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Implementation of EMR-Integrated Referrals to Link Clinical and Community Services to Reduce Health Inequity

Award Number: R01HL150909
ORGANIZATION: NATIONAL HEART, LUNG, & BLOOD INSTITUTE
OPDIV: NIH
AWARD CLASS: DISCRETIONARY
AWARD ACTIVITY TYPE: SCIENTIFIC/HEALTH RESEARCH (INCLUDES SURVEYS)

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Implementation of EMR-Integrated Referrals to Link Clinical and Community Services to Reduce Health Inequity - ABSTRACT Cardiovascular disease (CVD) exerts a disproportionate burden of morbidity and mortality on African Americans in the rural southeast. Much of this excess has been attributed, directly and indirectly, to social determinants of health and resulting health-related social needs. While CVD prevention interventions have reduced overall disease burden, they have failed to eliminate racial and geographic disparities in CVD. New models of care, such as Accountable Health Communities, address health-related social needs through screening, referral, and community navigation services and have begun to demonstrate improvement in health care cost, use, and CVD risk factors. Rural minority communities, where the burden of CVD risk factors and social needs are high, healthcare facilities may be more fragile and density of resources may be lower, have even greater need for effective and scalable solutions to addressing health and social needs. Our proposal is anchored by Bandura's Self-Efficacy theory, Grey's Self and Family Management Framework, and Andersen's Behavioral Model of Health Services Use. We will use the Consolidated Framework for Implementation Research to study implementation and effectiveness of integrating health-promoting community resource data into the EMR via CommunityRx (CRx). The CRx-CVD intervention is a digital solution that links patients with community-based resources to address health-related social needs and cardiometabolic health in rural AA patients. Our overall objective is to identify factors that influence implementation and assess the health impact of a closed-loop referral system to community health-promoting resources in a rural setting. We use a hybrid II implementation effectiveness design to conduct a controlled pragmatic trial of patients (adults 18 years and over, children 2-17 years; N=750) in a system of federally qualified health centers in rural North Carolina. We hypothesize that integration of closed-loop referrals will increase patient knowledge of community resources, enhance self-efficacy to manage CVD risk factors, increase utilization of community resources and improve markers of cardiometabolic conditions. To our knowledge, this trial will be the first to evaluate the implementation and health impact of a low intensity, scalable, clinic-initiated intervention targeting AA adults and children at risk of CVD. Furthermore, we will conduct cost-effectiveness analysis related to implementation of CRx-CVD to inform scaling the intervention. The long-term goal is to identify scalable interventions to reduce CVD risk and health-related social needs of African Americans using a “whole person” approach to health.


Issue Date FY	Funding FY	Legal Entity Name	Legal Entity Address	Legal Entity City	Legal Entity State	Legal Entity Zip Code	Legal Entity COUNTY	Legal Entity COUNTRY	Assistance Listing	Award Code	Budget Year	Action Date	Action Type	Action Amount

Issue Date FY: 2025 ( Subtotal = $0 )
2025	2024	UNIVERSITY OF NORTH CAROLINA AT CHAPEL HILL	104 AIRPORT DR STE 2200	CHAPEL HILL	NC	27599	ORANGE	USA	Translation and Implementation Science Research for Heart, Lung, Blood Diseases, and Sleep Disorders	000	5	2/28/2025	NON-COMPETING CONTINUATION	$0
														Subtotal = $0

Issue Date FY: 2024 ( Subtotal = $698,487 )
2024	2024	UNIVERSITY OF NORTH CAROLINA AT CHAPEL HILL	104 AIRPORT DR STE 2200	CHAPEL HILL	NC	27599	ORANGE	USA	Translation and Implementation Science Research for Heart, Lung, Blood Diseases, and Sleep Disorders	002	5	7/19/2024	NON-COMPETING CONTINUATION	$60,157
2024	2024	UNIVERSITY OF NORTH CAROLINA AT CHAPEL HILL	104 AIRPORT DR STE 2200	CHAPEL HILL	NC	27599	ORANGE	USA	Translation and Implementation Science Research for Heart, Lung, Blood Diseases, and Sleep Disorders	001	5	1/22/2024	NON-COMPETING CONTINUATION	$676,799
2024	2023	UNIVERSITY OF NORTH CAROLINA AT CHAPEL HILL	104 AIRPORT DR STE 2200	CHAPEL HILL	NC	27599	ORANGE	USA	Translation and Implementation Science Research for Heart, Lung, Blood Diseases, and Sleep Disorders	000	4	1/17/2024	SUPPLEMENT FOR EXPANSION	-$38,469
														Subtotal = $698,487

