Understanding Health-Related Social Risks

Because of the established contribution of social factors to health outcomes, approaches that address upstream determinants of health have increasingly been recognized as cost-effective means to improve population health. Understanding and usage of precise terminology is important to facilitate collaboration across disciplines. Social determinants of health affect everyone, not just the socially and economically disadvantaged, whereas health-related social risks (HRSR) are specific adverse conditions at the individual or family level that are associated with poor health and related to the immediate challenges individuals face. Health-related social needs account for patient preference in addressing identified social risks. The use of validated screening tools is important to capture risk factors in a standardized fashion to support research and quality improvement. There is a paucity of studies that address HRSR in the context of radiology. This review provides an understanding of HRSR and outlines various ways in which radiologists can work to mitigate them.

Designing an implementation strategy to increase health-related social needs screening: Applying the PRISM framework in a resource-limited clinical setting

Despite growing acceptability of health-related social needs (HRSN) screening and increasing policy incentives for adoption, clinical implementation of HRSN screening remains low. HRSN screening has been particularly difficult for Community Health Centers (CHCs), which have limited resources to implement and sustain new workflows. While CHCs provide care to patients with disproportionately high levels of unmet social needs, identifying HRSN screening implementation strategies that take CHC-specific contexts into account remains elusive. This study uses the Practical Robust Implementation and Sustainability Model (PRISM) to design an implementation strategy accounting for the unique context of CHCs. We used Rapid Ethnographic Assessment observations and stakeholder focus groups to identify current workflow barriers and facilitators to HRSN screening, and to develop implementation strategies that include multi-level contexts and perspectives. We identified eight themes contributing to low screening implementation: perceived stigma around screening; need for community-based solutions; re-confirming organizational priorities and values; Electronic Medical Record (EMR) limitations; multi-tasking pressures limiting implementation; staff turnover; limited knowledge of regulatory requirements; and community resource availability for referral. Based on the themes, we identified implementation strategies including non-EMR data collection; integration into the workflow for multiple staff members; creation of new training and educational modules; and identification of peer champions for retraining in real time. Administrative requirements are necessary but not sufficient for implementation of HRSN screening in CHCs. Resource-constrained settings benefit from context-specific stakeholder engagement to improve implementation success. The use of PRISM ensured contextual factors were central to the implementation strategy design.

Feasibility of Using Text Messaging to Identify and Assist Patients With Hypertension With Health-Related Social Needs: Cross-Sectional Study

BACKGROUND

Health-related social needs are associated with poor health outcomes, increased acute health care use, and impaired chronic disease management. Given these negative outcomes, an increasing number of national health care organizations have recommended that the health system screen and address unmet health-related social needs as a routine part of clinical care, but there are limited data on how to implement social needs screening in clinical settings to improve the management of chronic diseases such as hypertension. SMS text messaging could be an effective and efficient approach to screen patients; however, there are limited data on the feasibility of using it.

OBJECTIVE

We conducted a cross-sectional study of patients with hypertension to determine the feasibility of using SMS text messaging to screen patients for unmet health-related social needs.

METHODS

We randomly selected 200 patients (≥18 years) from 1 academic health system. Patients were included if they were seen at one of 17 primary care clinics that were part of the academic health system and located in Forsyth County, North Carolina. We limited the sample to patients seen in one of these clinics to provide tailored information about local community-based resources. To ensure that the participants were still patients within the clinic, we only included those who had a visit in the previous 3 months. The SMS text message included a link to 6 questions regarding food, housing, and transportation. Patients who screened positive and were interested received a subsequent message with information about local resources. We assessed the proportion of patients who completed the questions. We also evaluated for the differences in the demographics between patients who completed the questions and those who did not using bivariate analyses.

RESULTS

Of the 200 patients, the majority were female (n=109, 54.5%), non-Hispanic White (n=114, 57.0%), and received commercial insurance (n=105, 52.5%). There were no significant differences in demographics between the 4446 patients who were eligible and the 200 randomly selected patients. Of the 200 patients included, the SMS text message was unable to be delivered to 9 (4.5%) patients and 17 (8.5%) completed the social needs questionnaire. We did not observe a significant difference in the demographic characteristics of patients who did versus did not complete the questionnaire. Of the 17, a total of 5 (29.4%) reported at least 1 unmet need, but only 2 chose to receive resource information.

CONCLUSIONS

We found that only 8.5% (n=17) of patients completed a SMS text message-based health-related social needs questionnaire. SMS text messaging may not be feasible as a single modality to screen patients in this population. Future research should evaluate if SMS text message-based social needs screening is feasible in other populations or effective when paired with other screening modalities.

Narrative review: food as medicine across the pediatric age continuum

PURPOSE OF REVIEW

Poor diet and food insecurity contribute to the dramatic rise in diet-related chronic disease and increasing cost of healthcare. The Food as Medicine (FAM) framework describes food-based interventions designed to prevent, manage, and treat diet-related diseases. However, FAM interventions have not been widely implemented or evaluated in pediatric populations, so critical questions remain about their optimal delivery and design, efficacy, and funding opportunities. We have reviewed the recent literature and offer insights into potential funding and implementation strategies for pediatric healthcare providers.

