Project description:BackgroundDespite the importance of social determinants in health outcomes, little is known about the best practices for screening and referral during clinical encounters. This study aimed to implement universal social needs screening and community service referrals in an academic emergency department (ED), evaluating for feasibility, reach, and stakeholder perspectives.MethodsBetween January 2019 and February 2020, ED registration staff screened patients for social needs using a 10-item, low-literacy, English-Spanish screener on touchscreens that generated automatic referrals to community service outreach specialists and data linkages. The RE-AIM framework, specifically the constructs of reach and adoption, guided the evaluation. Reach was estimated through a number of approaches, completed screenings, and receipt of community service referrals. Adoption was addressed qualitatively via content analysis and qualitative coding techniques from (1) meetings, clinical interactions, and semi-structured interviews with ED staff and (2) an iterative "engagement studio" with an advisory group composed of ED patients representing diverse communities.ResultsOverall, 4608 participants were approached, and 61% completed the screener. The most common reason for non-completion was patient refusal (43%). Forty-seven percent of patients with completed screeners communicated one or more needs, 34% of whom agreed to follow-up by resource specialists. Of the 482 participants referred, 20% were reached by outreach specialists and referred to community agencies. Only 7% of patients completed the full process from screening to community service referral; older, male, non-White, and Hispanic patients were more likely to complete the referral process. Iterative staff (n = 8) observations and interviews demonstrated that, despite instruction for universal screening, patient presentation (e.g., appearance, insurance status) drove screening decisions. The staff communicated discomfort with, and questioned the usefulness of, screening. Patients (n = 10) communicated a desire for improved understanding of their unmet needs, but had concerns about stigmatization and privacy, and communicated how receptivity of screenings and outreach are influenced by the perceived sincerity of screening staff.ConclusionsDespite the limited time and technical barriers, few patients with social needs ultimately received service referrals. Perspectives of staff and patients suggest that social needs screening during clinical encounters should incorporate structure for facilitating patient-staff relatedness and competence, and address patient vulnerability by ensuring universal, private screenings with clear intent.Trial registrationClinicalTrials.gov, NCT04630041 .

Project description:ImportanceUS health expenditures have been growing at an unsustainable rate, while health inequities and poor outcomes persist. Targeting social determinants of health (SDOH) may contribute to identifying and controlling health care expenditures.ObjectiveTo determine whether SDOH are associated with US health care expenditures by Medicare, Medicaid, and private insurers.Design, setting, and participantsCross-sectional study of adults, representing the US civilian, noninstitutionalized population with Medicare, Medicaid, or private coverage, from the 2021 Medical Expenditure Panel SDOH Survey. Data analysis was conducted from October 2023 to April 2024.ExposureSDOH as individual-level, health-related social needs categorized by Healthy People 2030 domains: (1) educational access and quality, (2) health care access and quality, (3) neighborhood and built environment,(4) economic stability, and (5) social and community context.Main outcomes and measuresThe primary outcome was health care expenditures (US dollars) by Medicare, Medicaid, and private insurers. A 2-part econometric model (probit regression model and generalized linear model with gamma distribution) was used.ResultsAmong the 14 918 insured adults in the analytic sample (mean [SD] age, 52.5 [17.9] years; 8471 female [56.8%]), the majority had middle to high family income (10 524 participants [70.5%]) and were privately insured (10 227 participants [68.5%]). Annual median (IQR) expenditure was $1648 ($389-$7126) for Medicaid, $3643 ($1321-$10 519) for Medicare, and $1369 ($456-$4078) for private insurers. Educational attainment and social isolation were associated with Medicaid expenditures. Medicaid beneficiaries with a high school diploma or general educational development certificate had on average (mean difference) $2245.39 lower annual Medicaid expenditures (95% CI, -$3700.97 to -$789.80) compared with beneficiaries with less than high school attainment. Compared with those who never felt isolated, Medicaid beneficiaries who often felt isolated had on average $2706.94 (95% CI, $1339.06-$4074.82) higher annual Medicaid expenditures. Health care access, built environment, and economic stability were associated with Medicare expenditures. Medicare beneficiaries living in neighborhoods with lower availability of parks had on average $5959.27 (95% CI, $1679.99 to $10 238.55) higher annual Medicare expenditures. Medicare beneficiaries who were very confident in covering unexpected expenses had on average $3743.98 lower annual Medicare expenditures (95% CI, -$6500.68 to -$987.28) compared with those who were not confident. Medical discrimination and economic stability were associated with private expenditures. Private insurance beneficiaries who experienced medical discrimination had on average $2599.93 (95% CI, $863.71-$4336.15) higher annual private expenditures compared with those who did not. Private beneficiaries who were contacted by debt collections in the past year had on average $2033.34 (95% CI, $896.82 to $3169.86) higher annual private expenditures compared with those who were not contacted.Conclusions and relevanceIn this cross-sectional study of 14 918 insured adults, individual-level SDOH were significantly associated with US health care expenditures by Medicare, Medicaid, and private insurers. These findings may inform health insurers and policymakers to incorporate SDOH in their decision-making practices to identify and control health care expenditures, advancing health equity.

