Concept Title: Model Continuums of Care Initiative (MCCI) to Advance Health Equity Among Women and Girls in Racial/Ethnic Minority and Other Marginalized Communities 

Authors: Deidra Roach MD, Division of Treatment and Recovery

Purpose:  MCCI is a multi-ICO (ORWH, NHLBI, NIAAA, NIMH, NIDA, NIMHD, NICHD, NIDDK) implementation and dissemination science initiative to advance racial equity and end health disparities in racial/ethnic minority and other marginalized women and girls.  Specifically, the Model Continuums of Care Initiative will apply the latest implementation and dissemination science approaches to significantly reduce the prevalence and impact of multimorbidity among historically marginalized women of reproductive age at risk and living with mental health disorders, substance use disorders, cardiopulmonary diseases, and common metabolic disorders (e.g., diabetes).   

While historically marginalized women are the general priority population, special emphasis will be placed on using stakeholder partnerships, provider training, and infrastructure changes to improve access for subgroups of women who currently have the least access to high quality health care, including “hardly reached” populations of women who have a substance use disorder and/or serious mental illness or other mental health disorder; trans women; women involved with the criminal justice system; and women with intellectual and other disabilities. This concept proposes a continuum-of-care approach that integrates primary care, reproductive health, behavioral health, cardiopulmonary and endocrine specialties to fully address health care needs in each of these domains, and to have maximum impact on the overall health and well-being of racial/ethnic minority and other women who are underserved, understudied, and underreported.   

Background:   Of all women living in industrialized nations, U.S. women have the highest rates of multimorbidity.  Rising rates of anxiety and depression among U.S. women are acting as important drivers of the sharp increases in harmful alcohol and substance use, and may be related to increases in overdose-related deaths seen particularly in women of reproductive age.   Over the past 2 decades, overdose deaths among women have increased by 400%; however, the opioid crisis has disproportionately affected women from racial/ethnic minority communities.  Additionally, mental illnesses, including major depressive disorder (MDD), as well as abuse of substances including alcohol, nicotine and psychostimulants, increase the risk for cardiovascular (CVD) and other cardiopulmonary diseases (CPD); whereas CVD increases risk for MDD and cognitive impairment.  It is also well-established that people living with diabetes (type 1 or type 2) are at greater risk for depression, and there is mounting evidence that people living with depression may be at greater risk for developing type 2 diabetes.  The intersection of these processes may particularly impact maternal health across pregnancy (e.g. pre-eclampsia), childbirth, and beyond (e.g., postpartum depression).  Research has found multiple factors contributing to these disparities, such as variability in access to quality healthcare, underlying chronic health conditions, structural racism, and implicit bias.   

Statement of Work or Potential Research Projects:  Investigators will be expected to implement community-engaged research designed to increase the adoption of an integrated set of evidence-based practices delivered across healthcare (primary and specialty), behavioral health (Mental Health and SUD Services), and community-based settings to: 1) Strengthen state and community public health surveillance system infrastructure and capacity;  2) Promote provider education/training in the implementation of evidence-based practices to prevent/treat multimorbidity in women and girls; 3) Support the integration and coordination of primary healthcare, behavioral health  systems, and community-based services to meet the health and social needs of racial/ethnic minority and other underserved women of reproductive age; 4) Accelerate the adoption and implementation of evidence-based screening and interventions for common comorbidities affecting women of reproductive age in targeted communities; and 5) Leverage existing federal, state and local resources and collaborations for aligning community and clinical services.  Given that MCCI aims to increase the adoption of an integrated set of evidence-based practices delivered across the entire continuum of women’s health care, it involves conducting a suite of coordinated studies (up to 7*) in each selected community.     

We envision MCCI unfolding in 2 phases, including:  the 2 - 3 year Planning Phase supported by the U34 or similar mechanism.  Investigators will have 2 - 3 years to:  1) complete an assessment of local community surveillance, prevention and treatment needs; 2) identify a set of evidence-informed implementation research goals; 3) identify and develop plans to address essential policy, personnel, data, and other resource needs; and 4) complete or make substantial progress towards completing one or more pilot implementation research projects. 

During the 5 year Implementation Phase, we will use one or more Cooperative Agreement mechanisms (e.g., U24, U54, U19, etc.) to:  1) conduct large scale implementation studies to accelerate the translation of EBI’s to community practice; and 2) disseminate findings through participating community partnerships, with each partnering community serving as the “hub” for a regional learning community.

Research Scope Not Responsive to NOFO:  Model Continuums of Care is an implementation and dissemination science initiative.  Accordingly, Type 1,2, and 3 Hybrid Implementation Trials (i.e., those that evaluate a combination of effectiveness and implementation outcomes or a combination of implementation and clinical outcomes) will be considered to be responsive to the NOFO.  Preclinical and efficacy studies will be considered non-responsive.    

Outcomes and Justification:  This multi-Institute initiative will address gaps in the continuum of health care for racial/ethnic minority and other marginalized women and girls by bringing evidence-based, integrative interventions for mental health and substance use disorders and  common co-occurring physical conditions (e.g., hypertension; diabetes; HIV/AIDS, etc.) to population scale across the entire continuum of women’s health care, and by optimizing coordination of care.   By accelerating the scale-up of evidence-based interventions for common co-occurring conditions across multiple components of existing women’s health care continuums at the same time, MCCI is expected to have a transformative impact on women’s health care, significantly reducing longstanding inequities in the delivery of state-of-the-art prevention, diagnostic, and treatment services in historically marginalized communities.   It is also anticipated that a whole systems approach to strengthening the continuum of health care for women of reproductive age will significantly improve maternal health and birth outcomes among women most severely affected by health disparities. 

*Studies may be based in 5 – 7 components of the women’s health care continuum, including adolescent prevention services; adult prevention services; adolescent primary care services; adult primary care services; adult cardiopulmonary care; adult endocrinology services; and community-based wellness and health maintenance services.