RECENT FINDINGS

Data from adult and population-level interventions provide evidence that FAM interventions positively impact diet quality, food security, health outcomes, and healthcare utilization and cost in adults and households with children. Evidence from recent pediatric-based FAM interventions and population data from recent changes to federal nutrition programs support the use of food-based interventions to improve child diet quality, food insecurity, and potentially impact long-term health and healthcare utilization and cost.

SUMMARY

Applying the entire spectrum of evidence-based FAM interventions in pediatric settings from prenatal to adolescent stages will offer the greatest opportunity to ensure all children have access to enough healthful food so they can achieve their highest potential in life.

If you build it, they may not come: Understanding factors influencing use of a community resource referral technology

OBJECTIVE

Identify factors affecting the use of a community resource referral platform among local community-based organizations (CBOs) and test strategies to increase platform use.

DATA SOURCES AND STUDY SETTING

Data sources included platform usage data and semi-structured interviews. The study took place in a small city in the Northeastern United States from 2020 to 2022.

STUDY DESIGN

We analyzed platform data and conducted interviews with local organizations and organizations in other communities to understand barriers to CBOs' use of the referral platform and identify strategies that might increase use. We then tested 4 strategies and assessed impacts via time trend analysis of platform usage and qualitative interviews.

DATA COLLECTION/EXTRACTION METHODS

Platform usage data were obtained from the platform. Semi-structured interviews were conducted with staff and leaders of 36 local CBOs and 9 external organizations.

PRINCIPAL FINDINGS

Four years after launch, platform use remained relatively low. None of the tested strategies (data insight reports, a referral hub, tailored training, and a communication campaign) noticeably increased platform use. The main barrier to the use of the platform was the lack of perceived usefulness, mostly because existing processes for identifying resources and referring clients worked well enough and because many organizations were already required to use a client management or referral tool. Additional barriers included the lack of comfort with and, in some cases, active dislike of e-referrals, and lack of comfort with technology tools overall. Organizations that were most likely to find the platform useful and to use it were those that provided referrals for a wide range of needs and whose staff were not already familiar with local resources.

CONCLUSIONS

Organizations seeking to implement referral platforms should not assume that local CBOs will automatically take up these platforms. For these platforms to succeed, much more attention needs to be paid to ensuring the platforms provide value to the CBOs they seek to engage.

Patients' Perspectives on Health-Related Social Needs and Recommendations for Interventions: A Qualitative Study

RATIONALE & OBJECTIVE

People with low socioeconomic status are disproportionately affected by kidney failure, and their adverse outcomes may stem from unmet health-related social needs. This study explored hemodialysis patient perspectives on health-related social needs and recommendations for intervention.

STUDY DESIGN

Qualitative study using semistructured interviews.

SETTINGS & PARTICIPANTS

Thirty-two people with low socioeconomic status receiving hemodialysis at 3 hemodialysis facilities in Austin, Texas.

ANALYTICAL APPROACH

Interviews were analyzed for themes and subthemes using the constant comparative method.

RESULTS

Seven themes and 21 subthemes (in parentheses) were identified: (1) kidney failure was unexpected (never thought it would happen to me; do not understand dialysis); (2) providers fail patients (doctors did not act; doctors do not care); (3) dialysis is detrimental (life is not the same; dialysis is all you do; dialysis causes emotional distress; dialysis makes you feel sick); (4) powerlessness (dependent on others; cannot do anything about my situation); (5) financial resource strain (dialysis makes you poor and keeps you poor; disability checks are not enough; food programs exist but are inconsistent; eat whatever food is available; not enough affordable housing; unstable housing affects health and well-being); (6) motivation to keep going (faith, support system, will to live); and (7) interventions should promote self-efficacy (navigation of community resources, support groups).

LIMITATIONS

Limited quantitative data such as on dialysis vintage, and limited geographic representation.

CONCLUSIONS

Dialysis exacerbates financial resource strain, and health-related social needs exacerbate dialysis-related stress. The participants made recommendations to address social needs with an emphasis on increasing support and community resources for this population.

PLAIN-LANGUAGE SUMMARY

People receiving dialysis often experience health-related social needs, such as food and housing needs, but little is known about how these impact patients' health and well-being or how to best address them. We interviewed people receiving dialysis about how health-related social needs affect them and what they think dialysis facilities can do to help them address those needs. The participants reported that they often lose their independence after starting dialysis and health-related social needs are common, exacerbate their stress and emotional distress, and reduce their sense of well-being. Dialysis facilities may be able to enhance the experience of these patients by facilitating connections with local resources and providing opportunities for patients to support one another.

Feasibility of Screening for Financial Hardship and Health-Related Social Needs at Radiology Encounters

OBJECTIVE

To evaluate the prevalence of financial hardship and health-related social needs (HRSNs) among outpatients undergoing advanced imaging services and assess the feasibility of screening for financial and social needs during radiology encounters.

