Medical Certification for Utility Shut-Off Protection and Health-Related Social Needs

Our primary care office, which includes independent clinicians, academic pediatricians, and resident trainees, cares for patients primarily living in the New Haven, Connecticut region. According to deidentified electronic health record data, 85% of patients in our office have Medicaid coverage.

The MLP office in the Department of Pediatrics at our academic medical center offers diverse services, including legal support for housing, education, public benefits, and disability rights. Our MLP conducts outreach to all individuals who have received medical utility shutoff protection from medical clinicians. The office recently conducted telephone questionnaires with these families to identify HRSN and, when HRSNs were identified, an MLP representative connected families with relevant resources and legal rights.

We conducted an observational study of previously collected MLP outreach questionnaire data. The MLP lead attorney and medical director designed the questionnaire after recognizing cooccurring HRSNs at our office’s medical-legal utility clinics. They sought to assess HRSNs within the cohort of outpatients who had requested utility relief via a medical certification form.

Student volunteers contacted a purposive sample of all families who had documentation of receiving medical certification for utility shutoff protection from pediatric clinicians at our primary care office. At least 2 phone contact attempts were made for each family in preferred languages (English or Spanish). An automatically emailed summary of requested resources (Supplemental Table 3) was sent to the MLP office after survey completion. The MLP office contacted families with requested resources and offered advice about legal rights.

Demographic questions were based off the US Census Bureau’s American Community Survey.²¹  We queried the electronic medical record to obtain deidentified recorded sociodemographic data—race, ethnicity, and preferred language—of all office patients seen in the office during the same time period. Of note, while recognizing that race is a social construct, race and ethnicity were included in demographic data and analysis because of known disparate outcomes deriving from structural racism. Specifically, structural racism has contributed to persistently higher risks of health and economic hardship in African American, Hispanic, and American Indian families in spite of investment policies to reduce poverty more generally.²²  Questions related to income type and arrearages in utility payments were designed based upon MLP expertise and experience. Previously-validated HRSN screeners included food security screening with the Hunger Vital Signs,²³  housing security screening using questions from the Centers for Disease Control and Prevention Risk Factor Surveillance System,²⁴  and financial security screening with a previously validated question asking respondents to select their current financial situation as 1 of 4 responses ranging from “you are having difficulty paying the bills, no matter what you do” to “after paying the bills, you still have enough money for special things that you want.”²⁵  Questions related to COVID-19 specific resources, such as food resources, were also included.

Of 167 English- and/or Spanish-speaking families who had received utility shut-off protection from September 2019 to May 2020, 84 (50%) of parents and guardians were successfully contacted for follow-up and agreed to answer the telephone questionnaire. Medical Legal Partnership survey data were collected by phone and documented via Qualtrics (Qualtrics, Provo, UT) during the COVID-19 pandemic (June 2020 – December 2021). Of the families who were not successfully contacted, only 2 (1%) chose to not answer the survey (1 did not remember the utility form being completed, and 1 hung up during the call). One had already completed the survey on behalf of another family member, and the remainder (48% of those who had received utility shut-off protection) were not successfully reached after at least 2 attempts. We reviewed anonymized information with descriptive statistics in Stata 15 (StataCorp, College Station, TX) and quantitatively assessed most components of the data, including demographic characteristics of respondents, standardized measures of HRSNs, information about arrearages owed, and requests for additional services. The study was deemed exempt by our Institutional Review Board. We did not request or receive Institutional Review Board approval to investigate data of respondents or nonrespondents in the electronic health record.

Of the 84 successfully initiated surveys, most (96%) were conducted in English, and 4% were conducted in Spanish. Over half (57%) of respondents reported speaking only English at home. The most frequently reported race and ethnicities were non-Hispanic Black or African American (48%) and Hispanic (27%). By comparison, in the electronic health record of patients seen during this time, 23% of pediatric patients have Spanish selected as their preferred language and 69% have English; race and ethnicity is noted as 35% non-Hispanic Black or African American, 8% non-Hispanic White, 5% non-Hispanic Asian, and 46% Hispanic.

About two-thirds (69%) of respondents represented single-parent households, and 55% reported having at least 1 caregiver work in the past 12 months. Additional sources of income included Supplemental Security Income (24%) and unemployment (10%) (Table 1).

The majority (93%) of respondents reported that they found the clinicians’ completion of the utility medical necessity form helpful. Those who did not find it helpful either were unsure about the medical necessity form or reported they no longer needed the protection. Of those who responded to questions about supportive services, 68% had applied for Energy Assistance, and 69% reported they were on payment plans with their utility company. Over one-quarter (28%) of respondents reported that they received a utility shut-off notice, and 14% reported at least 1 utility was shut off in the prior year (Table 2). Most (78%) owed arrearages, ranging from under $500 to over $20 000, for gas, electric, and/or water bills (Table 2).

