Rheumatology-based Adaptive Intervention for Social Determinants and Health Equity

Arm 1 is the control arm which will receive the standard of care resource sheets. Patients in this arm will receive cultivated resource sheets for any SDoH-related needs that they screen positive for or request additional information on.

The CRS will help guide patients to the necessary community-based resources to help address their specific SDoH needs that impact their health and their ability to access sustained, high quality medical care. This may include forms to arrange for subsidized transportation to and from medical appointments or applications for Section 8 housing. The community resource specialist will reach out to patients in Arm 2 a minimum of 2 times per month, with more interactions guided by patients needs. All outreach attempts and contacts will be documented in EPIC and in REDCap. Actions taken by the CRS will be shared with members of the patient's healthcare team as appropriate (with EPIC notes routed to the rheumatologist and primary care provider, and if indicated and relevant, a social worker, nutritionist, prior CRS, nurse or mental health provider if previously involved in the patient's care).

The nurse navigator will both work with the CRS to connect the patient with community-based resources, independently connect the patient with relevant resources, and also help coordinate the patient's medical care and mental health needs. The nurse patient navigator will conduct her own needs assessment (the nurse navigator high risk assessment questionnaire at the time of the first conversation with the patient, originally developed as part of the MGB integrated care management program) and her actions will be guided by their responses. She will reach out to patients a minimum of 2 times per month with an increase in communication around patient appointments as reminders, and more frequent communication on a case-by-case basis depending on active illnesses, frequency of outpatient appointments, and needs of the patient. All outreach attempts and contact will be documented in EPIC and in REDCap and similar to the CRS, be shared via EPIC with the care team as indicated.