How to Address Social Factors Leading to Readmission

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

You know not all patients are the same. Medical problems, reactions to medications, and many other health-related issues make every patient — and their experience — truly unique.

Another key difference between patients are social factors. Poverty, lack of social support, lack of transportation, and racial disparities all contribute to increased hospital readmissions.

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:

Poverty. Patients in impoverished neighborhoods are 24% more likely to be readmitted to the hospital.

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

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%.

Living alone. Researchers across multiple studies have found higher readmission rates among patients who live alone than those living with a spouse.

Age and gender. Comorbidities stack up with age, making health management harder for older adults. In studies, patients over 65 show much higher readmission rates. Gender matters, too. Researchers found that older male patients had higher readmission rates than young female patients.

Insurance type. 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%.

Differences in insurance-related readmission rates may be due to age and demographic factors associated with certain insurance types.

Language. 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.

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. Racially linked economic disparities also lead to higher readmission rates and poorer health outcomes among minorities.

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 readmission 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.

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%.

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.

10. Connect to primary care. Racial minorities are less likely to be connected to a primary care provider. 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.

For additional reading:

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.