CommunityRx
“We want to know that connecting people to community resources during a medical visit ultimately improves health.”
Dr. Stacy Tessler Lindau, Newswise (February 21, 2019)
CommunityRx is an evidence and theory-based, low-intensity, highly scalable supportive care intervention designed with community input over time to connect people with personalized community-based resources that support basic/material, wellness, disease self- and family management, caregiving, grieving and end of life needs. The intervention has been delivered to more than 114 thousand people in the context of CommunityRx trials since 2012, including populations of people seeking care in community health centers and other primary care settings, geriatrics, pediatrics, inpatient and emergency care settings in urban, suburban and rural geographies. The intervention has been trialed in general and disease-specific populations including cardiovascular disease and chronic kidney disease and is being developed for adult oncology population. The essential components of this intervention are informed by the Grey, Schulman-Green et al. Self- and Family Management Framework and theory.
CRx interventions are comprised of three essential components:
- brief education about health-related social risks and related resources.
- activation of resources through delivery of and coaching on use of a personalized list of community resources (a HealtheRx).
- boosting through a series of proactive text messages and ongoing navigator support (informed by the Critical Time Intervention Model).
Current Clinical Trials
CommunityRx Bereavement
Missing Pieces Trial: Supporting Parents After Their Child’s Unexpected or Traumatic Death
Funded by: Patient-Centered Outcomes Research Institute
Funding Period: June 2023 – August 2029
Principal Investigators: Kelly Michelson, MD, MPH and Stacy Tessler Lindau MD, MAPP
Public Health Relevance
Of approximately 60,000 annual deaths of people <25 years old, ~45% occur unexpectedly or traumatically (e.g., from homicide, suicide, or unintentional injury) and become a medical examiner or coroner (hereafter ‘ME’) case. Parents and caregivers (hereafter ‘parents’) of these children suffer debilitating mental health issues like complicated grief and depression, physical problems and family dysfunction, and struggle to find support. Often, the ME is parents’ sole point of contact with the healthcare system. Yet MEs have limited education, guidance, and tools to support bereaved parents. Scalable systems-level interventions are needed, at the point of ME care, to connect bereaved parents to critical supports.
Aims
- Support bereaved parents of children under 25 years old in accessing resources within their community to help navigate the psychosocial and physical affects of grief
- Help ME/coroners’ offices support bereaved families by testing strategies that could be easily and sustainably implemented within their offices
- Help community organizations and providers connect bereaved parents to the resources they provide
Links
CommunityRx Chronic Kidney Disease (CRxCKD) in Rural North Carolina
Funded by: National Institute of Diabetes and Digestive and Kidney Diseases, U01DK137262
Funding Period: September 2023 – June 2028
Principal Investigators: Gaurav J Dave, MBBS, DrPH, MPH; Abhijit Kshirsaqar, MD, MPH; Stacy Tessler Lindau, MD, MAPP
Public Health Relevance
We propose to implement CRxCKD with community partners in a rural region of eastern North Carolina. This intervention integrates supportive with medical care to reduce the burden of CKD for individuals and communities.
Aims
- Use group model building and social network analysis to engage rural community members with researchers in developing a shared understanding of the factors that contribute to and can be leveraged for primary and secondary prevention of CKD.
- Optimize CRxCKD implementation through the Consolidated Framework of Implementation Research to ensure organizational readiness, fidelity, and acceptability.
- Test the effectiveness of the CRxCKD intervention
Links
Community Intervention to Reduce Cardiovascular Disease in Chicago (CIRCL)
Funded by: National Heart Lung and Blood Institute, UH3HL154297
Funding Period: September 2020 – August 2027
Principal Investigators: Abel Kho, MD; Paris Davis, PhD, MBA; Justin Smith, PhD
University of Chicago Site PI: Stacy Tessler Lindau MD, MAPP
Public Health Relevance
In Chicago, health status indicators show worsening disparities between black and white residents, with the highest rates of hypertension, heart disease, and stroke clustering in the predominantly black South and West Sides. CIRCL-Chicago will focus on the strategies used to support adoption, implementation with fidelity, and sustainability of the Kaiser bundle within a Chicago community with a high burden of hypertension. The Kaiser bundle demonstrated that a bundle of evidence-based interventions implemented within a large, integrated health system significantly increased blood pressure control.
