Screening Discordance and Characteristics of Patients With Housing-Related Social Risks.

INTRODUCTION: Healthcare systems are increasingly interested in identifying patients' housing-related risks, but minimal information exists to inform screening question selection. The primary study aim is to evaluate discordance among 5 housing-related screening questions used in health care. METHODS: This was a cross-sectional multisite survey of social risks used in a convenience sample of adults seeking care for themselves or their child at 7 primary care clinics and 4 emergency departments across 9 states (2018-2019). Housing-related risks were measured using 2 questions from the Accountable Health Communities screening tool (current/anticipated housing instability, current housing quality problems) and 3 from the Children's HealthWatch recommended housing instability screening measures (prior 12-month: rent/mortgage strain, number of moves, current/recent homelessness). The 2-sided Fisher's exact tests analyzed housing-related risks and participant characteristics; logistic regression explored associations with reported health (2019-2020). RESULTS: Of 835 participants, 52% screened positive for ≥1 housing-related risk (n=430). Comparing the tools, 32.8% (n=274) screened discordant: 11.9% (n=99) screened positive by Children's HealthWatch questions but negative by Accountable Health Communities, and 21.0% (n=175) screened positive by the Accountable Health Communities tool but negative by Children's HealthWatch (p<0.001). Worse health was associated with screening positive for current/anticipated housing instability (AOR=0.56, 95% CI=0.32, 0.96) or current/recent homelessness (AOR=0.57, 95% CI=0.34, 0.96). CONCLUSIONS: The 5 housing questions captured different housing-related risks, contributed to different health consequences, and were relevant to different subpopulations. Before implementing housing-related screening initiatives, health systems should understand how specific measures surface distinct housing-related barriers. Measure selection should depend on program goals and intervention resources.

Part I: A Quantitative Study of Social Risk Screening Acceptability in Patients and Caregivers.

INTRODUCTION: Despite recent growth in healthcare delivery-based social risk screening, little is known about patient perspectives on these activities. This study evaluates patient and caregiver acceptability of social risk screening. METHODS: This was a cross-sectional survey of 969 adult patients and adult caregivers of pediatric patients recruited from 6 primary care clinics and 4 emergency departments across 9 states. Survey items included the Center for Medicare and Medicaid Innovation Accountable Health Communities' social risk screening tool and questions about appropriateness of screening and comfort with including social risk data in electronic health records. Logistic regressions evaluated covariate associations with acceptability measures. Data collection occurred from July 2018 to February 2019; data analyses were conducted in February‒March 2019. RESULTS: Screening was reported as appropriate by 79% of participants; 65% reported comfort including social risks in electronic health records. In adjusted models, higher perceived screening appropriateness was associated with previous exposure to healthcare-based social risk screening (AOR=1.82, 95% CI=1.16, 2.88), trust in clinicians (AOR=1.55, 95% CI=1.00, 2.40), and recruitment from a primary care setting (AOR=1.70, 95% CI=1.23, 2.38). Lower appropriateness was associated with previous experience of healthcare discrimination (AOR=0.66, 95% CI=0.45, 0.95). Higher comfort with electronic health record documentation was associated with previously receiving assistance with social risks in a healthcare setting (AOR=1.47, 95% CI=1.04, 2.07). CONCLUSIONS: A strong majority of adult patients and caregivers of pediatric patients reported that social risk screening was appropriate. Most also felt comfortable including social risk data in electronic health records. Although multiple factors influenced acceptability, the effects were moderate to small. These findings suggest that lack of patient acceptability is unlikely to be a major implementation barrier. SUPPLEMENT INFORMATION: This article is part of a supplement entitled Identifying and Intervening on Social Needs in Clinical Settings: Evidence and Evidence Gaps, which is sponsored by the Agency for Healthcare Research and Quality of the U.S. Department of Health and Human Services, Kaiser Permanente, and the Robert Wood Johnson Foundation.

Part II: A Qualitative Study of Social Risk Screening Acceptability in Patients and Caregivers.

INTRODUCTION: This study aimed to better understand patient and caregiver perspectives on social risk screening across different healthcare settings. METHODS: As part of a mixed-methods multisite study, the authors conducted semistructured interviews with a subset of adult patients and adult caregivers of pediatric patients who had completed the Center for Medicare and Medicaid Innovation Accountable Health Communities social risk screening tool between July 2018 and February 2019. Interviews, conducted in English or Spanish, asked about reactions to screening, screening acceptability, preferences for administration, prior screening experiences that informed perspectives, and expectations for social assistance. Basic thematic analysis and constant comparative methods were used to code and develop themes. RESULTS: Fifty interviews were conducted across 10 study sites in 9 states, including 6 primary care clinics and 4 emergency departments. There was broad consensus among interviewees across all sites that social risk screening was acceptable. The following 4 main themes emerged: (1) participants believed screening for social risks is important; (2) participants expressed insight into the connections between social risks and overall health; (3) participants emphasized the importance of patient-centered implementation of social risk screening; and (4) participants recognized limits to the healthcare sector's capacity to address or resolve social risks. CONCLUSIONS: Despite gaps in the availability of social risk-related interventions in healthcare settings, patient-centered social risk screening, including empathy and attention to privacy, may strengthen relationships between patients and healthcare teams. SUPPLEMENT INFORMATION: This article is part of a supplement entitled Identifying and Intervening on Social Needs in Clinical Settings: Evidence and Evidence Gaps, which is sponsored by the Agency for Healthcare Research and Quality of the U.S. Department of Health and Human Services, Kaiser Permanente, and the Robert Wood Johnson Foundation.