AHRQ designate $6M in grants to analyze, aid community care

A federal agency has awarded $6 million in grants to encourage the use of data and analytics to support primary care and community interventions.

The Agency for Healthcare Research and Quality, which produces evidence to make healthcare safer and more accessible, has launched the program to improve chronic disease prevention and management, and enhance population health management.

Funds from the grants are going to Denver Health, the University of California at San Francisco and the Kaiser Foundation Research Institute.

The awards were announced and explained in a recent blog written by Cindy Branch, head of health literacy and cultural competence at AHRQ; Brent Sandmeyer, grants leader for healthcare affordability and transparency for the agency; and Arlene Bierman, MD, director of the Center for Evidence and Practice Improvement.

“There is growing recognition that optimizing individual and population health will require innovative approaches to integrating clinical care with social services and public health,” the AHRQ leaders note.

The goal of the program is to use data and analytics to identify vulnerable populations and work with physician practices and various social services, government entities and other organizations to help communities work together and align services to those who need them, Bierman explains.

For example, analytics may identify high-risk diabetics who live in a food desert with few grocery stores and are eating convenience foods, and find ways to increase the availability of better food.

Analytics also can help determine how a community can improve housing conditions and transportation needs, and data analysis can assist physicians in finding and making links to organizations that can help patients with various medical and social needs.


“The next step is to build evidence on what works and build a platform where data is linked, processed and used in a user-friendly way to help physicians and social services identify needs,” Bierman says.

Each of the three grantees will be responsible for developing specific programs.

The University of California, for example, has partnered with a network in San Diego to develop, refine and deploy integrated health and social risk dashboards for use in chronic disease-related patient care, population health management and community management to facilitate bidirectional referrals between health and social service providers.

Denver Health is building a safety net program to develop electronic health record-accessible tools that integrate health, correctional and social services data, along with workflows, to create tools that make a risk profile and specific needs available to a care team and care coordinators at the point of care.

Kaiser’s program focuses on care system analytics to support primary care patients with complex medical and social needs. The effort will use advanced data analytical techniques to identify patients with multiple chronic conditions who have potentially actionable social barriers to effective care. A social needs dashboard will help primary care teams prioritize patients with complex medical needs for specific interventions to address unmet social needs.

“Together, these grants will target AHRQ priorities of opioids/substance use disorders, cardiovascular disease risk, and multiple chronic conditions,” Bierman says. “The innovations will be implemented in diverse settings—a safety net health system, Federally Qualified Health Centers and a large geographically diverse integrated health system.

“AHRQ expects these projects to exert a powerful and sustained influence by harnessing the power of data to improve individual and community health among those at greatest risk for preventable adverse health outcomes from chronic conditions via 360-degree care that meets physical, behavioral and social service needs.”