METHODS

Adult patients receiving CT, MRI, or PET/CT at outpatient imaging centers of an academic tertiary center were asked to complete a 15-minute survey with adapted validated questions inquiring about their experience of financial hardship related to imaging and HRSNs, and the appropriateness of screening for financial and social needs at radiology encounters. Logistic regression analyses were performed to assess factors associated with perceived appropriateness of screening and level of interest in meeting with financial counselors.

RESULTS

A total of 430 patients responded (10.0% response rate; mean age: 57.1 years; 57.4% female; 54.5% White; 22.1% Hispanic; 19.1% Asian; 1% Black). A total of 35% reported experiencing financial hardship with imaging; 47.5% reported material hardship, 15.3% reported cost-related care nonadherence, and 5.3% reported cost-related imaging nonadherence. Overall, 35.9% had at least one HRSN, with food insecurity being the most common (28.3%). The majority (79.7%) felt that being screened for HRSNs at radiology encounters is appropriate, with those experiencing imaging hardship being more likely to feel that screening is appropriate (odds ratio [OR]: 2.93; 95% confidence interval [CI], 1.31-6.56). Overall, 29.5% were interested in meeting with a financial counselor, with those with imaging hardship (OR: 3.70; 95% CI, 1.96-6.97) and HRSNs (OR: 2.87; 95% CI, 1.32-6.24) and who felt uncomfortable with screening (OR: 2.83; 95% CI, 1.14-7.03) being more likely to be interested.

DISCUSSION

Financial hardship and HRSNs are common among outpatients undergoing advanced imaging, with the majority reporting that getting screened at radiology encounters is appropriate.

Addressing Health-Related Social Needs and Mental Health Needs in the Neonatal Intensive Care Unit: Exploring Challenges and the Potential of Technology

Unaddressed health-related social needs (HRSNs) and parental mental health needs in an infant's environment can negatively affect their health outcomes. This study examines the challenges and potential technological solutions for addressing these needs in the neonatal intensive care unit (NICU) setting and beyond. In all, 22 semistructured interviews were conducted with members of the NICU care team and other relevant stakeholders, based on an interpretive description approach. The participants were selected from three safety net hospitals in the U.S. with level IV NICUs. The challenges identified include navigating the multitude of burdens families in the NICU experience, resource constraints within and beyond the health system, a lack of streamlined or consistent processes, no closed-loop referrals to track status and outcomes, and gaps in support postdischarge. Opportunities for leveraging technology to facilitate screening and referral include automating screening, initiating risk-based referrals, using remote check-ins, facilitating resource navigation, tracking referrals, and providing language support. However, technological implementations should avoid perpetuating disparities and consider potential privacy or data-sharing concerns. Although advances in technological health tools alone cannot address all the challenges, they have the potential to offer dynamic tools to support the healthcare setting in identifying and addressing the unique needs and circumstances of each family in the NICU.

Health-Related Social Needs Screening: Promising Practices From the Accountable Health Communities Model

Health-related social needs (HRSNs), such as food insecurity and housing instability, drive health and well-being. The socioeconomic impacts of the COVID-19 pandemic increased the prevalence of HRSNs and highlighted the critical need for strategies to address those needs, particularly in communities experiencing health disparities. Implementing HRSN screening requires adopting effective strategies to overcome common challenges. This report synthesizes promising implementation approaches and lessons learned from the Accountable Health Communities Model, a national effort funded by the Centers for Medicare & Medicaid Services Innovation Center to systematically screen for and address HRSNs in clinical settings. Key strategies include increasing patient engagement and building trust through culturally tailored language and outreach; using and sharing data for monitoring and improvement; using technology to expand access to screening and referrals; dedicating staff to screening roles; integrating screening into existing workflows; and building buy-in among staff by communicating the impact of screening and encouraging peer connections.

Challenges connecting emergency department patients with oral health care: A qualitative analysis of patients, emergency department clinicians, and dentists

BACKGROUND

Unmet dental need shares many risk factors with unmet health-related social needs (HRSN) such as housing and food security and are a common cause for seeking treatment at the emergency department (ED).

METHODS

The authors recruited a purposive sample of English-speaking and Spanish-speaking patients, ED clinicians at 3 urban EDs, and dentists from nearby communities to participate in qualitative interviews to explore barriers to and facilitators of screening for HRSN and unmet dental needs in the ED. Themes were identified from transcripts using a modified grounded theory approach.

RESULTS

Interviews were conducted with 25 ED patients, 19 ED clinicians, and 4 dentists. Four themes were identified: (1) a preference for formalized resources, which more frequently exist for HRSN than for oral health; (2) frequent use of ad hoc resources that are less reliable or structured, particularly for dental referral information; (3) limited knowledge of oral health care resources in the community; and (4) desire for more assistance with identifying and addressing resource needs for both HRSN and oral health. Patients were amenable to screening through a variety of modalities and felt it would be helpful, but clinicians emphasized the need for easier referral processes because of frequent failure to connect patients to oral health care.

