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Article CommentaryCommentary

Advancing Social Prescribing with Implementation Science

Laura Gottlieb, Erika K. Cottrell, Brian Park, Khaya D. Clark, Rachel Gold and Caroline Fichtenberg
The Journal of the American Board of Family Medicine May 2018, 31 (3) 315-321; DOI: https://doi.org/10.3122/jabfm.2018.03.170249
Laura Gottlieb
From Department of Family & Community Medicine, University of California, San Francisco (LMG); Department of Family Medicine, Oregon Health & Science University (EKC, KDC); Departments of Family Medicine & Preventive Medicine, Oregon Health & Science University (BP); Kaiser Permanente NW Center for Health Research; OCHIN, Inc. (EKC, RG); Center for Health and Community, University of California, San Francisco (CF).
MD, MPH
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Erika K. Cottrell
From Department of Family & Community Medicine, University of California, San Francisco (LMG); Department of Family Medicine, Oregon Health & Science University (EKC, KDC); Departments of Family Medicine & Preventive Medicine, Oregon Health & Science University (BP); Kaiser Permanente NW Center for Health Research; OCHIN, Inc. (EKC, RG); Center for Health and Community, University of California, San Francisco (CF).
PhD, MPP
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Brian Park
From Department of Family & Community Medicine, University of California, San Francisco (LMG); Department of Family Medicine, Oregon Health & Science University (EKC, KDC); Departments of Family Medicine & Preventive Medicine, Oregon Health & Science University (BP); Kaiser Permanente NW Center for Health Research; OCHIN, Inc. (EKC, RG); Center for Health and Community, University of California, San Francisco (CF).
MD, MPH
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Khaya D. Clark
From Department of Family & Community Medicine, University of California, San Francisco (LMG); Department of Family Medicine, Oregon Health & Science University (EKC, KDC); Departments of Family Medicine & Preventive Medicine, Oregon Health & Science University (BP); Kaiser Permanente NW Center for Health Research; OCHIN, Inc. (EKC, RG); Center for Health and Community, University of California, San Francisco (CF).
PhD
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Rachel Gold
From Department of Family & Community Medicine, University of California, San Francisco (LMG); Department of Family Medicine, Oregon Health & Science University (EKC, KDC); Departments of Family Medicine & Preventive Medicine, Oregon Health & Science University (BP); Kaiser Permanente NW Center for Health Research; OCHIN, Inc. (EKC, RG); Center for Health and Community, University of California, San Francisco (CF).
PhD, MPH
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Caroline Fichtenberg
From Department of Family & Community Medicine, University of California, San Francisco (LMG); Department of Family Medicine, Oregon Health & Science University (EKC, KDC); Departments of Family Medicine & Preventive Medicine, Oregon Health & Science University (BP); Kaiser Permanente NW Center for Health Research; OCHIN, Inc. (EKC, RG); Center for Health and Community, University of California, San Francisco (CF).
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References

  1. 1.↵
    1. Link BG,
    2. Phelan J
    . Social conditions as fundamental causes of disease. J Health Soc Behav 1995;Spec No:80–94.
  2. 2.↵
    1. McGinnis JM,
    2. Foege WH
    . Actual causes of death in the United States. JAMA 1993;270:2207–12.
    OpenUrlCrossRefPubMedWeb of Science
  3. 3.↵
    1. Adler NE,
    2. Stewart J
    . Health disparities across the lifespan: meaning, methods, and mechanisms. Ann N Y Acad Sci 2010;1186:5–23.
    OpenUrlCrossRefPubMedWeb of Science
  4. 4.↵
    1. McGinnis JM,
    2. Williams-Russo P,
    3. Knickman JR
    . The case for more active policy attention to health promotion. Health Aff (Millwood) 2002;21:78–93.
    OpenUrlAbstract/FREE Full Text
  5. 5.↵
    1. Stringhini S,
    2. Sabia S,
    3. Shipley M,
    4. et al
    . Association of socioeconomic position with health behaviors and mortality. JAMA 2010;303:1159–66.
    OpenUrlCrossRefPubMedWeb of Science
  6. 6.↵
    1. Jemal A,
    2. Thun MJ,
    3. Ward EE,
    4. Henley SJ,
    5. Cokkinides VE,
    6. Murray TE
    . Mortality from leading causes by education and race in the United States, 2001. Am J Prev Med 2008;34:1–8.
    OpenUrlCrossRefPubMedWeb of Science
  7. 7.↵
    1. Galea S,
    2. Tracy M,
    3. Hoggatt KJ,
    4. Dimaggio C,
    5. Karpati A
    . Estimated deaths attributable to social factors in the United States. Am J Public Health 2011;101:1456–65.
