The COVID-19 pandemic made clear the need to better connect primary care with public health to improve population health through coordination of efforts such as disease surveillance and contact-tracing. There is also growing awareness about the need for primary care practices to be closely integrated with a range of social service organizations within the community. Evidence shows that social determinants of health (SDOH)—the underlying social, economic, and environmental factors that impact health—drive as much as 80% of health outcomes.(50) SDOH include socioeconomic factors (e.g., education and income levels), neighborhood and built environment, social and family support, and community safety.
Increasingly, primary care practices and healthcare systems are working to provide care that is responsive to SDOH, including integrating screening for social needs into clinical care services, and collocating or collaborating with community services.
AHRQ prioritizes supporting clinical-community linkages to improve patients’ access to care by connecting healthcare providers, public health agencies, and community organizations.51 Through these connections, communities are better able to build strong partnerships to help fill gaps in services and promote healthy behaviors. While AHRQ has identified Public Health and Community Integration in primary care as a topic area of interest, their research investments in 2021 and 2022 with a main focus on this topic were limited to a small number of grants and resources described in this section.
Grants with a focus on health equity are indicated with this icon.
Grants
Two AHRQ primary care grants actively funded during FYs 2021 and 2022 were mainly focused on public health and community integration, including one R36 (Dissertation Award) and one R18 (Research Demonstration and Dissemination Project). An additional seven grants had some focus on public health and community integration and are described elsewhere in this report depending on the main focus of the grant, including in Practice and Quality Improvement (2), Person-Centered Care (2), Healthcare Systems and Infrastructure (1), and Digital Healthcare (1).
Below is a table with summaries of the two primary care grants with a main focus on public health and community integration.
Patients' Decisions and Perspectives Regarding Healthcare-Based Social Risk Interventions (R36) |
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PI: Anna Steeves-Reece Organization: Oregon Health & Science University; Overall Medicine Assesses patient perspectives on a healthcare-based social risk intervention at healthcare sites, including primary care clinics, which links the EHR with a social risk screening tool to support the referral of Medicaid and Medicare patients to community resources to address their needs. Learn more about this study in a recent NCEPCR webinar: Qualitative Methods Used in AHRQ Funded Primary Care Research. |
| Using Social and Medical Data Integration to Improve Primary Care and Population Level Chronic Disease Prevention and Management (R18) |
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PIs: Danielle Marie Hessler-Jones; Caroline M Fitchenberg Organization: University of California, San Francisco; School of Medicine; Family Medicine Integrates a Community Information Exchange, a multi-organization data-sharing system designed to improve care coordination, into the EHRs of three Federally Qualified Health Centers. The grant uses a human-centered design process to understand barriers and facilitators to effective implementation, identifies factors that influence the use and uptake of these EHR dashboards, and evaluates the impact on patient care and population health management. |
Initiatives and Resources
In addition to supporting clinical-community linkages, AHRQ works to help healthcare systems and clinicians build understanding of SDOH and the social needs of patients to improve healthcare. An ongoing AHRQ SDOH database and a resource on addressing social needs in primary care from 2021 are described below.
Social Determinants of Health Database
AHRQ's SDOH database helps to facilitate patient centered outcomes research by allowing researchers to find a range of well documented and readily linkable SDOH variables without needing to access multiple source files. The SDOH Database was updated in July 2022 and now includes data through 2020 at the county, ZIP code, and census tract levels. Variables in the files correspond to five key SDOH domains: social context (e.g., age and race), economic context (e.g., income), education, physical infrastructure (e.g., housing and transportation), and healthcare context (e.g., health insurance).
Identifying and Addressing Social Needs in Primary Care Settings
Collecting information about a patient’s social needs can be used to help connect them to needed services available in the community, and also helps clinicians develop treatment plans that are tailored to the patient’s unique needs and priorities.
Social needs are what a patient perceives as what they need to address the negative SDOH they face. This tool is designed to help primary care practices start screening patients for social needs, and includes information about various screening tools and resources, different approaches for implementing social needs screening, and considerations for what practices can do with the social needs information they collect.
