Published in 2021

Addressing Social Determinants of Health Identified by Systemic Screening in a Medicaid Accountable Care Organization: A Qualitative Study

Julia Browne, Jessica L. McCurley, Vicki Fung, Douglas E. Levy, Cheryl R. Clark, Anne N. Thorndike Journal of Primary Care & Community Health. 2021; 12: 1-8.

In March 2018, Mass General Brigham began screening all Medicaid patients for social determinants of health (e.g., difficulty accessing food, lack of stable housing, unemployment, etc.) with the goal of connecting patients facing these challenges to community resources. To explore the factors that were both helping and hindering the success of the new system-wide effort, we interviewed fifteen staff members across five community health centers between January and March 2020. The staff members interviewed were responsible for contacting patients who reported having at least one of the social determinants of health (e.g., food insecurity) on the screening questionnaire and providing them with resource referrals.

Through the interviews, we found that maintaining updated community resource lists, being able to collaborate with community organizations, having supportive leaders, and developing trusting relationships were important for successful referrals of patients to community resources. On the other hand, we also found multiple obstacles that made it more difficult to connect patients to these community resources. These obstacles included high patient caseloads for resource staff, time constraints, inefficiencies in tracking referrals within the electronic medical record, and lack of some community resources. In addition to these barriers, resource staff described the often-overlooked psychological toll of their job, which could impact patient care and lead to staff burnout. Overall, these results highlighted health system, community, and individual-level factors that healthcare organizations should consider when addressing social determinants of health.

The full-length article can be viewed at this link

Published in 2022

COVID-19 stressors and one-year changes in depression and anxiety in a longitudinal cohort of low-income adults in the United States

Anne N. Thorndike, Vicki Fung, Jessica L. McCurley, Cheryl R. Clark, Sydney Howard, Douglas E. Levy

Although the COVID-19 pandemic has affected everyone, people with low income are at particularly high risk for COVID-19-related stressors (like losing a job, having food insecurity, or being unable to isolate if they have a COVID-19) and are also at high risk for depression and anxiety. In this study, we determined if adults who experienced more COVID-19 stressors had worsening depression and anxiety symptoms one year after the start of the pandemic. We analyzed data from 253 LiveWell participants who enrolled from December 2019 to March 2020 before the start of the pandemic. These participants each completed a baseline survey when they enrolled and another survey one year after they enrolled.  Both surveys included questions about depression and anxiety. One-year follow-up surveys also included questions about 19 different COVID-19 stressors (including infectious, social, and economic stressors) experienced by participants during the first year of the pandemic. We found that food insecurity and loss of job or income were the most common COVID-19-related stressors experienced by participants in the LiveWell study. Participants who experienced a higher number of COVID-19-related stressors had increased depression and anxiety symptoms after one year compared to those who experienced the lowest number of stressors. These results underscore the urgent need for interventions to address the dual burden of health-related social needs and poor mental health, both of which have been exacerbated by the COVID-19 pandemic.

The full-length article can be viewed at this link.

Social Determinants of Health and Hypertension Control in Adults with Medicaid

Ross Sonnenblick, Alexa Reilly, Karina Roye, Jessica L. McCurley, Douglas E. Levy, Vicki Fung, Sydney Howard McGovern, Cheryl R. Clark, Anne N. Thorndike

Social determinants of health (SDOH), such as difficulty accessing food, lack of stable housing, and unemployment, are linked to cardiovascular disease, but little is known about how that relationship works. We hypothesized that SDOH would be associated with uncontrolled hypertension in adults with Medicaid insurance. We collected data from adults with Medicaid who had hypertension diagnoses, received regular care at community health centers, and were enrolled in the LiveWell study. Surveys collected demographics and measures of food insecurity, housing stability, cost-related medication underuse, and financial stress. Blood pressure (BP) measurements after survey completion were obtained from health records. Participants were categorized as having controlled, uncontrolled, or unknown hypertension control. We then examined the association of SDOH (food insecurity, unstable housing, cost-related medication underuse, and financial stress) with uncontrolled hypertension and unknown hypertension control.

