Comparison of community-level and patient-level social risk data in a network of community health centers

Importance: Responding to the substantial research on the relationship between social risk factors and health, enthusiasm has grown around social risk screening in health care settings, and numerous US health systems are experimenting with social risk screening initiatives. In the absence of standard social risk screening recommendations, some health systems are exploring using publicly available community-level data to identify patients who live in the most vulnerable communities as a way to characterize patient social and economic contexts, identify patients with potential social risks, and/or to target social risk screening efforts.

Objective: To explore the utility of community-level data for accurately identifying patients with social risks by comparing the social deprivation index score for the census tract where a patient lives with patient-level social risk screening data.

Design, setting, and participants: Cross-sectional study using patient-level social risk screening data from the electronic health records of a national network of community health centers between June 24, 2016, and November 15, 2018, linked to geocoded community-level data from publicly available sources. Eligible patients were those with a recorded response to social risk screening questions about food, housing, and/or financial resource strain, and a valid address of sufficient quality for geocoding.

Exposures: Social risk screening documented in the electronic health record.

Main outcomes and measures: Community-level social risk was assessed using census tract-level social deprivation index score stratified by quartile. Patient-level social risks were identified using food insecurity, housing insecurity, and financial resource strain screening responses.

Results: The final study sample included 36 578 patients from 13 US states; 22 113 (60.5%) received public insurance, 21 181 (57.9%) were female, 17 578 (48.1%) were White, and 10 918 (29.8%) were Black. Although 6516 (60.0%) of those with at least 1 social risk factor were in the most deprived quartile of census tracts, patients with social risk factors lived in all census tracts. Overall, the accuracy of the community-level data for identifying patients with and without social risks was 48.0%.

Conclusions and relevance: Although there is overlap, patient-level and community-level approaches for assessing patient social risks are not equivalent. Using community-level data to guide patient-level activities may mean that some patients who could benefit from targeted interventions or care adjustments would not be identified.