Presentation (CTI)

OBJECTIVES: Health-Related Social Needs (HRSNs) such as food insecurity, transportation challenges, and medication cost barriers play a critical role in shaping chronic disease management and patient outcomes. Understanding how these unmet needs vary across patient populations is essential for developing targeted and equitable interventions. The purpose of this study was to evaluate associations between chronic disease status, specifically diabetes and hypertension, and key HRSN domains among adult patients in the Jefferson Health Green Cities Cohort.
METHODS: This retrospective analysis included 62,251 patients with complete HRSN and diagnosis data. Logistic regression models were used to estimate adjusted odds ratios for three priority HRSN domains: food insecurity, transportation difficulties, and medication finance barriers. Predicted probability plots were generated to visualize patterns across disease groups, race, sex and urban versus non-urban neighborhood.
RESULTS: Results showed that diabetes was strongly associated with higher odds of reporting medication cost barriers (OR=2.02) and transportation difficulties (OR=1.29). Hypertension was associated with lower odds of food insecurity (OR=0.66). Predicted probability curves demonstrated consistently higher unmet needs among diabetes patients, with notable geographic patterns showing elevated need in Philadelphia ZIP codes compared to non-urban regions. Women exhibited higher predicted probabilities across all three domains.
CONCLUSIONS: These findings suggest that chronic disease status is linked to unmet social needs and highlight the importance of integrating transportation, food access, and medication affordability initiatives into chronic disease management programs. Health systems may use these insights to identify high-need populations and develop targeted interventions that address the social barriers impacting disease control and care engagement.