Screening for and Addressing Social Determinants of Health at Transitions of Care

Abstract

Transitions of care from hospital to home are a vulnerable time for patients, particularly so for those with social determinants of health (SDOH) needs that may impact their ability to manage their health in the outpatient setting. Traditional interventions focus on medication, continuity of care, health information, and red flags and do not necessarily address patients’ SDOH needs. The objective was to evaluate the incorporation of an SDOH screening and intervention into transitions of care encounters (referred to here as CTI+). This is a retrospective analysis of electronic health record data of patients discharged from a large urban health system with a transition of care encounter between May 2022 and April 2024. Demographic characteristics of patients who participate in CTI + are presented, as well as the prevalence of screening positive for issues with health literacy, medical transportation, food insecurity, and financial resource strain. The 30-day readmission rates for patients with SDOH factors and those without were compared, as well as readmission rates in the year prior to and following implementation of CTI+. Of 5942 encounters, 31.9% screened positive for at least one SDOH. 25.6% reported issues with health literacy. Readmission rates rose slightly for each additional positive SDOH factor. After implementation of CTI+, readmissions dropped from 11.7% to 9.8%. These findings highlight the need to address health literacy and demonstrate that incorporating SDOH screening and interventions into transitions of care may help mitigate the effect of SDOH on readmissions.

Keywords

Social determinants of health transitions of care readmissions health literacy

Instituting processes to support a safe transition of care from the inpatient to the outpatient setting improves patient outcomes. Multiple models of care transitions exist, all of which include components designed to take a patient-centered approach to increase the safety of transitions across settings of care. Interventions to improve communication at discharge between patients and providers have been shown to positively impact adherence to post-discharge treatment, to lower readmission rates, and to improve patient satisfaction.¹ Pharmacy-supported transition of care interventions have also shown a 32% reduction in readmission odds.²

One model to support safe transition of care from hospital to the community, the care transitions intervention (CTI), was developed based on focus groups with older adults and their caregivers, which identified elements of care that would be useful in continuing care for the patient after discharge.³ The result was an intervention comprising the following four components: (1) medication reconciliation and ensuring that patients have a way to take medications correctly after discharge, (2) creating or updating personal health records to ensure the transmission of health information across settings of care, (3) appropriate and timely follow-up with primary and specialty care, and (4) education on “red flags” and symptoms of decompensation, the appropriate response to these symptoms, and where to seek help.³ Results of an early randomized control trial to test the CTI model, which occurred from 2002 to 2003, showed a decrease in 30-day readmissions (8.3% vs. 11.9%) and 90-day readmissions (16.7% vs. 22.%), as well as approximately $500 in cost savings per patient.⁴ The intervention has since been further studied, adapted, and applied with various populations, with different health care professionals implementing the intervention (such as the inclusion of social workers or paramedics).^5,6 The historical impact of the success of the CTI model and similar care transitions programs is the widespread implementation and adoption of these programs to reduce readmissions and costs.

While the CTI model is comprehensive, it does not address social determinants of health (SDOH), a key factor associated with many components of health—including transitions of care across settings—even though SDOH challenges are likely to be encountered by a large proportion of discharged patients, especially in hospitals that serve disadvantaged populations.⁷ Multiple studies have documented the challenges faced by underserved populations in obtaining necessary follow-up after hospital discharge. These challenges include factors such as cost burden (including cost of medications), health literacy, social support, transportation deficits, and housing instability; they also include constructs such as therapeutic misalignment between the patient and the treatment team.⁸ Specific social determinants, such as living alone and functional status, are associated with greater health care utilization, including return to the emergency department after discharge.⁹ Recent efforts to prevent readmissions have recognized the necessity of examining SDOH and incorporating screenings into the electronic health record.¹⁰ The absence of addressing SDOH at discharge may leave patients transitioning to the outpatient setting at greater risk for being unable to care for themselves in accordance with the treatment plan, thus leading to greater illness or readmission to the hospital.

At present, most formal models of transitions of care do not include SDOH. The Transitions of Care Center at this health system adapted the CTI model to include a SDOH screening and intervention component, which is referred to as the CTI+ Model. The objectives of this article are: to described the demographic characteristics of patients who participate in CTI+; to explore the prevalence of screening positive for issues with health literacy, medical transportation, food insecurity, and financial resource strain; to test whether there are differences in 30-day readmission rates for patients with SDOH factors and those without; and to assess whether there are differences in readmission rates in the year prior to and following implementation of CTI+.

Methods

Setting

This project and the associated cross-sectional quantitative analysis took place between May 2022 and April 2024 at a large urban health system with multiple hospital sites. It was designated as quality improvement and was exempt from IRB review.

