By Merin C. MacDonald | Date published: November 18, 2024

Elena Byhoff Among Investigators to Receive PACE Award 

Elena Byhoff, MD, associate professor of medicine in the Division of Health Systems Science, has been named one of the recipients of this year’s PACE Award. The award is for the project, “SDoH-MMC: Social Determinants of Health with Mobile Multi-disciplinary Clinics.” 

Adverse social determinants of health (SDoH) include challenges such as financial strain, food insecurity, housing insecurity, employment instability, language barriers, and mobility difficulties. Providing health care to populations experiencing adverse SDoH can pose challenges because of several factors including a lack of best practices for identifying communities with the highest social risks and needs, and a lack of health care infrastructure that specifically addresses inequities stemming from adverse SDoH.  

The study team aims to address this problem by using a geographic information systems (GIS) approach to identify communities with high social risks and low SDoH screening rates. They will then validate their GIS approach by implementing a community-based SDoH intervention at an established mobile multidisciplinary clinic (MMC). There, community navigators will enroll and train patients on how to use MyChart and will collect SDoH screening data. Patients who have an unmet social need will be automatically enrolled in the Get Well platform, a UMMH text messaging program, that will connect patients with community resources. The community navigators will follow up with patients who reported an unmet social need to note care received, reassess social needs, and provide further support, as needed.  

Dr. Byhoff is part of a collaborative team on this project that includes Drs. Daniel Amante and Adrian Zai of the Department of Population and Quantitative Health Sciences, and Dr. Tammy Nguyen of the Department of Surgery.