Health-Related Social Needs Linked to Higher ED Use

Breaking: New CMS‑Funded Study Links Unmet Health-Related Social Needs to Higher ED and Inpatient Use

In a five‑year CMS‑funded pilot, researchers find that most baseline health‑related social needs, or HSRNs, align with greater odds of emergency department visits and hospital admissions. The study draws on patient data from Allina Health in Minnesota and western Wisconsin, where screening and referrals were part of the Accountable Health Communities model.The research spans June 2018 thru January 2022, covering patients across 79 primary care clinics.

What We’re Learning About HSRNs

HSRNs represent unmet needs in areas that influence health beyond medical care-housing stability and quality,food security,reliable transportation,utility stability,and interpersonal safety. Researchers treated housing stability and housing quality separately, creating a total of six categories for analysis. Patients who screened positive received a tailored community referral summary to connect them with local resources.

Key Findings at a Glance

Among more than 166,000 patients screened, researchers identified clear links between HSRNs and higher hospital use. Baseline findings showed that nearly a quarter (24.3%) reported one or more needs. The prevalence of specific needs ranged from 1.4% for interpersonal safety to 14.5% for food security. The groups with the highest need burden included multiracial or American Indian patients, adults aged 18-64, dual‑eligible by Medicaid and Medicare, and Spanish speakers.

Patterns in health care utilization were most pronounced for housing instability and transportation. Patients reporting housing instability had a higher rate of ED visits in the six months prior to screening (26.9%) than those without this need (14.3%). Those with transportation needs also showed elevated ED use (25.6% vs. 13.9%). Interpersonal safety needs carried the highest ED usage at 27.7% versus 14.6% for those without such needs.

After adjusting for other HSRNs, demographics, and health conditions, two needs-housing stability and transportation-remained associated with higher inpatient utilization. The study also found higher ED use associated with transportation and housing stability, underscoring these domains as priorities for targeted interventions.

Interventions and Follow‑Up Within the AHC Program

Among the 166,682 patients who screened positive for at least one HSRN, 15,139 were included in a longitudinal analysis of HSRN resolution after receiving a community referral summary. The average interval between baseline and follow‑up screening was 13.6 months. Of these, 57.1% experienced fewer needs, 26.8% had the same number of needs, and 16.1% reported more needs at follow‑up. Resolution varied by need, with the interpersonal safety category showing the highest enhancement (72.1% no longer reporting this need), followed by housing quality (62.8%), unreliable transportation (62.7%), and food insecurity (48.5%).

The researchers acknowledge several limitations. Screening tools were broad and self‑reported, which may affect accuracy in measuring HSRN severity and outcomes. Not all patients identified with needs had follow‑up screenings, perhaps biasing results. Small sample sizes for some needs also limit the strength of certain analyses.

What This Means for Health Systems

Experts say the findings highlight a clear path: health systems should broaden collaborations with community resources to address HSRNs head‑on.By linking patients to housing assistance, transportation services, food help, and safety supports, hospitals can target interventions where they’re most likely to reduce ED and inpatient demand.

These results come as health systems increasingly test and expand social determinants of health (SDOH) programs.Expertise in coordinating across housing authorities, social services, and primary care is essential to translate screening into meaningful reductions in hospital use.

Table: Summary of Key Facts

Category	Details
Study design	Five‑year pilot cohort under CMS Accountable Health communities model
Setting & timeframe	Allina Health, Minnesota and western Wisconsin; June 2018-January 2022
Sites & participants	79 primary care clinics; 166,682 screened for HSRNs
Demographics (screened)	65+ years: 43.5%; female: 60.3%; racial/ethnic mix provided; 24.3% reported 1+ HSRN at baseline
HSRN domains	housing (stability and quality), food security, transportation, utilities, interpersonal safety (six total when split housing issues)
Highest ED‑use indicators	Transportation needs and housing instability showed the strongest ED use in prior six months
Inpatient utilization (adjusted)	Housing stability (OR 1.34); transportation (OR 1.16)
ED utilization (adjusted)	Transportation (OR 1.31); housing stability (OR 1.25)
Follow‑up findings	Among positive cases with follow‑up data, 57.1% had fewer needs; 16.1% more; interpersonal safety had the largest resolution rate (72.1%)
Limitations	Self‑reported, heterogeneous screening; incomplete follow‑up; small samples for some needs

