Accountable Health Communities Research Articles

Preliminary Pilot-Testing of Social Determinants of Health Screener for Individuals With Intellectual and Developmental Disabilities in Med-Peds.

In the United States, one in six children has an intellectual and/or developmental disability (I/DD), including attention deficit hyperactivity disorder (ADHD), autism, cerebral palsy, learning disabilities, seizures, and developmental delays, with or without intellectual impairment. Individuals with I/DDs experience disproportionate rates of immune, metabolic, cardiovascular, and neurological disorders, as well as anxiety, depression, functional somatic symptoms, and other co-occurring physical and mental health conditions. During the coronavirus disease 2019 (COVID-19) pandemic, having an I/DD emerged as one of the strongest predictors of contracting and dying from COVID-19. These findings spurred increased attention toward the myriad health inequities affecting this population well before the pandemic. While inequities for individuals with I/DD can be traced to many factors, social determinants of health (SDOH) - the underlying social, economic, and environmental conditionsthat lead to poor health outcomes and high healthcare costs - are key contributors. Our interdisciplinary combined internal medicine and pediatrics (Med-Peds) team of physicians, psychologists, and researchers within a large, diverse, academic health system aimed to pilot-test the implementation of a five-item SDOH screener within a Med-Peds specialty clinic focused on the developmental needs of individuals with I/DD and their families (Leadership Education in Neurodevelopmental Disabilities {LEND}) and a general primary care practice (PCP).The SDOH screener tested in this initiative includes five items from the Accountable Health Communities (AHC) Health-Related Social Needs Screening Tool (HRSN) assessing social isolation, food insecurity, transportation, and paying for basic needs, such as housing and medical care. In this study, we describe the process of implementing this screener and collecting initial pilot data from 747 patients between October 2022 and April 2023 across the LEND and the primary care practice. We also highlight the challenges and opportunities identified during the mid-way point of implementation and pilot testing. The results of this pilot study revealed low response rates among SDOH screeners, spurring several measures to increase uptake, including increasing the accessibility of the screener and ensuring the screener results in effective referrals. We call on additional Med-Peds healthcare teams without universal SDOH screening protocols in place - particularly those serving the I/DD population - to consider adopting these practices.

MP54-04 EXAMINING THE INFLUENCE OF RACE AND PELVIC FLOOR DISORDER SEVERITY ON HEALTH-RELATED SOCIAL NEEDS AMONG MINORITY WOMEN

You have accessJournal of UrologyCME1 Apr 2023MP54-04 EXAMINING THE INFLUENCE OF RACE AND PELVIC FLOOR DISORDER SEVERITY ON HEALTH-RELATED SOCIAL NEEDS AMONG MINORITY WOMEN Jasmine Kannikal, Sanjana Satish, Aaron Gurayah, Erin Kobetz, Katherine Amin, Ekene Enemchukwu, and Raveen Syan Jasmine KannikalJasmine Kannikal More articles by this author , Sanjana SatishSanjana Satish More articles by this author , Aaron GurayahAaron Gurayah More articles by this author , Erin KobetzErin Kobetz More articles by this author , Katherine AminKatherine Amin More articles by this author , Ekene EnemchukwuEkene Enemchukwu More articles by this author , and Raveen SyanRaveen Syan More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003307.04AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Pelvic floor disorders (PFD) affect 25% of American women 20 years or older and continues to increase in prevalence. While studies have explored racial disparities in PFD knowledge and treatment, few have analyzed the impact of health-related social needs (HRSN). This study aims to characterize unmet HRSN among minority women, as well as assess the impact of race and PFD severity. METHODS: Our IRB-approved, ongoing prospective study began recruitment in June 2022 from private urogynecology clinics; a general urology clinic at the public safety net hospital (SNH); and a community outreach mobile clinic (MC). The standardized Urinary Distress Index-6 (UDI), Pelvic Organ Prolapse Distress Inventory-6 (POPDI), and Female Genitourinary Pain Index (GUPI) were used to identify PFDs. PFDs exceeding the 33.3 (UDI) or third quartile (POPDI, GUPI) thresholds were characterized as severe. Unmet HRSN were based on the Centers for Medicare & Medicaid Services Accountable Health Communities HRSN Screening Tool: mild and severe represented <8 and >8 unmet HSRN, respectively. Chi-squared tests for PFD presence and severity by race and location were conducted using R. RESULTS: The study cohort (n=107) had a median age of 53 years [IQR 24]. 53 (49.5%) women identified as Hispanic, 38 (35.5%) as Black, and 16 (15%) as Other. Unmet HRSN ranged from 1 to 18. Private clinic participants were 20% less likely to report unmet social needs, compared to MC participants (p=0.020). No statistically significant differences in reported unmet HRSN between SNH and MC, or between racial groups, were observed. Upon chi-squared analysis, no association was found between participants with severe unmet HRSN and those scoring higher on UDI, POPDI, and GUPI (p>0.05). CONCLUSIONS: Community mobile clinic participants were more likely to report severe unmet HRSN, compared to private clinic participants. Black women have a higher prevalence of unmet HRSN, however this did not reach statistical significance with our sample size. This study contributes to an understanding of the role of social determinants of health in disease severity and access to care. This study is ongoing, with a focus on increasing our community-based participant population to better understand health determinants among underserved minorities in non-hospital settings. Source of Funding: Urology Care Foundation Research Scholar Award 2021 © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e754 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Jasmine Kannikal More articles by this author Sanjana Satish More articles by this author Aaron Gurayah More articles by this author Erin Kobetz More articles by this author Katherine Amin More articles by this author Ekene Enemchukwu More articles by this author Raveen Syan More articles by this author Expand All Advertisement PDF downloadLoading ...

