Evidence Bank

The Evidence Bank is a collection of research studies on common services provided by CBOs that demonstrate outcomes attractive to a health care partner. This collection is updated on a bimonthly basis. For more information, read our Explanations and Instructions page.

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Transportation April 22, 2022 Non-Emergency Medical Transportation Introduction Transportation is an important social determinant of health. We conducted a systematic review of the associations on health and health care utilization of interventions aimed at reducing barriers to non-emergency transportation and non-medical transportation. Methods We ... Read More
Home Modification August 28, 2021 Home Usability Program Background Community participation has become a key outcome measure for people with disabilities. This has resulted in a shift in researchers focus from the individual to the environment. However, research has focused primarily on participation barriers in the community with limited re... Read More
Disease Management February 12, 2016 Living Well with a Disability Approximately 56.7 million persons in the United States have functional impairments that can lead to disability. As a group, persons with disabilities show disparities in measures of overall health when compared with the general population. Much of this can be attributed to secondary co... Read More
Meals and Nutrition July 24, 2017 Supplemental Nutrition Assistance Program (SNAP) Background Although it has long been known that a broad range of factors beyond medical diagnoses affect health and health services use, it has been unclear whether additional income can decrease health service use. We examined whether Supplemental Nutrition Assistance Program (SNAP) r... Read More
Care Management/Care Coordination March 25, 2021 The Right Care, Right Place, Right Time Project: Health-Related Supports in Senior Housing Objective To test the impact of placing a wellness team (nurse and social worker) in senior housing on ambulance transfers and visits to emergency departments over 18 months. Data sources/study setting Intervention sites included seven Boston-area buildings, with five buildings at co... Read More
Care Management/Care Coordination May 31, 2021 Community Care Connections Program Background Integration of social services in health care delivery is increasingly recognized as a potential strategy for improving health and reducing the use of acute care services. Collaborative models that provide older adults with case management, linkages to social services, and a... Read More
Care Management/Care Coordination May 5, 2015 Social Work Care Coordination Abstract This study assessed how a social work–led care coordination intervention would reduce the within-30-day hospital readmission rate among moderate- and high-risk patients age 50 years or older. Authors ran a randomized controlled trial to determine whether there was a significan... Read More
Care Management/Care Coordination, Caregiving, Dementia Care October 16, 2019 Partners in Dementia Care Background and Objectives Numerous non-pharmacological programs for family caregivers and persons with dementia (PWDs) have been found efficacious in randomized controlled trials. Few programs have been tested in translation studies that assess feasibility and outcomes in less-controll... Read More
Fall Prevention/Mobility, Meals and Nutrition August 6, 2015 Home-Delivered Meals and Provision of Vitamin D Objectives To assess the feasibility of a vitamin D intervention delivered through a Meals-on-Wheels (MOW) program to improve 25-hydroxyvitamin D (25(OH)D) concentrations and reduce falls in homebound older adults. Design Single-blind, cluster randomized trial. Setting MOW, Forsy... Read More
Meals and Nutrition October 10, 2013 Home-Delivered Meals Abstract Programs that help older adults live independently in the community can also deliver net savings to states on the costs of long-term supports and services. We estimate that if all states had increased by 1 percent the number of adults age sixty-five or older who received h... Read More
Caregiving, Dementia Care August 19, 2019 REACH-TX Background and Objectives Family caregiving interventions have been proven efficacious at reducing dementia caregiver’s stress and burden, yet translation of evidence-based interventions into community-based support service programs requires modification to the original intervention pr... Read More
Care Management/Care Coordination, Medication Management June 6, 2021 HomeMeds and MedSafety Scan Objectives  Both social and medical factors can negatively affect health outcomes, especially in vulnerable populations. To address these 2 types of factors in a postdischarge population, 2 nonprofit organizations collaborated to combine their novel decision support programs and addres... Read More
