ASU-led initiative provides framework for better health outcomes

When it comes to the health outcomes of populations, social determinants can make or break them. And during a pandemic that requires social distancing at least and full-on self-isolation at most, if you’re among those more vulnerable populations who are more likely to be unable to take time off work or live in multigenerational homes, taking those kinds of precautions can be practically impossible.

The realization of that simple truth weighed heavily on the mind of Satya Sarma, an Arizona State University College of Health Solutions clinical associate professor, during a meeting with colleagues last fall where they were analyzing and discussing projection models for COVID-19.

“We were talking about the case counts and kind of grappling with the challenges of this pandemic as far as testing, and how the brunt of the pandemic — both in terms of the case counts and in terms of the economic impact — has really been visited most harshly on our most vulnerable communities,” Sarma said.

“And what we came to realize was that we needed to be able to support those populations in terms of what comes after testing, which is trace and treat. Because if I’m a single mother with three children at home and I test positive at one of the drive-thru sites, I still have to pick up their dinner and take it home before I can isolate, and that's just another exposure that feeds into this pandemic.”

But, Sarma thought, what if that single mom had some help from community resources? What if someone could bring food to her children and make sure they’re taken care of while she could safely isolate away from them and take time off work without worrying about the bills and rent going unpaid? Surely all it would take is a little coordination between existing entities.

Enter the COVID Community Action Alliance, a partnership that leverages the resources of private and public entities to help with everything from rent assistance, to a place to isolate, to delivering groceries and cleaning products.

“We realized that if we could align the private health care system with the resources already in place in public community health centers to focus on the most vulnerable, it would improve the scale of the pandemic for everybody,” Sarma said.

So she and a team of colleagues, including the College of Health Solutions’ William Riley, a professor of the science of health care delivery, and George Runger, a professor of biomedical informatics and director of the Center for Health Information and Research (CHiR), set out to accomplish the task.

With Runger’s deep well of data on social determinants of health via CHiR and Riley and Sarma’s combined years of experience in public health and quality improvement, they made a formidable team. Together, they reached out to several local health care providers and community health organizations to make connections and facilitate partnerships.

Valleywise Health was one of the first providers to come on board, along with the nonprofit Helping Families in Need. Late last fall, they launched a pilot program, focusing on Avondale, Arizona, one of the most hard-hit areas in the Valley.

“It's impossible to stop transmission in families who are living together if one person tests positive and then has to go back into that family environment to isolate,” said Barbara Harding, CEO of Valleywise’s FQHCFederally Qualified Health Centers are outpatient clinics that qualify for specific reimbursement systems under Medicare and Medicaid. clinics. “So the stories that you may have heard where whole families pass away as a result of COVID, that's what we're trying to prevent.”

Here’s how it works: Once someone tests positive at a Valleywise site, they are asked if they need additional help with isolation or other resources for their family. If they say yes — which about half so far have — a doctor refers them to a community health worker at Helping Families in Need who can provide additional educational information and personal protective equipment, as well as connect them with other community resources like food pantries and rental assistance, and even help find them a place to stay while they isolate.

“The numbers were getting so high and people were just kind of in panic mode,” said Amanda Heger, a registered nurse with Valleywise who has been overseeing the COVID Community Action Alliance efforts at the provider’s Avondale site. “So I think they were just looking for any kind of help they could get, and just having some kind of guidance is really important, because when you're sick or you have a sick loved one who you’re taking care of, it can be so overwhelming.”

By early January, the COVID Community Action Alliance had provided assistance to more than 20 individuals and their families in the Phoenix metro area.

“There's been a real commitment from providers like Valleywise and community organizations like Helping Families in Need, as well as the Maricopa County Department of Public Health Administration and Arizona Department of Health Services, in terms of making sure that our workflows and our processes are well aligned with their policies and public health goals,” Sarma said. “So they've been an invaluable support in building the alliance to this point, in addition to recognizing that we need to close the loop on test, trace, treat, and provide the tools to vulnerable communities to do that effectively.”

The scalability of the model Sarma and her colleagues and community partners have built is what excites them most. With over 2,000 community health centers across the U.S., there is already a national network of organizations that are situated in and have trusting relationships with the kinds of vulnerable communities who need this kind of help.

“What our project seeks to do is take the elements of this pilot that could be useful and build an implementation toolkit, which would contain all the tools anyone would need in any community in order to be able to recreate this project in their own community,” Sarma said.

“The use of community health workers in partnerships with providers is certainly nothing new. In fact, it's a very well-documented model of care and has shown in multiple different settings and studies a great return on investment. Frankly, part of the problem though has been that most of those programs have been grant-funded, and once the grants dry up, there is no mechanism in our health care system to continue to finance those services. So what we haven't seen is a sustained structure, which we believe we could achieve here. We hope this model will influence policy to eventually allow it to be sustained and financed by state programs and health care dollars.”

Now that vaccination efforts are well underway, Sarma sees great potential in applying the COVID Community Action Alliance framework to help educate patients and ensure they follow up with proper protocols following their inoculation. Looking even further into the future, she believes it could be applied to other health issues that have been exacerbated by the pandemic, such as behavioral health issues and chronic health conditions that have gone untreated.

“We really see this as a model that can help sustain health care beyond COVID,” she said. “With the right training, community health workers can be those navigators, can be those connectors and can be the educators communities need.”

Top photo courtesy of Pixabay