Nearly two-thirds (65%) of respondents screened positive for food insecurity, and 85% reported receiving supplemental sources of nutrition including the Supplemental Nutrition Assistance Program (SNAP). Most also screened at-risk for housing (65%) and financial (75%) insecurity. Most respondents (81%) requested to speak to an MLP representative for more information about at least 1 resource. All respondents who requested this support received additional telephone contact from an MLP paralegal and/or lawyer. As shown in Table 2, respondents were offered relevant information if they were not already enrolled in services. For energy-specific resources, of those who were offered information, 100% (20 of 20 respondents) were interested in Energy Assistance, 67% (14 of 21) were interested in payment plans with utility companies, and 71% (57 of 80) were interested in an energy audit to improve energy efficiency. Additional requests for resources for energy, food and nutrition, housing, and financial assistance are shown in Table 2.

In this observational study of patients who received medical certification for utility shut-off protection and agreed to participate in a follow-up survey, we found that nearly all respondents reported that the shut-off protection was helpful. Most had outstanding arrearages, many had experienced threatened and/or completed utility shutoffs, and most screened at-risk for food, housing, and financial insecurity.

Although energy insecurity has been found to be associated with other HRSNs,^3,4  the cooccurrence of medical certification requests with high levels of other HRSNs may be unique to the pediatric setting. A prior study of adults for whom a medical utility form was completed found few (16%) were at-risk for financial insecurity.¹²  There were higher rates of financial insecurity in respondents for this study (74%). Even if all who were not reached were financially secure, the hypothetical financial insecurity prevalence would be 32%. Alternatively, if all were not reached were financially insecure, the hypothetical financial insecurity prevalence would be 83%. Regardless of the degree of financial insecurity in the nonrespondents, financial insecurity would be higher than the prior reported rates in an adult cohort. This level of financial insecurity may be related to requests for households with children, as households with children have been found to have higher rates of multiple HRSNs compared with households without children.¹³  For families with children, financial support, including the recent 2021 Child Tax Credit program and other financial interventions, is associated with improved measures of HRSNs and with improved health outcomes, including reduced preterm births, improved birth weight, reduced postpartum depression, and decreased inflammatory markers.^26–30 

The sociodemographic characteristics of the respondents who answered this survey and who received medical certification did not match the overall characteristics of our pediatric office; fewer respondents identified as Hispanic and fewer spoke Spanish in the survey cohort. Although this finding will require additional exploration, multiple factors that may affect a patient’s ability to request certification, including knowledge of the service, language barriers, and fear of such requests affecting legal protected statuses. Recent United States policy related to public charge, for example, resulted in a chilling effect, with decreased enrollment in many social resources even for those who qualify.³¹  Additionally, there may be differences in energy insecurity by background; although race is a social construct, there are known sequalae of structural and historic racist policies that have resulted in disparities in energy poverty.^3,4,22 

Most families who were contacted by the MLP office requested a call-back to discuss additional, specific resources, including and beyond energy support. Although few respondents requested information for well-known nutrition support services (eg, Supplemental Nutrition Program for Women Infants and Children [WIC] and the SNAP), many were interested in information about energy support resources. In our office, the general protocol included completing the utility shutoff protection form and contacting the family to ensure children are caught up on routine health maintenance, including well visits, asthma management, and immunizations. The synergistic provision of support services resulting in increased preventive medical care has been observed with the other linked social services, such as WIC.^32–34  Future studies can assess if the medical certification process may offer another key entry point to address other cooccurring medical needs and HRSNs for some families. Expanded initiatives will also need to incorporate innovative outreach methods to families who may qualify for services who have not reached out to our office for support or who have been lost to medical follow-up, especially those with limited English proficiency.

Limitations included a single cohort from 1 academic institution in 1 US state. The surveys were also completed during the early COVID-19 pandemic (June 2020–December 2021) for families who had received medical certification mostly before the pandemic (September 2019 – May 2020). Thus, shifting social support policies related to the pandemic, ranging from eviction moratoriums (in place during most of the survey period) to the 2021 child tax credit (which occurred after the survey period), likely affected responses. There were potential sampling and social desirability biases. Some surveys were incomplete, so there may have been potential nonresponse bias. To mitigate biases, attempts at contact were made at different times of day, and if a number was out of service, charts were reviewed for additional contact information. Only 1 successfully contacted individual ended the survey without at least partially completing it, whereas most (83 of 85) nonrespondents were not reached by telephone. Social desirability bias mitigation was attempted with anonymized responses and having individuals not associated with the clinic administer the questionnaires. Studies from other settings are needed to assess generalizability.

Among families who received medical certification for utility shut-off protection and answered a Medical Legal Partnership survey, high rates of food, financial, and housing insecurity can cooccur. The provision of medical utility shut-off protection is 1 potential support for families with children who often have concurrent health-related social needs, and families should be referred to utility support and other health-related social and legal resources. Medical Legal Partnerships that embed in pediatric care practices can provide recommendations, referrals, legal advice, direct support, and advocacy when patients and families are screened to have these needs.

HRSN

health-related social need

MLP

Medical Legal Partnership

SNAP

Supplemental Nutrition Assistance Program

WIC

Women, Infants and Children