CONCLUSIONS

More robust infrastructure and clinician support are needed to ensure successful referral and screening without undue provider burden for both medical and dental clinicians.

PRACTICAL IMPLICATIONS

Patients are amenable to screening for unmet oral health needs and HRSN in the ED, which may improve access to care.

Learning in real world practice: Identifying implementation strategies to integrate health-related social needs screening within a large health system

Introduction

Health systems have many incentives to screen patients for health-related social needs (HRSNs) due to growing evidence that social determinants of health impact outcomes and a new regulatory context that requires health equity measures. This study describes the experience of one large urban health system in scaling HRSN screening by implementing improvement strategies over five years, from 2018 to 2023.

Methods

In 2018, the health system adapted a 10-item HRSN screening tool from a widely used, validated instrument. Implementation strategies aimed to foster screening were retrospectively reviewed and categorized according to the Expert Recommendations for Implementing Change (ERIC) study. Statistical process control methods were utilized to determine whether implementation strategies contributed to improvements in HRSN screening activities.

Results

There were 280,757 HRSN screens administered across 311 clinical teams in the health system between April 2018 and March 2023. Implementation strategies linked to increased screening included integrating screening within an online patient portal (ERIC strategy: involve patients/consumers and family members), expansion to discrete clinical teams (ERIC strategy: change service sites), providing data feedback loops (ERIC strategy: facilitate relay of clinical data to providers), and deploying Community Health Workers to address HRSNs (ERIC strategy: create new clinical teams).

Conclusion

Implementation strategies designed to promote efficiency, foster universal screening, link patients to resources, and provide clinical teams with an easy-to-integrate tool appear to have the greatest impact on HRSN screening uptake. Sustained increases in screening demonstrate the cumulative effects of implementation strategies and the health system's commitment toward universal screening.

A novel pharmacy liaison program to address health-related social needs at an urban safety-net hospital

PURPOSE

Patients with unmet health-related social needs (HRSNs) often experience poor health outcomes and have high levels of healthcare utilization. We describe a program where dually trained pharmacy liaison-patient navigators (PL-PNs) screen for and address HRSNs while providing medication management services to patients with high levels of acute care utilization in a Medicaid Accountable Care Organization. We are unaware of prior studies that have described this PL-PN role.

METHODS

We analyzed case management spreadsheets for the 2 PL-PNs who staffed the program to identify the HRSNs that patients faced and the ways PL-PNs addressed them. We administered surveys, including an 8-item client satisfaction questionnaire (CSQ-8), to characterize patient perceptions of the program.

RESULTS

Initially, 182 patients (86.6% English speaking, 80.2% from a marginalized racial or ethnic group, and 63.2% with a significant medical comorbidity) were enrolled in the program. Non-English-speaking patients were more likely to receive the minimum intervention dose (completion of an HRSN screener). Case management spreadsheet data (available for 160 patients who engaged with the program) indicated that 71% of participants faced at least one HRSN, most often food insecurity (30%), lack of transportation (21%), difficulty paying for utilities (19%), and housing insecurity (19%). Forty-three participants (27%) completed the survey with an average CSQ-8 score of 27.9, indicating high levels of satisfaction with the program. Survey participants reported receiving medication management services, social needs referrals, health-system navigation assistance, and social support.

CONCLUSION

Integration of pharmacy medication adherence and patient navigation services is a promising approach to streamline the HRSN screening and referral process at an urban safety-net hospital.

A Novel Framework to Address the Complexities of Housing Insecurity and Its Associated Health Outcomes and Inequities: "Give, Partner, Invest"

The association between housing insecurity and reduced access to healthcare, diminished mental and physical health, and increased mortality is well-known. This association, along with structural racism, social inequities, and lack of economic opportunities, continues to widen the gap in health outcomes and other disparities between those in higher and lower socio-economic strata in the United States and throughout the advanced economies of the world. System-wide infrastructure failures at municipal, state, and federal government levels have inadequately addressed the difficulty with housing affordability and stability and its associated impact on health outcomes and inequities. Healthcare systems are uniquely poised to help fill this gap and engage with proposed solutions. Strategies that incorporate multiple investment pathways and emphasize community-based partnerships and innovation have the potential for broad public health impacts. In this manuscript, we describe a novel framework, "Give, Partner, Invest," which was created and utilized by the University of Pittsburgh Medical Center (UPMC) Insurance Services Division (ISD) as part of the Integrated Delivery and Finance System to demonstrate the financial, policy, partnership, and workforce levers that could make substantive investments in affordable housing and community-based interventions to improve the health and well-being of our communities. Further, we address housing policy limitations and infrastructure challenges and offer potential solutions.

