Analyzing resource needs by zip code: A data project by the RUSH AmeriCorps team
By Kelly-Jessie Tounou
During our service year, AmeriCorps members worked on a project analyzing the correlation between patients' zip codes and resource needs. As AmeriCorps members, we work under the Social Work and Community Health Department at RUSH, conducting Social Determinants of Health (SDOH) screeners.
Social Determinants of Health (SDOH) are the conditions in which we are born, live, work, play, worship, and age that affect our quality of life and health outcomes. The C4P AmeriCorps at RUSH program was implemented to identify and mitigate SDOH disparities among high-risk patients by improving their access to socioeconomic resources.
In our program, AmeriCorps Members conduct the SDOH screener over the phone after a patient is discharged from the Emergency Department (ED). The screeners cover the 6 domains of SDOH: Transportation, Housing, Food, Employment, Utilities, and Interpersonal violence (IPV). If a patient screens positive for any of these domains, AmeriCorps Members send resources to address their needs. If a patient screens positive for housing needs or IPV, or if they have 2 or more SDOH needs, they are referred to our Community Practice social work team for further support and resource coordination.
This data project began as a professional development opportunity to build on and enhance our data and Excel skills, but it grew into a much larger learning experience. As part of our AmeriCorps program, we read and watched two pieces of media—Dr. David Ansell's book The Death Gap and the documentary Shame of Chicago, Shame of Nation—that inspired us to use this data project to learn more about the impact of the SDOH screeners that we’ve been conducting. We also reviewed the RUSH 2019 Community Health Needs Assessment (CHNA) to gain insight into what community members wanted to see in their neighborhoods.
METHODS
We gathered most of our data via the Post-ED SDOH tracker, a shared excel sheet where our team (and a larger team of Community Health Workers, or CHWs) inputs information from our outreach calls and SDOH screening outcomes. In the Excel tracker, we recorded:
date of the intervention
patient's MRN and zip code
name of the AmeriCorps member or CHW who performed the intervention
if an SDOH screener was completed
if needs were identified
if a primary care referral was made
if resources were provided.
Based on the existing data we were collecting, we decided to create our own Excel sheet to collect more specific information about our SDOH call outcomes. We added the following fields:
which specific resources were requested
if a Social Work referral was placed
if a referral was placed to Food is Medicine (a program at RUSH designed to address food insecurity in our patients)
This data was collected from November 20, 2023 to May 17, 2024. The specific Excel skills we learned and used were Pivot tables, COUNTIF formulas for resource needs, and conditional formatting. We also utilized filled maps in Excel to create data visualizations.
RESULTS
Figure 1. Percent of screened patients referred to social work, by zip code
In total, our team of 4 AmeriCorps Members called 2,221 patients during the 6-month period of our data collection. Of the 2,221 patients we called, 879 of those patients completed an SDOH screener. 60612 had the highest number of patients screened at 225. We then narrowed our focus to the West Side, since that is RUSH’s area of focus. Out of the 2,221 patients called, 1,285 were from the West Side and 424 completed an SDOH screener.
The map in Figure 1 shows the percentage of patients screened that the AmeriCorps team referred to social work. We escalate cases to social work when the patient screens positive for mental health needs/substance use, housing needs, burdened caregiver, financial/employment concerns, complex insurance issues, or for 2 or more positive needs. Because of these broad referral criteria, we used social work referral as a variable indicating overall social needs identified from our SDOH screeners. In total, 83 patients were referred to our Community Practice social work team during our data collection period, with the highest percentage of referrals coming from three zip codes: 60612, 60644, and 60624.
Two other variables we focused on were food and housing. During our AmeriCorps program’s service-learning discussions and educational programming, we often noted that when you go further South or West in Chicago, you see more disparities when it comes to health and housing. This disparity is reflected in the maps shown in Figure 2 and Figure 3. When comparing zip codes, we can see that the further west zip codes expressed a higher need for housing. This disparity can be due to various issues highlighted by community members—for example, a lack of affordable housing. The same can be said with food: in the RUSH Community Health Needs Assessment, community members described a lack of healthy food options, creating a need to travel out of their communities to find good quality food.
