SDoH: Keys to improved outcomes, lower hospitalization rates

By Judy Connelly RN, MSN, SHR and Maureen Kelleher, RN, MBA
SimiTree Senior Managers

Social Determinants of Health (SDoH) are defined by the Centers for Disease Control (CDC) as “Factors that contribute to a person’s current state of health: biological, socioeconomic, psychosocial, behavioral, or social in nature.” The National Association of Community Health Centers (NACHC) defines them as “Conditions in the places people live, learn, work, and play that affect a wide range of health risks and conditions.”

Typically, SDoH are identified within 5 Domains: Economic Stability, Education Access and Quality, Health Care Access and Quality, Neighborhood and Built Environment, and Social and Community Context. (health.gov). Examples of SDoH include:

  • Income and social protection
  • Education
  • Unemployment and job insecurity
  • Working life conditions
  • Food insecurity
  • Housing, basic amenities and the environment
  • Early childhood development
  • Social inclusion and non-discrimination
  • Structural conflict
  • Access to affordable health services of decent quality. (W.H.O. 2022)

Additional factors include:

  • Biologic or genetic issues
  • Lack of support systems
  • Behavior issues (Alcoholism, mental health conditions, addiction, STD, PTSD)

Regardless, SDoH are considered the greatest risk factors contributing to rehospitalizations and most recently, as a result of COVID-19 isolation, a key factor in mental health conditions leading to high emergency department utilization. Failure to identify and address determinants and disparities are core factors in fragmented health care and poor outcomes. We find one determinant impacts many others. For example, food insecurity can be caused by financial constraints, limited access to grocery stores, fear of leaving home, physical or transportation limitations. This may lead to poor nutrition, health risks such as diabetes, cardiac disease, stroke, and obesity – and may lead to increased hospitalization and lower life expectancy.

Determinants and Fragmented Care

Inpatient settings with short lengths of stay and staffing shortfalls are challenged to fully assess patient and family determinants of care. Traditional clinical assessments focus on physical and psychosocial aspects of health and are only recently inclusive of determinants and associated interventions. Historically, it has been left to post-acute care and social services to assess and intervene. Patients often fail to disclose the realities of their living environment, fear placement, and feel hopeless or disengaged at time of discharge. COVID-19 restrictions prohibited family members to be present to communicate discharge needs creating gaps in information and discharge planning challenges.

CMS has been paying close attention to social determinants at discharge in an effort to reduce rehospitalizations, connect care and identify failures as patients transition between healthcare arenas. Value-based payment structures have increased awareness of determinants and encouraged a more holistic approach to managing patient health. OASIS-E includes standardized data collection on Ethnicity, Race, and four new elements - Health Literacy, Transportation, Language, and Social Isolation. These support common patient outcome measures across post-acute care settings (IMPACT Act & CMS Initiatives). Other cross sector measures include 30-day readmissions, medication reconciliation, transfer of health information and care preferences – all potentially influenced by an awareness of patient/family determinants of health. The HOPE (Hospice Outcome and Patient Experience) assessment will surely include aspects of determinants. This standardized assessment tool is expected to drive ‘real time’ care planning as the patient condition changes.

Health Equity Initiative

In the Proposed FY2023 Rule for Hospice, CMS requested responses to questions related to SDoH. These responses will likely provide information for CMS to include SDOH questions on the HOPE Instrument. These questions include:

  • What efforts does your hospice employ to recruit staff, volunteers, and board members from diverse populations to represent and serve underserved populations? How does your hospice attempt to bridge any cultural gaps between your personnel and beneficiaries/clients? How does your hospice measure whether this has an impact on health equity?
  • How does your hospice currently identify barriers to access in your community or service area? What are barriers to collecting data related to disparities, social determinants of health, and equity? What steps does your hospice take to address these barriers?
  • How does your hospice collect self-reported data such as race/ethnicity, veteran status, socioeconomic status, housing, food security, access to interpreter services, caregiving status, and marital status used to inform its health equity initiatives?
  • How is your hospice using qualitative data collection and analysis methods to measure the impact of its health equity initiatives?