Aims
1. Convene community stakeholders in order to adapt implementation strategies using the Dynamic Adaptation Process model
2. Design, implement, and evaluate pilot projects in order to optimize implementation strategies within our community
3. Implement, test and evaluate an adapted implementation strategy to control hypertension through faith-based organizations in the South Side of Chicago. Our overall implementation is a hybrid Type 2 effectiveness–implementation design based within one primary community area (South Side Chicago) and in two settings (church and clinic). The overall study outcome is the Public Health Impact metric (reach * effect size of the intervention)
4. Disseminate findings internally to community stakeholders and externally through creation of community implementation toolkits
Links
CommunityRx Cardiovascular Disease
Implementation of EMR-Integrated Referrals to Link Clinical and Community Services
Funded by: National Heart Lung and Blood Institute, R01HL150909
Funding Period: January 2020 – December 2024, no-cost extension through December 2025
Principal Investigators: Giselle Corbie, MD, MSc; Gaurav J Dave, MBBS, DrPH, MPH; Stacy Tessler Lindau, MD, MAPP
Public Health Relevance
Heart disease prematurely ends African American lives in the rural southeast. New ways to prevent heart disease are needed that help people access resources to live a healthy life using a “whole person” approach to CVD and social needs.
Aims
1A. Determine contextual factors to inform implementation strategies for CRxCVD in rural clinical settings.
1B. Implement CRxCVD and assess: 1) barriers and facilitators and 2) organizational readiness to implement change
2. Conduct a pragmatic trial to evaluate the effectiveness of EMR-linked referrals on patient and healthcare utilization outcomes
3. Estimate costs and efficiency (costs-per-unit benefit) related to implementation of CRxCVD to inform scaling the intervention in a network of rural health care centers.
Links
My Diabetes, My Community
Funded by: National Institute of Diabetes and Digestive and Kidney Diseases, R01DK127961
Funding Period: September 2020 – July 2024
Principal Investigators: Elbert S. Huang, MD; Stacy Tessler Lindau MD, MAPP
Public Health Relevance
Older African Americans with diabetes suffer the highest rates of cardiovascular and microvascular complications as well as adverse drug events such as hypoglycemia. We will conduct a 12-month pragmatic clinical trial evaluating the impact of scalable interventions that are designed to support personalized goal setting and self-care through remote delivery of clinical and socioeconomic risk assessment, telephonic care management, and community resource linkage. This highly personalized approach to diabetes care has to potential to improve quality of life of this high-risk population while avoiding adverse drug events.
Aims
1. To evaluate the impact of My Diabetes GOAL Arms versus Usual Care on processes of personalized diabetes care (e.g., decisional conflict regarding goals of diabetes care)
2. To evaluate the relative impact of the three study arms on self-efficacy, self-care and utilization of community-based resources
3. To evaluate the relative effect of the three study arms on clinical outcomes (e.g., glycemic control, hypoglycemia, geriatric conditions, functional status) and health care utilization (ED visits and unplanned hospitalizations)
Links
CommunityRx Dementia
Funded by: National Institute on Aging, R01AG064949
Funding Period: July 2019 – February 2024
Principal Investigators: Stacy Tessler Lindau, MD, MAPP; Elbert S. Huang, MD
Public Health Relevance
The National Alzheimer’s Project Act calls for community resource linkages as a key strategy to support more than 16 million caregivers of the growing U.S. population of persons with dementia (PWD) living at home. Our objective is to evaluate the health impact and mechanisms of a low-intensity, scalable information technology- based intervention to systematically match caregivers at the point of their own primary care to nearby community resources for health-related social, caregiving and any other self-care needs. The long-term goal of this mixed methods research is to inform science, policy and practice in this emerging field and to advance NIH’s mission by generating new knowledge about resource connections that promote ADRD caregiving outcomes and supports.
Aims
1. Among caregivers with supportive care needs, evaluate the effects of CRxD versus usual care on caregiver self-efficacy and secondary psychosocial and behavioral outcomes, as well as health and healthcare utilization
2. Evaluate acceptability and effects of CRxD versus usual care on the healthcare experience and the likelihood of sharing community resource information with others
3. Qualitatively assess caregivers’: experiences with the CRxD intervention; the role of stigma in disclosing needs and accessing resources; and experiences sharing resource information with others
CommunityRx Hunger
Funded by: National Institute on Minority Health and Health Disparities, R01MD012630
Funding Period: March 2019 – November 2023
Principal Investigator: Stacy Tessler Lindau MD, MAPP
Public Health Relevance
Food insecurity is a prevalent and modifiable, but largely overlooked, driver of health and illness. Our objective is to improve self- and family management among food insecure caregivers of ill children by intervening at the critical time of the child’s hospital discharge. The long-term goal of this mixed-methods work advances the public health mission of NIH by promoting the health of caregivers and their families and reducing the health burden due to socioeconomic disadvantage.
Aims
1. Evaluate the effects of CRx-H versus UC on food insecure caregiver self-efficacy, caregiver and child food insecurity, and adult and child health outcomes
2. Among food secure and insecure caregivers, evaluate the effects of CRx-H versus UC on caregiver satisfaction with care and stigma
3. Qualitatively assess food insecure caregivers’ perspectives about: (a) their experiences with and attitudes toward the CRx-H intervention, (b) the role of stigma as a barrier to self- and family management, and (c) how healthcare providers can sensitively and effectively intervene to support food insecure caregivers
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