Introduction

This concept describes a method developed at MCHP to define and operationalize "social complexities". Information for this concept is taken directly from the deliverable A Comparison of Models of Primary Care Delivery in Winnipeg by Katz et al. (2016). The social complexities described in this deliverable and thus, in this concept, are similar to the psychosocial dimension of patient complexity described in Schaink et al. (2012).

The concept also describes how a social complexity index was developed and used in this research, including the social complexity factor loading scores, and the social complexity index scores by model of primary care and individual clinics. This concept also identifies additional areas of research investigated in this project and their relationship to social complexities. Links are provided to the relevant sections of the deliverable for access to more information and discussion of the results.

Conditions of Social Complexity

Primary care providers at alternative-funded clinics in Manitoba have consistently claimed that there are systematic differences between the patients seen at their clinics and those seen in fee-for-service (FFS) clinics. In particular, they believe that their patients’ needs are greater than other patients’, on average, due to social conditions known to influence health, such as unstable housing and poverty. These conditions are known as "social complexities".

In Katz et al. (2016) they identified and examined 11 social conditions they termed "social complexities". The data needed to define and operationalize these social complexities are readily available or easily developed from different data sources available the MCHP Data Repository. The following is a list of the 11 social complexities investigated in this research project. For more information on how each of these social conditions can affect health, please read the section titled Social Complexity in the deliverable.

Social Complexity Variables


• High Residential Mobility – high residential mobility patients were defined as patients who moved residences three or more times within 10 person-years. For more information, see the Residential Mobility concept.
  
  
• Low Income Quintile - income quintile is an area measure of neighbourhood socio-economic status that divides the population into five income groups (from lowest income to highest income) so that approximately 20% of the population is in each group. In this research, those patients identified as low income quintile were those from the population in the lowest 20%. For more information, see the Income Quintiles - Child Health Income Quintiles concept.
  
  
• Social Housing Resident – social housing residents were defined as patients having ever lived in social housing that is owned and directly managed by Manitoba Housing and Community Development. For more information, see the Social Housing glossary term.
  
  
• Income Assistance – patients on income assistance were identified as any patient who has ever received income assistance. For more information, see the Employment and Income Assistance (EIA) concept.
  
  
• Major Mental Health Diagnosis – patients with a major mental health diagnosis were defined as any patient who ever had a psychotic disorder. For more information, see the Psychotic Disorder glossary term.
  
  
• Newcomer (to Canada) – a newcomer was defined using the following approach:
  
  
  1. identify all patients who were new to Manitoba within the last five years;
     
  2. using the 2011 Canada Census, calculate the proportion of immigrants in each dissemination area (DA) in Manitoba who moved from another country; and
     
  3. each patient identified as new to Manitoba was given a probability of being a "newcomer" based on the proportion of immigrants in the DA in which he or she resided.
  
  
• Child of a Newcomer – a child of a newcomer was identified as a child of somebody who meets the definition of a newcomer – see definition of Newcomer above.
  
  
• Teen Mom – a teen mom was identified as a female patient of any age who first gave birth at the age of 19 or younger. For more information, see the Mother's Age at First Birth concept.
  
  
• Child of a Teen Mom – a child of a teen mom was identified as being the child of a female patient of any age who first gave birth at the age of 19 or younger.
  
  
• Child in Care - children in care were identified as patients aged 0-18 years on March 31, 2013 who were identified as having been removed from his or her family of origin and placed in the care of another adult due to concerns about proper provision of care in the family of origin. For more information, see the Children in Care (CIC) / Ever in Care glossary term.
  
  
• Involvement with the Justice System - involvement with the justice system was defined as a patient who has had contact with the justice system as a witness, victim, or accused.

The Social Complexity Index

The following information is taken directly from Appendix 3 - Social Complexity Index in Katz et al. (2016). Due to co-linearity among the social complexities, it was not feasible to include all the social complexities in a regression model to determine the individual effects of each complexity after controlling for other relevant factors. Factor analysis was performed on the social complexities to obtain a Social Complexity Index score. Each of the following social complexities resulted in factor loading scores of at least 0.40 and were included in the Social Complexity Index.

