Health-Related Social Needs Linked to Higher ED Use

Five of 6 baseline health-related social needs (HSRNs) were found to be associated with higher odds of an emergency department visit, leading researchers to encourage health care systems to redistribute resources to target disadvantaged populations, according to a new study published in JAMA Network Open.¹

HSRNs—an individual’s unmet needs that also impact their health—include stable, affordable housing, access to healthy food and transportation, and interpersonal safety; they are often manifested by social determinants of health, which encompass broader factors like societal, environmental, and economic structures.^1,2 Prior research has associated HSRNs with various forms of health care utilization, including an increase in emergency department (ED) visits and postponed medications linked to housing instability, missed well-child visits linked to food insecurity, and increased ED, primary care, and specialty care visits linked to physical abuse. Studies have also shown a decrease in ED visits among unhoused patients who were given housing services and meal delivery services for vulnerable adults.¹ Yet, there is limited evidence supporting HSRNs' association with health care utilization in the context of a large health system assessing the impact of health care interventions.

This study was a 5-year pilot cohort funded by CMS and conducted from June 5, 2018, to January 31, 2022, using data from Allina Health, a nonprofit health system serving Minnesota and western Wisconsin. Patients insured by Medicaid or Medicare at 79 primary care providers were screened for HSRNs under CMS’ Accountable Health Communities (AHC) model. The AHC tool assessed HSRNs in 5 domains:

• Housing: instability and quality
• Food security: worries about running out or having no money to get more
• Transportation: unreliability
• Utilities: the company threatened to shut off service
• Interpersonal safety: physical or verbal abuse from anyone

The investigators classified housing stability and housing quality (eg, pests, mold, leaks) separately, leading to 6 total HSRNs in their analysis. Patients who identified HSRNs were provided a community referral summary consisting of community resources tailored to their needs. Patients were categorized as high risk if they screened positive for HSRNs and self-reported 2 or more ED visits in the last year.

Patients Impacted by HSRNs

There were 166,682 patients screened for HSRNs during the study. Of them, 43.5% were 65 years and older, and 60.3% were women. Furthermore, 0.6% identified as American Indian or Alaskan Native, 3.9% as Asian or Pacific Islander, 12% as Black, 5.6% as Hispanic or Latino, 73% as White, 1.7% as multiracial, and 3.3% declined to answer or were missing race or ethnicity data.

At baseline, 24.3% of patients screened identified 1 or more HSRN. The prevalence of needs ranged from 1.4% for interpersonal safety (n = 2365) to 14.5% for food security (n = 24,106). Groups with a high prevalence of HSRNs included multiracial or American Indian patients, patients aged 18 to 44 years or 45 to 64 years, those dually insured by Medicaid and Medicare, and Spanish speakers. HSRNs were also more common among those with chronic diseases or conditions like asthma, depression, chronic liver disease, alcohol abuse, and substance abuse.

The findings showed a higher proportion of patients utilizing ED and inpatient services if they identified 1 or more needs at baseline compared with those without needs. Of patients who reported housing instability, 26.9% (2006 of 7463) had an ED visit in the 6 months prior to screening compared with 14.3% (22,695 of 159,219) of those without this need. Of patients who reported unreliable transportation, 25.6% of patients (3512 of 13,716) with transportation needs had an ED visit in the prior 6 months compared with 13.9% of patients (21,189 of 152,966) without this need. Patients reporting interpersonal safety needs had the highest prevalence of ED use in the last 6 months (27.7% [656 of 2365]) compared with 14.6% (24,045 of 164,317) of those without a safety need.

After adjustment for other HSRNs, demographic characteristics, and health conditions, only housing stability (OR, 1.34; 95% CI, 1.23-1.47) and transportation (OR, 1.16; 95% CI, 1.08-1.24) remained associated with an increase in inpatient utilization. The highest rates of ED use were also observed for transportation (OR, 1.31; 95% CI, 1.25-1.38) and housing stability (OR, 1.25; 95% CI, 1.18-1.33).

Health Care Interventions Addressing HSRNs to Alleviate ED and Inpatient Utilization

Out of the 166,682 patients who tested positive for HSRNs, 15,139 were included in the longitudinal analysis of HSRN resolution and received a community referral summary. The mean time between baseline and follow-up AHC screening was 13.6 months. Of them, 57.1% had fewer needs at follow-up screening, 26.8% had the same number of needs, and 16.1% had more needs. Resolution by HSRN was highest for those reporting interpersonal safety at baseline; by follow-up, 72.1% no longer reported this need, followed by 62.8% no longer reporting housing quality, 62.7% no longer reporting unreliable transportation, and 48.5% no longer reporting food insecurity.

The study was limited, as it relied on broad, heterogeneous, and self-reported screening tools, thus limiting accuracy in assessing HSRN severity and association with outcomes. Not all patients who identified needs at baseline had follow-up screenings, which could bias findings on need resolution and health care utilization. Additionally, small sample sizes for certain needs and uncertain timing or resolution reduced the strength of some analyses.

“This finding highlights the need to continue to strategize within health care settings about the best way to integrate services and partnerships to address HRSNs and to identify the best methods to address needs,” the study authors concluded. “By better understanding how HRSNs are associated with health care utilization, health systems can focus their resources on targets that are most meaningful for their patient populations.”

References

1. Sidebottom AC, Martins S, Vacquier MC, Dechaine C, Behrens D. Health-related social needs and health care utilization in the Accountable Health Communities model. JAMA Netw Open. 2025;8(12):e2548036. doi:10.1001/jamanetworkopen.2025.48036

2. McCrear S, Escudier S. Overcoming SDOH barriers in cancer care: Susan Escudier, MD. AJMC^®. October 22, 2025. Accessed December 16, 2025. https://www.ajmc.com/view/overcoming-sdoh-barriers-in-cancer-care-susan-escudier-md