• Kim Hanh Nguyen, Jessica D Fields, Anupama G Cemballi, Riya Desai, Anjali Gopalan, Tessa Cruz, Aekta Shah, Antwi Akom, William Brown, Urmimala Sarkar, and Courtney Rees Lyles.
• From the Center for Vulnerable Populations, University of California, San Francisco (KHN, JDF, AGC, RD, AA, WB, US, CRL); UCSF Department of Medicine, Division of General Internal Medicine at Zuckerberg, San Francisco General Hospital, CA (KHN, JDF, AGC, US, CRL); Department of Epidemiology and Biostatistics, University of California, San Francisco (KHN, JDF, RD, US, CRL); Kaiser Permanente Northern California, Division of Research, Oakland (AG, CRL); Streetwyze, Oakland, CA (TC, AS, AA); Social Innovation and Universal Opportunity Lab (SOUL), University of California, San Francisco, San Francisco State University (TC, AS, AA); Center for AIDS Prevention Studies, University of California, San Francisco (WB); Bakar Computational Health Science Institute, University of California, San Francisco (WB, CRL). kim.nguyen2@ucsf.edu.
• J Am Board Fam Med. 2021 Jul 1; 34 (4): 698708698-708.

IntroductionSocial determinants of health (SDoH) influence health outcomes and contribute to disparities in chronic disease in vulnerable populations. To inform health system strategies to address SDoH, we conducted a multi-stakeholder qualitative study to capture the multi-level influences on health for those living in socio-economically deprived contexts.MethodsVaried qualitative inquiry methods - in-depth interviews, participant-led neighborhood tours, and clinic visit observations - involving a total of 23 participants (10 patients with chronic illnesses in San Francisco neighborhoods with high chronic disease rates, 10 community leaders serving the same neighborhoods, and 3 providers from San Francisco's public health care delivery system). Qualitative analyses were guided by the Chronic Care Model (CCM).ResultsSeveral key themes emerged from this study. First, we enumerated a large array, neighborhood resources such as food pantries, parks/green spaces, and financial assistance services that interact with patients' self-management. Health service providers leveraged these resources to address patients' social needs but suggested a clear need for expanding this work. Second, analyses uncovered multiple essential mechanisms by which community-based organizations (CBOs) provided and navigated among many neighborhood health resources, including social support and culturally aligned knowledge. Finally, many examples of how structural issues such as institutional racism, transportation, and housing inequities are intertwined with health and social service delivery were elucidated.ConclusionThe results contribute new evidence toward the community domain of the CCM. Health care systems must intentionally partner with CBOs to address SDoH and improve community resources for chronic care management, and directly address structural issues to make progress.© Copyright 2021 by the American Board of Family Medicine.

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