# CommunityRx – Chronic Kidney Disease (CRx-CKD)” An EMR-integrated community resources referral intervention to address structural racism and kidney health disparities in rural North Carolina

> **NIH NIH U01** · UNIV OF NORTH CAROLINA CHAPEL HILL · 2024 · $694,999

## Abstract

Project Summary/Abstract
Mitigating progressive chronic kidney disease (CKD) to avoid kidney failure is well known --
management of CKD and its multimorbidity (hypertension, diabetes, obesity, and cardiovascular
disease). Yet unequal access to and utilization of quality medical and social resources present a
significant and under-addressed barrier to optimal management, especially in rural settings. As
advocated by the National Academies, we propose to address the endemic effects of structural
racism and systemic drivers of health by using an intervention that integrates medical with social
care for African Americans adults in rural eastern North Carolina. The intervention,
CommunityRx (CRx), systematically matches people to nearby community resources using
evidence-based algorithms at the point of care with a health care provider. CRx utilizes a three-
pronged approach to address integrated care among patients and caregivers: (a)
comprehensive, ongoing assessment of community resources (eligibility, capacity, quality) using
feet-on-the street (see Meaningful Active Productive Science in Service to Communities
(MAPSCorps) below) and phone survey methods; (b) integration of a simple automatic resource
referral process into routine, Electronic Health Record (EHR)-based clinical workflows; and (c)
availability of a community resource navigator. CRx for CKD (CRx-CKD) is an application of this
infrastructural approach to address CKD multimorbidity. Our community-engaged and
multidisciplinary health equity research team will leverage our infrastructural intervention and
implementation science expertise to test the effects of CRx-CKD through three related aims.
Aim 1 will contextualize implementation and effectiveness of a rural infrastructural integrated
care intervention by (a) building an inclusive model with system science to describe how
structural racism affects CKD progress on and its mitigation through integrated care; and (b)
conducting a network analysis to evaluate structures of clinic-community connectivity. Aim 2 will
optimize Crx-CKD implementation through the Consolidated Framework of Implementation
Research to ensure organizational readiness, fidelity, and acceptability. With aim 3, we will test
the effectiveness of the CRx-CKD intervention with a pragmatic cluster randomized controlled
trial at the clinic level. Three hundred seventy-five African American individuals with CKD
multimorbidity at the intervention clinics will be compared to 375 individuals at usual care clinics
for the primary outcome of reduction of the glomerular filtration slope decline and reduction of
albuminuria; other, secondary outcomes include control of blood pressure, control of blood
sugar, weight reduction, and blood lipid management.

## Key facts

- **NIH application ID:** 10911278
- **Project number:** 5U01DK137262-02
- **Recipient organization:** UNIV OF NORTH CAROLINA CHAPEL HILL
- **Principal Investigator:** Gaurav Dave
- **Activity code:** U01 (R01, R21, SBIR, etc.)
- **Funding institute:** NIH
- **Fiscal year:** 2024
- **Award amount:** $694,999
- **Award type:** 5
- **Project period:** 2023-09-01 → 2028-06-30

## Primary source

NIH RePORTER: https://reporter.nih.gov/project-details/10911278

## Citation

> US National Institutes of Health, RePORTER application 10911278, CommunityRx – Chronic Kidney Disease (CRx-CKD)” An EMR-integrated community resources referral intervention to address structural racism and kidney health disparities in rural North Carolina (5U01DK137262-02). Retrieved via AI Analytics 2026-05-26 from https://api.ai-analytics.org/grant/nih/10911278. Licensed CC0.

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