Sample of Collaborative Research & Innovation 

Problem/Aim – Approximately 108 million American adults have hypertension and 3 out of 4 of these individuals do not have it controlled.   

Solution: A team-based, patient-centered approach that relies on contributions of clinical pharmacists to better manage hypertension.    

CHC Partnership: Academic, CDC, and CHC researchers included patients in seven clinics of a CHC in rural South Carolina — Family Health Centers (FHC), which is the sole provider of comprehensive primary and preventive health care services in their service area.   

Target population: Their patient population is 89% Black/African American, 86% of patients are at or below the 100% Federal Poverty Guideline, and 21% are uninsured.  In 2017, FHC’s main site served 3,539 patients with a diagnosis of hypertension, and each satellite clinic served 500–800 patients with a diagnosis of hypertension. All seven clinics share a common EHR and were included in the evaluation.    

Outcome: Across all clinics at FHC, encounter-level hypertension control improved from 53.4% at baseline to 57.3%. Patients that were referred to participate in pharmacist-led hypertension management visits tended to have more uncontrolled hypertension but still saw significant improvements in hypertension control across patient encounters—from 28.7% pre-intervention to 33.0% after the intervention was implemented. 

Next Steps: Future replications of this model should consider the need for high levels of pharmacist engagement, and availability of staff and financial resources in high-burden settings. Future work could explore the viability of this model to be adapted, translated, or integrated into other chronic disease areas that require comparable ongoing management and patient care. 

Reference

Problem/Aim – During the COVID-19 pandemic public health emergency, states provided continuous Medicaid coverage to enrollees. In April 2023, states began to unwind this continuous coverage, prompting concern about the impact of this on pediatric patients. 

Data source: Electronic health record (EHR) data from OCHIN, a nonprofit organization with a fully hosted and shared EHR platform for a nationwide network of community-based health care organization. 

CHC Partnership: Academic and OCHIN researchers were funded by the Robert Wood Johnson Foundation.    

Target population: Pediatric patients from a multistate network of community-based health care organizations. Participants were aged up to 17 years at both their last Medicaid-insured visit during the continuous coverage period and at their first visit during the unwinding period  

Outcome: Among 450 146 pediatric patients, 8.7% were disenrolled from Medicaid to uninsured status. Patients aged 12 to 17 years had the highest estimated disenrollment among age group, females, patients with more complex issues had higher odds of disenrollment. 

Next Steps: Future work should continue to examine the impact of disenrollment to uninsured status on patients’ access to care and health outcomes and clinic operations. 

Reference

Problem/Aim- Increase access to fresh, seasonal fruits and vegetables and other healthy foods in low-income communities disproportionately affected by diabetes in Stockton, CA.  

Intervention: Healthy Food Rx Program provided healthy food boxes through community partnerships, enabling home delivery and complementary nutrition education opportunities, every other week for up to 12 months. 

Data source: Medical records and surveys at enrollment — after 6 months (Phase 1) and 12 months (Phase 2) in the program 

CHC Partnership: Community Medical Centers, local Stockton organizations,  and the Emergency Food Bank, along with Abbott (sponsor) and the Public Health Institute. 

Target population: People were eligible to participate in the Healthy Food Rx program if they were over the age of 18, diagnosed with diabetes (type 1 or type 2), currently under the care of their Community Medical Centers physician, resided in Stockton, California, and had current hemoglobin A1C (A1C) bloodwork labs on file, a measure of glycemic control over the previous two to three months. 

Outcome:  

• Hemoglobin A1C decreased significantly by 0.35% overall and by 0.80% among those outside of target range at baseline; 

• Food insecurity decreased significantly by 10% in the survey sample; 

• Diet quality, which include daily fruit and vegetable consumption, increased significantly (0.28 and 0.14 times per day); 

• Diabetes self-management tasks- 

• Overall number of tasks respondents reported doing regularly increased from around 3 to over 4, on average; 

• Percentages for more physical activity, attending diabetes education classes, following diabetes plan increased significantly. 

Next Steps: Studies like this can inform policies supporting a variety of food is medicine models including healthy meal boxes, produce boxes, and medically-tailored meals addressing social risk factors of health, increasing health equity, and improving disease self-management behaviors in low resourced communities.

Reference 

Problem/Aim- Better understand telehealth impact on chronic conditions such as diabetes in diverse and vulnerable populations. 

Intervention: Virtual encounters included both video and telephone visits. 

Data source: EHR data were collected from 20 Community Health Center or Community Health Center look alike organizations in 12 states. Final study sample was 35,305 patients. 

CHC Partnership: AllianceChicago and NIH 

Target population: The study population included patients aged 18 years and older with an active diagnosis of diabetes and at least one encounter and one hemoglobin A1c (HbA1c) lab result during the study period. Lab results were included in this analysis only if the result was available in the EHR.  

Outcome: Telehealth use was associated with 0.89 additional months of hemoglobin A1c control and 4.49 additional months of connection to care 

Next Steps: Further study is recommended exploring how telehealth can be optimized in conjunction with home monitoring devices and other technologies to improve glycemic control and other health outcomes. 

Reference