Segmenting Social Determinants of Health to Improve Care for High Utilizers in Community Mental Health

High service utilization in community mental health (CMH) is often framed as a financial challenge, yet such framing can obscure the deeper structural and social realities that drive intensive service needs. Hierarchical cluster analysis was used to examine the role of social determinants of health in shaping service utilization among adults receiving outpatient care at a CMH center. This approach uncovered meaningful subgroups, for example, Black men with schizophrenia facing housing instability and racially diverse women with depression and strong support networks. By segmenting high service utilizers, actionable insights were generated that informed program design and targeted interventions. Rather than presenting HSUs as a problem to be managed, this evaluation framed them as a source of insight for improving care. Through this lens, the clusters became a tool for engaging agency leadership and clinicians in shared conversations about how to meet the needs of our most vulnerable clients.

B. Andi Lee; Shaune-Ru Wang; Patricia Scherer; Ana Hauser; Christie Scheuler; Sae Lee