Problem Addressed

Recent research has shown that risk for hospital readmission can be largely attributed to factors like a patient’s economic opportunity and other social determinants of health.^2,3,4,5 Patients with unmet needs in employment, housing, psychosocial, or other socioeconomic domains are at significantly greater risk for 30-, 60-, and 90-day hospital readmission.⁶ Case management and supports for basic needs like housing have been shown to reduce hospitalization⁷ and rehospitalization.^8,9 Based on this evidence, Prime Healthcare sought to improve patient health and care value by improving its social needs assessment and care coordination processes for hospitalized and recently discharged patients.

Description of the Innovative Activity

After reviewing claims and other patient data showing an association between social determinants of health and patient outcomes, leaders at Prime Healthcare committed to addressing social determinants of health. As part of this initiative, the innovation team sought (a) to improve relationships with step-down care and social services providers, and (b) to improve identification and tracking of patients with unmet social needs. To address the latter goal, the team developed two social determinants of health screening tools: one administered at admission and one at discharge.

The admissions screening tool was based on the CMS Health Related Social Needs Screening Tool.¹⁰ The tool assessed patient needs in the domains of financial resources, food insecurity, housing stability, physical activity, and depression. The assessments assigned patients an “opportunity index” score to determine the level of need and flagged those with the highest need for additional resources. At discharge, a member of the care team assessed the patient’s social determinants of health needs using a web-based portal. The care team documented all screening information in the patient’s electronic health record. After discharge, the care navigators contacted the patient and/or community partners and tracked updates in a shared database for recording patient progress and needs after patient discharge. The database permitted updates in real time and allowed for bidirectional flow of information. Clinicians could access this information to inform their approach to continued care for the patient.

Concurrent to the screening and care navigation enhancements, hospital officials sought to identify a select list of preferred higher-performing community partners and to develop close relationships with these partners. Determining preferred partners is an ongoing process informed in part by the data collection in the online platform. Administrators at each site maintain a list of partners to contact for referrals. Finally, individual hospitals launched initiatives in their communities such as offering educational groups on chronic conditions and providing wellness screenings aimed at improving community health.

Context of the Innovation

Prime Healthcare sought to address social determinants of health using a systems-level approach in select communities. The initiative was part of ongoing efforts to reduce healthcare disparities and improve value. To focus their efforts, safety and quality leaders reviewed claims data over time. They concluded that the innovation should (a) use higher-performing community partners for step-down care and monitoring and (b) document the progress of the highest-need patients after discharge.¹

Results

The innovation reached around 50,000 patients each year.¹ The innovation team collected case studies of patients who benefited from the enhanced screening and care navigation and referral services. Additionally, Prime Healthcare reported that, over three years, the five hospitals that piloted the initiative saw decreased readmission rates between 2% and 7%.¹ In a later two-year study, adjusted Acute Myocardial Infarction mortality rates decreased between 0.5% and 1.5% across eight participating facilities. Based on these and other findings, Prime tailored the initiative to local needs and implemented it at all its hospitals.

Planning and Development Process

To prepare to implement the intervention, the innovation team recommends the following:

• Conduct an organizational readiness assessment to determine how to target training and awareness of social determinants of health, as well as how to strengthen assessment, care navigation, and referral services.
• Develop a platform for real-time data collection and share information with care teams and community partners.
• Begin to get buy-in from all clinicians engaged in patient care.

Resources Used and Skills Needed

The innovation team report that to lead and implement the initiative organizations need multidisciplinary teams that include hospital leadership, business development staff, physicians, community referral partners, case managers, and social workers. The innovation requires access to data to establish the links between social determinants of health and patient outcomes. The innovation also requires EHR-based resources and models for social needs screening tools. Important strategies include identifying early the social determinants of health risk factors, identifying the highest risk patients, and investing in a system to track those patients. Organizations should make efforts to vet and develop relationships with community partners and hospitals should keep a central resource directory of preferred partners for referrals.

