Studies show that social determinants of health contribute to more than 50% of hospital readmissions. These social risk factors make it harder for patients to get and stay healthy. In February 2019, Northwell Health implemented a social determinants of health screening tool to help newly discharged patients get the support they need to fully recover and avoid readmission.
The tool is a 15-item questionnaire that provides care teams with information about patients’ social determinants of health. Northwell’s goal is to screen patients within 48 hours of admission. A patient who screens positive for one or more social determinants is connected to resources that can address those needs, such as a community-based organization that can provide resources and assist with applying for benefits such as the Supplemental Nutrition Assistance Program, or Access-A-Ride, which provides transportation for people who are unable to use mass transit because of age or disabilities. The transitional care management team may also schedule home visits by a nurse after a patient is discharged to quickly address problems. Social determinants are documented in patients’ electronic medical records, ensuring physicians and other providers are aware of factors that may impact their patients’ health and allowing interventions to be tracked and assessed.
The screening tool performed well in a pilot program at Long Island Jewish Forest Hills, where it has been used to identify social determinants among patients whose hospital stays occurred within 30 days of an earlier discharge. In these patients, 64% screened positive for at least one social determinant, with transportation problems ranking highest. Other common social determinants included limited health literacy, inadequate social support and a lack of safe or secure housing.
For more information, contact Lisa Davis, director, corporate communications, at (205) 542-8053 or firstname.lastname@example.org.