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. 2019 Nov 1;35(1):360–364. doi: 10.1007/s11606-019-05393-w

Prevalence of Patient-Reported Social Risk Factors and Receipt of Assistance in Federally Funded Health Centers

Emilia De Marchis 1,✉, Matthew Pantell 2, Caroline Fichtenberg 3, Laura M Gottlieb 1,3
PMCID: PMC6957636  PMID: 31677105

INTRODUCTION

Interest in integrating social and medical care in the US health care system is growing.1 This is especially true in Bureau of Primary Healthcare (BPHC)–funded health centers, which disproportionately serve patients whose health is affected by socioeconomic disadvantage. Little is known about the prevalence of social risks2 or social care interventions in BPHC settings. The current study examines the prevalence of social risk factors and social care among patients served in BPHC-funded health centers.

METHODS

We analyzed data from the 2014 Health Center Patient Survey (HCPS), a cross-sectional survey administered by the Health Resources and Services Administration (HRSA). The HCPS was conducted with a random convenience sample of patients from health centers receiving BPHC grants, including Community Health Centers (CHCs), Migrant Health Centers (MHCs), Health Care for the Homeless (HCH), and Public Housing Primary Care (PHPC) programs. Details of HCPS sampling scheme and administration are described elsewhere.3,4 Survey data were merged with annually reported 2014 Uniform Data System (UDS) data, which include health center–reported characteristics.5

HCPS asked multiple questions related to patients’ social risks, including employment status, education level, housing stability, and household income. Patients were also asked if they had ever received social care, including assistance from their health center to obtain free medications, access medical transportation, apply for government benefits, or access other basic needs resources (e.g., housing, employment, childcare, food, or clothing/shoes). We examined patient- and health center–level predictors of both social risk and social assistance. Predictor variables from HCPS included patient sociodemographics, health status, health care utilization, clinic urbanicity, and grantee type. Health center–level predictors from UDS included proportion of total staff FTE dedicated to enabling services (non-clinical services to improve health care access and outcomes),6 panel size, and regional location.

Weighted frequencies of patient demographics, health, and social risk factors, as well as health center–reported characteristics, were calculated in the full sample, then again in only those reporting receiving assistance, stratifying by type of assistance received. Chi-squared tests were used to compare differences between stratified samples. All data analyses were conducted using Stata/SE 15.0.

RESULTS

Of the 7002 survey respondents, 4225 (60.3%) adult patients from 167 health centers had recorded responses to the measures of social risk factors or key study demographic variables and were included in the final study sample. Respondent-reported demographics, health status and health care utilization, social risk factors and social care, and health center–level characteristics are shown in Table 1. Assistance with different types of social care varied by patient and health center characteristics (Table 2).

Table 1.

Descriptors of Patient Respondents to 2014 Health Center Patient Survey (n = 4225 Patients) and Matched Bureau of Primary Health Care-Funded Health Center Characteristics (n = 167 Health Centers)

