Addressing basic resource needs to improve primary care quality: a community collaboration programme

The Role of Social Determinants of Health in Self-Reported Access to Health Care Among Women Undergoing Screening Mammography

Background: Social determinants of health (SDOH) contribute to health care disparities, with social and economic barriers often leading to difficulties in obtaining necessary care. We evaluated barriers to receiving health care, focusing on caretaker responsibilities, health insurance and cost, and transportation. Materials and Methods: We included women ages ≥40 years receiving screening mammography across three Breast Cancer Surveillance Consortium registries from 2012 to 2017. Women self-reported social and financial barriers to receiving health care in the 12 months before their screening mammogram. We evaluated woman- and census-based community-level factors associated with reporting a barrier using multivariate logistic regression. We assessed interaction with urban versus nonurban residence using Wald tests. Results: Among 393,430 women, 3.6% reported a barrier with a higher proportion in urban versus nonurban settings (3.9% [n = 11,977] vs. 2.2% [n = 1,655], respectively; p < 0.001). Among women reporting a barrier, health care cost and/or no insurance was the most common (49.3%), and no transportation was the least common (7.8%). Compared with white women, odds of reporting barriers were higher among black (adjusted odds ratio [aOR] = 1.30, 95% confidence interval [CI]: 1.16-1.44), Hispanic (aOR = 1.66, 95% CI: 1.53-1.80), and other race (aOR = 1.84, 95% CI: 1.65-2.04) women. Barriers were less likely in women with higher median household income (aOR = 0.69, 95% CI: 0.61-0.79) or higher average health insurance costs (aOR = 0.85, 95% CI: 0.74-0.98), but were more likely in high diversity index areas (aOR = 1.28, 95% CI: 1.11-1.48). Conclusions: Social and financial barriers exist based on race/ethnicity and SDOH related to income, insurance costs, and place of residence among women undergoing screening mammography. Breast imaging facilities could utilize information on these barriers to improve biennial screening adherence or ensure that women with abnormal findings obtain appropriate follow-up care through targeted interventions.

Prevalence of Emergency Department Social Risk and Social Needs

Introduction

Social risks, or adverse social conditions associated with poor health, are prevalent in emergency department (ED) patients, but little is known about how the prevalence of social risk compares to a patient’s reported social need, which incorporates patient preference for intervention. The goal of this study was to describe the relationship between social risk and social need, and identify factors associated with differential responses to social risk and social need questions.

Methods

We conducted a cross-sectional study with 48 hours of time-shift sampling in a large urban ED. Consenting patients completed a demographic questionnaire and assessments of social risk and social need. We applied descriptive statistics to the prevalence of social risk and social need, and multivariable logistic regression to assess factors associated with social risk, social need, or both.

Results

Of the 269 participants, 100 (37%) reported social risk, 83 (31%) reported social need, and 169 (63%) reported neither social risk nor social need. Although social risk and social need were significantly associated (p < 0.01), they incompletely overlapped. Over 50% in each category screened positive in more than one domain (eg, housing instability, food insecurity). In multivariable models, those with higher education (adjusted odds ratio [aOR] 0.44 [95% confidence interval {CI}, 0.24–0.80]) and private insurance (aOR 0.50 [95% CI, 0.29–0.88]) were less likely to report social risk compared to those with lower education and state/public insurance, respectively. Spanish-speakers (aOR 4.07 [95% CI, 1.17–14.10]) and non-Hispanic Black patients (aOR 5.00 [95% CI, 1.91–13.12]) were more likely to report social need, while those with private insurance were less likely to report social need (private vs state/public: aOR 0.13 [95% CI, 0.07–0.26]).

Conclusion

Approximately one-third of patients in a large, urban ED screened positive for at least one social risk or social need, with over half in each category reporting risk/need across multiple domains. Different demographic variables were associated with social risk vs social need, suggesting that individuals with social risks differ from those with social needs, and that screening programs should consider including both assessments.

The Centers for Medicaid and Medicare Services State Innovation Models Initiative and Social Risk Factors: Improved Diagnosis Among Hospitalized Adults With Diabetes

INTRODUCTION

Unaddressed social risks among hospitalized patients with chronic conditions contribute to costly complications and preventable hospitalizations. This study examines whether the Centers for Medicaid and Medicare Services State Innovation Models initiative, through payment and delivery system reforms, accelerates the diagnosis of social risk factors among hospitalized adults with diabetes.

METHODS

Encounter-level data were from the Agency for Healthcare Research and Quality Healthcare Cost and Utilization Project State Inpatient Databases (2010-2015, N=5,040,456). Difference-in-difference logistic regression estimated the extent to which hospitalized adults with diabetes in 4 State Innovation Models states (Arkansas, Massachusetts, Oregon, and Vermont) had increased odds of having a social risk factor diagnosed with an ICD-9 V code compared with hospitalized adults with diabetes in 4 comparison states (Arizona, Georgia, New Jersey, and New Mexico) 2 years after implementation. Data were analyzed between June and December 2019.

RESULTS

Adults with diabetes who were hospitalized in State Innovation Models states had a 30% greater increase in the odds of having a V code documented after implementation than adults with diabetes who were hospitalized in comparison states (AOR=1.29, 95% CI=1.07, 1.56). However, V code use remained infrequent, with only 2.05% of encounters, on average, having any V codes on record in State Innovation Models states after implementation.

CONCLUSIONS

The State Innovation Models initiative slightly but significantly improved the diagnosis of social risks among hospitalized adults with diabetes. State-led delivery system and payment reform may help support movement of hospitals toward better recognition and management of social determinants of health.

Unmet social needs among low-income adults in the United States: Associations with health care access and quality

OBJECTIVE

To describe social needs among low-income adults and estimate the relationship between level of unmet social needs and key indicators of health care access and quality.

DATA SOURCE

National survey data from 12 states from the 2017 Behavioral Risk Factor Surveillance System, which added a "Social Determinants of Health" Module in 2017.

STUDY DESIGN

We examined differences in eight measures of health care access and quality (eg, check-up in last 12 months, inability to see doctor due to cost, receipt of eye examination for diabetics) for low-income adults with 0, 1, 2-3, and 4+ unmet social needs based on 7 social needs measures. We used adjusted logistic regression models to estimate the association between level of unmet need and each outcome.

