Social and Behavioral Determinants of Health in High-Risk Veterans

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Background. Social factors exert a substantially more potent impact on health than does health care, especially among disadvantaged populations such as VA users. Adverse social determinants of health (SDH)—factors such as housing instability, food insecurity, social isolation, and transportation barriers—are linked to problems with access, poorer clinical outcomes, and increased health care costs. Despite the clinical and business case for integrating SDHs into health care, these factors are not systematically assessed or addressed in clinical settings. Significance/Impact. This study will leverage a previous survey of Veterans at high-risk for hospitalization, and a new survey to be fielded to a nationally-representative sample of Veterans, to determine how SDHs influence clinical, health care utilization, and experience outcomes. Review of findings by key stakeholders will generate recommended SDH measures for universal screening within VA. These steps, coupled with qualitative interviews about implementation challenges, will inform the future integration of high-value patient-reported SDH measures into VA’s health record. Innovation. The proposed work is innovative in its evaluation of a broad array of SDHs in high-need Veterans to identify candidate measures for electronic health record (EHR) integration. The study will leverage a theoretically-driven survey of SDH measures with a data-driven approach to identifying the associations between these SDHs and a range of health, utilization, and patient experience outcomes. Results from these analyses will inform a facilitated deliberative process to prioritize high-value, validated, and actionable measures that are predictive of outcomes that are important to Veterans and the VA. Specific Aims. In Aim 1, we will use data from an Office of Primary Care-funded survey of Veterans at high-risk for hospitalization to examine relationships between patient-reported SDH measures and utilization, cost, and days in the community outcomes. In Aim 2, we will field a survey to a nationally-representative sample of VA patients to determine the association between SDH measures and key outcomes, and to examine the prevalence of SDHs in subpopulations of Veterans who are disproportionately affected by disparities (e.g., women, racial/ethnic minorities, and rural Veterans). Aims 1 and 2 will inform partner and stakeholder discussions in Aim 3 to identify measures that are associated with key outcomes and that are perceived by operations partners as actionable (i.e., addressable through VA or community services) and thereby good candidates for EHR integration. Methodology. In Aim 1, we will leverage data from an operations-funded survey that our team administered in 2018. Using survey data for 4,685 Veterans at high-risk for hospitalization, we will examine the association between patient-reported SDHs and utilization (i.e., VA and Medicare emergency department visits and hospitalizations), VA and Medicare costs, and days in the community. In Aim 2, we will field a similar survey to a nationally-representative sample of Veterans, evaluate the association between SDHs, patient experiences (e.g., perceived access and coordination), and 12-month VA emergency department visits, hospitalizations, and costs, and describe the prevalence of SDHs in the general VA population and Veterans who are at risk for health disparities. In Aim 3, we will use a facilitated deliberative process with key stakeholders to prioritize actionable SDH measures for EHR integration, and then conduct qualitative interviews with health system leaders, clinicians, staff, and patients to examine implementation barriers and facilitators to assessing select SDH measures at point of care. Implementation/Next Steps. This study addresses health equity, particularly relevant in light of COVID-19, and will be conducted with partners from VA’s Offices of Primary Care, Health Equity, Rural Health, and Women’s Health. The study is especially timely with VA’s transition to the new Cerner EHR as the proposed aims will identify SDH measures for potential EHR integration that are concise, actionable, and predictive of important outcomes.