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How do you address the social determinants of health that affect discharge planning and readmission rates?

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Discharge planning and readmission rates are key indicators of quality and efficiency in health care. However, many factors beyond the clinical setting can influence the outcomes and experiences of patients after they leave the hospital. These factors are known as the social determinants of health (SDOH), and they include aspects such as income, education, housing, transportation, food security, and social support. As a case manager, how do you address the SDOH that affect discharge planning and readmission rates? Here are some tips and strategies to consider.

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1 Assess the patient's needs and preferences

The first step in addressing the SDOH is to conduct a comprehensive assessment of the patient's needs and preferences, both clinical and non-clinical. This can include asking questions about their living situation, family and social network, financial resources, access to services, and goals and expectations. The assessment should also involve the patient's caregivers, if applicable, and respect the patient's culture, values, and autonomy. The assessment can help identify the potential barriers and facilitators to a successful discharge and transition of care.

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Reeba M.
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This is true, except those who may not have supports in the community or those who are poor historians or even say what they want in order to get discharged and end up being admitted again.

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Jaimie Robinson

Director of Social Work
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Yea!! A good assessment is critical. But time constraints with large case loads and discharge length of stay goals can change the Case Managers priorities to focus only on discharge and not the possibilities of addressing SDoH.

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Lorna Brown
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Agree a comprehensive assessment should take place but is often missing. I have lost count of hearing ‘patient p is medically fit for discharge’ despite them having no money or access to basic utilities such as gas and electricity. A comprehensive assessment should start as soon as the person is admitted and where possible the client as an inpatient escorted home to check their living condition. There needs to be clear accountability for who leads on developing the sdoh and commitment across both health and social care.

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Shelia Carroll

Serving People to live better quality of life!
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1st question should always be; 60 plus- are you on PASSPORT program? Under 60 with disabilities- are you on waiver program, do you have Cas manager. This would help Social Workers and SNF, lesson their work and less change sending patients home with provider not contracted with these programs I agree with assessment being done on admission and discharge. I totally agree with collaboration as I've seen many benefits of this and preach it!

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Douglas Tavira

Medical Social Worker | Operations Manager | Adjunct Professor
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I certainly agree with the author. Having assisted in the developing of an SDOH Assessment for a medi-cal health plan in Southern California. Their are a significant amount of different criteria's, demographics, and areas to cover across the continuity of care spectrum. Distinct and under serviced populations require different sets of questions to be asked/addressed under a SDOH Assessment.

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2 Collaborate with the interdisciplinary team and community partners

The second step in addressing the SDOH is to collaborate with the interdisciplinary team and community partners to develop and implement a discharge plan that meets the patient's needs and preferences. The interdisciplinary team can include physicians, nurses, pharmacists, social workers, therapists, and educators, who can provide clinical guidance, education, and support. The community partners can include home health agencies, community health workers, transportation providers, food banks, housing agencies, and other organizations, who can offer resources and services that address the SDOH. The collaboration should be coordinated, timely, and consistent, and involve regular communication and follow-up.

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Ryan Iwamoto

Girl Dad of 2 ?? A life long learner ?? Passionate about leadership, org culture & getting 1% better every day ?? President & Co-Founder @24 Hour Home Care ?? EY Entrepreneur of the Year 2017 ?? Cal & HBS Alum ??
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Ensure you contact community partners well before patient discharge to avoid last-minute scrambles and stress. Instead of settling for an available caregiver, sufficient time allows finding the best fit based on experience and personality. This enables patients and families to interview caregivers, who can also train with PT/OT at the hospital for proper home exercise guidance. Ultimately, a smoother transition and reduced hospital readmission likelihood result in a better patient experience.

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Kathy Holdsworth MHA, BSN, RN, CCM

Director, Community Partnerships
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Completely agree! Sticking with the thought that discharge planning should begin upon admission. This allows effective and efficient planning to ensure a safe and appropriate discharge, with the right supports and resources in place to avoid readmissions. When this best practice isn't followed costly and unnecessary consequences occur, for the patient, family, and health care system.

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3 Educate the patient and caregiver on self-management and available resources

The third step in addressing the SDOH is to educate the patient and caregiver on self-management and available resources. Self-management refers to the skills and behaviors that enable the patient and caregiver to manage their health condition, medications, symptoms, and lifestyle. Self-management education can include topics such as medication adherence, symptom recognition, coping strategies, healthy eating, physical activity, and stress management. Available resources refer to the information and referrals that can help the patient and caregiver access and navigate the services and supports that address the SDOH. Available resources can include websites, phone numbers, brochures, directories, and applications.