Evergreen Insights for the Longer Term

Addressing health‑related social needs isn’t just about lowering hospital counts. it’s about building healthier communities through cross‑sector collaboration,stable housing,reliable transport,and dependable access to basics like food and safety. Standardized screening tools,proactive referrals,and robust tracking of outcomes are essential to turn screening into sustained health improvements.As health systems expand SDOH programs, policymakers and providers should prioritize integrated data sharing, transparent metrics, and accountable partnerships with community organizations to maximize impact.

For further context on the broader importance of social determinants of health, see resources from major health agencies and researchers, including guidance from the world Health Organization and federal programs that incentivize community‑level interventions.

External resources:
World Health Organization – Social determinants of health •
CMS – Accountable health Communities model •
CDC – Social determinants of health.

Have Your Say

What barriers to meeting housing and transportation needs exist where you live, and how can health systems partner with communities to overcome them?

Should hospitals invest more in social‑needs programs to reduce hospital use, or should focus remain on direct medical care? Share your views in the comments below.

Call to Action

If you found this breaking development crucial, please share it with friends and colleagues. Your experiences and questions can help shape how communities address health‑related social needs in the months ahead.

Disclaimer: This article provides general information and should not replace professional medical advice. For health decisions, consult a qualified professional.

Overall prevalence: 42 % of ED patients screened positive for at least one social risk factor (National Academy of Medicine, 2023).

Understanding the Link Between Health‑Related Social Needs and Higher Emergency Department (ED) Use

Patients who face unmet social needs-such as unstable housing, food insecurity, or transportation barriers-are statistically more likely to seek care in the emergency department. A 2023 study in Health affairs found that individuals reporting two or more social risk factors had a 38 % higher odds of an ED visit within the next 12 months (Health Affairs,2023).

---

Key Social Determinants Driving increased ED Visits

1. Housing Instability

• Frequent ED visits: Homeless patients account for ~15 % of all ED encounters despite representing <2 % of the population (CDC, 2024).
• Root causes: Lack of a safe place to store medications, limited access to primary‑care clinics, and exposure to environmental hazards.

2. Food Insecurity

• Impact on health: Chronic hunger aggravates diabetes, hypertension, and asthma, leading to acute exacerbations that end up in the ED.
• Statistics: Adults experiencing food insecurity are 2.2 times more likely to have an avoidable ED visit for chronic disease complications (JAMA Network, 2023).

3. Transportation Barriers

• Missed appointments: Patients without reliable transportation miss up to 30 % of scheduled primary‑care visits, prompting urgent care in the ED (American Journal of Public Health, 2022).
• Rural challenges: In geographically isolated areas, travel distances >20 miles correlate wiht a 27 % increase in ED utilization (Rural Health Quarterly, 2024).

4. Income & Employment Challenges

• Cost‑driven decisions: Out‑of‑pocket costs for urgent primary‑care visits frequently enough exceed those for a low‑triage ED visit,especially for uninsured or under‑insured patients.
• Work schedule constraints: Inflexible job hours limit the ability to attend daytime clinics, pushing patients toward after‑hours ED services.

5. Health Literacy & Language Barriers

• Communication gaps: Low health literacy is associated with a 31 % rise in repeat ED visits for the same condition (NEJM, 2022).
• Limited English proficiency: Patients lacking language support are more likely to use the ED for non‑emergent issues due to difficulty navigating the health system.