187 Exploring the role of maternal exposure to violence in post-partum weight retention among WIC program participants in Puerto Rico

OBJECTIVES/GOALS: Evaluate if exposure to violence is associated with post-partum weight retention among WIC participants, which can lead to overweight/obesity due to metabolic adaptations associated to new adapted weight. If confirmed, it would highlight the need for revision of screening for violence exposure as social determinant of health among participants. METHODS/STUDY POPULATION: Nested cohort study among women enrolled in the Baby Act Trial (BAT) who have been enrolled to the active study phase and completed the Accountable Health Communities Health Related Social Needs survey from the Centers for Medicare &amp; Medicaid services as the source of evidence of exposure to violence. BAT recruitment engaged women in their third trimester who were active participants of the Puerto Rico Women, Infants and Children Program (PRWIC), and planned to enroll their infant in the program. Anthropometric measures were documented at the following time points: prior to pregnancy, at delivery, and 12 months post-partum. Of the 530 women recruited to the study, 291 have completed study measures for inclusion into this exploratory analysis from this ongoing trial. RESULTS/ANTICIPATED RESULTS: A Total of 301 participants have met the criteria for inclusion in this preliminary analysis. Mean age among mothers was 26.5 years (SD 5.3), 46.6% had High School level education attainment or less, and 43.3% were actively working at the time of recruitment. Twelve percent of participants had BMI above 35 at 6 months post-partum, while the prevalence of violence exposure was reported as follows for each type of encounter: 3.3% responded yes to physical violence by friends of family, 9.7% reported exposure to insults or inappropriate treatment by any person including family or friends, 2% having been threatened by anyone including family or friends, 6.3% reported having been yelled/cursed at or insulted by anyone including family or friends. Even more concerning is that 7.5% reported severe social vulnerability. DISCUSSION/SIGNIFICANCE: Results reveals importance of providing integrated care in social assistance program. Participants belongs to vulnerable population with social determinants of health that affect the health care they receive. It shows that providing nutritional assistance it’s not enough to being healthy because other components also play a role in overall health.

Examining neighborhood-level hot and cold spots of food insecurity in relation to social vulnerability in Houston, Texas.