Descriptors
Unweighted (n) Weighted (%) (95% CI)
Patient-reported demographicsa
 Genderb: Female 2676 64.9 (60.4 to 69.2)
 Race/ethnicity
  Non-Hispanic White 1147 51.0 (43.2 to 58.7)
  Non-Hispanic Black 1095 21.2 (16.3 to 27.0)
  Non-Hispanic Asian 234 1.67 (0.87 to 3.18)
  Otherc 173 2.64 (1.49 to 4.65)
  Hispanic 1576 23.6 (18.1 to 30.2)
 Age
  18–45 1542 48.0 (43.0 to 54.1)
  45–65 2230 39.4 (33.7 to 45.4)
  65+ 453 12.6 (6.84 to 22.1)
 Recent immigrantd 1867 28.4 (22.9 to 34.7)
 Insurance
  Uninsured 1024 29.3 (22.5 to 37.2)
  Public 1741 41.2 (34.0 to 48.9)
  Private 1460 29.5 (23.1 to 36.8)
 Patient-reported health status/utilizationa
 Reported health status
  Excellent/very good/good 2057 55.9 (52.3 to 59.5)
  Fair/poor 2168 44.1 (40.5 to 47.7)
 Multiple chronic conditionse 2262 51.4 (46.9 to 55.8)
 Functional deficitsf 1151 26.8 (23.3 to 30.7)
 Serious mental illnessg 595 12.7 (9.83 to 16.2)
 Significant emotional distressh 705 15.0 (12.3 to 18.1)
 Lifetime drug usei 1855 46.3 (39.4 to 53.4)
 Continuity with health center
  < 6 months 507 9.87 (7.73 to 12.5)
  6 months to 1–3 years 1257 33.8 (29.5 to 38.3)
  > 3 years, < 5 years 590 14.5 (11.9 to 17.6)
  5+ years 1869 41.8 (36.1 to 47.7)
 ED utilization last 12 monthsj 2150 59.8 (45.6 to 54.0)
 Delay in medical carek 1655 40.7 (35.5 to 46.0)
 Unable to access medical carek 1574 39.3 (34.2 to 44.7)
 Delay in prescription accessl 1540 35.8 (30.9 to 41.0)
 Unable to access prescriptionl 1369 33.0 (28.8 to 37.4)
Health center–reported practice level variables
 State/regionm
  Midwest 584 20.9 (12.0 to 34.0)
  North East 720 19.7 (11.9 to 30.8)
  South 1208 30.5 (19.4 to 44.3)
  West 1713 28.8 (18.1 to 42.6)
 Urbanicitya Urban 3015 47.3 (34.7 to 60.1)
 Health center grantee typea
  Public Housing Primary Care (PHPC) 365 0.99 (0.68 to 1.44)
  Migrant Health Center (MHC) 590 3.14 (2.08 to 4.73)
  Health Care for the Homeless (HCH) 895 3.29 (2.23 to 4.82)
  Community Health Center (CHC) 2375 92.6 (90.4 to 94.3)
 Health center panel sizem
  ≤ 10k 583 16.1 (8.5 to 28.3)
  > 10k to ≤ 40k 1912 51.2 (38.4 to 63.9)
  > 40k 1730 32.7 (23.1 to 44.0)
Enabling services staffing < 10% FTEm,n 1834 51.7 (38.6 to 64.5)
Patient-reported social risk factorsa
 Unstable employmento 3104 70.3 (64.8 to 75.2)
 Unstable housingp 1866 32.1 (27.6. to 36.9)
 Education: <high school diploma/GEDq 1869 34.7 (30.4 to 39.2)
 %Federal poverty level (FPL)r
  ≤ 100 2732 57.9 (53.3 to 62.3)
  101–199 1224 32.0 (28.1 to 36.2)
  ≥ 200 269 10.1 (6.98 to 14.4)
Patient report of assistancea
 Obtaining free medications 1407 28.0 (23.5 to 33.1)
 Transportation to health center 774 11.6 (8.27 to 16.1)
 Applying for government benefits 1177 23.7 (19.5 to 28.5)
 Any basic needs 620 8.46 (6.24 to 11.4)
  Food 439 5.68 (4.15 to 7.74)
  Housing 296 2.57 (1.71 to 3.86)
  Employment 212 3.68 (2.38 to 5.67)
  Childcare 61 1.22 (0.691 to 2.16)
  Clothing/shoes 309 2.99 (1.88 to 4.72)
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aFrom 2014 Health Center Patient Survey (HCPS) dataset

bGender (biological sex at birth)

cNon-Hispanic other race (patients who selected multiple races or a specific race group with too few respondents to maintain confidentiality)

dRecent immigration (speaking non-English language at home and/or being born outside of the USA)

eMultiple chronic conditions (≥ 2 reported diagnoses of asthma, cancer, kidney disease, COPD, DM, CHF, hepatitis B or C, HIV, HLD, HTN, ischemic heart disease, stroke)

fFunctional impairment (≥ 1 difficulty with activities of daily living (ADLs))

gSerious mental illness (reported diagnosis of schizophrenia or bipolar disorder)

hHigh psychological distress in the past 30 days (score ≥ 13 on Kessler Psychological Distress Scale)

iLifetime drug use: WHO Alcohol, Smoking and Substance Involvement Screening Test (ASSIST)

jOne or more emergency department (ED) visits in past year

kNeeding medical care in the past year but experiencing delay or unmet needs

lNeeding prescription meds in the past year but experiencing delay or unmet needs

mFrom 2014 Uniform Data System

nProportion of full-time equivalents (FTEs) designated as enabling services, per UDS reporting guidelines. Absolute numbers were unavailable given the need to maintain health center anonymity. Within enabling services staffing, individual types of staff included case managers, patient and community education specialists, outreach workers, transportation workers, eligibility assistance workers, interpretation staff, and personnel performing other enabling services activities

oCurrently employed for pay vs. not

pUsually slept during the past week in either (1) in an emergency shelter, transitional shelter, or car, anywhere outside, or any other place not meant for habitation; (2) in a house, apartment, or room that they did not rent or own; (3) in their own place but moved two or more times in the past year or had been unable to pay the rent or mortgage at any time; (4) in their own place without multiple moves or difficulty paying rent/mortgage, but previously homeless versus stably housed without prior housing problems

q≥High school vs. not

rMeasure of household income

Table 2.