PRINCIPAL FINDINGS

Most common unmet social needs included not having enough money for balanced meals (33 percent) or food (32 percent). After adjusting for observable characteristics, higher levels of unmet social need were associated with poorer access and quality. Compared to those with no reported unmet needs, having 4+ unmet needs was significantly associated with reduced probability of having a yearly check-up (65 percent vs 78 percent, adjusted difference = -7.1 percentage points (PP)), receiving a flu vaccine (33 percent vs 42 percent, adjusted difference = -5.4 PP), having a personal doctor (74 percent vs 80 percent, adjusted difference = -3.1 PP), and having a foot (63 percent vs 80 percent, adjusted difference = -12.8 PP) or eye examination (61 percent vs 73 percent, adjusted difference = -12.6 PP) for diabetic patients, and increased probability of being unable to see a doctor due to cost (44 percent vs 9 percent, adjusted difference = 27.9 PP) and having diabetes affect the eyes (22 percent vs 19 percent, adjusted difference = 8.0 PP) at α = 0.05.

CONCLUSIONS

Higher levels of unmet social needs were associated with poorer access to and quality of care among low-income adults. Addressing social needs both inside and outside of health care settings may help mitigate these negative effects. Additional research on if and how to effectively do so is critical.

Comparing the performance of two social risk screening tools in a vulnerable subpopulation

Background

Research shows the profound impact of social factors on health, lead many healths systems to incorporate social risk screening. To help healthcare systems select among various screening tools we compared two tools, the Your Current Life Situation (YCLS) and the Accountable Health Communities (AHC) Screening tools, on key psychometric properties.

Method

Kaiser Permanente Southern California subsidized exchange members (n = 1008) were randomly invited to complete a survey containing either the YCLS or the AHC tool, as well as other measures related to care experience and health. Healthcare use was measured through the electronic health record. Agreement between the AHC and YCLS was assessed using adjusted kappas for six domains (food - worry, food - pay, insecure housing, housing quality, transportation, utilities). To assess predictive validity, items on the AHC and YCLS were compared to self-rated health and receipt of a flu shot.

Results

Responders (n = 450) and non-responders (n = 558) significantly differed on sex, language, and depression (P < 0.05) but not anxiety, race/ethnicity, or healthcare use. Agreement between the AHC and YCLS tools was substantial on all items (kappas > 0.60) except for housing quality (kappa 0.52). Four out of six screening questions on the AHC tool and four out of seven on the YCLS tool were associated with self-rated health (P < 0.03). No social needs were associated with flu shot receipt except utilities on the AHC tool (P = 0.028).

Conclusion

In this sample, the AHC and YCLS tools are similar in their ability to screen for social risks. Differences observed likely stem from the timeframe and wording of the questions, which can be used to guide selection in healthcare systems.

Social Needs Screening and Referral Program at a Large US Public Hospital System, 2017

Many health care providers and systems are developing and implementing processes to screen patients for social determinants of health and to refer patients to appropriate nonclinical and community-based resources. The largest public health care system in the United States, New York City Health + Hospitals, piloted such a program in 2017. A qualitative evaluation yielded insights into the implementation and feasibility of such screening and referral programs in health care systems serving low-income, minority, immigrant, and underserved populations.

A qualitative investigation of lived experiences of long-term health condition management with people who are food insecure

Background

As more people are living with one or more chronic health conditions, supporting patients to become activated, self-managers of their conditions has become a key health policy focus both in the UK and internationally. There is also growing evidence in the UK that those with long term health conditions have an increased risk of being food insecure. While international evidence indicates that food insecurity adversely affects individual’s health condition management capability, little is known about how those so affected manage their condition(s) in this context. An investigation of lived experience of health condition management was undertaken with food insecure people living in north east Scotland. The study aimed to explore the challenges facing food insecure people in terms of, i. their self-care condition management practices, and ii. disclosing and discussing the experience of managing their condition with a health care professional, and iii. Notions of the support they might wish to receive from them.

Methods

Twenty in-depth interviews were conducted with individuals attending a food bank and food pantry in north east Scotland. Interview audio recordings were fully transcribed and thematically analysed.

Results

Individuals reporting multiple physical and mental health conditions, took part in the study. Four main themes were identified i.e.: 1. food practices, trade-offs and compromises, that relate to economic constraints and lack of choice; 2. illness experiences and food as they relate to physical and mental ill-health; 3. (in) visibility of participants’ economic vulnerability within health care consultations; and 4. perceptions and expectations of the health care system.

Conclusions

This study, the first of its kind in the UK, indicated that participants’ health condition management aspirations were undermined by the experience of food insecurity, and that their health care consultations in were, on the whole, devoid of discussions of those challenges. As such, the study indicated practical and ethical implications for health care policy, practice and research associated with the risk of intervention-generated health inequalities that were suggested by this study. Better understanding is needed about the impact of household food insecurity on existing ill health, wellbeing and health care use across the UK.

From Policy Statement to Practice: Integrating Social Needs Screening and Referral Assistance With Community Health Workers in an Urban Academic Health Center

Purpose: Social and economic factors have been shown to affect health outcomes. In particular, social determinants of health (SDH) are linked to poor health outcomes in children. Research and some professional academies support routine social needs screening during primary care visits. Translating this recommendation into practice remains challenging due to the resources required and dearth of evidence-based research to guide health center level implementation. We describe our experience implementing a novel social needs screening program at an academic pediatric clinic. Methods: The Community Linkage to Care (CLC) pilot program integrates social needs screening and referral support using community health workers (CHWs) as part of routine primary care visits. Our multidisciplinary team performed process mapping, developed workflows, and led ongoing performance improvement activities. We established key elements of the CLC program through an iterative process We conducted social needs screens at 65% of eligible well-child visits from May 2017 to April 2018; 19.7% of screens had one or more positive responses. Childcare (48.8%), housing quality and/or availability (39.9%), and food insecurity (22.8%) were the most frequently reported needs. On average, 76% of providers had their patients screened on more than half of eligible well-child visits. Discussion: Our experience suggests that screening for social needs at well-child visits is feasible as part of routine primary care. We attribute progress to leveraging resources, obtaining provider buy-in, and defining program components to sustain activities.

Relationship between intervention dosage and success of resource connections in a social needs intervention

OBJECTIVES

Social needs interventions in medical settings aim to mitigate the effects of adverse social circumstances on health outcomes by connecting vulnerable patients with resources. This study examined the relationship between intervention dosage and the success of resource connections using data from a social needs intervention in multiple clinical settings across the US.

STUDY DESIGN

The intervention uses a case management approach to connect patients with unmet needs to resources and services in the community. Intervention dosage was conceptualized as the number of contacts between the navigator and the patient, categorized as direct contact (phone vs. in person) and indirect contact (initiated by the navigator vs. patient). Success of the intervention was conceptualized as 'none,' 'partial,' or 'optimal' for each patient, based on the number of social needs the resource connections addressed.