Food insecurity is prevalent and associated with poor health outcomes, but little is known about its geographical nature. The aim of this study is to utilize geospatial modeling of individual-level food insecurity screening data ascertained in health care settings to test for neighborhood hot and cold spots of food insecurity in a large metropolitan area, and then compare these hot spot neighborhoods to cold spot neighborhoods in terms of the CDC's Social Vulnerability Index. In this cross-sectional secondary data analysis, we geocoded the home addresses of 6,749 unique participants screened for food insecurity at health care locations participating in CMS's Accountable Health Communities (AHC) Model, as implemented in Houston, TX. Next, we created census-tract level incidence profiles of positive food insecurity screens per 1,000 people. We used Anselin's Local Moran's I statistic to test for statistically significant census tract-level hot/cold spots of food insecurity. Finally, we utilized a Mann-Whitney-U test to compare hot spot tracts to cold spot tracts in relation to the CDC's Social Vulnerability Index. We found that hot spot tracts had higher overall social vulnerability index scores (P <0.001), higher subdomain scores, and higher percentages of individual variables like poverty (P <0.001), unemployment (P <0.001), limited English proficiency (P <0.001), and more. The combination of robust food insecurity screening data, geospatial modeling, and the CDC's Social Vulnerability Index offers a solid method to understand neighborhood food insecurity.

Addressing non-medical health-related social needs through a community-based lifestyle intervention during the COVID-19 pandemic: The Black Impact program.

Non-medical health-related social needs (social needs) are major contributors to worse health outcomes and may have an adverse impact on cardiovascular risk factors and cardiovascular disease. The present study evaluated the effect of a closed-loop community-based pathway in reducing social needs among Black men in a lifestyle change program. Black men (n = 70) from a large Midwestern city participated in Black Impact, a 24-week community-based team lifestyle change single-arm pilot trial adapted from the Diabetes Prevention Program and American Heart Association's (AHA) Check, Change, Control Blood Pressure Self-Management Program, which incorporates AHA's Life's Simple 7 (LS7) framework. Participants were screened using the Centers for Medicare and Medicaid Services (CMS) Accountable Health Communities Health-Related Social Needs Screening Tool. Participants with affirmative responses were referred to a community hub pathway to address social needs. The primary outcome for this analysis is change in social needs based on the CMS social needs survey at 12 and 24 weeks using mixed effect logistic regressions with random intercepts for each participant. Change in a LS7 score (range 0-14) from baseline to 12 and 24 weeks was evaluated using a linear mixed-effects model stratified by baseline social needs. Among 70 participants, the mean age of participants was 52 ±10.5 years. The men were sociodemographically diverse, with annual income ranging from <$20,000 (6%) to ≥$75,000 (23%). Forty-three percent had a college degree or higher level of education, 73% had private insurance, and 84% were employed. At baseline 57% of participants had at least one social need. Over 12 and 24 weeks, this was reduced to 37% (OR 0.33, 95%CI: 0.13, 0.85) and 44% (OR 0.50, 95%CI: 0.21, 1.16), respectively. There was no association of baseline social needs status with baseline LS7 score, and LS7 score improved over 12 and 24 weeks among men with and without social needs, with no evidence of a differential effect. The Black Impact lifestyle change single-arm pilot program showed that a referral to a closed-loop community-based hub reduced social needs in Black men. We found no association of social needs with baseline or change in LS7 scores. Further evaluation of community-based strategies to advance the attainment of LS7 and address social needs among Black men in larger trials is warranted.

Patients' Willingness to Accept Social Needs Navigation After In-Person versus Remote Screening.

Social needs screening and referral interventions are increasingly common in health care settings. Although remote screening offers a potentially more practical alternative to traditional in-person screening, there is concern that screening patients remotely could adversely affect patient engagement, including interest in accepting social needs navigation. We conducted a cross-sectional study using a multivariable logistic regression analysis and data from the Accountable Health Communities (AHC) model in Oregon. Participants were Medicare and Medicaid beneficiaries in the AHC model from October 2018 through December 2020. The outcome variable was patients' willingness to accept social needs navigation assistance. We included an interaction term (total number of social needs + screening mode) to test whether in-person versus remote screening was an effect modifier. The study included participants who screened positive for ≥1 social need(s); 43% were screened in person and 57% remotely. Overall, 71% of participants were willing to accept help with social needs. Neither screening mode nor interaction term were significantly associated with willingness to accept navigation assistance. Among patients presenting with similar numbers of social needs, results indicate that type of screening mode may not adversely affect patients' willingness to accept health care-based navigation for social needs.

Association of Unmet Social Needs With Level of Capability in People With Persistent Knee Pain.

