Carluzzo K L, Bernstein L E, Chevan J, Erck E, Murphy H, Radske-Suchan T, Engebretsen B, Schifferdecker K E
Center for Program Design and Evaluation, The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine, Dartmouth College, Lebanon, NH, United States.
Center for Advancing Healthy Communities, National Association of Chronic Disease Directors, Decatur, GA, United States.
Front Health Serv. 2025 Aug 6;5:1630135. doi: 10.3389/frhs.2025.1630135. eCollection 2025.
The Public Health Framework for Collaborative Arthritis Management and Wellbeing ("the Framework") is being piloted as a model to improve health and wellbeing of people with arthritis. This model is built upon a foundational partnership between a clinical entity and a community care hub ("hub"), which recognizes the important role that hubs play in addressing both chronic care needs and unmet social needs of people with arthritis. Specifically, hubs partner with healthcare systems by coordinating and supporting networks of community-based organizations that provide patients with access to health-related resources and services [(such as Arthritis-Appropriate Evidence-Based Interventions (AAEBIs)]. In this Framework, the clinic engages patients in screening (based on physical activity, physical function, and pain), counseling (regarding benefits of physical activity), and referral to community care hubs. At the hub, patients are screened for unmet social needs and are matched with AAEBIs based on a shared-decision-making process. There are two types of AAEBIs: Physical Activity, and Self-Management Education, which may be offered in community-based, clinical, or virtual settings. Through the screening, counseling, and hub referral process, the pilot Framework seeks to increase identification of people who would benefit from AAEBIs, increase AAEBI participation among those who would benefit, and ultimately improve the health and wellbeing of people with arthritis. The evaluation of this Framework leverages an Implementation Research Logic Model (IRLM) and its component frameworks and taxonomies in methods and outcome selection. This study follows the implementation of the Framework through key stages: screening, brief advice and counseling, referral to hub, AAEBI selection and participation, outcomes measurement, and feedback of data to the clinic. This paper offers a practical example of the iterative process we used to make decisions for the evaluation, how the IRLM is used to guide decision-making and analysis, and the methods of our evaluation plan.
协作性关节炎管理与健康公共卫生框架(“框架”)正在作为一种改善关节炎患者健康与福祉的模式进行试点。该模式建立在临床实体与社区护理中心(“中心”)之间的基础伙伴关系之上,这种伙伴关系认识到中心在满足关节炎患者的长期护理需求和未满足的社会需求方面所发挥的重要作用。具体而言,中心通过协调和支持社区组织网络与医疗系统合作,这些社区组织为患者提供获得健康相关资源和服务的途径[例如关节炎适宜循证干预措施(AAEBIs)]。在这个框架中,诊所让患者参与筛查(基于身体活动、身体功能和疼痛)、咨询(关于身体活动的益处),并转介至社区护理中心。在中心,对患者未满足的社会需求进行筛查,并根据共同决策过程为其匹配AAEBIs。AAEBIs有两种类型:身体活动和自我管理教育,可在社区、临床或虚拟环境中提供。通过筛查、咨询和中心转介过程,试点框架旨在增加识别那些将从AAEBIs中受益的人群,提高受益人群对AAEBIs的参与度,并最终改善关节炎患者的健康与福祉。该框架的评估在方法和结果选择上利用了实施研究逻辑模型(IRLM)及其组成框架和分类法。本研究跟踪框架实施的关键阶段:筛查、简短建议和咨询、转介至中心、AAEBIs选择和参与、结果测量以及向诊所反馈数据。本文提供了一个实际例子,说明我们用于评估决策的迭代过程、IRLM如何用于指导决策和分析,以及我们评估计划的方法。