    OpenUrlCrossRefPubMedWeb of Science
  8. 8.↵
    1. Adler NE,
    2. Stead WW
    . Patients in context–EHR capture of social and behavioral determinants of health. N Engl J Med 2015;372:698–701.
    OpenUrlCrossRefPubMed
  9. 9.↵
    Institute of Medicine of the National Academies Committee on the recommended social and behavioral domains and measures for electronic health records. Capturing social and behavioral domains in Electronic Health Records: phase 2. Washington, DC: The National Academies Press; 2014.
  10. 10.↵
    Centers for Disease Control and Prevention. CMS timeline of important MU dates. https://www.cdc.gov/ehrmeaningfuluse/timeline.html. Published 2016. Accessed June 27, 2017.
  11. 11.↵
    Centers for Medicare and Medicaid Services. MACRA: delivery system reform, Medicare payment reform. Available from: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/MACRA-MIPS-and-APMs/MACRA-MIPS-and-APMs.html. Published 2016. Accessed June 27, 2017.
  12. 12.↵
    Centers for Medicare and Medicaid Services. CMS quality strategy. Baltimore, MD: Centers for Medicare & Medicaid Services. Available from: https://www.cms.gov/medicare/quality-initiatives-patient-assessment-instruments/qualityinitiativesgeninfo/downloads/cms-quality-strategy.pdf. Published 2016. Accessed June 27, 2017.
  13. 13.↵
    National Association of Community Health Centers, Association of Asian Pacific Community Health Organizations, Oregon Primary Care Association, Institute for Alternative Futures. The protocol for responding to and assessing patients' assets, risks, and experiences (PRAPARE). Available from: http://www.nachc.org/research-and-data/prapare/. Published 2017. Accessed August 18, 2017.
  14. 14.↵
    1. Alley DE,
    2. Asomugha CN,
    3. Conway PH,
    4. Sanghavi DM
    . Accountable Health Communities–addressing social needs through Medicare and Medicaid. N Engl J Med 2016;374:8–11.
    OpenUrlCrossRefPubMed
  15. 15.↵
    1. Bickerdike L,
    2. Booth A,
    3. Wilson PM,
    4. Farley K,
    5. Wright K
    . Social prescribing: less rhetoric and more reality. A systematic review of the evidence. BMJ Open 7(4):e013384, 2017.
    OpenUrlAbstract/FREE Full Text
  16. 16.↵
    Institute for Alternative Futures. Community health centers: leveraging the social determinants of health. Alexandria: Institute for Alternative Futures; 2012. Available from: http://www.altfutures.org/wp-content/uploads/2016/04/2012_Report_Community-Health-Centers-Leveraging-the-Social-Determinants-of-Health.pdf. Accessed April 3, 2018.
  17. 17.↵
    National Association of Community Health Centers. Health centers' role in reducing racial and ethnic health disparities. Bethesda, MD: National Association of Community Health Centers. Available from: http://www.nachc.org/wp-content/uploads/2015/06/DisparitiesFS.pdf. Published 2008. Accessed June 27, 2017.
  18. 18.↵
    1. Adashi EY,
    2. Geiger HJ,
    3. Fine MD
    . Health care reform and primary care–the growing importance of the community health center. N Engl J Med 2010;362:2047–50.
    OpenUrlCrossRefPubMedWeb of Science
  19. 19.↵
    Health Homes. Baltimore, MD: Department of Health and Human Services. https://www.medicaid.gov/medicaid/ltss/health-homes/index.html. Accessed September 5, 2017.
  20. 20.↵
    1. Sessums LL,
    2. McHugh SJ,
    3. Rajkumar R
    . Medicare's vision for advanced primary care: new directions for care delivery and payment. JAMA 2016;315:2665–6.
    OpenUrlCrossRefPubMed
  21. 21.↵
    1. Gottlieb LM,
    2. Hessler D,
    3. Long D,
    4. et al
    . Effects of social needs screening and in-person service navigation on child health: a randomized clinical trial. JAMA Pediatr. 2016;e162521.
  22. 22.↵
    1. Page-Reeves J,
    2. Kaufman W,
    3. Bleecker M,
    4. et al
    . Addressing social determinants of health in a clinic setting: the WellRx pilot in Albuquerque, New Mexico. J Am Board Fam Med 2016;29:414–8.
    OpenUrlAbstract/FREE Full Text
  23. 23.↵
    1. Berkowitz SA,
    2. Hulberg AC,
    3. Standish S,
    4. Reznor G,
    5. Atlas SJ
    . Addressing unmet basic resource needs as part of chronic cardiometabolic disease management. JAMA Intern Med 2017;177:244–52.