Population

Patient calls were prioritized according the following scheme: (1)The highest priority includes those patients who have a diagnosis that falls under the CMS Hospital Readmissions Reduction Program, including acute myocardial infarction, chronic obstructive pulmonary disease, heart failure, pneumonia, coronary artery bypass graft surgery, and elective primary total hip arthroplasty and/or total knee arthroplasty;¹¹ (2) patients with a diagnosis with a high risk of readmission, such as sepsis or status post Cesarean section; and (3) non-English speaking patients with a Risk of Unplanned Readmission (RoUR) score of 30 or greater. The RoUR score predicts unplanned readmissions within 30 days of discharge and is calculated every four hours during the patient’s admission. It incorporates the patient’s diagnosis, age, lab results, medications, orders, and utilization data such as length of stay and prior hospitalizations. The second tier included English-speaking patients covered under the value-based care model and oncology patients with a RoUR score of 30 or greater. The third tier was all other patients with a RoUR score of 30 or greater. The fourth tier included value-based care patients, oncology patients, and non-English speaking patients with a RoUR score of 20 or above, and the fifth tier was all other patients with a RoUR score of 20 or above.

Intervention

As part of an effort to reduce unnecessary re-hospitalizations and improve transitions of care, 12 nurses at the Transitions of Care Center routinely perform telephone encounters with patients who are discharged from one of the Health System hospitals, using the CTI + Intervention as a model. Each of the nurses has greater than five years of prior experience in various medical-surgical specialties. Several of the nurses are fluent in additional languages. In cases when a nurse who speaks the patient’s preferred language is unavailable, a professional interpreter service is utilized in accordance with health system policy for communication with patients with limited English proficiency. The first telephone encounter occurs within 3 days of discharge from the hospital. Telephone calls are made weekly for the first 30 days after discharge or until patients are determined to be stable, whichever comes first. Stability is determined as the patient not experiencing signs or symptoms of illness exacerbation or decompensation, reporting or demonstrating ability to manage his or her condition, having knowledge of signs or symptoms of exacerbation, taking all medications as prescribed, having all necessary durable medical equipment, having obtained post-acute care services as necessary, having established primary care services, and (after it was implemented in May, 2022) having completed the SDOH screening and being linked to appropriate resources.

If these items are complete, a patient is considered to be clinically stable from a transition of care perspective and does not receive further calls from the Transitions of Care Center.

In May 2022, the SDOH screening and intervention were added to the CTI intervention (the CTI+ model). This SDOH screening focuses on several areas of SDOH, with the understanding that SDOH may impact clinical stability after transitions of care. The questions pertaining to SDOH are described below. If a patient screened positive for any of the domains, the nurse conducting the encounter discussed community resources to address the issues described by the patient. With the incorporation of the SDOH screening, additional time was added to the transitions of care encounter. The encounter is provided at no cost to patients, and the health system does not bill for this service. Implementation of the SDOH screening was completed within six months from initial concept to full deployment.

All transitions of care encounters are recorded in the electronic medical record. Prior to implementation, the transitions of care flow sheet was updated to include the applicable SDOH questions. The encounter call script was also revised to integrate these questions into the standard workflow. Staff training included an overview of the SDOH domains, guidance on incorporating the questions into the call script, and instruction on appropriate documentation of assessment and interventions. Additionally, staff were trained on how to identify and access resources aligned with each SDOH category to support patient needs. An analytics platform was used to monitor and track response rates to the SDOH questions, as well as to track associated intervention rates.

Data and measures

Data for this study were derived from the electronic health record. The main dependent variable was 30-day readmissions. Four SDOH variables were examined: health literacy, transportation, food insecurity, and financial resource strain. These questions were adapted from the Centers for Medicare and Medicaid Service Accountable Health Communities Health-Related Social Needs Screening Tool, which was designed to identify social concerns that impact health.¹² Health literacy was identified by adapting the Brief Health Literacy Screen.¹³ Questions pertaining to SDOH, and answers that characterized a positive screening, are described in Table 1. Diagnosis was derived from the patient’s primary or admitting ICD-10 diagnosis, as well as from information on whether the patient was on a specified treatment pathway, had a specific consult note, or had specific CPT codes. Other demographic variables included age, gender, primary language (dichotomized to English or non-English), and marital status. An encounter was considered fully completed when the nurse was able to reach the patient by phone and completed all questions included in the transition of care assessment.

Table 1.

