Integrating Community Linkages into Care Management Workflows to Address Contextual Drivers of Health: Lessons from a...

Adverse contextual drivers (eg, food, housing, transportation insecurity) influence health outcomes, particularly among individuals with chronic conditions. Electronic health record (EHR)-based care management tools can support screening and referrals for contextual drivers, but under-resourced health centers often lack support to integrate these tools into routine workflows. This pilot study assessed the feasibility of a multicomponent implementation support model to improve care managers' use of EHR tools to address contextual drivers. Three health centers within a national network using a shared EHR participated in a 3-month intervention that included individualized training, practice facilitation, peer support, and audit and feedback. Qualitative data were collected through semi-structured interviews and periodic reflections with care management staff and analyzed thematically. Participants valued structured engagement, protected time for workflow refinement, and individualized guidance from practice coaches and technical experts. They also reported increased confidence using EHR tools to document referrals and coordinate care. Challenges included confusion about audit and feedback data sources, insufficient training on report generation, and variable value of peer discussions. Findings informed intervention refinements, including earlier training, revised peer support structures, enhanced technical assistance, and improved data transparency and accessibility. Results support the feasibility and acceptability of tailored implementation support for integrating contextual driver workflows into care management. The refined intervention will be tested in a stepped wedge cluster randomized trial to evaluate effectiveness, scalability, and impact on care teams.