    OpenUrl
  24. 24.↵
    1. Garg A,
    2. Toy S,
    3. Tripodis Y,
    4. Silverstein M,
    5. Freeman E
    . Addressing social determinants of health at well child care visits: a cluster RCT. Pediatrics 2015;135(2):e296–304.
    OpenUrlAbstract/FREE Full Text
  25. 25.↵
    1. Gottlieb LM,
    2. Wing H,
    3. Adler N
    . A systematic review of interventions on patients' social and economic needs. Am J Prev Med. 2017;53:719–729.
    OpenUrlPubMed
  26. 26.↵
    1. Proctor EK,
    2. Powell BJ,
    3. McMillen JC
    . Implementation strategies: recommendations for specifying and reporting. Implement Sci 2013;8:139.
    OpenUrlCrossRefPubMed
  27. 27.
    1. Gold R,
    2. Cottrell EK,
    3. Bunce A,
    4. et al
    . Development of EHR data tools for collecting, summarizing, and acting on community health center patients' social determinants of health: A stakeholder-led process. J Am Med Inform Assoc. In Press.
  28. 28.
    1. Goldstein NE,
    2. Kemp KA,
    3. Leff SS,
    4. Lochman JE
    . Guidelines for adapting manualized interventions for new target populations: a step-wise approach using anger management as a model. Clin Psychol (New York) 2012;19:385–401.
    OpenUrl
  29. 29.
    1. Kangovi S,
    2. Carter T,
    3. Charles D,
    4. et al
    . Toward a scalable, patient-centered community health worker model: adapting the IMPaCT intervention for use in the outpatient setting. Popul Health Manag 2016;19:380–8.
    OpenUrl
  30. 30.
    1. Kangovi S,
    2. Mitra N,
    3. Smith RA,
    4. et al
    . Decision-making and goal-setting in chronic disease management: baseline findings of a randomized controlled trial. Patient Educ Couns 2017;100:449–55.
    OpenUrl
  31. 31.
    1. Kangovi S,
    2. Mitra N,
    3. Grande D,
    4. Huo H,
    5. Smith RA,
    6. Long JA
    . Community health worker support for disadvantaged patients with multiple chronic diseases: a randomized clinical trial. Am J Public Health 2017;e1–e8.
  32. 32.
    1. Morgan AU,
    2. Grande DT,
    3. Carter T,
    4. Long JA,
    5. Kangovi S
    . Penn Center for Community Health Workers: step-by-step approach to sustain an evidence-based community health worker intervention at an academic medical center. Am J Public Health 2016;106:1958–60.
    OpenUrl
  33. 33.
    1. Sandberg SF,
    2. Erikson C,
    3. Owen R,
    4. et al
    . Hennepin Health: a safety-net accountable care organization for the expanded Medicaid population. Health Aff (Millwood) 2014;33:1975–84.
    OpenUrlAbstract/FREE Full Text
  34. 34.
    1. Hostetter M,
    2. Klein S,
    3. McCarthy D
    . Hennepin Health: A care delivery paradigm for new Medicaid beneficiaries. New York, NY: The Commonwealth Fund. Available from: http://www.commonwealthfund.org/publications/case-studies/2016/oct/hennepin-health. Published 2016. Accessed June 27, 2017.
  35. 35.↵
    1. Guzman-Corrales L,
    2. Vickery K,
    3. Shippee N,
    4. et al
    . Addressing the social and medical needs of complex patients through an accountable care organization: a mixed methods case study of Hennepin Health. North American Primary Care Research Group Annual Meeting; 2016 November 14; Colorado Springs, CO.
  36. 36.↵
    1. Pagel L,
    2. Schwartz T,
    3. Ryan J
    . The California whole person care pilot program: county partnerships to improve the health of Medi-Cal beneficiaries. Sacramento, CA: Harbage Consulting. Available from: http://harbageconsulting.com/wp-content/uploads/2017/02/WPC-Summary_Final_02282017.pdf. Published 2017. Accessed June 27, 2017.
  37. 37.↵
    California Department of Health Care Services. Whole person care program: Medi-Cal 2020 waiver initiative Sacramento, CA: California Department of Health Care Services. Available from: http://www.dhcs.ca.gov/provgovpart/Documents/WPCProgramOverview.pdf. Published 2016. Accessed June 27, 2017.
  38. 38.↵
    Health Leads. Our model. https://healthleadsusa.org/what-we-do/our-model/. Accessed June 27, 2017.
