A Multi-Sector Pilot Design in the Northeast Ohio QI Hub: Engaging Community Based Organizations to Advance Diabetes Equity

<h3>Context:</h3> This work was done in the context of a regional quality improvement (QI) collaborative funded by the Ohio Department of Medicaid (ODM) focused on advancing diabetes equity through cross-sectoral QI infrastructure. We are one of 6 regional QI collaboratives statewide. <h3>Objective:</h3> The goal of building regional community engagement (CE) infrastructure is to identify shared social risk priorities that have a potential to advance equity in diabetes outcomes and to establish linkages to social care for Medicaid beneficiaries through partnerships between managed care organizations (MCO), health care systems, and community-based organizations (CBO). <h3>Study Design and Analysis:</h3> Formative research to develop a needs-based preliminary collaboration model across the three sectors. <h3>Setting:</h3> Northeast Ohio. <h3>Population Studied:</h3> We conducted focus groups, key informant interviews, and in-depth interviews with leaders from ODM, CBOs, and regional health systems, triangulated with thematic review of community health needs assessments. <h3>Instrument:</h3> The discussion guide included questions on 1) identifying shared social care priorities across the three groups, and 2) describing best practices, facilitators, and barriers around screening and referral for social needs learned from existing and past collaborative models. <h3>Outcome Measures:</h3> We summarized key priorities around social needs across the cross-sector groups that will partner in our pilot project and synthesized barriers, facilitators, and best practices to design an initial collaborative model for pilot implementation. <h3>Results:</h3> Key priorities across all sectors included access to behavioral health, economic mobility, social cohesion, and transportation. <h3>Key best practices included:</h3> 1) systematic screening for social needs documented in the electronic health record; 2) mechanisms for care navigation for social needs referrals within the health system; 3) robust CBO network capacity to meet social needs and staff dedicated to cross-sector partnerships; 4) incentives for linkages to care for CBO partners; and 5) shared priorities across partners. We also developed a shared mental model prototype of the social needs screening and referral process based on our formative work. <h3>Conclusions:</h3> This approach is a model for implementing cross-sectoral collaboratives to reduce diabetes and other chronic condition disparities through screening and referral for social needs