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Cheri Lattimer

Assessing Social Determinants of Health: How Important Are They?

Cheri Lattimer, RN, BSN
Executive Director, National Transitions of Care Coalition (NTOCC)

Since the implementation of the Affordable Care Act, the health care industry has been working on reducing avoidable hospital readmissions. Although we have lowered the readmission rate for many hospital stays, we continue to see avoidable hospital readmissions and often wonder about the cause and reasons for the readmission:

  • Did the care team not provide an adequate transition plan including a patient care plan?
  • Did the patient and family caregiver not follow through with the PCP or Specialist follow up visit?
  • Was the discharge or transition plan not clear or specific enough for the patient to follow?
  • Was medication reconciliation and the management plan unclear or confusing?
  • Did the hospital care team ensure the transition plan was sent to the PCP or Specialist?
  • Were the patient and family engaged with the care team and felt confident they could follow through at home with the care of their loved one?
Any one or combination of these reasons could be the culprit but the readmission could be related to a poor assessment of various social determinants of health (SDOH) during the patient's hospital stay. In a recent study, Becker's Hospital Review shared, "social determinants of health, including transportation access and home stability, can have a significant effect on hospital readmissions, a study from Connance, a Waystar company, concluded. The findings from the study found that SDOH contributed to more than 50% of readmissions."1 Many health care professionals believe that SDOH have a definite impact on the ability of the patient and their caregiver to be successful at home or at the next level of care.

It is important that we understand and ask questions about the issues and concerns regarding social determinants of health and how they impact the health of populations. How are SDOH impacting hospital readmissions and transitions of care? Who is responsible for assessing SDOH and how does that help to determine treatment care plans, discharge instructions, and care coordination?

Social determinants of health have long been a foundation of improving population health management. Health People 2020 developed five key areas of SDOH:2
  • Neighborhood and Built Environment
  • Health and Health Care
  • Social and Community Context
  • Education
  • Economic Stability
Each of these areas should be a concern to the care team in developing an appropriate and achievable transition care plan. A holistic approach to patient care is often our focus and strategic objective. Unfortunately, we often fall short of achieving this goal. The answer may lie in coordination of assessing social determinants of health, transitions, and population health management.3

1. Becker's Hospital Review – Social determinants of health contributed to half of hospital readmissions, study finds, found at: https://www.beckershospitalreview.com/population-health/social-determinants-of-health-contributed-to-half-of-hospital-readmissions-study-finds.html.
2. Social Determinants of Health: https://www.healthypeople.gov/2020/topics-objectives/topic/social-determinants-of-health.
3. Zangerle C., Population health: The importance of social determinants, Nursing Management, February 2016.

42nd HCQ&PS conferenceLearn more about the issues and join me for "A Transition of Care Standard; Assessing Social Determinants of Health" at ABQAURP’s 42nd Annual Health Care Quality and Patient Safety Conference in San Antonio, TX on April 25-26, 2019. For more information and to register, visit www.abqaurp.org/AnnualConference.