Social determinant screening not enough to capture patients at risk of utility shut-off

Researchers at Boston Medical Center have found that only a fraction of patients at risk of having their utilities shut off were identified through social determinants of health (SDOH) screening. Published in The Journal of Ambulatory Care Management, the research showed that among the patients who received a utility protection letter in 2018, 70 percent were screened for SDOH and only 16 percent screened positive for difficulty paying their utility bills.

Preventing utility shut-off is vital to maintaining patients' health, which is why most states in the U.S. have laws prohibiting or delaying utility companies from terminating service to low-income households when occupants present a medical letter confirming a household member has a chronic serious illness. These laws ensure electricity-powered medical devices continue running, and that patients have electricity to refrigerate medications. Preventing utility shutoffs may help patients pay for other necessities like food, medicine, and shelter. It is widely-documented that SDOH can greatly impact a patient's health and their ability to manage a chronic serious illness.

"Patients experiencing difficulty paying utility bills may not be detected by systems of care that screen for SDOH, and this is concerning for at-risk populations," says Karen Lasser, MD, MPH, a general internist at BMC and professor at Boston University Schools of Medicine and Public Health. "This research calls for better approaches to identify those needing assistance, to ensure better health outcomes for all patients."

In January 2018, Boston Medical Center (BMC) implemented an electronic health record-based SDOH screening and referral program, which identifies eight domains of potentially unmet SDOH needs: housing and food insecurity, inability to afford medications, utilities or transportation, need for employment or education, and difficulty taking care of children or other family members.

There are several reasons why patients may not be identified for utilities insecurity. Difficulty paying utility bills may be a seasonal phenomenon—patients screened in warmer months may not identify this need as they would in the winter when heat is a necessity, especially in Boston. Screening for SDOH also takes place at medical appointments. Patients in precarious social circumstances may be less likely to attend visits and therefore may not get screened. Patients may also feel stigmatized by SDOH screening, or may not report difficulty paying for utilities if they are already receiving assistance.

Researchers also analyzed characteristics of adult patients at BMC, a safety-net hospital, who received a utility shut-off protection letter between 2009 and 2018. During the study period, 2,973 unique adult patients received a utility letter. Looking at the demographics of those receiving the letter, two-thirds were women, most were English-speaking, and the average age of the person receiving the letter was 56 years. Two thirds of the patients were non-Hispanic black and 75 percent had government insurance. Overall, these patients had high levels of medical and behavioral health comorbidities.