Social Complexity	Factor Loading
High Residential Mobility	0.91
Low Income Quintile (Q1 vs. Q5)	0.78
Social Housing Resident	0.93
Income Assistance	0.95
Teen Mom	0.72
Child of a Teen Mom	0.85
Child in Care	0.74
Involvement with the Justice System	0.79

Social Complexity Index Score by Model of Primary Care and Clinic

The following table presents the Social Complexity Index scores for each of the five models of primary care, as well as the clinics in all the models, except for Non-PIN FFS. A higher index score means more social complexity, while a lower score means less. The scores not only varied by model of primary care, but they also varied among the clinics within each model. The Community Health Clinic model had an index score of 0.71, suggesting that, on average, patients of the providers at those clinics had the highest social complexity among all the models of primary care.

Model of Primary Care and Clinic	Median
PIN FFS	-0.72
** Assiniboine Medical Clinic	-0.92
** Concordia Health Associates	-0.49
** Prairie Trail Medical Clinic	-0.75
** Clinique St. Boniface Clinic	-0.60
** Tuxedo Family Medical Centre	-1.04
WRHA Primary Care	0.07
** Access River East	0.05
** Access Transcona	-0.31
** Aikins Street Community Health Centre	0.86
** Access Downtown	1.81
** Corydon/River Heights Primary Care Clinic	-0.37
Community Health Clinic	0.71
** Aboriginal Health and Wellness Centre	2.82
** Centre de Santé Saint Boniface	-0.36
** Hope Centre Health Care Inc	2.57
** Klinic Community Health Centre	0.87
** Mount Carmel Clinic	2.13
** Nor’West Co-op Community Health Centre	0.66
** Women’s Health Clinic	0.09
Teaching Clinic	-0.59
** Family Medical Centre	-0.61
** Kildonan Medical Centre	-0.65
** Northern Connection Medical Centre	0.92
Non-PIN FFS	-0.20

Additional Areas of Research Related to Social Complexities

This section identifies additional areas of research related to social complexities that were investigated in Katz et al. (2016). This includes social complexities by model of primary care, social complexities and primary care quality indicators, social complexities and primary care provider panel size, and social complexities by individual clinics within each model of primary care, except non-PIN fee-for-service (FFS) clinics. Links are provided to the relevant sections of the deliverable for access to the discussion and results.

1. Social Complexities By Model of Primary Care

In this research, they investigated and compared the relationship between social complexities and the five different models of primary care. For more information and discussion of the results, please see:


• crude rates of patient social complexities by model of primary care – see Table 3.2 and Figure 3.5 in the deliverable; and
  
• crude rates of the number of patient social complexities by model of primary care – see Figure 3.6 in the deliverable.

2. Social Complexities and Primary Care Quality Indicators

In this research, they investigated the relationship between social complexities and individual primary care quality indicators, and between the number of social complexities and each primary care quality indicator. Odds ratios were developed to describe these relationships, and the results are presented in table / graph format identifying the relationships that have statistical significance. For more information on the results and discussion related to social complexities and the primary care quality indicators, please see the relevant information in each of the following chapters of the deliverable:


• Chapter 4: Prevention and Screening Indicator Results;
  
• Chapter 5: Chronic Disease Management Indicator Results;
  
• Chapter 6: Medical Care Indicator Results; and
  
• Chapter 7: Health Services Delivery and Use Indicator Results

3. Social Complexities and Primary Care Provider Panel Size

In this research they investigated the relationship between social complexities and primary care provider panel size. Panel size is defined as "the number of patients who are receiving care by a primary care provider".

Table 8.1: Association Between Patient and Provider Characteristics and Panel Size Unadjusted Values presents the results of the analysis on a number of social complexity variables and provider characteristics. The bold variables in the table with a positive estimate value are associated with an increase in panel size and those with a negative value are associated with a decrease in panel size.

4. Social Complexities by Clinic

On-line Appendix 1 from Katz et al. (2016) presents the population and crude rate (%) for each of the 11 social complexities investigated in this research for each of the individual clinics, in each model of primary care except the Non-PIN FFS clinics. This information is available in the On-line Appendix 1 - Social Complexities by Clinic of the deliverable.