Care Management/Care Coordination March 25, 2021 Health-Related Supports in Senior Housing Objectives To test the impact of placing a wellness team (nurse and social worker) in senior housing on ambulance transfers and visits to emergency departments over 18 months. Data sources/study setting Intervention sites included seven Boston-area buildings, with five bu... Read More
Home Modification, Social Engagement January 24, 2019 Seniors Optimizing Community Integration to Advance Better Living with ESRD (SOCIABLE) Rationale & Objective Older adults with end-stage kidney disease have increased morbidity, fatigue, and decreased physical function, which can inhibit self-care and social engagement. We pilot tested a home-based program to improve physical and social functioning of low socioec... Read More
Meals and Nutrition May 18, 2011 Home-Delivered Meals It is critical to use convincing research methodology to demonstrate the benefits of nutrition assistance programs targeted to vulnerable older adults. We examined the impact of Older Americans Act Nutrition Program (OAANP) participation on food security in participants and waitlisted p... Read More
Home Modification January 30, 2015 Community Aging in Place, Advancing Better Living for Elders (CAPABLE) Abstract Current medical models frequently overlook functional limitations and the home environment even though they partially determine healthcare usage and quality of life. The Centers for Medicare and Medicaid Services (CMS) Innovation Center funds projects that have potential to af... Read More
Dementia Care, Fall Prevention/Mobility November 18, 2015 The Healthy Habits Program (HHP) Objectives There is a growing demand to reduce ethnic health disparities. The Healthy Habits Program (HHP) was implemented to provide a community-based physical activity and education intervention for Chinese older adults living in Boston, Massachusetts. This study evaluated the HHP by... Read More
Fall Prevention/Mobility August 14, 2017 On the Move Program Importance Timing and coordination exercises may be an important addition to community-based health promotion exercise programs to improve walking in older adults. Objective To compare the effectiveness of the On the Move group exercise program, which focuses on the timing and coordi... Read More
Meals and Nutrition, Medication Management June 24, 2015 Medication Management, HomeMeds/Home-delivered Meal Program Meals On Wheels, Inc. of Tarrant County (MOWI) collaborated with local community-based organizations and hospitals to provide home-delivered meals and an evidence-based medication management intervention as a care transition service. The model program was designed to address risk factor... Read More
Meals and Nutrition June 3, 2013 Meals and Medical Nutrition Therapy Abstract Chronically ill populations have a strong need for quality public health nutrition services to aid in disease management and improve health outcomes. Evidence suggests that neglecting the importance of adequate nutrition in chronically ill patients has far-reaching implication... Read More
Fall Prevention/Mobility July 12, 2016 Tai Ji Quan: Moving for Better Balance (TJQMBB) in Community Senior Centers Objectives To evaluate the impact of implementing an evidence-based fall prevention intervention in community senior centers. Methods We used a single-group design to evaluate the Tai Ji Quan: Moving for Better Balance (TJQMBB) program’s adoption, population reach, implementation, ef... Read More
Telemedicine April 17, 2019 Telehealth Intervention Programs for Seniors (TIPS) Background Chronic disease in older adults is estimated to account for 84% of annual health care spending in the United States, with many preventable costs expected to rise as the population continues to age. Introduction Telehealth Intervention Programs for Seniors (TIPS) is a commu... Read More
Transportation January 29, 2018 Ride Share Background Transportation to primary care is a well-documented barrier for patients with Medicaid, despite access to non-emergency medical transportation (NEMT) benefits. Rideshare services, which offer greater convenience and lower cost, have been proposed as an NEMT alternative. Obj... Read More
Care Management/Care Coordination March 12, 2021 Connecting Provider to Home program Objective Patients with multiple medical conditions and complex social issues are at risk for high utilization and poor outcomes. The Connecting Provider to Home program deployed teams of a social worker and a community health worker (CHW) to support patients with social issues and acc... Read More
Fall Prevention/Mobility October 11, 2016 Project Healthy Bones Background Project Healthy Bones (PHB) is a 24-week, peer-led exercise and education program for older adults at risk of osteoporosis. Method Residents from an assisted living and senior community program were enrolled after medical clearance. Participant demographics, geriatric fit... Read More