Musculoskeletal providers are increasingly recognizing the importance of social factors and their association with health outcomes as they aim to develop more comprehensive models of care delivery. Such factors may account for some of the unexplained variation between pathophysiology and level of pain intensity and incapability experienced by people with common conditions, such as persistent nontraumatic knee pain secondary to osteoarthritis (OA). Although the association of one's social position (for example, income, employment, or education) with levels of pain and capability are often assessed in OA research, the relationship between aspects of social context (or unmet social needs) and such symptomatic and functional outcomes in persistent knee pain are less clear. (1) Are unmet social needs associated with the level of capability in patients experiencing persistently painful nontraumatic knee conditions, accounting for sociodemographic factors? (2) Do unmet health-related social needs correlate with self-reported quality of life? We performed a prospective, cross-sectional study between January 2021 and August 2021 at a university academic medical center providing comprehensive care for patients with persistent lower extremity joint pain secondary to nontraumatic conditions such as age-related knee OA. A final 125 patients were included (mean age 62 ± 10 years, 65% [81 of 125] women, 47% [59 of 125] identifying as White race, 36% [45 of 125] as Hispanic or Latino, and 48% [60 of 125] with safety-net insurance or Medicaid). We measured patient-reported outcomes of knee capability (Knee injury and Osteoarthritis Outcome Score for Joint Replacement), quality of life (Patient-Reported Outcome Measure Information System [PROMIS] Global Physical Health and PROMIS Global Mental Health), and unmet social needs (Accountable Health Communities Health-Related Social Needs Survey, accounting for insufficiencies related to housing, food, transportation, utilities, and interpersonal violence), as well as demographic factors. After controlling for demographic factors such as insurance status, education attained, and household income, we found that reduced knee-specific capability was moderately associated with experiencing unmet social needs (including food insecurity, housing instability, transportation needs, utility needs, or interpersonal safety) (standardized beta regression coefficient [β] = -4.8 [95% confidence interval -7.9 to -1.7]; p = 0.002 and substantially associated with unemployment (β = -13 [95% CI -23 to -3.8]; p = 0.006); better knee-specific capability was substantially associated with having Medicare insurance (β = 12 [95% CI 0.78 to 23]; p = 0.04). After accounting for factors such as insurance status, education attained, and household income, we found that older age was associated with better general mental health (β = 0.20 [95% CI 0.0031 to 0.39]; p = 0.047) and with better physical health (β = 0.004 [95% CI 0.0001 to 0.008]; p = 0.04), but effect sizes were small to negligible, respectively. There is an association of unmet social needs with level of capability and unemployment in patients with persistent nontraumatic knee pain. This finding signals a need for comprehensive care delivery for patients with persistent knee pain that screens for and responds to potentially modifiable social risk factors, including those based on one's social circumstances and context, to achieve better outcomes. Level II, prognostic study.

Examining the Implementation of Health-Related Social Need (HRSN) Screenings at a Pediatric Community Health Center.

Social determinants of health (SDoH) influence health outcomes and screening for health-related social needs (HRSN) is a recommended pediatric practice. In 2018, Denver Health and Hospitals (DH) implemented the Accountable Health Communities (AHC) model under the Centers for Medicare and Medicaid Services (CMS) and began using the AHC HRSN screening tool during selected well child visits (WCVs) at a DH Federally Qualified Health Center (FQHC). The current evaluation aimed to examine the program implementation and identify key lessons learned to inform the expansion of HRSN screening and referral to other populations and health systems. Patients who completed a WCV between June 1, 2020 and December 31, 2021 (N = 13 750) were evaluated. Frequencies and proportions were used to describe patient characteristics of those that had a WCV, were screened, and received resource information. Multivariable logistic regression models with odds ratios (OR) and 95% confidence intervals (CI) were used to determine the association between patient characteristics and completing HRSN screening and provision of resource information. The screening tool was completed by 80% (n = 11 004) of caregivers bringing children to a WCV at the DH Westside Clinic, with over one-third (34.8%; n = 3830) reporting >1 social need. Food insecurity was the most common concern (22.3%; n = 2458). Non-English, non-Spanish (NENS) speakers were less likely to be screened (OR 0.43, 95% CI 0.33, 0.57) and less likely to report a social need (OR 0.59, 95% CI 0.42, 0.82) than speakers of English, after adjusting for age, race/ethnicity, and health insurance. A high rate of screening indicates feasibility of administering HRSN screenings for pediatric patients in a busy FQHC. More than a third of patients reported one or more social needs, underscoring the importance to identity these needs and the opportunity to offer personalized resources. Comparatively lower rates of screening and potential underreporting among NENS may be indicative of the availability and acceptability of current translation procedures as well as how the tool translates linguistically and culturally. Our experience highlights the need to partner with community organizations and involve patients and families to ensure SDoH screening and care navigation is part of culturally-appropriate patient-centered care.

