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Updated: May 3, 2026

Digital Home-Monitoring of Patients after Kidney Transplantation: The MACCS Platform
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Patterns of health care utilization among vulnerable populations in Central Texas using data from a regional health
Purpose:
Describe patterns of health care utilization among vulnerable subgroups of an underserved population and identify populations that could benefit from interventions to reduce health care costs and improve quality of care.
Methods:
Health Information Exchange data focused on underserved patients was used to estimate the risk of an emergency department (ED) or inpatient (IP) visit among vulnerable patients.
Results:
Approximately 20.9% of the population was vulnerable, with behavioral health being the most predominant. Homeless, disabled, and severe behavioral health patients had an increased risk of ED utilization. Behavioral health, disabled, and near elderly patients had an increased risk of IP utilization. Inpatient risk was even greater for patients with multiple vulnerabilities.
Conclusions:
Improved primary care services are needed to address both the mental and physical needs of vulnerable populations, particularly people with severe behavioral health conditions. Improved access to services may help reduce the costly burden of providing hospital-based care.
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