Using Data to Promote Health Equity
June 2024
According to the Centers for Disease Control and Prevention (CDC), health equity is defined as the elimination of avoidable and unjust variances in health outcomes, as well as equitable access to health care and quality care across diverse populations. This stands as a fundamental guiding principle of modern health care systems. Despite advances in medical technology and health care delivery, significant disparities based on race, ethnicity, socioeconomic status, gender, geography, and other factors persist. Health centers play a crucial role in addressing these inequities, acting as primary provider for underserved populations. Leveraging the power of data analytics, health centers can identify disparities, understand the underlying causes, and implement targeted interventions to promote equitable health care access and outcomes.
This report aims to provide practical guidance for Health Care for the Homeless (HCH) centers by conducting a comprehensive examination of financial and operational benchmark trends, empowering HCH to leverage their data resources to effectively address health equity concerns. By adopting evidence-based approaches informed by robust data analysis, health centers can take significant strides towards achieving the goal of equitable health care for all individuals, regardless of their background or circumstances.
Table 1. Summary of Median HCH Data
In 2022, HCH programs employed a diverse staffing mix comprising of both health professionals and support staff to effectively address the complex needs of individuals experiencing homelessness (Table 2). This staffing mix included primary care physicians, nurse practitioners, physician assistants, nurses, social workers, mental health counselors, substance use counselors, case managers, outreach workers, and community health workers. Each member of the interdisciplinary team contributed unique expertise and perspectives, allowing HCH programs to deliver comprehensive and integrated health care services tailored to the specific needs of their patients. Many HCH programs also emphasized the importance of cultural competence and diversity within their staff to better serve the diverse populations they encountered. The staffing mix observed in HCH programs demonstrates a commitment to providing equitable and inclusive care to individuals experiencing homelessness, utilizing a holistic approach to address both the medical and social needs of their patients.
Recommendation: HCS programs should incorporate interdisciplinary teams to address the comprehensive needs of their patient population
Table 2. Staffing Mix at HCH Programs by Urban/Rural location in 2022
Table 3. Revenue Mix of HCH Programs between 2019 - 2022
In 2022, the revenue mix for HCH programs comprised a combination of federal, state, local, and private funding sources to sustain their operations and deliver essential health care services to individuals experiencing homelessness (Table 3). Federal funding, primarily through the Health Resources and Services Administration (HRSA) grants under the HCH Program, constituted a substantial portion of the revenue mix for numerous HCH programs. Additionally, state and local governments allocated funds to support HCH initiatives within their respective jurisdictions, often in collaboration with community partners and health care providers. Private foundations, philanthropic organizations, and individual donations also contributed to the revenue mix, providing supplementary support for innovative initiatives, and addressing gaps in service delivery. Furthermore, some HCH programs generated revenue through reimbursements from Medicaid, Medicare, and other third-party payers for health care services provided to eligible patients. This diversified revenue mix enabled HCH programs to operate sustainably and fulfill their mission of providing equitable access to health care and improving health outcomes for individuals experiencing homelessness.
Table 4. Patients by insurance type at all HCH Programs between 2019 - 2022
HCH patients utilize a variety of insurance options to access health care services, reflecting the diverse backgrounds and circumstances of individuals experiencing homelessness (Table 4). Many HCH patients are uninsured or underinsured. Some rely on safety-net programs such as Medicaid, which provides coverage for low-income individuals and families. Additionally, certain HCH patients may be eligible for Medicare, particularly older adults or individuals with disabilities. For those who do not qualify for public insurance programs, HCH programs often offer sliding fee scales or provide discounted services based on income level. Moreover, HCH patients may access care through health centers, free clinics, or charitable organizations that offer no cost or low-cost services regardless of insurance status. Private insurance plans, employer-sponsored coverage, and veteran's benefits may also be utilized by HCH patients who have access to these resources.
HCH programs have been successful in reducing the percent of self-pay/uninsured patients from 26% to 21% from 2019-2022, as well as raising the mix of Medicaid patients from 51% to 54%, along with the number of privately insured patients over the same time period. This is likely partly due to Medicaid expansion in key states and increased subsidies for plans on the health care marketplace. However, since the vast majority of the homeless population are also low-income, this population was already eligible for these programs before the expansion. It is plausible that a portion of the increase stemmed from intensified efforts to aid patients in enrolling for coverage. However, further research is required to pinpoint the precise factors driving these shifts.
Recommendation: The insurance landscape for HCH patients is multifaceted, reflecting the intricate socioeconomic factors that influence health care access for individuals experiencing homelessness. Given this intricacy, HCH programs should prioritize assisting their patients in enrolling for Medicaid and health marketplace coverage.
