What are vulnerable populations in healthcare?

Defining vulnerable populations for healthcare

According to Cleveland State University, defining vulnerable populations in healthcare is closely aligned with risk.

"Specialized or vulnerable populations in healthcare encompass groups of individuals who, under specific characteristics, circumstances or conditions, face an elevated risk of encountering disparities in access to and the quality of healthcare services," the University said on its website.

Said otherwise, vulnerable populations have a number of qualities that increase their risk of experiencing health disparities, both in terms of healthcare access, clinical quality and outcomes. This is due to structural racism and other structural and social inequities that inherently disadvantage certain groups of people.

Vulnerable populations can include, but are not limited to the following:

• Racial/ethnic minorities.
• Children.
• The elderly.
• People with low income.
• People with physical or intellectual disabilities.
• Individuals with no or limited insurance coverage.
• Those with a chronic illness.
• Homeless people.
• Veterans.
• Women.
• LGBTQ+ people.
• Those living in rural areas or healthcare deserts.

Those characteristics can be innate, ones an individual is born with, said the Texas Epidemic Public Health Institute. They can also be acquired, or ones that are extrinsic to an individual.

For example, being a racial or ethnic minority is an innate risk factor. Being socioeconomically disadvantaged is an acquired risk factor. Notably, risk is often intersectional, meaning an individual can have more than one. A person who is a racial or ethnic minority might also be socioeconomically disadvantaged.

For this reason, healthcare providers need an intersectional approach to understanding vulnerable populations to create tailored patient engagement strategies.

It is also essential for healthcare professionals to understand the nuances of the term vulnerable populations.

For example, the National Bioethics Advisory Commission previously proposed six categories of vulnerability, including cognitive or communicative vulnerability, institutional vulnerability, deferential vulnerability, medical vulnerability, economic vulnerability and social vulnerability.

These categories were primarily designed for research purposes to protect study participants but might be useful for consideration in clinical settings.

There is also the distinction between vulnerable and underserved populations. According to HHS, these terms have different meanings for the health insurance marketplaces.

"The term vulnerable is often used interchangeably with underserved," the agency said in a health insurance marketplace training module.

"While underserved consumers have limited access to health care services, vulnerable consumers tend to experience additional barriers to getting care. For example, an individual with LEP is considered vulnerable but might not be underserved (e.g., the consumer might have access to high-quality care)."

Understanding who qualifies as vulnerable can help healthcare providers and organizations detect those populations and tailor interventions to improve their outcomes.

Detecting vulnerable populations in healthcare

As noted previously, defining vulnerable populations is closely aligned with risk stratification. Hospitals and health systems want to identify members of vulnerable populations in order to tailor health interventions and practice good population health.

"Addressing the needs of these populations is essential for achieving healthcare equity and ensuring that all individuals have the chance to attain their highest level of health," according to the Cleveland State authors. "Efforts to understand and eliminate these disparities involve targeted interventions, policy changes and a commitment to fostering inclusivity within the healthcare system."

Like any risk stratification activity, identifying vulnerable populations requires adequate access to patient data. Healthcare organizations need access to social determinants of health data by way of patient surveying as well as third-party SDOH data sources. Such sources might include the social vulnerability index, ZIP code data or information from other public health databases.

Organizations can also capture demographic data, such as race/ethnicity and sexual orientation/gender identity data, during patient intake.

Aggregating this information effectively requires using data standards. A good data governance strategy and health IT interoperability ensures payers and providers can make sense of the patient information they have and adequately determine risk.

Population health strategies for healthcare's underserved

Strategies for supporting healthcare's underserved are as varied as the populations themselves. Because vulnerable populations do not have a one-size-fits-all definition, there is no one-size-fits-all approach to engaging them.

Focusing on SDOH and care access

Most experts agree that strong patient engagement, community-based care and other SDOH strategies can help address the health disparities faced by vulnerable populations.

Offering strong patient navigation services and improving patient access to care is critical.

Healthcare organizations, especially primary care clinics, might consider their appointment hours and whether those hours are accessible to all populations. Examining the physical space of the clinic and the modalities by which patients secure appointments is also important. Community-based care could be effective, especially for hard-to-reach populations like housing-insecure people.

There is also a key role technology can play in expanding healthcare access. Telehealth, for example, might help some vulnerable populations meet with a healthcare provider when they otherwise might not have. This is particularly salient among people living in healthcare deserts.

However, healthcare providers should exercise caution when using health IT to support vulnerable populations. Although some technologies, like smartphones, are nearly ubiquitous, the healthcare industry is still contending with a digital divide that disproportionately affects vulnerable populations. Overreliance on technology could risk deepening those disparities.

Supporting vulnerable populations with cultural competence

Some vulnerable populations may struggle to access healthcare not just because of logistical barriers, but also due to low patient trust. Members of the LGBTQ+ community or traditionally underserved racial and ethnic minorities might not access care due to poor previous experiences.

Improving cultural responsiveness, cultivating a more diverse medical workforce and supporting community-based care and public health messaging could be effective.

Enhancing traditional patient engagement strategies

Finally, healthcare providers must practice the same patient engagement strategies they use with all of their patients.

Shared decision-making, patient education and other communication techniques are key to improving the health outcomes of vulnerable populations. Providers should ensure they consider health literacy during written and verbal patient-provider communication, especially considering the limited health literacy many vulnerable populations possess.

Using policy to support interventions

Of course, these strategies are easier said than done. The most vulnerable populations are very expensive to treat, both because of their disproportionate burden of chronic illness and the higher likelihood of uncompensated care.

According to an article from the Duquesne University School of Nursing, industry-wide policy changes, such as shifting to a global budgeting system, could help manage this problem.

Other value-based care models that center on outcomes and consider risk as part of reimbursement also support these interventions. Value-based reimbursement that considers risk might provide hospitals and health systems with the capital necessary to implement some of these more costly interventions.

In addition to reimagining reimbursement models, supporting the clinics primarily responsible for treating vulnerable populations is key -- specifically, funding for community health centers. These health centers provide care to 31.5 million people in the U.S., most of whom are low-income, uninsured or housing insecure, according to the National Association of Community Health Centers (NACHC).

Most of the funding community health centers receive comes from the Community Health Center Fund, which Congress periodically needs to reauthorize. NACHC advocates for continued reauthorization to ensure that community health centers can support vulnerable populations.

By understanding vulnerable populations, and the strategies best suited to improve their health, industry professionals might achieve better overall population health and health equity.

Sara Heath has covered news related to patient engagement and health equity since 2015.