Social risks and social needs in a health insurance exchange sample: a longitudinal evaluation of utilization

BackgroundHealth systems are increasingly attempting to intervene on social adversity as a strategy to improve health care outcomes. To inform health system efforts to screen for social adversity, we sought to explore the stability of social risk and interest in assistance over time and to evaluate whether the social risk was associated with subsequent healthcare utilization.MethodsWe surveyed Kaiser Permanente members receiving subsidies from the healthcare exchange in Southern California to assess their social risk and desire for assistance using the Accountable Health Communities instrument. A subset of initial respondents was randomized to be re-surveyed at either three or six months later.ResultsA total of 228 participants completed the survey at both time points. Social risks were moderate to strongly stable across three and six months (Kappa range = .59-.89); however, social adversity profiles that included participants’ desire for assistance were more labile (3-month Kappa = .52; 95% CI = .41-.64 & 6-month Kappa = .48; 95% CI = .36-.6). Only housing-related social risks were associated with an increase in acute care (emergency, urgent care) six months after initial screening; no other associations between social risk and utilization were observed.ConclusionsThis study suggests that screening for social risk may be appropriate at intervals of six months, or perhaps longer, but that assessing desire for assistance may need to occur more frequently. Housing risks were associated with increases in acute care. Health systems may need to engage in screening and referral to resources to improve overall care and ultimately patient total health.

Barriers and facilitators to implementation of the Accountable Health Communities (AHC) Model: Findings from a between-site qualitative assessment of implementation strategies.

A multitude of HRSN interventions are undergoing testing in the U.S., with the CMS Accountable Health Communities (AHC) Model as the largest. HRSN interventions typically include screening for social needs, referral to community resources, and patient navigation to ensure needs are met. There is currently a paucity of evidence on implementation of HRSN interventions. The Consolidated Framework for Implementation Research (CFIR) is a determinant framework widely used to plan and assess implementation. To the authors knowledge, there are no published studies assessing CFIR constructs for HRSN intervention implementation in the U.S. In the Assessment step of the Strengthening Peer AHC Navigation (SPAN) model, a between-site qualitative assessment methodology was used to examine implementation within and between AHC bridge organizations (BOs) within six ERIC implementation strategies identified by the authors based on AHC Model requirements. Our aim was to identify and present between-site barriers and facilitators to AHC Model implementation strategies. A multi-site qualitative analysis methodology was used. CFIR determinants were linked to six Expert Recommendations for Implementing Change (ERIC) strategies: staff training, identify and prepare champions, facilitation, community resource engagement (alignment through advisory boards and working groups), data systems, and quality monitoring and assurance. Interviews were analyzed using thematic content analysis in NVivo 12 (QSR International). Five health-related bridge organizations participating in the AHC Model. Fifty-eight interviews were completed with 34 staff and 24 patients or patient proxies. Facilitators were identified across five of the six ERIC strategies. Barriers were identified across all six. While organizations found the AHC Model compatible and facilitators to implementation included previous experience, meeting patient needs and resources, and leadership engagement and support, a number of barriers presented challenges to implementation. Issues with adequate staff training, staff skills to resolve HRSN, including patient communication and boundary spanning, setting staff goals, beneficiary caseloads and measurement of progress, data infrastructure (including EHR), available resources to implement and differences in perceptions between clinical delivery site (CDS), and CSP of how to measure and resolve HRSN. The conduct of a pre-implementation readiness assessment benefited from identifying CFIR determinants linked to various ERIC implementation strategies.