Screening Health-Related Social Needs in Hospitals: A Systematic Review of Health Care Professional and Patient Perspectives

Health outcomes are markedly influenced by health-related social needs (HRSN) such as food insecurity and housing instability. Under new Joint Commission requirements, hospitals have recently increased attention to HRSN to reduce health disparities. To evaluate prevailing attitudes and guide hospital efforts, the authors conducted a systematic review to describe patients' and health care providers' perceptions related to screening for and addressing patients' HRSN in US hospitals. Articles were identified through PubMed and by expert recommendations, and synthesized by relevance of findings and basic study characteristics. The review included 22 articles, which showed that most health care providers believed that unmet social needs impact health and that screening for HRSN should be a standard part of hospital care. Notable differences existed between perceived importance of HRSN and actual screening rates, however. Patients reported high receptiveness to screening in hospital encounters, but cautioned to avoid stigmatization and protect privacy when screening. Limited knowledge of resources available, lack of time, and lack of actual resources were the most frequently reported barriers to screening for HRSN. Hospital efforts to screen and address HRSN will likely be facilitated by stakeholders' positive perceptions, but common barriers to screening and referral will need to be addressed to effectively scale up efforts and impact health disparities.

Association of Social Needs and Healthcare Utilization Among Medicare and Medicaid Beneficiaries in the Accountable Health Communities Model

BACKGROUND

Integration of health-related social needs (HRSNs) data into clinical care is recognized as a driver for improving healthcare. However, few published studies on HRSNs and their impact are available. CMS sought to fill this gap through the Accountable Health Communities (AHC) Model, a national RCT of HRSN screening, referral, and navigation. Data from the AHC Model could significantly advance the field of HRSN screening and intervention in the USA.

OBJECTIVE

To present data from the Greater Houston AHC (GH-AHC) Model site on HRSN frequency and the association between HRSNs, sociodemographic factors, and self-reported ED utilization using a cross-sectional design. Analyses included descriptive statistics and multinomial logistic regression.

PARTICIPANTS (OR PATIENTS OR SUBJECTS)

All community-dwelling Medicare, Medicaid, or dually covered beneficiaries at participating GH-AHC clinical delivery sites were eligible.

MAIN MEASURES

Self-reported ED utilization in the previous 12 months served as the outcome; demographic characteristics including race, ethnicity, age, sex, income, education level, number of people living in the household, and insurance type were treated as covariates. HRSNs included food insecurity, housing instability, transportation, difficulty paying utility bills, and interpersonal safety. Clinical delivery site type was used as the clustering variable.

KEY RESULTS

Food insecurity was the most common HRSN identified (38.7%) followed by housing instability (29.0%), transportation (28.0%), and difficulty paying utility bills (26.7%). Interpersonal safety was excluded due to low prevalence. More than half of the beneficiaries (56.9%) reported at least one of the four HRSNs. After controlling for covariates, having multiple co-occurring HRSNs was strongly associated with increased risk of two or more ED visits (OR 1.8-9.47 for two to four needs, respectively; p < 0.001). Beneficiaries with four needs were at almost 10 times higher risk of frequent ED utilization (p < 0.001).

CONCLUSIONS

To our knowledge, this is only the second published study to report screening data from the AHC Model. Future research focused on the impact of multiple co-occurring needs on health outcomes is warranted.

"It Made Me Feel like Things Are Starting to Change in Society:" A Qualitative Study to Foster Positive Patient Experiences during Phone-Based Social Needs Interventions

Many healthcare organizations are screening patients for health-related social needs (HRSN) to improve healthcare quality and outcomes. Due to both the COVID-19 pandemic and limited time during clinical visits, much of this screening is now happening by phone. To promote healing and avoid harm, it is vital to understand patient experiences and recommendations regarding these activities. We conducted a pragmatic qualitative study with patients who had participated in a HRSN intervention. We applied maximum variation sampling, completed recruitment and interviews by phone, and carried out an inductive reflexive thematic analysis. From August to November 2021 we interviewed 34 patients, developed 6 themes, and used these themes to create a framework for generating positive patient experiences during phone-based HRSN interventions. First, we found patients were likely to have initial skepticism or reservations about the intervention. Second, we identified 4 positive intervention components regarding patient experience: transparency and respect for patient autonomy; kind demeanor; genuine intention to help; and attentiveness and responsiveness to patients' situations. Finally, we found patients could be left with feelings of appreciation or hope, regardless of whether they connected with HRSN resources. Healthcare organizations can incorporate our framework into trainings for team members carrying out phone-based HRSN interventions.

