Social Needs and Resources in the Evaluation and Enhancement of Discharge Support: The NEEDS Study

项目总结 在近3500万在急性住院后出院的美国人中，18%的人 需要在30天内因相同或相关情况再次住院。研究继续记录 社会需求(如粮食和住房不安全)和支持性资源(如工具性社会支持) 在健康结果方面发挥重要作用，包括重新住院。然而，尽管入学时的评估 是医院认证机构和付款人所必需的，我们之前的研究已经发现，住院团队 往往没有意识到患者的社会需求和支持资源，并且在 病人和护士之间关于出院准备情况的出院(个人评估 地位、知识、应对能力和预期支持)与患者应对困难和 再次入院治疗。这些发现表明，促进患者、家人之间的沟通 会员和住院保健提供者对患者的社会需求和资源的关注度很高 承诺制定更知情的出院计划，并改善患者结局(例如，准备好 出院，减少再入院)。这项研究的目的是提供住院病人的健康护理 具有有关患者的社交需求和支持资源的信息的团队，评估它是否有助于 临床决策，影响出院准备，并最终减少医院 重新入院。本研究的目的是：1)测试评估和沟通患者社交的效果 医疗团队-患者-照顾者-结果的需求和支持资源；2)测试社会需求的影响 以及出院计划流程的支持性资源评估；以及3)检查提供者和患者 社会需求和支持性资源评估的经验。使用中断的时间序列设计 和回归不连续性分析，我们将检验沟通结果的社会需求和 常规出院期间对内外科住院团队的支持性资源评估结果 计划巡视。总体假设是将患者的社会需求和支持资源包括在内 住院期间的护理将导致更高和更一致的出院评级准备(在 患者、护理人员和他们的健康团队成员)与没有社会需求和 支持性资源评估。因为患者的社会需求和支持资源并不统一 或普遍评估，这项研究的结果将为卫生系统提供有关因素的额外信息 使患者在出院后面临预后不良的风险，并确定是否将社会需求和 支持性资源信息可提供信息并改进临床护理服务。

PROJECT SUMMARY Of the nearly 35 million Americans discharged to community settings after an acute hospitalization, 18% require re-hospitalization for the same or related condition within 30 days. Research continues to document how social needs (e.g. food and housing insecurity) and supportive resources (e.g. instrumental social support) play important roles in health outcomes, including hospital readmissions. Yet, while assessment at admission is required for hospital certification bodies and payers, our previous research has identified that inpatient teams are often unaware of patients’ social needs and supportive resources, and lack of agreement on the day of discharge between patients and nurses regarding readiness for hospital discharge (an assessment of personal status, knowledge, coping ability, and expected support) is associated with patient coping difficulties and hospital readmissions. These findings suggest that facilitating communication between patients, family members, and inpatient health care providers regarding patients’ social needs and resources holds high promise for developing more informed discharge plans, and for improving patient outcomes (e.g., readiness for hospital discharge, decreasing readmissions). The objective of this study is to provide inpatient health care teams with information about patients’ social needs and supportive resources, evaluating whether it facilitates clinical decision-making, impacts readiness for hospital discharge and, ultimately, reduces hospital readmission. The aims of this study are to 1) test the effect of assessing and communicating patients’ social needs and supportive resources on health team- patient- caregiver- outcomes; 2) test the effect of social needs and supportive resources assessment on discharge planning processes; and 3) examine provider and patient experiences of social needs and supportive resources assessment. Using an interrupted time series design and regression discontinuity analysis, we will test the effect of communicating results of a social needs and supportive resources assessment findings to medical and surgical inpatient teams during routine discharge planning rounds. The overall hypothesis is that inclusion of patients’ social needs and supportive resources during inpatient care will result in higher and more congruent readiness for hospital discharge ratings (between patients, caregivers, and members of their health team) compared to patients without social needs and supportive resources assessment. Because patients’ social needs and supportive resources are not uniformly or universally assessed, results of this study will provide health systems additional information about factors placing patients at risk for poor outcomes after discharge, and identify whether integrating social needs and supportive resource information informs and improves clinical care delivery.