Percentage of Patients Who Reported Receiving Assistance from Their Bureau of Primary Health Care–Funded Health Center, by Patient Demographics, Self-Reported Health Status and Health Care Utilization, Practice-Level Characteristics, and Self-Reported Social Risk Factors

Type of reported assistance
Obtaining free medications Health center transportation Applying to government benefits With basic needs*
Unwtd† (n) Wtd‡ (%) p value§ Unwtd (n) Wtd (%) p value Unwtd (n) Wtd (%) p value Unwtd (n) Wtd (%) p value
Patient-reported demographics
 Gender
  Female 624 31.7 0.24 358 11.4 0.92 751 23.6 0.87 564 27.9 0.90
  Male 783 26.0 416 11.7 426 24.0 910 27.6
 Race/ethnicity
  Non-Hispanic White 430 27.1 0.32 191 6.3 < 0.01 287 18.9 0.01 374 22.0 0.02
 Non-Hispanic Black 446 29.4 282 24.4 283 28.8 393 34.7
  Non-Hispanic Asian 63 21.9 24 14.8 97 39.9 109 43.7
  Other 63 4.5 56 18.5 51 15.1 64 38.3
  Hispanic 405 26.9 221 10.4 459 29.4 534 31.4
 Age
  18–44 413 24.5 < 0.01 239 11.3 0.05 440 25.1 0.34 530 28.0 0.12
  45–65 894 35.9 481 13.9 640 23.8 830 30.1
  65+ 100 17.1 54 5.5 97 16.3 114 19.3
 Recent immigrant
  Yes 498 28.0 0.97 255 10.8 0.65 568 29.3 0.04 661 31.2 0.241
  No 909 28.1 519 11.9 609 21.5 813 26.3
 Insurance
  Public 588 35.8 0.01 365 18.5 < 0.01 566 28.5 0.12 693 32.0 0.53
  Private 420 21.9 245 7.5 380 19.1 470 22.2
  Uninsured 399 37.4 164 6.1 231 21.7 311 27.2
Patient-reported health status/utilization
 Reported health status
  Excellent/very good/good 606 24.2 < 0.01 342 10.1 0.15 542 22.5 0.38 679 26.8 0.53
  Fair/poor 801 33.0 432 13.5 635 25.3 795 28.9
 Multiple chronic conditions
  Yes 852 33.4 0.01 457 12.4 0.42 636 22.8 0.59 809 26.9 0.59
  No 555 22.4 317 10.7 541 24.7 665 28.6
 Functional deficits
  Yes 466 37.2 < 0.01 273 15.4 0.03 358 27.4 0.17 457 32.7 0.05
  No 941 24.7 501 10.2 819 22.4 1017 25.9
 Serious mental illness
  Yes 267 45.0 0.01 165 20.1 0.02 168 25.8 0.66 233 32.4 0.32
  No 1140 25.6 609 10.4 1009 23.4 1241 27.0
 Significant emotional distress
  Yes 287 34.7 0.12 170 20.7 < 0.01 209 28.6 0.18 274 36.4 0.03
  No 1120 26.9 604 10.0 968 22.9 1200 26.2
 Lifetime drug use
  Yes 802 35.4 < 0.01 438 14.4 0.02 559 22.6 0.55 735 26.5 0.55
  No 605 21.7 336 9.2 618 24.7 739 28.8
 Continuity at health center
  < 6 months 169 17.8 0.22 86 5.6 0.01 103 13.5 0.09 157 19.9 0.23
  6 months to 1–3 years 409 30.3 205 8.3 317 23.4 408 26.1
  > 3 years, < 5 years 213 31.5 117 11.1 177 23.3 215 26.7
  5+ years 616 27.6 366 16.0 479 26.2 693 30.9
 Emergency department utilization last 12 months
  Yes 818 32.5 0.04 481 14.0 0.01 660 26.5 0.04 848 30.2 0.10
  No 589 23.6 293 9.3 517 21.0 626 25.3
 Delay in medical care
  Yes 461 20.5 < 0.01 265 10.7 0.62 425 23.7 0.97 522 26.2 0.45
  No 946 33.2 509 12.2 752 23.8 952 28.8
 Unable to access medical care
  Yes 453 21.5 0.01 259 11.5 0.96 405 23.7 0.99 503 26.3 0.55
  No 954 32.3 515 11.7 772 23.8 971 28.6
 Delay in prescription access
  Yes 515 28.3 0.89 292 11.7 0.96 434 26.7 0.16 559 31.4 0.14
  No 892 27.9 482 11.6 743 22.1 915 25.7
 Unable to access prescription
  Yes 457 30.0 0.46 261 10.7 0.60 382 25.7 0.29 484 30.2 0.24
  No 950 27.1 513 12.0 795 22.8 990 26.5
Health center–reported practice level variables
 Region
  North East 221 24.7 0.53 205 24.1 < 0.01 226 32.2 0.15 289 37.3 0.08
  South 386 27.5 151 4.3 209 18.9 283 20.9
  Midwest 236 34.0 152 15.0 183 20.0 237 24.1
  West 564 26.6 266 8.3 559 25.8 665 31.0
 Urbanicity
  Urban 1053 28.7 0.78 595 18.5 < 0.01 865 27.6 0.09 1102 32.1 0.07
  Rural 354 27.4 179 5.39 312 20.3 372 23.8
 Health center type
  PHPC 119 35.4 < 0.01 73 21.4 < 0.01 106 28.2 < 0.01 128 34.5 < 0.01
  MHC 124 16.9 87 12.6 165 29.1 190 32.2
  HCH 536 62.9 336 39.9 313 36.6 457 53.1
  CHC 628 27.1 278 10.5 593 23 699 26.6
 Health center panel size
  ≤ 10k 225 33.7 0.53 112 11.0 0.45 169 21.8 0.47 214 31.0 0.56
  > 10k to ≤ 40k 648 27.7 340 9.5 527 22.0 672 25.4
  > 40k 534 25.8 322 15.3 481 27.4 588 29.7
 Enabling services < 10% FTE
  < 10% 536 23.6 0.06 301 9.0 0.14 441 18.5 0.02 556 21.0 < 0.01
  ≥ 10% 871 32.8 473 14.4 736 29.3 918 34.9
Patient reported social risk factors
 Unstable job
  Yes 1103 28.0 0.96 646 12.6 0.21 886 23.8 0.98 1126 27.4 0.75
  No 304 28.2 128 9.2 291 23.7 348 28.6
 Unstable housing
  Yes 858 38.5 < 0.01 493 16.4 < 0.01 575 26.1 0.35 793 33.0 0.04
  No 549 23.1 281 9.4 602 22.6 681 25.2
 Education: < high school diploma/ GED
  Yes 592 26.7 0.52 359 13.2 0.32 518 24.5 0.77 647 28.4 0.80
  No 815 28.8 415 10.8 659 23.3 827 27.4
 %Federal poverty level (FPL)
  ≤ 100 1002 27.7 0.13 587 14.3 0.05 794 25.9 0.01 1026 30.9 < 0.01
  101–199 338 31.6 155 7.3 325 23.9 383 27.0
  ≥ 200 67 18.5 32 10.1 58 10.4 65 11.5
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*Basic needs assistance with housing, job, food, childcare, clothing/shoes

