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

Caring for high-need patients

OBJECTIVE

We aimed to explore the construct of "high need" and identify common need domains among high-need patients, their care professionals, and healthcare organizations; and to describe the interventions that health care systems use to address these needs, including exploring the potential unintended consequences of interventions.

METHODS

We conducted a modified Delphi panel informed by an environmental scan. Expert stakeholders included patients, interdisciplinary healthcare practitioners (physicians, social workers, peer navigators), implementation scientists, and policy makers. The environmental scan used a rapid literature review and semi-structured interviews with key informants who provide healthcare for high-need patients. We convened a day-long virtual panel meeting, preceded and followed by online surveys to establish consensus.

RESULTS

The environmental scan identified 46 systematic reviews on high-need patients, 19 empirical studies documenting needs, 14 intervention taxonomies, and 9 studies providing construct validity for the concept "high need." Panelists explored the construct and terminology and established that individual patients' needs are unique, but areas of commonality exist across all high-need patients. Panelists agreed on 11 domains describing patient (e.g., social circumstances), 5 care professional (e.g., communication), and 8 organizational (e.g., staffing arrangements) needs. Panelists developed a taxonomy of interventions with 15 categories (e.g., care navigation, care coordination, identification and monitoring) directed at patients, care professionals, or the organization. The project identified potentially unintended consequences of interventions for high-need patients, including high costs incurred for patients, increased time and effort for care professionals, and identification of needs without resources to respond appropriately.

CONCLUSIONS

Care for high-need patients requires a thoughtful approach; differentiating need domains provides multiple entry points for interventions directed at patients, care professionals, and organizations. Implementation efforts should consider outlined intended and unintended downstream effects on patients, care professionals, and organizations.

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.

Addressing Social Needs in Health Care Settings: Evidence, Challenges, and Opportunities for Public Health

There has been an explosion of interest in addressing social needs in health care settings. Some efforts, such as screening patients for social needs and connecting them to needed social services, are already in widespread practice. These and other major investments from the health care sector hint at the potential for new multisector collaborations to address social determinants of health and individual social needs. This article discusses the rapidly growing body of research describing the links between social needs and health and the impact of social needs interventions on health improvement, utilization, and costs. We also identify gaps in the knowledge base and implementation challenges to be overcome. We conclude that complementary partnerships among the health care, public health, and social services sectors can build on current momentum to strengthen social safety net policies, modernize social services, and reshape resource allocation to address social determinants of health.

How Do Social Needs Cluster Among Low-Income Individuals?

Social needs screening in health care settings reveals that many low-income individuals have multiple unmet social needs at the same time. Having multiple simultaneous social needs greatly increases the odds of experiencing adverse health outcomes. To better understand how and which social needs cluster in these cases, the authors examined data from 14,749 low-income adults who completed a social needs assessment in one of 4 separate studies conducted between 2008 and 2019 in the United States. Participants were Medicaid beneficiaries, helpline callers, and daily smokers. Findings were strikingly consistent across the 4 studies. Participants with ≥2 social needs (n = 5621; 38% of total) experienced more stress, depressive symptoms, sleep problems, and chronic diseases and were more likely to rate their health as fair or poor. Social needs reflecting financial strain were highly correlated, such as needing help paying utility bills and needing money for necessities such as food, shelter, and clothing (r = .49 to .71 across studies). Participants experienced 351 distinct combinations of ≥2 social needs. The 10 most common combinations accounted for more than half of all participants with ≥2 needs. Clusters of social needs varied by subgroups. Women with children were more likely than others to need more space in their home and help paying utility bills; low-income men were more likely to be physically threatened and need a place to stay; older, sicker adults were more likely to need money for necessities and unexpected expenses, as well as transportation. Findings are discussed in the context of creating smarter, more efficient social needs interventions.

Prescribing Housing: A Scoping Review of Health System Efforts to Address Housing as a Social Determinant of Health

US health systems have begun to address housing instability within a larger effort to address social determinants of health. To explore existing themes within efforts by health systems to reduce housing instability and improve health, the authors conducted a scoping review supplemented with key informant interviews. Twenty-two articles were analyzed and 7 participants from 6 health systems were interviewed. Themes identified from the literature and interviews included intervention strategies and funding, access, coordination, and administrative processes and evaluation. As more health systems integrate housing-related interventions, findings from this study highlight the need for more upstream focus, consistent funding, and reliable evaluation strategies.