PROJECT SUMMARY
Equity gaps in child health outcomes result, at least in part, from insufficiently addressed social determinants of
health, defined as “the conditions in which people are born, live, learn, work, play, worship, and age.” Patient
and family needs related to determinants like toxic housing, access barriers, and socioeconomic deprivation
undermine health and shift attention away from completion of follow-up visits, medication fills, and other ser-
vices that promote optimal health and well-being outcomes. Insufficiently addressed social determinants ex-
plain much of the persistence in health disparities. As a result, healthcare systems that effectively monitor for
risks and then integrate proactive responses to both medical and social needs will be more likely to achieve
better, equitable outcomes. Thus, the objective of this project is to co-design and evaluate the “Responding to
Identified Sociomedical risks with Effective Unified Purpose” System (RISEUP) to best meet both the medical
and social needs of children and their communities. The central hypothesis is that an integrated system co-
designed with healthcare-, human service-, payer-based stakeholders, and parents of pediatric patients, will
promote better, more equitable outcomes across conditions by enhancing situation awareness and informing
cross-sector actions directed at common root causes. This hypothesis will be tested through three specific
aims: 1) Identify common root causes of health equity gaps across three chronic pediatric conditions (asthma,
type 1 diabetes, and sickle cell disease) using an integrated monitoring system; 2) Co-design a response sys-
tem to operationalize shared theory and address medical-social risks; and 3) Evaluate the effects of a medical-
social monitoring and response system on patient- and population-level health outcomes, employing RISEUP
in the care of children with asthma, diabetes, and sickle cell living in high-morbidity, high-poverty communities.
The contribution of the proposed research is to co-design and evaluate RISEUP, this monitoring and response
system in partnership with healthcare-, human service-, and payer-based stakeholders, and parents of pediat-
ric patients. This research is significant because both medical and social data together would provide AHRQ-
prioritized 360-degree views of children and communities, getting us closer to those factors at the root of poor
health. This proposal is innovative in its monitoring of disparities’ root causes and the co-design and evaluation
of integrated, coordinated response systems. Such data integration, accelerated by human-centered co-design
and population-based quality improvement, holds great promise for subsequent scale and spread. Expected
outcomes include a potentially transformative template for healthcare and human service systems to collabora-
tively monitor and respond to disparities. Indeed, RISEUP will positively affect children by facilitating a preven-
tive approach to addressing the social determinants and equitably improving outcomes for children, a vulnera-
ble and AHRQ-prioritized population.