†Untd unweighted

‡Wtd weighted

§Two-tailed p values obtained from weighted chi-square analyses comparing differences in patients who reported receiving assistance from their health center vs. those who did not report assistance. When variables have multiple categories, p values reflect between-group differences across all categories

DISCUSSION

This study is the first to evaluate the prevalence of patient-reported social risk factors and delivery of social care in a nationally representative sample of federally funded health centers. The population surveyed reported relatively high levels of social risks and low levels of assistance. Patients primarily reported receiving assistance with health care access and other medical care–related social risks, like transportation. Fewer patients reported assistance around basic material needs like food or housing. Receiving assistance varied by sociodemographic, health care utilization, and health center characteristics. In general, higher proportions of patients with poorer health status reported assistance accessing medical transportation and obtaining free medications. At the health center level, patients of clinics with more enabling services staffing reported receiving more assistance with basic material needs resources.

The HCPS survey design should influence the interpretation of these findings. The cross-sectional survey relied entirely on patient-reported health indicators. Questions about assistance were not temporally bounded (e.g., “Have you ever received assistance with...”), nor did they have a corresponding question about whether the patient perceived a need for assistance. Additionally, questions about applying for benefits were ambiguous, but likely mostly pertained to enrolling in health insurance. Despite these limitations, the survey is a useful indicator of the prevalence of social risk factors and delivery of social care in federally funded health centers. We found that delivery of social care is uneven across health center settings, driven both by patient- and health center–level variables. This may suggest that equally complex patients may receive different services in different settings. As interest grows around integrated social and medical care delivery, policy innovations can use data about the prevalence of social risk and availability of social care initiatives to improve comprehensive health programs.

Acknowledgments

We would like to thank the Data Analytics Team within the Data and Evaluation Division in the Bureau of Primary Health Care at HRSA for their support.

Funding Information

This publication was supported by the Robert Wood Johnson Foundation (RWJF) and a fellowship training grant by the National Research Service Award (NRSA) T32HP19025. Its contents are solely the responsibility of the authors and do not represent the official views of the RWJF or NRSA.

Compliance with Ethical Standards

Conflict of Interest

The authors declare that they do not have a conflict of interest.

Footnotes

Prior presentations:

We presented an earlier version of the manuscript as a poster at Academy Health in Seattle, WA, on June 24, 2018, and as an oral presentation at the North American Primary Care Research Group in Chicago, IL, on November 12, 2018.

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References

Articles from Journal of General Internal Medicine are provided here courtesy of Society of General Internal Medicine

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