Project Summary
Closing the gap in stroke disparities cannot be accomplished without addressing the upstream factors driving
them. Structural Racism and Discrimination (SRD) produces adverse Social Determinants of Health (SDOH),
which have been shown increase stroke risk in a dose dependent manner. The present application focuses on
mitigating the effects of SDOH to improve stroke outcomes in underserved minority populations, using a multi-
level approach that includes the community, healthcare institution, interpersonal, and individual levels. Our
rationale is that the burden of mitigating the multi-level impact of SDOH on social and health inequities should
not fall solely on disenfranchised patients, which in our case is the economically disadvantaged African American
and Hispanic stroke patient. Our 4 Specific Aims intervene on major downstream health effects arising from
adverse SDOH. Stroke is the leading cause of adult disability in the US with the greatest burden on communities
of color, and it is not surprising that SDOH is a major driver of stroke disparities. Currently, there is a dearth of
effective SDOH interventions for stroke prevention and recovery. Our proposal seeks to address this gap by
developing a racial equity-trained, multidisciplinary homecare team, or SHIFT (SDOH-Homecare Intervention
Focus Team). SHIFT comprises a local Community Based Organization (CBO)-affiliated Community Health
Worker, a Community Nurse, and a Community Social Worker. We hypothesize that by targeting patient-specific
SDOH risk factors on a community, health systems, interpersonal and individual level with SHIFT, we will mitigate
the adverse effects of SDOH factors to improve functional and physiological outcomes after stroke in vulnerable
race-ethnicity groups. Specifically, we will examine the effect of the SHIFT approach on post-stroke outcomes
of African American and Hispanic patients with > 3 SDOH risk factors compared to Usual Care in a Randomized
Controlled Trial (RCT) embedded within a Hybrid Type I Implementation Effectiveness design. The primary
outcome will be the Stroke Impact Score (SIS 3.0) -- a measure of disability and health-related quality of life after
stroke -- measured at 6 months and 1 year (Aim 1a). Secondary outcomes will assess the effect of the
intervention on blood pressure control and cognitive status (Aim 1b) and explore the role of Allostatic Load – a
measure of physiological weathering – on our outcomes of interest (exploratory Aim 1c). Aim 2 will test the
hypothesis that improvement in functional and physiological stroke outcomes as measured in Aim 1 is associated
with reduction in specific SDOH variables. In Aim 3, at the healthcare system level, we will examine the effect of
the SHIFT intervention on health system process variables (Aim 3a) and stroke patient re-admission rates (Aim
3b). At the community level, guided by a standardized organizational capacity measure and scoring matrix, we
will engage in CBO capacity building of a local CBO partner to support the sustainability of its SDOH-mitigating
activities, while gathering multi-level contextual data influencing patient outcomes using a racism-conscious
adaptation of the Consolidated Framework for Implementation Research (Aim 4).
