1318 addressing social determinants of health in people experiencing homelessness: Determining change in healthcare access

Objectives: The objectives of this study are 1) to evaluate the change in insurance coverage rates in people experiencing homelessness (PEH) when community health workers (CHWs) intervene, and 2) to identify the change in insurance benefits usage, including access to a primary care provider (PCP), CalFresh, transportation services, prescription medication benefits, and/or housing benefits. Homelessness is an ongoing issue worldwide where PEH are generally associated with a higher risk of poor health outcomes due to limited access to resources. One of the main barriers identified with this population is the lack of addressing certain aspects of social determinants of health (SDOH), particularly healthcare access. PEH often struggle to access care due to limited knowledge in navigating the healthcare system. While many community outreach providers support patients in obtaining healthcare services, barriers to effective care persist due to lack of provider training in addressing SDOH. Having trained individuals with dedicated resources to assist PEH in overcoming these barriers would greatly improve their access to essential healthcare services. HOPE Outreach is a pharmacist-led non-profit community outreach program that aims to close the gap in healthcare for PEH. A challenge faced by providers in this program is patient reluctance to receive care, which stems from an absence of trust and competing priorities for other needs. However, CHWs can play a crucial role in addressing these issues and meeting the various needs of the community through their alignment and shared experiences. Existing literature highlights that CHWs have been effective in improving trust and engagement, which are critical to overcoming barriers in pharmacy services. CHWs have also been shown to facilitate better communication between patients and providers, support medication adherence, and help address cultural barriers to care. These outcomes highlight their potential value in bridging gaps in pharmacy services for PEH. Further investigation is needed to assess whether integrating CHWs into a pharmacy team can improve healthcare outcomes and effectively address the various SDOH barriers. 

Methods: The design is a pre-post survey-based study to determine changes in insurance coverage and insurance benefits usage in PEH. The study will be conducted at HOPE Outreach events in Los Angeles County, California. These events will occur 1-2 times weekly, with the total time frame of 7 months (from October 2024-April 2025). The target sample size is 34 patients, which was determined using the G Power sample size calculator with alpha of 0.05, power of 80%, and a medium effect size of 0.5. We aim to include 50 patients to account for attrition and potential loss to follow-up. Data collection will continue until the end of the study period (April 2025) to allow for proper follow-up visits with the participants. The study inclusion criteria will be PEH who are 18 years and older and English/Spanish speaking. Participants will be given a pre-intervention paper-based survey to identify barriers to healthcare access and the likelihood of using different insurance benefits. The intervention phase will involve training CHWs and having them address the healthcare access barriers related to SDOH. Two months after the intervention, the investigators will determine insurance coverage success rate through the Medi-Cal provider portal. Three months after the intervention, participants will be given the post-intervention survey. This survey will be similar to the pre-intervention survey to assess the changes in barriers, interest in using insurance benefits, and access to healthcare services. The survey is available in English and Spanish; both versions have been validated and IRB approved. The pre-intervention survey consists of 11 questions that address current healthcare access and barriers while the post-intervention survey consists of 6 questions that determine changes in healthcare access and insurance benefits usage. Descriptive analysis will be used to study the participants’ demographics and survey responses (objective 2). An independent t-test will be conducted to assess the difference in Medi-Cal enrollment rates pre- and post-intervention (objective 1). 

Results: In progress. 

Conclusions/Implications: In progress, pending results. Integrating CHWs into pharmacy teams has the potential to significantly improve health outcomes for people experiencing homelessness by addressing key healthcare access barriers, such as low insurance coverage and underutilization of insurance benefits. If this project is successful, it can serve as a model for replication in other outreach initiatives, providing CHWs with the training to assist diverse populations who face similar challenges. By bridging gaps in healthcare access and providing personalized support, CHWs can foster equitable healthcare delivery, ensuring that underserved populations receive the care they need to improve their overall health and well-being.