Overall, 58% of the participants reported food insecurity, 38% had unstable housing, 29% had financial stress, and 20% reported cost-related medication underuse. A fourth of the participants from whom we were able to collect BP measurements had uncontrolled hypertension. In multivariable models, neither individual nor cumulative SDOH were associated with uncontrolled hypertension or unknown hypertension control. In summary, we found that in a Medicaid-insured population receiving care at community health centers adverse SDOH were common but were not associated with hypertension control. Further research is needed to help understand mechanisms of how SDOH may lead to cardiovascular disease.

The full-length article can be viewed at this link.

Published in 2023

Food Insecurity and Diet Quality Among Adults on Medicaid With and Without a Mental Illness Diagnosis

Emma Anderson, Jessica L McCurley, Ross Sonnenblick, Sydney McGovern, Vicki Fung, Douglas E Levy, Cheryl R Clark, Anne N Thorndike

Prior research has shown that adults with mental illnesses are more likely to have low income and diet-related chronic diseases. To further understand this, this study examined associations of food insecurity and diet quality with mental illness diagnoses in adults with Medicaid. We conducted an analysis of data collected as part of the LiveWell study in its baseline year. Food security was measured on the LiveWell surveys, and Healthy Eating Index (HEI) scores were calculated from 24-hour dietary recalls. These scores measure how much a person’s diet aligns with U.S. dietary recommendations. We categorized participants as having mental illness diagnoses if they had anxiety, depression, or serious mental illness (e.g., schizophrenia, bipolar disorder) documented in their electronic health records.

Results found that fewer than half of participants reported high food security, with almost one third reporting low or very low food security. Overall, 40% of participants had one or more mental illness diagnosis. Those with a mental illness diagnosis were more likely to have food insecurity bit had similar HEI scores compared with participants with no mental illness diagnosis. The mean adjusted HEI scores did not significantly differ by food security status for those with or without a mental illness diagnosis. In conclusion, in this sample of adults on Medicaid, those with mental illness diagnoses experience a high rate of food insecurity. Overall, diet quality among all participants was low but did not differ by mental illness diagnosis or food security status. These results highlight the importance of increasing efforts to improve both food security and diet quality among all Medicaid participants.

The full-length article can be viewed at this link.

Assessment of the Massachusetts Flexible Services Program to Address Food and Housing Insecurity in a Medicaid Accountable Care Organization

Jessica L. McCurley, PhD, MPH; Vicki Fung, PhD; Douglas E. Levy, PhD; Sydney McGovern, MS; Christine Vogeli, PhD; Cheryl R. Clark, MD, ScD; Stephen Bartels, MD; Anne N. Thorndike, MD, MPH

This article sought to answer the question: What were the initial implementation challenges and solutions for a Medicaid accountable care organization participating in the Massachusetts Flexible Services program to address food and housing insecurity?

In this mixed methods study, we examined challenges and solutions in the initial implementation of the Massachusetts Flexible Services Program in a Medicaid accountable care organization (ACO). The Flexible Services Program addresses food and housing insecurity by connecting Medicaid ACO enrollees to community resources.

We found that among the 67,098 ACO enrollees, 57% completed at least 1 social needs screening; 16% screened positive for food insecurity and 11% for housing insecurity. There were 658 (1.6%) adults and 173 (0.7%) children (<21 years) enrolled in Flex; of these, 74% were female, 53% were Hispanic/Latinx, and 21% were Black. Most Flex enrollees (89% adults; 83% children) received the intended nutrition or housing services. Implementation challenges identified by staff interviewed included: administrative burden, coordination with community organizations, data and information sharing, and COVID-19 factors (e.g., reduced clinical visits). Implementation challenges included administrative burden, COVID-19 factors that influenced screening for social needs, data tracking and sharing, and coordinating with community organizations. Solutions included administrative funding for hiring enrollment staff, bidirectional communication with community partners, new strategies to identify eligible patients, and raising clinician awareness of the Massachusetts Flexible Services program. In Flex enrollee interviews, those receiving nutrition services reported increased healthy eating and food security; they also reported higher program satisfaction than Flex enrollees receiving housing services. Enrollees who received nutrition services that allowed for selecting food based on preferences reported higher satisfaction than those not able to select food.

Findings of this research suggests that future state and health systems’ programs to address health-related social needs may benefit from minimizing administrative burden, providing funding for enrollment staff and evaluation, and developing effective information-sharing platforms.

The full-length article can be viewed at this link.