METHODS

Administrative data were extracted for 38,404 unique patients who screened positive for unmet resource needs between 2012 and 2017. Owing to the large sample size, statistical corrections were made to reduce type I error.

RESULTS

Multinomial logistic regression analyses showed that higher intervention dosage was related to greater success of resource connections, after adjusting for the patient and site characteristics, and the number of needs (odds ratios ranged from 1.62 to 2.89). In-person contact, although received by only 25% of the patients, was associated with the highest probability of optimal success.

CONCLUSIONS

This study demonstrates a feasible way to conceptualize an intervention dose for a social needs intervention that uses a case management approach and has implications for how intervention delivery may improve success of resource connections.

Unmet Social Needs and No-Show Visits in Primary Care in a US Northeastern Urban Health System, 2018-2019

Objectives. To characterize the association between social needs prevalence and no-show proportion and variation in these associations among specific social needs.Methods. In this study, we used results from a 10-item social needs screener conducted across 19 primary care practices in a large urban health system in Bronx County, New York, between April 2018 and July 2019. We estimated the association between unmet needs and 2-year history of missed appointments from 41 637 patients by using negative binomial regression models.Results. The overall no-show appointment proportion was 26.6%. Adjusted models suggest that patients with 1 or more social needs had a significantly higher no-show proportion (31.5%) than those without any social needs (26.3%), representing an 19.8% increase (P < .001). We observed a positive trend (P < .001) between the number of reported social needs and the no-show proportion-26.3% for those with no needs, 30.0% for 1 need, 32.1% for 2 needs, and 33.8% for 3 or more needs. The strongest association was for those with health care transportation need as compared with those without (36.0% vs 26.9%).Conclusions. We found unmet social needs to have a significant association with missed primary care appointments with potential implications on cost, quality, and access for health systems.

Scientific literature on food and nutrition security in primary health care: A scoping review

There is a growing interest in the scientific community regarding Primary Health Care practices aiming at assessing and addressing Food and Nutrition Security. The focus is usually on outcomes, instruments and effectiveness, with no concern regarding theories or concepts. We aimed to map the theoretical frameworks regarding practices towards Food and Nutrition Security in Primary Health Care and describe its conceptualisations based on Ludwik Fleck's epistemological approach. We conducted a scoping review, including 14 databases. Within the 56 publications, the notion of Food and Nutrition Insecurity as a risk for health without further theorisations predominates. Other two minor theoretical frameworks coexist: Food and Nutrition Security as a social determinant of health and as the realisation of a human right. Few publications present Food and Nutrition Security conceptualisations. Of those who define it, there is great variability in the content and sources used. The most elaborated and homogenous conceptualisations are in the human rights group. This review exposes how the disputes surrounding a concept mostly built on policy and international relations penetrate the scientific field. When studying topics in the interface between science and health practices, notably those where controversies exist, researchers should explicitly express their theoretical and conceptual backgrounds.

Patient and Community Organization Perspectives on Accessing Social Resources from the Emergency Department: A Qualitative Study

INTRODUCTION

Social risks adversely affect health and are associated with increased healthcare utilization and costs. Emergency department (ED) patients have high rates of social risk; however, little is known about best practices for ED-based screening or linkage to community resources. We examined the perspectives of patients and community organizations regarding social risk screening and linkage from the ED.

METHODS

Qualitative interviews were conducted with a purposive sample of ED patients and local community organization staff. Participants completed a brief demographic survey, health literacy assessment, and qualitative interview focused on barriers/facilitators to social risk screening in the ED, and ideas for screening and linkage interventions in the ED. Interviews were conducted in English or Spanish, recorded, transcribed, and coded. Themes were identified by consensus.

RESULTS

We conducted 22 interviews with 16 patients and six community organization staff. Three categories of themes emerged. The first related to the importance of social risk screening in the ED. The second category encompassed challenges regarding screening and linkage, including fear, mistrust, transmission of accurate information, and time/resource constraints. The third category included suggestions for improvement and program development. Patients had varied preferences for verbal vs electronic strategies for screening. Community organization staff emphasized resource scarcity and multimodal communication strategies.

CONCLUSION

The development of flexible, multimodal, social risk screening tools, and the creation and maintenance of an accurate database of local resources, are strategies that may facilitate improved identification of social risk and successful linkage to available community resources.

Addressing Social Determinants of Health Within Healthcare Delivery Systems: a Framework to Ground and Inform Health Outcomes

Social determinants of health (SDoH) are the conditions in which people live and work that shape access to essential social and economic resources. Calls for healthcare systems to intervene on unmet social needs have stimulated several large-scale initiatives across the country. Yet, such activities are underway in the absence of a unifying conceptual framework outlining the potential mechanisms by which healthcare-based unmet social need interventions can improve health outcomes. Drawing on theoretical foundations and empirical evidence about the relationship between unmet social needs and health, the authors developed the OASIS (Outcomes from Addressing SDoH in Systems) conceptual framework to map the known and hypothesized pathways by which unmet social need screening and referral interventions may impact outcomes. The OASIS framework may help guide policy makers, healthcare system leaders, clinicians, and researchers to utilize a more unified approach in their efforts to implement and evaluate unmet social need interventions and thus foster the development of an evidence base to inform healthcare systems to more effectively mitigate the consequences of unmet social needs. Adopting an overarching conceptual framework for addressing unmet social needs by healthcare systems holds promise for better achieving health equity and promoting health at the individual and population levels.

Implementing an EHR-based Screening and Referral System to Address Social Determinants of Health in Primary Care

BACKGROUND

Social determinants affect health, yet there are few systematic clinical strategies in primary care that leverage electronic health record (EHR) automation to facilitate screening for social needs and resource referrals. An EHR-based social determinants of health (SDOH) screening and referral model, adapted from the WE CARE model for pediatrics, was implemented in urban adult primary care.

OBJECTIVES

This study aimed to: (1) understand the burden of SDOH among patients at Boston Medical Center; and (2) evaluate the feasibility of implementing a systematic clinical strategy to screen new primary care patients for SDOH, use EHR technology to add these needs to the patient's chart through autogenerated ICD-10 codes, and print patient language-congruent referrals to available resources upon patient request.

RESEARCH DESIGN

This observational study assessed the number of patients who were screened to be positive and requested resources for social needs. In addition, we evaluated the feasibility of implementing our SDOH strategy by determining the proportion of: eligible patients screened, providers signing orders for positive patient screenings, and provider orders for resource referral guides among patients requesting resource connections.

