# oREgon medicaid policy, SOciaL serVices, and hEalth (RESOLVE)

> **NIH NIH R01** · UNIVERSITY OF CALIFORNIA, SAN FRANCISCO · 2024 · $824,665

## Abstract

Project Abstract
The circumstances in which people are born, grow, live, and work—often referred to as social determinants of
health (SDH)—have well-documented impacts on chronic disease outcomes and disparities. Stemming from
this strong and compelling evidence linking SDH, health, and health equity, healthcare organizations are
increasingly integrating screening for select forms of social adversity such as food insecurity, followed by
referrals to connect patients to local social services (community-clinical linkages (CCLs)). Although these
activities are being widely promoted at both the national and state levels, robust evidence about their impacts
on chronic disease prevalence and outcomes is lacking. Furthermore, there is not yet any evidence about
policy levers to increase uptake of CCLs. The state of Oregon’s Medicaid environment offers a unique
laboratory for studying both the impacts of policy levers on CCLs activities as well as the impacts of CCLs on
chronic disease outcomes and related disparities. In 2024 and 2025, the state is launching two new policies
intended to increase CCLs, including a new “Health Related Social Needs” (HRSN) benefit covering 10
categories of non-medical services and Medicaid health plan quality measures related to social risk screening
and social service referrals. We propose to conduct a quasi-experimental mixed-methods study that (1)
evaluates the impacts of Oregon’s new Medicaid social care policies on social risk screening and related
community-clinical linkages, as well as on disparities in these outcomes, and (2) evaluates the impacts of
social risk screening and related community-clinical linkages on chronic disease outcomes and healthcare
utilization, as well as on disparities in these outcomes. In the oREgon medicaid policy, SOciaL serVices, and
hEalth (RESOLVE) study, we will create a novel, comprehensive dataset that includes information about
social risk screening, referrals to social services, receipt of social services, and EHR and claims data from >
170,000 Medicaid members seen in community health centers (CHCs) across Oregon. We will use interrupted
time series methods to examine whether and how the new Medicaid policies affect rates of social risk
screening, social services referrals, and receipt of specific social services. We will also investigate the impacts
of social care activities on key chronic disease risk factors, disease outcomes, receipt of preventive care, and
healthcare utilization, as well as on disparities in these outcomes using instrumental variable analysis and
sequential target trial emulation. Qualitative interviews with healthcare and community-based organization
leaders will inform our understanding of the policies’ influence on social care activities. Interviews with clinical
delivery team members and Medicaid members will explore the mechanisms and circumstances under which
community-clinical linkages influence chronic disease outcomes and related disparities. RESOLV...

## Key facts

- **NIH application ID:** 11025783
- **Project number:** 1R01NR021390-01
- **Recipient organization:** UNIVERSITY OF CALIFORNIA, SAN FRANCISCO
- **Principal Investigator:** CAROLINE M FICHTENBERG
- **Activity code:** R01 (R01, R21, SBIR, etc.)
- **Funding institute:** NIH
- **Fiscal year:** 2024
- **Award amount:** $824,665
- **Award type:** 1
- **Project period:** 2024-09-24 → 2029-05-31

## Primary source

NIH RePORTER: https://reporter.nih.gov/project-details/11025783

## Citation

> US National Institutes of Health, RePORTER application 11025783, oREgon medicaid policy, SOciaL serVices, and hEalth (RESOLVE) (1R01NR021390-01). Retrieved via AI Analytics 2026-05-25 from https://api.ai-analytics.org/grant/nih/11025783. Licensed CC0.

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