Figure 2. Percent of screened patients who indicated housing needs
Figure 3. Percent of screened patients who indicated food insecurity
CONCENTRATION OF COMMUNITY RESOURCES BY ZIP CODE
AmeriCorps members and CHWs on our team use a social referral platform to share resources and refer patients to social service organizations. We looked at the resources offered through our social referral platform to explore the geographic concentration of the resources we provide to our patients. Within the platform, we examined the number of resources available within one mile of each of our West Side zip codes and within given social service categories. We then compared the density of available resources to the number social work referrals we made this year, and the data revealed a mismatch between where resources are most available compared to where resources are most needed. As shown in the table below, our social referral platform has the highest availability of resources in 60661 and 60606 zip codes—despite the fact that resource needs are higher in other zip codes. This misalignment between patients’ needs and the relevant resources available nearby puts pressure on the reallocation of resources.
Figure 4. Resources available on on our social referral platform, located within 1 mile of each West Side zip code
DISCUSSION
Of all the patients contacted, 57.86% were from the West Side. We were able to screen patients from 15 of the 16 West Side zip code areas. Unfortunately, our data does not allow us to determine whether there has been an improvement or increase in the quantity of resources within these communities. However, the SDOH screeners conducted by our AmeriCorps team show an ongoing need for greater resource availability on the West Side. Our analysis of resources available through our resource referral platform shows that resources are distributed disproportionately on the West Side, and resource availability does not necessarily reflect the areas of greatest need.
One limitation of this data project that we’d like to acknowledge is that we likely have some inaccurate zip code data due to several factors. We found that sometimes patients’ addresses were not up to date in the electronic health record system we use to track patient information and document our outreach. Additionally, the zip code 60612 is used as a “catch-all” zip code for unhoused patients—so our data may show an over-representation of the 60612 zip code and under-representation of homelessness among the patients that we reached out to.
We were also unable to measure the distribution of mental health and substance use resources because the psychotherapy clinic at RUSH was unable to accept referrals for most of our service year. Another thing to note is that our maps reflect a percentage of needs per patients screened rather than the total number of patients with a resource need. This visualization might inaccurately show which zip codes have a higher demand for resources, potentially skewing the true distribution of need across different areas.
A final consideration for this project is that Chicago zip codes do not necessarily correlate with specific neighborhoods. For example, North Lawndale residents can have one of four zip codes: 60608, 60612, 60623, or 60624. Similarly, 60612 spans across several different neighborhoods of Chicago including North Lawndale, Near West Side, Tri-Taylor, Ukrainian Village and West Town. Our project collected data based on zip codes because this is the geographic information available through our electronic health record system when we conduct patient outreach, but many other studies and initiatives (including the RUSH CHNA) organize information based on neighborhood.
For future research, we would recommend:
Focusing on specific neighborhoods (to better align research results with the RUSH CHNA), and
Including patient demographics such as race, ethnicity, age, sex, and preferred language (to help understand not only which geographic areas have certain resource needs, but also which demographic populations have certain resource needs).
ABOUT AMERICORPS
AmeriCorps is a national service program that involves people in “getting things done” in communities. AmeriCorps members develop an ethic of service while strengthening local communities. Each year in Illinois, thousands of AmeriCorps members give millions of dollars in service back to their communities. Serve Illinois administers 45 AmeriCorps State programs and over 1,800 Members committing to a year of service. These Members serve 70+ counties in over 400 host sites. For up-to-date information on the impact on our state, visit AmeriCorps.gov.
RUSH is proud to partner with The Comprehensive Care, Community and Culture Program (C4P) at the University of Chicago, which hosts AmeriCorps members across all of its participating service sites in 2024-2025. RUSH is a satellite host site under this program, hosting four full-time service members each year. The RUSH service members are responsible for extending the reach of RUSH’s program to impact patient experience with care and health outcomes, lower hospitalization rates, and resolve unmet social needs for participants. By hosting AmeriCorps Members at RUSH, CHaSCI aims to train and educate future leaders in medicine, healthcare, social work, and public health to incorporate social care concepts (social determinants of health, integration of social work into healthcare settings, and inter-professional collaboration) to quality and equity of care for all.
Learn more:
To learn more about and apply to the C4P AmeriCorps at RUSH program, visit our AmeriCorps at RUSH webpage.
To hear more about the program from a RUSH AmeriCorps alum, view this blog post.
To learn about C4P’s other AmeriCorps opportunities, please visit their website here.