ArticleJournal of general internal medicine2022
Association of Social Needs and Healthcare Utilization Among Medicare and Medicaid Beneficiaries in the Accountable Health Communities Model.
Article in Journal of general internal medicine, 2022. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Cited by 21 papers.
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The trial behind it
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Who cites it
21 citing papers in PubMed, 32 citations in OpenAlex.
- Parental and Provider Perceptions of Social Care Impacts on Infant Nutrition.Childhood obesity (Print) · 2026Article
- Health-Related Social Needs and Health Care Utilization in the Accountable Health Communities Model.JAMA network open · 2025Article
- The Community Vulnerability Compass: a novel, scalable approach for measuring and visualizing social determinants of health insights.JAMIA open · 2025Article
- Modeling Patients' Progression through Health-Related Social Needs.Applied clinical informatics · 2025Article
- Food insecurity prior to hematopoietic stem cell transplant is associated with malnutrition and worse outcomes.Bone marrow transplantation · 2025Article
- The Role of Patient-Reported Outcomes in Cirrhosis.The American journal of gastroenterology · 2025Review
- Clusters of Health-Related Social Needs Among Adult Primary Care Patients.Journal of the American Board of Family Medicine : JABFM · 2025Article
- Are unmet health related social needs associated with emergency department utilization among Medicare beneficiaries?BMC health services research · 2025Article
- Implementing Social Determinants of Health Screening in US Emergency Departments.JAMA network open · 2025Article
- Housing instability and psychological distress in African American cancer survivors: findings from the Detroit Research on Cancer Survivors study.Journal of cancer survivorship : research and practice · 2025Observational
- Co-creation of staff training to address health-related social needs in emergencies.Frontiers in public health · 2025Article
- Helping patients with cancer address their social needs.Proceedings (Baylor University. Medical Center) · 2025Article
- Patterns of Social Needs Predict Quality-of-Life and Healthcare Utilization Outcomes in Patients from a Large Hospital System.Journal of general internal medicine · 2024Observational
- Examining the Association Between Social Needs and Care Gap Closure Among Older Adults Receiving Dental Care.AJPM focus · 2024Article
- Toward standardization, harmonization, and integration of social determinants of health data: A Texas Clinical and Translational Science Award institutions collaboration.Journal of clinical and translational science · 2024Article
- Screening for Health-Related Social Needs and Collaboration With External Partners Among US Hospitals.JAMA network open · 2023Article
- Diet and Food and Nutrition Insecurity and Cardiometabolic Disease.Circulation research · 2023Review
- Assessing and Addressing Social Determinants of Cardiovascular Health: JACC State-of-the-Art Review.Journal of the American College of Cardiology · 2023Review
- Learning in real world practice: Identifying implementation strategies to integrate health-related social needs screening within a large health system.Journal of clinical and translational science · 2023Article
- Prevalence of social risk factors and social needs in a Medicaid Accountable Care Organization (ACO).BMC health services research · 2022Article
Corrections and comments
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Authors and funding
4 authors at 1 institution in 1 country.
Funding
No grant is acknowledged in the PubMed record.
Abstract
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 MEASURES: Self-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.
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