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

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.