Reduce readmissions by addressing social determinants of health

Although not all readmissions can be avoided, a significant portion of unplanned readmissions can be reduced by addressing the social determinants of health (SDoH). These determinants include barriers that patients face before, during, and after admission and discharge. Public policy encourages discharged patients to remain stable and healthy without returning to the hospital.

As a result, new practices in the health industry aim to encourage hospitals and providers to be paid based on their positive outcomes, so-called ” value carand. The model involves establishing financial incentives and penalties designed to improve patient quality of life and control the cost of hospital care. It is estimated that more than 2 million patients are readmitted to the hospital each year, costing Medicare more than $26 billion. An estimated $17 billion of this comes from readmissions that might have been avoided by addressing social factors.

To address this issue, the Centers for Medicare & Medicaid Services (CMS) implemented the Hospital Readmissions Reduction Program (HRRP) in 2012. The CMS plan imposes financial penalties on hospitals with relatively high Medicare readmission rates. To determine penalties for each hospital in the first phase of the program, CMS examined readmission rates for patients who were initially admitted for heart failure, heart attacks and pneumonia but returned within 30 days of discharge. In fiscal year 2015, two more conditions were added: elective hip and knee replacements and chronic obstructive pulmonary disease (involving bronchitis and emphysema). In fiscal year 2017, CMS added coronary artery bypass surgery to the HRRP measure and expanded the types of pneumonia cases evaluated. Currently, hospitals could lose up to 3% of Medicare payments under the program.

The report’s findings show that beneficiaries with social risk factors, such as low income, black race, Hispanics, and rural residents, perform better on quality measures than providers who serve large numbers of beneficiaries with social risk factors. The results are worse. Social risks, are subject to more severe sanctions in certain schemes such as the HRRP. The reasons for this are multifactorial and require efforts to measure and report performance and quality of care, including differences in readmissions. Additionally, research shows that certain patient characteristics, such as race, ethnicity, language proficiency, age, socioeconomic status, residence, and disability, can predict readmission risk and readmissions, particularly for costly medical conditions and complex diseases. Such as heart failure, pneumonia, acute myocardial infarction, etc.

Race, ethnicity, residence in disadvantaged neighborhoods, and low social support were associated with 30-day readmissions. The findings also highlight that heart failure readmissions include other factors beyond traditional SDoH that may influence postdischarge outcomes in older adults with heart failure. Hospitalized Medicare beneficiaries have multiple comorbidities, are frail, and have functional, cognitive, and sensory impairments.

It is estimated that addressing the social determinants of health through coordinated care planning can reduce readmission costs and reduce 30-day, 60-day, and 90-day readmission rates by 14% or more compared to the U.S. sample average. These impacts were driven by Black and Latino patients as well as patients who were eligible for both Medicare and Medicaid.

Health literacy is one of many factors that contribute to readmissions. Examples include limited knowledge of medical conditions, poor ability to manage medications and self-care, and lack of compliance with treatment plans.

To help reduce readmissions, you can take the following steps:

• Conduct an assessment to obtain important sociodemographic data on social determinants.
• Provide appropriate educational materials to promote patient understanding of diagnosis and treatment options.
• Adopt a tool that enables organizations to identify social needs based on social determinants. But beyond that, once identified, the platform allows case managers to digitally match and refer those needs to organizations that can provide those services and see the real-time status of those referrals. Timely and well-executed referrals can save lives.
• Connect patients to community-based resources such as adult day care programs, personal care, home-delivered meals, services that address social determinants of health (such as housing, food security, transportation, and employment) and services that disproportionately impact patients Financial barriers to racial and ethnic minorities.
• Coordinate electronic referrals with community programs based on health education, nutrition, and elder care provided by trusted institutions (e.g., faith-based organizations, social programs) through the social collaboration network in Sociants.

Hospitals must take steps to ensure they are prepared to provide high-value healthcare to diverse patient populations. Addressing readmission disparities is key to delivering on the promise of high-value care for all patients, families and caregivers.

To effectively address readmissions among diverse populations, hospitals should consider the strategies outlined in this report:

• Use data to identify differences and the root causes of those differences.
• Establish multidisciplinary teams to meet diverse patient needs.
• Be prepared to address social risk factors for readmission.
• Makes nursing culturally sensitive and focuses on effective communication.
• Extend patient care beyond the four walls of the institution to connect and coordinate with community organizations.

If you would like to learn more about this topic and other content related to the health industry in Puerto Rico, we recommend that you attend the Puerto Rico Hospital Association Annual Conference in San Juan, Puerto Rico on Friday, October 20th at the Sheraton Hotel in Puerto Rico. If you are interested in learning more about the Sociants 3.0 platform, please visit our website, www.sociants.com Or call 787-294-5556.

The author is Director of the Social Collaboration Network; and President of the Association.