# Implementation of EMR-Integrated Referrals to Link Clinical and Community Services to Reduce Health Inequity

> **NIH NIH R01** · UNIV OF NORTH CAROLINA CHAPEL HILL · 2021 · $751,997

## Abstract

ABSTRACT
Cardiovascular disease (CVD) exerts a disproportionate burden of morbidity and mortality on African
Americans in the rural southeast. Much of this excess has been attributed, directly and indirectly, to social
determinants of health and resulting health-related social needs. While CVD prevention interventions have
reduced overall disease burden, they have failed to eliminate racial and geographic disparities in CVD. New
models of care, such as Accountable Health Communities, address health-related social needs through
screening, referral, and community navigation services and have begun to demonstrate improvement in health
care cost, use, and CVD risk factors. Rural minority communities, where the burden of CVD risk factors and
social needs are high, healthcare facilities may be more fragile and density of resources may be lower, have
even greater need for effective and scalable solutions to addressing health and social needs. Our proposal is
anchored by Bandura's Self-Efficacy theory, Grey's Self and Family Management Framework, and Andersen's
Behavioral Model of Health Services Use. We will use the Consolidated Framework for Implementation
Research to study implementation and effectiveness of integrating health-promoting community resource data
into the EMR via CommunityRx (CRx). The CRx-CVD intervention is a digital solution that links patients with
community-based resources to address health-related social needs and cardiometabolic health in rural AA
patients. Our overall objective is to identify factors that influence implementation and assess the health
impact of a closed-loop referral system to community health-promoting resources in a rural setting. We use a
hybrid II implementation effectiveness design to conduct a controlled pragmatic trial of patients (adults 18
years and over, children 2-17 years; N=750) in a system of federally qualified health centers in rural North
Carolina. We hypothesize that integration of closed-loop referrals will increase patient knowledge of community
resources, enhance self-efficacy to manage CVD risk factors, increase utilization of community resources and
improve markers of cardiometabolic conditions. To our knowledge, this trial will be the first to evaluate the
implementation and health impact of a low intensity, scalable, clinic-initiated intervention targeting AA adults
and children at risk of CVD. Furthermore, we will conduct cost-effectiveness analysis related to implementation
of CRx-CVD to inform scaling the intervention. The long-term goal is to identify scalable interventions to
reduce CVD risk and health-related social needs of African Americans using a “whole person” approach to
health.

## Key facts

- **NIH application ID:** 10078633
- **Project number:** 5R01HL150909-02
- **Recipient organization:** UNIV OF NORTH CAROLINA CHAPEL HILL
- **Principal Investigator:** Giselle Corbie
- **Activity code:** R01 (R01, R21, SBIR, etc.)
- **Funding institute:** NIH
- **Fiscal year:** 2021
- **Award amount:** $751,997
- **Award type:** 5
- **Project period:** 2020-01-01 → 2024-12-31

## Primary source

NIH RePORTER: https://reporter.nih.gov/project-details/10078633

## Citation

> US National Institutes of Health, RePORTER application 10078633, Implementation of EMR-Integrated Referrals to Link Clinical and Community Services to Reduce Health Inequity (5R01HL150909-02). Retrieved via AI Analytics 2026-05-24 from https://api.ai-analytics.org/grant/nih/10078633. Licensed CC0.

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