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A life-changing illness caused by a genetic predisposition or an unhealthy lifestyle choice can hurl an individual’s life into an unexpected and sudden flurry of motion. But for some, it’s a slower build caused by social factors such as food insecurity or lack of transportation.

“My team encountered a patient who had been in the emergency department 50 times over the course of a year because he was diabetic and not getting the food he needed,” says Linda Highfield, PhD, principal investigator of an innovative project to address social factors that affect the health of Medicare and Medicaid beneficiaries in Harris County. Along with one of the highest uninsured rates in the nation, Harris County has a poverty rate of nearly 17%.

“What motivated me to focus on public health was recognizing that where people live and how they live affects their health,” explains Highfield, adding that 80% of health outcomes are driven by factors outside of health care. “If you don’t have food or a stable home, you can’t be healthy.”

Led by Highfield and funded by the Centers for Medicare & Medicaid Services—part of the United States Department of Health and Human  Services—the five-year project began in 2017 at UTHealth School of Public Health in partnership with community and clinical partners, including UT Physicians, Memorial Hermann-Texas Medical Center, and Harris Health System.

The team began by building an electronic questionnaire to assess five social determinants of health: housing insecurity, food insecurity, transportation, interpersonal violence, and ability to pay utility bills. The questionnaire is designed to not disrupt the current workflow of clinical sites and to automate processes as much as possible.

When a patient is scored as high risk for poor health outcomes on the questionnaire at any of the partner clinical sites, the health care team seamlessly accesses a database of 550 resources in Harris County. Thanks to geographic information system software, they are able to identify resources closest to the patient and find organizations that provide more than one resource at a time, increasing the efficiency and likelihood of the patient completing social services.

“We are seeing about 40% of our patients are at high risk,” explains Highfield. Since switching to the new system, Highfield says the research team’s productivity has increased six-fold.

By December 2019, Highfield’s team screened approximately 6,400 beneficiaries. Nearly 45% were identified as having a social need and referred to community resources.

Furthermore, the system was built to be easily scalable across the nation with the majority of the work involving the creation of the local community’s resource list. “We have received a lot of requests from other groups wanting to expand the project, particularly in rural parts of the community,” says Highfield. “It’s far less costly and more efficient to address health issues upstream, and we can get a much better return on investment.”

But it is the individuals who truly inspire Highfield and her team. “While in the emergency department, we screened a Medicaid patient who had been on her way to her husband’s funeral when she was involved in a vehicular accident,” shares Highfield.

Using the project’s system, Highfield and her team uncovered that the patient was deeply concerned about her living situation, food, and transportation now that her husband was deceased. She did not know how she could remain in her current home, which was in need of repairs, or  how she would continue to get food.

“Our team spent the next several months working through the fragmented system of local organizations to get nearby agencies to repair her home on multiple occasions and to connect her with food assistance,” says Highfield. “Her story is one of many that keep me going every day.”

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Using a portable electronic questionnaire, Linda Highfield, PhD, trains health care workers to assess social factors that may affect their patients’ health.