The SDOH-Homecare Intervention Focus Team (SHIFT) Trial to Mitigate SDOH in Stroke Outcomes and Build Community Capacity

Project Summary Closing the gap in stroke disparities cannot be accomplished without addressing the upstream factors driving them. Structural Racism and Discrimination (SRD) produces adverse Social Determinants of Health (SDOH), which have been shown increase stroke risk in a dose dependent manner. The present application focuses on mitigating the effects of SDOH to improve stroke outcomes in underserved minority populations, using a multi- level approach that includes the community, healthcare institution, interpersonal, and individual levels. Our rationale is that the burden of mitigating the multi-level impact of SDOH on social and health inequities should not fall solely on disenfranchised patients, which in our case is the economically disadvantaged African American and Hispanic stroke patient. Our 4 Specific Aims intervene on major downstream health effects arising from adverse SDOH. Stroke is the leading cause of adult disability in the US with the greatest burden on communities of color, and it is not surprising that SDOH is a major driver of stroke disparities. Currently, there is a dearth of effective SDOH interventions for stroke prevention and recovery. Our proposal seeks to address this gap by developing a racial equity-trained, multidisciplinary homecare team, or SHIFT (SDOH-Homecare Intervention Focus Team). SHIFT comprises a local Community Based Organization (CBO)-affiliated Community Health Worker, a Community Nurse, and a Community Social Worker. We hypothesize that by targeting patient-specific SDOH risk factors on a community, health systems, interpersonal and individual level with SHIFT, we will mitigate the adverse effects of SDOH factors to improve functional and physiological outcomes after stroke in vulnerable race-ethnicity groups. Specifically, we will examine the effect of the SHIFT approach on post-stroke outcomes of African American and Hispanic patients with > 3 SDOH risk factors compared to Usual Care in a Randomized Controlled Trial (RCT) embedded within a Hybrid Type I Implementation Effectiveness design. The primary outcome will be the Stroke Impact Score (SIS 3.0) -- a measure of disability and health-related quality of life after stroke -- measured at 6 months and 1 year (Aim 1a). Secondary outcomes will assess the effect of the intervention on blood pressure control and cognitive status (Aim 1b) and explore the role of Allostatic Load – a measure of physiological weathering – on our outcomes of interest (exploratory Aim 1c). Aim 2 will test the hypothesis that improvement in functional and physiological stroke outcomes as measured in Aim 1 is associated with reduction in specific SDOH variables. In Aim 3, at the healthcare system level, we will examine the effect of the SHIFT intervention on health system process variables (Aim 3a) and stroke patient re-admission rates (Aim 3b). At the community level, guided by a standardized organizational capacity measure and scoring matrix, we will engage in CBO capacity building of a local CBO partner to support the sustainability of its SDOH-mitigating activities, while gathering multi-level contextual data influencing patient outcomes using a racism-conscious adaptation of the Consolidated Framework for Implementation Research (Aim 4).