Health-related social needs (HRSN), such as housing instability, food insecurity, and poor transportation or social support, adversely affect health. In diabetes, where evidence links health behaviors, which are influenced by social/environmental factors, to disease onset and progression, a deeper understanding of the degree to which specific HRSN, or multiple needs, affect health may be crucial to achieving one’s best health. HRSN for adults with Medicare Advantage coverage (n=33,690) who responded to an abridged version of the Accountable Health Communities screener developed by the Centers for Medicare and Medicaid Services were evaluated. Overall, 56% (n=18,925) of people with diabetes reported one or more HRSN. A higher percentage of people with diabetes screened positive for financial strain (47%), food insecurity (31%), and poor housing quality/safety (24%) compared to those without diabetes (38%, 24%, and 19%, respectively). As the HSRN burden increased, healthcare utilization and cost also increased while compliance with certain quality indicators decreased. Our findings highlight the interplay between clinical and social needs and indicate that an increased awareness and incorporation of patients’ HRSN into clinical care may be essential for achieving optimal health in patients with diabetes. As more practices move to value-based arrangements, data on HRSN, combined with proven interventions, will help drive better health outcomes.


S. Franklin: Employee; Self; Humana. A. Hagan: None. P. Hansen: Employee; Self; Humana. G. Haugh: Employee; Self; Humana. C. Long: Employee; Self; Humana.

Readers may use this article as long as the work is properly cited, the use is educational and not for profit, and the work is not altered. More information is available at