RESULTS

In total, 1696 of 2420 (70%) eligible patients were screened. Employment (12%), food insecurity (11%), and problems affording medications (11%) were the most prevalent concerns among respondents. In total, 367 of 445 (82%) patients with ≥1 identified needs (excluding education) had the appropriate ICD-10 codes added to their visit diagnoses. In total, 325 of 376 (86%) patients who requested resources received a relevant resource referral guide.

CONCLUSIONS

Implementing a systematic clinical strategy in primary care using EHR workflows was successful in identifying and providing resource information to patients with SDOH needs.

Changing the Pediatric Paradigm: Focusing on Strengths

Pediatricians need to adopt a strengths-based approach within their practices to better address their patients' health-related social needs. This approach becomes even more important as the pediatric population in the United States becomes increasingly diverse. Pediatricians must be cognizant of and address biases within their practices to maximize effectiveness of a strengths-based approach. With evidence mounting about their significance to health, a paradigm shift is needed to address health-related social needs by focusing on assets, not deficits. This shift will hopefully improve pediatric health outcomes which have languished in the United States, despite outspending other wealthy nations for decades.

Social Risks Among Primary Care Patients in a Large Urban Health System

INTRODUCTION

Health systems are increasingly interested in addressing the social determinants of health via social risk screening. The objective of this study is to understand the variability in the number and types of social risks overall and in population subgroups among primary care patients routinely screened in a large urban health system.

METHODS

Between April and December 2018, a total of 24,633 primary care patients completed a 10-item screener across 19 ambulatory sites within a health system in the Bronx, NY. The prevalence of any social risk and specific social risks was estimated overall and for population subgroups. Wald tests were used to determine statistically significant differences by subgroup. Data were analyzed in winter/spring 2019.

RESULTS

Twenty percent of patients presented with at least 1 social risk. The most frequently reported risks included housing quality (6.5%) and food insecurity (6.1%). Middle-aged (30-59 years) respondents (24.7%, 95% CI=23.6%, 25.7%) compared with those aged 18-29 years (17.7%, 95% CI=16.4%, 19.2%, p<0.001), and Medicaid patients (24.8%, 95% CI=24.0%, 25.5%) compared with commercially insured patients (11.8%, 95% CI=11.1%, 12.5%, p<0.001), were more likely to report social risks. The strongest predictor of housing quality risk was residing in public housing (15.1%, 95% CI=13.8%, 16.6%) compared with those not in public housing (5.6%, 95% CI=5.3%, 5.9%, p<0.001). Housing quality was the most frequently reported risk for children (aged <18 years) and older adults (aged ≥70 years), whereas, for middle-aged respondents (30-69 years), it was food insecurity.

CONCLUSIONS

There are important differences in the prevalence of overall and individual social risks by subgroup. These findings should be considered to inform clinical care and social risk screening and interventions.

Screening for Social Determinants of Health Among Children: Patients' Preferences for Receiving Information to Meet Social Needs and a Comparison of Screening Instruments

To characterize optimal strategies for screening for social determinants of health (SDOH) among children, the authors performed a cross-sectional study of parents and adolescents ages ≥13 years in a community health center. Participants were queried about how they prefer to receive information about social needs resources and 2 screening instruments were compared: Well Child Care, Evaluation, Community Resources, Advocacy, Referral, Education (WE CARE) and Accountable Health Communities (AHC). In July 2019, 154 parents and 21 adolescents were surveyed. Surveys were administered via tablet and required 5.6 minutes (standard deviation [SD] 3.9 minutes) for parents and 3.9 minutes (SD 1.4 minutes) for adolescents to complete. Parents identified technology (text message, email) and informational printouts as preferred mechanisms for information receipt (58% and 32% of participants, respectively); adolescents preferred text message (57%) and printouts (19%). Few (<10% overall) preferred in-person consultation with a care coordinator. Adolescent/parent pairs (n = 19 pairs) agreed, on average across SDOH, 82% of the time for WE CARE and 85% for AHC. AHC elicited more positive screens than WE CARE for housing insecurity (12% of parents versus 7%) and food insecurity (47% versus 16%) but fewer positive screens than WE CARE for difficulties paying for utilities (27% versus 39%). Routine screening for SDOH in children requires 2-3 minutes per screening instrument. Screening can target parents of young children and either adolescents themselves or their parents. Families prefer to receive information about meeting social needs via technologically-based methods as opposed to in-person consultation with enabling services providers.

Food Insecurity and Major Diet-Related Morbidities in Migrating Children: A Systematic Review

Children of migrant families are known to be at a higher risk of diet-related morbidities due to complex variables including food insecurity, cultural and religious beliefs, and sociodemographic factors like ethnicity, socioeconomic status, and education. Several studies have assessed the presence of specific diseases related to dietary issues in migrant children. This systematic review aims to highlight the existing body of work on nutritional deficiencies in the specific vulnerable pediatric population of immigrants. Refugees were intentionally excluded because of fundamental differences between the two groups including the reasons for migration and health status at the time of arrival. A total of 29 papers were included and assessed for quality. Most of them described a strong correlation between obesity and migration. A high prevalence of stunting, early childhood caries, iron and vitamin D deficiency was also reported, but the studies were few and heterogeneous. Food insecurity and acculturation were found important social factors (nevertheless with inconclusive results) influencing dietary habits and contributing to the development of morbidities such as obesity and other metabolic disorders, which can cause progressive unsustainability of health systems. Public health screening for diet-related diseases in migrant children may be implemented. Educational programs to improve children’s diet and promote healthy-living behaviors as a form of socioeconomic investment for the health of the new generations may also be considered.

Psychometric and Pragmatic Properties of Social Risk Screening Tools: A Systematic Review

CONTEXT

Health systems increasingly are exploring implementation of standardized social risk assessments. Implementation requires screening tools both with evidence of validity and reliability (psychometric properties) and that are low cost, easy to administer, readable, and brief (pragmatic properties). These properties for social risk assessment tools are not well understood and could help guide selection of assessment tools and future research.

EVIDENCE ACQUISITION

The systematic review was conducted during 2018 and included literature from PubMed and CINAHL published between 2000 and May 18, 2018. Included studies were based in the U.S., included tools that addressed at least 2 social risk factors (economic stability, education, social and community context, healthcare access, neighborhood and physical environment, or food), and were administered in a clinical setting. Manual literature searching was used to identify empirical uses of included screening tools. Data on psychometric and pragmatic properties of each tool were abstracted.

