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

Health-related social needs (HRSNs) are individual manifestations of social factors, such as housing instability, which impact healthcare utilization, cost, and/or health outcomes, but are not treatable by medical care^1‐6. Unmet HRSNs result in higher rates of chronic conditions, emergency department (ED) use, hospital readmissions, and no-show appointments.^7‐11 Few studies have examined multiple HRSNs through a standardized screening tool, large-scale randomized controlled trials (RCT), diverse healthcare settings, geographies, and populations.^12‐14 We analyzed data from a representative sample of community-dwelling Medicare and Medicaid beneficiaries through the national CMS Accountable Health Communities (AHC) Model.¹⁵ The AHC Model, launched in May 2017,^1,15 uses the AHC screening tool to assess five HRSNs: housing instability, difficulty paying utility bills, food insecurity, transportation, and interpersonal safety. Screening is administered through various modes (i.e., paper or electronic), multiple languages, and multiple healthcare settings (e.g., clinics, EDs).^1,15,16 Lewis et al.¹⁷ demonstrated concordance between the AHC screening tool and the Your Current Life Situation (YCLS) screening tool developed by Kaiser Permanente Care Management Institute (adjusted kappas range .75–.87) on food insecurity, transportation needs, and utility needs. Only housing quality had a lower kappa (.52). The authors hypothesized that wording differences in the items might lead to differences in performance between AHC and YCLS, with AHC housing items being more sensitive to identifying housing problems. The ACH screening tool was also predictive of fair or poor self-rated health (ORs 1.80 to 2.85 across needs).¹⁷ In AHC, beneficiaries who reported at least one HRSN and two or more ED visits in the last 12 months prior to visiting the clinical delivery site (CDS) are deemed “high risk” and randomized to receive one of two interventions, referral to community resources or referral plus patient navigation. In the first AHC Model-wide evaluation report, the relationship of multiple HRSNs and healthcare utilization was identified as a focus for future examination.¹⁸ No studies to date have reported on the impact of multiple HRSNs on ED utilization risk. We present data from the Greater Houston AHC (GH-AHC) Model site describing HRSNs and association with self-reported utilization.

Beneficiaries who had no screening responses or were ineligible were excluded, yielding a total sample of 15,071. Beneficiaries with a food need made up the largest group (n = 5830; 38.7%) compared to housing (n = 4373; 29.0%), transportation (n = 4227; 28.0%), and utility (n = 4024; 26.7%) need. 43.1% (n = 6489) of beneficiaries had zero needs, 20.2% (n = 3049) had one need, 16.3% (n = 2455) had two needs, 12.1% (n = 1817) had three needs, and 8.4% (n = 1261) had four needs. The correlation of HRSN ranged from .33 (utilities and transportation) to .4 (housing and food) for all combinations, indicating a fairly consistent strength of association between HRSNs for those with multiple needs.

Although our demographic data was limited, beneficiaries who completed social needs screening were mostly non-Hispanic, Black or African American, had low education and income levels, and lived in households with less than five people. A study by Meyer et al. similarly found most of their respondents were Hispanic, Black, low income, and living in households with 3.6 or less people.²⁴ Our analysis extends their findings by comparing these demographic characteristics with ED utilization and HRSN status. We found that beneficiaries with two or more ED visits in the previous year were more likely to be Black or African American and have lower education and income levels compared to those with zero or one ED visit. All four HRSNs were related to frequent ED utilization, as was screening positive for more than one HRSN.

In our multinomial logistic regression model, after controlling for covariates (age, insurance, sex), having multiple co-occurring social needs was strongly associated with increased risk of two or more ED visits. Beneficiaries with four needs were at almost 10 times higher risk. Interestingly, food insecurity was negatively associated with frequent ED utilization when multiple needs and other domains (e.g., transportation) were included in the model. Since food insecurity was the most frequently identified need in our study, it is likely that the discriminatory power of this variable was absorbed within the multiple needs variable rather than our findings representing a true negative association between food insecurity and ED utilization. Previous studies have demonstrated an association between food insecurity and ED utilization, showing increased ED spending for food insecure households when controlling for confounders such as chronic disease status.²⁵ It is important to note, however, that these previous studies of HRSN have focused on single need domain assessment, limiting their ability to discern the impact of multiple needs. In our analysis, the individual need indicators were largely non-informative in the model once the total number of needs was accounted for. Despite national initiatives to identify and address HRSN, few screening tools have included multiple need domains in a standardized way across clinical settings.²⁶ Recent studies show that only 15% of providers nationwide are screening for more than one social need.²⁷ More data is needed to better understand the relationship of social needs collectively and individually on ED utilization.

We also found higher rates of HRSN in the hospital rather than the outpatient setting. Much of the published literature has focused on primary care as the setting of choice for screening and intervention.^28,29 Our data indicates that in order to reach high-risk, high-need populations, EDs should be a focal setting. Similar findings are starting to emerge.³⁰ The first AHC Model evaluation report similarly found a higher percentage of beneficiaries screened in the ED were eligible for navigation (i.e., high risk) than the primary care setting (74% vs. 29%).¹⁸ It is well known that EDs serve a disproportionate share of underserved populations due to their inability to turn patients away who cannot pay.³¹ Research has also established that a number of patients use EDs as their primary source of care.^30‐32 Recent data from Wallace et al. support the feasibility and value of screening HRSN in EDs.³⁰ Our current study adds to this emerging knowledge base by showing the frequency of positive social needs screening, ED utilization, and types of HRSN found in a large geographic area serving a diverse population across multiple health systems.

Identification of HRSN is also highly dependent on the screening tool used. Recent work by De Marchis et al.³³ has demonstrated differences in positive identifications of housing problems obtained from the the AHC tool versus positive identification based on another widely used tool. These differences stemmed partly from different item content, e.g., housing quality versus housing stability/instability, and partly from differences in item focus, e.g., subjective stability/instability versus self-reports of actual instability. Selection of screening questions should be based on a clear understanding of the target population and the sensitivities of available tools. Further, assessing HRSNs by assessing individuals who have successfully accessed a healthcare provider may not be providing the most accurate information on the relationship between HRSN and population level health burden. Patients with lower income and educational levels tend to be less able to successfully manage their health conditions³⁴. Low-income patients with unmet HRSNs have also been found to have poorer health outcomes, including increased numbers of chronic diseases.³⁴ However, these patients also have well-documented difficulties accessing healthcare resources.^29,35 Prospective studies of HRSN screening in non-healthcaresystem–based populations are needed to gain a more accurate picture of the health risks associated with increased need and the values of screening for those needs for population health. Interestingly, the AHC Model evaluation report found substantially higher rates of social needs in patients screened versus available community-level data (e.g., County Health Rankings).¹⁸ This is true for our GH-AHC implementation as well. Reasons for this discrepancy may include differences in constructs assessed and secondary data used to determine rates in the County Health Rankings. For example, County Health Rankings asks about budget for food, coupled with data from the USDA on food deserts, whereas AHC asks about having enough food to eat in the past month.