When Mónica Pérez Jolles, MA, PhD, was researching screenings for adverse childhood events (ACEs) a mom said, “If you ask me these questions, you better have services for me to access.”
It’s a statement Pérez Jolles will never forget. This mom’s vulnerability and lived experience continue to guide her research. She serves as associate professor of pediatrics at the University of Colorado School of Medicine and is an investigator with the Dissemination and Implementation Science Core at the Adult and Child Center for Outcomes Research and Delivery Science (ACCORDS).
Integrating psychosocial screenings for social determinants of health has been prioritized in Federally Qualified Health Centers (FQHCs) across the country. But linking families to services based on their screenings remains challenging.
“We know from research that there’s still a lot of work to do in this area,” Pérez Jolles says. “Even if resources are limited, clinics can benefit from a clear map of what’s available and how to connect families to community organizations.”
Pérez Jolles’ 2022 study demonstrated that clinics lack knowledge of available services. There is also a lack of processes for the crucial step of referral follow-through to close the loop, leaving some families confused about the clinic-to-community linkage process.
Recently, the Agency for Healthcare Research and Quality provided R01 funding for Pérez Jolles to map the referral process and build on this work. The project team will include leadership from ACCORDS, with input from the Dissemination and Implementation Science Core and the Biostatistics and Analytics Core. This project will also continue a long-standing partnership with community partner Denver Health.
The project team will map the process from screening to referral to service linkage by engaging with clinical partners, providers, support personnel, community-based organizations, and English and Spanish-speaking families.
“Through this co-creation and co-development with our partners, step one is about understanding what’s happening right now—what the different pathways are and what families’ experiences are. We’ll identify drop-offs for both English and Spanish speakers, as well as challenges and assets throughout the service pathway,” Pérez Jolles says.
The findings will inform the CARELOOP Intervention (Clinics cAtch needs, REfer, Link to services, and close the lOOp using an equitable family-centered Process), a complex systems methodology that incorporates implementation science and co-creation partner engagement to refine processes within healthcare systems and the community. CARELOOP aims to provide better integration between primary care and community-based organizations that provide support for needs such as behavioral health, and food and housing insecurity.
The team will conduct a randomized control trial to determine if clinics applying CARELOOP increase both their number of families receiving service referrals and whether those referrals are successfully linked. This will be compared to the standard of care, i.e., the usual practices the clinics use to refer families to services.
The cluster-randomized trial involves 11 clinics, with six implementing the CARELOOP intervention and five serving as control sites using the standard of care. The focus is on children aged 0 to 5. The team anticipates impacting hundreds of families served by these clinics. The researchers will also follow a smaller subset of 30 families per clinic, assessing their experiences, and journeys from service referral to linkage, at key stages of the process to gather qualitative data. Outcomes will be evaluated at both the clinic and family levels.
Starting in year two, they will also obtain data to determine if CARELOOP is effective and feasible, considering measures such as implementation costs.
The CARELOOP intervention will be shaped by the real-life experience of families. Pérez Jolles said the team hopes to help families feel comfortable and cared for throughout the process. And, not have to tell their entire story at each step.
“Think about it: being repeatedly asked questions like, ‘Do you have insecure housing?’ Imagine having to answer that over and over,” Pérez Jolles says.
In addition to supporting families, Pérez Jolles says CARELOOP will provide a visual tool that gives healthcare systems a clear, actionable map. By working collaboratively with Denver Health clinical partners and leadership as well as families to develop strategies, teams will have a foundational tool they can keep updating and improving upon.
“My hope is to increase the capacity of FQHC systems to integrate these screenings and close to loop with local community-based organizations. We aim to develop practical ways for clinics to check in with these organizations regularly. Ultimately, we want to improve family experiences, increase access, build trust, and provide more holistic support for their overall needs,” Pérez Jolles says.
Pérez Jolles and her team plan to use the results of this study to share with state policymakers and healthcare providers, focusing on an existing task force in the state working to address psychosocial screenings in primary care. The research team plans to create a roadmap on how to best implement screenings that include tested strategies, identified challenges, and solutions identified by both English and Spanish-speaking families. They will also present a cost evaluation to inform practices and hopefully, create reimbursement models.
Over the next five years, Pérez Jolles has made a goal to also address the resource needs of community-based organizations, including funding.
“By gathering data, we can contribute to policy by demonstrating the costs, the roadmap, and tested strategies for bridging primary care and community-based organizations,” Pérez Jolles says. “We want to continue co-creating these solutions with families and informing potential policy that could integrate community-based organizations into Medicare policies and reimbursement.”
Pérez Jolles says this study is unique because it brings together three fields that to her knowledge, haven’t been formally integrated.
“We're using process mapping, a novel approach in health services drawn from systems and business fields. We’re also integrating participatory engagement through co-creation and community-based participatory research. Finally, we’re applying implementation science by identifying challenges and facilitators and aligning strategies,” Pérez Jolles says.
Pérez Jolles is excited to partner with Denver Health to leverage their expertise over the next five years.
“We’re excited to roll up our sleeves and address equity at the systems level.”