EVIDENCE SYNTHESIS

Review of 6,838 unique citations yielded 21 unique screening tools and 60 articles demonstrating empirical uses of the included screening tools. Data on psychometric properties were sparse, and few tools reported use of gold standard measurement development methods. Review of pragmatic properties indicated that tools were generally low cost, written for low-literacy populations, and easy to administer.

CONCLUSIONS

Multiple low-cost, low literacy tools are available for social risk screening in clinical settings, but psychometric data are very limited. More research is needed on clinic-based screening tool reliability and validity as these factors should influence both adoption and utility.

SUPPLEMENT INFORMATION

This article is part of a supplement entitled Identifying and Intervening on Social Needs in Clinical Settings: Evidence and Evidence Gaps, which is sponsored by the Agency for Healthcare Research and Quality of the U.S. Department of Health and Human Services, Kaiser Permanente, and the Robert Wood Johnson Foundation.

Screening for poverty and intervening in a primary care setting: an acceptability and feasibility study

BACKGROUND

A movement is emerging to encourage health providers and health organizations to take action on the social determinants of health. However, few evidence-based interventions exist. Digital tools have not been examined in depth.

OBJECTIVE

To assess the acceptability and feasibility of integrating, within routine primary care, screening for poverty and an online tool that helps identify financial benefits.

METHODS

The setting was a Community Health Centre serving a large number of low-income individuals in Toronto, Canada. Physicians were encouraged to use the tool at every possible encounter during a 1-month period. A link to the tool was easily accessible, and reminder emails were circulated regularly. This mixed-methods study used a combination of pre-intervention and post-intervention surveys, focus groups and interviews.

RESULTS

Thirteen physicians participated (81.25% of all) and represented a range of genders and years in practice. Physicians reported a strong awareness of the importance of identifying poverty as a health concern, but low confidence in their ability to address poverty. The tool was used with 63 patients over a 1-month period. Although screening and intervening on poverty is logistically challenging in regular workflows, online tools could assist patients and health providers identify financial benefits quickly. Future interventions should include more robust follow-up.

CONCLUSIONS

Our study contributes to the evidence based on addressing the social determinants of health in clinical settings. Future approaches could involve routine screening, engaging other members of the team in intervening and following up, and better integration with the electronic health record.

How Are Patients Accessing Primary Care Within the Patient-Centered Medical Home? Results From the Veterans Health Administration

The patient-centered medical home (PCMH) expands access by providing care same-day, by phone, and after hours; however, little is known about which patients seek these services. We examined the association of patient, clinical, and local economic characteristics with the self-reported use of 5 routine and nonroutine ways to access primary care within the Veterans Health Administration. We identified sets of characteristics, including gender- and age-specific, racial and ethnic, and socioeconomic differences of how veterans report seeking primary care. As the PCMH model develops, it will be important to further understand the differential demand for these services to optimize patient-centered access.

A systematic review of reasons for and against asking patients about their socioeconomic contexts

Background

People’s social and economic circumstances are important determinants of their health, health experiences, healthcare access, and healthcare outcomes. However, patients’ socioeconomic circumstances are rarely asked about or documented in healthcare settings. We conducted a systematic review of published reasons for why patients’ socioeconomic contexts (including education, employment, occupation, housing, income, or wealth) should, or should not, be enquired about.

Methods

Systematic review of literature published up to and including 2016. A structured literature search using databases of medicine and nursing (pubmed, embase, global health), ethics (Ethicsweb), social sciences (Web of Science), and psychology (PsychINFO) was followed by a ‘snowball’ search. Eligible publications contained one or more reasons for: asking patients about socioeconomic circumstances; collecting patients’ socioeconomic information; ‘screening’ patients for adverse socioeconomic circumstances; or linking other sources of individual socioeconomic data to patients’ healthcare records. Two authors conducted the screening: the first screened all references, the second author screened a 20% sample with inter-rater reliability statistically confirmed. ‘Reason data’ was extracted from eligible publications by two authors, then analysed and organised.

Results

We identified 138 eligible publications. Most offered reasons for why patients’ should be asked about their socioeconomic circumstances. Reasons included potential improvements in: individual healthcare outcomes; healthcare service monitoring and provision; population health research and policies. Many authors also expressed concerns for improving equity in health. Eight publications suggested patients should not be asked about their socioeconomic circumstances, due to: potential harms; professional boundaries; and the information obtained being inaccurate or unnecessary.

Conclusions

This first summary of literature on the subject found many published reasons for why patients’ social and economic circumstances should be enquired about in healthcare settings. These reasons include potential benefits at the levels of individuals, health service provision, and population, as well as the potential to improve healthcare equity. Cautions and caveats include concerns about the clinician’s role in responding to patients’ social problems; the perceived importance of social health determinants compared with biomedical factors; the use of average population data from geographic areas to infer the socioeconomic experience of individuals. Actual evidence of outcomes is lacking: our review suggests hypotheses that can be tested in future research.

Low and Higher Wage Workers Report No Differences in Four Barriers to Primary Care Access

Lower wage workers, known to seek more care in the emergency department (ED), may encounter more barriers to timely outpatient primary care. This study aimed to identify differences in self-reported delays in care related to 4 modifiable barriers (phone availability, appointment wait time, in-clinic wait time, and limited service hours) across self-reported wage and to examine the relationship between these care delays and self-reported ED use. The authors examined data from the 2011-2015 National Health Interview Surveys for 58,298 self-identified full-time workers. Multivariable logistic models with geographical region and year fixed effects were used to test the association of wage group and barriers to care. In addition, the multiplicative and additive interaction effects upon self-reported ED use were tested. No association was observed between wage level and barrier to timely care. Lower wage workers (<$25,000 vs. >$75,000/yr.; OR 1.53, 95% CI 1.20-1.94, P = 0.001) and those reporting any of the 4 barriers to care (OR 1.99, 95% CI 1.71-1.94, P < 0.001) were more likely to report 2 or more ED visits in the past year. Multiplicative effects were not statistically significant. Additive interaction effects of wage and barriers were only significant among workers with wages $35,000-$44,999 annually (vs. >$75,000: relative excess risk coef. 1.23, 95% CI 0.07-2.38, P = 0.037) for 2 or more ED visits in past year. Although these modifiable barriers may explain the differences in repeat ED use for workers earning $35,000-$44,999 annually, these barriers do not explain disparities in ED use between highest and lowest wage workers.