Table 5. Health Center Organization Growth and Expansion, All HCH Programs
The COVID-19 pandemic prompted a rapid shift towards virtual health care delivery, leading to a surge in the number of virtual clinic visits (Table 5). Faced with the need to minimize in-person interactions and reduce the risk of virus transmission, health care providers swiftly adopted telemedicine and virtual care platforms to ensure continuity of care for patients. This transition enabled patients to access medical consultations, receive diagnoses, and manage chronic conditions from the safety and comfort of their homes. The widespread adoption of telehealth during the pandemic highlighted its potential to improve health care access, particularly for underserved populations and those in remote areas. As a result, virtual clinic visits have become an integral component of modern health care delivery, offering convenience, flexibility, and accessibility to patients while also enhancing health care provider efficiency and capacity.
Recommendation: HCH programs should maintain their focus to prioritize telehealth and further build on their success in reaching homeless patients who face challenges visiting a traditional clinic.
6. Median Mix of Visits by Practice Type at all HCH Programs between 2019 – 2022.
Table 7. Change in Selected Quality of Care Measures between 2021 – 2022 at all HCH Programs
of Children Receiving Appropriate Vaccinations by Age 2
of Patients 3-17 with BMI, Nutrition & Physical Activity Documented
Percentage of Patients 18 and over with BMI & Follow Up Documented (If BMI outside normal)
Percentage of Patients Screened for Colorectal Cancer
Percentage of Patients 12 and over Screened for Depression and Follow-up Plan Documented (If Positive)
Percentage of Patients 6-9 at Moderate to High Risk of Caries Receiving Sealant on First Permanent Molar
of Patients with Controlled High Blood Pressure
Percentage of Patients with Diabetes and Hemoglobin A1c Poor Control
2-point Decline
Food insecurity poses significant challenges for individuals experiencing homelessness, impacting their ability to adhere to consistent medication schedules and manage chronic health conditions effectively. Without access to stable and nutritious meals, many HCH patients struggle with being malnourished,
Table
which makes it difficult to take medications as prescribed, leading to suboptimal health outcomes and increased health care utilization, as seen in Table 7. Moreover, food insecurity exacerbates the financial strain faced by HCH patients, often forcing them to prioritize basic needs such as food and shelter over medications and health care expenses. HCH programs play a crucial role in addressing these challenges by providing comprehensive support services, including access to food assistance programs, nutrition counseling, and medication management support. By addressing the underlying social determinants of health, including food insecurity, HCH programs help individuals experiencing homelessness overcome barriers to medication adherence and achieve better health outcomes. Additionally, partnerships with community food banks, meal programs, and social service agencies enable HCH programs to connect patients with resources to address immediate food needs while also working towards long-term solutions to food insecurity.
Many of the quality-of-care measures highlighted in Table 7 declined from 2021-2022, including the "Percentage of Children Receiving Appropriate Vaccinations by Age 2,"“Percentage of Patients 3-17 with BMI, Nutrition & Physical Activity Documented," Percentage of Patients 18 and over with BMI & Follow Up Documented (If BMI outside normal),” and “Percentage of Patients with Diabetes and Hemoglobin A1c Poor Control". On the other hand, the "Percentage of Patients 12 and over Screened for Depression and Follow-up Plan Documented (If Positive)”and “Percentage of Patients with Controlled High Blood Pressure" increased. This suggests uneven progress in primary care screening and prevention for this population.
Recommendation: HCH programs should prioritize a holistic approach to ensure their patients are able to progress in both prevention and management of chronic diseases. They must also take special care to make sure they do not backslide on key quality care measures.
Conclusion
Analyzing health center data for health equity purposes is imperative not only from a moral standpoint but also as a strategic move to enhance population health outcomes and mitigate health care costs. The data shows that HCH programs play a key role in reaching this underserved population. It also identifies areas of success and key challenges that health centers should be aware of when evaluating their programs. Health centers should continue to emphasize interdisciplinary teams and holistic services, assistance to patients in getting health coverage, and integrate telehealth into their programs. They must also take care, however, to maintain quality of care in key areas to ensure both prevention and management of disease.
By harnessing the power of data analytics and actively engaging with communities, health centers can drive meaningful change and create a health care system that is truly equitable and inclusive for all.
This publication was supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) as part of awards totaling $1,788,315 with 0% financed with non-governmental sources, and 1,168,750 with 0 % financed with non-governmental sources. The contents are those of the author and do not necessarily represent the official views of, nor an endorsement, by HRSA, HHS, or the U.S. Government. For more information, please visit HRSA.gov.