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Drs. Gaurav Dave, associate professor of medicine, and Abhijit V. Kshirsagar, Covington Distinguished Professor of Medicine, received a grant from the NIH National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) to address structural racism to reduce kidney health disparities in rural North Carolina.

North Carolina has the second largest rural population in the country. Inequalities such as lack of access to quality health care, food insecurity, low socioeconomic status, and other adverse social determinants of health often burden these communities. These conditions bolster structural racism and amplify disparities in health outcomes. Structural racism is linked to the accelerated development of chronic conditions like kidney disease.

To dismantle these adverse conditions and mitigate structural racism, researchers at UNC have partnered with the University of Chicago to implement a community resource referral technology. The system will be provided to a network of rural primary care practices in 12 counties across eastern and southern NC.

UNC will be one of five intervention sites across the US in a consortium supported by a coordinating center and the NIDDK.

“We are integrating community in every clinic visit and shifting the paradigm of chronic kidney disease care to a whole person integrated care.”

-Dr. Gaurav Dave, Principal Investigator

“By addressing upstream drivers of kidney disease, we hope to maximally impact downstream complications of kidney disease,” added Dr. Kshirsagar.

Implementing A Community Resource Referral Platform

Drs. Gaurav Dave and Abhijit V. Kshirsagar

Dr. Dave is an expert in community-engaged health equity research and his research focuses on evaluating the implementation and effectiveness of clinic-community embedded structural interventions. He, alongside Dr. Abhijit Kshirsagar, a kidney disease expert, and Dr. Stacy Lindau, a health technology expert at the University of Chicago, will partner with Goshen Medical Centers and Project GRACE (Growing, Reaching, Advocating for Change & Empowerment). Project GRACE is a long-standing community-academic coalition in the Rocky Mount area, represented by 20+ community-, faith, and healthcare-based organizations.

They will implement a community resource referral platform in the electronic medical record system at Goshen Medical Centers and operationalize the technology in the clinic workflow. When a provider identifies a patient with kidney disease who is also struggling to afford groceries or pay rent, they can utilize the system to connect the patient with available local resources- a food bank, library offering employment assistance, financial assistance center, etc.

This project takes the referral process a step further by creating a closed loop between clinics and community service providers. Not only will the patient be given referral information, but the community organization will also be notified and be able to contact the patient. Once the service is provided the organization will convey details about how the individual was assisted, which is sent back to the clinician.

All information related to the patient’s condition, their integrated needs, and closed loop referrals will be available in the electronic health record for a streamlined, easy to track process.

Reducing Health Disparities

Dr. Dave and the research team will test the implementation of the closed loop referral system and its effectiveness in addressing upstream factors that influence chronic kidney disease progression and management.

“We also want to understand if the patient is more aware of resources in the community and does that knowledge enhance patient’s self-efficacy to utilize those resources.”

“And if they did receive the service, can we demonstrate a change in their health outcomes and amplify chronic kidney disease health equity as a result of activating those clinic-community linked resources?” Dr. Dave said.