How to Address Social Factors Leading to Readmission

Reduce Hospital Readmissions Through Personalized Planning for Patients at the Highest Risk

Some of your patients must fight harder to achieve good health and stay out of the hospital than others.

Extensive research on the social determinants of health consistently links poverty, lack of social support and transportation, and racial disparities to increased hospital readmissions.[1]

Who is at higher risk of readmission?

To target interventions, you must first identify patients at higher risk of readmission. Some social factors that lead to higher risk include:

Living in a poverty-stricken area

Poverty is complex and affects health in a profound way: Patients in impoverished neighborhoods are 24% more likely to be readmitted to the hospital.[2]

Lacking transportation

Research shows patients with private transportation are more likely to attend doctor’s appointments than those who rely on public transport.[3]

Having poorly controlled mental illness

Poverty and mental illness feed each other in a vicious circle and can impact hospital readmissions. In one study, having depression increased the chance of hospital readmission by 20%.[4]

Living alone

Researchers across multiple studies have found higher readmission rates among patients who lived alone than those living with a spouse. [3], [4]

Age and Demographics

Comorbidities stack up with age, making health management harder. In studies, patients over 65 show much higher readmission rates.[4] Gender matters too. Researchers found that older male patients had higher readmission rates than young female patients.[3]

Having certain types of insurance

Healthcare leaders may be able to use insurance status for insight into readmission risk. The Agency for Healthcare Research and Quality reports the highest readmission rates in patients with Medicare as their primary insurance at 17%. Medicaid follows at 13.9%. Self-pay is in third place at 11.9%, and private insurance is associated with the lowest readmission rates at 8.5%.[5] [PS1] Differences in insurance-related readmission rates may be due to age and demographic factors associated with certain insurance types.

Language barrier

A language barrier makes it difficult for providers to communicate instructions and leaves the potential for misunderstanding. Spanish speakers — over 12% of the United States population — have a 50% higher likelihood of readmission than English speakers.[6],[7]

Race

Ties between race and health are complex. Certain conditions affect minority races more and complicate health management: For instance, Black patients have a 4.24% higher prevalence of diabetes than white patients.[8] Racially linked economic disparities also lead to higher readmission rates and poorer health outcomes among minorities.[9], [10], [11],[12]

How to address social factors

Once you identify patients at risk for social challenges, use focused interventions to overcome barriers:

1. Target interventions. Offer an outpatient navigation program to help patients with multiple social risk factors. You may use phone check-ins, home visits, and ongoing social worker support.

2. Start early. Applying for assistance and connecting patients to resources takes time. The sooner you start the process, the sooner patients will have help.

3. Personalize planning. Address the root causes behind your patients' challenges. For example, for a patient treated for an overdose, was it due to confusion, cognitive impairment, a suicide attempt, or addiction? Each root cause leads to very different solutions.

4. Discharge level of care. A hospital admission can indicate patients are not successfully managing at home. Secure a stay in a skilled nursing facility for patients who may struggle to care for themselves after discharge. Patients who previously had difficulties with activities of daily living are at higher risk of readmission overall. [12]

5. Identify community programs. Maintain a list of community resources, including disease–specific programs, such as foundations and support networks. Some examples of community resources are:

1. Adult day programs

2. Home care

3. Home-delivered meals

4. Public medical transportation services

6. Make a proactive follow-up plan. Take it a step further than making an appointment. Ensure your patient has a ride to their follow-up appointment before they leave the hospital. Keeping a 7-day follow-up appointment with a primary care doctor reduces readmissions by 5%.[12]

7. Make insurance connections. Assess insurance coverage and connect uninsured and underinsured patients with insurance wherever possible.

8. Remove medication barriers. Consider economic and transportation-related barriers to medication compliance. Offer medication assistance or connect patients with resources to help. If your hospital provides an outpatient pharmacy, deliver prescriptions to the bedside so patients have them in hand before they leave. Sending prescriptions as early as possible can also help avoid prior authorization delays.