Assessment of Unmet Health-Related Social Needs Among Patients With Mental Illness Enrolled in Medicare Advantage

A large body of literature has found associations between unmet health-related social needs (HRSNs) and adverse mental health outcomes. A comparative analysis of the risks associated with HRSNs among patients with varying severity of mental illness and an assessment of how these risks compare with those of individuals without mental illness are needed. To examine the prevalence and risks of HRSNs among patients with serious and persistent mental illness (SPMI), patients with mental health diagnoses but no serious and persistent mental illness (non-SPMI), and patients with both SPMI and non-SPMI compared with individuals without mental illness. This retrospective cohort study used data from the Accountable Health Communities HRSN Screening Tool surveys, which target a nationally representative sample of Medicare Advantage members of a large payer (Humana Inc). The surveys were conducted between October 16, 2019, and February 29, 2020. Of the initial 329 008 eligible Medicare Advantage enrollees, 70 273 responded to the survey (21.4% response rate). Of those, 56 081 respondents (79.8%) had complete survey responses and were included in the final analytic sample. Outcomes of interest included 7 HRSNs (financial strain, food insecurity, housing instability, housing quality, severe loneliness, transportation problems, and utility affordability) based on responses to the survey. The major independent variable was the presence of mental illness up to 12 months preceding the date of survey completion. Codes indicating mental illness listed as the primary, principal, or secondary diagnoses of a patient's inpatient or outpatient medical claims data were identified, and participants were grouped into 4 cohorts: SPMI, non-SPMI, SPMI plus non-SPMI, and no mental illness. Among 56 081 older adults, the mean (SD) age was 71.31 (8.59) years; 32 717 participants (58.3%) were female, and 43 498 (77.6%) were White. A total of 21 644 participants (38.6%) had at least 1 mental illness diagnosis in the past year, 30 262 (54.0%) had an HRSN, and 14 163 (25.3%) had both mental illness and an HRSN. Across all specific HRSNs, the odds of experiencing the respective HRSN was most substantial for those with SPMI plus non-SPMI vs those with only non-SPMI or SPMI. The HRSN with the largest risk differences among the study cohorts was severe loneliness; compared with the cohort without mental illness, the non-SPMI cohort had 2.07 times higher odds (95% CI, 1.84-2.32; P < .001), the SPMI cohort had 3.35 times higher odds (95% CI, 3.03-3.71; P < .001), and the SPMI plus non-SPMI cohort had 5.13 times higher odds (95% CI, 4.68-5.61; P < .001) of severe loneliness. In this study, the increased risk of having HRSNs associated with SPMI, alone or in combination with non-SPMI, emphasizes the need for more targeted interventions to address social needs in this vulnerable population.

Accountable Communities for Health: What We Are Learning from Recent Evaluations.

Accountable Communities for Health: What We Are Learning from Recent Evaluations.

Lessons on Increasing Racial and Health Equity From Accountable Health Communities.

The Accountable Health Communities model (AHC) was developed to test whether systematically screening for health-related social needs and referrals to community-based organizations to resolve unmet needs would affect healthcare use and costs for CMS beneficiaries. Purpose: The AHC model required applicants to develop Disparities Impact Statements (DIS), to increase the model's potential impact on health equity. Authors conducted a thematic analysis of awardees' DISs to identify minority and underserved populations of focus, and the strategies awardees used to increase equitable participation in the model by minority and underserved populations. Most awardees focused on multiple minority and underserved populations and used multipronged innovative strategies to pursue equity goals. Considering recent health equity advancements as Executive Order 13985 and the release of CMS Innovation Center's Strategy Refresh, with highlights of health equity best practices from the AHC model, assessing use of DISs in the AHC model provides valuable lessons. Implications: Given HHS' broadscale promotion of DISs adoption as a viable quality improvement approach to achieving health equity, disseminating how the tool was used by a myriad of organizational types in the AHC model is critically important to improving future efforts to increase equity.