---

Data highlights: Recent Statistics on Social Needs and ED Utilization

• Overall prevalence: 42 % of ED patients screened positive for at least one social risk factor (National Academy of Medicine, 2023).
• Repeat visits: Patients with ≥3 unmet social needs had an average of 4.5 ED visits per year versus 1.8 for those with no identified needs.
• Cost impact: Social‑needs‑related ED visits account for an estimated $7.2 billion in excess health‑care spending annually (CMS, 2024).

---

Real‑World Case Studies

Boston Health care for the Homeless (BHCH) Program

• Intervention: Integrated social workers within the ED triage area to conduct immediate housing assessments.
• Outcome: 22 % reduction in repeat ED visits among participants over a 12‑month period (Boston Public Health Review, 2023).

Ohio Medicaid waiver – “Housing First” Initiative

• Strategy: Provided rapid‑access temporary housing and case management for Medicaid enrollees with frequent ED use.
• Result: ED visit frequency dropped from an average of 6.3 to 3.1 visits per patient per year; Medicaid costs decreased by 18 % (Ohio Department of Health, 2024).

---

Practical Strategies for Healthcare Systems

1. Screen for Social Needs at Triage

• Deploy a validated 2‑item questionnaire (e.g., PRAPARE) during registration.
• Flag positive screens in the electronic health record (EHR) for immediate referral.

2. Build Partnerships with Community Organizations

• Establish formal referral pathways to local housing agencies,food banks,and transportation services.
• Use “community health liaisons” to coordinate follow‑up outside the hospital.

3. Implement Mobile Health Units

• Deploy vans equipped for primary‑care visits in underserved neighborhoods on a scheduled basis.
• Track reductions in local ED volume through geospatial analytics.

4. Leverage Telehealth for Post‑ED Follow‑up

• Offer video or phone visits within 48 hours of discharge, focusing on medication reconciliation and appointment scheduling.
• Provide a subsidized device or data plan for patients lacking connectivity.

5. Use Data Analytics to Identify High‑Risk Patients

• Apply predictive modeling (e.g., machine‑learning algorithms) to EHR data to flag individuals with multiple social risk factors.
• Prioritize outreach to this cohort with intensive case management.

---

Benefits of Addressing Social needs

• Cost Savings: Hospitals report average savings of $1,200 per patient per year after implementing social‑needs interventions (Hospital finance Journal,2024).
• Improved Patient Outcomes: Reduced readmission rates, better chronic disease control, and higher patient satisfaction scores.
• Enhanced Provider Satisfaction: Clinicians note decreased moral distress when patients receive comprehensive, non‑clinical support.

---

Tips for Patients and Caregivers

• Communicate openly: Mention housing, food, or transportation concerns during every medical visit.
• Utilize available resources:
• 211 (U.S. nationwide) for immediate assistance with basic needs.
• Local food pantries (search “food bank near me”).
• Community health centers offering sliding‑scale primary care.
• Prepare a personal health record: Include medication lists, appointment dates, and a brief summary of social challenges to streamline discussions with providers.

---

References

1. Health Affairs. (2023). Social Risk Factors and Emergency Department Utilization.
2. Centers for Disease Control and Prevention (CDC).(2024). Homelessness and Emergency Department Visits.
3. JAMA Network. (2023). Food Insecurity and Preventable ED Visits.
4. American Journal of Public Health. (2022). Transportation Barriers and Healthcare Access.
5. Rural Health Quarterly. (2024). Geographic Isolation and ED Use.
6. New England journal of Medicine. (2022). health Literacy and Repeat ED Visits.
7. National Academy of Medicine. (2023). Prevalence of Social Determinants in ED Populations.
8. Centers for Medicare & Medicaid Services (CMS). (2024). Cost Implications of Social‑Needs‑Related ED Visits.
9. Boston Public Health Review. (2023). Impact of Integrated Social Work in EDs.
10. Ohio Department of Health. (2024). Housing First Medicaid Waiver Outcomes.
11. Hospital Finance Journal. (2024). Economic Benefits of Social Needs Screening.