How patient's unmet needs impact their health and health care

"Rather than focus on a single specific need patients may have, as earlier studies have done, we sought to comprehensively assess patients' needs and determine how they relate to illness management and the use of health services," says Seth Berkowitz, MD, MPH, of the MGH Division of General Internal Medicine, lead author of the report. "While there has been a lot of interest in addressing social determinants of health, we haven't known much about the specific issues faced by patients in particular situations."

The authors note that programs designed to address the unmet needs of patients often take a complex care management approach involving comprehensive assessments and individualized care plans, which while effective may be too resource intensive to offer to all of a practice's patients, including those whose unmet needs are not apparent to medical professionals. The current study was designed to determine which unmet needs were most common in participating practices and how those needs related to both specific medical conditions and to patients' use of health services.

From October 2013 through April 2014 all patients seen at the participating practices were asked to complete a form -- available in five languages -- indicating whether they would like to receive help with needs like paying for healthy food, prescription medicine or utility bills; finding a job or receiving assistance for housing or other financial needs. Patients indicating a desire for help were referred to advocates from Health Leads, who were located in the practices and could either see them the same day or arrange to follow up by phone or text message. Advocates worked with the patients to define their needs more specifically, to identify community services or programs that could help meet those needs and to connect patients with those programs. For example, patients indicating difficulty accessing nutritious food for themselves or their children might receive assistance in applying for the SNAP (Supplemental Nutrition Assistance Program) program or given information about local food pantries and soup kitchens. The research team also investigated how these unmet needs related to health conditions and other information noted in medical records.

Of more than 3,000 patients seen during the seven-month study period, 416 indicated one or more unmet needs and enrolled in the Health Leads program. Compared with patients reporting no needs, these individuals were more likely to be women, members of racial or ethnic minorities, and receive Medicaid health insurance. The most commonly reported unmet needs were difficulty affording health care -- including prescription drugs -- food or utilities. The prevalence of conditions like depression, diabetes and hypertension was greater among patients with unmet needs, and those individuals were more likely to be frequent users of hospital emergency departments and to miss scheduled clinic appointments. In patients with chronic conditions like diabetes or elevated cholesterol levels, those with unmet needs were more likely to have trouble controlling risk factors.

The services with which patients were most frequently connected included assistance with food, utility payments or energy costs, prescription drugs and health insurance. Patients' cases were open an average of seven weeks, and at the end of the study period, 62 percent of identified needs either were met or patients indicated no longer needing help. In 4 percent of cases needs were still unmet, and in 34 percent, the patients were lost to follow up. Relationships between unmet needs and health issues often were clear -- such as food access and diabetes control or transportation difficulties and missed clinic appointments -- although the study was not long enough to determine whether accessing needed services reduced the identified problems.

"One thing we are learning is that unmet needs are so common in the U.S. -- one third of American adults with a chronic illness have trouble affording food, medication or both -- that issues like this will come up in almost any practice," say Berkowitz, who is an instructor in Medicine at Harvard Medical School. "If practices are willing, programs designed to link patients to basic resources could be relatively easy to generalize. We also need to further refine our interventions so we can connect patients with programs that more completely meet their needs." He adds that the program described in this paper is now offered in an additional MGH practice and may be expended further, and that a follow-up study of participants in the current study is currently underway.