In support of point-of-care social needs screening: The effects of five social determinants on the health of children with chronic diseases in British Columbia

Background

Prior to introducing social needs screening into our subspecialty clinics, we first wanted to understand the health effects of the major social challenges facing children with chronic diseases in British Columbia.

Methods

Using a strict prospective methodology, avoiding use of health databases and proxy end points, we studied the effects of five social health determinants (distance from care, family income, gender, ethnicity, caregiver education), on health outcomes in three groups of children with chronic diseases: cystic fibrosis (CF), type 1 diabetes (T1D), chronic kidney disease (CKD). Social determinant data were collected at a face-to-face interview during a clinic visit. These were correlated with diagnosis-specific health outcomes, measured at the same visit. Main outcomes were: forced expired volume in 1 second (FEV₁) (CF group), HbA1c (T1D group), estimated glomerular filtration rate (CKD group).

Results

We studied 270 children: 85 CF, 89 T1D and 96 CKD. In all three groups, children from families with annual income less than $45,000 had significantly worse health than those from families above this cut-off. Lower caregiver education was related to worse health in the CKD and T1D groups. We found no adverse health effects associated with distance from subspecialty care, patient ethnicity or gender.

Conclusion

Even in a prosperous province, family poverty and lack of caregiver education still impose measurable adverse effects on the health of children with chronic diseases. We hope these results help support the integration of social needs screening into routine multidisciplinary outpatient clinics. Early detection of social problems and targeted interventions will hopefully help to equalize health outcomes between children from different social groups.

Evaluating a Community-Placed and Clinically Integrated Community Health Worker Program: A Realist Approach

Community health worker (CHW) programs can act as bridges between patients and health care teams, but the complexity and variability of program components and outcomes make them difficult to evaluate. This evaluation used a realist approach to identify underlying mechanisms and contextual factors associated with successful implementation of a community-placed CHW program affiliated with a primary care practice in the Midwest United States. The analysis identified mechanisms by which stakeholders built trust, self-efficacy, and empowerment to improve patient-centered outcomes and experiences. It also identified conditions that support activation of these mechanisms, including the ability of CHWs to make home visits, effective communication between members of the care team across settings, and clarity about the role of the CHW relative to other support services for patients. This type of context-mechanism-outcome evaluation facilitated development of recommendations responsive to local context.

Integrating Social Needs Into Health Care: A Twenty-Year Case Study Of Adaptation And Diffusion

The US health care system has recently begun to account for patients' unmet social needs in care delivery and payment reform. This article presents a twenty-year qualitative case study of five stages of diffusion-testing and learning, standardization, replication, shifting from doing to enabling, and catalyzing broad adoption-of a practical approach for integrating social needs into clinical care. This case study of Health Leads and its funders confirms the importance of focusing on a clear aim, investing in model testing and standardization to enable subsequent responsiveness to the market, and the willingness of innovators and their investors to cede control of a model to allow local adaption and accelerate broad adoption.

Screening for Both Child Behavior and Social Determinants of Health in Pediatric Primary Care

OBJECTIVE

To implement comprehensive screening for child behavior and social determinants of health in an urban pediatric practice and explore rates of referrals and follow-up for positive screens.

METHOD

Quality improvement methodology was used to implement routine screening using an adapted version of the Survey of Well Being of Young Children, a child behavior and social screen, for all children aged 6 months to 10 years. Rates of screen administration and documentation were assessed for 18 months. Medical records of a convenience sample (N = 349) were reviewed to track referrals and follow-up for positive screens. A secondary analysis explored associations between reported parental concern for their child's behavior and both child behavior symptoms and social stressors.

RESULTS

Over 18 months, 2028 screens were administered. Screening rates reached 90% after introducing a tablet for screening. Provider documentation of screens averaged 62%. In the convenience sample, 28% scored positive for a behavioral problem, and 25% reported at least 1 social stressor. Of those with positive child behavior or social stressor screens, approximately 80% followed up with their primary medical doctor, and approximately 50% completed referrals to the clinic social worker. Further analysis indicated that referral and follow-up rates varied depending on whether the family identified child behavior or social issues. Logistic regression revealed that parental concern was independently associated with child behavior symptoms (p = 0.001) and social stressors (p = 0.002).

CONCLUSION

Implementing a comprehensive psychosocial screen is feasible in pediatric primary care and may help target referrals to address psychosocial health needs.

Mechanisms Associated with Clinical Improvement in Interventions That Address Health-Related Social Needs: A Mixed-Methods Analysis

Linking individuals to community resources in order to help meet health-related social needs, such as food, medications, or transportation, may improve clinical outcomes. However, little is known about the mechanisms whereby such linkage interventions might improve health. The authors conducted a mixed-methods analysis consisting of outcomes from a prospective cohort study of a linkage intervention and a qualitative analysis of case records from participants. The cohort study included intervention participants who first enrolled between December 2014 and March 2015. Participants were excluded if they could not complete the assessment because of illness or language. The authors examined changes in cost-related medication underuse (CRMU), transportation barriers, and food insecurity (FI). For the qualitative analysis, a random sample of 80 participants was selected for electronic health record review - 40 cases who showed clinical improvement (responders) and 40 cases who did not (nonresponders). Themes were extracted by 3 reviewers guided by the immersion/crystallization approach. For the cohort study, 141 individuals were included; 138 (97.9%) completed follow-up. Comparing baseline to follow-up, there were significant reductions in the prevalence of CRMU (from 44.2% to 39.1%, P = .003) and transportation barriers (from 46.3% to 30.2%, P = .001), but not FI (from 40.4% to 38.2%, P = .73). For the qualitative study, emergent themes that helped differentiate responders and nonresponders included acuity of need, resource availability/access, and adequacy of the resource utilized. CRMU and transportation barriers may be important mechanisms by which linkage interventions improve health-related social needs. Patient-centered themes can help guide intervention improvements.

How 6 Organizations Developed Tools and Processes for Social Determinants of Health Screening in Primary Care: An Overview

Little is known about how health care organizations are developing tools for identifying/addressing patients' social determinants of health (SDH). We describe the processes recently used by 6 organizations to develop SDH screening tools for ambulatory care and the barriers they faced during those efforts. Common processes included reviewing literature and consulting primary care staff. The organizations prioritized avoiding redundant data collection, integrating SDH screening into existing workflows, and addressing diverse clinic needs. This article provides suggestions for others hoping to develop similar tools/strategies for identifying patients' SDH needs in ambulatory care settings, with recommendations for further research.