Social Determinants of Health Screening Questions

Category	Question	Options	Positive screen
Language and Health Literacy	Are you/patient able to understand written information in [your] preferred language?	Yes, no, not appropriate to ask at this time, patient declined to answer.	No
Language and Health Literacy	Are you/patient able to express your thoughts on paper in [your] preferred language?	Yes, no, not appropriate to ask at this time, patient declined to answer.	No
Language and Health Literacy	How often do you/the patient have someone help you/the patient read hospital materials?	Always, often, sometimes, occasionally, never, patient declined to answer.	Always, often, sometimes
Language and Health Literacy	How often do you/the patients have problems learning about your /the patient’s medical condition because of difficulty understanding written information?	Always, often, sometimes, occasionally, never, patient declined to answer.	Always, often, sometimes
Language and Health Literacy	How often do you/the patient have problems understanding what is told to you/the patient about your/the patient’s medical condition?	Always, often, sometimes, occasionally, never, patient declined to answer.	Always, often, sometimes
Language and Health Literacy	How confident are you/the patient filling out medical forms by yourself?	Not at all, a little bit, somewhat, quite a bit, extremely, patient declined to answer.	Not at all, a little bit, somewhat
Food Insecurity	Within the past 12 months, you worried that your food would run out before you got money to buy more.	Never true, sometimes try, often true, patient unable to answer, and patient declined to answer.	Sometimes true and often true
Food Insecurity	Within the past 12 months, the food you brought didn’t last, and you didn’t have money to get more.	Never true, sometimes try, often true, patient unable to answer, and patient declined to answer.	Sometimes true and often true
Financial Resource Strain	How hard is it for you to pay for basics like food, housing, medical care, and heating	Very hard, hard, somewhat hard, not very hard, not hard at all, Patient unable to answer, patient declined to answer.	Very hard, hard, somewhat hard
Transportation	In the past 12 months, has a lack of transportation kept you from medical appointments or from getting medications?	Yes, No, patient unable to answer, patient declined.	Yes

Adapted from the Accountable Health Communities Health-Related Social Needs screening Tool (Centers for Medicare &Medicaid Services, n. d.)¹² and the Brief Health Literacy Screen (Wallston, 2014).¹³

Analysis

First, descriptive statistics were performed for demographic characteristics for each category of SDOH. Next, the percentage of 30-day readmissions by number of positive screenings for SDOH factors was examined. Finally, the overall change in readmission rate between the year with just the CTI+ implementation without health literacy measures and in the year following implementation of the health literacy measures were examined. All analyses were conducted in Tableau.

Results

Demographic characteristics for each of the SDOH are presented in Table 2. Of 5942 encounters, 1520 (25.6%) patients screened positive for health literacy issues. Over half of those who screened positive were between 65 and 84 years old; approximately two-thirds selected English as their primary language; patients were nearly evenly split between male and female; and 60% were single, divorced, or widowed. Eighty-four patients (1.4%) screened positive for transportation issues, 226 (3.8%) screened positive for food insecurity, and 419 (7.1%) screened positive for financial resource strain. Readmission rates (Fig. 1) were slightly higher for each additional positive SDOH factor (no SDOH: 9.4%; one positive: 10.7%; two positive: 11.0%). Of 5045 encounters between May 2022 and April 2023, where there was no additional health literacy screening, 11.7% were readmitted. After the implementation of health literacy measures, there was a statistically significant difference in readmissions: From May 2023 through April 2024, 9.8% of the total 5924 encounters resulted in readmissions (P < 0.001) (Fig. 2).

FIG. 1.

Overall readmission rate by number of positive screening for social determinants of health needs.

FIG. 2.

Transitions of Care Center (TOCC) enrolled readmission rates before and after additional health literacy screening, May 2022–April 2023 (n = 5045) and May 2023–April 2024 (n = 5924).

Table 2.

Description of Demographic Characteristics for Patients Who Screened Positive for Social Determinants of Health Needs, May 2023–April 2024 (n = 5942). Missing Responses Excluded

Characteristics	Health literacy	Transportation	Food insecurity	Financial resource strain	Total
Characteristics	n (%)	n (%)	n (%)	n (%)	Total
Age
18–39	34 (2.2)	4 (4.8)	14 (6.2)	32 (1)	262
40–64	358 (23.6)	26 (31)	115 (50.9)	197 (47)	1758
65–84	841 (55.3)	40 (47.6)	81 (35.8)	164 (39)	2965
85+	287 (18.9)	14 (16.7)	16 (7.11)	26 (6.2)	957
Gender
Female	761 (50)	44 (52.4)	122 (54)	203 (48.4)	2941
Male	757 (49.8)	40 (47.6)	104 (46)	216 (51.6)	2996
Language
English	1004 (66.1)	57 (67.9)	169 (74.8)	324 (77.3)	4619
Non-English	516 (33.9)	27 (32.1)	57 (25.2)	95 (22.7)	1312
Marital status
Married/etc.	595 (39.1)	20 (23.8)	64 (28.3)	137 (32.7)	2315
Single/etc.	895 (59.9)	57 (67.9)	158 (69.9)	276 (65.9)	3489
Other	30 (2)	7 (8.3)	4 (1.8)	6 (1.4)	138
Total	1520 (25.6)	84 (1.4)	226 (3.8)	419 (7.1)	5942