9. Speak their language. Translate printed materials in the patient's native language. Patient Guide Solutions educational materials are available in Spanish translations, the primary language of 42 million people in the United States.[9]

10. Connect to primary care. Racial minorities are less likely to be connected to a primary care provider.[13], [14] Assess all patients for a primary care provider and help them make an appointment.

11. Support social workers. Social workers make individualized resource planning possible. Assess that they have adequate capacity to meet the needs of your patients.

You can create personalized interventions to help your patients overcome social barriers. By prioritizing health equity and social support, you can establish yourself as a healthcare system committed to the well-being of every individual.

References:

[1] Guide to Reducing Disparities in Readmissions. Centers for Medicare and Medicaid Services; 2018.

[2] Baker MC, Alberti PM, Tsao TY, Fluegge K, Howland RE, Haberman M. Social Determinants Matter For Hospital Readmission Policy: Insights From New York City: Study examines social determinants and hospital readmissions. Health Aff (Millwood). 2021;40(4):645-654. doi:10.1377/hlthaff.2020.01742

[3]  Rao D, Rebello A, Mamatha HK, Shalini N, Mahalakshmi AM. Transportation in Hospitals. In: A Guide to Hospital Administration and Planning. Springer Nature Singapore; 2023:137-164.

[4] Obuobi S, Chua RFM, Besser SA, Tabit CE. Social determinants of health and hospital readmissions: can the HOSPITAL risk score be improved by the inclusion of social factors? BMC Health Serv Res. 2021;21(1):5. doi:10.1186/s12913-020-05989-7

[5] Characteristics of 30-Day All-Cause Hospital Readmissions, 2016-2020. (n.d.). Ahrq.Gov. Retrieved October 31, 2023, from https://hcup-us.ahrq.gov/reports/statbriefs/sb304-readmissions-2016-2020.jsp

[6] US Census Bureau. Nearly 68 Million People Spoke a Language Other Than English at Home in 2019. Published online 2022. Accessed November 3, 2023. https://www.census.gov/library/stories/2022/12/languages-we-speak-in-united-states.html

[7] Karliner LS, Kim SE, Meltzer DO, Auerbach AD. Influence of language barriers on outcomes of hospital care for general medicine inpatients. J Hosp Med. 2010;5(5):276-282. doi:10.1002/jhm.658

[8] Seixas AA, Henclewood DA, Langford AT, McFarlane SI, Zizi F, Jean-Louis G. Differential and combined effects of physical activity profiles and prohealth behaviors on diabetes prevalence among Blacks and Whites in the US population: A novel Bayesian belief network machine learning analysis. J Diabetes Res. 2017;2017(2017):5906034. doi:10.1155/2017/5906034

[9] Allaudeen N, Vidyarthi A, Maselli J, Auerbach A. Redefining readmission risk factors for general medicine patients. J Hosp Med. 2011;6(2):54-60. doi:10.1002/jhm.805

[10] 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. doi:10.1007/s11606-016-3869-x

[11] Joynt KE, Orav EJ, Jha AK. Thirty-day readmission rates for Medicare beneficiaries by race and site of care. JAMA. 2011;305(7):675-681. doi:10.1001/jama.2011.123

[12] Wiest, D., Yang, Q., Wilson, C., & Dravid, N. (2019). Outcomes of a citywide campaign to reduce medicaid hospital readmissions with connection to primary care within 7 days of hospital discharge. JAMA Network Open, 2(1), e187369. https://doi.org/10.1001/jamanetworkopen.2018.7369

[13] Chan KS, Parikh MA, Thorpe RJ Jr, Gaskin DJ. Health care disparities in race-ethnic minority communities and populations: Does the availability of health care providers play a role? J Racial Ethn Health Disparities. 2020;7(3):539-549. doi:10.1007/s40615-019-00682-w

[14] Guide to Reducing Disparities in Readmissions. Centers for Medicare and Medicaid Services; 2018.

 [PS1]Just a question on this one: This makes it sound like having Medicare is a risk for readmission, but isn’t it just as likely that private insurance may be refusing to authorize a readmission or that if you’re paying yourself, you may not be able to afford a needed hospital stay?