Impact of Health Care and Socioeconomic Needs on Health Care Utilization and Disease Management: The University of New Mexico Hospital Care One Program

Understanding how unmet basic needs impact health care in patients with complex conditions is vital to improve health outcomes and reduce health care costs. The purpose of this observational study was to explore the association between health care and socioeconomic needs and health care utilization and disease management among patients with chronic conditions at an intensive, patient-centered, office-based program. The study used a cross-sectional design and a convenience sampling approach. Data were collected through a patient questionnaire and medical records. Analysis included descriptive and inferential statistics. Data from 48 established patients were analyzed. Financial and lack of transportation were the 2 most frequently reported unmet needs. More than 65% of participants had their chronic condition(s) under control. Sex and ethnicity were the only 2 demographic variables that yielded significant differences (P ≤ 0.01) on visits to the emergency room and having chronic condition(s) under control. Those who reported having unmet transportation needs were more likely to have a condition uncontrolled and to have lost medical appointments compared to those who had this social need met (P ≤ 0.05). Statistically significant differences in terms of missing medical appointments also were found between those whose overall financial and housing needs were unmet and those who had those needs met (P ≤ 0.05). Results indicate that participating patients generally had good control of their conditions. The study adds evidence in support of the call for health care to address patients' socioeconomic needs, and the health care benefits of intensive case management programs. The model may be considered for adoption throughout New Mexico, and nationally.

Adverse childhood experiences: Evidence for screening beyond preventive visits

Primary efforts to screen for adverse childhood experiences (ACE/ACEs) are often focused on the well child/adolescent visit. The purpose of this study was to examine relationships between ACEs and youth likelihood of receiving preventive care. Data are from 126,868 students in the 8th, 9th, and 11th grades who participated in the 2016 Minnesota Student Survey, an anonymous, self-report questionnaire examining youth behaviors, experiences, and perceptions. Logistic regression models were used to determine if 10 types of ACEs, including abuse, household dysfunction, and food and housing insecurity were associated with receipt of recommended preventive medical and dental care after adjustment for demographic covariates and self-reported health. ACEs scores were entered into regression models to test for cumulative impact of adversities on preventive care outcomes. More than one third (38.5%) of youth identified at least one ACE, most commonly having a parent or guardian who had ever been in jail or prison. Each type of ACE was significantly associated with reduced odds of receiving preventive care in the last year. Associations with food insecurity were of greatest magnitude, associated with 0.32 [CI: 0.64-0.72] to 0.54 [CI: 0.44-0.49] decreased odds of receiving care. Each one point increase in the total ACE score was associated with 0.07 [CI: 0.92-0.94] to 0.15 [CI: 0.84-0.86] decreased odds of having had a preventive care visit in the last year. Findings add to the growing literature documenting significant relationships between ACEs and health, in this case, youth missing opportunities to receive recommended surveillance and anticipatory guidance.

Impact of a Population Health Management Intervention on Disparities in Cardiovascular Disease Control

BACKGROUND

Healthcare systems use population health management programs to improve the quality of cardiovascular disease care. Adding a dedicated population health coordinator (PHC) who identifies and reaches out to patients not meeting cardiovascular care goals to these programs may help reduce disparities in cardiovascular care.

OBJECTIVE

To determine whether a program that used PHCs decreased racial/ethnic disparities in LDL cholesterol and blood pressure (BP) control.

DESIGN

Retrospective difference-in-difference analysis.

PARTICIPANTS

Twelve thousdand five hundred fifty-five primary care patients with cardiovascular disease (cohort for LDL analysis) and 41,183 with hypertension (cohort for BP analysis).

INTERVENTION

From July 1, 2014-December 31, 2014, 18 practices used an information technology (IT) system to identify patients not meeting LDL and BP goals; 8 practices also received a PHC. We examined whether having the PHC plus IT system, compared with having the IT system alone, decreased racial/ethnic disparities, using difference-in-difference analysis of data collected before and after program implementation.

MAIN MEASURES

Meeting guideline concordant LDL and BP goals.

KEY RESULTS

At baseline, there were racial/ethnic disparities in meeting LDL (p = 0.007) and BP (p = 0.0003) goals. Comparing practices with and without a PHC, and accounting for pre-intervention LDL control, non-Hispanic white patients in PHC practices had improved odds of LDL control (OR 1.20 95% CI 1.09-1.32) compared with those in non-PHC practices. Non-Hispanic black (OR 1.15 95% CI 0.80-1.65) and Hispanic (OR 1.29 95% CI 0.66-2.53) patients saw similar, but non-significant, improvements in LDL control. For BP control, non-Hispanic white patients in PHC practices (versus non-PHC) improved (OR 1.13 95% CI 1.05-1.22). Non-Hispanic black patients (OR 1.17 95% CI 0.94-1.45) saw similar, but non-statistically significant, improvements in BP control, but Hispanic (OR 0.90 95% CI 0.59-1.36) patients did not. Interaction testing confirmed that disparities did not decrease (p = 0.73 for LDL and p = 0.69 for BP).

CONCLUSIONS

The population health management intervention did not decrease disparities. Further efforts should explicitly target improving both healthcare equity and quality. Clinical Trials #: NCT02812303 ( ClinicalTrials.gov ).

What Do High-Risk Patients Value? Perspectives on a Care Management Program

BACKGROUND

There is growing interest in coordinating care for high-risk patients through care management programs despite inconsistent results on cost reduction. Early evidence suggests patient-centered benefits, but we know little about how participants engage with the programs and what aspects they value.

OBJECTIVE

To explore care management program participants' awareness and perceived utility of program offerings.

DESIGN

Cross-sectional telephone survey administered December 2015-January 2016.

PARTICIPANTS

Patients enrolled in a Boston-area primary care-based care management program.

MAIN MEASURES

Our main outcome was the number of topics in which patients reported having "very helpful" interactions with their care team in the past year. We analyzed awareness of one's care manager as an intermediate outcome, and then as a primary predictor of the main outcome, along with patient demographics, years in the program, attitudes, and worries as secondary predictors.

KEY RESULTS

The survey response rate was 45.8% (n = 1220); non-respondents were similar to respondents. More respondents reported worrying about family (72.8%) or financial issues (52.5%) than about their own health (41.6%). Seventy-four percent reported care manager awareness, particularly women (OR 1.33, 95% CI 1.01-1.77) and those with more years in the program (OR 1.16, 95% CI 1.03-1.30). While interaction rates ranged from 19.8% to 72.4% across topics, 81.3% rated at least one interaction as very helpful. Those who were aware of their care manager reported very helpful interactions on more topics (OR 2.77, 95% CI 2.15-3.56), as did women (OR 1.25, 95% CI 1.00-1.55), younger respondents (OR 0.98 for older age, 95% CI 0.97-0.99), and those with higher risk scores (OR 1.04, 95% CI 1.02-1.06), preference for deferring treatment decisions to doctors (OR 2.00, 95% CI 1.60-2.50), and reported control over their health (OR 1.67, 95% CI 1.33-2.10).

