February 7, 2017

Primary care physicians in Fairfax County, one of the four counties in the Northern Virginia region, recognize that social and economic challenges affect the health of patients and their families. The Robert Graham Center—a Washington, D.C.-based policy institute of the American Academy of Family Physicians—has proposed that family physicians track “community vital signs,” using population-level data to address the social and economic conditions that affect their patients. With CTSA funding from VCU, the Graham Center is collaborating with the Center and the VCU Department of Family Medicine and Population Health to conduct a proof-of-concept pilot at 12 primary care practices in Fairfax, Virginia that serve more than 182,000 patients. The project is integrating clinical and population-level data for practice populations by merging data from electronic health records with census data for the patients’ neighborhoods. Patient addresses have been geocoded in a software tool, HealthLandscape, so that patients who reside in disadvantaged communities can be identified. These data will be used to determine relationships between living in a disadvantaged community and clinical outcomes, and clinicians will prospectively document how this knowledge influences care.

The investigators formed three learning collaboratives to advise this project. The 28 members include primary care clinicians, care coordinators, office managers, quality directors, and patient advisory board members. The learning collaboratives inform the study design, intervention, interpretation of findings, and dissemination of findings.

This project represents one of the first in an emerging portfolio of projects at the intersection between medicine and public health—exploring the role of clinicians and health care systems in addressing the social determinants of health is expected to become an explicit focus of future Center work. This project is ongoing, but the investigators have already discussed the project in a presentation at the Practice Based Research Network Conference in July 2016. Further reporting awaits completion of the project.