Implementing health-related social needs screening in western Colorado primary care practices: Qualitative research to inform improved communication with patients

Social determinants profoundly impact health. Many primary care practices now seek to screen their patients for health-related social needs (HRSN) and refer them to resources in the community. However, there is little empirical evidence to guide communication with patients in order to ensure their comfort with the process and increase the likelihood that it results in positive outcomes. This paper describes the first phase of the Improving Messaging Around Gaps in Needs and rEfferals (IMAGINE) study-a multi-phase study aiming to develop and test patient-centred messages about screening and referral for HRSN. In this initial qualitative phase, our objective was to identify communication strategies that might make western Colorado primary care patients more comfortable with the HRSN screening and referral process. From May to July 2020 we interviewed 10 staff members responsible for HRSN screening from primary care practices participating in the western Colorado Accountable Health Communities (AHC) initiative and 20 patients from 2 of these practices. We used a rapid qualitative analysis process that involved summarising interview transcripts across key domains of interest and then identifying emergent themes within each domain using a data matrix. Through this process, we examined current communication about HRSN screening, as well as suggestions for messages and other strategies that could improve communication. In most practices, the AHC Screening Tool was handed to patients by front desk staff at check-in with little explanation as to its purpose. Patients and staff alike recommended that patients be provided with information that: normalises the screening and referral process; assures privacy; clarifies that the purpose is to help and support rather than judge or report; emphasises community benefits; and respects patient autonomy. Interviewees also suggested broader strategies to support more effective communication, such as practice staff and clinicians building trusting relationships with patients and understanding and acknowledging the complex structural barriers that often prevent patients from accessing meaningful assistance. These findings provide actionable suggestions for improving communication about HRSN screening and referral in primary care settings. The next steps include developing specific messages based on these findings and testing their impact on screening tool completion rate, referral uptake, and patient-reported comfort with the process.

Post-Identification Approaches to Addressing Health-Related Social Needs in Primary Care: A Qualitative Study

BACKGROUND

Social determinants of health play a fundamental role in a patient's health status. In recent years, health systems across the nation have implemented numerous strategies aimed at identifying and addressing the health-related social needs of the patients they serve. Despite the influx of peer-reviewed research highlighting outcomes of specific health-related social needs interventions, the spectrum of practices utilized by primary care clinics has not been established.

OBJECTIVE

To determine the range of ways primary care clinics address health-related social needs after identification and initial contact with a frontline staff person is completed.

DESIGN

We conducted 12 semi-structured, in-person interviews with staff from purposively sampled clinics. If the interview included more than one staff person, all participants were interviewed together.

PARTICIPANTS

Twenty-one administrative staff and frontline clinic personnel with experience in 24 separate primary care clinics in the Minneapolis-St. Paul, Minnesota metropolitan area.

APPROACH

Interviews focused on the range of health-related social needs processes utilized by clinics, including staff titles, referral procedures, and barriers to addressing needs. Interview recordings were transcribed and coded using thematic analysis.

KEY RESULTS

Thematic analysis identified variation in four key areas involving how clinics address patients' health-related social needs after identification and initial contact by frontline staff: clinic personnel involved in addressing needs, clinic referral processes, "resource" and "success" definitions, and barriers to accessing community-based supports.

CONCLUSIONS

This study describes the large variation in primary care clinic practices to address health-related social needs after they are identified. The results suggest challenges to standardization and real-world application of previously published studies. Our findings also highlight the opportunity for improved relationships between health systems and community-based agencies.

Housing Cost Burden and Health Decline Among Low- and Moderate-Income Older Renters

OBJECTIVE

To examine the association between housing cost burden and health decline among low- and moderate-income older renters in the U.S.

METHODS

Baseline data include low- and moderate-income community-dwelling older renters (N = 1,064) from the nationally representative 2015 National Health and Aging Trends Study. Housing cost burden (HCB) was defined as the percentage of monthly income spent on rent, categorized as "no HCB" (<30%), "moderate HCB" (30-49%), and "severe HCB" (≥50%). We used weighted logistic regression models to estimate whether HCB status in 2015 and change in HCB between 2015 and 2017 were associated with self-rated health decline and developing a new limitation related to activities of daily living (ADL) or instrumental activities of daily living (IADL) between 2015 and 2017.

RESULTS

Older renters with severe HCB in 2015 were the most likely to develop a new ADL/IADL limitation (63.4%) over time (p < .05). The association between HCB status in 2015 and self-rated health decline was not statistically significant, but older renters with persistent HCB had 1.64 times greater odds of self-rated health decline (p < .05) and 2.01 times greater odds of developing a new ADL/IADL limitation (p < .01), compared to older renters with no HCB at baseline and follow-up.

DISCUSSION

Even in the short term, HCB contributes to health decline in later life. Efforts to promote equity and healthy aging in the community must consider how to best address housing affordability among the growing population of older renters.

Patient Experiences with Screening and Assistance for Social Isolation in Primary Care Settings

BACKGROUND

Social isolation is a known predictor of mortality that disproportionately affects vulnerable populations in the USA. Although experts began to recognize it as a public health crisis prior to 2020, the novel coronavirus pandemic has accelerated recognition of social isolation as a serious threat to health and well-being.

OBJECTIVE

Examine patient experiences with screening and assistance for social isolation in primary care settings, and whether patient experiences with these activities are associated with the severity of reported social isolation.

DESIGN

Cross-sectional survey conducted in 2018.

PARTICIPANTS

Adults (N = 251) were recruited from 3 primary care clinics in Boston, Chicago, and San Francisco.

