTS national network, via RWJF networks, and a Community Forum with local stakeholders, partners and collaborations.