The Dallas Accountable Health Community: Its Impact on Health-Related Social Needs, Care, and Costs

Summary In May 2017, the U.S. Centers for Medicare & Medicaid Services (CMS) launched the Accountable Health Communities (AHC) Model, a 5-year initiative to address a critical gap between clinical care and community services in the current delivery system. The initiative tested whether systematically identifying and addressing the health-related social needs (HRSNs) of Medicare and Medicaid beneficiaries through screening, referral, and community navigation would reduce utilization and health care expenditures. As one of 32 original awardees, the Parkland Center for Clinical Innovation (PCCI) served as an Alignment Track bridge organization. PCCI partnered with 17 clinical sites, representing five Dallas health care systems and more than 100 local community-based organizations (CBOs), to establish the Dallas Accountable Health Community (DAHC). Using a CMS-developed HRSN screening tool, PCCI and its partners screened 12,548 unique Dallas County beneficiaries meeting the criteria for Model eligibility. PCCI and partner community health workers provided 9,161 unique individuals with active navigation services consisting of referrals to aligned CBOs, accompanied by monthly follow-up calls for up to 12 months or until the documented HRSNs were addressed successfully. Over the initiative’s 5-year course, PCCI identified more than 19,000 distinct needs, with 61% of individuals having two or more concurrent needs. Through the referral process, CBOs provided a multitude of support services, including more than 200,000 pounds of food and $540,000 in utility and rent assistance. Results show that actively navigated individuals experienced a greater decrease in per-person ED visits than those in a comparable control cohort, with the navigation cohort having a statistically significant reduction in average ED utilization, both while actively navigated and in the 12 months after navigation. The navigated cohort also demonstrated a greater likelihood to seek — and keep — outpatient visits compared with the control cohort. Although inpatient admissions were reduced within both cohorts, the between-cohort differences were not statistically significant. Not including the CBO-provided intervention costs and using Model year 4 data (May 2020 to April 2021), the DAHC demonstrated a positive ROI of 1.3 to 1 with a gross savings exceeding $1.25 million. The impact analysis accounted for the dynamic, multidimensional Covid-19 impact via an innovative control group matching algorithm. This study demonstrated the nature and scope of HRSNs among a high-risk vulnerable Dallas County population, a positive impact on health care outcomes, and a more muted impact on expenditures using regularly occurring active navigation of engaged beneficiaries. Importantly, the DAHC showed that combining clinical care with appropriate social services to address HRSNs — at the right time and by the right personnel — resulted in lower utilization and a decrease in health care expenditures. These two factors alone argue for the expansion of the initiative to other at-risk populations while establishing the initiative’s long-term sustainability.

326 High patient acceptability of social needs screening in dermatology clinic

Social risks affect health outcomes and contribute to health inequity. Social needs screening has been evaluated in primary care but not yet in specialty care like dermatology. Our study aimed to: 1) determine patient acceptability of social needs screening and 2) explore patient attitudes & beliefs about social needs screening in dermatology clinic. We conducted a cross-sectional mixed methods study of 140 adult patients from the dermatology clinic at Zuckerberg San Francisco General Hospital. The survey included Accountable Health Communities Health-Related Social Needs Screening questions plus 30 additional questions that explored social factors affecting patient acceptability of screening.

The Impact of Social Determinants of Health on Female Sexual Function

ABSTRACT Introduction Social Determinants of Health (SDOH) like economic stability, education, neighborhood &amp; environment, and social and community context, may significantly impact overall health and drive health disparities. Objective Our aim was to evaluate the association between female sexual function and SDOH. Methods We conducted a cross-sectional study of women 18 and older presenting to outpatient female pelvic medicine and reconstructive surgery (FPMRS) clinics at Montefiore Medical Center (Bronx, NY) from November 2018 to November 2019. The Female Sexual Function Index (FSFI-6) was administered to screen for female sexual dysfunction (FSD) and The Accountable Health Communities Health-Related Social Needs Screening Tool to evaluate unmet social needs. Ordinal logistic regression models were used to examine the association between FSD (defined as FSFI-6 score 19 or less for FSD and FSFI-6 &amp;gt;20 as no FSD) and each social need item, while adjusting for potential confounders. Results 89 women were included in the analysis, with mean age 55.7 years (SD=13.5) and mean BMI 32 (SD=8.4). 4.5% were White, 38.2% Black, 48.3% Hispanic, and 9% did not identify a race or ethnicity. FSD was associated with women who spoke a language other than English or wanted more schooling/training, whereas women who were searching for employment were less likely to have FSD. However, needing family or community support for completion of their activities of daily living (AOR=4.27, 95% CI:(1.05, 17.38), p = .04) was the only social need statistically significantly associated with FSD after adjusting for age, race, BMI, parity and previous pelvic surgery in ordinal logistic regression analysis. Conclusions Family or community support is a social need that was associated with FSD in our diverse, urban cohort. Further exploration with patient interviews may reveal social and cultural beliefs that explain this association. Urologists should consider screening for SDOH to better serve patients with FSD. Disclosure No