MAIN MEASURES

A modified version of the Berkman-Syme Social Network Index (SNI), endorsed by the National Academies of Sciences, Engineering, and Medicine; items to assess for prior experiences with screening and assistance for social isolation.

KEY RESULTS

In the sample population, 12.4% reported the highest levels of social isolation (SNI = 0/1), compared to 36.7%, 34.7%, and 16.3% (SNI = 2-4, respectively). Most patients had not been asked about social isolation in a healthcare setting (87.3%), despite reporting no discomfort with social isolation screening (93.9%). Neither discomfort with nor participation in prior screening for social isolation was associated with social isolation levels. Desire for assistance with social isolation (3.2%) was associated with a higher level of social isolation (AOR = 6.0, 95% CI, 1.3-28.8), as well as poor or fair health status (AOR = 9.1; 95% CI, 1.3-64.1).

CONCLUSIONS

In this study, few patients reported being screened previously for social isolation in a primary care setting, despite low levels of discomfort with screening. Providers should consider broadening social isolation screening and referral practices in healthcare settings, especially among sicker and more isolated patients who express higher levels of interest in assistance with social isolation.

The Health and Social Needs of Patients Discharged From the Emergency Department With Suspected COVID-19

Health-related social needs (HRSNs), such as food or housing insecurity, are important drivers of disparities in outcomes during public health emergencies. We describe the development of a telehealth follow-up program in Boston, Massachusetts, for patients discharged from the emergency department after coronavirus disease 2019 (COVID-19) testing to identify patients with worsening clinical symptoms, to screen for unmet HRSNs, and to deliver self-isolation counseling and risk-reduction strategies for socially vulnerable people. We prioritized telephone calls to patients with public health insurance and patients without primary care physicians. In the first 43 days of operation, March 30-May 12, 2020, our intervention reached 509 patients, with 209 (41.1%) patients reporting an HRSN, most commonly related to food, housing, or utilities. Thirty-one (6.1%) patients required assessment by a clinician for clinical worsening. This public health intervention may be useful for other institutions developing programs to address the social and health needs of patients discharged with suspected COVID-19.

Health-Related Social Needs and Increased Readmission Rates: Findings from the Nationwide Readmissions Database

BACKGROUND

While health-related social needs (HRSN) are known to compromise health, work to date has not clearly demonstrated the relationship between clinically acknowledged social needs, via ICD-10 Z-codes, and readmission.

OBJECTIVE

Assess the rate of 30-, 60-, and 90-day readmission by the level of ICD-10-identified social need. In addition, we examined the associations between demographics, social need, hospital characteristics, and comorbidities on 30-day readmission.

DESIGN

Retrospective study using the 2017 Nationwide Readmission Database PARTICIPANTS: We identified 5 domains of HRSN from ICD-10 diagnosis codes including employment, family, housing, psychosocial, and socioeconomic status (SES) and identified how many and which an individual was coded with during the year.

MAIN MEASURES

The proportion of patients with 30-, 60-, and 90-day readmission stratified by the number of HRSN domains with a multivariable logistic regression to examine the relationship between the number/type of and readmission adjusting for sex, age, payer, hospital characteristics, functional limitations, and comorbidities.

KEY RESULTS

From 13,217,506 patients, only 2.4% had at least one HRSN diagnosis. Among patients without HRSN, 11.5% had a 30-day readmission, compared to 27.0% of those with 1 domain, increasing to 63.5% for patients with codes in 5 domains. Similar trends were observed for 60- and 90-day readmission; 78.7% of patients with documented HRSN in all 5 domains were hospitalized again within 90 days. The adjusted odds ratio for readmission for individuals with all 5 domains was 12.55 (95% CI: 9.04, 17.43). Housing and employment emerged as two of the most commonly documented HRSN, as well as having the largest adjusted odds ratio.

CONCLUSIONS

There is a dose-response relationship between the number of HRSN diagnoses and hospital readmission. This work calls attention to the need to develop interventions to reduce readmissions for those at social risk and demonstrates the significance of ICD-10 Z-codes in health outcomes studies.

Patients With Health-Related Social Needs More Likely to Report Poor Clinic Experiences

Measuring patients' care experience is necessary to understanding and improving health care quality and is a core component of patient-centered care. In this study, we test whether patient health care experiences differed between patients with and without health-related social needs, above and beyond demographic differences previously studied. This study relies on survey data from 2341 patients who visited 1 of 7 primary care clinics in Portland, Oregon, and surrounding communities during the latter half of 2018. Survey analysis reveal that patients with at least 1 health-related social need had greater odds of reporting staff not always answering questions, not getting all the care they need, not getting the information to manage care, not being treated with respect by their provider, and getting care being a hassle. The findings from this study suggest that patients with health-related social needs are not getting the holistic care they expect in their primary care clinics and find it a hassle to get care regardless of their demographic characteristics and insurance status. This study may help to inform how health care systems and clinics can best serve patients with health-related social needs.