Discussion

The results presented here demonstrate the implementation of a SDOH screening and intervention via telephone encounters with patients after hospital discharge, the goals of which were to facilitate smooth transitions between the acute and post-acute care settings and to promote positive outcomes. Among patients who participated in this intervention, over a quarter screened positive for issues with health literacy. There was a slight decrease in readmissions in the year after the intervention was implemented.

This intervention is based on a broader understanding that SDOH have major impacts on health outcomes. Health systems have started developing ways to incorporate social determinants into the health informatics infrastructure and workflows in order to ensure more seamless transitions for specific at-risk populations.^10,14 While screening for and addressing SDOH is appropriate at any encounter with the health care delivery system, it is particularly valuable to do so at the shift point between settings of care from hospital to the community, in order to minimize disruption for the patient and maximize the patient’s recovery. The transition from hospital to community should include an evaluation of the patient’s ability to care for his or her health independently, as well as a plan for providing timely intervention as needed. Integrating the screening into the electronic medical record and into standardized clinical workflows enables the health care team to consistently and regularly identify barriers and provide resources.

The widespread challenges with health literacy were a notable finding, underscoring that issues with health literacy are endemic and should not be overlooked. Health literacy has been identified as a major problem across populations: Around 39% of Americans with heart failure are estimated to have poor health literacy,¹⁵ and a survey of Medicaid Members in New York State found that 20% had poor organizational health literacy.¹⁶ Low health literacy has been associated with manifold negative health outcomes, such as increased rates of hospitalization and emergency department visits, lower rates of receiving preventive care such as vaccines and mammograms, inappropriate medication use, and greater mortality rates.¹⁷ Hospitals give patients discharge instructions before they leave, but successful transitions of care rely on the ability of patients to comprehend the instructions for managing their health in the community, including when and how to obtain follow-up care. This analysis suggests that many opportunities remain for improving health literacy.

Finally, there was a correlation between the number of SDOH challenges and readmission rates, which may signify that social determinants put patients at greater risk for readmission. There was also a slight decrease in overall readmissions in the year after the health literacy screening was implemented compared to the year prior, which may indicate that screening for and addressing SDOH challenges at transitions of care is beneficial. These findings should be interpreted with caution, as (1) this analysis did not distinguish between necessary and avoidable readmissions, (2) it does not control for outside factors that may have decreased readmission rates, and (3) it did not track which patients accessed the community resources to which they were referred.

Limitations

There are several limitations to this analysis. There may be response bias to the post-discharge transitions of care call, which may have influenced the characteristics of patients who completed the intervention. Patients may have reporting bias, resulting in SDOH barriers being underreported and possibly suggesting that these issues may be more widespread than reported here. Sampling bias is also a concern, as only patients with a limited set of diagnoses were able to participate in the intervention. Finally, this project took place in a single urban health system, which may limit the generalizability of findings to other settings. Future work may shed light on the frequency and success of patients obtaining appropriate community resources that were discussed in the screening encounter.

Conclusion

Incorporating a SDOH screening into transitions of care encounters is both feasible and advisable for promoting patients’ ability to care for themselves in the community after discharge. While numerous challenges exist in addressing SDOH, particularly health literacy, there remain opportunities for providers, health systems, and communities to improve the identification of these challenges and to offer solutions for improving health outcomes across settings of care.

Authors’ Contributions

S.W.: Conceptualization, analysis, methodology, writing—original draft, writing—review and editing. K.M.: Conceptualization, data curation, analysis, methodology. C.J.: Conceptualization, project administration, writing—review and editing. A.W.: Conceptualization, project administration, writing—review and editing. E.P.: Conceptualization, methodology, project administration, writing—review and editing, supervision.

Ethical Considerations

This project was approved by the Mount Sinai Nursing Project Approval Council and designated as quality improvement. No approval number provided. Approval date: December 13, 2024.

Consent to Participate

Requirement for informed consent has been waived.

Data Availability

It is not possible to share the data, as these are owned by the health system.

Footnotes

Acknowledgment

The authors acknowledge Bevin Cohen, PhD, MS, MPH, RN for her contribution to this manuscript.

Author Disclosure Statement

The authors declare no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding Information

The authors received no financial support for the research, authorship, and/or publication of this article.

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