Predicting health-related social needs in Medicaid and Medicare populations using machine learning

Providers currently rely on universal screening to identify health-related social needs (HRSNs). Predicting HRSNs using EHR and community-level data could be more efficient and less resource intensive. Using machine learning models, we evaluated the predictive performance of HRSN status from EHR and community-level social determinants of health (SDOH) data for Medicare and Medicaid beneficiaries participating in the Accountable Health Communities Model. We hypothesized that Medicaid insurance coverage would predict HRSN status. All models significantly outperformed the baseline Medicaid hypothesis. AUCs ranged from 0.59 to 0.68. The top performance (AUC = 0.68 CI 0.66–0.70) was achieved by the “any HRSNs” outcome, which is the most useful for screening prioritization. Community-level SDOH features had lower predictive performance than EHR features. Machine learning models can be used to prioritize patients for screening. However, screening only patients identified by our current model(s) would miss many patients. Future studies are warranted to optimize prediction of HRSNs.

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

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

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

BackgroundIntegration of health-related social needs (HRSNs) data into clinical care is recognized as a driver for improving healthcare. However, few published studies on HRSNs and their impact are available. CMS sought to fill this gap through the Accountable Health Communities (AHC) Model, a national RCT of HRSN screening, referral, and navigation. Data from the AHC Model could significantly advance the field of HRSN screening and intervention in the USA.ObjectiveTo present data from the Greater Houston AHC (GH-AHC) Model site on HRSN frequency and the association between HRSNs, sociodemographic factors, and self-reported ED utilization using a cross-sectional design. Analyses included descriptive statistics and multinomial logistic regression.Participants (or Patients or Subjects)All community-dwelling Medicare, Medicaid, or dually covered beneficiaries at participating GH-AHC clinical delivery sites were eligible.Main MeasuresSelf-reported ED utilization in the previous 12 months served as the outcome; demographic characteristics including race, ethnicity, age, sex, income, education level, number of people living in the household, and insurance type were treated as covariates. HRSNs included food insecurity, housing instability, transportation, difficulty paying utility bills, and interpersonal safety. Clinical delivery site type was used as the clustering variable.Key ResultsFood insecurity was the most common HRSN identified (38.7%) followed by housing instability (29.0%), transportation (28.0%), and difficulty paying utility bills (26.7%). Interpersonal safety was excluded due to low prevalence. More than half of the beneficiaries (56.9%) reported at least one of the four HRSNs. After controlling for covariates, having multiple co-occurring HRSNs was strongly associated with increased risk of two or more ED visits (OR 1.8–9.47 for two to four needs, respectively; p < 0.001). Beneficiaries with four needs were at almost 10 times higher risk of frequent ED utilization (p < 0.001).ConclusionsTo our knowledge, this is only the second published study to report screening data from the AHC Model. Future research focused on the impact of multiple co-occurring needs on health outcomes is warranted.

Addressing social determinants of health in pediatric health systems: balancing mission and financial sustainability.

With increasing recognition of the impact of poverty, racism and other social factors on child health, many pediatric health systems are undertaking interventions to address Social Determinants of Health (SDoH). This review summarizes these initiatives and recent developments in state and federal health policy impacting funding for these efforts. Although the evidence defining optimal approaches to identifying and mitigating SDoH in children is still evolving, pediatric health systems are making significant investments in different initiatives to address SDoH. With limited reimbursement available through traditional payment streams, pediatric health systems and Accountable Care Organizations are looking to value-based payments to help fund these interventions. Federal and state policy changes, including use of Medicaid funds for nonmedical interventions and introduction of the Accountable Health Communities model to pediatrics, offer additional funding sources to address SDoH. Initiatives among mission-driven pediatric health systems to address SDoH are increasingly common despite funding challenges. Value-based payments, expansion of Medicaid funding resulting from policy changes and delivery system reform, along with health system philanthropy and operating revenues, will all be needed to meet mission-based goals of addressing SDoH while supporting financial sustainability.