Rapid-Cycle Community Assessment of Health-Related Social Needs of Children and Families During Coronavirus Disease 2019

OBJECTIVE

To identify unmet health and social resource needs during a county-wide coronavirus disease 19 (COVID-19) stay-at-home order and phased re-opening in Western Pennsylvania.

METHODS

With public health, social service, and community partners connected through an ongoing academic-community collaborative, we developed and fielded a weekly repeated cross-sectional electronic survey assessing usage of and unmet need for health and social service resources. Using 10 weeks of surveys (April 3-June 11, 2020) by Allegheny County residents, we examined variation in responses by week and by sociodemographic characteristics using chi-square tests. We shared written reports weekly and discussed emerging trends with community partners.

RESULTS

Participants ranged from 229 to 1001 per week. Unmet need for at least 1 health or health-related social need resource varied by week, ranging from 55% (95% confidence interval [CI] 50%-59%) of participants in week 2 to 43% (95% CI 37%-49%) of participants in week 9 (P = .006). Increased use of at least 1 resource ranged from 53% (95% CI 47%-58%) of participants in week 3 to 36% (95% CI 31%-42%) in week 9 (P < .001). Unmet need for food and financial assistance peaked early during the stay-at-home order, while unmet need for mental health care rose later. Unmet need for food assistance varied significantly by race and ethnicity and by household prepandemic income.

CONCLUSIONS

Over half of families with children reported unmet health or social service needs during the first month of a county-wide COVID-19 stay-at-home order. Unmet needs varied with race, ethnicity, and income and with duration of the stay-at-home order.

Feasibility of Mobile Technology to Identify and Address Patients' Unmet Social Needs in a Primary Care Clinic

Mobile health tools may overcome barriers to social needs screening; however, there are limited data on the feasibility of using these tools in clinical settings. The objective was to determine the feasibility of using a mobile health system to screen for patients' social needs. In one large primary care clinic, the authors tested a tablet-based system that screens patients for social needs, transmits results to the electronic health record, and alerts providers. All adult patients presenting for a nonurgent visit were eligible. The authors evaluated the feasibility of the system and conducted follow-up surveys to determine acceptability and if patients accessed resources through the process. All providers were surveyed. Of the 252 patients approached, 219 (86.9%) completed the screen. Forty-three (19.6%) required assistance with the tablet, and 150 (68.5%) screened positive for at least 1 unmet need (food, housing, or transportation). Of the 150, 103 (68.7%) completed a follow-up survey. The majority agreed that people would learn to use the tablet quickly. Forty-eight patients (46.6%) reported contacting at least 1 community organization through the process. Of the 27 providers, 23 (85.2%) completed a survey and >70% agreed the system would result in patients having better access to resources. It was feasible to use a tablet-based system to screen for social needs. Clinics considering using mobile tools will need to determine how to screen patients who may need assistance with the tool and how to connect patients to resources through the system based on the burden of unmet needs.

Impact of a Low-Intensity Resource Referral Intervention on Patients' Knowledge, Beliefs, and Use of Community Resources: Results from the CommunityRx Trial

BACKGROUND

Connecting patients to community-based resources is now a cornerstone of modern healthcare that supports self-management of health. The mechanisms that link resource information to behavior change, however, remain poorly understood.

OBJECTIVE

To evaluate the impact of CommunityRx, an automated, low-intensity resource referral intervention, on patients' knowledge, beliefs, and use of community resources.

DESIGN

Real-world controlled clinical trial at an urban academic medical center in 2015-2016; participants were assigned by alternating week to receive the CommunityRx intervention or usual care. Surveys were administered at baseline, 1 week, 1 month, and 3 months.

PARTICIPANTS

Publicly insured adults, ages 45-74 years.

INTERVENTION

CommunityRx generated an automated, personalized list of resources, known as HealtheRx, near each participant's home using condition-specific, evidence-based algorithms. Algorithms used patient demographic and health characteristics documented in the electronic health record to identify relevant resources from a comprehensive, regularly updated database of health-related resources in the study area.

MAIN MEASURES

Using intent-to-treat analysis, we examined the impact of HealtheRx referrals on (1) knowledge of the most commonly referred resource types, including healthy eating classes, individual counseling, mortgage assistance, smoking cessation, stress management, and weight loss classes or groups, and (2) beliefs about having resources in the community to manage health.

KEY RESULTS

In a real-world controlled trial of 374 adults, intervention recipients improved knowledge (AOR = 2.15; 95% CI, 1.29-3.58) and beliefs (AOR = 1.68; 95% CI, 1.07-2.64) about common resources in the community to manage health, specifically gaining knowledge about smoking cessation (AOR = 2.76; 95% CI, 1.07-7.12) and weight loss resources (AOR = 2.26; 95% CI 1.05-4.84). Positive changes in both knowledge and beliefs about community resources were associated with higher resource use (P = 0.02).

CONCLUSIONS

In a middle-age and older population with high morbidity, a low-intensity health IT intervention to deliver resource referrals promoted behavior change by increasing knowledge and positive beliefs about community resources for self-management of health.

NIH TRIAL REGISTRY

NCT02435511.