Meeting patients' socioeconomic needs can improve cardiovascular risk factors

"We know that unmet basic resource needs for things like nutritious food, housing, transportation and medication are very common and are associated with poor health outcomes," says Seth A. Berkowitz, MD, MPH, of the MGH Division of General Internal Medicine, corresponding author of the report published in JAMA Internal Medicine. "We've offered the Health Leads program at several of our internal medicine practices for the past few years, but we did not yet know whether this strategy for addressing patients unmet needs would lead to changes in clinical outcomes."

The current study is a follow-up to one reported in a December 2015 paper in BMJ Quality & Safety . In that investigation, Berkowitz and his colleagues showed that screening primary care patients for unmet social needs through a simple survey and referring those expressing a desire for help to Health Leads advocates located in the practices connected patients with local services that helped meet the identified needs of most participants. That study ran only seven months and was not long enough to evaluate whether meeting those needs had any clinical effects, something the current study was designed to investigate.

Primary care patients seen at three MGH primary care practices -- including the two involved in the 2015 study -- from October 2013 through April 2015 were surveyed regarding their desire for assistance with needs like paying for healthy food, prescription medicine or utility bills; finding a job or receiving assistance for housing or other financial needs. Of more than 5,000 screened patients, 1,774 had at least one unmet need, and 1,021 of them agreed to enroll in the Health Leads program. Patients with unmet needs were more likely to be members of racial or ethnic minorities and to have less than a high school education, a primary language other than English and Medicaid coverage.

Patients participating in the Health Leads program had an average of five contacts with their advocates and cases were open for an average of six weeks. At the end of the study period, almost 60 percent of the identified needs either had been met or patients indicated no longer needing help. While around 35 percent of cases were classified as unsuccessful, more than 93 percent of those involved patients who stopped responding to contacts from their Health Leads advocates.

Based on a review of medical records for all screened patients -- those with unmet needs who enrolled in Health Leads, those with unmet needs who did not enroll in Health Leads and those for whom no unmet needs were identified -- Health Leads participants with hypertension had greater reductions in both systolic and diastolic blood pressure than did patients with hypertension not enrolled in Health Leads. Participants with elevated LDL cholesterol levels who enrolled in Health Leads also saw greater improvement. But no significant differences were seen in the HbA1c levels of Health Leads participants with diabetes.

"While we don't know why there was no effect on blood sugar levels for participants with diabetes, improving dietary quality is probably the most important factor for improving HbA1c," says Berkowitz, who is an instructor in Medicine at Harvard Medical School. "It's possible that the resources people can be linked to for food are not as robust as are those assisting with medication, which is more important for blood pressure and cholesterol control. We do plan future studies to determine whether the program can be modified to better address blood sugar control and, eventually, whether these risk factor improvements actually reduce cardiovascular events."

Rocco Perla, president of Health Leads and previously a senior official with the U.S. Centers for Medicare & Medicaid Services, says, "This study is one of the first to draw a positive association between social needs interventions and clinical outcomes and illuminates the potential impact of these programs across the health system on quality, cost and health. Dr. Berkowitz and MGH are among a growing group of leading, forward-thinking researchers who are building the much-needed evidence base around social needs interventions, and Health Leads is committed to supporting these efforts."