PT  - JOURNAL ARTICLE
AU  - Kim Hanh Nguyen
AU  - Jessica D. Fields
AU  - Anupama G. Cemballi
AU  - Riya Desai
AU  - Anjali Gopalan
AU  - Tessa Cruz
AU  - Aekta Shah
AU  - Antwi Akom
AU  - William Brown III
AU  - Urmimala Sarkar
AU  - Courtney Rees Lyles
TI  - The Role of Community-Based Organizations in Improving Chronic Care for Safety-Net Populations
AID  - 10.3122/jabfm.2021.04.200591
DP  - 2021 Jul 01
TA  - The Journal of the American Board of Family
                Medicine
PG  - 698--708
VI  - 34
IP  - 4
4099  - http://www.jabfm.org/content/34/4/698.short
4100  - http://www.jabfm.org/content/34/4/698.full
SO  - J Am Board Fam Med2021 Jul 01; 34
AB  - Introduction: Social determinants of health (SDoH) influence health outcomes and contribute to disparities in chronic disease in vulnerable populations. To inform health system strategies to address SDoH, we conducted a multi-stakeholder qualitative study to capture the multi-level influences on health for those living in socio-economically deprived contexts.Methods: Varied qualitative inquiry methods – in-depth interviews, participant-led neighborhood tours, and clinic visit observations – involving a total of 23 participants (10 patients with chronic illnesses in San Francisco neighborhoods with high chronic disease rates, 10 community leaders serving the same neighborhoods, and 3 providers from San Francisco's public health care delivery system). Qualitative analyses were guided by the Chronic Care Model (CCM).Results: Several key themes emerged from this study. First, we enumerated a large array, neighborhood resources such as food pantries, parks/green spaces, and financial assistance services that interact with patients' self-management. Health service providers leveraged these resources to address patients' social needs but suggested a clear need for expanding this work. Second, analyses uncovered multiple essential mechanisms by which community-based organizations (CBOs) provided and navigated among many neighborhood health resources, including social support and culturally aligned knowledge. Finally, many examples of how structural issues such as institutional racism, transportation, and housing inequities are intertwined with health and social service delivery were elucidated.Conclusion: The results contribute new evidence toward the community domain of the CCM. Health care systems must intentionally partner with CBOs to address SDoH and improve community resources for chronic care management, and directly address structural issues to make progress.