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

项目摘要 在近3500万美国人中，18%的人在急性住院后出院到社区， 需要在30天内因相同或相关疾病再次住院。研究继续记录 社会需求（如粮食和住房无保障）和支助资源（如工具性社会支助）如何 在健康结果中发挥重要作用，包括再次入院。然而，虽然入学评估 是医院认证机构和付款人所必需的，我们以前的研究已经确定， 通常不了解患者的社会需求和支持资源，并且在治疗当天缺乏一致意见。 出院病人和护士之间关于出院准备（个人评估） 状态、知识、应对能力和预期支持）与患者应对困难相关， 再入院这些研究结果表明，促进患者、家属和 会员和住院医疗保健提供者对患者的社会需求和资源持有很高的 承诺制定更知情的出院计划，并改善患者结局（例如，准备情况 出院，减少再入院）。这项研究的目的是提供住院医疗保健 团队提供有关患者社会需求和支持资源的信息， 临床决策，影响出院准备，并最终减少医院 再入院本研究的目的是：1）测试评估和沟通患者社会关系的效果 需求和支持资源对医疗团队-患者-照顾者-结果的影响; 2）检验社会需求的影响 和支持性资源评估出院计划过程;和3）检查提供者和患者 社会需求和支持资源评估的经验。使用中断时间序列设计 和回归不连续性分析，我们将测试一个社会需求的沟通结果的效果， 对内科和外科住院团队在常规出院期间的支持性资源评估结果 计划回合。总的假设是，包括患者的社会需求和支持资源， 在住院治疗期间，将导致更高和更一致的出院评级准备（之间 患者，护理人员及其健康团队成员）与无社会需求的患者相比， 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，这项研究的结果将提供卫生系统有关因素的额外信息， 将患者置于出院后不良结局的风险中，并确定是否将社会需求和 支持性资源信息告知并改进临床护理交付。

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.