Project description:ImportanceManaged care payment formulas commonly allocate more money for medically complex populations, but ignore most social determinants of health (SDH).ObjectiveTo add SDH variables to a diagnosis-based payment formula that allocates funds to managed care plans and accountable care organizations.Design, setting, and participantsUsing data from MassHealth, the Massachusetts Medicaid and Children's Health Insurance Program, we estimated regression models predicting Medicaid spending using a diagnosis-based and SDH-expanded model, and compared the accuracy of their cost predictions overall and for vulnerable populations. MassHealth members enrolled for at least 6 months in 2013 in fee-for-service (FFS) programs (n = 357 660) or managed care organizations (MCOs) (n = 524 607).ExposuresWe built cost prediction models from a fee-for-service program. Predictors in the diagnosis-based model are age, sex, and diagnoses from claims. The SDH model adds predictors describing housing instability, behavioral health issues, disability, and neighborhood-level stressors.Main outcomes and measuresOverall model explanatory power and overpayments and underpayments for subgroups of interest for all Medicaid-reimbursable expenditures excepting long-term support services (mean annual cost = $5590 per member).ResultsWe studied 357 660 people who were FFS participants and 524 607 enrolled in MCOs with a combined 806 889 person-years of experience. The FFS program experience included more men (49.6% vs 43.6%), older patients (mean age of 26.1 years vs 21.6 years), and sicker patients (mean morbidity score of 1.16 vs 0.89) than MCOs. Overall, the SDH model performed well, but only slightly better than the diagnosis-based model, explaining most of the spending variation in the managed care population (validated R2 = 62.4) and reducing underpayments for several vulnerable populations. For example, raw costs for the quintile of people living in the most stressed neighborhoods were 9.6% ($537 per member per year) higher than average. Since greater medical morbidity accounts for much of this difference, the diagnosis-based model underpredicts costs for the most stressed quintile by about 2.1% ($130 per member per year). The expanded model eliminates the neighborhood-based underpayment, as well as underpayments of 72% for clients of the Department of Mental Health (observed costs of about $30 000 per year) and of 7% for those with serious mental illness (observed costs of about $16 000 per year).Conclusions and relevanceSince October 2016, MassHealth has used an expanded model to allocate payments from a prespecified total budget to managed care organizations according to their enrollees' social and medical risk. Extra payments for socially vulnerable individuals could fund activities, such as housing assistance, that could improve health equity.

Project description:BackgroundHealth disparities and the unequal distribution of social resources impact health outcomes. By considering social determinants of health (SDH), clinicians can provide holistic and equitable care. However, barriers such as lack of time or understanding of the relevance of SDH to patient care prevent providers from addressing SDH. Simulation curricula may improve learners' ability to address SDH in practice.ObjectivesThe primary objective was to increase the percentage of pediatric emergency simulations that included SDH objectives from 5% to 50% in 12 months at one institution. As a balancing metric, we examined whether trainees approved the incorporation of SDH objectives.MethodsUsing the Model for Improvement approach, we conducted interviews of residents and simulation facilitators to identify challenges to integrating SDH objectives into the simulation curriculum. Review of interviews and visual representation of the system helped identify key drivers in the process. A team of simulation leaders, residents, and fellows met regularly to develop simulation cases with embedded SDH objectives. Using a plan, do, study, act approach, we tested, refined, and implemented interventions including engaging residency program and SDH leadership, piloting cases, providing facilitators concise resources, inviting SDH-specific experts to co-debrief, and eliciting and incorporating learner and facilitator feedback to improve cases. SDH topics include homelessness, undocumented status, and racism.ResultsPrior to the start of the quality improvement work, SDH were rarely incorporated into emergency simulations for pediatric residents. A p-chart was used to track the percentage of monthly cases that incorporated SDH topics. During the study period, the percentage of simulations including SDH topics increased to 57% per month. Most trainees (94%) welcomed incorporating SDH objectives.ConclusionsUsing the Model for Improvement, we incorporated SDH objectives into pediatric resident emergency simulations. Next steps include examining effectiveness of the curriculum, dissemination to additional learners, and examining sustainability in practice.

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Integrating Social Determinants of Health in Critical Care

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