Issue Date FY: 2023 ( Subtotal = $860,102 )
2023	2023	UNIVERSITY OF NORTH CAROLINA AT CHAPEL HILL	104 AIRPORT DR STE 2200	CHAPEL HILL	NC	27599	ORANGE	USA	Translation and Implementation Science Research for Heart, Lung, Blood Diseases, and Sleep Disorders	002	4	2/28/2023	SUPPLEMENT FOR EXPANSION	$108,105
2023	2023	UNIVERSITY OF NORTH CAROLINA AT CHAPEL HILL	104 AIRPORT DR STE 2200	CHAPEL HILL	NC	27599	ORANGE	USA	Translation and Implementation Science Research for Heart, Lung, Blood Diseases, and Sleep Disorders	001	4	2/22/2023	NON-COMPETING CONTINUATION	$751,997
2023	2022	UNIVERSITY OF NORTH CAROLINA AT CHAPEL HILL	104 AIRPORT DR STE 2200	CHAPEL HILL	NC	27599	ORANGE	USA	Translation and Implementation Science Research for Heart, Lung, Blood Diseases, and Sleep Disorders	000	3	1/19/2023	NON-COMPETING CONTINUATION	$0
														Subtotal = $860,102

Issue Date FY: 2022 ( Subtotal = $843,854 )
2022	2022	UNIVERSITY OF NORTH CAROLINA AT CHAPEL HILL	104 AIRPORT DR STE 2200	CHAPEL HILL	NC	27599	ORANGE	USA	Translation and Implementation Science Research for Heart, Lung, Blood Diseases, and Sleep Disorders	004	3	9/26/2022	SUPPLEMENT FOR EXPANSION	$0
2022	2022	UNIVERSITY OF NORTH CAROLINA AT CHAPEL HILL	104 AIRPORT DR STE 2200	CHAPEL HILL	NC	27599	ORANGE	USA	Translation and Implementation Science Research for Heart, Lung, Blood Diseases, and Sleep Disorders	000	3	12/20/2021	NON-COMPETING CONTINUATION	$676,798
2022	2022	UNIVERSITY OF NORTH CAROLINA AT CHAPEL HILL	104 AIRPORT DR STE 2200	CHAPEL HILL	NC	27599	ORANGE	USA	Translation and Implementation Science Research for Heart, Lung, Blood Diseases, and Sleep Disorders	001	3	4/5/2022	SUPPLEMENT FOR EXPANSION	$91,857
2022	2022	UNIVERSITY OF NORTH CAROLINA AT CHAPEL HILL	104 AIRPORT DR STE 2200	CHAPEL HILL	NC	27599	ORANGE	USA	Translation and Implementation Science Research for Heart, Lung, Blood Diseases, and Sleep Disorders	003	3	6/15/2022	NON-COMPETING CONTINUATION	$75,199
2022	2022	UNIVERSITY OF NORTH CAROLINA AT CHAPEL HILL	104 AIRPORT DR STE 2200	CHAPEL HILL	NC	27599	ORANGE	USA	Translation and Implementation Science Research for Heart, Lung, Blood Diseases, and Sleep Disorders	002	3	4/29/2022	SUPPLEMENT FOR EXPANSION	$0
														Subtotal = $843,854

Issue Date FY: 2021 ( Subtotal = $751,997 )
2021	2021	UNIVERSITY OF NORTH CAROLINA AT CHAPEL HILL	104 AIRPORT DR STE 2200	CHAPEL HILL	NC	27599	ORANGE	USA	Translation and Implementation Science Research for Heart, Lung, Blood Diseases, and Sleep Disorders	000	2	12/18/2020	NON-COMPETING CONTINUATION	$676,798
2021	2021	UNIVERSITY OF NORTH CAROLINA AT CHAPEL HILL	104 AIRPORT DR STE 2200	CHAPEL HILL	NC	27599	ORANGE	USA	Translation and Implementation Science Research for Heart, Lung, Blood Diseases, and Sleep Disorders	001	2	5/24/2021	NON-COMPETING CONTINUATION	$75,199
														Subtotal = $751,997

Issue Date FY: 2020 ( Subtotal = $793,622 )
2020	2020	UNIVERSITY OF NORTH CAROLINA AT CHAPEL HILL	104 AIRPORT DR STE 2200	CHAPEL HILL	NC	27599	ORANGE	USA	Translation and Implementation Science Research for Heart, Lung, Blood Diseases, and Sleep Disorders	000	1	12/31/2019	NEW	$739,878
2020	2020	UNIVERSITY OF NORTH CAROLINA AT CHAPEL HILL	104 AIRPORT DR STE 2200	CHAPEL HILL	NC	27599	ORANGE	USA	Translation and Implementation Science Research for Heart, Lung, Blood Diseases, and Sleep Disorders	001	1	2/17/2020	NEW	$53,744
														Subtotal = $793,622

Grand Total All Awards = $3,948,062

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Implementation of EMR-Integrated Referrals to Link Clinical and Community Services to Reduce Health Inequity

Award Number: R01HL150909

ORGANIZATION: NATIONAL HEART, LUNG, & BLOOD INSTITUTE

OPDIV: NIH

AWARD CLASS: DISCRETIONARY

AWARD ACTIVITY TYPE: SCIENTIFIC/HEALTH RESEARCH (INCLUDES SURVEYS)

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