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Renée P.

As an RN and health coach, I partner with stressed out, overwhelmed women to create boundaries and heal. I also partner with other health coaches to help them create powerful programs to support their clients.
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In addition, help the patient schedule the follow up appointment and discuss the logistics of how to get to the appointment, who can help, what to bring (a list of medications or a the medications).

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Melissa Jarrard-Mahayni RN, MS, CPC

Retired Nurse Case Manager.
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A huge draw back here is that the resources are scarce and hard to access when available by the people who need the services. On line sites and applications for people who don't have access to computers, or know how to use them - no smart phones, no training. People who are passed from one agency to another; have heard no so many times and are tired enough of rejection to just say no. I agree that assessment and bringing the true level of need for patients is critical. But this simplification of the - give them resources. Our chronic readmission patients really need a warm handoff from inpatient CM to outpatient CM services to assist with getting patients truly connected to services they critically need- if actually there.

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4 Monitor the patient's progress and outcomes

The fourth step in addressing the SDOH is to monitor the patient's progress and outcomes after discharge. This can include conducting phone calls, home visits, or telehealth sessions to check on the patient's health status, satisfaction, and adherence to the discharge plan. It can also include reviewing the patient's records, claims, or reports to track the patient's utilization of services, quality of care, and readmission rates. Monitoring can help identify any issues, gaps, or changes in the patient's needs or preferences, and adjust the discharge plan accordingly.

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5 Evaluate the impact of the SDOH interventions

The fifth step in addressing the SDOH is to evaluate the impact of the SDOH interventions on the patient's outcomes and experiences. This can include measuring and comparing the patient's clinical indicators, such as blood pressure, blood sugar, or pain level, before and after the discharge. It can also include collecting and analyzing the patient's feedback, such as satisfaction surveys, testimonials, or complaints, to assess the patient's perception of the quality and value of the discharge planning and transition of care. Evaluating can help demonstrate the effectiveness and efficiency of the SDOH interventions, and identify areas for improvement or best practices.

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6 Advocate for policies and programs that support the SDOH

The sixth step in addressing the SDOH is to advocate for policies and programs that support the SDOH at the organizational, local, state, or national level. This can include sharing the evidence and stories of the impact of the SDOH interventions on the patient's outcomes and experiences with stakeholders, such as managers, administrators, policymakers, funders, or media. It can also include participating in or initiating coalitions, campaigns, or initiatives that promote awareness, education, or action on the SDOH issues and solutions. Advocating can help create a culture and environment that values and supports the SDOH as an integral part of health care.

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7 Here’s what else to consider

This is a space to share examples, stories, or insights that don’t fit into any of the previous sections. What else would you like to add?

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Sam Simmons

CEO of The Community Initiative. Healthcare Junkie. Set my sights on making the lives of Social Workers & Case Managers easier through our new product CaseEZ! We focus on the patient's Social Determinants of Health.
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This is such a complicated subject, with so many variables. Everything listed above is important and needed. A couple of items missing are; 1 -making sure you track and report on what was provided to the patient. 2- help provide SDoH data to all those you work with. Many caregivers and providers have vast knowledge of community resources, however that knowledge lives in their heads. We need to get that in a central place for all to use. 3- push payors to reimburse on the current Zcodes that help define the needs of the community.

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How do you address the social determinants of health that affect discharge planning and readmission rates?

1

2

3

4

5

6

7

1 Assess the patient's needs and preferences

2 Collaborate with the interdisciplinary team and community partners

3 Educate the patient and caregiver on self-management and available resources

4 Monitor the patient's progress and outcomes

5 Evaluate the impact of the SDOH interventions

6 Advocate for policies and programs that support the SDOH

7 Here’s what else to consider

Case Management

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How do you address the social determinants of health that affect discharge planning and readmission rates?

1

2

3

4

5

6

7

1 Assess the patient's needs and preferences

2 Collaborate with the interdisciplinary team and community partners

3 Educate the patient and caregiver on self-management and available resources

4 Monitor the patient's progress and outcomes

5 Evaluate the impact of the SDOH interventions

6 Advocate for policies and programs that support the SDOH

7 Here’s what else to consider

Case Management

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感谢您的反馈

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