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The Development, Implementation, and Evaluation of a Social Engagement Support System

Award Number: R01MD019814
ORGANIZATION: NATIONAL CENTER ON MINORITY HEALTH AND HEALTH DISPARITIES
OPDIV: NIH
AWARD CLASS: DISCRETIONARY
AWARD ACTIVITY TYPE: SCIENTIFIC/HEALTH RESEARCH (INCLUDES SURVEYS)
PERIOD OF PERFORMANCE START DATE: 09/20/2024
PERIOD OF PERFORMANCE END DATE: 04/30/2029

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The Development, Implementation, and Evaluation of a Social Engagement Support System - PROJECT SUMMARY Social drivers of health (SDoH) are the largest factors affecting our health and wellbeing but are difficult for healthcare systems to address. The lack of healthy food, inadequate housing, and sparse social supports disproportionately affect individuals burdened by health disparities, both exacerbating chronic conditions and preventing people from receiving the care they need. The nearly 90 million Medicaid recipients are at particularly high risk with overrepresentation of individuals vulnerable to health disparities, including those with low or no income, racial or ethnic minorities, children, the elderly, or individuals with disabilities. Health systems face two problems when reaching beyond clinical care to improve patient health outcomes. The first problem is one of identification; providers undercode social needs in existing schemas and ancillary data collection methods such as social screens are not common, standardized, or easily shared. The second problem is a lack of engagement between individuals and social services, which is especially frustrating since there are many evidence-based practices that community-based organizations (CBOs) use to address social needs. Our project will apply a precision medicine approach to the identification of, and engagement with, Medicaid recipients with social needs. We will enhance the health information infrastructure of a managed care organization that coordinates benefits for over 250,000 Maryland Medicaid members by: ● Developing and deploying a set of machine learning models that use multiple individual- and community-level data sources to predict which members use the emergency department to fulfill social or non-urgent needs as opposed to treatment for urgent medical conditions. ● Developing and deploying an engagement support system that identifies and displays the characteristics of members that are predicted to prevent them from engaging with a CBO. ● Implementing a continuous qualitative and quantitative improvement process that identifies recurring themes and disengagement points in cases where members did not complete their social intervention. The study team is well positioned to develop a social needs intervention protocol and will include rigorous evaluations to assess the effects of our intervention on the health and social outcomes of participating members by their demographic and geographic characteristics. Together, our Aims will help identify and address social needs and shrink disparities in health outcomes across a large, high-risk population.


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 = $668,087 )
2025	2025	UNIVERSITY OF MARYLAND BALTIMORE COUNTY	1000 HILLTOP CIR	BALTIMORE	MD	21250	BALTIMORE	USA	Minority Health and Health Disparities Research	003	2	7/10/2025	NON-COMPETING CONTINUATION	$668,087
2025	2024	UNIVERSITY OF MARYLAND BALTIMORE COUNTY	1000 HILLTOP CIR	BALTIMORE	MD	21250	BALTIMORE	USA	Minority Health and Health Disparities Research	001	1	5/24/2025	TERMINATION	$0
2025	2024	UNIVERSITY OF MARYLAND BALTIMORE COUNTY	1000 HILLTOP CIR	BALTIMORE	MD	21250	BALTIMORE	USA	Minority Health and Health Disparities Research	002	1	7/5/2025	OTHER REVISION	$0
2025	2024	UNIVERSITY OF MARYLAND BALTIMORE COUNTY	1000 HILLTOP CIR	BALTIMORE	MD	21250	BALTIMORE	USA	Minority Health and Health Disparities Research	000	1	12/18/2024	NEW	$0
														Subtotal = $668,087

Issue Date FY: 2024 ( Subtotal = $643,798 )
2024	2024	UNIVERSITY OF MARYLAND BALTIMORE COUNTY	1000 HILLTOP CIR	BALTIMORE	MD	21250	BALTIMORE	USA	Minority Health and Health Disparities Research	000	1	9/17/2024	NEW	$643,798
2024	2024	UNIVERSITY OF MARYLAND BALTIMORE COUNTY	1000 HILLTOP CIR	BALTIMORE	MD	21250	BALTIMORE	USA	Minority Health and Health Disparities Research	001	1	9/18/2024	NEW	$0
														Subtotal = $643,798

Grand Total All Awards = $1,311,885

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The Development, Implementation, and Evaluation of a Social Engagement Support System

Award Number: R01MD019814

ORGANIZATION: NATIONAL CENTER ON MINORITY HEALTH AND HEALTH DISPARITIES

OPDIV: NIH

AWARD CLASS: DISCRETIONARY

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

PERIOD OF PERFORMANCE START DATE: 09/20/2024

PERIOD OF PERFORMANCE END DATE: 04/30/2029

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