CONCLUSIONS

High-risk patients reported helpful interactions with their care team around medical and social determinants of health, particularly those who knew their care manager. Promoting care manager awareness may help participants make better use of the program.

A Systematic Review of Interventions on Patients' Social and Economic Needs

CONTEXT

Healthcare systems are experimenting increasingly with interventions to address patients' social and economic needs. This systematic review examines how often and how rigorously interventions bridging social and medical care have been evaluated.

EVIDENCE ACQUISITION

The review included literature from PubMed published between January 2000 and February 2017. Additional studies were identified by reference searches and consulting local experts. Included studies were based in the U.S.; addressed at least one social or economic determinant of health (e.g., housing, employment, food insecurity); and were integrated within the medical care delivery system. Data from included studies were abstracted in June 2015 (studies published January 2000-December 2014) and in March 2017 (studies published January 2015-February 2017).

EVIDENCE SYNTHESIS

Screening of 4,995 articles identified 67 studies of 37 programs addressing social needs. Interventions targeted a broad range of social needs and populations. Forty studies involved non-experimental designs. There was wide heterogeneity in outcome measures selected. More studies reported findings associated with process (69%) or social or economic determinants of health (48%) outcomes than health (30%) or healthcare utilization or cost (27%) outcomes. Studies reporting health, utilization, or cost outcomes reported mixed results.

CONCLUSIONS

Healthcare systems increasingly incorporate programs to address patients' social and economic needs in the context of care. But evaluations of these programs to date focus primarily on process and social outcomes and are often limited by poor study quality. Higher-quality studies that include common health and healthcare utilization outcomes would advance effectiveness research in this rapidly expanding field.

Diabetes quality of care and outcomes: Comparison of individuals with and without schizophrenia

OBJECTIVE

Individuals with schizophrenia are more likely to develop diabetes than individuals without schizophrenia. The objective of this study was to determine the quality of diabetes care and diabetes-related health outcomes among individuals with and without schizophrenia.

METHOD

We conducted a retrospective cohort study. As of April 1, 2011, we identified all individuals with diabetes in Ontario with and without a diagnosis of schizophrenia. The main outcomes were quality of diabetes care (guideline-concordant testing for HbA1c, lipid testing, eye exams) and diabetes-related Emergency Department (ED) visits and hospitalizations between April 1, 2011 and March 31, 2013. We compared quality of care and diabetes outcomes among those with and without schizophrenia, adjusting for demographic, illness severity, and health service utilization variables.

RESULTS

We identified 1,131,375 individuals with diabetes, among whom 25,628 (2.3%) had schizophrenia. Schizophrenia was associated with reduced likelihood of optimal diabetes care (all 3 of HbA1c, lipid testing, and eye exams) (adjusted OR (95% CI): 0.64 (0.61-0.67)) and increased likelihood of diabetes-related ED visits (adjusted OR (95% CI): 1.34 (1.28-1.41)) and hospitalizations (adjusted OR (95% CI): 1.36 (1.28-1.43)).

CONCLUSION

Individuals with diabetes and schizophrenia have lower rates of recommended testing and higher rates of diabetes-related hospital visits than those with diabetes but without schizophrenia. Research is needed to understand patient, provider, and system factors underlying these disparities and test related interventions to close the gaps in quality of care.

Addressing Unmet Basic Resource Needs as Part of Chronic Cardiometabolic Disease Management

IMPORTANCE

It is unclear if helping patients meet resource needs, such as difficulty affording food, housing, or medications, improves clinical outcomes.

OBJECTIVE

To determine the effectiveness of the Health Leads program on improvement in systolic and diastolic blood pressure (SBP and DBP, respectively), low-density lipoprotein cholesterol (LDL-C) level, and hemoglobin A1c (HbA1c) level.

DESIGN, SETTING, AND PARTICIPANTS

A difference-in-difference evaluation of the Health Leads program was conducted from October 1, 2012, through September 30, 2015, at 3 academic primary care practices. Health Leads consists of screening for unmet needs at clinic visits, and offering those who screen positive to meet with an advocate to help obtain resources, or receive brief information provision.

MAIN OUTCOMES AND MEASURES

Changes in SBP, DBP, LDL-C level, and HbA1c level. We compared those who screened positive for unmet basic needs (Health Leads group) with those who screened negative, using intention-to-treat, and, secondarily, between those who did and did not enroll in Health Leads, using linear mixed modeling, examining the period before and after screening.

RESULTS

A total of 5125 people were screened, using a standardized form, for unmet basic resource needs; 3351 screened negative and 1774 screened positive. For those who screened positive, the mean age was 57.6 years and 1811 (56%) were women. For those who screened negative, the mean age was 56.7 years and 909 (57%) were women. Of 5125 people screened, 1774 (35%) reported at least 1 unmet need, and 1021 (58%) of those enrolled in Health Leads. Median follow-up for those who screened positive and negative was 34 and 32 months, respectively. In unadjusted intention-to-treat analyses of 1998 participants with hypertension, the Health Leads group experienced greater reduction in SBP (differential change, -1.2; 95% CI, -2.1 to -0.4) and DBP (differential change, -1.0; 95% CI, -1.5 to -0.5). For 2281 individuals with an indication for LDL-C level lowering, results also favored the Health Leads group (differential change, -3.7; 95% CI -6.7 to -0.6). For 774 individuals with diabetes, the Health Leads group did not show HbA1c level improvement (differential change, -0.04%; 95% CI, -0.17% to 0.10%). Results adjusted for baseline demographic and clinical differences were not qualitatively different. Among those who enrolled in Health Leads program, there were greater BP and LDL-C level improvements than for those who declined (SBP differential change -2.6; 95% CI,-3.5 to -1.7; SBP differential change, -1.4; 95% CI, -1.9 to -0.9; LDL-C level differential change, -6.3; 95% CI, -9.7 to -2.8).

CONCLUSIONS AND RELEVANCE

Screening for and attempting to address unmet basic resource needs in primary care was associated with modest improvements in blood pressure and lipid, but not blood glucose, levels.