CMS is also seeking comment on a potential structural composite measure based on hospices submitting documentation and activities related to specific domains. Potential domains are:

  • Domain 1: Hospice commitment to reducing disparities is strengthened when equity is a key organizational priority.
  • Domain 2: Training board members, leaders, staff, and volunteers in culturally and linguistically appropriate services (CLAS), health equity, and implicit bias is an important step which hospices need to take to provide quality care to diverse populations.
  • Domain 3: Leaders and staff could improve their capacity to address disparities by demonstrating routine and thorough attention to equity and setting an organizational culture of equity.

Assessing Social Determinants of Health

Best practice encourages home health and hospice to foster ‘top of mind’ awareness in recognizing the importance of assessing for social determinants of care, discussing them at case conference and IDT meetings and developing inclusive plans of care to assist patients in managing such challenges.

NACHC recommends the use of the PRAPARE tool: Protocol for Responding to and Assessing Patients’ Assets, Risks, and Experiences created in 2016. This patient-centered, evidence-based tool is a simple and short way to uncover social needs and is widely used in Community Health Clinics across the country. Outcomes resulting from the use of the tool indicate positive impacts on patient care, team participation, provider relationships, reduced risk, disparities and inequalities, and payment reform. Although software products in use may not include this tool, staff can still draw upon the assessment to foster skilled assessments and interventions for patient care.

SDOH, Home Health and Hospice

Social workers have long been identified as one of the key players in assessing, managing, and improving factors related to determinants of health and reducing rehospitalizations. They are often undervalued and underutilized in the post-acute space. Many home health agencies, despite the nurse shortfall, expect nurses to adequately cover this element of care. This additional burden can lead to burnout and turnover. Although nursing curriculum covers psychosocial issues and their impact on clinical care, there is little comparison to the depth of knowledge social workers bring to the table for patients and families. In many cases, nurses have been exposed to social workers only in the role of discharge planning, rarely seeing their counseling and coaching skills, and therefore fail to identify the appropriate use of social work. Managed care products generally authorize only one social work visit. Hospice, on the other hand, is regulated to involve social work as an active member of the IDG and patient/family plan of care. Even so, patients/families often refuse their involvement due to negative experiences or perceptions associated with the title “Social Work” and nurse-centric teams fail to involve social work early and often.

Bridging the Social Work Gap

There are a variety of approaches and interventions home health, and hospice can take to improve patient care and reduce the impact of SDoH:

  • Include the role and skills of social workers in staff and volunteer orientation
  • Hold staff accountable to identify SDoH and involve social work in a timely manner
  • Provide education on inclusion, diversity and disparities and hire staff which represents the diversity of communities served when possible
  • Joint admissions (RN & SW), especially in hospice, to promote the team concept as outlined by the hospice insurance benefit
  • Design job descriptions outlining and requiring team practice involving social work
  • Educate case conference, IDT facilitators, and clinical managers to role in ensuring management of SDoH
  • Develop tip sheets or ticklers to increase awareness of social work role
  • Work with marketing, community education, and development to build long-term, trusting relationships with underserved communities, clinics, religious entities, etc.
  • Develop guides/directories to provide education regarding all community services, their location and contact information to staff and patients/families (including non-medical needs)
  • Participate on community boards focused on healthcare services
  • Review operating policies and procedures to address potential disparities in patient access, patient/family/caregiver experience and overall quality of life

Editor’s Note: Authors Judy Connelly, RN, MSN, SPHR, and Maureen Kelleher, RN, MBA, are SimiTree Senior Managers in Clinical Operations. They help home health and hospice agencies understand and implement clinical regulations, shore up clinical documentation, define roles and improve clinical performance by addressing challenges from intake to discharge. Use the form below to contact SimiTree for help with your organization’s clinical operations.


Social Determinants of Health. Health People 2030. www.Health.gov/healthypeople/priority-areas/social-determinants-health
About Social Determinants of Health (SDOH). CDC. www.cdc.gov/socialdeterminants/about.html

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