  39. 39.↵
    Community Care Coordination Learning Network and The Pathways Community HUB Certification Program. Pathways community HUB manual: a guide to identify and address risk factors, reduce costs, and improve outcomes. Rockville, MD: Agency for Healthcare Research and Quality. Available from: https://innovations.ahrq.gov/sites/default/files/Guides/CommunityHubManual.pdf. Published 2016. Accessed June 27, 2017.
  40. 40.↵
    Jewish Healthcare Foundation, The Network for Excellence in Health Innovation. Community health workers: getting the job done in healthcare delivery. Available from: http://www.nehi.net/writable/publication_files/file/jhf-nehi_chw_issue_brief_web_ready_.pdf. Published 2015. Accessed June 27, 2017.
  41. 41.↵
    1. Johnson D,
    2. Saavedra P,
    3. Sun E,
    4. et al
    . Community health workers and medicaid managed care in New Mexico. J Community Health 2012;37:563–71.
    OpenUrlCrossRefPubMed
  42. 42.↵
    1. Bailit M,
    2. Houy M,
    3. Waldman B
    . Three emerging challenges for sustained payment and delivery system reform. Princeton, NJ: Robert Wood Johnson Foundation. Available from: http://www.academyhealth.org/files/publications/files/FileDownloads/RWJF%255FAH%2520Emerging%p2520Challenges%2520FINAL.pdf. Published 2015. Accessed June 27, 2017.
  43. 43.↵
    1. Hostetler C,
    2. Sisulak L,
    3. Cottrell E,
    4. Arkind J,
    5. Likumahuwa S
    . Origins in Oregon: the Alternative Payment Methodology Project. Health Affairs Blog. Millwood, VA: Project HOPE: the People-to-People Health Foundation, Inc.; 2014.
  44. 44.↵
    1. Ash AS,
    2. Mick EO,
    3. Ellis RP,
    4. Kiefe CI,
    5. Allison JJ,
    6. Clark MA
    . Social determinants of health in managed care payment formulas. JAMA Intern Med 2017;177:1424–1430.
    OpenUrlPubMed
  45. 45.↵
    1. Gottlieb L,
    2. Ackerman S,
    3. Wing H,
    4. Adler N
    . Evaluation activities and influences at the intersection of medical and social services. J Health Care Poor Underserved 2017;28:931–51.
    OpenUrl
  46. 46.↵
    Agency for Healthcare Research and Quality. Primary Care Practice-Based Research Networks: An AHRQ Initiative. Available from: https://www.ahrq.gov/research/findings/factsheets/primary/pbrn/index.html. Published 2012. Accessed June 27, 2017.
  47. 47.↵
    Science News Staff. What's in Trump's 2018 budget request for science? Science. Available from: http://www.sciencemag.org/news/2017/05/what-s-trump-s-2018-budget-request-science. Published 2017. Accessed June 27, 2017.
  48. 48.↵
    1. Lee M,
    2. Dickson V
    . Trump budget would cut $636 billion from HHS agencies. Modern Healthcare. Available from: http://www.modernhealthcare.com/article/20170522/NEWS/170529978. Published 2017. Accessed June 27, 2017.
  49. 49.↵
    1. Powderly H
    . Trump's budget cuts HHS spending by $15 billion, rolls AHRQ into the NIH. Healthcare Finance. Available from: http://www.healthcarefinancenews.com/news/trumps-budget-cuts-hhs-spending-15-billion-rolls-ahrq-nih. Published 2017. Accessed June 27, 2017.
  50. 50.↵
    1. Fox M
    . Trump budget cuts to scientific, medical research would have ‘devastating’ effect: Experts. NBC News. Available from: http://www.nbcnews.com/health/health-news/trump-budget-cuts-scientific-medical-research-will-have-devastating-effect-n734401. Published 2017. Accessed June 27, 2017.
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The Journal of the American Board of Family     Medicine: 31 (3)
The Journal of the American Board of Family Medicine
Vol. 31, Issue 3
May-June 2018
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Advancing Social Prescribing with Implementation Science
Laura Gottlieb, Erika K. Cottrell, Brian Park, Khaya D. Clark, Rachel Gold, Caroline Fichtenberg
The Journal of the American Board of Family Medicine May 2018, 31 (3) 315-321; DOI: 10.3122/jabfm.2018.03.170249

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Advancing Social Prescribing with Implementation Science
Laura Gottlieb, Erika K. Cottrell, Brian Park, Khaya D. Clark, Rachel Gold, Caroline Fichtenberg
The Journal of the American Board of Family Medicine May 2018, 31 (3) 315-321; DOI: 10.3122/jabfm.2018.03.170249
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