The innovation team emphasizes that systems should invest in the following:

• A real-time data tracking system that can be accessed by care navigators and clinical teams, in addition to community organizations
• Participation and training of multidisciplinary patient care teams
• Additional care navigators

Funding Sources

Prime Healthcare used no outside funding for the initiative.

Getting Started with This Innovation

• Obtain commitment to the initiative at all levels of a hospital.
• Examine trends in patient outcomes at potential partner institutions to determine preferred facilities and social services organizations for patient referrals.
• Establish relationships and obtain business associate agreements to ensure the secure transmission of personal health information.
• Create a resource directory of preferred partners for patient referrals.
• Ensure resources are available for care coordination, data collection, and training.
• Create a multidisciplinary innovation team.
• Develop screening tools.
• Develop a platform for tracking patient progress after discharge.

Sustaining This Innovation

To sustain the innovation requires transparency, teamwork, commitment, and a culture of willingness to invest in the health of patients and the community. To achieve sustained improvements, the team emphasized the importance of identifying social needs early, using risk stratification to identify high-risk patients and allocate resources appropriately, assessing for changes in patient needs over time, and establishing an integrated digital workflow to track patient needs and progress.

References/Related Articles

Centers for Medicare & Medicaid Services (CMS). The Accountable Health Communities Health-Related Social Needs Screening Tool. Accessed March 13, 2023. https://innovation.cms.gov/files/worksheets/ahcm-screeningtool.pdf 

U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion. Social Determinants of Health. Accessed March 13, 2023. https://health.gov/healthypeople/priority-areas/social-determinants-health 

Evans WN, Kroeger S, Munnich EL, et al. Reducing readmissions by addressing the social determinants of health. Am J Health Econ. 2021;7(1):1-40. 

Imran A, Rawal MD, Botre N, et al. Improving and promoting social determinants of health at a system level. Jt Comm J Qual Patient Saf. 2022;48(8):376-384. 

 

Footnotes

1. Imran A, Rawal MD, Botre N, et al. Improving and promoting social determinants of health at a system level. Jt Comm J Qual Patient Saf. 2022;48(8):376-384.
2. Wagner JL, White RS, Tangel V, et al. Socioeconomic, racial, and ethnic disparities in postpartum readmissions in patients with preeclampsia: a multi-state analysis, 2007–2014. J Racial Ethn Health Disparities. 2019;6(4):806-820.
3. Bettenhausen JL, Noelke C, Ressler RW, et al. The association of the Childhood Opportunity Index on pediatric readmissions and emergency department revisits. Acad Pediatr. 2022;22(4):614-621.
4. Evans WN, Kroeger S, Munnich EL, et al. Reducing readmissions by addressing the social determinants of health. Am J Health Econ. 2021;7(1):1-40.
5. Meddings J, Reichert H, Smith SN, et al. The impact of disability and social determinants of health on condition-specific readmissions beyond Medicare risk adjustments: a cohort study. J Gen Intern Med. 2017;32(1):71-80.
6. Bensken WP, Alberti PM, Koroukian SM. Health-related social needs and increased readmission rates: findings from the nationwide readmissions database. J Gen Intern Med. 2021;36:1173–1180.
7. Sadowski LS, Kee RA, VanderWeele TJ, et al. Effect of a housing and case management program on emergency department visits and hospitalizations among chronically ill homeless adults: a randomized trial. JAMA. 2009;301(17):1771-1778.
8. Gould H. SDOH Initiative Reduces Readmission Penalties in One Year. Healthcare Financial Management Association; 2019. Accessed March 13, 2023. https://www.hfma.org/topics/finance-and-business-strategy/article/sdoh-initiative-reduces-readmission-penalties-in-one-year.html
9. Weaver RH, Bolkan C, Robbins SL, et al. Caring beyond health care: lessons learned from a community-based partnership to reduce hospital readmission among high-risk adults. J Comm Engag Scholarship. 2021;14(1).
10. Centers for Medicare & Medicaid Services (CMS). The Accountable Health Communities Health-Related Social Needs Screening Tool; 2019. Accessed March 13, 2023. https://innovation.cms.gov/files/worksheets/ahcm-screeningtool.pdf