Designing Equitable Care for Kidneys (DECK): Community-Based Interventions for Addressing Social Determinants of Health and Kidney Disease Risk Factors

Background: Health disparities in kidney disease are often attributed to higher rates of risk factors such as diabetes and hypertension among minority groups. While research has extensively focused on clinical risk factors, little is known about the intersection of chronic kidney disease (CKD) risk and unmet social determinants of health (SDOH) needs. Methods: The DECK Pilot Study, guided by the Equitable Diagnosis Pathway (EDP) model for chronic kidney disease, selected Richmond’s East End for community-based screenings. The EDP model informed our intervention to address the silent nature of CKD, as 9 in 10 individuals are unaware of their condition until it is advanced. Using the CDC’s Social Vulnerability Index (SVI) and HOLC ratings, we identified the East End for its high social vulnerability and history of redlining. This data-driven approach aims to identify and address CKD risk and unmet social needs to slow disease progression. Results: Based on U.S. Census data, Richmond, VA has over 225,000 residents, of which 54.8% are non-White. Analysis revealed the East End has a high burden of CKD risk factors, including diabetes, hypertension, and obesity. The Dialysis Facility Report indicated 75% of dialysis patients in Richmond are Black, compared to 22% White. Additionally, 19% of individuals with ESRD in Richmond did not receive pre-dialysis nephrology care, and 5% to 12% of those starting dialysis lacked medical coverage, compared to 3% to 7% statewide. Diabetes is the major cause of kidney disease in Richmond, emphasizing the need for early detection and intervention. Conclusion: The DECK Pilot Study demonstrates the critical need for integrating community-based interventions to address both medical and social determinants of kidney health. DECK serves as a model for enhancing kidney health equity and can be replicated in other underserved communities to reduce health disparities and improve care quality. Funding: Private Foundation Support Disease and Health Burden of East End Richmond, VA - Location HOLC Grade Percent Minority SVI Diabetes Hypertension Obesity Kidney Disease Creighton Court D5 98.9 0.840 22.1 48.0 50.5 5.7 Fairmount D5 87.2 0.796 22.5 50.8 45.0 5.4 Church Hill North D6 77.5 0.731 23.3 50.6 46.6 5.6 Oakwood D6 84.6 0.723 20.3 47.8 43.4 4.8 Rocketts C13 78.3 0.818 14.6 37.6 42.5 3.8 Lower Rocketts C12 82.3 0.733 18.0 44.3 42.7 4.4