Kaiser Permanente study finds patients with social needs are up to 30% more likely to be hospitalized, go to the emergency department, or receive a mental health visit
Kaiser Permanente finds that one in five patients with multiple medical diagnoses also has social risks that increase their chances of being hospitalized, going to the emergency room, or needing mental health care. A new study has revealed this.
“We know that medically complex patients, those with two or more chronic conditions, utilize a disproportionate amount of health care services,” said lead author Kaiser Permanente Research Division Delivery said Dr. Emma L. Tucher, Science Fellow. “The message from our study is that there is a complex subgroup of patients with social risks, and this population has high health care utilization, as these patients can be identified through electronic health records. Opportunities arise to address societal risks and potentially improve outcomes.”
the studyHighly medically complex patients at social risk are more likely to be hospitalized or readmitted or treated in the emergency department than similar patients without social risk, according to a paper published in JAMA Network Open. It turns out that the probability is 20% higher. These patients were also 30% more likely to see a mental health professional. Patients with moderate medical complexity and social risk had 20% higher odds of hospitalization, emergency department visit, and mental health consultation compared to similar patients without social risk.
Impact of social risks
National surveys of health care utilization show that medically complex patients incur significantly higher costs to the health care system than other patients. This new study examines whether medically complex patients with social risks such as financial burden, housing instability, and food insecurity use more services than patients without social risks. Evaluated.
The study involved 97,252 adult members of Kaiser Permanente Northern California (KPNC) who were identified as medically complex through electronic medical records. To get a more accurate picture, the research team categorized patients as having moderate or high medical complexity.
The patients we studied are in the top 5% of health care complexities.
— Dr. Emma L. Tucher
“The patients we studied are in the top 5% of health care complexities,” Tucher said. “But we also wanted to know whether there were differences in social risk for people with more complex medical conditions. The most medically complex patients are more likely to be older; We felt this was important because we knew that younger, medically complex patients were more likely to require different types of interventions.”
Moderately complex patients had multiple medical conditions, were at high risk of hospitalization, and had more than one previous ED admission. Highly complex patients meet these criteria: are prescribed at least seven or high-risk medications, have at least one uncontrolled health condition, have a history of falls, or have fallen. patients who are at risk for or who require medical equipment at home or in a nursing home.
The study measured inpatient visits and readmissions, emergency department use, and outpatient visits to primary care providers, specialists, or mental health providers over a 12-month period from January 2023 to January 2024. Analyzed. Researchers identified 27,827 moderately medically complex patients in the overall group. Patients; 18.2% were at social risk. There were 69,425 medically complex patients. 25% had social risks. Overall, patients most likely to have social risks were women, people who were black or Hispanic, and people eligible for Medicaid.
“The increased risk of emergency department visits and hospitalizations among patients with co-occurring social needs highlights the important role that social needs play in the health of the most complex patients.” said senior author Richard Grant, MD, MPH. research department and Permanente Medical Group Regional Director of Complex Needs Research and Evaluation. “Our results support the value of Kaiser Permanente’s efforts to address unmet societal needs to improve clinical outcomes.”
Grant recently received $4 million from the Patient-Centered Outcomes Research Institute (PCORI) Comparing ways to address the social needs of adults with multiple chronic conditions.
Kaiser Permanente and other health care providers are investing in programs that coordinate care, connect individuals to resources, and provide health education and health management. The results of the new study will contribute to ongoing efforts to identify and address social risks for patients.
“Our research shows that there are certain characteristics of social risk in electronic health records that help identify patients at social risk, making it the first place to get help for patients. “It will be a step forward,” Tucher said.
This research was funded by the Kaiser Permanente Northern California Research Offered Science Fellowship Program.
Co-authors include Alison L. Steele, MPH; Connie S. Uraz, RN, MS, PHN. Jody K. McCloskey MPH, Research Department;
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About Kaiser Permanente Research Department
Kaiser Permanente’s Research Division conducts, publishes, and disseminates epidemiology and health services research to improve the health and health care of Kaiser Permanente members and society as a whole. We aim to understand the determinants of disease and health and improve the quality and cost-effectiveness of healthcare. Currently, DOR’s more than 600 staff members are working on more than 450 epidemiology and health services research projects. For more information, visit divisionofresearch.kaiserpermanente.org or follow @KPDOR.
