Background: Improving health requires interventions far beyond traditional medical care. The Comprehensive Care, Community, and Culture Program (C4P) seeks to address the complex medical and social needs of patients at increased risk of hospitalization, a group that accounts for most US health care spending and poor health outcomes and is disproportionately disadvantaged socioeconomically. C4P builds on the Comprehensive Care Program (CCP), which provides patients with inpatient and outpatient care from a physician with whom they have an established relationship and has produced promising evidence of improved patient experience and outcomes, and lower costs. Nevertheless, 30% of patients offered CCP care do not engage despite systematic efforts to reach them. C4P adds screening of unmet social needs, access to Community Health Workers and a community, arts and cultural program. As part of implementing C4P we seek to first understand unmet needs in this population.
Methods: Using a tool adapted from Health Leads, we have screened 227 patients for 17 unmet social need categories.
Findings: Early findings are: 1) Large variability in the prevalence of specific social needs, ranging from 3%-56% of patients. The most prevalent are: healthy eating/physical activity, engaging in enjoyable activities, health/dental insurance, transportation, and money for basic needs. 2) Needs are highly concentrated in a subset of patients. 3) Many needs co-occur, suggesting opportunities to intervene simultaneously, e.g. “healthy eating”/“food”, “companionship”/“engagement”, “insurance”/“employment.” 4) Unmet needs often persist, but new needs constitute a substantial fraction of unmet needs at any given time. 5) Patients with more unmet needs are less likely to resolve existing needs and more likely to develop new unmet needs. Qualitative interviews help us further understand patients’ needs within these categories and the dynamics of unmet needs over time, and highlight depression and social isolation as key factors.
Implications for D&I Research: Early findings suggest that needs are multifaceted and dynamic and that mental health issues create cross-cutting barriers to receiving services. Combining need-oriented and patient-specific interventions, especially psychosocial support and strong patient-provider relationships, has promise to holistically address complex patients’ unmet social needs, which has the potential to reduce healthcare utilization and improve patients’ health and experience.